Attach_11-USAID_Ghana_Int_Nut_Invest_Fr_2012.pdf

INTEGRATED NUTRITION INVESTMENT FRAMEWORK (INIF)

USAID/GHANA

August 2010

Prepared by:

Laura Birx, GH/HIDN/NUT Eunyong Chung, GH/HIDN/NUT Roshelle Payes, GH/HIDN/NUT Rosanna Agble, Consultant

Contents

EXECUTIVE SUMMARY

Situational Analysis

Demographic indicators

Progress toward MDG1, MDG4, MDG5

Nutrition status and progress

Agriculture status and progress

Current policy directions for improving nutrition

Health and nutrition policies

Agriculture and food security policies

Community‐based approaches for improving health and nutrition

Programming Options, Priority Investments and Action Plan

Integrating nutrition into value chain approaches

Nutrition Strategic Approach

PREVENTION OF UNDERNUTRITION

Recommended Investment 1: Social and Behavior Change Communication for National Infant and

Young Child Feeding (IYCF) Campaign

Recommended Investment 2: Strengthen Maternal Anemia Interventions

Recommended Investment 3: Child Anemia

Recommended Investment 4: Integrated Nutrition‐Agriculture Program

NUTRITION SERVICE DELIVERY

Recommended Investment 5: National Scale‐up of CMAM with Expanded Outreach

ENABLING ENVIRONMENT & COUNTRY OWNERSHIP

Existing capacity and limitations

Strategic Use of USG Resources

Annexes

Annex 1: Nutrition policies, strategies and major programs in Ghana

Annex 2: USAID/Ghana Feed the Future Results Framework

Annex 3: USAID/Ghana: Potential Nutrition Program Coverage

Annex 4: Household Hunger Scale & Dietary Diversity Questionnaires

Annex 5: August TDY, GH/Nutrition Team Agenda

Annex 6: People Consulted during August GH/Nutrition Team Visit

Annex 7: References & Documents Consulted

Tables & Figures

Table 1. Core Nutrition Indicators Table 2. Estimated population by region Table 3. Ghana’s Progress toward MDG1, 4, and 5 Table 4. Trends in Child Disease Table 5. Nutritional status of children and women in Ghana Table 6. FASDEP Objectives and METASIP Components Table 7. Distribution of MOFA staff Table 8. Nutrition programming timeline Table 9. Recommended Investments

Figure 1. Trends in Nutritional Status of Children under Five Figure 2. Complementary feeding indicators for Ghanaian children 6‐23 months Figure 3. Integrating nutrition into the value chain (Source: Adapted from REACH, Sierra Leone) Figure 4. USAID Strategic Approach

INTEGRATED NUTRITION INVESTMENT FRAMEWORK (INIF)

USAID/GHANA

EXECUTIVE SUMMARY

Ghana is often highlighted as a model country in sub‐Saharan Africa with aspirations to transition from a low‐income to middle‐income country by 2020. Strong economic growth, stable democratic governance, and, steady increases in per capita income since 2000 have put Ghana on track to meet Millennium Development Goal 1 (MDG1). However, opportunities to address persistent food insecurity, health, and nutrition challenges must be addressed before Ghana achieves long‐term improvements in poverty reduction and nutritional status.

The prevalence of underweight, wasting, and stunting among young children is significantly lower in Ghana than most West African countries, such as Mali, Niger, and Burkina Faso. However, with the exception of underweight, child growth has not improved substantially over the last five years.

According to the 2008 Demographic and Health Survey (DHS) the prevalence of stunting among children under five is 28%, compared to 30% in 2003. During the same period, wasting among young children actually increased from 7% to 9%. Even more alarming are the critical and stubborn levels of maternal and children anemia, 59% and 78% respectively (45% and 76% in 2003). If these indicators were measurements of progress toward MDG1, Ghana would find itself far off‐track.

Figure 1. Trends in Nutritional Status of Children under Five

National average also masks substantial disparities within the country. The Northern regions (Upper East, Upper West, and Northern) have greater rates of underweight and wasting which are linked closely to food insecurity. Lack of access to food is also a determining factor for acute undernutrition in the Coastal zone. While Upper East and Northern regions are also burdened with high rates of chronic undernutriton, the Southern regions of Central and Eastern demonstrate above average rates of stunting. While food access is less of an issue for these regions, chronic malnutrition here is linked to household poverty levels, disease burden (malaria, HIV/AIDS, intestinal worms), inadequate sanitation facilities, and infant and young child feeding practices.

In October 2009, Ghana was the 10th country to sign the Comprehensive Africa Agricultural Development Program (CAADP) Compact to confirm the country’s commitment to the CAADP agenda of achieving economic growth through agriculture‐led development. The CAADP implementation process has been integrated into and complemented by the Government of Ghana’s (GOG) Food and Agriculture

9 14

Stunting (height-for-age)

Wasting (weight-for-height)

Underweight (weight-for-age)

Anemia

2003 DHS 2008 DHS

Sector Development Policy (FASDEP II) and the Medium‐Term Agricultural Sector Investment Plan (METASIP). Policy objectives and plans focus on: 1) food security and emergency preparedness; 2) Improved growth in incomes and reduced income variability directly promoting commodity development; 3) Increased competitiveness and enhanced integration into domestic and international markets; 4) Science and technology applied in food and agriculture development; and, 5) Enhanced institutional coordination.

To support the GOG achieve its vision for agriculture‐led growth and improved food security, USAID/Ghana completed a Feed the Future (FTF) Implementation Plan in March 2010 and presented a draft Multi‐Year Food Security Strategy (MYFSS) in August 2010 to a USG interagency committee. The MYFSS emphasizes value chain approaches to assist Ghana to meet internal demand for staple crops and fish, increase the availability and access to nutritious foods, and, improve government capacity and policies to strengthen the agricultural sector. In addition to supporting inclusive agriculture‐led growth, improving the nutritional status of women and children is a high‐level goal of FTF. Nutrition also falls within ‘Pillar 3 – Food supply and hunger’ of CAADP which aims to reduce hunger by addressing constraints to availability, access, and utilization/consumption of nutritious food.

To assist USAID/Ghana identify priority areas for food security and nutrition efforts, a GH/Nutrition team along with a local consultant visited Ghana in August 2010. The purpose of the visit was to provide strategic planning assistance by conducting an analysis of current USG nutrition investments, existing nutrition links and gaps between sectors, country needs, and gaps in knowledge, programming, and capacity. Partner roundtables, consultations with GOG representatives and other stakeholders, as well as field visits to nutrition, agriculture, and livelihood interventions sites, and a debriefing with USAID/Ghana informed the development of the following Integrated Nutrition Investment Framework (INIF). The INIF provides a roadmap for USAID/Ghana for planning and implementing nutrition programs and activities for FY11‐FY15. The INIF primarily focuses on potential programming options of FY10 and FY11 GHCS Nutrition funds, $2.5m and $12m respectively. However, existing and potential MCH and DA/Agricultural investments are also taken into consideration to ensure coordinated programming and planning.

The recommended priority nutrition investments for USAID/Ghana are briefly summarized in the box below. The document provides a more detailed situational analysis of nutrition and food security in Ghana, a review of current policy directions, and, presents priority investments, programming options and an action plan.

Recommended Priority Nutrition Investments for USAID/GHANA Develop and launch social and behavior change communication for national infant and young child feeding campaign Improve quality of ANC services for addressing maternal anemia, including appropriate education on dietary requirements during pregnancy and infectious disease control.

Conduct rapid operations research to increase knowledge of contributing factors and potential program constraints to reducing high prevalence of child anemia. Utilize findings to inform development of a national child anemia program.

Scale‐up of community management of acute malnutrition (CMAM), including strengthening outreach component as platform for prevention of undernutrition.

Design and implement integrated nutrition‐agriculture program that focuses on female‐centered value chains, targeting vulnerable communities that may be excluded from staple crop value chain approaches. Incorporate health and nutrition education along with social and behavior change communication components to ensure a comprehensive approach for improving nutrition outcomes.

Increase support and leadership for nutrition enabling environment, including facilitating collaboration and consensus building for integrated approaches, improved metrics, and, capacity strengthening at national, regional, and district levels.

Through these investments and in partnership with the GOG, USG can contribute to the following nutritional outcomes:

Table 1. Core Nutrition Indicators

Baseline

Targets

2013 2015

% of children (under 5 years) underweight* 14 12 11

% of children (under 5 years) stunted 28 25 21

% of children (under 5 years) wasted 9 5 4

% of women with Body Mass Index <18.5 9 8 7

% of women with anemia 59 52 44

% of children (under 5 years) with anemia 78 66 55

% of infants exclusively breastfed <6 months 63 71 79

% of children with minimal acceptable diet (6‐23 mos)

27 31 35

% of children (6‐59 months) supplemented with vitamin A twice a year

56 67 90

*GOG target; Source: DHS 2008

Situational Analysis

Demographic indicators Ghana is located in the middle of West Africa and is home to an estimated 24 million inhabitants, with over half (53%) of the labor force involved in the agriculture sector. The total land area of 238,537 square kilometers is divided into 10 administrative regions, which are subdivided into 170 districts. Ashanti and Greater Accra are the most populated regions, while Upper East and Upper West are the least populated. Currently, USAID/Ghana’s health office programs cover the three southern regions – Western, Central, and Greater Accra – representing 37% of the total population. Meanwhile, USAID’s Economic Growth office plans to focus on the less populated regions of Upper West, Upper East, and Northern, a cumulative total of 16% of national population. These coverage levels should be considered when planning for national scale‐up of food security programs.

Table 2. Estimated population by region

Region 2010 %

Ashanti 4,839,100 20%

Greater Accra 4,358,263 18%

Western 2,558,113 11%

Eastern 2,297,565 10%

Northern 2,259,671 9%

Brong‐Ahafo 2,257,304 9%

Volta 1,878,316 8%

Central 1,864,104 8%

Upper East 1,001,926 4%

Upper West 637,157 3%

Total 23,951,519

Source: Ghana Statistical Service

Overall, the country’s population is young and increasingly urban. Forty‐four percent of the population is under 18 years and children under five years represent 14 % of the population. Since 1970, the population in urban centers has increased from 29% to an estimated 50% in 2010.

Falling drastically over the last 20 years from a total fertility rate (TFR) of 6.4 in 1988, Ghana achieved its fertility target of 4.0 in 2008 (DHS 2008). As in many countries, the TFR is higher in rural regions compared to urban areas (4.9 versus 3.1). Annual population growth is 2.2%, but the urban population growing at 4% per year.

There are distinct regional differences in Ghana’s economy, with the Southern regions experiencing greater prosperity due in large part to expanding urban centers, the concentration of national resources, better rainfall, and, direct access to the Gulf of Guinea and Lake Volta. Meanwhile, the Northern regions face climatic challenges of one rainy season and a long dry season leading to scarcer vegetation. These climatic variations, along with economic and social factors, have contributed to the three Northern regions experiencing substantially more food insecurity, reduced economic opportunity, and stagnated growth compared to the rest of the country. According to World Food Program’s 2009 Comprehensive Food Security and Vulnerability Assessment, 5% of the Ghana’s population has limited access to sufficient and nutritious food. However, in the Northern, Upper East, and Upper West, the proportion of food insecure population jumps to 10%, 15%, and 34% respectively.

Progress toward MDG1, MDG4, MDG5 Overall, Ghana has made important strides in child health and nutrition over the last decade. Under‐five mortality has declined and more children receive basic vaccinations. Ghanaian children are much less likely to die in infancy and young childhood than children in Mali, Sierra Leone, Nigeria, and Niger. With a per capita income of USD 450, Ghana is the first sub‐Saharan African country to meet the poverty target of MDG1 and it is one of the few on‐track to meet hunger target by 2015 (halving the proportion of underweight children under five). In 1991/2, the proportion of those in extreme poverty was estimated at 37%, but by 2005/6 this proportion was reduced to 18%. The country’s progress in poverty reduction has also been notable because almost all districts and regions, with the exception of Greater Accra and Upper West, recorded declines in poverty. The poverty rate actually increased in Greater Accra from 5.2% in 1998/9 to 12% in 2005, largely as a result of increasing rural migration. Nonetheless, there is evidence that poverty and hunger reductions are not equitable across the country. Poverty rates are much higher in the north (63%) compared to 20% for the rest of Ghana.

Ghana has also made progress in halving the prevalence of underweight children under five. This is the nutritional target where most progress has been made; rates have declined from 25% in 1998 to 14% in 2008. During the same period, both infant and under‐five mortality rates also declined. Despite these achievements, major child health challenges must be addressed before Ghana attains sustainable and equitable improvements. One in seven children in the Northern region dies before their fifth birthday and nearly 80% of children under five are anemic. Overall, the three northern regions and the Central region continue to experience unacceptable levels of undernutrition. Death in the first three months after birth have not declined and represents 60% of all infant mortality. In addition, one in every 20 children dies in the first year of life. While downward movement has been made in regards to underweight, one in three Ghanaian children are stunted, an indication of chronic undernutrition.

Table 3. Ghana’s Progress toward MDG1, 4, and 5

MDG, by 2015… Indicator DHS 1998 DHS 2003 DHS 2008

1a. Halve the proportion of people whose income is less than one dollar a day

Proportion of population below $1 (PPP) per day

XX% XX% 30%

1b. Halve the proportion of people who suffer from hunger

Prevalence of underweight among children five

24% 22% 14%

4. Reduce by two‐thirds the under‐five mortality rate

Under five mortality rate

108/1,000 111/1,000 80/1,000

Infant Mortality Rate 57/1 ,000 64/1,000 50/1,000

5. Reduce by three quarters the maternal mortality ratio

Maternal Mortality Ratio

450/100,000

Proportion of births attended by skilled health personnel

25% 47% 59%

Sources: Ghana Maternal Health Survey 2007; DHS 1998, 2003, and 2008

Prospects for achieving MDG targets are threatened by several interrelated challenges, including stagnant levels of chronic undernutrition, acute respiratory infections, diarrhea, anemia, and malaria, Again, national figures mask wide regional disparities across indicators.

Table 4. Trends in Child Disease

Region Fever Diarrhea ARI Anemia

2003 2008 2003 2008 2003 2008 2003 2008 Ashanti 20 25 14 20 8 6 79 78 Greater Accra 21 13 13 12 8 6 61 62 Western 23 10 14 15 13 4 80 80 Eastern 20 16 16 17 10 4 74 73 Northern 16 21 15 33 7 9 83 81 Brong‐Ahafo 18 27 14 28 10 6 75 78 Volta 31 19 13 5 20 3 73 79 Central 24 23 16 19 11 4 77 85 Upper East 21 22 21 20 9 3 79 89 Upper West 30 20 27 24 8 8 78 88 Total 21 20 15 20 10 6 76 78

Source: DHS 2003 and 2008

Nutrition status and progress Undernutrition in Ghana is characterized by significant variations in stunting, underweight, and wasting across wealth quintile and geographic region. Maternal and child anemia are widespread public health concerns across the country. While undernutrition rates stay below emergency thresholds, serious nutritional challenges threaten Ghana’s overall social and economic development. The Northern regions (Upper East, Upper West, and Northern) have greater rates of underweight and wasting which are linked closely to food insecurity, including availability and access issues. Lack of access to food is also a determining factor for acute undernutrition in the Coastal zone. While Upper East and Northern regions are also burdened with high rates of chronic undernutriton, the Southern regions of Central and Eastern demonstrate above average rates of stunting. While food availability is less of an issue for these regions, chronic malnutrition here is linked to household poverty levels, disease burden (malaria, HIV/AIDS, intestinal worms), inadequate sanitation facilities, and feeding practices. Mother’s education is also associated with child’s nutritional status (DHS 2008).

The rate of underweight children decreased from 18% in 2003 to 14% in 2008. Children in rural areas are more likely to be underweight than those residing in urban settings: 16% versus 11%. There are also disparities between regions with prevalence of underweight as high as 27% in Upper East and as low as 7% in Greater Accra. Children in the highest wealth quintile are less likely to be underweight compared to those in the lowest (9% vs 19%).

The prevalence of stunting among Ghanaian children declined in 2008 to 28% after staying at the same rate of 35% for nearly 15 years. However, stunting still poses a serious public health concern in many regions of the country where long‐term reductions are challenged by food availability, access, and consumption constraints. Chronic undernutrition is highest in Eastern (38%), Upper East (36%), and Central (34%). Greater Accra has the lowest prevalence at 14%. Furthermore, children of mothers with no education are almost twice as likely to experience poor linear growth compared to children of mothers with a secondary education or higher (30% versus 18%).

Wasting among young children is a result of failure to receive adequate nutrition in a specific period and is likely a consequence of recent illness or of seasonal variations of food availability. Wasting is more common in Upper West (14%), Northern (13%), and Central (12%). In these three regions, wasting is a serious public health problem with rates creeping toward emergency threshold level of 15%. The linkage between food insecurity and nutritional status is most apparent in this indicator, so these three regions are clearly areas where directly linking income improvement/food production with nutritional outcomes (reduction in wasting) is likely to be the most relevant.

Table 5. Nutritional status of children and women in Ghana

Children under five years (DHS 2008)

Region Stunting (HFA) (‐2 Z‐scores)

Wasting (WFH) (‐2 Z‐scores)

Underweight

(WFA)

(‐2 Z‐scores)

Prevalence of anemia

Prevalence of anemia among women

Western 27 6 10 80 71

Central 34 12 17 85 64

Greater Accra

14 6 6 62 51

Volta 27 5 14 79 58

Eastern 38 6 9 73 58

Ashanti 27 9 12 78 60

Brong Ahafo 25 5 14 78 58

Northern 32 13 22 81 59

Upper East 36 11 27 89 48

Upper West 25 14 13 88 67

Total 28 9 14 78 59

Source: DHS 2008

Due to concentrated efforts over the last decade, breastfeeding is nearly universal in Ghana. In 2008, 98% of children were ever breastfed and 63% were breastfed exclusively for the recommended period of 6 months. Nonetheless, the same progress has not been achieved for complementary feeding for children 6‐23 months, which represents an extremely critical period for growth and development. The figures below demonstrate the status of breastfeeding in comparison to complementary feeding.

Figure 2. Complementary feeding indicators for Ghanaian children 6‐23 months

Source: WHO, Infant and Young Child Feeding Practices, Country Profiles ‐ Ghana

Beginning at six months and onward the introduction of appropriate quality and quantity of complementary foods is essential. In Ghana, complementary foods are generally cereal based from maize, millet and sorghum. Less than half of children 6‐23 months receive foods from four or more food groups and just half are fed the minimum meal frequency. Inadequate complementary feeding practices also has implications for iron deficiency. Infants, especially low birth weight babies or those born to anemic mothers, are prone to iron deficiency during this critical period. Early introduction of cereal‐based weaning foods, from which iron absorption can be as low as 5%, can make iron deficiency more severe (Miller 2003). While the prevalence of minimum acceptable diet (27%) is higher in Ghana than other countries in the region (Mali 7%, Niger 3%, Nigeria 21%), it must be further improved in order to reduce chronic undernutrition.

Poor complementary feeding practices, illness (malaria, diarrhea, parasitic worms), and micronutrient deficiency are leading contributors to childhood morbidity and mortality. The most severe micronutrient deficiency among Ghanaian mothers and children is iron deficiency. When combined with a high malaria burden, the result is an alarming prevalence of anemia among young children – 78% among children under five. Anemia in children negatively impacts mental and physical development.

Iron deficiency is also particularly serious for pregnant women, since anemia can contribute to premature delivery and low birth weight. At a macro level, iron deficiency negatively impacts the development of human capital and future labor forces. Although growth among Ghanaian children is better than among children in neighboring countries, prevalence of child anemia rates are among the highest worldwide. Prevalence as high as 89%, 88%, and 85% can be found in Upper East, Upper West, and Central. Northern region follows closely with an anemia prevalence of 81% among young children.

Agriculture status and progress Agriculture plays an extremely important role in Ghanaian society. The sector accounts for 37% of GDP, of which 23% is attributed to the cocoa industry. Crop production has steadily expanded between 1995 and 2006. In addition, FAO estimates 55% of the population works in the agricultural sector. Despite the country’s high potential for agriculture, Ghana is not self sufficient in regards to food production and has been increasingly dependent on food imports in recent years. Despite economic growth, Ghana has been facing increasing vulnerability to food price hikes and regional food insecurity.

CAADP stocktaking documents highlight several constraints in the agricultural sector which have limited economic growth and food security. In general, there is a lack of good water management and soils are coarse with poor water holding capacity. The use of fertilizers, improved seed varieties, mechanized equipment and services is extremely limited throughout the country.

In addition to productivity challenges, access challenges are also widespread including poor quality roads and infrastructure which limit market access; poor breed stock within the livestock sector; high cost feed for poultry; competitions from imports; and inadequate post‐harvest storage and management. The poor performance of the agriculture sector is largely attributed to inadequate input supplies, inappropriate technology, low output and productivity growth

Similar to trends in health, nutrition, and poverty in Ghana, farming and crop systems are also largely determined by geographic region. Food crop production is present across the country, but in the forest zones, tree crops, cocoa, palm oil, coffee, and rubber are also important. Maize is especially grown in the South and middle zones. In the northern regions, millet and sorghum are more prominent (FAO).

FAO identifies five major food and agricultural commodities that are produced in Ghana primarily for human consumption: cassava, yams, plantains, taro and maize. Cassava is grown principally in the South and central regions of the country. Meanwhile, the production of plantain (an important staple crop) has declined over the last ten years due to pests, diseases, poor management practices, and lack of production technology. During the visit, several informants noted that the technologies and improved practices common to cocoa have not transferred into other value chains.

Current policy directions for improving nutrition

Health and nutrition policies The Ministry of Health (MOH) has the mandate to develop health policies while the Ghana Health Service (GHS) provides the technical aspects and implements programs. The ultimate goal of the MOH is to provide quality health services to ensure a healthy and productive population. The health sector plans to achieve this goal through pursuing three inter‐related and mutually reinforcing objectives: 1) To ensure that people live long, healthy and productive lives with reduced risk of injuries or death; 2) To reduce the excess risk and burden of morbidity, mortality and disability especially among poor and marginalised groups; and, 3) To reduce inequalities in access to health, population and nutrition services and health outcomes.

The National Medium Term Development Framework (MTDPF) aims to address the economic imbalances, re‐stabilize the economy, and place it on a path of sustained accelerated growth and poverty reduction towards achieving the millennium development goals and middle income status. In this context, the health sector will contribute in the development of the human capital required for ensuring the attainment of the set goals. The health sector will therefore work with all stakeholders to protect and promote the attainment of the highest level of health for development.

MTDPF aims to contribute to socio‐economic development by promoting health and vitality, through access to quality health services for all people living in Ghana using motivated personnel and promoting the development of a local health industry. Under this framework, health sector activities are cross‐ cutting and undernutrition is identified as a key challenge and concern. The five strategic objectives of the health sector for the period 2010 – 2013 are to:

1. Bridge the equity gaps in access to health care and nutrition services and ensure sustainable financing arrangements that protect the poor

2. Improve governance and strengthen efficiency and effectiveness in health service delivery, including medical emergencies

3. Improve access to quality maternal, neonatal, child and adolescent health services

4. Intensify prevention and control of non‐communicable and communicable diseases and promote healthy lifestyle

5. Strengthen institutional care, including mental health service delivery

Among the indicators to track progress of the MTDPF is the percentage of households consuming iodized salt and the prevalence of stunting in children under five years.

Even though no nutrition policy has yet been developed for Ghana, there has been considerable commitment at the national and ministerial level towards improving nutrition. A number of nutrition initiatives have been championed by high level policy makers, as reflected in the various nutrition related policies and the inclusion of nutrition in multiple policy documents (see Annex 1). The policy document “Imagine Ghana Without Malnutrition” developed by GHS explored the role of the health sector and especially the GHS in reducing the unacceptably high levels of malnutrition among the population. It is based on seven main objectives including improvement of breast feeding and complementary feeding practices, virtual elimination of micronutrient deficiencies, and enhancing collaboration with partners and relevant agencies involved in food and nutrition issues. Even though it is a concept, the strategies and objectives are not different from the activities being presently pursued by the Ghana Health Service. This document has succeeded in bringing together into one document the various programs being implemented in the Ghana Health Service to address nutrition issues.

Agriculture and food security policies The GOG has also developed and enacted several policies and strategies to improve the agriculture sector’s capacity to improve productivity and access to better meet national demand. The current GOG agenda stresses the importance of strong plans in all sectors and calls for the improvement of existing policies. The need for a coordinated approach for effective development of the agricultural sector has become paramount in the face of global crisis with the potential to undermine development efforts aimed at combating food insecurity and poverty reduction. Overcoming the increasing risks of food insecurity and poverty requires that the right policies and working approach. These can only be achieved through effective planning, monitoring and review of policies and plans in a manner that is inclusive and participatory. It is in the light of ensuring that key stakeholders play a critical role in the shaping of the agricultural sector that the signed COMPACT is designed.

GoG’s long term vision for economic and social development is set out in the National Development Program, translated into policy and an operational plan for the agricultural sector through the FASDEP II and Sector Plan. The overall agricultural sector goal is to achieve sustainable economic growth and social development, leading to the increase and diversification of household incomes, and ensuring food and nutrition security for all.

In line with the FASDEP, the sector plan outlines the following six major programs for 2009‐2015.

1. Food Security and Emergency Preparedness.

2. Improved Growth in Incomes and Reduced Income Variability

3. Increased Competitiveness and Enhanced Integration into Domestic and International

Markets

4. Sustainable Management of Land and Environment

5. Science and Technology Applied in Food and Agriculture Development

6. Enhanced Institutional Coordination

GOG’s effort to respond to the continued high levels of undernutrition and a need for improved coordination around nutrition is expanded under FASDEP objectives and the corresponding METASIP (2009‐2015), programs and components.

Table 6. FASDEP Objectives and METASIP Components

FASDEP Objectives

METASIP (2009‐2015), programs and components

Food Security and Emergency Preparedness. Includes vulnerability in food security through contingency planning, emergency preparedness including establishment of strategic stocks to address the negative effects of climatic change and natural disasters.

Productivity improvement

Support to improved nutrition

Support for Diversification of Livelihood Options of the poor with Off farm Activities Linked to agriculture

Food storage and distribution

Early Warning Systems and Emergency preparedness

Irrigation and water management

Mechanisation services

Enhanced Institutional Coordination.

Includes enhanced partnership and harmonisation of efforts in order to achieve maximum results in growth and development of the sector.

Strengthen Intra‐ministerial coordination

Inter‐ministerial coordination

Partnership with Private sector and Civil Society Organisations

Coordination with Development Partners

(Sources: ECOWAS Agricultural Policy; CAADP Compact; FASDEP II)

These sector policies demonstrate the GOG’s increased attention and effort to address undernutrition.

However, more concentrated efforts will be required to improve coordination and define roles and responsibilities between Ministries and sectors in order to translate these policies into effective action.

Community‐based approaches for improving health and nutrition As a process of bridging equity gaps in access to quality health services and removing non‐financial constraints to health care delivery, the GHS has developed a ‘Close to Client’ (CTC) System. At the heart of this system is the community‐based health planning and services (CHPS) initiative, a national program for reorienting and relocating primary health care from sub‐district health centres to convenient community locations. The CHPS initiative enables the GHS to improve access, reduce health inequalities, and promote equity of health outcomes by removing geographic barriers to health care.

The CHPS approach is based on the evidence that placing a nurse in the community substantially reduces childhood mortality, and combining nurse outreach with traditional leader and volunteer involvement builds male participation in family planning and improves health service system accountability. The human resource policy of the Ministry supports the CHPS program and there are plans to implement the program in all communities by training adequate numbers of community health officers for all communities.

Nurses termed Community Health Officers (CHO) are posted in communities to become community‐ based front‐line health workers who visit households, organize community health services and organize

Community health compounds clinics. Under CHPS, CHO receive advanced clinical and community organizational training enabling them to assume their additional duties and responsibilities as they reside in the community.

CHOs are selected, trained and relocated to community locations, where a resident nurse provides health services. By the end of 2008, 409 CHPS compounds have been made functional bringing services closer to 7.2% of the population. The Ministry plans to accelerate CHPS expansion in underserved areas and has projected that the number of CHPS compounds would be increased from 409 in 2008 to 2000 in 2013. USAID/Ghana health programs have already implemented activities through the CHPS platform and further collaboration should be considered as part of any future nutrition and food security interventions.

Programming Options, Priority Investments and Action Plan

Integrating nutrition into value chain approaches Under FTF, USAID/Ghana will emphasize value chain approaches with a particular focus on staple crops (rice, maize, soya) in the Northern regions and marine fisheries in coastal areas. USAID/Ghana’s Economic Growth (EG) office aims to increase income, reduce poverty, and improve food security by building upon and expanding existing mechanisms, such as the ADVANCE program managed by ACDI/VOCA. Through ADVANCE, USAID will integrate large numbers of small and medium size enterprises into increasingly comprehensive value chains. Embedded advisors and other technical assistance will influence structures, systems and relationship across the value chain, and support the GOG to reform binding constraints to agriculture, including land reform, marine fisheries, and institutional performance management.

Although USAID/Ghana’s health activities are not currently active in the geographic focus regions of the planned agriculture and economic growth interventions, there are options for integrating nutrition into value chain approaches and hence making these efforts more ‘nutrition‐sensitive’. As a starting point, nutrition indicators and targets should be integrated within interventions at the design, planning, implementation, monitoring, and evaluation stages. Household hunger scale, minimum acceptable diet, and women’s diet diversity indicators provide good indications of the availability of specific foods and can help assess household nutritional vulnerability and food insecurity. They could also potentially measure any changes in food security and nutrition among communities experiencing increases in income as a result of participating in USAID EG programs. Detailed information on these indicators and sample questionnaires are available in Annex 4.

Improving food availability, access, and utilization are all necessary for attaining positive nutritional outcomes. Within staple crop value chains, production AND use of these foods must be promoted.

Although commercialization and modernization of markets is important, food security and nutritional status in the most vulnerable communities depends largely on rural, local markets. Small farms provide over 90% of Africa’s agriculture production and women produce 60‐80% of the food that is consumed (Fanzo et al 2010). These smaller farms and markets cannot be overlooked by economic growth interventions. Improving food security and rural development depend on short, medium, and long‐term strategies that address food production, livelihoods, and infrastructure. Interventions at each of these levels also have implications for improving nutritional outcomes. Decreasing post‐harvest storage losses in both quantity and quality can increase a community’s resiliency, especially during lean seasons or unexpected shocks. Concurrently, livelihoods can be improved by supporting agribusiness and agroprocessing technologies which can contribute to increased incomes. When these programs are targeted toward women and coupled with health and nutrition education, food utilization and care practices can be significantly improved. The figure below illustrates how nutrition sensitive approaches can be integrated into the value chain and potential impact on income generation as well as improved nutritional status.

Figure 3. Integrating nutrition into the value chain (Source: Adapted from REACH, Sierra Leone)

Within value chain approaches, investments in multiple forms of capital have been effective in improving nutritional status of vulnerable populations (World Bank 2008). Effective agricultural approaches for improved nutritional outcomes include coordinated and comprehensive support for nutrition education and gender considerations (human capital); focus on participatory processes (social capital); access to credit, training, education, and other resources to enable most vulnerable populations to “step up” (financial); improved and sustainable agricultural practices (natural); along with investments in physical capital of tools, land, and other agricultural inputs.

Value chain approaches are characterized by establishing and strengthening linkages between value chain actors, transforming these relationships, facilitating changes in behavior, targeting leverage points, and empowering the private sector. These elements are also necessary for improving nutritional outcomes. When working to strengthen linkages between value chain actors and facilitate changes in behavior, nutrition education should be integrated within that work with a particular emphasis on dietary diversity and the use of increased income for improved nutrition. Health status should be linked to productivity and economic potential. Medium and large enterprises should also promote and support the use of maternal and child health services, i.e. encourage households to participate in child health days. A 2008 World Bank synthesis report found that agricultural programs that incorporated

Complementary, supplementary therapeutic feeding

Community and household messaging about nutritional needs of mothers and young children

Innovative marketing of nutritious & diverse food products

Entire Chain: Nutrition education, increase resources controlled by women

Local procurement, market info. & increased access

Post‐harvest, technology transfer and facility set‐ up/financing, local formulation, quality assurance

Farmer organization & training, access to inputs & credit

Improved nutritional status Preparation and consumption

Intra-household allocation of food

Purchase diverse & nutritious foods

Food for Own Consumption

Productio n of staple crops

Processing & fortification

Commercializa tion and

Income Generat ion Smallholder value chain

Impact to smallholders

Institutional Interventions nutrition outreach and behavior change increased the likelihood of positive nutritional impacts.

Nutrition education and communication strategies may include instruction on food preparation, child‐ care and feeding practices, and how to recognize the signs of nutritional deficiency. Although most of the documented program experiences of nutrition education and agricultural interventions are with homestead food production programs, the incorporation of nutrition education into larger scale agricultural activities is still feasible and should not be overlooked.

A study in Indonesia found that maternal nutrition knowledge is actually a more central determinant of child micronutrient outcomes than is maternal schooling (Block 2003). The study examined household level data from Central Java where Helen Keller International was implementing a UNICEF supported social marketing campaign in collaboration with the Indonesian Ministry of Health. The program included a mass media campaign along with interpersonal communication through rural health centers.

The campaign sought to increase intake of vitamin A by children and mothers by promoting the consumption of eggs and dark green leafy vegetables. Starting in 1996 and covering a population of over 30 million people, HKI regularly collected household level data on dietary diversity, expenditure, asset ownership, morbidity, and nutritional status. The 2003 study classified ‘micronutrient rich foods’ as a composite commodity inclusive of beef, fish, chicken, vegetables, fruits, milk and eggs. The study found that mothers with nutrition knowledge devoted larger shares of their food budget to these foods and that nutrition knowledge also substitutes for income in driving demand for micronutrient‐rich foods.

When comparing households that received nutrition education versus those that did not, the data demonstrated that while the food budget of both households was identical, those with nutrition knowledge devoted a greater allocation of their food budget to micronutrient‐rich foods. Nutrition knowledge also serves as a coping tool. Faced with increases in the price of staple foods, household without nutrition knowledge sharply reduce their budget share on micronutrient‐rich foods, but mothers with nutrition knowledge do not and may even reallocate income towards diverse foods.

These findings and programmatic experiences can be adapted to the Ghanaian context and potential platforms for expanding nutrition knowledge. Many experts and local informants suggested exploring the feasibility of utilizing MOFA’s Agricultural Extension Officers as an additional platform for promoting dietary diversity and improved nutrition practices. The feasibility and capacity of these extension officers for implementing such activities should be seriously considered by the EG office and implementing partners.

Nutrition Strategic Approach FTF aims to strengthen and improve the link between agriculture and improved nutrition outcomes.

While increased production of food can lead to increased income, increased purchasing of food, and reduced food prices, increased production alone does not lead to long‐term improvements in nutrition, especially among the most vulnerable households. The multiple dimensions and causes of undernutrition require smart integration and a comprehensive approach to addressing food security and undernutrition through multiple pathways, including agriculture, health, social and behavioral issues, and social protection. The approach illustrated below represents our foundation for maximizing the synergies of health and agriculture‐based interventions to address the challenge of undernutrition. This strategic approach has been adapted to the meet the needs and opportunities in Ghana.

Figure 4. USAID Strategic Approach

Under the USAID/Ghana Health Sector Strategy 2009‐2013, the Health Office currently supports programs in family planning, maternal, newborn, and child health, nutrition, HIV/AIDS, as well as water and sanitation in three regions – Western, Central, and Greater Accra. These represents approximately one‐third of Ghana’s total population. While activities currently do not coincide with the EG’s offices proposed target regions (Northern, Upper East, and Upper West), existing health platforms have potential for improved coordination and expansion into additional areas. The following section outlines programming options and priority investments primarily for GHCS‐N in support of FTF and GHI goals and objectives.

PREVENTION OF UNDERNUTRITION

Recommended Investment 1: Social and Behavior Change Communication for National Infant and Young Child Feeding (IYCF) Campaign Given the decrease in prevalence of underweight along with significant levels of chronic undernutrition and child anemia, USAID/Ghana and partners should place greater emphasis on prevention of undernutrition in addition to integrating Community Management of Acute Malnutrition (CMAM).

Preliminary steps have already been taken by implementing partners and GHS to expand and improve health education and training guidelines for infant and young children feeding and dietary diversity.

Many informants applauded communication, advocacy, and training efforts which contributed to dramatic increases in exclusive breastfeeding and noted that similar intensive efforts are needed now for improving complementary feeding. A top priority for early FY10 should be for USAID/Ghana to develop and launch a national IYCF campaign using mass media, improved IEC materials, and other communication channels. A well coordinated and designed communication campaign, including mass media and interpersonal communication efforts, could contribute significantly to improved feeding practices and increase the prevalence of minimum acceptable diet among children 6‐23 months.

USAID STRATEGIC APPROACH

The development window of opportunity ‐Maternal nutrition ‐Early initiation, exclusive, and continued breastfeeding ‐Minimum acceptable diet (infant and young child feeding practices 6‐23 months) ‐Adequate water, sanitation and hygiene Diet quality and diversification ‐Community and home food production ‐Post‐harvest food preservation and processing ‐Food fortification

Micronutrient supplementation ‐Targeted micronutrient supplementation for pregnant women and young children

Community Management of Acute Undernutrition ‐Management of moderate undernutrition ‐Treatment of severe acute undernutrition with ready‐to‐use therapeutic foods

NUTRITION SERVICE

DELIVERY

PREVENTION OF

UNDERNUTRITION

Country Ownership and Enabling Environment

Consensus and capacity strengthening

Nutrition and food security policy

Private sector engagementCommunity‐oriented platforms

Advance new tools and approaches Monitoring and evaluation

These activities should overlap in the northern regions where USAID/Ghana’s economic growth activities are planned and target actors across the value chain. BCS could be a potential mechanism to ensure coordination with GHS as well as UNICEF who is very active in these regions. Although BCS does not have funding or a mandate for community‐level efforts in the northern regions, they could still play a critical role in the development of a national campaign. This would ensure that messages to be heard across they country are uniform and consistent. BCS could also potentially collaborate with other agencies such as UNICEF or JICA, which are more established in the target regions to implement community‐level interventions. USAID/Ghana and partners should also explore the possibility of collaborating with FAO who is doing several farmer focused activities with rural radio. The interagency group on nutrition is a potential vehicle for coordination and harmonizing materials.

Recommended Investment 2: Strengthen Maternal Anemia Interventions Maternal anemia interventions are not new in Ghana and IEC materials are available to interventions.

Past evaluations and assessments report awareness among the MOH and GHS of the serious public health problem of maternal anemia. Beginning in 2001, USAID (through the MOST project) supported the development of a maternal anemia policy and mass media campaign, protocols for intermittent preventive treatment (IPT) of malaria during pregnancy, and guidelines for iron‐folate supplementation, deworming, and nutrition education. Additionally, an Anemia Control Coordinating Committee (ACCC) with multi stakeholder representation was established to oversee the strategy development and control program implementation. However, a 2005 evaluation found the ACCC’s inadequate leadership and inactivity resulted in poor implementation and scale‐up of the control program.

Other barriers highlighted by the MOST report were also confirmed by experts during the visit. Many noted that a persistent challenge has been that health care providers often do not inform mothers of the purpose of iron folate (IFA) supplements and importance over the course of pregnancy. Although women may be accessing ANC services earlier and receiving IFA supplements, most women still only visit the centers an average of three times and end up receiving an incomplete supply of supplements since these are provided on a monthly basis (MOST evaluation). Furthermore, counseling on maternal anemia rarely includes information on maternal nutrition and dietary diversity.

USAID/Ghana should revisit lessons learned from past anemia control efforts and renew support and technical assistance for quality services which are also coordinated with malaria and deworming activities. It is probably not necessary to revive the ACCC, but work through the already active Nutrition Interagency Working Group. Communication materials, training or job aids, and guidelines at all levels should be harmonized across partners and coordinated with GHS.

Despite the wealth of information on…