Malnutrition_in_Timor-Leste_Provo_2016.pdf

Malnutrition in Timor-Leste: A review of the burden, drivers, and potential response

Anne Provo, Steve Atwood, Eileen Brainne Sullivan, Nkosinathi Mbuya i

Table of Contents Acknowledgements ................................................................................................................................................... ii List of Acronyms ...................................................................................................................................................... iii Glossary ......................................................................................................................................................................v

Foreword .................................................................................................................................................................. ix

Executive Summary Chapter 1. Background Chapter 2. Nutrition Situation in Timor-Leste Chapter 3. Determinants of Malnutrition in Timor-Leste Chapter 4. Commitment and Capacity to Address Malnutrition Chapter 5. Nutrition-Specific Interventions and Approaches Chapter 6. Nutrition-Sensitive Programs and Approaches Address Underlying Determinants of Malnutrition Chapter 7. Development Partner Coordination and Support for Nutrition Chapter 8. Costing and Financing for Nutrition Chapter 9. Conclusions and Recommendations References Annexes:

Annex 1: Sources of Data in the Report Annex 2: Nutrition and Maternal, Infant, and Young Child Feeding-Related Knowledge, Attitudes, and Practices

Annex 3. Immediate and Underlying Causes of Stunting by District Annex 4. KONSSANTIL Structure Annex 5. Nutrition-relevant considerations in the National Health Sector Strategic Plan Annex 6. Ministry of Health Organizational Structure Annex 7. Structure of District Health Services Annex 8. Ministry of Agriculture and Fisheries Organizational Structure Annex 9: Nutrition Capacity Assessment Framework Annex 10. Job Description for RDTL Workforce with Potential to Improve Nutrition Annex 11: Comparison of international, national priority actions & interventions for mitigation of Mother and Child

Undernutrition Annex 12. Nutrition components of Primary Health Care in Timor-Leste Summary of Services Offered through

Primary Health Care Annex 13. The SISCa Program Annex 14. The LISIO Card Annex 15. Maps of the distribution of malnutrition, immediate, and underlying drivers in Timor-Leste ii

Acknowledgements

This report was prepared under the overall guidance of Toomas Palu (Practice Manager of East Asia and Pacific

Region, Health, Nutrition and Population Global Practice), Franz Drees-Gross (Country Director for Timor-Leste, Papua New Guinea & Pacific Islands, East Asia and Pacific Region) and Bolormaa Amgaabazar (Representative for Timor-Leste) by a team consisting of Eileen Brainne Sullivan (Senior Health Operations Officer and Task Team

Leader), Anne Provo (Research Analyst, Lead Author), Steve Atwood (Consultant), and Nkosinathi Mbuya (Senior

Nutrition Specialist and author). Antoninho Pereira, Cornelio Quintao De Carvalho, David Knight, Eric Vitale, provided technical and administrative support throughout the field work and the preparation of the report. Xiaohui

Hou and Augustine Asante conducted the analyses which formed much of the basis of Chapter 8. The team also thanks Heather Grieve, Kate Snowball, Elizabeth Belo (Australian Government, Department of Foreign Affairs and

Trade), Marrie-Ann Merza (Food and Agriculture Organization), TMap, and the Office of the President (RDTL) for their collaboration on identifying drivers of malnutrition and informed the preparation of Chapter 3.

The authors are very grateful to the peer reviewers, Jumana Qamruddin (Senior Health Specialist), Junko Onishi

(Senior Social Protection Specialist), and Ziauddin Hyder (Senior Nutrition Specialist) who provided technical guidance and quality review of the work. We also thank Gayatri Acharya (Lead Economist), Venkatesh

Sundararaman (Program Leader, Human Development) for their valuable comments.

The authors would also like to sincerely thank the Minister and staff of the Ministry of Health, the Ministry of

Agriculture and Fisheries, Ministry of Social Solidarity, Ministry of Commerce, Industry and Environment, Ministry of Finance, and the many development partners and key agencies who are referenced in this report for their guidance, assistance and major contributions throughout this study.

This study was completed as a part of the World Bank’s Externally Financed Output “Support Nutrition Analysis and Activities in East Asia and Pacific Region” and would not have been possible without the financial support from the Australian Department of Foreign Affairs and Trade, Canberra, Australia, and the financial contribution from the European Commission for the dissemination of the study.

http://isearch.worldbank.org/skillfinder/ppl_profile_new/000275629 http://www.google.com.kh/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiF5MG7_sfOAhWINpQKHYWIBF4QjRwIBw&url=http://dfat.gov.au/about-us/corporate/pages/logos-and-style-guides.aspx&psig=AFQjCNFo3Bhvz7mK7cOWg4Yub7Elnap5iQ&ust=1471507417223798 iii

List of Acronyms ACIAR Australian Centre for International Agricultural Research

ADB Asian Development Bank

ANC Antenatal Care

BdM Bolsa da Mae

BESIK Bee, Saneamentu no Igiene iha Komunidade

BMI Body Mass Index

CEDAW Convention on the Elimination of Discrimination Against Women

CHC Community Health Center

CICL Corporation International for Countries Linga Portugues

CPLP Community of Portuguese Language Speaking Countries

CSO Civil Society Organization

DFAT Australian Department of Foreign Affairs and Trade

DFNSC District Food and Nutrition Security Committee

DNSP National Directorate of Public Health

DP Development Partner

DV Domestic Violence

EU European Union

FAO Food and Agriculture Organization of the United Nations

FNSWG Food and Nutrition Security Working Group

GIZ Deutsche GesellschaftfürInternationale Zusammenarbeit

GNI Gross National Income

HIES Household Income and Expenditure Survey

IDA Iron Deficiency Anemia

IFA Iron Folic Acid

INGO International Non-Governmental Organization

JICA Japan International Cooperation Agency

JMAK Community Management of Acute Malnutrition

KONSSANTIL National Council on Food Security, Sovereignty and Nutrition

MAF Ministry of Agriculture and Fisheries

MAM Moderate Acute Malnutrition

MCIE Ministry of Commerce, Industry and Environment

MDG Millennium Development Goals

M&E Monitoring and Evaluation

MOE Ministry of Education

MOF Ministry of Finance

MOH Ministry of Health

MNP Micronutrient Powder

MPW Ministry of Public Works

MSS Ministry of Social Solidarity

NGO Non-Governmental Organization

NIEWS National Information and Early Warning System

NNS Timor-Leste National Nutrition Strategy

ODF Open Defecation Free

PAKSI Community Action Plan for Sanitation and Hygiene

PAN-HAM-TIL National Action Plan for a Hunger and Malnutrition Free Timor-Leste (Zero Hunger

Challenge)

PDD Program for Decentralized Development iv

PDID Planeamento Desenvolvimento Integrado Distrital, Integrated District Development Planning

PNDS National Program for Village Development

PNC Post-Natal Care

PSF Family Health Volunteer

PTS Permanent Technical Secretariat

RUTF Ready-to-Use Therapeutic Food

SAM Severe Acute Malnutrition

SDG Sustainable Development Goal

SDP Strategic Development Plan (Timor-Leste National)

SGA Small for gestational age

SLS Survey of Living Standards

SLMS Suco-Level Food Security Monitoring System

TLDHS Timor-Leste Demographic Health Survey

TLFNS Timor-Leste Food and Nutrition Survey

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

WASH Water, Sanitation, and Hygiene

WFP World Food Programme

WHO World Health Organization v

Glossary

Term Definition

Anemia Anemia is defined as a hemoglobin concentration below a specified cut-off point, which can change according to the age, gender, physiological status, smoking habits and altitude at which the population being assessed lives. WHO defines anemia in children under 5 years of age and pregnant women as a hemoglobin concentration < 110 g/l at sea level. Low hemoglobin concentration impairs the ability to supply oxygen to body tissues and is associated with increased risks for maternal and child mortality. Anemia can be caused by inadequate intake/poor absorption of iron, folate, vitamin B12 and other nutrients, as well as infectious diseases (including malaria and hookworm infections) and genetic causes. Iron-deficiency anemia reduces the work capacity of individuals and entire populations, with serious consequences for the economy and national development. In addition, the negative consequences of iron-deficiency anemia on the cognitive and physical development of children and on physical performance - particularly the work productivity of adults - are major concerns.

Anthropometry The measurement of physical body characteristics, most commonly weight and height, but also circumference of body parts (head, arm, waist, etc.) as a tool for monitoring growth. Anthropometry is also used as a proxy indicator of nutritional status. Anthropometric indicators can point to malnutrition, but do not provide evidence of deficiencies in specific macronutrients or micronutrients.

Body Mass Index

(BMI)

A measure of relative weight given by weight in kilograms divided by height in meters squared (kg/m2). In adults, both underweight (thinness) and overweight are measured using BMI.

Colostrum The first breastmilk secreted in the first few days after childbirth, often thick and yellow. Colostrum has many health and nutrition benefits: it contains antibodies and other proteins which help transfer immunity from the mother to child and protect the infant from infection; it contains growth factors to keep the intestines mature; and is rich in vitamin A, vitamin K, and other nutrients.

Complementary

Feeding (CF)

The process of introducing age-appropriate, adequate and safe solid or semi-solid foods in addition to breast milk or a breast milk substitute when breast milk alone is no longer sufficient to meet nutritional requirements of an infant.

The target range for complementary feeding is 6-23 months.

Double Burden of

Malnutrition

The coexistence of undernutrition (as evidenced by anthropometry in children and women, or micronutrient deficiencies) and overweight/obesity in the same country, community, household or even individual.

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Epigenetic

Modifications

Changes in the expression of genes (rather than genes, themselves) which can be due to external and internal environmental exposures and influence physiological processes such as metabolism and the development of disease.

Epigenetic modifications provide a potential link between maternal nutrition, early life environmental exposures, and susceptibility to disease.

Food Fortification Addition of micronutrients to food during or after processing.

Infant and young child feeding (IYCF)

Feeding of infants (less than 12 months old) and young children (12-23 months old). The key interventions of IYCF include protection, promotion and support of optimal breastfeeding practices (exclusive breastfeeding for the first six months and continued breastfeeding for two years or beyond) and support for and promotion of optimal CF practices (e.g. timely introduction of CF). Issues of policy and legislation around the regulation of marketing infant formula and other breast milk substitutes are also addressed by these interventions.

Low Birth Weight

(LBW)

Weight of less than 2,500 grams at the time of birth. Low Birth Weight (LBW) is a significant public health concern and a major risk factor for perinatal mortality. It is associated with greater likelihood of stunting and chronic diseases later in life. It includes preterm neonates (born before 37 weeks of gestation), small for gestational age neonates at term, and the overlap between these two situations (preterm, small for gestational age neonates).

Macronutrients Fat, protein, and carbohydrates needed for a wide range of body functions and processes.

Malnutrition A broad term commonly used as an alternative to 'undernutrition' but which technically refers to any dysfunction of nutrition, including inadequate, excessive or unbalanced nutrition.

Metabolic Syndrome A group of risk factors including abdominal obesity, dyslipidemia, hypertension, and impaired glucose tolerance.

Micronutrients Essential vitamins and minerals required in miniscule amounts for the maintenance of essential body processes.

Mid-upper Arm

Circumference

(MUAC)

The circumference of the mid-upper arm measured on a straight left arm midway between the tip of the shoulder and the tip of the elbow. Can be used to measure acute malnutrition/wasting in children 6-59 months.

Nutrition-Specific

Interventions

Address the immediate determinants of malnutrition, including fetal and child nutrition and development, and/or the nutritional status of older children and adults (adequate food and nutrient intake, feeding, caregiving and parenting practices, and burden of infectious disease).

Nutrition-sensitive interventions

Address the underlying determinants of malnutrition and development (food security; adequate resources) at the individual (especially maternal and caregiver), household and community levels; access to health services and a safe and hygienic environment; access to information about healthy food choices) and that incorporate specific nutrition goals and actions. Nutrition sensitive programs can be used as delivery platforms for nutrition-specific interventions, which can increase their scale, coverage and effectiveness.

Obesogenic Factors tending to make individuals overweight/fat, such as environments that promote decreased physical activity and/or increased intake of energy dense foods.

Overnutrition Consumption of calories in excess of those needed to maintain growth and health.

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Overweight/obesity Among children under-five, overweight is measured as children who have a weight-for-height more than two standard deviations higher than the median for a child of the same height and sex according to the WHO Growth Standard.

WHO has recommended classifications of overweight (BMI>=25) and obesity

(BMI >=30) which are associated with increased risk of some non-communicable diseases. As a measure of relative body weight, BMI is easy to obtain. It is an acceptable proxy for fatness and has been directly related to health risks and death rates in many populations. At a population level, prevalence of overweight/obesity derived from BMI cutoffs can be useful to develop and implement policy actions and to facilitate prevention. BMI cutoffs for overweight and obesity can also be used as screening tools to identify high risk individuals and to be used for diagnostic purposes in combination with other clinical measurements and risk factors.

Short stature Often measured in women of reproductive age and defined as height <145 cm.

Women of short stature are at greater risk for obstetric complications because of a smaller pelvis. Small women are at greater risk of delivering an infant with low birth weight, contributing to the intergenerational cycle of malnutrition, as infants of low birth weight or retarded intrauterine growth tend to be smaller as adults.

Stunting Often referred to as 'chronic malnutrition' and measured as low height-for-age, stunting is the most common form of undernutrition. Stunting is reflected in low height-for-age (being of a height that is more than two standard deviations below the median height for a child of the same age and sex according to the

WHO Growth Standard) among children under age five. The percentage of children with a low height for age (stunting) reflects the cumulative effects of undernutrition and infections since and even before birth. This measure can therefore be interpreted as an indication of poor environmental conditions or long-term restriction of a child's growth potential.

Undernutrition A state of inadequate and/or unbalanced intake and/or absorption of nutrients needed for growth and maintenance of health, resulting in nutritional deficiency.

Undernutrition covers a range of disorders, including growth failure and micronutrient deficiencies.

Underweight Low weight-for-age. Among children under age five, underweight reflects being of a weight that is more than two standard deviations below the median weight for a child of the same age and sex according to the WHO Growth Standard.

The percentage of children who are underweight can represent both children who have low weight-for-height and low height-for-age. As such, it is a composite indicator and can be difficult to interpret.

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Wasting Also known as acute malnutrition. Among children under age five, wasting can be measured using weight-for-height or mid-upper arm circumference

(MUAC). Using weight-for-height cutoffs, wasting is defined as a weight that is more than two standard deviations below the median weight for a child of the same height and sex. Using MUAC, acute malnutrition is defined as MUAC lower than 125 mm and/or presence of bilateral pitting edema. There are different levels of wasting severity: moderate acute malnutrition (MAM) and severe acute malnutrition (SAM). Wasting in children is a symptom of acute undernutrition, usually as a consequence of insufficient food intake or a high incidence of infectious diseases, especially diarrhea. Wasting in turn impairs the functioning of the immune system and can lead to increased severity and duration of and susceptibility to infectious diseases and an increased risk for death.

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Foreword

The World Bank Group (WBG) has conducted a nutrition assessment, gap analysis, and donor mapping report as part of the WBG’s technical assistance to the Government of Timor-Leste. This report is intended for a technical and programmatic audience, providing an overview of the country’s “nutrition system” for stakeholders seeking to engage in this area in the country. Specifically, the report aims to:

Document the magnitude and severity of malnutrition in Timor-Leste and country-specific key determinant.

Reviews the present capacity, institutional and implementation arrangements to address malnutrition and its determinant.

Assesses the current nutrition-specific and nutrition-sensitive programs in Timor-Leste: map the coverage of various donor and government programs; document gaps in the scope, coverage and financing of these programs.

Provides recommendations to the Government of Timor-Leste (RDTL) and the development partner community to scale-up programs and interventions and strengthen the overall response to malnutrition in the country.

Methods and Analytical Approach The report documents the state of the nutrition system using recent data from a variety of sources, including:

Synthesis of demographic and nutrition epidemiology data from existing surveys.

Network assessment of key stakeholders in nutrition in Timor-Leste.

Review of legal, strategy, policy, and guideline documents from relevant RDTL ministries and agencies in health and non-health sectors.

Review of grey and published literature, as well as program and evaluation reports in health and non-health sectors from the Government of Timor-Leste and non-government agencies.

Primary quantitative data were not collected as a part of the assessment and the report does not serve as an evaluation of the impact and effectiveness of programs. It draws upon extant data and sources to synthesize what is already known about the nutrition situation, policies, and programs to identify promising areas for further consideration.

Structure of the Report This report is organized into nine chapters:

Chapter 1 describes the Timor-Leste country context and the global nutrition landscape to provide background for the subsequent analyses.

Chapter 2 gives an overview of magnitude of the burden of malnutrition in Timor-Leste.

Chapter 3 draws upon the United Nations Children’s Fund (UNICEF) conceptual framework and provides a systematic description of the key context-specific immediate and underlying determinants of malnutrition.

Chapter 4 reviews the political commitments, institutional arrangements, and capacity to address malnutrition across sectors in Timor-Leste.

Chapter 5 describes the nutrition-specific programs gaps.

Chapter 6 describes programs aimed at the underlying drivers of malnutrition.

Chapter 7 explores the nature of development partner coordination for nutrition issues.

Chapter 8 reviews the costs of scaling up nutrition interventions and provides an overview of the fiscal space to do so.

Chapter 9 provides a series of policy and programmatic recommendations to strengthen the response to malnutrition, leveraging opportunities and addressing the identified gaps and challenges.

Executive Summary

This report presents the findings of nutrition assessment, gap analysis, and donor mapping exercise in the

Democratic Republic of Timor-Leste (RDTL). Timor-Leste, though as a young and fragile state, has the preconditions for successful development. However, persistent high levels of malnutrition threaten to impede efforts to reduce poverty, capitalize on gains in human and skills development, increase productivity, and stimulate economic growth.

Though progress has been in other areas of human development, malnutrition -- particularly maternal and child undernutrition -- is the single greatest contributor to premature death and disability in the country and presents an unparalleled development challenge. In 2013, over half (50.2%) of all children under-five were stunted in their physical and cognitive development. Timor-Leste has the third highest stunting prevalence in the world, higher than all other g7+ countries and a significant outlier relative to its level of economic development. In 2013, nearly one in three (63.2%) children (6-59 months) and 2 in 5 women age 14-60

(39.5%) were anemic. Although the country is no longer in an emergency situation, the prevalence of wasting (11%)—an indicator of acute malnutrition and a prominent risk factor for child mortality— exceeds the WHO threshold for high public health significance, with emergency levels of wasting experienced in

Covalima and Oecusse districts. Overweight prevalence is low relative to global averages, but has risen more than five-fold among adult women over the past decade. Though Timor-Leste does not yet suffer from the double burden of malnutrition, it will soon emerge if the problem continues unaddressed.

Findings and Key Themes

Malnutrition has serious—but preventable—adverse consequences for health, human capital, and economic development. Recent estimates indicate that malnutrition leads to US$41.0 million annually in lost economic activity, equivalent to nearly the entire MOH budget and roughly 2% of the economic activity in the non-oil sector. These very high levels of malnutrition affect the health of women and children, cognitive development, schooling attainment, lifelong productivity, and wage earning potential.

The causes of maternal and child undernutrition in Timor-Leste are multiple and span across sectors.

These can be categorized as immediate (nutrient intake and disease burden), underlying (child care and feeding practices; reproductive health and women’s status; household hygiene environment; dietary diversity and food insecurity; and demand for and access to quality health services), and basic (household poverty and macroeconomic context, sociocultural factors, and political context). Given the very high burden of undernutrition in Timor-Leste, all factors play a role in the country. For these causes—as well as dietary behaviors related to development of overweight—improvements are most often constrained by both demand-side factors related to knowledge, behaviors, and attitudes, as well as supply side factors related to resource availability and service delivery.

Timor-Leste has high level political commitment, overarching strategic frameworks, and a multisectoral coordinating body to provide the foundation for a strong national response to malnutrition. The Honorable

President and Prime Minister have both publicly championed nutrition, while the National Strategic

Development Plan (2011-2030) highlights nutrition as essential input for social and economic development.

The National Council for Food Security, Sovereignty, and Nutrition in Timor-Leste (KONSSANTIL) is a high level coordinating body established to guide the national multisectoral response to food insecurity and malnutrition. KONSSANTIL has stewardship functions for the National Action Plan for a Hunger and

Malnutrition-Free Timor-Leste (PAN-HAM-TL), which outlines the activities required across sectors to end malnutrition in the nation. However, the plan covers over 170 actions, and as nutrition accounts for only one of five pillars, KONSSANTIL has focused primarily on food security and food sovereignty.

The Ministry of Health (MOH) is the technical home for nutrition in Timor-Leste. The National

Nutrition Strategy (2014-2019) defines an approach to improve nutrition through nutrition-specific, nutrition-sensitive, and enabling environment interventions. A Specific Nutrition Intervention Package

(SNIP) has been developed for delivery through the health system and is aligned with the global evidence base focusing on the first 1,000 days between conception and age two. However, key gaps remain, including: stimulating the MOH leadership and ownership over strategic directions, development partner coordination, and technical directions; finalizing the supportive policy and strategy frameworks needed to guide future interventions; scaling up the coverage and quality of SNIP interventions and addressing anemia; building the nutrition capacity of frontline health workers; and enhancing community-based delivery of nutrition services.

The Ministries of Agriculture and Fisheries (MAF), Social Solidarity (MSS), Education (MOE), Commerce, Industry, and Environment (MCIE), and State Administration (MSA) are critical partners for addressing malnutrition in Timor-Leste. The strategies, policies, and guidelines for these ministries acknowledge the contributions of the respective sectors in reducing malnutrition. The ministries have programs which address underlying drivers of malnutrition, targeting areas such as: (a) increased productivity and income from agriculture production; support to vulnerable mothers and children; (b) provision of school meals; (c) increased access to locally produced foods; and promotion of community-driven development, among others. However, the nutritional impact of these and other programs tends to be limited by one or more of the following factors: (a) limited consideration of nutrition in technical program design decisions; (b) capacity constraints in relation to organizational, human resource, and public financial management; (c) weak data collection and availability for evidence-informed decision making;

and (d) insufficient attention to supervision, resources, and skill-building needed by frontline workers.

Development partners play a key role in the response to malnutrition and its determining factors, but greater leadership and coordination is required to maximize the impact of these investments. Non-state actors have filled a critical gap in the delivery and financing of nutrition-specific and nutrition-sensitive programs and have provided systems strengthening and capacity building support across all relevant ministries. Though a large number of agencies are involved in addressing the immediate and underlying determinants of malnutrition, they often act in silos without a harmonized and convergent approach to social and behavior change communication, training, and programming.

The current level of nutrition investment is not sufficient to support the goals outlined in national plans. The Zero Hunger Action Plan approximates that US$176.0 million annually (roughly 1/10th of the

General State Budget) will be required to implement the plan over ten years. However, overall fiscal space is tightening as oil revenues decline and key KONSSANTIL Ministries (Health, Education, Social

Solidarity, and Agriculture and Fisheries) experience budgetary contractions due to frontloading of investments in infrastructure. With high recurrent expenditure on wages and salaries, ministries increasingly rely on donor support to supplement goods and services budgets and to deliver services to citizens. As donors begin to scale down their development assistance to the country, there is a need for greater advocacy and engagement with the Ministry of Finance and Parliamentarians to increase budget allocations for nutrition, maximize available resources, and develop a nutrition financing strategy to ensure sustainable service delivery.

nfongagd Highlight

Recommendations

Timor-Leste has endorsed the Zero Hunger Challenge and Sustainable Development Goals (SDGs) and has built the necessary strategic and institutional foundations to improve nutrition. The key challenges is to build awareness among a broad-based constituency which can elevate the quantity and quality of implementation and financing to levels necessary to achieve the targets in these ambitious commitments.

Recommendations for rising to this challenge are divided into actions at five levels, building from the grassroots family/community to the cross-sectoral coordination and financing of institutions at the highest levels. Chapter 9 presents specific, recommended short-, medium-, and long-term actions which are applicable to government and non-state stakeholders working at each level. To maximize impact and accelerate progress, it is critical that actions are initiated at each level and build off of the comparative advantages of the various players working in this space.

1. Family/Community: Empower families and communities with the knowledge and resources necessary to demand optimum nutrition and growth for their children. Improvements in nutrition in Timor-Leste will not be possible without close engagement with families and communities to reduce the normalcy of stunting, build knowledge of malnutrition, and define solutions, building off of community assets and institutions. Appropriately crafted messages must reach communities through a variety of channels, supported by a cadre of motivated frontline workers and para-professionals who can build the dialogue on how to take the recommendations forward.

2. Services: Scale up the delivery of a package of evidence-based nutrition-specific and key nutrition-sensitive interventions focused on improving nutritional status in the first 1,000 days.

The package of nutrition-specific interventions needs to be delivered as component of an integrated

Primary Health Care package with universal coverage. Attention is needed to implement supplementation and fortification interventions which can address anemia and micronutrient deficiencies and define and strengthen the community-based delivery platform for these intervention.

Key evidence-based nutrition-sensitive services need to be scaled up to address the underlying determinants of early life malnutrition. Among others, these include: (i) improving knowledge and access to reproductive health and family planning counselling and services; (ii) increasing the prevention and identification of nutrition-related chronic diseases; (iii) harnessing agriculture as a means of improving dietary quality and reducing exposure to environmental pathogens; (iv) improving hygiene and sanitation behaviors; (v) providing safety nets and health/nutrition demand-generation activities for women and children; and (vi) improving parents’ ability to provide appropriate care and stimulation for young children. Delivery platforms for these interventions should also, as possible, be leveraged for the delivery of nutrition-relevant messages. In order to increase likelihood of impact, these programs need to focus on nutritionally vulnerable women and children, but also need to be available to adolescents (the next generation of parents) and support systems (husbands, mothers-in-law, community leaders). These programs also need clearly defined pathways from intervention to nutritional outcome, gather appropriate data and indicators of nutritional status, and address underlying assumptions.

3. Institutions: Build capacity and strengthen institutions to promote efficient, quality service delivery. Within ministries at the central and sub-national levels, critical systems strengthening actions must be taken in order for services to be scaled up and ensure that they are of sufficient quality. Many of these actions are ongoing and should continue, including: (a) nutrition training and capacity building for frontline service providers to maximize investments in the public sector workforce; (b) strengthening human resource management and supportive supervision functions, especially at lower levels; (c) improving supply chain management; and (d) strengthening public financial management capacity.

4. Coordination: Strengthen coordination and accountability mechanisms for a multisectoral response to malnutrition. High level coordination and leadership is needed to move the nutrition agenda forward in Timor-Leste. Improving nutrition must become a central priority for KONSSANTIL and member ministries, and can be evidenced through leadership commitment, prioritization of PAN-

HAM-TIL activities, which has five pillars, with priority nutrition results included under Pillar 2 (with nutrition-sensitive sub-activities found across pillars), and creation of a common results framework with sectors responsible for appropriate nutrition-related indicators. The creation of a multi-stakeholder coordination platform for nutrition, involving the public sector, donors and development partners, and private sectors is also urgently required and can contribute to improved convergence at national and sub-national levels.

5. Financing: Secure domestic and donor financing needed to deliver the package of nutrition programs at scale. In order for nutrition improvements to be realized, it is imperative that sufficient domestic, donor, and private sector financing is available and used efficiently. Advocacy with the Prime

Minister, Parliamentarians, Ministry of Finance, and civil society throughout the budget cycle is needed, supported by actions to improve efficiency and execution of budget allocations. These include the development of a system for monitoring nutrition budget allocations and expenditures against the common results framework, moving towards results-based financing for nutrition as appropriate.

Chapter 1. Background

A. Timor-Leste Country Context

1. History, Economic Development, and Poverty

The Democratic Republic of Timor-Leste (RDTL) is a small lower-middle income country in the World

Bank’s East Asia and Pacific (EAP) region. Gaining independence in 2002, the nation is the second youngest in the world. The Island of Timor is divided between Timor-Leste (also known as East Timor) and Indonesian West Timor. Administratively, Timor-Leste is divided into 13 districts, with each district further subdivided into sub-districts (65 total), sucos (442 total) and aldeias (2225 total). Administrative decentralization is outlined in the Constitution of Timor-Leste and a slow process is underway to transfer budgetary power from central level ministries to the districts. District and sub-district administration will be combined into municipalities, and municipal administrators/authorities will be delegated powers for spending and management for delivery of services (including civil registration, primary healthcare, primary education, water and sanitation, and roads).

Timor-Leste achieved lower-middle income status in 2011, largely due to oil income and high global oil prices. To increase the sustainability of its oil wealth, the government channels its oil revenue into the

Petroleum Fund (PF), which had a balance of $16.6 billion at the beginning of 2016 (around ten times non-oil gross domestic product (GDP)). The annual per capita non-oil GDP growth rate peaked in 2008 at 14.2% and has slowed steadily (World Bank 2015a). Non-oil growth has been largely driven by public spending:

the public sector experienced average annual growth of 11% over the period 2002-2010 as the civil service was built. There have been recent improvements in poverty reduction. Data from the recently completed

2014-15 Timor-Leste Survey of Living Standards (TLSLS-3) show that the share of the Timorese population living in poverty declining from 50% in 2007 to an estimated 41.8% in 2014 based on the national poverty line. This provides the most accurate measure of poverty in Timor-Leste, given local conditions but is not directly comparable with poverty rates in other countries. The share of the Timorese population living in extreme poverty ($1.90 a day in 2011) has fallen from 47.2% in 2007 to 30.3% in 2014

(NSD 2016; NSD 2008).

CHAPTER 1 KEY MESSAGES

1. Timor-Leste has made progress in building peace and establishing institutions since gaining independence in 2002.

2. Economic growth has been driven by oil wealth, allowing Timor-Leste to achieve lower middle-income status in 2011.

3. Although improvements have been made in human development, Timor-Leste has high fertility and an epidemiological profile comparable to many low-income countries. Over one third

(36%) of all deaths are attributable to communicable and infectious diseases.

4. Child and maternal malnutrition is an underlying risk factor for 27% of all deaths in children under age 5.

5. There is a critical window of opportunity during the first 1,000 days of life from conception through a child’s second birthday where interventions can have the greatest impact on reducing the lifelong consequences of malnutrition.

6. There is global and national momentum to accelerate progress on malnutrition as a key driver of sustainable development.

2. State-Building

Timor-Leste is a post-conflict country emerging from a long history of occupation, a violent struggle for independence, and internal conflicts between 1999 and 2006. Substantial achievements were realized since gaining independence in 2001, including the development of political and state institutions, physical infrastructure, and a sustainable economy.1 Given that, on average, post-conflict countries take 15-30 years to transition out of fragility (World Bank 2011a), Timor-Leste’s pace of peace building and state building is impressive. The influx of petroleum revenue provided the economic basis for securing stability, including provision of: incentives for “petitioners” to surrender; cash grants to displaced residents to encourage them to return home; generous pension benefits for veterans; and work opportunities through infrastructure development and construction contracts (ICG 2013). However, these programs now continue and divert fiscal resources away from inclusive growth and human development. A recent government-led fragility assessment2 suggested that economic foundations remain weak, as demonstrated by persistently high youth unemployment, poor human development outcomes, regional inequities, and food vulnerability.

Timor-Leste was a founding member of the g7+ group of conflict and fragile states, which aims to draw upon the shared experiences of these nations as they transition towards resilience and the next stages of development. The country is also a member of the Community of Portuguese Language Countries (CPLP), aims for full accession to Association of Southeast Asian Nations (ASEAN), and belongs to the United

Nations group of small-island developing state (SIDS).

3. Climate and Food Production

With over 70% of the population living in rural areas, Timor-Leste is an agrarian society which has adapted to the tropical climate of wet (i.e., November to May depending on elevation and geography) and dry seasons. Agriculture on the island has not reached its full productive potential. Only 30% of arable land is in use for crops or grazing. Due to chronic underproduction the food supply must be supplemented with imported cereals. Higher elevations (over nine months in the high cold zone) and the moist zone of the south coast tend to receive greater rainfall (as much 2000 mm per year and ~1500 mm over 7-8 months, respectively), while the northern coast is hotter and drier. The mountainous and steep terrain is predisposed to extensive soil erosion on the slopes. Climate change is expected to intensify wind and rainfall, increasing erosion from steep, deforested hillsides and affect agricultural productivity. Along with climate change, population growth will exert further pressure on the agricultural system, potentially exacerbating food insecurity if cropping systems and varieties do not improve (Molyneaux et al. 2012).

1 Up to 70% of Timor-Leste’s infrastructure, including houses, schools, offices, irrigation systems, water supplies, and the electrical grid was destroyed as the Indonesian military withdrew in 1999.

2 The Fragility Assessment reviewed Timor-Leste’s progress against five Peacebuilding and Statebuilding Goals (PSGs) agreed as part of the New Deal for Engagement in Fragile States. The New Deal for Engagement in Fragile States is a compact championed by the g7+ group of fragile and conflict affected countries and regions, a multi-government advocacy and policy body made up of

18 countries across Africa, Asia, and the Pacific. The New Deal establishes new principles for development architecture and calls for new ways of working that better respond to the needs and challenges faced by fragile countries; the PSGs promote the development and delivery of services which do not promote conflict. Forty countries and international organizations, including the

World Bank, endorsed the New Deal at the Fourth High Level Forum on Aid Effectiveness in Busan (November 2011).

nfongagd Highlight

4. Demographics, Health and Human Development

According to the 2015 Population and Housing Census, Timor-Leste has a total population of 1.17 million

(NSD 2015). Timor-Leste is one of the youngest nations in the world, with estimates indicating that up to

60% of the total population is under the age of 25 (Figure 1). The population has doubled since 1980 and is expected to reach 2.5-3 million by 2050. Population growth is slowing, and declined from 15.5% during the period 2004-2010 to 9.5% during 2010-2015 (RDTL 2015).

Figure 1. Sex-specific age distribution of the population of Timor-Leste, 2015

Improvements have been made, but human development remains at levels expected among low-income countries. In 2015, Timor-Leste ranked 133rd of 187 countries and territories countries on the UN’s Human

Development Index3 (UNDP 2015). Despite increased access to education, primary school completion rates remain low and education quality is a concern: a 2009 Early Grade Reading Assessment found that 70% of students were unable to read a single word of a simple text by the end of grade one, decreasing to 20% by the end of grade three (World Bank 2013a). Timor-Leste continues to experience rates of high fertility and infant mortality (Table 1), while maternal mortality is among the highest in the world, a reflection of lack of access to health care, poor infrastructure, and insufficient care for mothers during pregnancy and delivery. High maternal and child undernutrition contributes to poor health outcomes, low school achievement and productivity, and a cycle of impoverishment.

Table 1. Human development indicators, 2000-2014, Timor-Leste

Indicator 2000 2002 2007 2010 2014

Total fertility rate 7.1 7.0 5.7 5.6 5.1

Contraceptive prevalence rate, any method (% of women age 15-49)

19.8 22.3

Under five mortality rate

(deaths per 1,000)

110.2 99.1 74.1 63.8 54.5

3 The Human Development Index is a summary measure of key dimensions of human development: a long and healthy life, being knowledgeable, and having a decent standard of living.

Source: United States Census Bureau 2015

Infant mortality rate (per

1,000 live births)

86.3 76.8 60.7 53.1 46.1

Maternal mortality ratio

(national estimate per

100,000 live births)

570.0

Life expectancy at birth 59.3 61.2 65.8 67.3 68.3 Source: World Bank 2015

An epidemiological transition, though at the early stages, is underway. Infectious, communicable, maternal and nutritional issues remain the key causes of the disease burden (Table 2) but new challenges are rapidly emerging. Child and maternal malnutrition remain the greatest risk for disease, but tobacco smoking, dietary risks, high blood pressure, and high fasting plasma glucose were among the top 10 risk factors in 2013

(IHME 2015). Critically, this growing burden of non-communicable diseases and associated risk factors has gone largely unaddressed.

Table 2. Timor-Leste, top ten causes and risk factors for death and disability in 2013 and trends in burden of disease, all ages, 1990-2013

Rank

(2013)

Disease/condition DALYs

(% of total)

Rank

(2013)

Risk Factors DALYs

(% of total)

1990 2013 1990 2013

1 Lower respiratory infections

11.9 8.6 1 Child and maternal malnutrition

32.1 15.4

2 Preterm birth complications

6.9 8.2 2 Dietary risks 2.5 6.5

3 Diarrheal diseases 19.2 5.6 3 Unsafe water, sanitation, and handwashing

19.2 6.2

4 Congenital anomalies

2.8 5.6 4 Air pollution 5.2 5.8

5 Ischemic heart disease

2.0 4.8 5 High systolic blood pressure

2.1 5.8

6 Other neonatal disorders

3.9 4.0 6 Tobacco smoke 1.6 3.7

7 Iron-deficiency anemia

2.5 3.5 7 High fasting plasma glucose

1.0 2.6

8 Cerebrovascular disease

1.5 3.5 8 Alcohol and drug use 1.0 2.0

9 Neonatal encephalopathy due to birth asphyxia and trauma

2.3 3.3 9 Occupational risks 0.8 1.7

10 Road injuries 1.4 2.9 10 High total cholesterol 0.5 1.4

DALYs per

100,000

79,565 28,697

Source: IHME 2015.

B. Rationale for intervention: The Global Nutrition Landscape

1. Maternal and Child Undernutrition: The First 1,000 Days Window of Opportunity

The greatest opportunity to reduce the risk of malnutrition—inadequate, excessive, and/or unbalanced nutrition—is in the first 1,000 days of a child’s life. Stunting, an indicator of chronic malnutrition in children under five, represents a child’s failure to attain the height4 expected among healthy children of the same age and sex. In 2006, the World Health Organization released the Child Growth Standards which demonstrated how children should grow in all countries. The Child Growth Standards were developed based on a six-year study5 of children’s growth in diverse country settings which had the pivotal finding that “when health and key environmental needs are met, the world’s children grow very similarly” (de Onis

2006). Thus, the variance in attained height between populations is determined to a greater extent by variations in environmental and behavioral factors than variations in genes. High levels of stunting at a population level are associated with poor socioeconomic conditions and frequent and early exposure to poor conditions such as inappropriate feeding, unsanitary environments, and food insecurity.

Nutrition influences child growth even before an infant is born. In utero factors related to the poor nourishment of the mother influence fetal development and a child’s potential for growth, cognitive development and health. Low oxygen and nutrients during gestation can lead to low birth weight, short stature, and impaired brain tissue development (which—in terms of neuron multiplication—is largely completed by the second trimester) (Dobbing 1974). This may explain the association between cognitive deficiencies and some cases of stunting, as the deficiencies in utero that lead to short stature and low birth weight are likely to have an effect on other developing organs, especially the brain.

Through a multitude of studies, the first 1,000 days between conception and the child’s second birthday was identified as a critical window to intervene and have lifelong impacts on nutrition outcomes.

Interventions to reduce stunting will have their maximum effect during this window. The greatest losses in mean height-for-age z-score are accumulated between 6 and 18 months of age (Figure 2) (Victora et al.

2010), and growth in height not achieved during the first thousand days from conception to two years is largely irrecoverable. This growth failure has negative consequences across the life course (Shrimpton et

al. 2001, Victora et al. 2010) and results in deficits in later life earning and poverty outcomes (Horton and

Hoddinot 2014).

4 Height-for-age encompasses linear growth in children under five. In children under age two or <85 cm tall, linear growth is measured as recumbent length (distance from crown of the head to heel) when the child is lying down; in children over age two, linear growth is measured using stature, or standing height (WHO 1997).

5 The 2006 Child Growth Standards were based on the findings of the WHO Multicentre Growth Reference Study (MGRS). The

MGRS was implemented between 1997 and 2003 and collected data on growth among 8440 affluent children from various ethnic, cultural, and geographic settings (Brazil, Ghana, India, Norway, Oman, and the USA). Children were required to have been breastfed, to have non-smoking mothers, and to live in environments which promoted optimum growth. The proportion of total variability between sites was 3%, while the proportion of variability attributable to individuals within sites was 70%, revealing inter-population differences (differences among the children living in one study site) were much stronger than cross-cultural differences. This study provided the rationale for constructing a single international growth standard (de Onis 2006).

Figure 2. Mean anthropometric z-scores according to age relative to the WHO standard

(1 to 59 months)

Source: Victora et al. 2010

2. The Double Burden of Malnutrition

Though undernutrition has long been considered the most salient form of malnutrition in the EAP region, the rapidly rising burden of overweight/obesity is of urgent concern.