RFI-671-22-EG-00001-Nutrition.pdf

Subject: Request for Information No. RFI-671-22-EG-00001-Nutrition Activity Name: USAID/Tanzania Regional Multi-Sectoral Nutrition Activity Date of Issuance: June 29, 2022 Submission Deadline: July 31, 2022

To All Interested Organizations:

Pursuant to Federal Acquisition Regulation (FAR) Part 10, the U.S. Agency for International Development Mission to Tanzania (USAID/Tanzania) is conducting market research for a prospective activity. Specifically, USAID/Tanzania is soliciting input from interested organizations on a draft scope of work for a prospective activity.

This Request for Information (RFI) relates to an activity with the preliminary title of “Tanzania Regional Multi-Sectoral Nutrition Activity.” USAID/Tanzania is contemplating to provide $35-40 million over five years for this activity to strengthen the quality and coverage of nutrition services in the health system, increase consumption of safe, nutrition foods through food systems approaches, and increase capacity of local urban and rural councils for multi-sectoral nutrition planning, budgeting, data use, and delivery of services.

The RFI is solely for information gathering purposes and is not a Request for Proposal (RFP), a Request for Quotation (RFQ), an Invitation for Bids (IFB), a solicitation, or an indication that USAID will contract for the activities described herein. In accordance with FAR 15.201(e), responses to this notice are not offers and cannot be accepted by the Government to form a binding contract. Any proposals submitted in response to this request will not be considered and will be discarded. If a solicitation is eventually issued, it will be announced on https://www.sam.gov/ at a later date, and any interested party must respond to that solicitation. It is the responsibility of interested organizations to monitor that site for additional information pertaining to any potential future requirement.

This RFI is not to be construed as a commitment by the USG to issue any solicitation or ultimately award a contract for services similar to those described in this RFI. Responses to this notice are strictly voluntary and USAID will not pay respondents for information provided in response to this notice.

Respondents are solely responsible for all expenses associated with responding to this RFI.

Responses to this RFI will be retained by USAID and will not be returned. USAID may elect to use the information submitted at its discretion. Organizations should not submit any proprietary or otherwise sensitive information. This RFI does not restrict the Government's acquisition approach on a future solicitation, and USAID reserves the right to modify the scope, scale, or other details of the planned activities. Similarly, USAID is not obligated to modify its planned approach or otherwise incorporate the input that respondents offer.

Responding to or providing input in response to this RFI will not give any advantage to an organization in any subsequent procurement action. Likewise, organizations that choose not to respond will not be precluded from submitting a proposal in response to a subsequent solicitation if one is ultimately issued. Respondents will receive a confirmation of receipt of their submission. However, USAID will not provide feedback on submissions or answers to any questions submitted in response to this request.

Phone inquiries will not be entertained.

Instructions:

https://www.sam.gov/

RFI-671-22-EG-00001-Nutrition

USAID welcomes all segments of the public (in the U.S. and abroad) to reply to the RFI. Small businesses are encouraged to respond. Interested organizations must respond in accordance with instructions below.

All responses to this RFI must be submitted via email by the date and time indicated above to rselemani@usaid.gov and skemper@usaid.gov. Submission must be in Microsoft Word format as a single email attachment. All pages must be numbered consecutively. The email subject line must include the RFI number and the name of the submitting organization, i.e., “RFI-671-22-EG-00001- Nutrition – [Organization name]”. Responses sent by any other means or in any other format will not be reviewed. Submissions must not exceed five pages (including the cover page). Only one submission will be accepted per organization.

a. Cover Page

The cover page (one page maximum) must include the following information:

● Organization name and address

● Organization points of contact name, UEI number (if applicable), telephone number, and email address

● Organization type, i.e., commercial, public sector, educational institution, non-profit, etc.

● If applicable, socioeconomic status, e.g., other than small business, small business, woman owned, veteran-owned, etc.

b. Technical Response

Respondents must review the attached draft scope of work and respond to any of the following questions:

1. Which local partners have experience working in the technical areas of this activity and what are their approaches?

2. Are there best practices or innovative approaches that this activity should consider to achieve the intermediate results and expected outcomes?

3. How can this activity empower urban and/or rural councils to mobilize innovative financing and implementation from non-traditional sources, including the private sector, for nutrition? What opportunities exist within the private sector for mobilizing resources for nutrition?

4. What are the most significant challenges and/or opportunities in achieving the activity results regarding climate change?

5. Are there other districts/regions that should be considered, and what criteria would you use to determine them?

Thank you for your interest in and support of USAID/Tanzania’s

Best regards, Sascha Kemper Contracting Officer mailto:rselemani@usaid.gov

Attachment 1 – Draft Scope of Work

1. Introduction

The USAID Tanzania Regional Multi-sectoral Nutrition Activity is part of the U.S. Government's (USG) Global Food Security Strategy (GFSS) 2022-2026, which promotes global food security, resilience, and nutrition and the USAID global health initiative to prevent maternal and child deaths.

The purpose of this activity is to strengthen the health and food market systems that promote adoption of optimal nutrition-related behaviors across a range of stakeholders in targeted regions. This purpose will be achieved by a) increasing the coverage of quality nutrition services at health facilities and community; b) improving consumption of safe, nutritious foods; and c) increasing capacity of councils to utilize data, plan, budget, and deliver quality nutrition services.

2. Background

Multiple forms of malnutrition remain one of the most serious public health problems affecting infants, children, and women of reproductive age in Tanzania. Despite progress in the past decades and significant political commitment, women and children, particularly those in the first 1,000 days, continue to experience poor health and nutrition outcomes, receive poor quality nutrition services, and are unable to obtain sufficient safe, nutritious foods. Weaknesses in the health system cause poor quality nutrition services to be delivered. Gaps related to the food system hinder access to and availability of safe, nutritious foods throughout the year, particularly for women and children. Barriers exist for Tanzania Local Government Authorities (LGAs) to plan and execute nutrition commitments.

Across these systems and stakeholders, existing social norms and behaviors sometimes hinder the ability to promote the uptake and adoption of optimal nutrition practices. The USAID Tanzania Regional Multi-sectoral Nutrition Activity will work hand in hand with LGAs to address these barriers.

2.1 Tanzania Country Nutrition Context

The Government of Tanzania (GOT) is committed to addressing malnutrition through multisectoral actions. The National Multi-Sectoral Nutrition Action Plan (NMNAP) II 2022-2026 and its accompanying Resource Mobilization Strategy were officially launched in November 2021 and guide all national ministries, LGAs, and other stakeholders on their relevant roles and responsibilities for nutrition.

Accelerated progress is needed to meet the national nutrition goals, including early initiation of and exclusive breastfeeding under six months, minimum dietary diversity for children, iron, and folic acid (IFA) consumption among pregnant women, and vitamin A supplementation in children. There are several health systems challenges that are impeding increased coverage of nutrition services at community and facility level, particularly inadequate adherence to nutrition guidelines and standards during service provision, low capacity of health care providers to effectively provide nutrition services and counseling, and lack of appropriate staffing of clinical nutritionists.

Improvements and innovations in the food system are needed to increase access to and availability of safe, nutritious foods throughout the year. Entry points include food production and processing, mechanisms to improve affordability, and policy and regulation. Distribution is another key challenge faced by the Tanzanian food system. Improving distribution networks and processes will reduce transport-related losses, allowing increased quantities of food to reach markets and support improved food quality.

The President's Office Regional Administration and Local Government (PO-RALG) supports regional and district level councils to execute the budgeting, planning, implementation, and monitoring of nutrition activities. District nutrition officers are responsible for organizing the local multi-sectoral nutrition steering committee meetings among many other activities; however, many regions do not have fully staffed councils with the required number of nutrition officers. Inadequate staffing of district nutrition officers and low capacity for budgeting, planning, and monitoring of activities hinders the success of the district plans.

Further background on the context and barriers in the health and food systems is provided in Annex 1.

The USAID Tanzania Regional Multi-sectoral Nutrition Activity will work directly with local government authorities and other stakeholders to address these barriers.

2.2 Relationship to USG Strategies

● CDCS Tanzania1: This activity will primarily support the achievement of the Mission’s CDCS

2020-2025 Development Objective 1 (DO1): “Foundational skills of children below age 15 improved” with specific contributions to IR 1.2: Household nutrition and health outcomes improved. In addition to this activity’s placement under the DO1, the activity will also support Development Objective 2 (DO 2): Empowerment, productivity, and engagement of Tanzanians aged 15 to 35 increased and Development Objective 3 (DO 3): Capacity of state and non-state actors strengthened to benefit future generations.

● USAID Multi-Sectoral Nutrition Strategy2: provides a framework for reducing malnutrition, especially during the critical 1,000-day window from pregnancy to a child’s second birthday across sectors, including health, nutrition, agriculture, and water, sanitation, and hygiene.

● USG GFSS3: is an integrated whole-of-government approach that aims to end global hunger, poverty, and malnutrition through the Feed the Future initiative. The GFSS includes an emphasis on food systems and diets and complements enhanced efforts to coordinate with essential nutrition-specific services, often provided through the health system, to maximize impact on nutrition.

2.3 Government of Tanzania Priorities

A Nutrition Compact was signed in 2017 between the vice president and regional commissioners that stipulated the regional commitment to implement the minimum budget allocations for nutrition agreed upon in the NMNAP, TSH 1,000 per child under five years of age. The compact measures the performance of regions on a set of nutrition-specific indicators and disbursement of nutrition-related funds, using a scorecard approach. Other strategies and guidelines that will be critical for the successful implementation of this Activity include the following:

● NMNAP II4

● NMNAP II Resource Mobilization strategy5

● National Guidelines for the Ten Steps to Successful Breastfeeding

● National Nutrition Quality Improvement Guidelines (forthcoming)

1 https://www.usaid.gov/tanzania/cdcs 2 https://www.usaid.gov/nutrition-strategy 3https://www.usaid.gov/what-we-do/agriculture-and-food-security/us-government-global-food-security-strategy 4 https://www.tfnc.go.tz/nutrition-cockpit/18 5 https://www.tfnc.go.tz/nutrition-cockpit/17 https://www.usaid.gov/tanzania/cdcs https://www.usaid.gov/nutrition-strategy https://www.usaid.gov/what-we-do/agriculture-and-food-security/us-government-global-food-security-strategy https://www.tfnc.go.tz/nutrition-cockpit/18 https://www.tfnc.go.tz/nutrition-cockpit/17

● Health Sector Strategic Plan (HSSP) V, July 2021-June 2026

● GOT’s Agriculture Sector Development Programme (ASDP) II

● Tanzania’s Development Vision 2025 (TDV 2025)

● National Post-Harvest Management Strategy (NPHMS) 2019-2029

3. Scope Of Work

3.1 Purpose and Theory of Change

Goal: Improve the nutritional status of women of reproductive age and children under 5.

Purpose: Strengthen the health and food market systems that promote adoption of optimal nutrition-related behaviors across a range of stakeholders in targeted regions.

Theory of Change: IF coverage of quality nutrition services is improved at health facility and community levels, and IF consumption of safe, nutritious foods is increased, and IF the capacity of councils is increased to utilize data, plan, budget, and deliver multi-sectoral nutrition services; THEN, the health and food market systems will effectively enable optimal nutrition-related behaviors, which will lead to improved maternal and child nutritional status.

3.2 Geographic Focus

The focus regions proposed for this Activity currently have sub-optimal coverage of nutrition services, poor uptake and practice of key nutrition and hygiene behaviors and are underperforming in regard to Nutrition Compact requirements (see Annex 2). Geographic targeting may be refined during mission consultations with successful applicant(s) and key stakeholders. However, the following regions have been proposed to maximize programmatic impact of USAID investments, accelerate sustainable and inclusive programming, and build on existing relationships. The proposed focus regions are Njombe, Iringa, Rukwa, Songwe, and Kigoma.

3.3 Sub-Objectives and Expected Results

The results areas in this activity are integrated. It is expected that there will be interrelated activities and that results in each area will contribute to results in other areas.

Intermediate Result 1: Increased coverage of quality nutrition services at health facilities and community

The Activity will aim to increase coverage of nutrition services that are provided at health facilities and at the community level. The Contractor/Offeror will provide technical assistance (TA) for nutrition services across various health areas and levels of care, from community health platforms to regional referral hospitals. The Contractor/Offeror will work with PO-RALG and regional and council health management teams (R/CHMTs) to ensure QI activities for nutrition are included in facility QI plans and adequate supportive supervision is provided. The Contractor/Offeror will work with the R/CHMTs to implement QI activities in accordance with the forthcoming guidelines, but also with a “ground up” approach to ensure health care providers themselves are identifying the gaps, developing plans, monitoring performance, and institutionalizing the changes. The Contractor/Offeror will work with PO-RALG and R/CHMTs to develop and document learning activities related to improving the quality of services, for example testing different intensity and frequency of approaches to ensure optimal outcomes. Furthermore, the Contractor/Offeror will provide TA to promote social and behavior change interventions for prioritized behavior beyond traditional health behavior change models. They will work closely with the community members and partners to identify multidisciplinary, multi-pronged approaches to apply, including state-of-the-art approaches, such as digitalization, to generate demand for services and adoption of key practices.

In order to sustain improvements in quality and coverage of essential nutrition services, and successful implementation of the NMNAPII, a mix of pre-service, in-service, and continuing education must be available to all health care providers. The Contractor/Offeror will work closely with various stakeholders to ensure that the schemes of service for clinical nutritionists are updated; that nutrition competencies and counseling skills for health care workers are defined and disseminated; and support training as needed. The Contractor/Offeror may also identify and assess feasibility of opportunities to engage the private sector for capacity building of health care workers in nutrition.

The Activity will take a systems approach to close nutrition related gaps in the national supply chain system. The Contractor/Offeror will not be responsible for direct procurement, but will work closely with multiple stakeholders, including other USAID activities, to improve guidance and capacity strengthening in forecasting, reporting, and ordering of nutrition commodities, for regional, district, and facility level stakeholders (e.g., supply officers, district reproductive and child health coordinators, pharmacists, and nutritionists).

Expected Results

● Increased nutrition competencies and counseling skills of health care providers

● Improved clinical nutrition human resource availability at district level

● Institutionalization of quality improvement approaches applied to nutrition services provided in health facilities and community

● Strengthened systems and processes for procurement and delivery of essential nutrition commodities

● Scaled up implementation of the Ten Steps to Successful Breastfeeding

● Nutrition and hygiene behaviors prioritized and improved through various platforms

Intermediate Result 2: Improve consumption of safe, nutritious foods

The GOT has committed to developing a sustainable and resilient food system that is responsive to nutrition needs. The Activity aims to work through food systems to improve the diets of Tanzanians.

Improving the consumption of safe, nutritious foods using a systems lens means that there is sufficient nutritious food to meet appropriate dietary needs that are accessible and affordable throughout the year.

It is particularly important for women and young children, given the critical effects healthy diets have on early childhood development and lifelong productivity. The Contractor/Offeror will work with LGAs, private sector actors, and other relevant stakeholders to identify effective behaviors, actions, and activities to promote the availability and consumption of safe and nutritious food within the food system. TA provided by the Contractor/Offer may include approaches to increase utilization of technologies for the production and processing of safe food; mitigate food loss and waste; and increase demand for safe, nutritious foods.

● Reduced food loss and waste to increase availability of nutrient-dense food

● Improved access to new post-harvest technologies

● Improved storage of nutritious foods

● Increased desirability of safe, nutritious foods

● Input availability for production of nutrient-dense foods better aligned with market demand

Intermediate Result 3: Increase capacity of councils to utilize data, plan, budget, and deliver quality nutrition services

Successful implementation of the NMNAP II depends on the capacity of the LGAs to plan, budget, deliver, monitor, and analyze data for nutrition activities, in partnership with PO-RALG. The Contractor/Offeror will provide TA to PO-RALG to support councils to utilize the national planning and accountability tools and to integrate nutrition into the comprehensive development plans. The Activity will also support dissemination of the Tanzania Resource Mobilization Strategy for the NMNAP II and support the Councils to identify and execute feasible financing options for their development plans. The Contractor/Offeror will provide TA to TFNC and PO-RALG to ensure Councils are oriented and trained to use the new Multisectoral Nutrition Information System. This includes capacity to ensure quality implementation, reporting, but also using the data for planning, and disseminating results back to the community. The Contractor/Offeror will provide TA to PO-RALG and LGAs to reduce human resource gaps for nutrition at the Council level.

● Increased dissemination and uptake of nutrition planning and budgeting guidelines and tools

● Strengthened nutrition data management system and capacity at the village, ward, and district level

● Improved planning and implementation for adequate nutrition workforce at LGA levels

● Increased percentage of allocated funds spent to implement nutrition interventions

● Increased per capita expenditure for nutrition in regions

3.4 Cross Cutting Areas:

3.4.a Social and Behavior Change: The Activity aims to promote social behavior change by identifying and prioritizing behaviors that have the greatest opportunity to improve nutrition and hygiene outcomes without overwhelming community members by pushing for too many changes at one time. Interventions should be selected based on their ability to address the most critical factors influencing the priority behaviors in each region. This should include factors that are both within and outside the bounds of the health system and those affecting consumer demand in the food and market systems. These factors may include social norms, gender inequities, and cultural practices associated with different ethno-linguistic groups. The Contractor/Offeror should look beyond the traditional health behavior change models to identify multidisciplinary, multi-pronged approaches to generate demand for services, while also addressing identified barriers. This should include a variety of communications and non-communications SBC interventions across a range of key actors in both the health and food systems.

3.4.b Gender and Social Inclusion: In alignment with USAID’s Gender Equality and Female Empowerment Policy, USAID Tanzania seeks to promote gender equality and social inclusion. The activity must incorporate results of relevant data analyses and address gender-specific gaps and constraints and implement gender-sensitive and gender transformative programming. Mitigating actions should be taken to ensure that all children and members of households can benefit from the program, that activities do not exacerbate gender inequalities, and that interventions aim to reduce gender-based violence and promote positive parenting. The activity will contribute to these crosscutting gender priorities by helping to strengthen an enabling environment in which Tanzanians can equally access, contribute, and benefit from the services regardless of gender.

3.4.c Coordination and Collaboration: Partnerships and synergies with other relevant USAID and donor activities in the target districts will be critical. The Contractor/Offeror must coordinate activities with other implementing partners and development partners working in the target geographies across various sectors. In consultation with the COR, the Contractor/Offeror may coordinate technical approaches with other USAID activities outside of target geographies, particularly for the health system interventions. The Contractor/Offeror must participate in coordination platforms, joint work planning exercises, joint quarterly reviews, joint field visits, and share monitoring data and learning with other relevant partners. The Contractor/Offeror must coordinate with other USAID funded activities in the activity’s districts to identify all possible areas of collaboration including private sector engagement and nutrition. The Contractor/Offeror must include the identified areas of collaboration in the annual work plan. The Contractor/Offeror must coordinate with other health, horticulture market and youth livelihood activities, whether by USAID, other donors, GOT, civil society groups, or the private sector. They shall employ adaptive management to activity programming to complement other development stakeholders’ interventions.

3.4.d Localization and Sustainability: The Contractor/Offeror will work hand in hand with the GoT, PO-RALG, and local councils to ensure that activities are strategic, inclusive, and locally led. In line with USAID’s goals to increase local capacity development, the Contractor/Offeror will build partnerships with local stakeholders based on mutual respect, trust, and transparency. The Contractor/Offeror shall provide TA in a manner that prioritizes leadership, ownership, decision making, and implementation by local stakeholders. This localization approach will foster more sustainable results for the objectives of this Activity.

3.4.e Private Sector Engagement: The Contractor/Offeror shall explore, support, coordinate, and establish partnerships with private sector actors whose interests and values align with goals and results of the Activity to catalyze investments into local systems and markets. This may include private sector actors in the food system or the health system. Areas to engage with the private sector should align as much as possible to the goals for private sector engagement with the NMNAP II. National legislation and regulatory frameworks6 and other international guidance7 shall guide any private sector engagement to ensure that ethical and appropriate marketing practices are applied, particularly for foods and beverages for children.

4. MEL & CLA Considerations

USAID’s Collaborating, Learning, and Adapting (CLA) methodology is central to the overall Activity strategy and the Monitoring, Evaluation and Learning (MEL) approach. CLA allows a project to maintain a culture of learning that guides adaptation and improves the quality of project design and interventions. The Contractor/Offeror will promote a strong ethos of generating and disseminating evidence and learnings that the Contractor/Offeror expects will lead to improved nutrition.

6 Marketing of Food and Designated Products for infants and Young Children Regulations (2013) Updated February 7https://apps.who.int/nutrition/publications/infantfeeding/manual-ending-inappropriate-promotion-food/en/index.html https://apps.who.int/nutrition/publications/infantfeeding/manual-ending-inappropriate-promotion-food/en/index.html https://apps.who.int/nutrition/publications/infantfeeding/manual-ending-inappropriate-promotion-food/en/index.html

Sources for learning include data from monitoring, portfolio reviews, findings of research, evaluations, analyses conducted by USAID or third parties, knowledge gained from experience, stocktaking exercises, and other sources. Knowledge generated by learning will be applied throughout programming to implementation approaches, processes, and stakeholder engagement. Knowledge generated by learning should also be disseminated to activity stakeholders, partners, and collaborators in an appropriate forum and format so that it may be translated into decisions and actions that enhance the success of approaches and interventions designed to achieve common intermediate results.

Knowledge generated by learning is also encouraged to be shared in global fora, as appropriate and agreed upon with USAID.

These sources will be used to develop and implement plans, manage adaptively, and contribute to the national and USAID/Tanzania knowledge base in order to improve development outcomes. A collaborating, learning, and adapting focus helps to ensure that programming is coordinated, grounded in evidence, and adjusted as necessary to remain relevant and effective throughout implementation.

The Contractor/Offeror will demonstrate adaptability that is informed by knowledge gained through learning and recognize behaviors and incentives necessary to create change. Knowledge gained through learning will influence decision making, resource allocation, and adaptation to contextual shifts.

The Contractor/Offeror must develop an Activity Monitoring, Evaluation, and Learning Plan (AMELP), which explicitly aligns with the theory of change, proposed activity strategy, and the work plan. The AMELP will specify indicators, targets, and methodologies that allow the Contractor/Offeror and USAID/Tanzania to monitor the progress of activities towards achieving expected targets and outcomes, in addition to identifying learning priorities for the activity.

Annex 1: Further Country Context

The Government of Tanzania (GoT) is committed to improving nutrition across the country. At the global level, Tanzania is a member of the Scaling Up Nutrition (SUN) Movement and has signed on to the Sustainable Development Goals, the World Health Assembly Nutrition Targets 2025, and the WHO Global Non-Communicable Disease Targets 2025. The GoT has established a strong nutrition policy framework, beginning with the Tanzania Food and Nutrition Policy which was first developed in 1992 and updated in 2016 to reflect the GoT’s adoption of a multi-sectoral strategy to prevent malnutrition. The National Multi-Sectoral Nutrition Action Plan (NMNAP) II 2022-2026 and its accompanying Resource Mobilization Strategy were officially launched in November 2021.8 Translation of this commitment to improved nutrition outcomes, particularly for women and children in the first 1,000 days, remains to

Since 2004, exclusive breastfeeding under six months has increased from 40 percent to nearly 60 percent, and the national goal is to reach 70 percent by 2025.1, 9 Despite this progress, early initiation of breastfeeding is still low. Although 60 percent of women deliver in a facility, only 51 percent of

8 Prime Minister’s Office. 2021. National Multisectoral Nutrition Action Plan 2021/22 – 2025/26.

9 Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) [Tanzania Mainland], Ministry of Health (MoH) [Zanzibar], National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS), and ICF. 2016. Tanzania Demographic and Health Survey and Malaria Indicator Survey (TDHS-MIS) 2015-16. Dar es Salaam, Tanzania, and Rockville, Maryland, USA:

MoHCDGEC, MoH, NBS, OCGS, and ICF.

infants initiate breastfeeding in the first hour of birth. Great variation in breastfeeding practices exists at the regional level, with many still having low prevalence of optimal breastfeeding. Complementary feeding practices after six months comprises what children eat (age appropriate, nutrient-dense foods), how they eat (with caregiver engagement), and when they eat (age-appropriate frequency), along with continued breastfeeding. In most regions of Tanzania, these practices are poor, with only about one quarter of children 6-23 months meeting minimum dietary diversity and only 40 percent meeting minimum meal frequency.2 There is no nationally representative data available on women’s dietary diversity, but various cross-sectional studies in different regions demonstrate that the majority of women are not achieving a minimally diverse diet, with recent results ranging from 10-40 percent.10,11

Vitamin and mineral deficiencies are also a public health problem in Tanzania. New nationally representative data on micronutrient deficiencies are expected in 2023. Coverage of critical micronutrient programs in Tanzania such as vitamin A supplementation of children 6-59 months and IFA supplementation among women during pregnancy is not optimal in many regions. Although vitamin A should be available through the Expanded Programme on Immunization (EPI) at the health facility and through campaigns twice a year, coverage was below 90% in all regions, ranging from 30.0% in Katavi to 84.9% in Iringa according to the last Tanzania National Nutrition Survey 2018.13 This survey also found that only 30 percent of women took the recommended 90+ days of iron or iron/folate tablets during their last pregnancy, and nearly 20 percent took none in mainland Tanzania, while in Zanzibar, only about 13 percent took the recommended amount, and over one third of women took none.

Multiple forms of malnutrition burden women and children in the Tanzania mainland and Zanzibar.

Stunting is prevalent among 34% of children under 5 years of age, and 15 out of 26 regions have levels of stunting above 30%. The prevalence of wasting, or acute malnutrition, is fairly low at the national level (4.5 percent), but at the regional level varies from 5 percent in Simiyu to 9.0 percent in Kusini Pemba. This indicates that various systems need to be strengthened to improve prevention, assessment, and treatment measures are needed at facility and community level. Meanwhile, overweight and obesity is rising in women of reproductive age, from 21 percent in 2010 to 28 percent in 2016. The proportion of underweight women and children has stayed fairly constant between 2010 and 2016, around 14 percent of children under five and around 10 percent of women 15-49.

Several health systems challenges exist that impede increasing coverage and delivery of quality nutrition services at community and facility level, particularly in services for women of reproductive age and children under five. The Ministry of Health (MOH) conducted an assessment in a couple of regions of nutrition services delivered at the health facility in 2020. Findings revealed that despite the existence of several nutrition service guidelines, there are several gaps in quality and delivery of nutrition services in the health system, particularly inadequate adherence to nutrition guidelines and standards during service provision. While only conducted in two regions, it is likely these findings are similar in other regions. For example, the assessment found use of outdated nutrition guidelines, 10 https://journals.sagepub.com/doi/full/10.1177/0379572119892405 11 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5726653/ 12 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8932689/ 13 MoHCDGEC [Tanzania Mainland], Ministry of Health (MoH) [Zanzibar], Tanzania Food and Nutrition Centre (TFNC), National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS) [Zanzibar] and UNICEF. 2018. Tanzania National Nutrition Survey using SMART Methodology (TNNS) 2018. Dar es Salaam, Tanzania: MoHCDGEC, MoH, TFNC, NBS, OCGS, and UNICEF https://journals.sagepub.com/doi/full/10.1177/0379572119892405 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5726653/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8932689/ inadequate use of RCH monitoring booklets or cards, weak referral systems, nutrition personnel were not involved in functions of facility quality and work improvement teams, and generally a lack of nutrition capacity among other health service providers. The GoT has developed several guidelines for improving delivery and quality of care in essential nutrition services, including: the Infant and Young Child Feeding Guidelines; Nutrition Assessment, Care and Support and Integrated Management of Acute malnutrition. Recently the Ten Steps Guideline was revised to develop national standards to protect and promote breastfeeding, and nutrition indicators have been incorporated into the national Star Rating Assessment tools. Nevertheless, the widespread implementation of the Ten Steps at the regional level is yet to start, use of the Star Rating Assessment tools is not widespread, and the Nutrition Quality Improvement Guidelines are still being developed. While the MOH provides leadership in QI policy and guidelines, PORALG, RHMTs, and CHMTs are responsible for scaling up implementation of these QI models and approaches for nutrition services to the community. Human resources capacity at facility and community levels for effective delivery of nutrition services are also sub-optimal. Not only do all health care providers have limited nutrition skills and competencies, but there are also not sufficient clinical nutritionists at facilities. Gaps have also been identified in the management and procurement and delivery of critical nutrition commodities and supplies, such as mid-upper arm circumference tapes, counseling materials, vitamin A, iron and folic acid, ready-to-use therapeutic foods.

Several food systems challenges exist that impede the consumption of safe, nutritious foods, particularly for women of reproductive age and children under five. The World Food Programme conducted a study on Tanzania’s food system that found that distribution is a key challenge faced by the Tanzanian food system. Improving distribution networks and processes will reduce transport-related losses, allowing increased quantities of food to reach markets and support improved food quality. In addition, the study found that post-harvest loss occurs at various stages of the food supply chain in Tanzania, including at the producer, distribution, and retail level.

The mid-term review of the previous NMNAP 2016/17-2020/21 revealed that while political commitment is felt, even at local levels, budgets allocated are not always resulting in action and expenditures and that planning and implementation capacity of local councils and nutrition officers is still low. The President’s Office, Regional Administration, and Local Governments Authority (PO- RALG) is a critical link between ministries and regions and districts for implementation of nutrition interventions at the local level. PO-RALG’s specific responsibilities are outlined in the NMNAPII and include coordination, supervision, and guidance of nutrition activities of regional and local government authorities (R/LGAs), such as including nutrition interventions in R/LGA’s plans and by-laws, facilitating capacity development of administrations of R/LGAs, and monitoring of nutrition activities.

With PO-RALG’s support, regional and district level councils execute the budgeting, planning, implementation, and monitoring of nutrition activities, mostly through district nutrition officers, which exist in the majority of local councils, and are responsible for organizing the local multi-sectoral nutrition steering committee meetings. Regional and district nutrition officers are a relatively new position, and many regions have not fully staffed councils with the required number of officers. Those that are employed still face barriers in effectively fulfilling their duties. Each Regional Secretariat should have one nutrition officer, and each LGA should have two district nutrition officers. The Regional Secretariat and Local Government Authority Nutrition Planning and Budgeting Scrutinization Report for Financial Year 2021/202214 found that only 22 regions (85%) have a Nutrition Officer as part of the Regional Secretariat, and only 133 nutrition officers are currently

14 Nutrition Section, Department of Health, Social Welfare and Nutrition - PORALG. 2021. Regional Secretariat and Local Government Authority Nutrition Planning and Budgeting Scrutinization Report for Financial Year 2021/2022.

employed in LGAs, or only 36% of the required number. Three regions, Katavi, Singida, and Tabora, do not have any nutrition officers. There are a number of vacancies set for the financial year 2021/2022, however none are planned for Katavi, Songwe, or Tabora.

In 2011, the GoT introduced a budget line for nutrition and included nutrition in the guidelines for preparing the annual plan and budget. These guidelines instruct ministries, departments, and other agencies; regional secretariats; and local government authorities to allocate resources for nutrition interventions in accordance with the national nutrition plan. To facilitate this, PO-RALG issued a directive during planning and budgeting requiring all regions and councils to allocate funding in their budget plans, and developed specific tools for planning and monitoring, like Nutrition Compact, PLAN REP and Nutrition Scorecards. Accountability for regional implementation of plans occurs in various ways, including Annual Joint Multisectoral Nutrition Reviews, Public Expenditure Reviews, PO- RALG Nutrition Planning and Budgeting Scrutinization Reviews, and Nutrition Compact Evaluation Meetings. Recommendations from the mid-term review included the following: increase deployment of nutrition officers; develop training initiatives for nutrition officers and focal points in MDAs; and to increase the minimum budget allocations for nutrition to be increased to at least TSh 2,5000 per child under five.

In 2020, Tanzania launched the Multisectoral Nutrition Information System aimed to ensure better quality and more timely collection and dissemination of outcomes (and program performance) data for evidence informed advocacy, communication, and adaptive management of the NMNAP. The system is made up from a series of data sources including large-scale national surveys such as the Tanzania Demographic and Health Survey, the STEPS survey, the Nutrition Public Expenditure Review, and the National Nutrition Survey, as well as program specific data, Routine Sectoral data systems from 9 Sectoral Ministries, RS and LGAs data and periodic programmatic nutrition assessments and reviews.

Aggregation and collation of data from all these sources results in a one stop platform for the nutrition landscape in Tanzania. Challenges identified so far include limited user knowledge on the platform and therefore the need to orient Nutrition Focal Persons and relevant officers from key line ministries on the use of MNIS. On the other hand, Data Quality Assessment of the MNIS conducted in 2021 revealed that in spite of having an operationalized information system which receives data from other existing sectoral routine systems, the quality of nutrition information collected is unsatisfactory hence the need to improve the quality of routine data.

Annex 2: nutrition indicators/measurements and spending by region

Region

EBF

<6 mo.

EIBF MDD MFF

Pregnant women took 90+ Days of

IFA

Budget allocated

2021-2022 (Tsh)

Proportion of budget spent 2019- 2020 (%)

Stunting among

CU5 (%)

Njombe 52.2 70 23.9 83.9 35.3 1,645 48 53.6 Rukwa 41.9 42.9 41.9 44.1 17.6 1,356 34 47.9 Iringa 55 66.2 25.4 22.9 28.8 1,478 68 47.1 Songwe 53 60.7 31.3 61 21.8 355 32 43.3 Kigoma 76.9 90.8 35.4 67.5 40.8 693 50 42.3