Attachment_J.10_Nutrition_in_the_EU's_Annual_Action_Programme_2014.pdf

THE EUROPEAN UNION DELEGATION TO AFGHANISTAN

Overview of EU planned interventions in nutrition under the Annual Action Plan 2014

Malnutrition in Afghanistan: key features

Chronic undernutrition and micronutrient deficiencies are highly prevalent in Afghanistan. Malnutrition results from food insecurity, gender dynamics (poor education of mothers, status of women), cultural practices, poor sanitation and hygiene, poverty, uneven access to health services and is aggravated by the country's security situation.

The child and maternal undernutrition throughout the country has remained a major, and partially unaddressed, concern. The results of the last National Nutrition Survey (NNS) conducted by the Ministry of Public Health (MoPH) and UNICEF in 2013, showed that chronic undernutrition (stunting prevalence of 40.9%) is among the highest in the world and the acute malnutrition (wasting prevalence) affects 9.5% of the children under five years old.

Approximately 25% of the children are underweight, and 8% of the adolescent girls, with a body mass index of less than 18.5, are undernourished. Among women of reproductive age, 9.2% were found having a body mass index of less than 18.5 and only 58.4% of women practice six months of exclusive breastfeeding. On the other hand, overweight and obesity affects an increasing part of the population, with about one fifth of women (20.7%) being overweight and 8.3% obese.

Micronutrient deficiencies are widespread. Rates of Anemia among preschool aged children and pregnant women were found to be 44.9% and 40.4% respectively, while Vitamin A deficiency was 45.8% among children and 10.8% among women. Iron, Zinc, Iodine and Vitamin D deficiencies are common among women of reproductive age and children, with the highest deficiency rate for Vitamin D affecting 95.3% of women and 81% of the children.

In terms of water and sanitation, 62.9% of Afghanistan's population has access to improved drinking water sources, but only 40.4% of the population uses improved sanitation facilities. Lack of adequate water and sanitation facilities, together with poor hygiene practices, has a direct impact on the health and nutrition status of the afghan population. Although 89.7% of women reported to wash their hands with soap after defecation, only 45.1% of households had soap available at hand washing places . Food insecurity affects a relative low portion of the population (6.3% of households are classified as having a poor Food Consumption Score, while 75.7% have an adequate diet).

Access to reproductive health services, social status of women and girls and mothers' education and prevailing social norms are major underlying causes of malnutrition in Afghanistan. Nationally, only 48.1% of women sought antenatal care (ANC) during their last pregnancy and only 16.4% had four or more antenatal care visits.

Afghanistan ranks 36 out of 45 countries classified by the Hunger and Nutrition Commitment Index (HANCI), which compares their performance on 22 indicators of political commitment to reduce hunger and undernutrition.

Situation analysis

Although the health and nutrition status of the Afghans has improved in the last ten years as showed by the comparative results of the two National Nutrition Surveys 2004 and 2013, chronic malnutrition continues to affect a significant part of the population. Most development interventions have been geared towards curative aspects and treatment of acute malnutrition and the emergency driven approach has not addressed adequately the prevalence of stunting. Whereas nutrition is part of the Basic Package of Health Services (BPHS) and the Essential

1 The source of all data in this section is the National Nutrition Survey, 2013.

2 According to the findings of the KAP module of the National Nutrition Survey (NNS), MoPH and UNICEF, 2013.

Package of Hospital Services (EPHS), poor implementation of this component has hampered progress. Findings of the NNS showed that only 2.5% of children with acute malnutrition were registered in one of the BPHS's Integrated

Management of Acute Malnutrition (IMAM) programs . Of these 2.5%, almost half were hospitalized in IPD-SAM, which can be explained by the limited number of sites providing OPD-SAM.

Lack of technical capacity, workload of the medical staff and dearth of sufficient funds are some of the reasons for poor delivery of the nutrition component under BPHS and EPHS. The scarcity of health professionals with a nutritional background continues to hamper access of the population to quality nutrition services. Efforts have been made by the Public Nutrition Department (PND) of the MoPH to functionalize the nutrition component of

BPHS. In 2011, a Training of Trainers (ToT) was conducted, which brought together two trainers for each province of the country. Subsequently, resources were mobilized to cascade the trainings to the health facilities and communities, but the initiative proved less effective than expected. Other initiatives included provision of complementary foods, improvement in the reporting formats and development of a database. These efforts are still under assessment for their effectiveness. Furthermore, Save the Children and Worldvision are conducting on the job training programs in nine provinces of Afghanistan to reinforce the nutrition component of the BPHS. The

Global Alliance for Improved Nutrition works with the private sector and the UN to develop programs on reducing micronutrient deficiencies and stunting. WHO, WFP and UNICEF support various NGOs to treat Severe and

Moderate Acute Malnutrition. A Nutrition Surveillance and Monitoring System is being developed with the support of DFATD.

Notwithstanding the ongoing interventions described above, a comprehensive coordination among key stakeholders (NGOs, UNICEF, WFP, WHO, DFATD, WB, USAID and EU) is still lacking. However, the need for a multi-sectoral approach and to focus on prevention has been recently acknowledged by development partners and discussions are ongoing to improve coordination.

Nutrition specific component of the AAP2014

The EU's Action "Support to Health and Nutrition Services to the Afghan Population", under the Annual Action Plan

2014, aims at addressing malnutrition in Afghanistan in coordination with development partners and under the auspices and lead of the Public Nutrition Department. The programme will address the capacity building needs of health professionals, service providers and training institutions and will seek to promote innovative ways to increase communities' awareness of nutrition issues and the outreach capacity of the BPHS and EPHS implementers.

The Overall Objective of the Action is to support the Government of Afghanistan towards the improvement of the health and nutrition status of the Afghan population, while its Specific Objective is to strengthen the public health system and the delivery of public health services.

In particular, Result 2 of the Action focuses on nutrition: Availability and quality of nutrition services are enhanced and nutrition awareness is increased among health service implementers and users throughout the country.

Foreseen activities under Result 2 of the Action include:

2.1. Upgrading of the nutrition curricula in the existing diplomas of health professionals at the Institute of Health

Sciences (IHS) and the Medical University of Kabul and establishing a specific nutrition diploma.

2.2.a Increasing access to nutrition services regarding curative measures and prevention of malnutrition via the establishment under SEHAT of an innovation award mechanism to contract improved nutrition services with current service-providing NGOs.

2.2.b Building capacity of current service providers in delivering nutrition related services.

4 Inpatient and Outpatient Departments for Severe Acute Malnutrition and Outpatient Departments for Moderate

Acute Malnutrition

The indicative operational implementation period of the Action is 48 months from the date of entry into force of the financing agreement between the EU and the Ministry of Finance. The financial envelope for nutrition related activities is of EUR 22 500 000.

The main target group of the nutrition component of the Action is the Afghan population, with a focus on the most vulnerable groups, in particular women and children under 2 years old.

The activities mentioned above can be further broken down as follow.

Activity 2.1

1. Upgrading of the nutrition curricula in the existing diplomas of nurses and midwives at the Institute of Health

Sciences (IHS) and training of teachers in the new curricula.

2. Revision of the nutrition curricula in the Bachelor Degrees for Medical Doctors, Nurses and the Public Health

Post-graduate program of the Kabul Medical University.

3. Integration of a specific Nutrition Diploma under the Public Health Post-graduate program at the Medical

University of Kabul.

Implementation modality: the EU will award a service contract aimed at providing Technical Assistance to the

Institute of Health Sciences and the Medical University of Kabul.

Activity 2.2.a

An "innovation award mechanism" will be created under SEHAT. It will provide current BPHS implementers with the opportunity to access extra funds through a competitive selection process based on pre-defined criteria. The aim of the additional funds will be to implement innovative actions to increase the nutrition status of the served population. The nature of activities foreseen under this component will be specified by a designated working group led by the Public Nutrition Department and the Nutrition Coordination Committee. The allocation of further instalments will be results-based. Innovative interventions to be considered could include but are not limited to:

• Innovative approaches to identify and address the underlying causes that keep women from making appropriate use of preventive and curative health care.

• Use of birth registration for early identification of mothers and new-borns to target women/families for home delivery of nutrition counselling and timely referral to health facilities.

• Organisation of local meetings for families with vulnerable and at risk children to identify the causes and context-sensitive solutions.

• Introduction of new Information Communication Technology (i.e. through mobile phones) to improve timely and accurate reporting of results, birth reporting, etc.

• Close collaboration with other sectors and nutrition related programmes of other Agencies and

Development Partners (UNICEF, WHO, WFP, USAID, DFADT, etc.) to create synergies, ensure the complementarity and scale of the actions, exchange good experience and lessons learned and avoid duplication of activities.

• Purchase and distribution of RUTF and other nutrition commodities.

• Use of appropriate methods of measurement of the quality, effectiveness and impact of the proposed interventions, by the providers and by an independent monitoring firm.

Implementation modality: on budget through ARTF/SEHAT.

Activity 2.2.b

1. In-service training to service providers (NGOs) responsible of the implementation of BPHS and EPHS.

2. On-the-job training, follow up and mentoring to the same services providers (NGOs).

3. Specific training to Public Nutrition Officers (MoPH) on the follow up, supervision and M&E of nutrition activities.

Implementation modality: on budget through ARTF/SEHAT

Results and activities FRAMEWORK

Overall Objective:

To support the

Government of

Afghanistan towards the improvement of the health and nutrition status of the

Afghan population.

Specific Objective:

To strengthen the public health system and the delivery of public health services.

Expected result:

Availability and quality of nutrition services are enhanced and nutrition awareness is increased among health service implementers and users throughout the country.

Objectively verifiable indicators of achievement:

- 60% of health facilities provide all nutrition services (growth monitoring and promotion, nutrition education and counselling, breast feeding counselling and complementary feeding counselling, screening and treatment of malnutrition, provision of iron and folic acid to target groups)

- Percentage of pregnant and lactating women attending BPHS who received counselling on healthy nutrition and infant and young child feeding up to 50% from approximately 15.5% (exclusive breastfeeding)

- Percentage of Exclusive Breastfeeding up to 70% from 58.4%.

- Coverage of pregnant women with iron and folic acid supplementation up to 50% (now sporadic)

- Vitamin A deficiency among 6-59 month old children decreased from 45.8% to 30%.

Activities Sub-Activities Budget and

Implementation modalities

2.1. Upgrading of the

nutrition curricula in the existing diplomas of health professionals at the

Institute of Health

Sciences (IHS) and the

Medical University of

Kabul and establishing a specific nutrition diploma.

1. Integration of the nutrition curricula in the existing diplomas of nurses and midwives at the Institute of Health Sciences (IHS) and training of teachers in the new curricula.

2.Revision of the nutrition curricula in the bachelors for Medical

Doctors, Nurses and the Public Health Post-graduate program of the

Kabul Medical University

3. Establish a specific Nutrition Diploma under the Public Health Post-graduate program at the Medical University of Kabul.

EUR 5 Million

Technical Cooperation through service contract

2.2.a Increasing access to nutrition services regarding curative measures and prevention of malnutrition via the establishment under

SEHAT of an innovation award mechanism to contract improved nutrition services with current service-providing

NGOs.

Innovative approaches to strengthen the nutrition component of the

BPHS and EPHS under SEHAT with additional outreach and innovative interventions.

Activities will look at ensuring that nutrition targets will be met and the quality, effectiveness and coverage of nutrition-specific interventions will be improved

EUR 9.5 Million

On-budget through

SEHAT program.

2.2.b Building capacity of current service providers in delivering nutrition related services.

1.In-service training to service providers (NGOs) responsible of the implementation of BPHS and EPHS.

2. On-the-job training, follow up and mentoring to the same services providers (NGOs).

3. Specific training to Public Nutrition Officers (MoPH) on the follow up, supervision and M&E of nutrition activities.

EUR 8 Million

On-budget through

SEHAT program.

Alignment to Government priorities and strategies

The overall EU's Annual Action Plan 2014 is aligned with the Ministry of Public Health's Strategic Plan 2011-2015 and the National Health and Nutrition Policy (2012-2020). Specifically, the nutrition activities will contribute to achieving the Strategic Objectives 1, 2 and 3 of the Strategic Plan (SO1. Improve the nutritional status of the Afghan population, SO2. Strengthen human resource management and development and SO3. Increase equitable access to quality health services) and the 4 main targets of the National Health and Nutrition Policy (2012-2020): 1) To reduce the Maternal Mortality Rate, 2) To reduce Infant Mortality Rate, 3) To reduce Under Five Children mortality and 4) To reduce chronic malnutrition among children under 5 years of age.

The institutional support to the training institutions (Institute of Health Sciences and the Medical University of

Kabul) is aligned with Government’s health and nutrition policies and strategies. The proposed new nutritionist diploma was explicitly requested by the Public Nutrition Department of the Ministry of Public Health.

The innovation award mechanism will reinforce the SEHAT program in the delivery of nutrition services and the outreach capacity of the BPHS and EPHS systems. The implementation of the nutrition activities included under

BPHS and EPHS is an upmost priority of the Public Nutrition Department and development partners engaged in

SEHAT.

Building the capacity of current service providers will strengthen the system and its capacity to effectively deliver preventive and curative nutrition services as included in the BPHS (2010). The list of activities under BPHS includes four main areas: nutrition assessment, prevention of malnutrition, treatment of malnutrition and screening and surveillance. The capacity building activities will address the specific needs of each staff category (medical doctors, nurses, midwives, Community Health Workers and NGO focal points for nutrition) as defined by the Public Nutrition

Department in the recently developed training package for nutrition services.