Nutrition element portfolio review usaid_ Roshelle Payes & Rebecca Egan_10.14.11


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  • Welcome everyone. On behalf of the Global Health Bureau and the Bureau for Food Security, we look forward to your input and the discussion that will follow this presentation.The subject for today’s discussion is nutrition. As nutrition is such a multisectoral issue, some of you who were present at the Child and Maternal Health reviews will remember that we discussed nutrition briefly then. Today, we’re planning to discuss the integration of nutrition in both our health and food security programming.
  • BFS
  • AMIE
  • There is one nutrition goal for both the Global Health Initiative and Feed the Future, which is to reduce child undernutrition by 30% as measured by any one of the core indicators listed here.
  • The agenda today is divided as follows:First, we’ll briefly review the current global nutrition situation.Second, we’ll highlight some substantial changes that have occurred in the global nutrition field over the past several years. These changes provide the basis for how USAID’s new nutrition strategy is implemented.Lastly, we want to highlight some key questions for discussion. We’re looking forward to your feedback on the following:-Achieving our goal in the face of constrained funding-Approaches for delivery of a comprehensive set of interventions-Engaging the private sector
  • Globally, progress has been made on reducing chronic undernutrition. Two decades ago, 40% of children in developing countries were stunted. Today, the prevalence is 30%.Most of the progress has been made in South Asia. Sub-Saharan Africa is actually backsliding: while the prevalence of stunting has declined by a modest 4%, the sheer number of stunted children has actually increased by 10 million.Stunting is one of three core anthropometric indicators that we use. The other two are wasting, which reflects acute undernutrition, and underweight, which is the MDG 1 C target and reflects both chronic and acute undernutrition. Here at USAID, we are focused on stunting as the key indicator. The measurement of stunting reflects a impairment of physical growth—but we know that the impairments from stunting are also cognitive, which impedes a child’s ability to learn, do well and stay in school, and eventually to make as much money as her non-stunted peers.
  • In addition to stunting, wasting, and underweight, anemia in women and children is of critical importance to health and productivity. Nearly one third of women of reproductive age and one half of children under five suffer from anemia. But this global prevalence masks some significantly higher rates—countries Mali, Uganda, and Tanzania, where three in four children are anemic, or Haiti, Ghana, and Malawi, where half of women are anemic.Anemia can be caused by a variety of factors—iron deficiency, hookworm, and malaria are the big three. Like stunting, ANY anemia (not just severe, but even mild and moderate anemia) has consequences for the productive capacity of individuals and for the economic growth of nations. Anemia saps individuals of energy and of capacity to learn and work. And when we talk about our Feed the Future initiative, which seeks to—among many other things—improve productivity of smallholders, the majority of whom are women…reducing anemia becomes critically important. Estimates suggest that it costs Sierra Leone $100 million in agriculture productivity every five years due to losses in women’s work capacity. So we’re focusing on anemia, in addition to chronic undernutrition, as a high level goal of both Feed the Future and the Global Health Initiative.
  • Just as the causes of undernutrition are multisectoral, so too are the consequences. Chronic undernutrition undermines many of our development investments in:Health, contributing to increased mortality and increased susceptibility to diseasesEducation, as stunting in early childhood has permanent effects on a child’s cognitive development, which lowers their school performance……costs countries in terms of economic growth…and costs families in terms of lifelong earningsLastly, undernutrition and infectious diseases tend to become a vicious cycle, and undernutrition hastens HIV progression and reduces adherence to treatment.
  • That’s a brief snapshot of the global context. Now we’ll discuss some of the recent global developments in nutrition that have led USAID to where it is today.
  • Over the past five years, there have been 5 major developments on programmatic evidence and global consensus:First, the Copenhagen Consensus identified nutrition interventions as some of the most cost-effective development investments. Five of the top ten were nutrition-related. Second, the Lancet series on undernutrition was published in 2008. This series, among many other things, identified a core package of nutrition interventions and analyzed the potential impact of these interventions in terms of health and development.Third, the year following the Lancet, the World Bank costed that package of interventions.Throughout this time, more and more evidence was emerging that we need to target the window of opportunity from pregnancy to two years.And lastly, given this “burden of knowledge” as some call it, our partners are increasingly aligning ourselves around the scaling up nutrition movement, or SUN to support countries as they continue to make strides. More on this later.
  • So, what is the sea change? We have tried to simplify into six key changes, which USAID is embracing to achieve our ambitious target. We’ll go through each of these with specific examples of our investments. First, USAID has long invested in micronutrient supplementation. While we also invested in food-based programs, and have serious investments in improving infant and young child feeding practices, in the past—we’re transitioning to more smart integration.Second, we’re strategically focusing on that critical pregnancy to two years of age period in order to have the most impact.Third, we’ve supported and are now tracking new indicators that help us move from what some call “nutritionism”—which includes measuring nutrient-specific deficiencies—to look at a minimum acceptable diet for young children, which includes infant and young child feeding practices like exclusive breastfeeding—something USAID programs have done historically.Fourth, we’re balancing prevention and treatment. We know we need to do both, and while USAID has always invested in both, some would argue that the global community—USAID included—has emphasized treatment far too much in the past. So we’re shifting that balance more toward prevention.Fifth, we’re maximizing synergies with other sectors like agriculture and social protection.And sixth, the emphasis is on moving to geographic scale rather than pilot programs.
  • The first change is that we’re going from vertical micronutrient programs to food-based, integrated approaches. A great example is Tanzania. We’ve supported the government of Tanzania over the past decade to scale up its national vitamin A supplementation program, which has achieved high levels of coverage for the past decade. As we work to strengthen district level planning and budgeting for vitamin A, we are now transitioning our support to focus on an integrated health and agriculture program that is aligned with both FTF and GHI.
  • The second change reflects a shift in our targeting. We used to believe in “catch up growth” which means that we delivered interventions to all children under five, thinking that if they suffered from undernutrition it could be fixed. We now know that it can’t—and that we must target pregnant women and children under two to have any impact. Our programs are all embracing 1,000 days as both the development window of opportunity, and as a political window of opportunity that was launched last September in support of the scaling up nutrition movement. More on that in a minute.
  • The third change is around indicators. The field has evolved from measuring nutrient-specific deficiencies to measuring diet quality and diversity. USAID has worked closely with our global partners to develop new improved measurement tools, validating new indicators, building consensus, and calculating baselines using the Demographic and Health Surveys. Three such indicators are: women’s dietary diversity, the household hunger scale, and minimum acceptable diet. I’d like to highlight the last one, because it’s an excellent measure of both practices in the household, diet quality, and diet diversity. And it focuses on children 6-23 months, which as we highlighted before is the period of time we want to focus on. This is a key indicator in the 1,000 day window that complements exclusive breastfeeding from 0 to 5 months by measuring appropriate feeding practices—including the quality and frequency of feeding from 6 to 23 months, while factoring in continued breastfeeding. This chart is an example of the minimum acceptable diet for young children in Ethiopia: a whopping 3% consume a diet that is minimally acceptable. The average across our Feed the Future countries is only 17%. So clearly, there’s a big gap there and this indicator is now incorporated into the FTF results framework as a core indicator to drive progress toward.
  • The fourth change is not quite from one thing to another, but rather an emphasis on balancing prevention with treatment. The example used here is a result of some research in Haiti, where a food-assisted program was studied using two different methods. One was the traditional recuperative model, where children were given food if they were suffering from undernutrition. The other was a preventive model, where all children under two—regardless of nutritional status—and pregnant women were given food. The latter proved to be more effective in reducing stunting.Based on these results, our Food for Peace office has identified this approach—known as Preventing Malnutrition in under twos approach (or PM2A)—as the preferred approach in multi-year program guidance. Food for Peace PM2A programs are now underway in Burundi, Guatemala, Bangladesh…and because this is relatively new for Food for Peace, we are doing a lot of operations research related to cost-effectiveness, the product used, effective program/targeting approaches etc.
  • We are emphasizing multisectoral synergies in agriculture and health. Rather than just viewing nutrition as something best associated with a health delivery system, we recognize that by combining health and agriculture, we can achieve substantial reductions in stunting, wasting and underweight.So we have developed integrated bilateral programs in the vast majority of our focus countries. These programs have health components, agriculture components, and in some cases, social protection components. In many countries, we also have investments through PEPFAR or the President’s Malaria Initiative that are linked with our undernutrition programs. One of the key questions that we can return to later, raised by someone here in the audience already, is around supporting national capacity to develop these nutrition-sensitive policies across these sectors. USAID and many of our partners in the room are investing in strengthening this national capacity to inform policies and measure future impact.In addition, we have a new nutrition collaborative research support program that will be working in two countries—uganda and nepal—to conduct research on agriculture-nutrition linkages.
  • Lastly, the sixth sea change is moving from pilots and bringing nutrition to scale. Senegal is a great example. For about a decade, undernutrition stagnated—actually, increased in the early 1990s—until the government launched the National Nutrition Enhancement Program. USAID supported program models that demonstrated success and so were incorporated into this national program. Senegal was able to reverse the previous upward trend in undernutrition and is now seeing steady decreases in underweight prevalence, in line with its MDG 1 goal.
  • Now, we are going to highlight USAID’s programs to demonstrate how we’ve embraced this sea change.
  • Our programs are aligned with and support countries as part of the Scaling Up Nutrition movement. This is a movement that has a tremendous amount of momentum at the country level, and it has garnered a great deal of support from many of our development partners. This slide presents a list of why we’re involved, but I want to highlight that the core tenant of SUN is about countries being in the drivers’ seat. In fact, over 10 countries—we’ll show you this slide in a few—are now “early risers” in SUN. That means that the countries themselves have said they are committed to scaling up nutrition, that they are calling for increased alignment and partnership, and that they have or are planning to take some positive steps on policy and accountability.
  • Guided by both GHI and FTF principles, USAID is working with missions to develop strategic plans for USAID nutrition specific investments at the country level. These frameworks consist of an analysis of the multisectoral factors that lend to undernutrition as well as identify specific programs, partnerships and activities to move these strategies forward in line with national priorities and policies.
  • As you can see here, since 2009 (the red dots), the number of completed nutrition strategic plans has gone from 0 to 15 in just 2 years. In addition, these strategic plans have helped to inform a number of new nutrition procurements (in the middle) which are either nutrition sensitive or strengthened in an existing health or agriculture led program or nutrition focused which is a new program with specific goals to improve nutrition. To support these programs, USAID has increased its staffing to develop and manage these programs and 17 of the 19 countries now have a dedicated staff member or point of contact for nutrition. We’re also working on capacity strengthening of our staff by identifying technical training opportunities for nutrition and providing programmatic guidance for this relatively new way of doing USAID programs and funding for nutrition.
  • To choose countries, USAID started by looking at the 36 countries that account for 90% of the global burden (in numbers) of stunting. From there, we also looked at additional criteria including: FTF/GHI priority countries, country commitment and opportunities for synergy with other USG or partner programs.
  • Based on these criteria, USAID has identified 17 core countries where 80% of the Global Health and Child Survival nutrition resources will be invested. While Food for Peace and PEPFAR also have investments in some of the core countries, FFP has nutrition investments in an additional 6 countries and PEPFAR an additional 4 countries. Finally, a number of countries have also been identified as SUN early risers and are a focus of the Scaling Up Nutrition partnership mentioned earlier.
  • Measuring progress is an important component of the nutrition strategy and specific core indicators have been identified and incorporated into GHI and FTF Monitoring and Evaluation systems. These indicators will be collected primarily through DHS surveys and all of the new globally recognized indicators such as minimal acceptable diet, are being collected.
  • How does the sea change of interventions come together at the country level? This example from Malawi shows the multisectoral nature of nutrition and how the different sectors will contribute to improving nutrition. Each of the different programs were separated often geographically (for example, social protection in south and agriculture in the central region) and in looking at how to harness or leverage each other’s activities, changes are being made to create better synergies. Here in Malawi, we’ve also done a lot of work on PEPFAR programs and nutrition. There are opportunities to maximize our impact through nutrition assessments, counseling, and support; or through OVC programs; or with behavior change programs for infant feeding and PMTCT. And actually, we’re following the government of Malawi’s lead here and working closely with the Office of the President’s Director of HIV/AIDS and Nutrition who is passionate about scaling up nutrition.
  • Nepal, a FTF and GHI country, is another example of how the different aspects of the sea change in the nutrition strategy come together. Nepal’s nutrition activities focus on the prevention of stunting, which currently affects nearly half of Nepal’s children under five. Because the major causes include low exclusive breastfeeding rates and low dietary diversity in all areas of the country, these activities will be integrated into both agriculture and health led programs. Access to food, another critical contributor to child undernutrition takes on various roles in an ecologically diverse country like Nepal; therefore, while value chain work may be more appropriate as a platform in the west, income generating activities are more suited to isolated areas in the mountains where agriculture is limited and thus will be integrated into health led activities.
  • USAID works with a large number of US government agencies on nutrition. These activities are merely illustrative and capture the technical elements of our collaboration at a global level. Of course in some countries, we may work more closely with our interagency colleagues on a variety of issues.
  • In addition to the interagency, we are working with any number of civil society, private sectors partners, and the UN. Currently in USAID/Washington we have 4 main implementing partners—though as two are soon coming to an end, we plan to award a new one in the next few months. The Scaling up Nutrition movement helps facilitate collaboration between all of these partners in support of countries.
  • Now, to some important review questions.
  • First—our goal was to reduce undernutrition by 30% in five years. We recognized that this was quite ambitious to begin with. In light of higher food prices and a different funding scenario than we planned on, can we reach this goal? It certainly depends how much is leveraged as a result of US engagement in overall national efforts and the multilateral support systems. We’ve listed some possible options here, and we’d really appreciate your feedback on these options. For a bit of perspective in this discussion, we have a few slides that give you a snapshot of the tough budget choices we’ve had to make.
  • In two years alone, we’ve made some very difficult choices. The funding for nutrition has nearly doubled in a tough budget environment—so that’s the good news. We’ve actually cut the number of countries receiving nutrition funds in half though, in order to increase the average funding levels and make sure our priority countries receive enough funding to have robust programming. So in two years, we’ve gone from 16 countries programming less than $750,000 to zero, and from one country with more than $3 million to 13. On the positive side, that means the countries that Jim highlighted are able to implement evidence-based nutrition programs. On the down side, it means that over a dozen countries—some with significant burden of undernutrition—no longer have nutrition resources, however small.
  • But we are making this tough choices because we believe that a deeper level of investment means bigger impact. We haveIncreased concentration on top priority countriesDecreased resources for non-priority countriesPhasing out of sprinkled resourcesWe plan to continue this trajectory in the future to sustain our commitment. We recognize there are tradeoffs—so again, appreciate your thoughts on how to approach overall targeting.
  • For the second review question, we’d appreciate your thoughts on approaches for delivering a comprehensive package of nutrition interventions. At the heart of this is that we know we can’t do everything—so what is our strategic choice? There are just a few options listed here, though we recognize there are many more. To me, and one of our colleagues on the phone has actually stressed this, it comes down to the results framework: How well established is it, what are the multisectoral coordination and implementation mechanisms in place to support that results framework, and do we have evidence for the causal linkages between what our investments are and the impact we’re trying to achieve? And most importantly, as USAID, is what we’re investing in through this results framework owned by the government and supported by our other partners?
  • And lastly, engaging the private sector. There has been a tremendous amount of interest and work over the past few years on this subject, and we still have a lot of work to do. The key question is how do we engage in win-win partnerships that will enable poor communities in developing countries to access the products and services they need. And another key question that was raised by someone in the audience is how we are defining the private sector—it is certainly not homogenous and thus, our approach will be different depending on whether we’re talking about a huge multinational for profit, or a small local non profit, or a regional private sector body…And with that, we’ll close the presentation. Thanks for the opportunity to discuss our nutrition portfolio with you, and we look forward to your feedback and comments as we think through our nutrition programs under GHI and FTF moving forward.
  • Nutrition element portfolio review usaid_ Roshelle Payes & Rebecca Egan_10.14.11

    1. 1. USAID Nutrition Approach: Where are we now? Where are we going? How are we getting there?<br />
    2. 2. Global Health Initiative principles, components and target areas<br />Principles <br />Promote women, girls and gender equality focus<br />Encourage country ownership/leadership<br />Strengthen health system and program sustainability<br />Leverage and strengthen key multilateral organizations, global health partnerships and the private sector <br />Foster strategic coordination and integration<br />Improve metrics, monitoring and evaluation<br />Promote research and innovation<br />Implementation components<br />Target areas<br /><ul><li>Collaborate for impact
    3. 3. Do more of what works
    4. 4. Build on and expand existing platforms to foster stronger systems and sustainable results
    5. 5. Innovate for results
    6. 6. HIV/AIDS
    7. 7. Malaria
    8. 8. Tuberculosis
    9. 9. Maternal Health
    10. 10. Child Health
    11. 11. Nutrition
    12. 12. Family Planning and Reproductive Health
    13. 13. Neglected Tropical Diseases</li></ul>2<br />
    14. 14. 3<br />AComprehensiveApproach<br />PATHWAYS:<br />Addressing the root causes of hunger that limit the potential of millions of people<br />Establishing a lasting foundation for change by aligning our resources with country-owned strategies and supporting local capacity. <br />PRINCIPLES:<br />1) Invest in country-owned plans that support results-based programs;<br />2) Strengthen strategic coordination – globally, regionally, and locally;<br />3) Ensure a comprehensive approach – advancing agriculture-led growth, reducing under-nutrition, and increasing impacts of humanitarian food assistance;<br />4) Leverage the benefits of multilateral institutions; and<br />5) Deliver on sustained and accountable commitments.<br />OBJECTIVES:<br /><ul><li>Inclusive agriculture sector growth
    15. 15. Improve nutritional status</li></ul>Cross-cutting priorities:<br /><ul><li>Global research and innovation
    16. 16. Gender
    17. 17. Natural resources and climate consideration</li></li></ul><li>Role of Operating Units<br /><ul><li>Bi-lateral planning and program implementation
    18. 18. Coordination with host country
    19. 19. In-country donor coordination</li></ul>Missions<br /><ul><li>Policy guidance to Missions
    20. 20. Oversight of Mission programs
    21. 21. Regional programs</li></ul>Regional Bureaus<br />Global Health Bureau<br /><ul><li>Technical support to the field
    22. 22. Global technical leadership
    23. 23. Operations research and innovation
    24. 24. Economies of scale in commodity procurement and highly specialized expertise
    25. 25. Funding of and representation to international health organizations</li></ul>Food Security Bureau <br />4<br />
    26. 26. GHI/FTF Nutrition Goal<br />Our goal is to reduce child undernutrition by 30% in focus countries, measured by any one of four core indicators<br /><ul><li>Underweight (MDG 1c)
    27. 27. Stunting
    28. 28. Child Anemia
    29. 29. Maternal Anemia</li></ul>5<br />
    30. 30. Outline<br />Program Context <br /><ul><li>Burden of undernutrition
    31. 31. Causes and consequences</li></ul>Recent Sea Change in Nutrition Strategy<br />How the New Nutrition Strategy is implemented globally and in USAID’s programs<br />4. Review questions<br /><ul><li>Is it feasible to reach our 30% goal?
    32. 32. What is the optimal approach for delivering a comprehensive set of nutrition interventions?
    33. 33. How do we overcome the issues related to engaging the private sector?</li></ul>6<br />
    34. 34. One in three children suffers from stunting<br /><ul><li>South Asia has made the most progress
    35. 35. Overall number of stunted children in Africa has actually increased</li></ul>Number of stunted children, 2010<br />1990<br />Prevalence of children with stunting, by region<br />2008<br />7<br />
    36. 36. High global prevalence of anemia in children and women<br /><ul><li>In some countries, anemia prevalence is significantly higher
    37. 37. Any anemia has health and productivity consequences</li></ul>Global Burden of Anemia in Children and Women<br />Children: 47% prevalence293 million children<br />Haiti: 48%<br />Mali: 82%<br />Uganda: 72%<br />Ghana: 59%<br />Tanzania: 72%<br />Women of reproductive age:<br />30% prevalence<br />468 million women<br />Malawi: 44%<br />8<br />
    38. 38. Determinants of nutrition<br />NUTRITION<br />Health<br />Food/nutrientintake<br />Maternal and child care practices<br />Access to food<br />Water, sanitation, and health services<br />Revised Source: Ruel, SCN News 2008<br />9<br />
    39. 39. Improving nutrition is required to achieve all MDGs<br />Health: contributes to 3.5 million deaths each year from common illnesses otherwise not fatal<br />Education: lower IQ and school performance<br />Economic growth: costs countries 3-6% of GDP<br />Poverty: wages that are half as high in adulthood in children who were undernourished in early life<br />Infectious disease treatment: hastens HIV progression and reduces adherence to treatment<br />10<br />
    40. 40. Outline<br />Program Context <br /><ul><li>Burden of undernutrition
    41. 41. Causes and consequences</li></ul>Recent Sea Change in Nutrition Strategy<br />How the New Nutrition Strategy is implemented globally and in USAID’s programs<br />4. Review questions<br /><ul><li>Is it feasible to reach our 30% goal?
    42. 42. What is the optimal approach for delivering a comprehensive set of nutrition interventions?
    43. 43. How do we overcome the issues related to engaging the private sector?</li></ul>11<br />
    44. 44. Evidence-based and consensus-driven global efforts exist<br />1<br />Investing in nutrition is one of the most cost-effective buysin development (Copenhagen Consensus 2006)<br />2<br />A core package of interventions isproven to improve nutrition (Lancet Series 2008)<br />3<br />That core package costs a certain amount(World Bank 2009)<br />4<br />Targeting from pregnancy to two yearswill have the most impact<br />5<br />Countries are eager to scale up nutritionand our partners are aligned to support them (SUN)<br />12<br />
    45. 45. The sea change in global nutrition programs is reflected in USAID’s nutrition programs<br />Integrated, food-based<br />1,000 days<br />Diet quality and diversity<br />+Prevention<br />+Agriculture, social protection<br />National<br />1. Type of interventions<br />2. Age target<br />3. Measurement<br />4. Focus<br />5. Delivery systems<br />6. Scale<br />Vertical, supplementation<br />Under fives<br />Nutrient-specific<br />Treatment<br />Health<br />Pilot<br />With these new approaches we aim for a 30% reduction in undernutrition<br />13<br />1<br />2<br />3<br />4<br />5<br />6<br />
    46. 46. From vertical micronutrient programsto food-based, integrated approaches<br />1<br />2000<br />2005<br />2010<br />USAID supports Tanzania’s vitamin A supplementation program which has achieved high coverage for the past 10 years<br />USAID supports district-level planning and budgeting to transition the VAS program to GOT ownership<br />2011<br />In support of Tanzania’s draft National Nutrition Strategy, USAID launches a new bilateral in high burden focus regions (FTF zone of influence) with a focus on preventing stunting and behavior change<br />Improving nutrition in Tanzania bilateral <br />14<br />
    47. 47. From under five or population-wide targeting to the 1,000 days window<br />2<br />By 2009<br />1<br />It is the period of most vulnerability<br />2<br />Interventions after this period are not likely to have impact<br />Programs target pregnant women and young children under 2 years of age<br />3<br />Interventions in this period have immediate and long term consequences<br />2010<br />15<br />
    48. 48. From nutrient-specificto measuring diet quality and diversity<br />3<br />2005<br />2007<br />2010<br />USAID provides technical assistance to WHO and UNICEF to improve measurement assessing infant and young child feeding practices <br />Consensus Meeting: Definitions Established<br />Indicators Calculated for All Countries and Guidance Provided<br />2011<br /><ul><li>Minimum acceptable diet used to measure progress for GHI and FTF
    49. 49. Modules and calculation methodology provided to Demographic Health Surveys</li></ul>16<br />
    50. 50. From recuperative to preventive approaches<br />4<br />2000<br />2005<br />Prevalence of stunting, 2000 and 2005<br />Haiti Study: prevention approach has greater impact on nutritional status than recuperative approach<br />2011<br />2010<br />2011<br /><ul><li>Technical Reference Materials developed for FFP applicants
    51. 51. Food for Peace lists PM2A as preferred MCHN approach in multi-year program guidance
    52. 52. Burundi and Guatemala to identify most cost effective approaches</li></ul>17<br />
    53. 53. From health delivery systemsto maximizing multi-sectoral synergies <br />5<br />2000<br />2007<br />2010<br />Changes in anthropometry, 2004-2009<br />Most Nutrition Programs focused on health platforms ONLY: Minimal evidence for Agriculture and Health Linkages<br />Analysis of program approaches that worked: World Bank Report , CSHGP and FFP MYAP evaluations<br />2011<br /><ul><li>Bilateral programs with integrated platforms developed in 15 FTF/GHI countries
    54. 54. Synergies with FFP, PEPFAR and other donors (e.g. in Uganda, Mozambique, Bangladesh)
    55. 55. New Research (CRSP) to further evaluate synergies between agriculture and nutrition (e.g. Ugandaand Nepal)</li></ul>18<br />
    56. 56. From pilots to scale<br />6<br />2002: Senegal began the Nutrition Enhancement Program (NEP)<br />SENEGAL: National Nutrition Enhancement Program<br />2006: USAID-funded community-based growth promotion programs were introduced nationwide as part of phase II of NEP<br />1996-2006: USAID supported preventive nutrition programs in 4 health regions<br />2015 MDG 1 GOAL<br />19<br />
    57. 57. Outline<br />Program Context <br /><ul><li>Burden of undernutrition
    58. 58. Causes and consequences</li></ul>Recent Sea Change in Nutrition Strategy<br />How the New Nutrition Strategy is implemented globally and in USAID’s programs<br />4. Review questions<br /><ul><li>Is it feasible to reach our 30% goal?
    59. 59. What is the optimal approach for delivering a comprehensive set of nutrition interventions?
    60. 60. How do we overcome the issues related to working with the private sector in the nutrition program?</li></ul>20<br />
    61. 61. USAID is part of a multilateral partnership to scale up nutrition<br />WHAT IT IS:<br /><ul><li>Over 100 of our development partners involved (civil society, private sector, UN, donors)
    62. 62. Coordination of these partners to encourage synergy of purpose and ensure complementarity of action based on countries’ requests</li></ul>WHY WE ARE INVOLVED:<br /><ul><li>GHI/FTF principles are aligned with SUN
    63. 63. Increases our leverage and alignment with partners
    64. 64. Provides us with concrete milestones to measure progress on scaling up nutrition
    65. 65. Facilitates high-level dialogue/advocacy on nutrition in countries that can drive policies and programs
    66. 66. Provides a barometer for country ownership: political leadership, inclusivity of process, country budgetary commitments</li></ul>SCALING UP NUTRITIONMOVEMENT<br />21<br />
    67. 67. Integrated frameworks reflect country priorities in multiple sectors and our FTF-GHI principles<br />GHI<br />Health zones<br />Women, girls and gender equality <br />Country ownership<br />Health systems strengthening<br />Multilaterals and partnerships<br />Coordination and integration<br />Metrics, monitoring, evaluation<br />Research and innovation<br />Ministry of Health<br />Health bilaterals and local partners<br />Country health sector strategy<br />FTF MYSBESTGHI STRATEGYCDCS<br />INTEGRATED NUTRITION INVESTMENT FRAMEWORK<br />FFP MYAPs<br />Agriculture production potential areas<br />FTF<br />Local civil society<br />Country investment plan/CAADP<br />1. Country ownership<br />2. Coordination<br />3. Comprehensive approach<br />4. Multilaterals and partnerships<br />5. Results and commitments<br />Ministry of Agriculture<br />22<br />
    68. 68. USAID’s rapid mobilization of country programming has made good progress since 2009<br />23<br />On track<br />In progress<br />Little/no change<br />Integrated Nutrition Frameworks: from 0 to 15 countries<br />Nutrition procurements: from 7 to 16 countries (9 nutrition-sensitive and 7 nutrition-focused)<br />Nutrition focused staff: from 5 to 19 countries<br />
    69. 69. USAID’s country focus is driven by the magnitude of the problem, country context and GHI and FTF strategy<br />Criteria:<br /><ul><li>Prevalence and magnitude of undernutrition
    70. 70. Country ownership
    71. 71. Existing platforms
    72. 72. Alignment with FTF and GHI</li></ul>36 countries account for 90% of the global burden of stunting<br />24<br />
    73. 73. USAID nutrition programs in 22 of the 36 highest burden countries<br />Ethiopia<br />Ghana*<br />Kenya<br />Liberia*<br />Malawi<br />Mali<br />Mozambique<br />Rwanda*<br />Senegal*<br />Tanzania<br />Uganda<br />Zambia<br />Bangladesh<br />Cambodia<br />Nepal<br />Guatemala<br />Haiti*<br />Burundi<br />Burkina Faso<br />DR Congo<br />Madagascar<br />Niger<br />South Sudan<br />Cote D’Ivoire<br />Nigeria<br />South Africa<br />Vietnam<br />17core countries<br />+6Food for Peace <br />+4PEPFAR<br />SUN+Peru+Benin+Laos<br />17 countries with over 80% of the GHCS nutrition resources<br />25<br />*Not in the 36 highest burden countries due to population size<br />
    74. 74. Monitoring and evaluation<br /><ul><li>DHS baselines
    75. 75. DHS includes new indicators
    76. 76. Core set of nutrition indicators for both GHI-FTF
    77. 77. Working with global partners to align monitoring and evaluation for nutrition (SUN)</li></ul>26<br />
    78. 78. Comprehensive Nutrition Investment Plan<br />MATERNAL CHILD HEALTH<br />INFECTIOUS DISEASES<br /><ul><li>Health worker capacities to screen and refer
    79. 79. Nutrition service delivery (including CMAM)
    80. 80. Birth spacing and family planning</li></ul>WATER<br /><ul><li>Community-facility referrals
    81. 81. Ready-to-use therapeutic food production
    82. 82. OVCs as target population
    83. 83. Maternal and child anemia
    84. 84. Access to improved water sources
    85. 85. Hygiene behaviors
    86. 86. Sanitation</li></ul>NUTRITION<br />+Social and behavior change<br />+Monitoring and evaluation<br />+Community capacity<br />AGRICULTURE<br />SOCIAL PROTECTION<br /><ul><li>Small holder production diversification
    87. 87. Women’s control of productive assets
    88. 88. Agriculture extension workers
    89. 89. Income and employment generation
    90. 90. Food supplementation to the most vulnerable
    91. 91. Asset transfers
    92. 92. Community volunteers
    93. 93. Nutrition service delivery (including CMAM)</li></ul>HARNESSED AND MAXIMIZED TO ACHIEVE IMPACT<br />27<br />
    94. 94. USAID Mission bilaterals: NEPAL EXAMPLE<br />Nepal Family Health Program II<br /><ul><li>Prevention
    95. 95. Scale up</li></ul>Child Survival and Health Grants<br /><ul><li>Food Based
    96. 96. Agriculture
    97. 97. Dietary Diversity</li></ul>UNICEF<br /><ul><li>Prevention
    98. 98. Social Protection</li></ul>Integrated MCH, FP and Nutrition Bilateral<br />Integrated Agriculture and Nutrition Bilateral<br />Integrated, Food Based<br />1,000 Days<br />Prevention<br />Agriculture, Social Protection<br />Dietary Diversity and Quality<br />Scale up<br />Reduction in underweight from 38% to 29%, Government of Nepal Target <br />28<br />
    99. 99. USAID partners with a number of other USG agencies on a range of programs …<br />ILLUSTRATIVE<br /><ul><li>Nutrition surveillance and M&E
    100. 100. Chronic diseases
    101. 101. Food fortification</li></ul>CDC<br /><ul><li>McGovern Dole (school feeding)
    102. 102. Nutrition and agriculture research
    103. 103. Food safety systems</li></ul>USDA<br /><ul><li>Micronutrient biomarkers (BOND program)
    104. 104. Non Communicable Diseases
    105. 105. HIV and nutrition</li></ul>NIH<br />State<br /><ul><li>1,000 Days Partnership
    106. 106. SUN-related diplomacy</li></ul>PEPFAR<br /><ul><li>Nutrition Assessment, Counseling, and Support, including Food by Prescription
    107. 107. Linking with economic strengthening/livelihoods/food security programs
    108. 108. Community-based agriculture
    109. 109. Community worker nutrition training</li></ul>Peace Corps<br /><ul><li>MYAPs
    110. 110. Commodity improvement
    111. 111. Monitoring, evaluation, early warning, surveillance</li></ul>DCHA<br />29<br />
    112. 112. … as well as with a number of other stakeholders and USAID/W implementing partners<br />Civil society<br /><ul><li>Comprehensive approach
    113. 113. Advocacy
    114. 114. Food products
    115. 115. Market-driven solutions</li></ul>Private sector<br /><ul><li>WFP: emergency nutrition
    116. 116. UNICEF: IDD, Comprehensive approach</li></ul>UN<br /><ul><li>WHO: surveillance and capacity
    117. 117. FAO: agriculture policies
    118. 118. REACH: country-specific</li></ul>FANTA 2<br />SUN<br /><ul><li>Food and Nutrition Technical Assistance in 20+ countries
    119. 119. Food security programming and policy
    120. 120. HIV and nutrition</li></ul>A2Z<br /><ul><li>Micronutrient supplementation and fortification programs
    121. 121. Child blindness </li></ul>IYCN<br /><ul><li>Infant and young child feeding practices
    122. 122. PMTCT</li></ul>GAIN<br /><ul><li>Public-private partnerships
    123. 123. Food fortification
    124. 124. Nutritionizing agriculture value chains</li></ul>30<br />
    125. 125. Outline<br />Program Context <br /><ul><li>Burden of undernutrition
    126. 126. Causes and consequences</li></ul>Recent Sea Change in Nutrition Strategy<br />How the New Nutrition Strategy is implemented globally and in USAID’s programs<br />4. Review questions<br /><ul><li>Is it feasible to reach our 30% goal?
    127. 127. What is the optimal approach for delivering a comprehensive set of nutrition interventions?
    128. 128. How do we overcome the issues related to engaging the private sector?</li></ul>31<br />
    129. 129. Review question 1<br />Can we reach our goal with our funding levels?<br />The goal of reducing undernutrition by 30% was established in anticipation of significant increases and front-end loading of funding. Food prices have also increased drastically. The current budget scenario requires us to examine the feasibility of that 30% target.<br />Options:<br /><ul><li>Identify efficiencies
    130. 130. Use subnational targets
    131. 131. Reduce global target based on country-level analysis
    132. 132. Cut additional countries
    133. 133. Increase multilateral cooperation</li></ul>32<br />
    134. 134. USAID has made budget choices to increase our impact and depth of investment<br />33<br />
    135. 135. USAID has prioritized countries and plans to sustain this commitment<br />34<br />
    136. 136. Review question 2<br />What are the most important approaches for delivering a comprehensive package of interventions?<br />Options:<br /><ul><li>Co-locate nutrition, health, agriculture, and social protection to achieve geographic synergies
    137. 137. Develop socio-economic targeting approach (poverty quintile)
    138. 138. Support high-level multisectoral government coordination mechanisms (e.g. Malawi)
    139. 139. Work with other donors on prioritization of interventions
    140. 140. Continued learning on cost-effectiveness of agriculture-health linkages</li></ul>35<br />
    141. 141. Review question 3<br />How do we overcome the issues related to engaging the private sector?<br />OPTIONS:<br /><ul><li>How do we nutritionalize value chains?
    142. 142. How do we focus them on the bottom of the pyramid?
    143. 143. How do we build capacity of small and medium scale enterprises?
    144. 144. What are meaningful incentives for the private sector?</li></ul>36<br />
    145. 145. 37<br />Update: GH Portfolio<br />2010<br />2012<br /><ul><li>Food and Nutrition Technical Assistance Project 2 (FANTA 2)
    146. 146. A2Z Micronutrient and Child Blindness Project
    147. 147. Infant and Young Child Nutrition Project
    148. 148. Global Alliance for Improved Nutrition
    149. 149. Child Survival and Health Grants Program
    150. 150. Maternal and Child Health Integrated Program
    151. 151. Iodine Deficiency Disorder (UNICEF)
    152. 152. NEW AWARD: Food and Nutrition Technical Assistance Project 3 (FANTA 3)
    153. 153. NEW AWARD: Strengthening Partnerships, Results, and Innovation for Nutrition Globally (SPRING)
    154. 154. Global Alliance for Improved Nutrition
    155. 155. Child Survival and Health Grants Program
    156. 156. Maternal and Child Health Integrated Program
    157. 157. Iodine Deficiency Disorder (UNICEF)</li>