Nutrition element portfolio review usaid_ Roshelle Payes & Rebecca Egan_10.14.11

USAID Nutrition Approach: Where are we now? Where are we going? How are we getting there?

Global Health Initiative principles, components and target areas

• HIV/AIDS• Malaria• Tuberculosis• Maternal Health• Child Health• Nutrition• Family Planning and

Reproductive Health• Neglected Tropical

Diseases

Target areas

Implementation components

• Collaborate for impact

• Do more of what works

• Build on and expand existing platforms to foster stronger systems and sustainable results

• Innovate for results

Principles

1. Promote women, girls and

gender equality focus

2. Encourage country

ownership/leadership

3. Strengthen health system

and program sustainability

4. Leverage and strengthen key

multilateral organizations,

global health partnerships

and the private sector

5. Foster strategic coordination

and integration

6. Improve metrics, monitoring

and evaluation

7. Promote research and

innovation 2

3

PRINCIPLES:

1) Invest in country-owned plans that support results-based programs;

2) Strengthen strategic coordination – globally, regionally, and locally;

3) Ensure a comprehensive approach – advancing agriculture-led growth, reducing under-nutrition, and increasing impacts of humanitarian food assistance;

4) Leverage the benefits of multilateral institutions; and

5) Deliver on sustained and accountable commitments.

A Comprehensive ApproachPATHWAYS:Addressing the root causes of hunger that limit the potential of millions of people

Establishing a lasting foundation for change by aligning our resources with country-owned strategies and supporting local capacity.

OBJECTIVES: Inclusive agriculture

sector growth Improve nutritional

status

Cross-cutting priorities: Global research and

innovation Gender Natural resources

and climate consideration

• Bi-lateral planning and program implementation• Coordination with host country• In-country donor coordination

Missions

Regional Bureaus

Global Health Bureau

• Technical support to the field• Global technical leadership• Operations research and innovation• Economies of scale in commodity procurement and highly

specialized expertise• Funding of and representation to international health organizations

• Policy guidance to Missions• Oversight of Mission programs• Regional programs

Food Security Bureau

Role of Operating Units

4

Our goal is to reduce child undernutrition by 30% in focus countries, measured by any one of four core indicators

Underweight (MDG 1c) Stunting Child Anemia Maternal Anemia

GHI/FTF Nutrition Goal

5

Outline

1. Program Context Burden of undernutrition Causes and consequences

2. Recent Sea Change in Nutrition Strategy

3. How the New Nutrition Strategy is implemented globally and in USAID’s programs

4. Review questions Is it feasible to reach our 30% goal? What is the optimal approach for delivering a

comprehensive set of nutrition interventions? How do we overcome the issues related to engaging the

private sector? 6

South Asia has made the most progress Overall number of stunted children in Africa has actually increased

One in three children suffers from stunting

7

19902008

Prevalence of children with stunting, by region

Number of stunted children, 2010

Mali: 82%

Children: 47% prevalence293 million children

Tanzania: 72%

Uganda: 72%

Women of reproductive age:30% prevalence468 million women

Ghana: 59%

Haiti: 48%

Global Burden of Anemia in Children and Women

High global prevalence of anemia in children and women

In some countries, anemia prevalence is significantly higher Any anemia has health and productivity consequences

8

Malawi: 44%

Revised Source: Ruel, SCN News 2008

Determinants of nutrition

NUTRITION

Food/nutrientintake

Health

Access to food Water, sanitation, and health services

9

Maternal and child care practices

Health: contributes to 3.5 million deaths each year from common illnesses otherwise not fatal

Education: lower IQ and school performance

Economic growth: costs countries 3-6% of GDP

Poverty: wages that are half as high in adulthood in children who were undernourished in early life

Infectious disease treatment: hastens HIV progression and reduces adherence to treatment

Improving nutrition is required to achieve all MDGs

10

Outline

1. Program Context Burden of undernutrition Causes and consequences

2. Recent Sea Change in Nutrition Strategy

3. How the New Nutrition Strategy is implemented globally and in USAID’s programs

4. Review questions Is it feasible to reach our 30% goal? What is the optimal approach for delivering a

comprehensive set of nutrition interventions? How do we overcome the issues related to engaging the

private sector? 11

Targeting from pregnancy to two yearswill have the most impact

That core package costs a certain amount(World Bank 2009)

A core package of interventions isproven to improve nutrition (Lancet Series 2008)

Investing in nutrition is one of the most cost-effective buysin development (Copenhagen Consensus 2006)

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THE RESULTSTop Ten

1 Micronutrient supplements (vitamin A & zinc) - Malnutrition2 The Doha development agenda - Trade3 Micronutrient fortification (iron and salt) - Malnutrition4 Expanded immunization coverage for children - Diseases5 Agricultural R&D - Malnutrition6 Deworming and nutrition programs at school - Malnutrition7 Lowering the price of schooling - Education8 Increase and improve girls’ schooling - Women9 Community-based nutrition promotion - Malnutrition10 Provide support for women’s reproductive role - Women

Evidence-based and consensus-driven global efforts exist

Countries are eager to scale up nutritionand our partners are aligned to support them (SUN)

1

2

3

4

5

12

The sea change in global nutrition programs is reflected in USAID’s nutrition programs

1. Type of interventions

2. Age target

3. Measurement

4. Focus

5. Delivery systems

6. Scale

Vertical, supplementation

Under fives

Nutrient-specific

Treatment

Health

Pilot

Integrated, food-based

1,000 days

Diet quality and diversity

+Prevention

+Agriculture, social protection

National

With these new approaches we aim for a 30% reduction in undernutrition13

1

2

3

4

5

6

From vertical micronutrient programsto food-based, integrated approaches

USAID supports Tanzania’s vitamin A supplementation program which has achieved high coverage for the past 10 years

In support of Tanzania’s draft National Nutrition Strategy, USAID launches a new bilateral in high burden focus regions (FTF zone of influence) with a focus on preventing stunting and behavior change

2000 2005 2010

USAID supports district-level planning and budgeting to transition the VAS program to GOT ownership

2011

14

1

Improving nutrition in Tanzania bilateral

From under five or population-wide targeting to the 1,000 days window

By 2009

1 It is the period of most vulnerability

2 Interventions after this period are not likely to have impact

3 Interventions in this period have immediate and long term consequences

Programs target pregnant women and young children under 2 years of age

2010

15

2

From nutrient-specificto measuring diet quality and diversity

2005 2010

2011

USAID provides technical assistance to WHO and UNICEF to improve measurement assessing infant and young child feeding practices

Minimum acceptable diet used to measure progress for GHI and FTF

Consensus Meeting: Definitions Established

Modules and calculation methodology provided to Demographic Health Surveys

2007

Indicators Calculated for All Countries and Guidance Provided

16

3

From recuperative to preventive approaches

2000

2011

Haiti Study: prevention approach has greater impact on nutritional status than recuperative approach

• Technical Reference Materials developed for FFP applicants

• Food for Peace lists PM2A as preferred MCHN approach in multi-year program guidance

• Burundi and Guatemala to identify most cost effective approaches

2010

2005

2011

17

4

Prevalence of stunting, 2000 and 2005

From health delivery systemsto maximizing multi-sectoral synergies

2000 2007 2010

2011

Most Nutrition Programs focused on health platforms ONLY: Minimal evidence for Agriculture and Health Linkages

Analysis of program approaches that worked: World Bank Report , CSHGP and FFP MYAP evaluations

• Bilateral programs with integrated platforms developed in 15 FTF/GHI countries

• Synergies with FFP, PEPFAR and other donors (e.g. in Uganda, Mozambique, Bangladesh)

• New Research (CRSP) to further evaluate synergies between agriculture and nutrition (e.g. Uganda and Nepal)

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5

Changes in anthropometry, 2004-2009

17%

22%20%

14%

10%

28%

34%

30%

20%

Underweight Stunting

1996-2006: USAID supported preventive nutrition programs in 4 health regions

From pilots to scale

2002: Senegal began the Nutrition Enhancement Program (NEP)

2006: USAID-funded community-based growth promotion programs were introduced nationwide as part of phase II of NEP

2015 MDG 1 GOAL

SENEGAL: National Nutrition Enhancement Program

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6

Outline

1. Program Context Burden of undernutrition Causes and consequences

2. Recent Sea Change in Nutrition Strategy

3. How the New Nutrition Strategy is implemented globally and in USAID’s programs

4. Review questions Is it feasible to reach our 30% goal? What is the optimal approach for delivering a

comprehensive set of nutrition interventions? How do we overcome the issues related to working with

the private sector in the nutrition program? 20

WHAT IT IS: Over 100 of our development partners involved (civil society, private

sector, UN, donors) Coordination of these partners to encourage synergy of purpose and

ensure complementarity of action based on countries’ requests

WHY WE ARE INVOLVED: GHI/FTF principles are aligned with SUN Increases our leverage and alignment with partners Provides us with concrete milestones to measure progress on scaling up

nutrition Facilitates high-level dialogue/advocacy on nutrition in countries that

can drive policies and programs Provides a barometer for country ownership: political leadership,

inclusivity of process, country budgetary commitments

USAID is part of a multilateral partnership to scale up nutrition

SCALING UP NUTRITIONMOVEMENT

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1. Women, girls and gender equality

2. Country ownership3. Health systems

strengthening4. Multilaterals and

partnerships5. Coordination and integration6. Metrics, monitoring,

evaluation7. Research and innovation

1. Country ownership2. Coordination3. Comprehensive approach4. Multilaterals and partnerships5. Results and commitments

GHI

FTF

Country health sector strategy

Country investment plan/CAADP

FFP MYAPs

Ministry of Agriculture

Ministry of Health

Health zones

Agriculture production potential areas

Health bilaterals and local partners

FTF MYSBEST

GHI STRATEGYCDCS

Integrated frameworks reflect country priorities in multiple sectors and our FTF-GHI principles

INT

EGR

ATED

NU

TR

ITIO

N

INV

EST

MEN

T F

RA

MEW

OR

K

Local civil society

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Integrated Nutrition Frameworks: from 0 to 15 countries

Nutrition procurements: from 7 to 16 countries (9 nutrition-sensitive and 7 nutrition-focused)

Nutrition focused staff: from 5 to 19 countries

USAID’s rapid mobilization of country programming has made good progress since 2009

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On track

In progress

Little/no change

Prevalence and magnitude of undernutrition Country ownership Existing platforms Alignment with FTF and GHI

36 countries account for 90% of the global burden of stunting

USAID’s country focus is driven by the magnitude of the problem, country context and GHI and FTF strategy

Criteria:

24

USAID nutrition programs in 22 of the 36 highest burden countries

EthiopiaGhana*KenyaLiberia*MalawiMaliMozambiqueRwanda*Senegal*TanzaniaUgandaZambiaBangladeshCambodiaNepalGuatemalaHaiti*

BurundiBurkina FasoDR CongoMadagascarNigerSouth Sudan

Cote D’IvoireNigeriaSouth AfricaVietnam

17 core countries +6Food for

Peace

+4PEPFAR

17 countries with over 80% of the GHCS nutrition resources

SUN+Peru

+Benin+Laos 25*Not in the 36 highest burden countries due to

population size

Indicator Average across priority countries

Underweight 23%

Stunting 42%

Wasting 9%

Underweight Women 15%

Women with anemia 45%

Children with anemia 66%

Exclusive breastfeeding 48%

Minimum acceptable diet 17%

Vitamin A supplementation 52%

Iodized salt 59%

Monitoring and evaluation

DHS baselines DHS includes new

indicators Core set of nutrition

indicators for both GHI-FTF

Working with global partners to align monitoring and evaluation for nutrition (SUN)

26

NUTRITION+Social and behavior change+Monitoring and evaluation

+Community capacity

AGRICULTURE SOCIAL PROTECTIONFood supplementation to the most vulnerableAsset transfersCommunity volunteersNutrition service delivery (including CMAM)

Small holder production diversificationWomen’s control of productive assetsAgriculture extension workersIncome and employment generation

WATER INFECTIOUS DISEASES

MATERNAL CHILD HEALTHHealth worker capacities to screen and referNutrition service delivery (including CMAM)Birth spacing and family planning

Community-facility referralsReady-to-use therapeutic food productionOVCs as target populationMaternal and child anemia

Comprehensive Nutrition Investment Plan

Access to improved water sourcesHygiene behaviorsSanitation

HARNESSED AND MAXIMIZED TO ACHIEVE IMPACT27

USAID Mission bilaterals: NEPAL EXAMPLE

Reduction in underweight from 38% to 29%, Government of Nepal Target

Integrated MCH, FP and Nutrition

Bilateral

Integrated Agriculture and

Nutrition BilateralChild Survival and Health Grants

• Food Based• Agriculture• Dietary Diversity

Nepal Family Health Program II

• Prevention• Scale up

UNICEF• Prevention• Social Protection

Integrated, Food Based1,000 DaysPrevention

Agriculture, Social ProtectionDietary Diversity and Quality

Scale up

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USAID partners with a number of other USG agencies on a range of programs …

CDC

USDA

NIH

PEPFAR

Peace Corps

DCHA

Nutrition surveillance and M&E Chronic diseases Food fortification McGovern Dole (school feeding) Nutrition and agriculture research Food safety systems

Micronutrient biomarkers (BOND program) Non Communicable Diseases HIV and nutrition

Nutrition Assessment, Counseling, and Support, including Food by Prescription Linking with economic strengthening/livelihoods/food security programs

Community-based agriculture Community worker nutrition training

MYAPs Commodity improvement Monitoring, evaluation, early warning, surveillance

State 1,000 Days Partnership SUN-related diplomacy

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ILLUSTRATIVE

UN

WFP: emergency nutrition UNICEF: IDD, Comprehensive approach WHO: surveillance and capacity FAO: agriculture policies REACH: country-specific

Civil society

Private sector

Food products Market-driven solutions

Comprehensive approach Advocacy

FANTA 2 Food and Nutrition Technical Assistance in 20+ countries Food security programming and policy HIV and nutrition

A2Z Micronutrient supplementation and fortification programs Child blindness

IYCN Infant and young child feeding practices PMTCT

GAIN Public-private partnerships Food fortification Nutritionizing agriculture value chains

… as well as with a number of other stakeholders and USAID/W implementing partners

30

SU

N

Outline

1. Program Context Burden of undernutrition Causes and consequences

2. Recent Sea Change in Nutrition Strategy

3. How the New Nutrition Strategy is implemented globally and in USAID’s programs

4. Review questions Is it feasible to reach our 30% goal? What is the optimal approach for delivering a

comprehensive set of nutrition interventions? How do we overcome the issues related to engaging the

private sector? 31

The goal of reducing undernutrition by 30% was established in anticipation of significant increases and front-end loading of funding. Food prices have also increased drastically. The current budget scenario requires us to examine the feasibility of that 30% target.

Identify efficiencies Use subnational targets Reduce global target based on country-level analysis Cut additional countries Increase multilateral cooperation

Options:

Review question 1

Can we reach our goal with our funding levels?

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USAID has made budget choices to increase our impact and depth of investment

FY09 FY10 FY11 (TBC)

Total GHCS Funding

$55 million $75 million $90 million

Number of countries

37 30 19

Average funding $900,000 $1,365,000 $2,685,000

Number of countries receiving less than $750,000

16 6 0

Number of countries receiving more than $3,000,000

1 6 13

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Tier One Tier Two Non-priority0

10,000,000

20,000,000

30,000,000

40,000,000

50,000,000

60,000,000

70,000,000

80,000,000

90,000,000

100,000,000

FY09FY10FY11FY12

26%

18%57%

FY09 N ($55 million)

43%

26%

31%

FY10 N ($75 million)

63%

32%

5%

FY11 N ($90 million)

Percent total tier 1

Percent total tier 2

Percent total NP

USAID has prioritized countries and plans to sustain this commitment

34

What are the most important approaches for delivering a comprehensive package of interventions?

Co-locate nutrition, health, agriculture, and social protection to achieve geographic synergies

Develop socio-economic targeting approach (poverty quintile) Support high-level multisectoral government coordination

mechanisms (e.g. Malawi) Work with other donors on prioritization of interventions Continued learning on cost-effectiveness of agriculture-health

linkages

Options:

Review question 2

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OPTIONS: How do we nutritionalize value chains? How do we focus them on the bottom of the pyramid? How do we build capacity of small and medium scale enterprises? What are meaningful incentives for the private sector?

Review question 3

How do we overcome the issues related to engaging the private sector?

36

37

Update: GH Portfolio

Food and Nutrition Technical Assistance Project 2 (FANTA 2)

A2Z Micronutrient and Child Blindness Project

Infant and Young Child Nutrition Project

Global Alliance for Improved Nutrition

Child Survival and Health Grants Program

Maternal and Child Health Integrated Program

Iodine Deficiency Disorder (UNICEF)

2010

NEW AWARD: Food and Nutrition Technical Assistance Project 3 (FANTA 3)

NEW AWARD: Strengthening Partnerships, Results, and Innovation for Nutrition Globally (SPRING)

Global Alliance for Improved Nutrition

Child Survival and Health Grants Program

Maternal and Child Health Integrated Program

Iodine Deficiency Disorder (UNICEF)

2012