J.13 Nutrition Strategy.pdf

Multi-Sectoral Nutrition Strategy for

The USAID Mission to Liberia

Prepared by

F. James Levinson and Lani Fortier

May 2014

USAID/Liberia

Table of Contents:

I. List of Acronyms II. Introduction

III. Relationship to Mission CDCS and Other United States Government (USG) Policy Frameworks and Initiatives

IV. Relationship to Government of Liberia Policy, Programs and Strategies V. Relationship to Current USAID Portfolio

VI. Relationship to Other Donor Programs VII. Background and Rationale for a Multisectoral Approach

• Nutrition Situational Analysis

• Constraints in Current Nutrition Programming

• Conceptual Framework for a Multi-sectoral Approach

VIII. Overall Strategic Approach

• IR 1: Improved Coordination and Management

• IR 2: Improved Nutrition Related Behavior

• IR 3: Increased Access and Utilization of Quality Services

IX. Management X. Monitoring, Evaluation and Learning

I. List of Acronyms

ACF Action Against Hunger AfT Agenda for Transformation AYP Advancing Youth Project CAADP Comprehensive African Agriculture Development Program CDCS Country Development Coordination Strategy CLTS Community Led Total Sanitation CM Certified Midwife EHELD Excellence in Higher Education for Liberian Development ENA Essential Nutrition Actions FARA Fixed Amount Reimbursement Agreement FED Food and Enterprise Development Program FSNS Food Security and Nutrition Strategy FtF Feed the Future gCHV General Community Health Volunteer GHI Global Health Initiative GMP Growth Monitoring and Promotion GOAL Girls' Opportunities to Access Learning GOL Government of Liberia HANDS Health, Agriculture and Nutrition Development for Sustainability HMIS Health Management Information System ICCM Integrated Community Case Management IMAM Integrated Management of Acute Malnutrition IWASH Improving Water Supply, Sanitation and Hygiene LASIP Liberia Agriculture Sector Investment Program LAUNCH Liberian Agricultural Upgrading, Nutrition and Child Health LDHS Liberia Demographic and Health Survey MAM Moderate Acute Malnutrition MOA Ministry of Agriculture MOHSW Ministry of Health and Social Welfare MOYS Ministry of Youth and Sport MUAC Mid Upper Arm Circumference NCC National Nutrition Coordination Committee NHSWPP National Health and Social Welfare Policy and Plan NFSNS National Food Security and Nutrition Strategy ORS Oral Rehydration Salts SAM Severe Acute Malnutrition SBCC Social and Behavior Change Communication SUN Scaling up Nutrition TTM Traditionally Trained Midwife USG United States Government VSLA Village Savings and Loan Association WFP World Food Program

II. Introduction

USAID presently supports a broad array of nutrition-specific and nutrition-sensitive interventions, across multiple sectors in Liberia. Despite this substantial involvement, however, there is, at present, no Mission-wide goal relating specifically to improved nutrition, nor an overall guiding strategy. As a result, the Mission’s efforts to date have been inadequately harmonized across sectors. It also has been difficult to evaluate these efforts and to attribute change to USAID assistance.

This Mission-wide, Multi-Sectoral Nutrition Strategy aims to formalize these linkages, and provide structure and focus for the Mission’s efforts through consolidation, permitting, in turn, measurable results in key nutritional outcomes, which can be attributed to the combined efforts of USAID-assisted programs.

The approach presented here exemplifies USAID’s new global approach to nutrition, as outlined in the USAID Multi-Sectoral Nutrition Strategy: 2014-2025, and is consistent with state-of-the-art international multi-sectoral nutrition experience. It identifies the critical nutrition outcomes where Liberia is falling short of its national goals, and, accordingly, describes a strategic objective supported by actions under three intermediate results which are designed to guide the Mission in assisting the country in attaining these goals during the next decade.

III. Relationship to Mission Country Development Cooperation Strategy and Other United States Government (USG) Policy Frameworks and Initiatives

USAID Country Development Cooperation Strategy, 2013-17 (CDCS): In support of Liberia’s national efforts to shift from stabilization and recovery to economic growth and long-term development, USAID/Liberia’s CDCS identifies an overall strategic goal of Strengthened Liberian Institutions to Drive Inclusive Economic Growth and Poverty Reduction. The Mission aims to achieve this goal through a package of interventions, supporting four Development Objectives related to governance, economic growth, health and education. In achieving its goal of Improved Nutritional Status of Liberians, this Strategy will contribute directly to key outcomes in related to Development Objective 3 (DO3) - Improved Health Status of Liberians. Additionally, by utilizing a multi-sectoral approach that calls for improved services and strengthened systems in agriculture, education, water, sanitation and hygiene (WASH), the Strategy will be supporting outcomes in all four DOs.

Furthermore, with a focus on geographic convergence of multiple interventions in the same vulnerable communities, the Strategy is solidly rooted in the CDCS development hypothesis, which states that “co‐locating investments in infrastructure, education, health, and agricultural value chains will help to jump‐start inclusive, poverty‐reducing growth and produce tangible development impacts in an accelerated time frame ”.

USAID Multi-Sectoral Nutrition Strategy: 2014 – 2025: In addition to its close alignment with the Mission’s development priorities, this Strategy also promotes Agency-wide nutrition efforts, particularly the new USAID Multi-Sectoral Nutrition Strategy, which describes the Agency’s updated approach to addressing global nutrition challenges, placing increased emphasis on scaling up effective, integrated nutrition-specific and -sensitive interventions, programs, and systems.

Specifically, the USAID strategy hopes to accomplish four Intermediate Results (IRs):

• Increased equitable provision and utilization of high quality nutrition services

• Increased country capacity and commitment to nutrition

• Increased multi-sectoral programming and coordination for improved nutrition outcomes

• Increased global nutrition leadership

With a shared foundation in the belief that improved nutrition is vital to advancing development, and a mutual focus on reducing malnutrition in women of reproductive age and young children, particularly by reducing the prevalence of chronic and acute malnutrition and micronutrient deficiencies, this USAID/Liberia Multi-Sectoral Nutrition Strategy closely aligns itself with Agency priorities, putting the Mission at the forefront of USAID’s intensified global efforts to address nutrition.

USAID/Liberia Five-year FTF Strategy: The aim of Liberia’s national FTF strategy is twofold: 1) Support equitable growth in Liberia‘s agricultural sector and 2) Improve the nutritional status of Liberians. In order to achieve these goals, the FTF strategy has outlined eight intermediate results that target key areas for intervention.

While the first four of these IRs relate specifically to agricultural sector growth, this Strategy will closely align and directly contribute to the achievement of IRs 5 – 8 of the FTF strategy:

• Increased resilience of vulnerable communities and households

• Improved access to diverse and quality foods

• Improved nutrition related behaviors

• Improved use of maternal and child health and nutrition services

With mutual focus on (a) the prevention and early identification and treatment of malnutrition in children under the age of two and among pregnant and lactating women, and on (b) increasing the availability of nutritious food, empowering female farmers, promoting positive behavior change related to nutrition, and facilitating high-impact health and nutrition interventions at household, community and facility levels, this Strategy will work in concert with the FTF Strategy, identifying opportunities to combine, consolidate and focus resources for a comprehensive approach to improving nutrition status.

IV. Relationship to Government of Liberia (GOL) Policy, Programs and Strategies

Recognizing the critical role that nutrition plays in the overall development of the country, the GOL has taken steps to translate its commitment to improving the nutritional wellbeing of Liberians into action. Recently, Liberia has reiterated this commitment by becoming the 47th country to join the Scaling Up Nutrition (SUN) Movement – an initiative that calls for increased prioritization of efforts to address malnutrition through a multi-sectoral approach that targets both direct and underlying causes of malnutrition with a focus on the first 1000 days of life.

In addition to this commitment Liberia’s has emphasized the importance of nutrition in its Agenda for Transformation (AfT), (a five-year National development strategy), that emphasizes the contributions that multiple sectors must make if the nation hopes to meet its nutrition goals.

Additional sector-specific policies and strategies detail the steps to be taken at the national, county and community levels in order to build sustainable structures and systems in which all Liberians will be food secure and adequately nourished. Key among these strategies are the National Food

Security and Nutrition Strategy (NFSNS)1 prepared by the Ministry of Agriculture (MOA)2, and the Ministry of Health and Social Welfare’s (MOHSW) 2011-2021 National Health and Social Welfare Policy and Plan (NHSWPP), which is supplemented by the sector specific National Nutrition Policy, and the Liberian Agriculture Sector Investment Program3 (LASIP), which outlines a plan for sustainable agricultural development that focuses on investments in four program areas, including Food and Nutrition Security

With shared emphasis on the importance of nutrition to national development, common goals related to improving nutritional status, especially of women and young children, and a mutual commitment to addressing direct and underlying causes of malnutrition through a multi-sectoral approach, USAID/Liberia’s Multi-sectoral Nutrition and Food Security Strategy is well aligned with GOL priorities and approaches. This alignment will serve to strengthen GOL buy-in, and thus, sustainability of USAID investments in nutrition.

V. Relationship to Current USAID Portfolio

Currently, USAID/Liberia has a number of nutrition-specific and nutrition-sensitive interventions that address both direct and underlying causes of malnutrition, and are contributing to nutrition outcomes:

Table 1: Current Nutrition Activities Project Key Activities Location

Food and Enterprise Development Program (FED)

• Nutrition messaging through radio broadcasts and in interpersonal communication with farming groups

• Development of “Back to School Gardens” to encourage youth to engage in agriculture (in partnership with AYP)

• Training volunteers to provide technical support to schools for gardens (in partnership with MOYS and UNICEF)

• Forming Village Savings and Loans Associations (VSLAs) with women farmers

• Support for agriculture sector growth and development, with focus on cassava, rice, goat and vegetable value chains

Grand Bassa, Margibi, Bong, Nimba Lofa and rural Montserrado

Health, Agriculture, and Nutrition Development for Sustainability

(HANDS)

• Piloting aquaculture projects

• Producing “Super Gari” (cassava flour fortified with soy, micro-nutrients and vitamins) for distribution to pregnant women and mothers of children under 23 months in target areas

• Forming women’s associations, teaching business and hygiene skills and encouraging women to produce and sell Super Gari on their own

• Delivery of 31 health and nutrition messages through jingles, billboards and Community Health Promoters

• Improve WASH practices through provision of clean water, training of community water committees and promotion of Community Led Total Sanitation (CLTS)

Grand Gedeh and River Gee

Liberian Agricultural Upgrading,

• Formation of farming and care groups in rural communities

• Provision of agricultural inputs and technical training to increase

Bong and Nimba

1 The MOA is currently working with partners to update the NFSNS 2 The MOA is also working to develop a nutrition-specific BCC strategy that is appropriate for accompanying agriculture activities.

3http://www.gafspfund.org/sites/gafspfund.org/files/Documents/Liberia_4_of_7_LASIP_Sector_Investment_Plan_0.pdf

Nutrition, and Child Health (LAUNCH) production in cassava, rice, vegetables and poultry

• Working with school garden groups to raise skills and understanding of farming and nutrition practices

• Promoting kitchen gardens and fruit trees at the household level to increase dietary diversity

• Improve WASH practices through provision of clean water, training of community water committees and promotion of (CLTS)

Rebuilding Basic Health Services project (RBHS)/ Fixed Amount Reimbursement Agreement (FARA)

• Supports delivery of EPHS in Bong, Nimba and Lofa counties including pre- and post-natal care and iron-folate supplementation for pregnant and lactating women, ENA, and deworming and facility-based growth monitoring

• Strengthen MOHSW capacity to deliver community health services via gCHVs including ICCM of childhood illness and identification and referral of acute malnutrition through mid-upper arm circumference

(MUAC)

Bong, Nimba and Lofa

Improved water Sanitation and Hygiene (IWASH)

• Promoting Open Defecation Free Communities by triggering CLTS in rural communities

• Promotion and sale of WaterGuard water treatment product along with BCC on safe sanitation and hygiene practices

• Training WASH Entrepreneurs to repair hand pumps and manage small businesses supplying WASH-related products and services

Bong, Nimba and Lofa

Advancing Youth Project (AYP), Girls Opportunities to Access Learning (GOAL)/ Excellence in Higher Education for Liberian Development Project (EHELD)

• Formation of clubs for out-of-school youths that offer basic life skills training, literacy, numeracy and family planning

• School gardening projects that promote production and sale of produce

• Development of agriculture/business curriculums

• Provision of grants to Parent Teachers Associations (PTAs) to build

“girl-friendly” learning environments, scholarships for girls in grades 1-6 and formation of girls clubs to promote enrollment, retention, attendance and completion

Grand Bassa, Margibi, Bong, Nimba, Lofa and Montserrado

While each of these projects is making significant contributions towards addressing the direct and underlying causes of poor nutrition, there has not, to date, been a movement to make nutrition outcomes the central goal of a holistic approach. This Strategy is designed to facilitate this movement, building on the existing activities within the Mission, scaling up those that have the highest potential to positively influence nutrition outcomes, and increasing collaboration and reinforcing relationships among current activities by creating a common framework around which project planning, monitoring and evaluation can occur. Additionally, the Strategy will help identify those areas where there are gaps in current programming and provide the basis for new project design.

VI. Relationship to Other Partners

The problem of chronic malnutrition in Liberia is large and complex, and will require the coordinated efforts of multiple stakeholders. In order to maximize the impact of USAID assistance, it is critical that the Mission leverage the activities of other donors and concentrate efforts in those areas where there are gaps, or where USAID has a comparative advantage. Below is a table of key partners in nutrition and their primary activities.

Table 2: Key Development Partners Activities Organization Key Activities

FAO

• Distribution of agricultural inputs

• Inputs and technical support for school gardens

• Implements the Technical Cooperation Program project to help GOL strengthen their capacity to monitor and analyze the food security situation

• Formation and support of production and post-harvest agro-processing groups to improve production and value addition capabilities

UNICEF

• Provision of ready-to-use therapeutic food (RUTF) for management of severe acute malnutrition (SAM) cases

• Financial and technical support to the MOHSW Nutrition Division

• Pilot Micronutrient Powder (MNP) program in Montserrado in 2013 with plans to scale up in

Maryland, River Gee and Bomi

• Training of gCHVs in the ENA and the integrated management of acute malnutrition (IMAM)

• Ensuring compliance with nutrition services in the EPHS

• Piloting community-based distribution of iron supplements through gCHVs in Bomi

WFP

• Blanket feeding program targeting pregnant and lactating women and children

• Provision of supplementary feeding commodities (corn soy blend) for management of moderate acute malnutrition (MAM) in children under five

• Supplemental feeding for people affected by crisis (i.e. refugees in areas affected by the Ivorian crisis)

• Nutritional support to people living with TB, HIV&AIDS

• School feeding programs

ACF

• Demonstration gardens at outpatient therapeutic care centers for SAM/hospitals

• Increasing access to safe drinking water in the Lofa by building capacity of local non-governmental organizations (NGOs) to improve water infrastructure and building capacity of small businesses to maintain water points

• Provides food, health services and water to communities in crisis

• Supports GOL to manage acute malnutrition

Improved cooperation and coordination among donors and partners working in nutrition will allow for better distribution of resources, fewer gaps in programming, and better coverage in service delivery. Currently, the Nutrition Division of the MOHSW heads a National Nutrition Coordination Committee (NCC) comprised of Government, NGOs and other development partners. This committee is tasked with coordinating the implementation of national strategies and plans.

In addition to the NCC, the Minister of Agriculture chairs a Food Security and Nutrition Technical Committee, which is meant to guide key ministries as well donors and partners in implementing the

NFSNS.

While these coordinating bodies exist, both lack the resources and capacity to effectively coordinate the sector and there is a need for clear delineation of roles and responsibilities as the nation moves towards a multi-sectoral approach to nutrition. In the absence of strong leadership from the GOL, efforts among organizations working in nutrition are fragmented, testing their ability to result in sustainable, long-term improvements in nutritional status.

As discussed in the following sections, improving coordination within the Mission will be key to successful implementation of a multi-sectoral nutrition strategy; and this strategy recommends the formation of an inter-team nutrition coordination committee to address the issue. It is suggested that, in addition to coordination among themselves, this committee (a) work with the GOL to strengthen the capacity of the existing coordination mechanisms;4 and (b) while these improved mechanisms are emerging, take the initiative in organizing periodic meetings of donors working on similarly oriented projects, both nationally and by county.

In addition to collaborating with GOL, NGOs and other donors, the Mission should explore ways to better engage the private sector in food security and nutrition. The new USAID Multisectoral Nutrition Strategy5 recommends specifically partnerships with the private sector to develop stronger communications and marketing approaches and in the generation of new knowledge. In Liberia, this may be particularly important in demand creation for dietary diversity and for low cost commercialized products – including multi-micronutrient powders, should a decision be made to promote them as a social marketing undertaking. In this regard, it may be useful to involve the private sector more actively in national discussions on food security and nutrition.

VII. Background and Rationale for a Multi-sectoral Approach

Nutrition Situational Analysis: As is the case elsewhere in the developing world, malnutrition, especially undernutrition among mothers and young children, continues to threaten the health and wellbeing of Liberians, limits their educational and economic potential, and inhibits the development of the country.

In recognition of the critical role nutrition plays in the development of the nation, the GOL and its development partners have put concerted effort into improving the nutritional status of Liberians.

Thanks to these efforts, the country has made considerable strides in reducing malnutrition in recent years. Stunting has been reduced from an estimated 42% in 2010 to 36% in 2013 within the USAID Zone of Influence.6 Over the same period, the under-five mortality rate has fallen from 110 deaths per 1,000 live births to 947. A driving force in these improvements is the progress that has been made in rebuilding the nation’s health system. In support of the GOL’s transition from a post-conflict orientation to a long-term vision for sustainable progress in health outcomes, the MOHSW, as mentioned above, developed the 2011-2021 NHSWPP. The NHSWPP calls for delivery of the

4 This should include a definition of roles and responsibilities, the establishment of joint planning and monitoring mechanisms, and the coordination of input distribution as necessary.

5 USAID Multisectoral Nutrition Strategy: 2014-25. May 2014. P. 28.

6 2010, 2013 Comprehensive Food Security and Nutrition Survey

7 2007, 2013 LDHS

Situation at a Glance

• Stunting afflicts 32% of children under-five

• More than 30% of women and children are anemic

• Malaria prevalence in children under-five is estimated at 45%

• Only 55% of children are exclusively breastfed until 6 months

• 41% of people outside of Monrovia have low dietary diversity

• Just 13% of rural households have access to improved sanitation

• Diarrhea rates in children under-five are 29%

Sources: Liberia Demographic and Health Survey, 2013;

Malaria Indicator Survey, 2011; National Micronutrient Survey, 2011; Comprehensive Food Security and Nutrition Survey, 2013

Essential Package of Health Services (EPHS), which includes nutrition-specific interventions (ENA messaging at clinics and via general Community Health Volunteers (gCHVs), pre- and post-natal care including iron-folate and vitamin A supplements).

Through the RBHS project, and the FARA with the MOHSW, USAID is supporting the delivery of the EPHS in health facilities in Bong, Nimba and Lofa counties, as well as supporting the implementation of the National Community Health Services strategy. These efforts are resulting in impressive steps towards improved nutrition - well beyond those seen in most other developing countries. Within USAID-focus counties, 85% of young children receive vitamin A supplements and deworming every six months, and over 60% of children aged 6-59 months with diarrhea in the previous two weeks have received both oral rehydration salts (ORS) and zinc. Over 98% of mothers of children under 2 years received at least some iron-folate during their last pregnancy.

Supporting the facility-based interventions in the EPHS, and in line with GOL BCC strategies, numerous organizations working in the agriculture, education, WASH and health sectors are helping to disseminate key ENA messages and appropriate Infant and Young Child Feeding (IYCF) messages.

Additionally, partners including UNICEF, WFP and ACF are addressing acute malnutrition through the provision of RUTF, as well as support for facility-based care for SAM with medical complications, supplemental feeding programs targeting vulnerable groups, particularly pregnant and lactating women and children aged 6-23 months, and innovative pilot programs exploring the use of micronutrient supplements, and food fortification. Largely due to these efforts, the acute malnutrition rate dropped from 8% in 2007 to 6% in 20138 and each of Liberia’s 15 counties now has at least one facility capable of providing inpatient care for SAM.

At the same time, however, on average, more than 60 percent of households in the six USAID target counties experience moderate or severe food insecurity and 27 percent of rural Liberians have low dietary diversity9 with problems being particularly severe during the pre-harvest “lean seasons”.

Additionally, over 30% of young children and reproductive age women10 suffer from anemia, and exclusive breast feeding rates are low at only 47 percent11.

Furthermore, beyond the serious problems of food insecurity, further reductions in stunting are likely to be constrained by widespread poverty (84 percent of the population living on less than $1.25 day12), by low levels of literacy and female education (only 15 percent of primary school age children in the poorest quintile attend school), by poor water and sanitation (only 13 percent of rural households have access to improved sanitation and just over 50 percent enjoy improved water sources13) and by infectious disease (malaria prevalence rates among children aged 6-59 months has been estimated at 4514).

As a result of these ongoing problems with the primary determinants of under-nutrition, the indicators of nutritional status per se, including child stunting and maternal and child anemia

8 2007, 2013 LDHS

9 Liberia Comprehensive Food Security and Nutrition Survey, 2013 10 National Micronutrient Survey, 2011 11 Liberia Comprehensive Food Security and Nutrition Survey, 2013 12 http://www.unicef.org/infobycountry/liberia_statistics.html 13 Liberia Comprehensive Food Security and Nutrition Survey, 2013 14 National Malaria Indicator Survey, 2011 remain high.15 Without addressing these underlying factors, the notable improvements in nutrition that Liberia has experienced in the years following the end of the conflict are likely to plateau. With this in mind, this Strategy is designed to facilitate a multi-sectoral approach to improving nutrition outcomes, building on the country’s and the Mission’s considerable achievements in nutrition thus far, and supporting the GOL’s16 and the USG’s ongoing commitment to putting nutrition at the forefront of the development agenda. The strategy will accelerate the Mission’s work to achieve the following nutritional outcomes:

• Reduce stunting among infants and young children;

• Reduce maternal under-nutrition and improving pregnancy outcomes;

• Reduce anemia among infants, young children, adolescent girls and reproductive age women; and

• Improve dietary diversity, particularly among infants, young children, adolescent girls and reproductive age women.

Constraints in Current Nutrition Programming: The development of this Strategy identified several constraints and challenges that are currently limiting the Mission’s ability to achieve nutrition goals:

Weak coordination and management in the nutrition sector: Poor nutrition in Liberia is a multi-faceted issue that requires the attention and collaboration of multiple actors from a variety of sectors. Poor coordination among those stakeholders and unharmonized management of information limits the ability of donors, implementing partners and the GOL to achieve nutrition goals.

At the Mission level, as indicated, while there are multiple USAID-supported activities addressing facets of the nutrition problem in Liberia, there is currently a lack of coordination and collaboration among teams with regard to overall approaches, choosing target beneficiaries, setting goals, and evaluating the effects of interventions related to nutrition. This lack of coordination within the Mission, in turn, leads to a lack of coordination among implementing partners and a failure to take advantage of potential collaborations in the field that could help improve nutrition outcomes.

The Income‐Nutrition Translation: Liberian income-specific survey data indicate that improvements in income from any source, including cash crops do not translate well – in the short or medium run -into positive behavioral change or nutritional outcomes regarding young children or pregnant women. This is particularly evident in indicators such as anemia rates, and IYCF, which show little difference based on wealth17.

Such absence of translation is frequently seen in countries or regions with inadequate access to satisfactory services and information and in areas where, according to cultural norms, men take precedence over women and adults take precedence over children when it comes to the consumption of quality food items. This suggests that those agriculture activities seeking to increase agricultural productivity and farmer income need to give serious attention also to positive behavior change relating to household food consumption, child caring practices and maternal self-care if they hope to also achieve nutrition objectives.

15 Nutrition Assessment and Gap Analysis (NAGA) 16 On 3 February 2014, Liberia became the 47th country to commit to scaling up nutrition with the SUN Movement 17 National Micronutrient Survey 2011

The Agriculture/Livestock – Nutrition Translation: It is similarly clear that simply increasing the availability of food sources does not automatically improve food consumption or nutrition. Explicit efforts are necessary to help translate increased food availability into improved household dietary intake.

With respect to USAID’s small livestock investments, for example, this means that simply increasing availability of goats or chickens may have no discernible effect on the home consumption of foods associated with these animals unless intensive – well formulated utilization‐based messaging and counseling is provided.

In addition to assessing their potential contributions to economic growth, value chains should be chosen and prioritized with consideration of their potential to positively influence nutrition and household food security outcomes. Regardless of what value chains are prioritized, compelling Liberia-specific messaging is needed on the nutrition and health benefits associated with dietary diversity. Moreover, messages based on an understanding of constraints and resistance points, building on aspirations, and incentives, and utilizing facilitators, are inevitably more effective than didactic messages.

Weak government capacity: It is critical that the GOL have the capacity, resources and will to enact nutrition-specific and nutrition-sensitive policies and carry on nutrition activities beyond the presence of donors. Both the MOA and MOHSW have mandates for improved nutrition, but there are human and institutional capacity constraints in both, and limited financial and technical support for relevant divisions have left them ill equipped to assume a lead role. In the absence of strong GOL support and ongoing capacity to implement policy, the sustainability of USAID nutrition investments is unlikely. More now than ever, as Liberia moves further away from humanitarian crisis and transitions into long-term development, it is critical that USAID and other donors and partners place simultaneous focus on implementing the projects and providing the services that are critical to the health and wellbeing of Liberians while strengthening the Government’s and private sector’s capacity to carry on these interventions in a self-sustaining manner. The strategy’s long-term movement toward performance-based incentives is designed to reinforce this momentum for sustainability.

Conceptual Framework for a Multisectoral Approach: Nutrition is a multifaceted issue, and a growing body of evidence suggests that a successful nutrition intervention requires both nutrition-specific and nutrition-sensitive components.18 The conceptual framework below illustrates the causal relationship between basic, underlying and direct causes of malnutrition, as well as the key areas for nutrition-specific and nutrition-sensitive interventions this Strategy will employ to address them.

18 http://download.thelancet.com/flatcontentassets/pdfs/nutrition-eng.pdf

Figure 1: Conceptual Framework for a Multi-Sectoral Approach to Nutrition19

19 Adapted from UNICEF, 2013; The Lancet, 2013

Sociocultural, economic and political context

Inadequate financial, human, physical and social capital

Inadequate quantity and quality of household resources: income, land, education, employment, and technology

Unhealthy household environment and inadequate health services

Poor maternal and child care and feeding practices

Household food insecurity

Disease Inadequate dietary intake

Maternal and child undernutrition

Increased morbidity, mortality and disability

Decreased adult stature, cognitive ability, school performance, economic productivity, reproductive health

Ba sic

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Di re ct

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Support an enabling environment by:

• Advocating for nutrition-sensitive policies and legislation

• Investing in MOA and MOHSW capacity to enact nutrition-sensitive policies

• Supporting development of incentives, regulatory and accountability mechanisms

• Building evidence base through rigorous evaluation and information sharing

• Strengthening coordination between GOL, donors, partners and private sector

Address underlying causes of malnutrition by supporting policies and programs in:

• Agriculture and food security

• Early childhood development

• Education

• Public health and health system strengthening

• Social protection and safety nets

• Women’s empowerment

• Water sanitation and hygiene

• Family planning and reproductive health

Address direct causes of malnutrition through:

• Promoting optimal infant and young child feeding and care practices

• Increasing micronutrient intake among mothers and young children

• Improving adolescent health and preconception nutrition

• Dietary diversification

• Identification and treatment of growth faltering

• Disease prevention and management

Key Areas for Intervention

VIII. Overall Goal and Strategic Approach

Despite significant progress across sectors in recent years, Liberia continues to face challenges as the country transitions from a state of recovery to long-term development. As with other sectors, there is significant work to be done to improve the health and wellbeing of Liberians, and recent demographic and health surveys, as well as sector-specific studies and assessments, indicate that nutrition issues, particularly stunting in children and maternal and child anemia are still areas of critical need.20

With this in mind, the overall goal of the USAID/Liberia Multi-Sectoral Nutrition Strategy is to improve the nutritional status of Liberians with the specific strategic objective of reducing maternal and child undernutrition.

The Strategy proposes a multi-sectoral approach to address both direct and indirect factors that contribute to poor nutrition by supporting the provision of much needed services in the short-term and the building local capacity to sustain ongoing nutrition improvements in the long-term. By scaling up and integrating best practices and lessons learned in health, agriculture, WASH and education, by providing strategic support to the GOL to strengthen the skills and systems required for effective planning and implementation of nutrition interventions, and by improving coordination and collaboration within the Mission and among partners in the nutrition sector, the Strategy aims to accelerate progress towards achieving key nutrition outcomes.

Considering USG, GOL, and Mission priorities and strategies, while building on lessons learned from previous nutrition activities and exploring emerging opportunities as Liberia’s needs and capabilities continue to evolve, the Strategy has identified three interrelated and mutually reinforcing Intermediate Results (IRs) to prioritize in order to better focus and integrate USAID’s efforts in those areas that are constraining progress towards achieving strategic objective of reduced maternal and child under-nutrition.

Additionally, these IRs have been designed with the aim of delivering sustainable improvements in nutrition by fostering country ownership and GOL support through close alignment with key country strategies and priorities. The Strategy will simultaneously seek to directly support the delivery of nutrition interventions for impact in the short-term while developing GOL capacity across sectors to provide quality services that are required for sustainable improvements in the nutritional status of Liberians.

The results framework below outlines the components of this Strategy.21 22 23

20USAID Food and Enterprise Development Program Nutritional Needs and Gap Assessment, 2013; Micronutrient Survey, 2011;

LHDS 2013

21 Note that in the framework below, reference is made both to nutrition and food security services. Given the now internationally accepted theories of change embedded in this framework, it is considered essential to address both in order to achieve desired nutritional outcomes.

22 Action plans emerging from this strategy might usefully develop indicators for these IRs that can also be utilized in forthcoming projects.

23 See http://feedthefuture.gov/sites/default/files/resource/files/ftf_handbook_indicators_sept2013_2_0.pdf for definitions of key indicators

Figure 2: USAID/Liberia Nutrition Strategy Results Framework

Key Performance Indicators

• Prevalence of stunted children under five years of age

• Prevalence of anemia among women of reproductive age

• Prevalence of anemia among children 6-59 months

• Household food consumption scores

• Minimum acceptable diet for children 6-23 months

• Exclusive breastfeeding for children under 6 months

• Women’s dietary diversity

Goal: Improved Nutritional Status of Liberians

Strategic Objective: Reduced Maternal and Child Undernutrition

IR 1: Improved coordination and convergence

IR 3: Improved nutrition-related behaviors and practices

IR 2: Increased availability and quality of N&FS services

Convergence of USAID-supported N&FS activities in the same communities

Improved county level coordination among N&FS donors, partners and county-level GOL

Increased coordination in monitoring/evaluation and improved N&FS data for decision-making

Improved household consumption and dietary diversity

Improved maternal self-care and IYCF and care practices

Increased availability and utilization of community-based nutrition services

Strengthened institutional capacity of national level counterparts

Improved county-level planning of N&FS activities

Increased availability of a diversity of nutritious food

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Ad eq ua te

Ca pa ci ta te d Hu an so ur ce s

Ev id en ce

-b as ed P la nn in g

In te gr at ed E ss en tia l

N ut rit io n Ac tio ns

Ap pr oa ch

Guiding Principles

IR 1: Improved Coordination and Convergence

Reducing malnutrition requires addressing the problem directly and addressing its determinants in the same geographic areas – not just some of this here and some of that there. Placing both nutrition-specific and nutrition-sensitive interventions in the same vulnerable districts has been found to create important synergistic effects, with countries employing this approach seeing up to

4.5 percentage point reductions in stunting per year.24 For example:

• Households with improved household food security are more likely to be able to comply with nutrition counseling messages.

• Households in which women are actively involved in home gardens or small animal production, and sell a portion of their produce, are likely to have an increased decision making role in the family leading to improved family food consumption and health services.

• Children in households with improved WASH will have a reduced prevalence of diarrheal infection and environmental entheropathy, and, in turn, improved nutritional status.

• In schools offering nutrition education classes and school gardening increased school enrollment and attendance, facilitated in part by school meals, will often translate into better nutrition practices in the home and increased homestead gardening.

Recognizing the importance of these synergies, IR 1 calls for focusing nutrition- specific and nutrition-sensitive interventions not only in the six USAID/Liberia priority counties, but within the same communities, thus utilizing multi-sectoral convergence for improved nutritional outcomes.

The key to achieving this IR will be improved coordination between teams at the Mission, and in turn, among partners at the county-level.

A convergence program could be initiated almost exclusively by bringing current USAID-assisted activities into the same communities of target counties. This would require that multiple teams within the Mission (health, education, economic growth) commit to locating their activities in the same communities, and coordinating on the development of targets, baseline data and monitoring related to nutritional outcomes. Doing so would address both the direct and underlying causes of malnutrition in the same communities, and enable the Mission to better attribute outcomes and monitor the cumulative effect of their programs on nutrition.

For the Education Team, its most important contributions to nutrition convergence programs are:

• Increasing the primary school enrollment and attendance of females;

• Increasing literacy and numeracy rates among non-school going youth and adults; and

• The provision of knowledge and skills relating to general and reproductive health, nutrition and life skills through girls clubs.

For the Health Team, continued support for the delivery of the EPHS and implementation of the MOHSW’s Community-Based Health Services Strategy will be essential. These activities will address key determinants of nutritional status through support for integrated community case management (iCCM) of childhood illnesses, deworming, vaccination, and clinic-based growth monitoring and promotion (GMP).

24 http://www.mdgfund.org/sites/default/files/Addressing%20malnutrition%20multisectorally-FINAL-submitted.pdf

Additionally, it should be noted that rates of childhood diarrhea in Liberia are among the highest in the world at 29 percent25, 26. This being the case, the Health Team’s work in WASH will be a critical component of the convergence approach. The ongoing USAID-supported IWASH program has reduced the prevalence of childhood diarrhea in its coverage communities dramatically through its social and behavior change communication (SBCC) activities, and by supporting GOL’s CLTS approach, and similar interventions will remain at the forefront of this Strategy.

Key contributions from the Economic Growth Team will include those activities, which contribute to the economic empowerment of women, and the scaling up of nutrition- sensitive agriculture activities. This will include examining agriculture value chains through a nutrition lens and ensuring that SBCC messaging is appropriately targeted for agriculture groups (see IR 2 for further discussion). Additionally, as the Economic Growth team plans future activities, it should strive to utilize the seven key pathways from agriculture to nutrition27 to ensure that its agriculture activities are poised to contribute to nutrition outcomes.

It is worth noting that the LAUNCH program, although limited in its geographic coverage, comes close to embodying the multi-sectoral nutrition convergence model. Although the program has not yet systematically tracked the effect of its overall program on stunting, some of its results are highly impressive. (Evaluations were carried out externally):

2010 2013

Exclusive Breastfeeding 29% 73%

Minimum acceptable diet:

young children

12% 26%

Minimum acceptable hygiene 17% 54%

To help streamline the convergence of nutrition-sensitive and nutrition-specific interventions, the Mission should establish a multi-team nutrition coordination committee – with sub-committees (comprised of implementing partners and county-level GOL representatives) functioning in each of the target counties. Beyond coordination of the convergence actions, this committee structure will permit regular review of monitoring data, provide sufficient supervision to ensure that all interventions are actually reaching the target beneficiaries, and then facilitate the shifting of particular foci within projects where necessary to improve nutritional and food security outcomes.

25 There is now conclusive evidence (a) that childhood diarrheal infection has a major deleterious effect on nutritional status (see e.g. Brown, 2003) and (b) that WASH interventions are highly effective in reducing diarrheal infection and environmental enteropathy (see e.g. Waddington H et al, 2009.) WHO estimates that 50% of malnutrition is associated with repeated diarrhea or intestinal worm infections as a result of unsafe water, inadequate sanitation and/or insufficient hygiene (WHO, 2008.) Open defecation has been found to explain 54% of international variation in child height. By contrast GDP explains only 29% (Spears D, 2013).

26 2007 LDHS

27 The seven pathways were presented at the 2012/2013 Agriculture and Nutrition Global Learning and Evidence Exchange and comprise a guide for strengthening the linkages between agriculture and nutrition which is based on the best evidence available from the literature on food security, health, and nutrition and are supported by the experiences of field practitioners.

Further information is available at http://www.spring-nutrition.org/sites/default/files/pathways_document.pdf and http://www.spring-nutrition.org/publications/briefs/understanding-and-applying-primary-pathways-and -principles

This structure would also foster information sharing and reduce management burden by creating common instruments among activities.

Finally, under this IR, improved coordination within the Mission, among the implementing partners, and with the GOL at the county level will lead to improved data collection and sharing with the intent of improving the national evidence base for decision making. It also will identify missing information inhibiting the implementation and, in turn, opportunity for operations research.

Outputs:

• 1.1: Convergence of all USAID-supported nutrition and food security28 activities in the same communities 1.2: Improved county-level coordination between N&FS donors, partners and county-level

GOL

1.3: Increased coordination in monitoring/evaluation and improved N&FS data for decision-making

Illustrative activities:

• Co-locate existing county-level nutrition and food security-related activities (plus WASH and nutrition-related education services) in the same communities. (Where inadequate resources are available to provide services in every community, selection should be made, together with county officials, of the most vulnerable communities):

• Establish a multi-team nutrition coordination committee within the Mission;

• Develop management and reporting protocols for nutrition-related activities;

• Revise TORs of Mission staff to include mandated responsibilities to the nutrition coordination committee;

• Develop appropriate nutrition-related objectives and indicators in activities, and, in turn, monitor these indicators;

• Establish county-level subcommittees in each of the USAID-focus counties; and

• Build capacity of existing national coordinating mechanisms (NCC, FS&N Technical

Committee).

IR 2: Increased Availability and Quality of Nutrition and Food Security Services

IR 2 relates to the increased availability and quality of those services, which contribute to a multi-sectoral nutrition program (Health, WASH, Education, Agriculture). In order to achieve this IR, the Strategy calls for a two-pronged approach: 1) identify and provide support to sectors where additional services are required to deliver a comprehensive, multi-sectoral package of nutrition interventions; and 2) strengthen GOL capacity to sustainably deliver quality service across sectors.

First, while the convergence of USAID activities called for in IR1 will greatly increase the availability of nutrition-related services in target communities, certain sectors will require significant scaling-up of existing projects or the design of new activities in order to meet sector-specific targets related to nutrition.

One area in which such increased support is needed is in the health sector, where increased focus will be placed on community-based nutrition interventions. To date, most nutrition activities in the

28 As indicated above, achieving nutrition impacts also requires improved household food security.

country have been focused at the facility level and through national campaigns. Much has been accomplished, including remarkably high coverage of vitamin A supplementation and deworming for young children (together with high immunization rates), and the provision of both ORS and zinc to young children with diarrheal infection. Further reductions in stunting and improvements in maternal nutrition, however, are unlikely using these mechanisms alone. Young children are not brought regularly to the facilities, and while a very large proportion of women have at least one ANC checkup and at least an initial supply of iron-folate tablets, a relatively small percentage have all of the necessary check-ups and receive all the necessary iron-folate.

One essential element for effective and sustainable nutrition…