Progress Report on Nutrition

Component of CMDG 1

Prepared for Health Partners

MeetingMay 2011

UNICEF, WHO, WFP

The Cambodia Millennium Development Goals Gap Analysis in 2009 stated that it is still possible to reach CMDG1, if changes occur…

Positive ChangeEarly breastfeeding and exclusive breastfeeding show great progress (CDHS 2010)

Coverage of deworming and micronutrient supplementation for pregnant/postpartum women and children climbing to above 50% (CDHS 2010)

Eight out of ten households consume iodized salt (CDHS 2010)

Household dietary diversity is improving with a higher percentage of calories from animal sources, especially in urban areas (CSES 2009)

The poorest households are consuming 13% more calories (CSES 2009) and spending a lower percent of overall expenditure on food

CDHS 2000 CDHS 2005 CAS 2008 CDHS 2010

11.4

6065.9

73.5

Percentage of youngest children 0-5 months (living with mother) exclusively breastfed in the past 24 hours

ANY ANEMIA MODERATE ANEMIA SEVERE ANEMIA

63.4

30.6

2

61.9

32.1

0.7

55.1

26.1

0.9

Percentage of Cambodian children under 5 with anemia from 2000-2010

CDHS 2000 CDHS 2005 CDHS 2010

On Track?

CDHS 2000 CSES 2004 CDHS 2005 CAS 2008 CSES 2009 CDHS 20100

5

10

15

20

25

30

35

40

45

38.4

36.728.2 28.8 29.6

28.3

Percentage of U-5 children underweight (weight-for-age<-2SD) from 2000-2010 in Cambodia

CMDG 2015 Target=19%

CMDG 2010 Target=24.5%

The (2007-2011) 2008 Food Price Crisis

• Rice prices more than doubled in 2008

• In 2011 rice prices remain 35% higher, inflation adjusted, and wages have not kept pace

• 2011 international spike in other food prices also affecting Cambodia

80

100

120

140

160

180

200

220

240

Jan

-07

Apr

-07

Jul

-07

Oct

-07

Jan

-08

Apr

-08

Jul

-08

Oct

-08

Jan

-09

Apr

-09

Jul

-09

Oct

-09

Jan

-10

Apr

-10

Jul

-10

Oct

-10

Jan

-11

Inde

x (10

0 =

Oct

-Dec

200

6)

general food rice non-food

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

Cambodia Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5 Urban Rural

PERCEN

TAGE

2004 2009

Share of Food Consumption to total consumption in monetary value (%)

Negative Developments

30% of children 6-9 months use a bottle; this is triple the 2005 percent

34% of children 1-2 years old are not breastfeeding, up from 26% in 2005

Estimated annual cases of severe acute malnutrition increased to 70,000; only 2% currently receive therapeutic feeding

Improvement in stunting has stagnated at 40%

RURAL URBAN RURAL URBANSEVERELY WASTED WASTED

1.9 1.6

98.5

2.33.3

10.811.6

Percentage of U-5 children wasted by residence from 2008-2010

CAS 2008 CDHS 2010

These children are cousins living in the same house in Kampong Speu Province. One child is 5 months old and the other is nearly twice that age.

The child on the left is 9 months old; the mother is working in a garment factory and the child is enrolled in the only HC outpatient therapeutic feeding programme in the country.

Ongoing and Recent Efforts at Scale

• Behavior change communication on VA, IFA compliance, complementary feeding, and continued breastfeeding

• Hospital based treatment of acute malnutrition

• Salt iodization• Training of HC staff on MPA

10, volunteers on BFCI, and hospital staff on BFHI

Localized Ongoing and Recent Efforts

• Initial implementation of HC management of acute malnutrition

• Initial implementation of MNP• Iron fortification of fish/soy sauce• Rice fortification effectiveness study (school

children)• Incentivized GMP• Private sector distribution of ORS and zinc• Locally produced complementary food• Pilot on cash transfers linked to nutrition

PROGRAMMATIC PRIORITIES

Immediate Priority for Health Sector

• Micronutrient policy including MNP for children nearly finalized

• Cambodia pilot on MNP already carried out with positive results

• MNP can be scaled up quickly through monthly outreach if prioritized by government and partners10 20 30 40 50 60 70 80 90 100

$-

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

215,202

430,403

645,605

860,807

1,076,008

1,291,210

1,506,411

1,721,613

1,936,815

2,152,016

Annual cost of multiple micronutrient supply by coverage of 6-24 month old children

Coverage

Cost

of S

uppl

y (U

SD)

MNP Policy Consideration

55% child anaemia calls for universal supplementation and the NNP draft policy stipulates public sector distribution…

What is a feasible funding arrangement for MNP supply for government and partners?

Will universal coverage be possible without private sector engagement?

Immediate Priority for Health Sector (more difficult to implement)

Zinc for treatment of diarrhea policy in place

Stock is available at all levels

Memo sent to implementing units from MoH to distribute during outreach

10 20 30 40 50 60 70 80 90 1000

100000

200000

300000

400000

500000

600000

700000

800000

900000

1000000

Annual cost of zinc supply for treatment by coverage of diarrhea cases

Coverage

Cost

of Z

inc U

SD [s

hipp

ing

incl.

]

Zinc Policy Consideration

If health sector distribution will not reach high coverage and there is no concern over toxicity or resistance,

Should partners focus on a private sector distribution system for zinc that utilizes community workers?

Immediate Priorities for Health Sector (more difficult to implement)

• Identification and treatment of acute malnutrition policy nearly finalized and IMCI currently being revised

• System relies on consistent screening by volunteers and proper implementation of IMCI by HC staff

• Complicated cases rely on expertise/commitment at hospital level

10 20 30 40 50 60 70 80 90 1000

100000200000300000400000500000600000700000800000900000

1000000

Annual cost of therapeutic food supplies and shipping by coverage of children under 5 with severe acute malnutrition

Coverage

MAM Policy Considerations

MAM requires a substantial amount of work from HC and volunteers…

Should MAM be incentivized independently or is there potential to strengthen IMCI as a whole?

Is there a need to formalize community volunteers under a single compensation framework?

Medium-term Priorities • Expanded food fortification• Improve ANC/PNC to

monitor weight gain and provide IPC on key issues such as IFA compliance

• Focus on pre-pregnancy nutrition, including targeted distribution of WIF

• Connect social protection priorities to nutrition

Immediate Strategic Priorities• Increased attention to

urban poor• Better integration of

nutrition into health systems strengthening

• Commitment from government

• Strategy for dealing with moderate acute malnutrition in a targeted manner

• More targeted approach to breastmilk substitutes

Discussion- Policy Questions Repeated

• What is a feasible funding arrangement for MNP supply for government and partners?

• Should partners focus on a private sector distribution system for zinc that utilizes community workers?

• Should MAM be incentivized independently or is there potential to strengthen IMCI as a whole?

• Is there a need to formalize community volunteers under a single compensation framework?