Attach_12-UNICEF-WFP-_Tackling_Malnutrition.pdf

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Progress and Utilization

Report No. 2

Donor:

CIDA

Prepared by:

WFP and UNICEF

Ghana Country Offices

May 2011

Tackling Malnutrition in Northern Ghana

SC/2009/0248

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TABLE OF CONTENTS

CONTRIBUTION DATA

LIST OF ACRONYMS

I. EXECUTIVE SUMMARY

II. PROJECT PURPOSE

III. RESULTS

IV. CONSTRAINTS, CHALLENGES AND RECCOMENDATIONS

V. FINANCIAL IMPLEMENTATION

VII. FUTURE WORK PLAN

VIII. EXPRESSION OF THANKS

APPENDIXES .............................................................................................. XXI

Photo on cover: A severely malnourished child receiving ready-to-eat therapeutic food at

Kperisi CHPS in Wa.

CONTRIBUTION DATA

Utilization/Progress Report # Second Progress and Utilization Report

Donor

CIDA

Assisted Country

Ghana

Assisted Programme/Project

Tackling Malnutrition in Northern Ghana

PBA Number

SC/2009/0248

Total Contribution (in USD)

UNICEF WFP TOTAL

2,199,863 1,095,318 3,295,181

Programmable Amount (USD)

2,055,992 1,053,191 3,109,183

Funds Utilized to date (USD)

1,873,565 659,170 2,532,735

Balance of Funds Available

(USD)

182,427 394,021 541,877

Duration of Support 1 March 2009 – 31 Dec 2011

Period Covered by Report

31 May 2010 – April 30, 2011

Date Prepared

May 2011

WFP and UNICEF contacts: For UNICEF:

UNICEF Representative: Iyabode Olusanmi iolusanmi@unicef.org

Deputy Representative: René van Dongen rvandongen@unicef.org

For WFP:

WFP Representative: Ismail Omer ismail.omer@wfp.org

Head of Programme: Hoang NguyenDuc nguyenduc.hoang@wfp.org mailto:yhaque@unicef.org mailto:rvandogen@unicef.org mailto:ismail.omer@wfp.org mailto:nguyenduc.hoang@wfp.org

LIST OF ACRONYMS

CBAs Community based Agents CBOs Community Based Organizations CBMF Community-Based Milling and Fortification CIDA Canadian International Development Agency CMAM Community-based Management of severe Acute Malnutrition CFSVA Comprehensive Food Security and Vulnerability Assessment DA District Assembly DCD Department for Community Development DHS Demographic Health Survey DNO District Nutrition Officer FANTA Food and Nutrition Technical Assistance FSMS Food Security Monitoring System FM Frequency Modulation FRI Food Research Institute GHC Ghana Cedis GHS Ghana Health Service GoG Government of Ghana IDD Iodine Deficiency Disorder IPC In-Patient Care IMCH Integrated Maternal and Child Health campaign IMCI Integrated Management of Childhood Illnesses MICS Multiple Indicator Cluster Survey MOFA Ministry of Food and Agriculture MDAs Ministries Departments and Agencies MOH Ministry of Health MOWAC Ministry of Women and Children MICS Multiple Indicator Cluster Survey NCCE National Commission for Civic Education NE New Energy NGO Non-Governmental Organization NR Northern Region OPC Out-Patient Care ORS Oral Rehydration Salt RSIS Re-bagging and Sale of Iodized Salt RUTF Ready to Use Therapeutic Foods SME Small and Medium Enterprises SAM Severe Acute Malnutrition ToT Trainer of Trainers UER Upper East Region UNICEF United Nations Children’s Fund UWR Upper West Region WFP United Nations World Food Programme WIAD Women in Agricultural Development WVI World Vision International

I. EXECUTIVE SUMMARY

In 2009, CIDA approved CAD 4,000,000 (equivalent to US$ 3.3 million) for the joint UNICEF-WFP programme to tackle malnutrition in the three Northern regions in Ghana. To date UNICEF and WFP have received US$ 2,055,992 and USD 1,053,191, respectively. Expenditure as of May 2011 totaled US$1,873,565 by UNICEF and US$ 694,167 by WFP.

The project seeks to address malnutrition and improve food security particularly among pregnant/ lactating women and children below five years of age in the three northern regions of Ghana. The results are summarized below:

Nutrition rehabilitation of severely malnourished children Following the training of trainers (ToTs) within the first reporting period, UNICEF supported Ghana Health Service (GHS) to roll out the Community Management of Acute Malnutrition (CMAM) programme at the district level. To date, CMAM is being implemented in six, three and five districts in Northern, Upper East and Upper West Regions respectively.

Capacity building in the scale up of CMAM – which involved targeted training of health workers in health facilities with inpatient or outpatient CMAM facilities – was carried out in a cascading fashion due to the limited number of high quality trainers in Ghana from June 2010.

Overall, a total of 2,530 children aged five years and below were admitted to the CMAM project in the three northern regions. Out of these, 70.4 per cent were cured, 25.8 per cent of the cases defaulted, 1.5 per cent died and 2.8 per cent were non-recovery cases. UNICEF, together with Food and Nutrition Technical Assistance - 2 (FANTA-2) supported the GHS to convene a review meeting where progress made in the first scale up phase was reviewed and plans for 2011 drawn.

As a result, intense follow up has been carried out to improve on the relatively high default rate and support is ongoing.

UNICEF continues to provide therapeutic supplies such as ready-to-use therapeutic food (RUTF), therapeutic milks (F75 and F100), Complex Mineral and Vitamin mix (CMV), ReSoMal and anthropometric equipment in support of CMAM in the three northern regions.

Use of Zinc to treat Diarrhea In 2010, two thirds of the original community volunteers were targeted for a second round of training, which qualified them to treat diarrhea with zinc in addition to Oral Rehydration Salt (ORS), respiratory infections with amoxicillin, and screen children for severe acute malnutrition using Mid- Upper Arm Circumference (MUAC) tapes. In the first three months of 2011, approximately 4,000 children with diarrhea received treatment with combined ORS and zinc. Following the successful integration of zinc and ORS therapy at the community level, zinc will become part of diarrhea treatment protocol at all primary care facilities by the end of 2011.

Infant and Young Child Feeding

UNICEF supported the Ghana Health Service in improving the feeding of infants and young children by behavior change of care givers through the communications for development (C4D) approach. As a follow up to the need to change social norms, UNICEF supported the designation of maternity facilities as baby friendly and in lactation management for health workers. The broader objective of these activities is to support mothers to exclusively breastfeed their children for the first six months of life and to make this practice a norm in the northern regions (behavior change).

A total of 95 GHS staff from the northern and upper west regions were trained in lactation management. UNICEF also supported the Ghana health service to print and disseminate IEC materials targeting mothers and health care workers as part of a coordinated effort to increase adoption of behaviors related to proper and adequate infant and young child feeding.

Increased access to fortified foods and iodized salt at the household and community level

Under the WFP scale up, over 1000 women from 27 women’s groups selected from districts with high micronutrient malnutrition across the three northern regions were provided with the requisite machinery, equipment and training to enable them to improve the nutrition of their households and their communities under phase one of the scale up. Another batch of 27 women’s groups are benefiting from this assistance under a second phase of the project. In addition to increase access to fortified foods and iodized salt, women’s groups are being provided with incomes, which have the ripple effect of impacting their food security as well as their ability to improve their livelihoods.

WFP has implemented the scale up in close coordination and partnership with the Ghana Health Service, Women in Agricultural Development of the Ministry of Food and Agriculture (MOFA) and the Department for Community Development (DCD). Roadmap development, beneficiary selection criteria and trainings have been done jointly with counterparts from government to ensure effective handover.

Training of Trainers has been provided for the Department of Community Development to ensure sustainability of the programme.

Strengthening the nutrition and food security monitoring and evaluation and advocacy:

In close partnership with government partners, WFP has coordinated the increase of the number of sentinel sites from 102 to 182 to ensure better representation of the indicators and to strengthen the usefulness of the Food and Nutrition Security Monitoring System (FSNMS) bulletin as a tracking tool for the food security status of vulnerable households in specific geographic regions of the three northern regions.

As a strategy to improve the timeliness and information flow for data collection, dissemination and analysis, whilst also equipping decision makers with timely and relevant information of food security and nutrition indicators to inform appropriate response and decision making, WFP has procured 40 personal digital assistants (PDAs) with training, for use by data collectors. Requisite training in data collection using the PDAs has been provided for various categories of staff in partner organizations. Institutionalization is essential to the sustainability of the bulletin, and WFP builds the capacity of the government partners to ensure this.

WFP has coordinated the meeting of a broad range of stakeholders in agriculture, natural resource management, meteorology and livelihoods programming to develop livelihoods zone maps for the three northern regions. In the context of food security analysis, knowledge of local livelihood patterns is necessary for understanding the impact - at the household level - of hazards such as drought, floods or market dislocation, and will assist to better customize indicators for the food security monitoring system as the basis for targeting assistance to the most vulnerable areas.

II. PROJECT PURPOSE

The overall goal of the project is to reduce the number of food insecure people and reduce malnutrition-related diseases and deaths among children under the age of five years in the three northern regions of Ghana. The objective is to improve the health and nutritional status of children 0-59 months and pregnant/nursing women in the three northern regions through individual, household/ community, regional and domestic interventions.

The targeted outcomes of the project include a 5 percentage point reduction in underweight rates, a 3 percentage point reduction in wasting rates in children under 5 years, an increase in the number of households consuming adequately iodized salt from 15 to 50 per cent, an increase in the number of Food Security Monitoring System (FSMS) sentinel sites in the three regions from 102 sites (average of 3 per district) to at least 5 sites per district and local production of Ready-to- Use Therapeutic Food in Ghana.

Project Components

The project seeks to address malnutrition and improve food security particularly among pregnant/ lactating women and children below five years of age in the three northern regions of Ghana. The project is implementing the following six categories of activities at the individual, household/ community, regional and domestic levels. In some cases, activities with a national scope are supported, especially when rolling out an intervention is dependent on developing national guidelines.

1. Strengthening scale-up of High Impact Rapid Delivery (HIRD) interventions including the scale up of the use of zinc in the treatment of diarrhea; promoting, protecting and supporting optimal infant and young child feeding; vitamin A supplementation and deworming.

2. Rehabilitation of children with severe acute malnutrition using lipid-based nutrient supplements (plumpy’nut) within the community management of acute malnutrition (CMAM) programme.

3. Increased access to fortified foods at the household and community level. This involves:

Scale-up of WFP community-based cereal milling and fortification sites throughout the three Northern Regions, along with training community based interest groups in sustainable implementation and small business management, to ensure overall project sustainability.

Impact assessment of targeted communities; monitoring the number of women able to participate in the activity in the community, the number of households using the fortified flour at the household level, the percentage of total flour used at the household level that is fortified.

Behaviour change communication to promote household consumption of fortified foods.

4. Increased household consumption of iodized salt; This project component involves:

Support the scale-up of the WFP-supported program in which women’s groups re-bag iodized salt for resale to serve as an income-generating activity and further strengthen household food security.

Training of community-based interest groups on salt re-bagging and resale, and the management of small businesses.

An intensive behaviour change communication strategy in support of household consumption of iodized salt at community-based groups, producers, consumers, decision and policy makers.

Capacity building of the government enforcement agencies with training and logistics support.

5. Strengthening the Nutrition and Food Security Monitoring and evaluation component.

This activity involves supporting the Ministry of Food and Agriculture to strengthen the Food Security Monitoring System for the three northern regions in the following ways:

Increasing sentinel surveillance sites from a total of 102 to 184 (average of under 3 per district to a minimum of 5 per district)

Implementing community baseline studies selected sentinel sites to provide a context for the food security analysis and identify any root causes of continuing food insecurity.

Mapping of livelihood zones -

Provision of anthropometric measuring equipment to enable all sites to measure height and mid upper arm circumference.

Training of agriculture extension and health workers on data collection, collation and/or analysis.

Supporting national, regional and district nutrition directorates to (a) collect routine data more accurately, (b) collate district and regional-level data efficiently, and (c) analyze and disseminate district and regional level data in a timely manner for decision-making.

Operational research looking at social protection schemes’ effects on household nutrition and food security and to learn implementation lessons on the introduction of ‘sprinkles’ at the household level will be undertaken.

Rapid surveys for baseline and end of project evaluation.

6. Advocacy and support for the local production of ready to use therapeutic foods in Ghana.

Project Strategies

Child and maternal under nutrition in Ghana are important causes for child death and contribute to numerous diseases. The third lancet series on maternal and child under nutrition reviewed interventions that affect nutrition-related outcomes (linear growth, micronutrient status and related functional outcomes, mortality, morbidity and birth outcomes) and recommended low cost high impact interventions that should be scaled up to improve child survival. These interventions are part of the Accelerated Child Survival and Development package that has been adopted by the Ghana Ministry of Health (MOH) as one of the main strategies to reduce child and maternal mortality in Ghana. Specific nutrition interventions under the high impact rapid delivery strategy that are being implemented under the joint UNICEF/ WFP project include increasing rates of exclusive breastfeeding, boosting vitamin A supplementation, promotion of optimal complementary feeding, management of diarrhea using low osmolarity oral rehydration therapy and zinc and the rehabilitation of children who are severely malnourished.

The project focuses on three strategies to reduce micronutrient malnutrition in the three northern regions (a) food supplementation (b) food fortification and (c) promotion of dietary diversity especially in complementary foods. The community management of severe acute malnutrition employs a strategy of early identification, referral and treatment of severely malnourished children under 5 years old.

The approach to food security and nutrition monitoring is partnership-driven at the regional and district levels and involves monitoring of the key factors affecting food security - notably risks and livelihood trends, to enable stakeholders to better anticipate, prepare and respond to future crises.

The goal therefore of the FSNMS is to ensure that decision-makers are equipped with timely and relevant information for an appropriate response to a deteriorating food security situation. Thus, WFP has developed a strategy to monitor food security and nutrition indicators that foretell early warning signs of food and nutrition insecurity, using the food and nutrition security monitoring system bulletin.

Capacity building support to counterparts ensures the needed capacity to institutionalize the monitoring system to ensure sustainability

The project incorporates a gender analysis by recognizing the important and largely unrecognized role played by women by balancing the gender inequalities through increasing women’s participation in economic activities related to food fortification, resale of iodized salt by women groups etc.

Project Management

The project is implemented as a UN joint initiative between UNICEF and WFP and seeks to employ each agency’s comparative advantage. UNICEF has the primary responsibility and oversight in strengthening of HIRD interventions, rehabilitation of severely malnourished children, supporting the local production of lipid-based nutrient supplements (RUTF), supporting WFP on anthropometric data collection and analysis in the nutritional surveillance system and in the operational research on tackling anemia. WFP has the primary responsibility and oversight for community-based cereal milling and fortification, community-based re-bagging and resale of iodized salt and food security monitoring and analysis.

Joint coordination meetings are conducted at both field level and in Accra on a quarterly basis. The coordination meetings serves to discuss implementation bottlenecks, tackle technical and operational challenges, provide agency updates on implementation and as a forum for information sharing regarding programme implementation.

III. RESULTS

General description of results

Activities supported by the grant contributed to the scaling-up of high-impact nutrition interventions in partnership with the government of Ghana and other partners to reduce the number of young child deaths from preventable and easily treatable causes.

Interventions that were supported during the reporting period included:

The use of zinc in the treatment of diarrhea, Capacity building in the community management of acute malnutrition project, Breastfeeding support through designation of baby friendly hospitals and training health workers in lactation management, Behavior change targeting infant and young child feeding practices

Food fortification activities which have increased access to and consumption of fortified local cereals and increased availability and consumption of iodized salt at the community and household levels, whilst also providing an alternate source of income for the women groups as a business.

Increasing the number of FSNMS sentinel sites in the three regions from 102 sites (average of 3 per district) to 182 sites (5 sites per district) to ensure effective food security and nutrition data capture which informs planning by government and partners.

Project specific achievements

1. Strengthening scale-up of High Impact Rapid Delivery interventions

The use of Zinc to treat Diarrhea

Funds from the joint programme were leveraged with funds from the catalytic initiative to roll out the community-based treatment of diarrhea with ORS and Zinc in the three northern regions. Joint programme funds were used to procure essential supplies (including zinc tablets and MUAC tapes) and in providing technical support (staff costs) to GHS in implementing Community Case Management (CCM) services in the three northern regions.

UNICEF Ghana has partnered with the GHS since 2008 to provide Community Case Management services in areas of the country with poor access to facility-based health services. Community case management services include community-based diagnosis and treatment of simple cases of malaria, diarrhea and respiratory infections in children by trained community volunteers.

Volunteers also provide counseling on healthy home behaviors, including infant and young child feeding and hygiene. These services are particularly critical in Ghana’s three Northern regions, where poverty is concentrated, populations are most dispersed, and access to health services is poor. CCM covers three of four of the leading causes of under-five mortality (all but neonatal causes).

In 2010, two thirds of the original community volunteers were targeted for a second round of training, which qualified them to treat diarrhea with zinc in addition to ORS, respiratory infections with amoxicillin, and screen children for severe acute malnutrition using MUAC tapes. In the first three months of 2011, approximately 4,000 children with diarrhea received treatment with combined ORS and zinc. Following the successful integration of zinc and ORS therapy at the community level, zinc will become part of diarrhea treatment protocol at all primary care facilities by the end of 2011.

Utilization of CBA services, 2010. Data source: CCM monthly reports (from CBA registers)

NR UER UWR Total

# children treated for diarrhea by CBA (ORS) 4,712 11,118 1,312 17,142

Utilization of CBA services, January-March 2011. Data source: CCM monthly reports (from CBA registers)

NR UER UWR Total

# children treated for diarrhea by CBA (ORS+zinc) 2,830 Pending 486 3,316

2. Rehabilitation of children with severe acute malnutrition using lipid-based nutrient supplements

Following the training of ToTs within the first reporting period, UNICEF supported the roll out of district level trainings. To date, CMAM is being implemented in six, three and five districts in Northern, Upper East and Upper West Regions respectively.

Capacity building in the scale up of CMAM – which involved targeted training of health workers in health facilities with inpatient or outpatient CMAM facilities – was carried out in a cascading fashion due to the limited number of high quality trainers in Ghana. In general, the capacity building for the scale up started in June 2010. The table below lists the key performance of the implementing Districts from June 2010 to March 2011.

Overall, a total of 2,530 children aged five years and below were admitted to the CMAM project in the three northern regions. Out of these, 70.4 per cent were cured, 25.8 per cent of the cases defaulted, 1.5 per cent died and 2.8 per cent were non-recovery cases. A regional breakdown of this performance is outlined below;

Regional Summary of the CMAM programme

Upper West:

A total of 1,137 children suffering from severe acute malnutrition were admitted in 92 outpatient and 4 inpatient health facilities. Out of this total number of children admitted, 67 per cent were cured, 28 per cent defaulted from the treatment centers, 2.3 per cent died and another 2.3 per cent were classified as non-recovery cases (possibly due to HIV-AIDS related complications).

Performance of CMAM - Upper West

DISTRICT

Total

Admission Cure rate

Default rate

Death rate

Non recovery

JIRAPA 187 72.9 23.2 1.3 0

LAWRA 299 83.9 13.5 2.6 0

WA EAST 134 57.0 35.4 5.1 0

WA MUNICIPAL 201 73.5 18.5 2.0 8.5

WA WEST 316 44.3 52.0 1.8 1.8

Regional Total 1137 67.3 27.9 2.3 2.3

Summary of capacity building for the CMAM programme in Upper West

District # trained in OPC

# trained in IPC

# of CBAs trained

# of

OPC

sites

# of IPC sites

Jirapa 34 231 16 1

Lawra 30 326 21 2

Wa East 30 290 17 0

Wa Municipal 29 195 21 1

Wa West 27 474 17 0

Sub-total 150 1,516 92 4

Upper East In the Upper East region, a total of 709 children with severe acute malnutrition were admitted in 56 outpatient and 3 inpatient facilities. Out of this total, 72 per cent were cured, 25 per cent of the cases defaulted from the programme, 1 per cent died and 2 per cent were classified as non-recovery cases.

Performance of CMAM - Upper East

Total

Admission Cure rate

Default rate

Death rate (%)

Non recovery

BOLGA 244 67.1 30.5 1.4 0.95

KASSENA/NANKANA 103 48.5 51.5 0.0 0

BAWKU WEST 362 81.5 14.8 1.0 3.0

Regional Total 709 72.4 24.8 1.0 1.9

Summary of capacity building for the CMAM programme in Upper East trained in OPC trained in IPC

# of CBAs trained

# of

OPC

sites

# of IPC sites

Kassena/Nankana 38 7 250 21 1

Bawku West 44 4 250 23 1

Bolga 41 8 250 12 1

Sub-total 123 19 750 56 3

Northern Region

In the northern region, a total of 684 children with severe acute malnutrition were admitted in 58 outpatient and 10 inpatient health facilities. Out of this caseload, 73 per cent were cured, 23 per cent defaulted, 1 per cent died and 4 per cent were non-recovery cases.

Performance of CMAM - Northern Region

Total

Admission Cure rate

Default rate

Death rate

Non recovery

NANUMBA NORTH 147 68.5 28.8 0.0 10.95

GUSHIEGU 184 62.3 26.2 4.1 7.37

SABOBA 273 91.9 8.1 0.0 0

EAST GONJA 80 44.6 55.4 0.0 0

Regional Total 684 73.3 23.5 0.9 4.43

Summary of capacity building for the CMAM programme in Northern region

# trained in OPC

# trained in IPC

# of CBAs trained

# of

OPC

sites

# of IPC sites

Nanumba North 36 8 765 10 1

Gushiegu 32 6 950 9 1

East Gonja 35 10 461 12 1

Saboba 40 14 969 9 1

Savelugu/Nanton 35 12 0 11 1

East Mamprusi 35 12 0 7 1

Tamale 0 23 0 0 3

Yendi 0 5 0 0 1

Total 213 90 3,145 58 10

In February 2011 UNICEF and FANTA-2 provided support to GHS to convene a CMAM review meeting where programme data and progress in the first scale up plan was reviewed. Following issues raised during the review meeting, UNICEF is providing GHS with technical and logistical support in all three northern regions to improve the quality of the CMAM program especially in tackling the high default rates. Different components of the support are currently ongoing and include data management, analysis and interpretation, review and coordination meetings, the formation of regional SAM technical committees to support efforts to improve quality and intensified social behavior change communication. The cause of the high defaulter rate in the CMAM programme is due to a perception that malnutrition is a spiritual condition rather than a medical one– leading to many care seekers going to sooth sayers and religious leaders to ‘cure’ the condition.

UNICEF continues to provide therapeutic supplies such as ready-to-use therapeutic food (RUTF), therapeutic milks (F75 and F100), Complex Mineral and Vitamin mix (CMV), ReSoMal and anthropometric equipment for the roll out and scaling up of CMAM in the three northern regions.

3. Support for Infant and Young Child Feeding

UNICEF supported the Ghana Health Service in improving the feeding of infants and young children by behavior change of care givers through the communications for development (C4D) approach. As a follow up of the need to change social norms, UNICEF supported the designation of maternity facilities as baby friendly and in lactation management for health workers. The broader objective of these activities is to support mothers to exclusively breastfeed their children for the first six months of life and to make this practice a norm in the northern regions (behavior change).

A total of 95 GHS staff from the northern and upper west regions were trained in lactation management. UNICEF also supported the Ghana health service to print and disseminate IEC materials targeting mothers and health care workers as part of a coordinated effort to increase adoption of behaviors related to proper and adequate infant and young child feeding.

4. Increased households’ (HH) access to fortified foods by expanding community-based cereal milling and fortification across communities in the three Northern Regions.

The first reporting period saw the successful scale up of the first phase of community milling and fortification to a total of 403 women in 12 women groups across the three northern regions by WFP. Under this reporting period, 529 women from 12 women groups in 12 districts are benefiting from the intervention. Stakeholder meetings organized in all three regions for partners and stakeholders at the field level assessed the progress of phase one of the scale up, obtained district level updates from partners on RSIS and Community-based Milling and Fortification (CBMF) activities. The meetings also introduced partners to planned activities under phase II of the scale up.

From June 2010 to date, WFP has in collaboration with GHS, MOFA and DCD profiled all groups who were selected under the guidance of the Ghana Health Service, to obtain much-needed information on the membership and to ensure effective targeting of assistance to obtain maximum results. The profiling of the communities enabled assessment of the agro-processing potential of the communities and capacity gaps of the women groups, to gather appropriate recommendations for the technical and financial viability of the project in the communities.

WFP has purchased 12 grinding mills and their accessories as part of the package for women’s groups for the up-scaling of CBMF. The equipment is to be used to mill cereals for households and the community. The grinding mills are currently being installed in communities in the three districts of the Upper West region where phase 2 of the scale-up is being implemented. In collaboration with the Food Research Institute, WFP has fabricated 12 user-friendly fortification mixers for use by groups.

To house the grinding mills and be used as the operational site for the CBMF, structures are being constructed in all 12 communities with support from WFP. To ensure community ownership and sustainability of the project, this assistance is provided on a need basis only. Each beneficiary community contributes local construction materials, with WFP supplementing on need-basis.

A baseline survey has been undertaken in all the phase one communities, as a basis for comparison in an impact assessment at the end of the programme.

5. Increased HH consumption of iodized salt by increasing its distribution to 96 communities including salt re-bagging and resale.

In the first phase of the project, 508 women in 15 districts benefited from the project. Under this reporting period, 582 women from 15 districts have been selected and profiled in partnership with the Ghana Health Service, Department for Community Development, and Ministry of Food and Agriculture to catalogue background information of proposed communities/groups and determine the level of communities’ readiness for the intervention.

Thirty (30) electric sealers, 15 diesel powered generators, handy measures, packaging material and 13.5 metric tons of iodized salt have been provided to women groups. Provision of seed capital is ongoing.

To ensure the sustainability and active community/government participation in the project, WFP organized and facilitated training for 23 district officers (12 in Northern Region, 5 each in Upper West and Upper East Regions) of the Department for Community Development in 15 districts where the Re-bagging and Sale of Iodized Salt (RSIS) intervention is being implemented to build the capacity of the officers in the re-bagging of iodised salt to enable them effectively monitor the women groups under the project. The training sessions were facilitated by WFP and experienced WFP women’s group members from the pilot communities. Training for the Northern and Upper East Regions were facilitated by group members.

6. Food Security and Nutrition Monitoring System

During the previous reporting period, WFP coordinated the identification and selection of 76 new sentinel sites in the 3 northern regions (2 new sites per district) by Ghana Health Service in consultation with MoFA bringing the total number of sentinel sites to 190.

40 Personal Digital Assistants (PDAs) were procured to aid in the timely collection, analysis and dissemination of data for the FSNMS. .Government partners from the Ghana Health Service and Ministry of Food and Agriculture have been trained in data collection and analysis using the PDAs

There has also been timely production and release of monthly bulletins from June to April 2011 and mapping of livelihood zones.

Table 1: Project Specific Achievements

Objectives Area of activities Achievement

1. Strengthen scale-up of Catalytic Initiative and HIRD interventions

Zinc treatment for diarrhea UNICEF is supporting GHS to implement community case management of diarrhea within the larger context of providing CCM services for diarrhea, pneumonia and malaria. Funds have supported technical assistance (staff time) and procurements of zinc and MUAC tapes.

Training of health workers for ENA roll-out

UNICEF has continued to support exclusive breastfeeding, consumption of iodized salt and adequate complementary feeding both at national and regional levels.

Designation of hospitals/ Health Centers for Baby Friendly

UNICEF is continually strengthening the institutional capability of health centers to support, protect and promote exclusive breastfeeding. This is an ongoing activity being carried out in collaboration with GHS.

Strengthen Capacity for Vitamin A capsule supplementation/ distribution

Capacity for deworming of children under years

Technical support was provided during the Integrated Maternal and Child Health Campaign (Nov 2010) that included Vitamin A supplementation and deworming. UNICEF provided support to GHS in carrying out the deworming and VAS in the NID round carried out in April 2011.

2. Children with severe acute malnutrition in 26 districts rehabilitated using plumpy nuts.

Community-based rehabilitation of severely malnourished children.

Supplies for treatment of severe malnutrition (Plumpynut, resomal, F-100, F-75, CMV) have been procured. Emergency stocks of therapeutic foods have also been procured and prepositioned using the CIDA grants. The first phase of CMAM scale up is currently being implemented in 6 districts in the northern region, 3 in upper east and 6 in upper west.

Objectives Area of activities Achievement

3. Increased household access to fortified foods

Scale up of community based milling and fortification equipment, training and seed money.

WFP has provided 12 women groups from 12 districts with milling and fortification equipment following selection and profiling by government partners.

WFP is supporting communities in construction of structures to house grinding mills and fortificant mixers on a needs basis.

Fortificant premix provided, and fortification training scheduled to commence following completion of structures for the grinding mills and fortificants.

BCC for increased consumption of fortified cereals

Training of CBAS on effective health communication skills and innovative community outreach methods completed.

Impact assessment of community milling

Baseline data collected on Phase 1 groups in preparation for impact assessment at the project end.

Advocacy for consumption of fortified cereals

Ongoing

4. Increased households consumption of iodized salt

Scale-up of community-based re-bagging of iodized salt: equipment, training, seed-money facility, etc (15 new communities)

15 women’s groups in 15 districts selected as beneficiaries and profiled in collaboration with partners.

Electric sealers, diesel generators and packaging material procured for all groups.

Training of trainers provided by partners in the Department for Community Development.

Provision of seed money ongoing for all groups.

BCC for increased consumption of iodized salt

Training of approximately 15,000 CBAS on effective health communication skills and innovative community outreach methods completed. Stakeholder meetings at the regional directorate level have been supported as part of a wider strategy.

Training of women in income generating from resale of salt

Training in income-generation, business management and group dynamics in collaboration with the Department for Community Development pending for all 15 groups.

5. Strengthened nutritional and food security M&E system for Northern Ghana

Inclusion of more Food Security Monitoring System sentinel sites

WFP in collaboration with MoFA and GHS has coordinated the increase of sentinel sites from 102 to 180 across the three northern regions

Mapping of Livelihood zones

WFP has coordinated a meeting of a broad range of stakeholders in agriculture, natural resource management, meteorology and livelihoods programming to develop livelihoods zone maps for the three northern regions.

Baseline survey of Sentinel sites A baseline survey has been undertaken in all selected sentinel sites.

Anthropometric and office equipment

Training on data collection, collation and analysis

Following initial PDA training for M & E staff of MoFA, WFP VAM unit has provided refresher training in the use of PDAs in data collection and analysis for data collectors at MoFA and GHS in all three regions.

Operational Research on the use of Sprinkles and the evaluation of LEAP

This activity has been put on hold due to GHS’s concerns of iron and malaria endemicity in the 3 northern regions. The LEAP evaluation study was discontinued after consultations by both agencies.

Support MICS preparatory work

Preparatory work ongoing. Data collection scheduled for 2011.

6. Advocate for and support plumpy nut production facility in Ghana

This activity has been discontinued due to business enterprise management issues between Nutriset (France) and the proposed local franchise company (Athena Foods).

IV. CONSTRAINTS, CHALLENGES AND RECCOMENDATIONS

The following challenges and constraints were identified in the implementation of the project.

Measures being taken to mitigate the challenges and constraints are also listed.

1. Lack of a national nutrition policy: There is need for the development of a strong policy framework to support the implementation and coordination of nutrition programmes in Ghana to ensure programmatic coherence is achieved. UNICEF is currently supporting the Ghana Health Service in the policy development process.

2. High default rates in the CMAM programme in the three northern regions: A review of data from all three northern regions showed relatively high default rates. An assessment and follow up showed that the underlying reasons were (a) a misperception that severe undernutrition was caused by spiritual reasons, leading to care seekers avoiding bringing their sick children to the formal health care system (b) poor access to health care facilities during the rainy season (c) inadequate social mobilization. To this end, UNICEF has increased support for social mobilization to GHS.

3. Coordination of community level interventions: Approaches are still fragmented across the country, with different profiles, tools and inputs being utilized. Both UNICEF and WFP are supporting a centrally led initiative to harmonize and strengthen all existing approaches, including the development of national guidelines.

V. FINANCIAL IMPLEMENTATION

To date UNICEF and WFP have received US$ 2,055,992 and US$1,053,191 respectively.

Expenditure as of 1 May 2011 totaled US$1,873,565 by UNICEF and US$ 659,170 by WFP, with a balance of US$ 182,427 and US$ 394,021 to UNICEF and WFP respectively. Total programme utilization is 82.6 per cent. Detailed utilization reports are attached to this report. A summary of expenditures against planned budget is included below.

Objectives

Area of activity

Budget allocation per agency (CAN$)

Financial Utilization 1 Mar 2009 – 31 May

2011(US$)

UNICEF WFP UNICEF WFP

1. Strengthen scale-up of the Catalytic Initiative and

HIRD

interventions

Zinc treatment for diarrhea:

supplies, training and advocacy

240,000 142,926

Training of health workers for ENA roll-out

150,000 17,832

Designation of hospitals/ Health Centers for Baby Friendly 35,000 45,307

Strengthen Capacity for Vitamin A capsule supplementation/ distribution

10,000 0

Capacity for deworming of children 2-5 years

5,000 0

2. Children with severe acute malnutrition in 26 districts rehabilitated using Plumpy’nuts.

Community-based rehabilitation of severely malnourished children < 5 years in 201 communities: purchasing of plumpy'nuts and other equipment, training, etc.

1,100,000 1,066,921

Implementation of Positive Deviance/ Hearth model for improving nutrition and food security outcomes in 50 communities

5,000 0

Development and dissemination of national protocol for community-based management of acute malnutrition

80,000 10,664

3. Increased household access to fortified foods

Scale-up of community-based cereal milling and fortification:

equipment, training seed-money facility, 14 communities @ $50,000 per community

700,000 332,868

BCC for increased consumption of fortified cereals

30,000 0

Impact Assessment of community milling and fortification

75,000 5,700

Advocacy for consumption of fortified cereals

30,000 7,240

4. Increase household consumption of iodized salt

Scale-up of community-based re-bagging of iodized salt:

equipment, training, seed-money facility, etc (15 new communities @ $15,000 per community;

180,000 50,820

BCC for increased consumption of iodized salt

30,000 2,316

VII. FUTURE WORK PLAN

1. Multiple Indicator Cluster Surveys (MICS): UNICEF is planning to carry out a comprehensive MICS survey in the three northern regions from September to November 2011. This will allow comparison with the baseline data for the project that was carried out in 2008.

2. Food fortification training for women groups.

3. Impact assessment on Women groups implementing the CBMF programme will be undertaken at the end of the programme, so that these activities will be scaled up widely across the three Northern Region .

4. Undertake a final scale up of milling and fortification.

5. Business management and record keeping training for 15 women groups across the three regions: WFP will collaborate with the Department for Community Development and the Ghana Health Service to conduct this training with the objective of strengthening the capacity of the 15 women’s groups to sustainably manage the iodized salt activities as business and income generating ventures.

VIII. EXPRESSION OF THANKS

UNICEF and WFP would like to thank the Canadian International Development Agency for the continued assistance being provided through this grant. The generous support from CIDA has enabled support to government to decrease vulnerability and contribute to the reduction of morbidity and mortality rates in the targeted regions.

Training of women in income generation from resale of salt

30,000 2,766

5. Strengthened nutritional and food security M&E system for Northern Ghana

Inclusion of more Food Security Monitoring System (FSMS) sentinel sites (at least 5 sites x 34 districts of three northern regions)

95,000 66,944

Mapping of Livelihood zones 40,000 12,336

Baseline survey of FSMS sentinel sites

25,000 34,708 8,590

Anthropometric and office equipment, etc.

60,000 0

Training on data collection, collation and/ or analysis

162,800 0 30,000

Operational research on the use of Sprinkles to treat anemia at the community level & LEAP

0 0

Support MICS preparatory work 200,000 0

6. Advocate for and support Plumpy’nut production facility in Ghana

Support to initial efforts towards production of plumpy’nuts in Ghana

0 0

7. Program Support Costs office support costs, travel, logistics, staff support etc.

250,000 150,000 488,554 151,912

Update knowledge and skills of partners for EPR (including one simulation per year

0 5,233

Printing of additional maternal health record book

0 49,100

Sub-total 2,417,800 1,215,000 1,873,567 659,170

CAN$ USD

Appendixes Page XXI

APPENDIXES

Appendix 1: Maps of Intervention Regions

Bolgatanga Municipal

Bole

East Gonja

West Gonja

Yendi

Central Gonja

Karaga

West Mamprusi

Gushiegu

Sawla-Tuna-Kalba

Nanumba North

Tolon- Kumbumgu

Zabzugu- Tatale

East Mamprusi

Saboba- Cherepone

Savelugu- Nanton

Bunkprugu- Yunyoo

Nanumba South

Tamale Metropolitan

525000

525000

550000

550000

575000

575000

600000

600000

625000

625000

650000

650000

675000

675000

700000

700000

725000

725000

750000

750000

775000

775000

800000

800000

825000

825000

850000

850000

875000

875000

Nominal Scale 1:200,000 at A3 size

Data Source: ESRI, Bartholomew, NGA, UNICEF, WFP, SRTM

Map Doc Num:

The boundaries, names and the designation used on this map do not imply official endorsement or acceptance by WFP Ghana or the

WFP01-GHA-PM

Created: 30th December 2008/9:07

Projection/Datum: UTM Zone 30N/WGS84

Legend

Boundary of Northern Region Region

Districts of Northern Region

0 6 12 18 24 30 km

WFP Ghana

Districts of the Northern Region

Northern Region

Kpandai

Chereponi

Nadowli

Sissala East

Wa East

Sissala West Lawra

Wa West

Jirapa-Lambussie

Wa Municipal

500000

500000

525000

525000

550000

550000

575000

575000

600000

600000

625000

625000

650000

650000

675000

675000

Nominal Scale 1:200,000 at A3 size

Data Source: ESRI, Bartholomew, NGA, UNICEF, WFP, SRTM

Map Doc Num:

The boundaries, names and the designation used on this map do not imply official endorsement or acceptance by WFP Ghana or the

WFP01-GHA-PM

Created: 30th December 2008/9:07

Projection/Datum: UTM Zone 30N/WGS84

Legend

Boundary of Upper West Region

Districts ofUpper West Region

0 3 6 9 12 15 km

WFP Ghana

Districts of the Upper West Region

Upper West

Region

Lambusie-Karni

Appendixes Page XXII

Builsa

Kassena-Nankana

Bawku West

Bongo

Garu-Tempane

Talensi-Nabdam

Bawku Municipal

Bolgatanga Municipal

675000

675000

700000

700000

725000

725000

750000

750000

775000

775000

800000

800000

825000

825000

Nominal Scale 1:200,000 at A3 size

Data Source: ESRI, Bartholomew, NGA, UNICEF, WFP, SRTM

Map Doc Num:

The boundaries, names and the designation used on this map do not imply official endorsement or acceptance by WFP Ghana or the

WFP01-GHA-PM

Created: 30th December 2008/9:07

Projection/Datum: UTM Zone 30N/WGS84

Legend

Boundary of Upper East Region

Districts of Upper East Region

0 2 4 6 8 10 km

Burkina Faso

Northern Region

WFP Ghana

Districts of Upper East Region

Upper East

Region