INFANT AND YOUNG CHILD FEEDING PROGRAMMING STATUS

Transcription

1 INFANT AND YOUNG CHILD FEEDING PROGRAMMING STATUS Results of assessment of key actions for comprehensive infant and young child feeding programmes in 65 countries

2 United Nations Children s Fund (UNICEF) April 2012 Cover photo: Ghana: UNICEF/HQ020570/Pirozzi Permission to reproduce or extract any part of this document is required. Requests may be sent to C. Rudert, Nutrition Section, UNICEF New York, [email protected] i

3 Acknowledgements Nutrition staff from UNICEF country offices compiled the information on IYCF programmes in each of the 65 countries which completed the matrices, and in many countries Government staff and partners were also involved in the exercise. UNICEF consultant Avril Armstrong collected and inputted the data and drafted the report. Adebayo Ogunlade conducted additional analysis and editing of the report and produced country profiles for 22 countries with poor IYCF practices and large burdens of children suboptimally fed and undernourished. From UNICEF headquarters, Christiane Rudert (Nutrition Specialist Infant Feeding) conceptualized the assessment matrix and prepared the first draft; she was also responsible for overseeing the assessment, managing the consultancies and finalizing the report. Mandana Arabi (formerly Nutrition Specialist Complementary Feeding) oversaw the development of the final version of the matrix and contributed to following up on the conducting of the assessment. The assessment was supported by Nune Mangasaryan (Senior Advisor Infant and Young Child Nutrition). Any questions or comments should be addressed to Christiane Rudert, ii

4 Table of Contents Acronyms and abbreviations... v Executive summary Introduction Objectives Methodology Data collection Data analysis procedure Results Response rates National level IYCF actions Health service level IYCF actions Communitybased IYCF actions Communication on IYCF Complementary feeding interventions/components IYCF in difficult circumstances HIV and infant feeding Infant feeding in emergencies IYCF monitoring and evaluation Conclusions and recommendations References Section 4: IYCF profiles: 22 countries with poor IYCF practices and large burdens of undernutrition among children under five years ANGOLA BANGLADESH BURKINA FASO COTE D IVOIRE DEMOCRATIC REPUBLIC OF THE CONGO ETHIOPIA INDIA INDONESIA KENYA iii

5 MALAWI.. 70 MALI. 72 MOZAMBIQUE NIGER NIGERIA NORTH SUDAN PHILIPPINES SIERRA LEONE SOMALIA SOUTH SUDAN UGANDA UNITED REPUBLIC OF TANZANIA.. 92 YEMEN ANNEXES ANNEX 1: Assessment matrix questionnaire ANNEX 2: Completion of assessment matrix and response rate ANNEX 3: Key IYCF interventions and indicators ANNEX 4: Country descriptions ANNEX 5a: IYCF policy, strategy and plan of actions ANNEX 5b: IYCF legislation and law ANNEX 5c: National level IYCF action score ANNEX 5d: IYCF health service training curricula ANNEX 5e: IYCF health workers capacity development ANNEX 5f: Training of health providers on IYCF counseling ANNEX 5g: IYCF health system counseling ANNEX 5h: BabyFriendly Hospital Initiative ANNEX 5i: Health system level IYCF actions score ANNEX 5j: Communitybased IYCF actions ANNEX 5k: Capacity development and coverage of communitybased IYCF actions ANNEX 5l: IYCF community activity implementor ANNEX 5m: Communication on IYCF ANNEX 5n: Communication on IYCF: Strategy, materials and monitoring/evaluation. 141 ANNEX 5o: Communication on IYCF action scores ANNEX 5p: Complementary feeding components / interventions ANNEX 5q: IYCF in difficult circumstances (HIV and infant feeding) ANNEX 5r: IYCF in difficult circumstances (Infant feeding in emergencies) ANNEX 5s: Overall IYCF in difficult circumstances ANNEX 5t: IYCF monitoring and evaluation iv

6 Acronyms and abbreviations ANC BCC BFHI BMS CAR CEE/CIS CF CHW Code DRC EAPR ESAR GMP GSIYCF HIV HMIS HW IF ILO IMCI IYCF IYCN KAP LAM LBW LNS LQAS MAM MICS M&E PMTCT ROSA SOWC TBA UNFPA UNICEF U5MR WCAR WHO antenatal care behaviour change communication Baby Friendly Hospital Initiative breastmilk substitutes Central African Republic Central and Eastern Europe/Commonwealth of Independent States complementary feeding community health worker International Code of Marketing of Breastmilk Substitutes and subsequent relevant World Health Assembly Resolutions Democratic Republic of Congo East Asia and the Pacific and South Asia Region Eastern and Southern Africa Region growth monitoring and promotion Global Strategy for Infant and Young Child Feeding human immunodeficiency virus health management information system health worker infant feeding International Labour Organization integrated management of childhood illness infant and young child feeding infant and young child nutrition knowledge, attitudes and practices lactation amenorrhea method low birth weight lipid nutrient supplements lot quality assurance sampling moderate acute malnutrition multiple indicator cluster survey monitoring and evaluation prevention of mother to child transmission Regional Office for South Asia State of the World s Children traditional birth attendant United Nations Population Fund United Nations Children s Fund underfive mortality rate Western and Central African Region World Health Organization v

7 Executive summary This comprehensive infant and young child feeding (IYCF) situation assessment was conducted with the primary objective of providing an uptodate overview of the scope and scale of IYCF programming and implementation status globally, which will enable gaps and constraints as well as areas of achievement to be highlighted and actions to strengthen the programmes identified. Since 2010, the equityfocused approach has emerged as a pivotal priority for UNICEF as an organization [1]. The present report is highly relevant to this effort. It presents the detailed IYCF profile for 22 nutritionally vulnerable countries, countries with the poorest IYCF practices and largest burden of undernutrition among children less than five years 1. Furthermore, optimal IYCF practices play an important role in reducing early childhood morbidity and mortality, as well as in improving early child growth and development. WHO/UNICEF recommend exclusive breastfeeding from birth to first six months of life, with the introduction of complementary foods thereafter, and continued breastfeeding until two years of age [2]. Guidance on IYCF actions In support of countrylevel actions in strengthening IYCF programmes, UNICEF has recently developed a programming guide on IYCF [3] for country level managers and public health/nutrition staff. The programming guide is based on scientific evidence, lessons learned, best practices and presents the how of programming at all levels. Key IYCF action areas at the national, health service and community levels for a comprehensive, atscale IYCF strategy, including the design and implementation steps are outlined. IYCF assessment matrix Accompanying the IYCF Programming Guide is an assessment matrix. The matrix is structured around the components of the Guide. This tool is intended for use by UNICEF s country offices, in close collaboration with governments and other partners involved in IYCF programming, to regularly monitor and assess the scope and scale of recommended IYCF incountry actions and identify areas for improvement. The matrix can be used periodically to assess whether progress is being made to address identified gaps. The aggregated information is also helpful for regional and headquarters staff to prioritize support and additional guidance on the areas most commonly reflected as problematic. Methodology Between 2010 and 2011, the UNICEF Nutrition Section at HQ requested its country offices to complete the IYCF assessment matrix. In most cases the exercise was undertaken in collaboration with Government counterparts and other partners. The data collected were compiled, analyzed and will be used as baseline data for the scope and scale of IYCF programming globally. This report summarizes the results of the analysis. In total, the assessment matrix was sent to 86 (including 22 designated nutritionally vulnerable countries) country offices in 6 regions [East and South Asia region (ESAR), West and Central African region (WCAR), Region of South Asia (ROSA), Middle East and North African region (MENA) and East Asia and Pacific region (EAPR)] for completion. IYCF action score was calculated for each country on each of the action areas. Scores were then scaled from 0 to 10 and rated based on a colour scale 2. It is emphasized that the results are principally qualitative and are based on the responses received from the countries. Overall, approximately 65 countries (76%) responded within the stipulated timeframe and returned completed assessment matrices. 1 It is noted that these 22 countres do not represent the entire set of countries with poor nutrition indicators, but a selection. 2 Colour scale interpreted as follows: Red = 03 [ Poor very low number of key IYCF actions implemented]; Orange = 46 [ Fair low number of key IYCF actions implemented; Green = 78 [ Good average number of key IYCF actions implemented]; Purple = 910 [ Very good High number of key IYCF actions implemented]. 1

8 Key findings National level IYCF actions National level IYCF action scores in 65 countries Overall more countries had IYCF policies than strategies and plans of actions. Approximately 84% of the countries (n=51) had policies (standalone or integrated), 60% (n=38) had strategies and only 48% (n=30) had plans of action. An estimated 62% of the countries (n=39) had national legal frameworks related to the Code of Marketing of Breastmilk Substitutes in place and only 19 countries (50%) had a Code monitoring or enforcement system in place. Paid maternity leave existed in most of the countries [92% (n=56)] but only about 52% of the countries (n=32) provided paid nursing breaks for mothers after they returned to work. On average, countries were rated fair on their national level IYCF actions, indicating implementation of low number of key IYCF actions at the national level. Overall, 12% of the countries were rated Very good, 28% Good, 40% Fair and 20% Poor on the national IYCF actions. Health service IYCF actions Health service level IYCF action scores in 65 countries Preservice trainings for nurses and other health professionals on IYCF were more likely to occur than training for medical doctors. Only 51% of the countries (n=33) conducted IYCFfocused preservice trainings for medical doctors, and about 88% (n=38) conducted preservice trainings for nurses and other health professionals. Inservice trainings occurred in about 37 countries (60%). About 69% of the countries (n=44) had job aids and counselling cards available for health professionals (medical doctors, nurses and other health professionals). Although about 43 countries indicated that health workers were trained on IYCF counselling since 2006, none of the countries were able to report on the geographic scale and target population coverage of counselling activities taking place within the maternal and child health centres. Among the 55 countries that indicated that at least one hospital/maternity facility was evercertified as BabyFriendly, the average proportion evercertified was 23% (ranging from 1 to 100%). Among the 22 countries that indicated that at least one hospital/maternity facility was ever recertified as BabyFriendly, the average proportion ever recertified is extremely low at 5.6% (ranging from 1 to 76%). On average, countries were rated fair on their health service IYCF actions, indicating the implementation of low number of key IYCF actions at the health service level. Overall, 12% of the countries were rated Good, 57% Fair and 31% Poor on the health service IYCF actions. Community level IYCF actions Community level IYCF action scores in 65 countries Eightyfour percent of the countries (n=53) had established communitybased IYCF activities either as standalone and/or integrated within other programmes. Only 11 countries reported having standalone IYCF activities within the community. Some countries indicated integrating activities within other programmes [such as Integrated Management of Childhood Illnesses (n=12), antenatal care (n=9), growth monitoring and promotion (n=7)]. About 66% of the countries (n=39) indicated training of community health workers on community IYCF counselling had occurred since 2

9 2006, while 27 countries (60%) conducted specific capacity building on communication skills for community health workers. The average proportion of community health workers trained on IYCF counselling since 2006 was 26 % (ranging from 1 to 73%). Only 13 countries routinely monitored the counselling skills of the community health workers and very few monitored the counselling quality On average, countries were rated Poor on their communitybased IYCF actions, indicating the implementation of very low number of key IYCF actions at the community level. Overall, only 8% of the countries were rated Good, 31% Fair and 61% Poor on the communitybased IYCF actions. Communication on IYCF Communication on IYCF action scores in 65 countries Only 36 countries (55%) conducted communication on IYCF through five or more communication channels. Countries also indicated having communication strategies at the national (n=33), health service (n=54) and community (n=50) levels. Behavioural change and communication materials were available in most [95% (n=61)] of the countries. However, few countries had monitoring and evaluation systems for communication on IYCF. Only 16 countries (28%) routinely monitored ongoing communication on IYCF activities. Additionally, about 20% of the countries (n=9) routinely monitored the number of people reached through media messages. As a result, only a few countries were able to report on the coverage of communication on IYCF activities in their country. On average, countries were rated Fair on their communication on IYCF actions, indicating the implementation of low number of key communication on IYCF actions. Overall, 12% of the countries were rated Good, 62% Fair and 26% Poor on the communication on IYCF actions. Complementary feeding interventions/components Complementary feeding interventions/ components scores in 65 countries About 60% of the countries (n=37) indicated that caregivers/mothers were counselled on home preparation of complementary foods for children 624 months. Countries d a variety of counselling channels, such as counselling cards (at the health service and community level), cooking classes, published recipe guides for mothers and broadcast food preparation demonstrations on TV. Micronutrient supplements (multiple/single) were provided to improve complementary feeding for children 624 months in about 79% of the countries (n=51). Furthermore, 58% of the countries (n=19) provided fortified industrially blended complementary foods, while only 26% of the countries (n=10) provided fortified local complementary foods. On average, countries were rated Fair on their complementary feeding interventions/components. Overall, 11% of the countries were rated Very good, 4% Good, 36% Fair and 49% Poor on the complementary feeding interventions/components. IYCF in exceptionally difficult circumstances HIV and infant feeding action scores in 65 countries HIV and infant feeding HIV and infant feeding policy and guidance were available in about 84% of the countries (n=54). Approximately 72% of the countries (n=47) d infant feeding counselling for HIV positive mothers, while about 83% countries (n=45) trained health workers on infant feeding and HIV. However, only about 67% (n=38) of the countries provided support on infant feeding for HIV positive mothers. 3

10 Infant feeding and HIV training materials and job aids/counselling cards were updated with the WHO 2010 recommendation in approximately 76% (n=31) and 74% (n=23) of the countries, respectively. Only 27.4% (n=17) of the countries had a monitoring system on infant feeding practices among HIV positive mothers in place. On average, the countries were rated fair on their actions related to HIV and infant feeding interventions. Overall, 12% of the countries were rated Very good, 38% Good, 25% Fair and 25% Poor. Infant feeding in emergencies Only 41% (n=26) of the countries indicated that their national IYCF policy included infant feeding in emergencies. Similarly, 24 countries (41%) also reported having a national emergency preparedness plan which included IYCF in emergencies. About 24% (n=14) countries provided training for health providers or IYCF counsellors on infant feeding in emergencies. Fifteen (15) countries (25%) indicated that they provide breastmilk substitutes in emergencies. On average the countries are rated poor on their actions related to infant feeding in emergencies. Overall, 4% of the countries were rated Good, 17% Fair and 78% Poor. Infant feeding in emergencies action scores in 65 countries IYCF monitoring and evaluation IYCF monitoring and evaluation action scores in 65 countries Routine monitoring and evaluation of ongoing IYCF activities and the monitoring of process indicators took place in about half of the countries Evaluation or review of the IYCF situation only occurred in about two thirds of the countries. At the same time, monitoring of national IYCF programmes only took place in 39 countries (64%). Almost none of the countries were able to report on the geographic scale and population coverage of IYCF counselling services, either in the health system or at community level. Coverage of communication activities was also not reported. On average, countries were rated Fair on the IYCF monitoring and evaluation action score. Overall, 4% of the countries were rated Very good, 11% Good, 37% Fair and 48% Poor. Summary of recommendations These recommendations represent a summary of major lines of action that are suggested by the results of the assessment; they are not meant to be allencompassing or detailed. For detailed guidance see the UNICEF IYCF Programming Guide, which covers all the steps to design, plan and monitor comprehensive IYCF interventions that will be required to strengthen the various components and address constraints and gaps. National level IYCF actions i. Gaps at the policy level still need to be addressed. Although most countries had some form of IYCF policy (standalone/integrated), very few countries had a combination of policy, strategy and plan of action to operationalize the policy and strategy. ii. IYCF policy comprehensiveness should be reviewed. National IYCF policies still did not reflect certain key IYCF practices or components. iii. National IYCF policies should be comprehensive to ensure that all relevant health and community services protect, promote and support breastfeeding and ensure timely, safe and ageappropriate 4

11 complementary feeding at 624 months as well as guidelines on ensuring appropriate IYCF in exceptionally difficult circumstances. iv. More countries need to establish national legislation on the Code of Marketing of Breast milk Substitutes and continually check the status of their Code. v. Gaps existed with monitoring and enforcement systems for the Code, even for those countries with a law already in place. Regular independent monitoring is needed, which is free from commercial interests using standard protocols to document violations. vi. Maternity leave was provided in many countries but a large percentage of countries do not provide nursing breaks for mothers. Health service level IYCF actions i. Inservice training and preservice education gaps in countries need to be comprehensively addressed. The standard preservice and inservice training curricula in countries should be based on the WHO 2009 IYCF model chapter for textbooks for medical students and allied professionals noting that the HIV and infant feeding chapter needs to be updated in line with the 2010 WHO recommendations on HIV and infant feeding. ii. It is also vital to ensure that the capacities of health professionals are substantially strengthened in providing recommended IYCF counseling and support. iii. Appropriate systems and structures to routinely deliver IYCF counselling services within the health system need to be developed as well as supervision and performance monitoring mechanisms need to be in place to ensure sustained implementation and documentation of performance. IYCF indicators need to be integrated within the health management information systems (HMIS), especially in countries where these systems function relatively well. Rapid assessment tools such as lot quality assurance sampling (LQAS), SMART and other nutrition surveys, health facility assessment tools and qualitative assessments can be used to measure coverage and quality of IYCF counseling, and established assessment and survey instruments need to integrate appropriate IYCF indicators. iv. Given that the BabyFriendly Hospital Initiative was reported as having extremely low coverage of recertification of facilities, it must be properly institutionalized within the national health system in order to ensure continuity and sustainability. The Ten Steps and the tools to assess compliance with them need to be fully integrated within the standard operating procedures of health facilities and the supervisory, monitoring, quality assurance, accreditation systems. Community level IYCF actions i. Communitybased initiatives can extend the delivery of interventions, particularly important in countries that have a weak health infrastructure or low health facility delivery rates. However, current IYCF actions at the community level in most countries appear to be not as welldeveloped as the health service level. ii. More effort is required to strengthen and scale up community level IYCF actions and ensure that IYCF is promoted and supported in communities. Communitybased IYCF activities and programmes should build upon existing health and nutrition programmes at community level to the extent possible. iii. Training community health workers in communitybased IYCF counseling and communication skills should be intensified in countries and largescale coverage pursued. The distinction between promotive actions/communication and counselling and skilled support needs to be more clearly made, and the importance and complementarity of both underscored, as many countries do not yet pursue largescale actions related to counselling and support at the community level. iv. Monitoring and evaluation of communitybased IYCF activities should be strengthened to include supportive supervision and a recognition mechanism for wellperforming workers in more countries. Additionally, monitoring systems should be comprehensive enough to be able to provide sufficient detail on the coverage, quality of training and counseling activities among others. A combination of routine data and rapid assessment and survey tools should be used to monitor coverage and quality of community IYCF interventions (see recommendation iii) in the section on the health system above). Communication on IYCF i. Comprehensive communication strategies on IYCF based on formative research and using 5

12 multiple channels to reach priority participant groups with age and contextspecific messages should be an integral part of incountry IYCF intervention. ii. Gaps exist with respect to routine monitoring of ongoing communication on IYCF activities. Countries need to strengthen or develop appropriate system to monitor and evaluate communication activities, outcomes and impact on behaviour. Complementary feeding additional interventions/components i. Counseling mothers or caregivers on optimal complementary feeding practices and using multiple communication channels will be crucial for improving mothers/caregivers knowledge and skills on home preparation of nutrientrich complementary foods for children 624 months. ii. For some countries provision of complementary food supplements may be needed to fill the nutrient gap when locally available foods alone cannot satisfy nutrition requirements. Appropriate decisionmaking processes are needed to determine whether, when and for whom supplements are needed, and where implemented, monitoring systems are needed to be able to report on coverage. IYCF in difficult circumstances HIV and infant feeding i. HIV and infant feeding recommendations, based on the latest 2010 guideline, need to be fully integrated within all the incountry IYCF guidelines, materials, training sessions and counselling contacts. ii. These revised materials need to be thoroughly disseminated to all relevant health and community workers across the whole country, and systematic follow up and mentoring on quality and appropriate application is needed iii. More emphasis on the importance of providing support and followup for HIV positive mothers is required. Infant feeding in emergencies i. National policies should be updated to include infant feeding in emergencies and not wait until after an emergency strikes before prioritizing infant feeding in emergencies. ii. Capacities for the design, planning, management and monitoring of IYCF interventions in emergencies need to be strengthened among Governments, partners, NGOs and other institutions. iii. Free breast milk substitutes were still provided in some of the countries. Actions should be taken to inform governments in advance (as part of emergency preparedness and planning) in these countries about the negative impact of accepting donations of these products on IYCF practices, and to ensure effective systems are in place to prevent, block and handle donations in case an emergency occurs. In situations where breast milk substitutes are necessary for eligible children then close control and monitoring is necessary. Monitoring and evaluation system for IYCF i. Monitoring and evaluation systems need to be substantially strengthened as evidenced by the low proportion of countries that were able to report on geographical scale, target population coverage and quality of IYCF interventions in the health services, at community level, on complementary feeding supplements and related to communication currently taking place in their countries. Steps to strengthen this aspect will involve a number of initiatives, for example to include IYCF indicators within HMIS systems where these systems are functioning well; to improve communitybased tallying and reporting by CHWs; to integrate IYCF indicators of outcome (IYCF practices) and programme performance (e.g. coverage of counselling and communication, coverage of complementary feeding supplements or social protection schemes; training received, counselling services provided, etc., within rapid assessment tools such as LQASbased small household surveys, CHW surveys and health facility surveys; and systematically integrating all IYCF indicators within household surveys such as SMART and MICS. ii. The monitoring and evaluation system needs to be carefully designed from the outset to ensure that it comprehensively captures relevant information for the key IYCF action areas. 6

13 1. INTRODUCTION Supported by unequivocal evidence of its impact on child survival and health, key IYCF actions are an integral part of UNICEF programmes that seek to improve early childhood survival, growth and development. Optimal IYCF entails the initiation of breastfeeding within one hour of birth, exclusive breastfeeding for the first six months of a child s life and continued breastfeeding up to two years or beyond, together with safe, ageappropriate complementary foods starting at 6 months of age [2]. Several countries, including those with high burden of undernutrition and suboptimal IYCF practices, are beginning to strengthen and enhance the scope and scale of their programmes. In support of these countrylevel IYCF actions, UNICEF s Nutrition Section in New York HQ has recently developed a comprehensive programming guide on IYCF [3] for programme managers and public health/nutrition staff. The programming guide is based on scientific evidence, lessons learned, best practices and presents the how of programming at all levels. Key IYCF action areas at the national, health system and community levels for a comprehensive, atscale IYCF strategy are outlined, including the design and implementation steps. The guide offers a number of benefits, including opportunity to assess the current scale, scope and status of IYCF programmes compared to the recommended approach. An IYCF assessment matrix is included as an adjunct to the programme guide. This matrix is intended for use by UNICEF country offices, in collaboration with governments and IYCF partners, to regularly monitor and assess the scope and scale of recommended IYCF actions in each country. As country offices engage in the design and implementation of IYCF interventions, this matrix is meant to be applied in assessing the status of incountry existing programmes and ultimately identifying gaps in recommended key IYCF action areas. Between 2010 and 2011, the UNICEF Nutrition Section at HQ requested its country offices to complete the assessment matrix. The data collected were compiled and analysed and will be used as the baseline data of the scope, scale and status of IYCF programming globally. This report summarizes the results of the analysis. Structure of the document This document is divided into five main sections. Sections 1 and 2 contain the background information, objective and the detailed methodology as well as the data analysis procedure employed. Section 3 is the result section which contains the key findings of the assessment of key IYCF actions in 65 countries. Section 4 contains the IYCF profile for 22 selected countries with poor IYCF practices and large burdens of undernutrition among children less than five years. Section 5 of the document contains the annexes with the assessment matrix questionnaire, tables with detailed results for each of the action areas, responses received, contacts etc. 1.1 OBJECTIVE The main objective of this analysis was to provide an overview of the scope, scale and status of comprehensive IYCF programmes, encompassing all of the recommended key IYCF action areas [3] at the countrylevel. Special emphasis was placed on the 22 nutritionally vulnerable countries. 2. METHODOLOGY 2.1 DATA COLLECTION A version of the 2009 IYCF matrix is included in Annex 1. There are two versions of the IYCF assessment matrix. Annex 2 shows the different completion phases of the matrix and the countries that responded at each phase. Version 1: In 2008, the first version of the assessment matrix was pilottested in 10 countries. Version 2: In 2009, the assessment matrix was revised and more detailed questions were added, including detailed questions on the International Code of Marketing of Breastmilk Substitutes, maternity protection laws, IYCF partners, UNICEF and government IYCF specific activity budgets, availability of job aids and counseling cards for health professionals, community and health system level monitoring and evaluation and monitoring and training on IYCF in difficult circumstances. In 7

14 addition, the new matrix was updated in 2009 to reflect current available guidelines and reference documents on IYCF. Twentythree countries in ROSA, EAPR and CEE/CIS completed this 2009 matrix between 2009 and 2010 (Annex 2). The 2009 matrix was then sent to a new group of countries for completion in January Between January and April 2011, 33 countries completed the 2009 assessment matrix (Vietnam completed the matrix in 2009 and 2011); only the 2011 responses were included in this analysis. In total between 2009 and 2011 the new 2009 assessment matrix was sent to 86 (including 22 nutritionally vulnerable countries) country offices in six world regions (ESAR, WCAR, ROSA, MENA and EAPR) for completion. All responses were compiled and the data cleaned and managed using File Maker Pro 11, and analyzed using Microsoft Excel. For two countries, Liberia and Cote d Ivoire, the completed 2008 version of the matrix was used. These countries did not complete the 2009 version of the matrix. 2.2 DATA ANALYSIS PROCEDURE Country scores and ratings Indicators were developed based on selected key IYCF action areas outlined in the programming guide (Tables 2a 2m). These indicators were used to guide the analysis procedure and only the questions on the assessment matrix related to these indicators were included in this analysis. From these indicators, an IYCF action score was calculated for each country for each IYCF action area. Each country s score represented its performance on a particular IYCF action area. Scores at each action level were combined to calculate a total overall score for each country as well. Scores were then scaled from 0 to 10 and rated based on the colour scale as shown in Table 1. Country scores were grouped and analyzed regionally and as a whole. At the end of the analysis each country had a score that represented its performance on each IYCF action level. Table 1: IYCF action score and rating keys Score Colour Rating 0 3 POOR (very low number of the key IYCF actions or interventions implemented) 4 6 FAIR (low number of the key IYCF actions or interventions implemented) 7 8 GOOD (average number of the key IYCF actions or interventions implemented) 9 10 VERY GOOD (high number or all of the key IYCF actions or interventions implemented Calculation of country scores and sub scores The scores are calculated based on the average of the subscores for each of the components that are considered to be required for that action area. For example, the national level IYCF action score is calculated by determining the mean between the two subscores for i) the national policy, strategy and plan of action subscore and (ii) national legislation action subscore, which make up the aggregate score. These subscores are derived from country s responses to the questionnaire (each of the questions that were selected was awarded a score of 1 for positive response and 0 for negative response). The detailed composition of each of the two sub scores are as shown in Annexes 5a to 5c; (i) Policy, strategy and plan of action subscore is composed and derived based on response on key national IYCF policy actions areas, including key IYCF practices reflected in the national IYCF policy (initiation of breastfeeding within the first hour, exclusive breastfeeding, complementary feeding from 6 to 24 months and beyond); the national IYCF strategy and plan of action, as well as other components (including BabyFriendly Hospital Initiative (BFHI), international Code for Marketing of 8

15 Breastmilk Substitutes, behaviour change and communication, IYCF in emergencies and HIV and infant feeding). (ii) The legislation subscore is composed and derived from the response from key IYCF legislation action areas including the Code law, maternity protection law, maternity leave, paid nursing break. The detailed composition for each of the other IYCF action areas are as shown in the respective tables in annex 5d 5t, including health service level IYCF actions (Annexes 5d to 5i), community level IYCF actions (Annexes 5j to 5k), communication on IYCF (Annexes 5m to 5o), the complementary feeding components/interventions (Annex 5p), IYCF in exceptionally difficult circumstances (Annexes 5q to 5r) and IYCF monitoring and evaluation action (Annex 5t). Limitations The result of the present assessment should be interpreted within the context of a qualitative assessment and its inherent limitations. The results are based on the assessment and judgement of UNICEF countrylevel representatives (in close collaboration with governments and other partners involved in IYCF programming). However in few instances the results might not reflect an absolute picture of a country s overall IYCF programme, as there may be some elements of subjectivity inherent with this type of assessment. For example, in some cases a particular component may appear to be scored highly based on the reported status, when in fact the reality may be less positive. In addition, it was apparent that the majority of countries were unable to report on the component of scale as information systems do not exist to record the geographic and population coverage of IYCF interventions. Nevertheless, efforts were undertaken to ensure that the assessment results reflect the best possible, uptodate incountry IYCF programming status. 9

16 3. RESULTS 3.1 RESPONSE RATES The UNICEF nutrition specialists and managers, in many cases in collaboration with country government officials and other partners completed the matrices (See annex 4). Of the 86 countries that received the matrix between 2009 and 2011, 65 responded (22 designated as nutritionally vulnerable countries and 43 others). Pakistan and Cote d Ivoire were the only two nutritionally vulnerable countries that did not respond during the above timeframe. For Cote d Ivoire, the 2008 version of the matrix was used. Based on this, the overall response rate was 76% (96% for which profiles were developed) (Annex 2). Responses varied across regions. Response rates regionally were 100% for MENA, 93% for EAPR, 86% for ROSA, 80% for ESAR, 77 % for WCAR, and 42% in CEE/CIS. The majority (79%) were completed by UNICEF country officers (including nutrition and health professionals) alone or in collaboration with the MOH, but with 14% solely by the Ministry of Health (MOH) or other government bodies responsible for nutrition. 3.2 NATIONAL LEVEL IYCF ACTIONS NATIONAL IYCF POLICY, STRATEGY AND PLAN OF ACTION A national IYCF policy is usually a formal document setting out the position of the government on recommended IYCF practices and the principles of action to achieve national goals, such as legislative and systems frameworks, main areas of intervention and accountabilities [4]. The IYCF programming guide highlights what an IYCF should include and emphasizes that it should be up to date and reflect all the key practices and major areas of action. An IYCF strategy involves highlevel national strategic thinking that defines why the issue of IYCF is being addressed, the overarching goals and specific objectives, the interventions and major lines of action to achieve the objectives and by whom. The strategy document is a broad outline considering and choosing between possible choices of IYCF interventions and actions, while focusing on the most critical needs [3]. The recommended contents and structure of an IYCF strategy are outlined in the programming guide. National IYCF policy Approximately 31% of the countries (n=19) had a standalone IYCF policy. IYCF was integrated into either a nutrition or health policy in 32 countries (53%) that did not have a standalone policy. Botswana and Zimbabwe had draft policies; Somalia s IYCF policy was included in its nutrition strategy and in Southern Sudan it was mentioned in the draft nutrition and health policy. The key IYCF practices (Table 2) that are reflected in most country s national IYCF policy were exclusive breastfeeding [85% (n=51)] and complementary feeding of 624 month old children [83% (n=48)] while early initiation of breastfeeding appeared in only 68% (n=40) of the countries. In less than half (n=32) countries were all three practices reflected in the national policies. Regionally, in CEE/CIS only Uzbekistan and Turkmenistan had standalone IYCF policies (25% of countries). Although these countries had standalone IYCF policies, in Turkmenistan, the policy did not reflect key IYCF practices related to complementary feeding for 624 month olds, while Uzbekistan s policy lacked the key practice related to early initiation of breastfeeding. Although Kyrgyzstan and Kazakhstan did not have standalone IYCF policies, their policies were integrated into their child health policies and contained all the key practices 3 of a comprehensive IYCF policy as well as over 6 additional components (Annex 5a). 3 The three key IYCF practices reflected in the national policy as captured by the assessment matrix, included (i) initiation of breastfeeding within one hour of birth, (ii) exclusive breastfeeding and (iii) appropriate and adequate complementary feeding with continued breastfeeding from 6 to 24 months and beyond 10

17 Four countries (29%) in EAPR had a standalone IYCF policy. These countries were Vanuatu, Cambodia, China and the Philippines. Three countries (Korea, Indonesia and Thailand) were not specific regarding whether IYCF was included in another national policy; however, Thailand s IYCF policy reflected all the key components (Annex 5a). The other country with a comprehensive national IYCF policy was Vietnam. In the ESAR, (Angola, Burundi, Ethiopia, Kenya, Madagascar, Namibia, Rwanda, Uganda, Zambia, Malawi, Somalia and South Africa] 71% had IYCF policies. Mozambique had no officially approved IYCF policy, only a draft, but had other planning or policy documents where IYCF featured prominently. These were listed on the assessment matrix as: the Communication and Social Mobilization Strategy for Protection, Promotion and Support of Breastfeeding Table 2a: Key practices and indicators at the national IYCF policy level (all regions) National level actions Selected Indicators Results, n (%) Countries with national IYCF policy (standalone/integrated) 51 (83.6%) National IYCF Policy Countries with standalone IYCF policy 19 (31.0%) Countries with integrated IYCF policy 32 (52.5%) National strategy and plan of action Countries with national IYCF strategy 38 (60.3%) Countries with national plan of action 30 (47.6%) Key IYCF practices* reflected in the national IYCF policy Countries with all key IYCF practices* reflected in the national IYCF policy Countries with initiation of breastfeeding in the first hour of birth reflected in the national IYCF policy Countries with exclusive breastfeeding reflected in the national policy 32 (49.2%) 40 (67.8%) 51 (85.0%) Countries with appropriate and adequate complementary 48 (82.8%) feeding from 6 to 24 months and beyond reflected in the national IYCF policy *Key IYCF practices reflected in the policy, (i) included initiation of breastfeeding within one hour of birth, (ii) exclusive breastfeeding and (iii) appropriate and adequate complementary feeding with continued breastfeeding from 6 to 24 months and beyond Zimbabwe was in the process of drafting an IYCF policy; however, all key practices and components were integrated into its nutrition policy. South Africa planned to update its policy. In the MENA region, only three countries (Yemen, Sudan and South Sudan) were assessed. Yemen and Sudan (67%) indicated having IYCF policy. In South Sudan, IYCF was included in the drafted nutrition and health policy and key practices reflected included exclusive breastfeeding, and complementary feeding. In Sudan, IYCF was integrated in the nutrition policy and it reflected all the key IYCF practices. Five countries (83%) in ROSA reported having a national IYCF policy. Two of the countries (33%), Nepal and Bhutan had standalone IYCF policies, while India, Sri Lanka and Afghanistan have their IYCF policies as part of the nutrition/health policies. Bangladesh s policy reflected all key components with the exception of initiation of breastfeeding, while India had only the initiation of breastfeeding reflected in its national IYCF policy. In WCAR, all the countries had IYCF policies either as a stand 11

18 alone [4 countries (24%)] or as part of nutrition/health policies in 13 countries (77%). Data were not available for Liberia regarding the key practices and components of its IYCF policies. National IYCF Strategy and plan of action About 60% of countries (n=38) that responded had an IYCF national strategy but only 48% (n=30) had a national action plan. Only Uzbekistan in the CEE/CIS region had a strategy and two countries (Uzbekistan and Tajikistan) had a plan of action. Uzbekistan had policy, strategy and plan of action. In the EAPR region, 36% of the countries (n=5) had a strategy and plan of action. Vanuatu, China, Myanmar, Philippines and Thailand had strategies. Countries with plan of action were Korea, Vanuatu, TimorLeste, Vietnam and Thailand. Only Vanuatu and Thailand had both a strategy and a plan of action. In the ESAR, 65% of the countries (n=11) had a strategy and 47% a plan of action. Half of the countries Madagascar, Zambia, Tanzania, South Africa, Swaziland, Uganda, Kenya and Ethiopia had both a plan of action and strategy. South Africa, Uganda and Kenya had a policy, strategy and plan of action. In the MENA region, 2 (Yemen and North Sudan) of the 3 countries had both an IYCF Box 1: Summary of national IYCF policies, strategies and plan of actions in the 65 countries assessed Overall, more countries had IYCF policies than strategies and plan of action. Approximately 84% of the countries had national IYCF policies (standalone or integrated), 60% had strategies and 48% had plan of action. Having a standalone policy was not a requirement for having a comprehensive IYCF policy. Some standalone IYCF policies were not comprehensive and several of the integrated IYCF policies were comprehensive in all key IYCF practices or components. strategy and plan of action. Yemen was the only country with all three: policy, strategy and plan of action. In the ROSA region, all countries had a strategy but India and Nepal reported having no plan of action. Afghanistan, Bhutan and Sri Lanka all had policy, strategy and plan of action. In the WCAR region most of the countries that responded [87% (n=13)] had a strategy but only 60% of these countries (n=13) had a plan of action. Mauritania, Nigeria, CAR, Gambia, Ghana, Gabon, Togo and Senegal reported having both a strategy and a plan of action and DRC had neither a strategy nor a plan of action. Gambia, CAR, Gabon, Ghana, Mauritania, Senegal, Togo and Nigeria had policy, strategy and plan of action. NATIONAL IYCF LEGISLATION The International Code of Marketing of Breast Milk Substitutes and subsequent World Health Assembly Resolutions need to be translated into national legislation and regulations, integrated into the legislative and regulatory frameworks of the country. The code, adopted by the World Health Assembly in 1981, provides guidelines for the marketing of breast milk substitutes, bottles, and teats [5]. International code of marketing of breast milk substitutes law / regulation About 62% of the countries (n=39) reported having an existing international code of marketing of breastmilk substitutes law or regulation but only 50% (n=19) had systems of Code monitoring or enforcement in place (Table 2b, Annex 5b). The entire CEE/CIS region responded that their country had an existing international code of marketing of breastmilk substitute law. Romania and Kyrgyzstan had a system of Code monitoring and enforcement in place. 12

19 Table 2b. Key components and indicators at the national level on IYCF legislation National action level Indicators Results, n (%) Development & enforcement of national legislation on the marketing of breast milk substitute Countries with existing international code of marketing of breast milk substitute law/regulation Countries with Code monitoring and enforcement system in place 39 (61.9%) 19 (50.0%) Development & enforcement of national legislation on maternity protection Countries with maternity protection laws or regulations in place 50 (79.4%) Countries with paid maternity leave 56 (91.8%) Countries with paid nursing breaks provided for mothers after they return to work 32 (51.6%) In the EAPR, 71% of the countries (n=10) that responded reported having a law or regulation in place; only 5 countries (55.6%) had a system of monitoring or enforcement in place. Korea, Indonesia, Myanmar, TimorLeste had no laws or regulation. In the ESAR, 41% of the countries (n=7) had laws or regulation in place and these countries are Zimbabwe, Uganda, Tanzania, Botswana, Mozambique, Malawi and Zambia. Almost all of these countries except Mozambique had a system of monitoring and enforcement in place. Only Yemen in the MENA region had a national Code law/regulation but with no system of enforcement. In the ROSA region 83.3% of the countries (n=5) had laws or regulations on the Code (all except Bhutan). India and Sri Lanka were the only two with systems of monitoring or enforcement. In the WCAR region, 9 (60%) of the 15 countries that responded, had a Code related law / regulation. These include Mauritania, Nigeria, Ghana, Burkina Faso, Gambia, Gabon, Benin, Congo and Senegal. Only 4 of these countries had a system of monitoring and enforcement in place (Senegal, Nigeria, Gambia, and Ghana). Maternity Protection Laws and Nursing breaks Overall, 50 countries (79%) out of those that responded had maternity protection laws, about 92% (n=56) provided paid maternity leave for women and 52% (n=32) provided paid nursing breaks for mothers after they returned to work. In the CEE/CIS region, 50% of the countries (n=4) Bosnia, Turkmenistan and Romania and Kazakhstan had maternity protection laws and all of the countries provided paid maternity leave for mothers but only Romania, Kyrgyzstan and Kazakhstan provided paid nursing breaks for mothers. Box 2. Summary of national IYCF legislations/regulations in the 65 countries assessed Generally, countries performed slightly better on IYCF legislative actions than on IYCF policy (Annex 5b); however, there were still gaps in the monitoring and enforcement of the International Code of Marketing of Breastmilk Substitutes and the provision of nursing breaks for mothers after they return to work. Thirtynine countries (62%) had International Code of Marketing of Breastmilk Substitutes laws or regulations in place, 19 countries had code monitoring or enforcement in place. Nevertheless, 56 countries (92%) have paid maternity leave in place but only 32 countries (52%) provided paid nursing breaks for mothers after they returned to work. In the EAPR region, TimorLeste and Fiji were the only two countries without maternity protection laws (14%). All EAPR countries except TimorLeste provided paid maternity leave for mothers and 64% of the countries (n=9) provided paid nursing breaks. Among those who did not provide paid nursing breaks were Timor Leste, Fiji, Korea, Myanmar, Indonesia and Thailand. About 14 countries (82%) in ESAR regions had a maternity protection law in place. Only Rwanda and Somalia did not provide maternity 13

20 leave for women and 41% of the countries (n=7) provided paid nursing breaks for mothers. All the 6 countries in the ROSA had maternity protection laws. Nepal was the only country without paid maternity leave for mothers and only Bhutan and Afghanistan provided paid nursing breaks for mothers. Most of the countries [93% (n=14)] in WCAR that responded had maternity protection law in place with the exception on Mali. Furthermore, all the countries [100% (n=15)] that responded had paid maternity leave for women. However, the DRC, Benin, Congo Brazzaville, Sierra Leone and Gambia had no paid nursing breaks for mothers returning to work. North Sudan was the only country in the MENA region with a maternity protection law and this country provided paid maternity leave for women and paid nursing breaks as well as Yemen (although Yemen had no maternity protection law or regulation). NATIONAL LEVEL IYCF ACTIONS SCORE The national level IYCF action score was calculated for each country based on performance in the key action areas related to IYCF policy and legislation. National level IYCF action scores and how countries performed are shown in figure 1. The average national IYCF action score was 6 out of 10. MENA had the lowest score (4) and ROSA the highest (7). The other four regions had averages of 5 (ESAR and CEE/CIS) and 6 (WCAR and EAPR). Countries with a score between 0 3 poor had, at the time of the survey, very few or none of the key national level actions related to IYCF policy, strategy, plan of action and legislation. Twenty per cent of the countries (n=13) fell in this category and had many gaps in their national IYCF policy and legislative actions. Countries with a score between 4 and 6 were still below average and were rated as having a low fair national IYCF action level; 26 countries (40%) fell in this category. These countries need to intensify efforts to strengthen their national IYCF actions. Countries with scores between 7 and 8 were categorized as good regarding the status of national level IYCF action in their countries. About 28% of the countries (n=18) fell into this category. A score between 9 and10 indicated a high level of actions at the national level. Senegal and Gambia WCAR, Zimbabwe, and Botswana in ESAR, Vietnam and the Philippines in EAPR, Afghanistan and Sri Lanka in ROSA all had scores 9. 14

21 Kyrgyzstan Kazakhstan Bosnia and Herz. Romania Tajikistan Turkmenistan Uzbekistan Kosovo Philippines Vietnam Cambodia Lao D. Rep. Thailand Vanuatu Mongolia P. New Guinea China Korea Myanmar Fiji Indonesia TimorLeste Botswana Zimbabwe Malawi Madagascar Uganda Kenya Tanzania South Africa Zambia Angola Mozambique Namibia Rwanda Somalia Swaziland Burundi Ethiopia North Sudan Yemen South Sudan Afghanistan Sri Lanka Bangladesh Bhutan Nepal India Senegal Gambia Togo Nigeria Mauritania Ghana Gabon Cen.Afr.Rep. Burkina Faso Sierra Leone Niger Congo Brazzaville D. Rep. Congo Benin Mali Liberia Cote d'ivoire Socre Figure 1: National level IYCF actions score* CEE/CIS EAPR ESAR MENA ROSA WCAR *The scores were measured on a scale of 0 to 10 The countries for which profiles were developed are indicated with the striped bars (see page 45) COLOUR KEY VERY GOOD GOOD FAIR POOR High number of key IYCF actions or intervention implemented Medium number of key IYCF actions or intervention implemented Low number of key IYCF actions or intervention implemented Very Low number of key IYCF actions or intervention implemented 15

22 Inservice curriculum Preservice curriculum 3.3 HEALTH SERVICE LEVEL IYCF ACTIONS Health service interventions for IYCF are one of the key pillars of the overall IYCF policy and strategy, and are crucial even if service coverage and utilization are not high for all of the maternal and child health services. Even if the health system is weak or access is poor, IYCF actions should still be an important part of it, for a number of reasons: health professionals are influential; they are often the trainers and supervisors of community cadres; the advice and messages provided at health facility and community level, as well as through communication channels, should be harmonized, and health professionals should be able to deal with problematic cases referred by community health workers or lay counsellors. IYCF HEALTH SERVICE CURRICULA Incorporating IYCF topics in the basic curriculum of medical and paramedical health professionals is most likely to be the most feasible and sustainable way to address the current knowledge gaps. The standard preservice curricula should be based on the recent WHO Model Chapter for Medical Textbooks on IYCF [6]. A number of other WHO reference documents on IYCF also inform curricula 4. Only Mauritania, Sri Lanka and Togo (7% out of the 41 countries that provided a response) used all four references/documents (Table 2c) to update both their preservice IYCF packages for medical doctors, nurses and health professionals. The reference used by the largest percentage of countries to update preservice curricula for medical doctors was the revised Baby Friendly Hospital Initiative (BFHI) material 2009 [7] [66% (n= 27)]. The other references, including the Global Strategy on IYCF [2] or the Guiding Principles for Complementary Feeding of the Breastfed Child [8], were the key IYCF documents/references used in 24 countries (59%). Table 2c. Health service level actions: IYCF training curricula for health professionals Health system actions Selected indicators Results, n (%) Development/updating of IYCF integrated curriculum for health providers preservice education (Medical doctors only) Countries that used the global strategy on IYCF* to develop/update their medical curriculum Countries that used the revised BFHI material 2009* to develop/update their medical curriculum 24 (58.5%) 27 (65.9%) Development/updating of IYCF integrated curriculum for health providers preservice education (Nurses and other health professionals only) Countries that used the global strategy on IYCF* to update/develop the curriculum for nurses and other health professionals Countries that used the revised BFHI material 2009* to update /develop the curriculum for nurses and other health professionals 14 (30.4%) 18 (39.1%) Development/updating of IYCF integrated curriculum for health providers inservice training (for all health professionals) Countries that used the global strategy on IYCF* to update/develop the curriculum for of all health professionals 11 (100%) Countries that used the revised BFHI material 2009* to update /develop their medical curriculum 3 (27.3) 4 The four key IYCF documents/references used in updating/developing health professionals pre/inservice curricula as captured by the assessment matrix, included (i) Global strategy for IYCF 2003; (ii) Revised BFHI material 2009; (iii) Guiding principles for complementary feeding of breastfed child 2001; and (iv) Guiding principles for feeding nonbreastfed children 6 to 24 months WHO

23 The WHO 2005 Guiding Principles for Feeding NonBreastfed Children 6 to 24 months [9] was used in approximately 56% of the countries (n=23) to update their medical curricula. For nurses and other health professionals, most of the countries [83% (n=38)] used WHO/PAHO 2001 Guiding Principles for Complementary Feeding of the Breastfed Child to update their preservice training curricula 4. Furthermore, about 14 countries (30%) used the Global Strategy for IYCF [2] for updating nurses and other health professional curricula. Furthermore, all the countries that responded (11), indicated updating their inservice IYCF training package for their health professionals using the global strategy for IYCF [2] document (Table 2c). Babyfriendly practices was the element 5 that was least likely [70% (n=39)] to be included in medical curricula and Appropriate breastfeeding practices was the most likely [84% (n=47)] element to be included in medical training curricula. Similarly, for nurses and other health professionals; preservice curricula, Appropriate complementary feeding was the element least likely [70% (n=38)] and Appropriate breastfeeding [85% (n=46)] was the most likely to be reflected in the curricula. About 57% of the countries (n=32) had preservice curricula for medical doctors that were comprehensive, that is, contains all three key IYCF elements and 52% (n=28) had comprehensive curricula for nurses and other health professionals. Regionally for medical curricula, CEE/CIS [71% (n=5)], EAPR [64% (n=7)] and WCAR [67% (n=10)] had the highest percentage of countries reporting that their preservice medical curricula contained a comprehensive IYCF package. ESAR [(47% (n=8)], MENA [33% (n=)] and ROSA [40.0% (n=2)] were all below 50%. Turkmenistan noted that the elements were only partially developed and Benin that there were no specific IYCF elements but only elements on nutrition. Additionally, the IYCF training packages for nurses and other health professionals were comprehensive among 10 countries (59%) in ESAR; 3 (60%) in ROSA, 4 (67%) in CEE/CIS, 7 (54%) in WCAR and 4 countries (36%) in EAPR. No countries in MENA had a comprehensive IYCF package for their preservice curricula for nurses and other health professionals. CAPACITY DEVELOPMENT ON IYCF FOR HEALTH PROVIDERS Building the capacity of health providers whether through inservice training or preservice education is critical for ensuring optimal IYCF practices. Fewer countries [51% (n=33)] conducted IYCFfocused preservice trainings for their medical doctors than the IYCFfocused inservice trainings for nurses and other health professionals [88% (n=38)]. This was a similar trend across regions except in MENA where the training conducted was for medical doctors (Annex 5e). Only the countries in MENA and Benin and CAR in WCAR responded that there was no IYCF preservice training for nurses and other health professionals. Box 3. Summary of training/capacity development on IYCF for health providers in the 65 countries assessed Preservice IYCF trainings for nurses and other health professionals were more likely to occur than training for medical doctors. About half of the countries conducted preservice trainings for medical doctors and a little over fourfifths preservice IYCF training for nurses. Inservice trainings occurred in roughly twothird of the countries (All health professionals). Approximately 60% of countries (n=37) indicated that standalone IYCF inservice trainings were conducted for health professionals (medical doctors, nurses and other health professionals). The regions with the lowest percentage of countries that had inservice training were ROSA [50% (n=3)] and WCAR [56% (n=9)]. The other regions had between 62% (n=8) [ESAR] and 67% (n=10) [ESAR] of countries conducting inservice IYCF trainings. Sixtynine per cent of the countries (n=44) indicated having IYCF job aids and counselling cards for health professionals. CEE/CIS (50%) and WCAR (56%) had fewer countries with job aids, compared to MENA (67%), EAPR (71%), ESAR (82%) and ROSA (83%). Training on IYCF counseling took place in 55 countries (85%). Additionally, training of 5 The three key IYCF elements reflected in the training package as captured by the assessment matrix, included (i) the Baby Friendly practices to support early initiation of breastfeeding, (ii) appropriate breastfeeding practices and (iii) appropriate complementary feeding practices 17

24 health workers on standalone IYCF counseling since 2006 occurred in 94% (n=43) out of the 46 countries that responded. Only 54% of the countries were able to report on the proportion of health workers trained. Where countries were able to estimate this, the average proportion of health workers trained on IYCF counseling since 2006 is 10%, with a range of 0.2% to 82%. Also, most countries were not able to report on the coverage of the training on IYCF counselling by district. Among the few which did report, the average proportion districts in which IYCF training took place was 47 %, ranging from 2% to 100% coverage. Regionally, only Bosnia and Romania in CEE/CIS did not have IYCF training since 2006; however, the other countries in the region (Kosovo, Bosnia, Uzbekistan, Kyrgyzstan, Kazakhstan and Tajikistan) that conducted IYCF training also indicated training of their health workers in standalone IYCF counselling. In EAPR 82% of the countries (n=9) which responded that they had conducted trainings since 2006 indicated training their health workers in standalone IYCF counselling. One country, Vanuatu, did not conduct any IYCF trainings since All of the countries (n=6) in ROSA had some form of training since 2006 and only 4 countries responded that health workers were trained in standalone IYCF counselling. For India and Nepal, data were not available. Both ESAR and WCAR had 14 countries in each region that trained health workers in IYCF since All of those countries in WCAR and only 12 in ESAR indicated training health workers in IYCF counseling. Table 2d. Health service level actions: IYCF capacity development Health system actions Selected indicators Results, n (%) Pre and inservice capacity development on IYCF for health providers/lactation counsellors Training of health workers on standalone IYCF training since 2006 Countries with IYCFfocused preservice trainings for health professionals (medical doctors only) Countries with IYCFfocused preservice trainings for nurses and other health professionals. Countries with IYCFfocused inservice trainings for all health professionals (medical doctors, nurses and other health professionals) Countries in which health workers are trained on IYCF counseling since 2006 Average proportion of health workers trained on IYCF counseling since 2006 Average proportion of district covered by the training on IYCF counseling 33 (50.8%) 38 (88.4%) 37 (59.7%) 43 (93.5%) 10% [range 0.2% 82%] 47% [range 2.0% 100%] IYCF COUNSELING AT THE HEALTH SERVICE LEVEL IYCF counseling and support in health services is important for establishment and sustaining of good infant and young child feeding practices, as well as for solving problems at relevant health care contacts. Most countries [91% (n=59)] indicated that IYCF counselling occur at the health service level. Countries that did not have IYCF counselling activities were Romania in CEE/CIS, Mongolia in EAPR, and Somalia in ESAR, South Sudan in MENA and Sierra Leone and Liberia in WCAR. Mongolia reported that the country had just begun the process of training its health workers on IYCF counselling. The assessment aimed to determine the major programmes and services within which IYCF was integrated in countries. Of the countries who reported that IYCF counselling took place in their health system, 56% (n=33) of the counselling took place during antenatal care (ANC), 76% (n=44) in prevention of mother to child transmission (PMTCT) services, 58% (n=34) in growth monitoring and 18

25 Monitoring and evaluation of IYCF counseling services within the health system Establishment of integrated IYCF counseling services within health system promotion (GMP) services, 78% (n=46) in the integrated management of childhood illness (IMCI) programme and only 25% (n=15) of the countries had IYCF counselling taking place through the essential nutrition action (ENA) programme. A few countries mentioned other services such as the BabyFriendly Hospital Initiative, maternal and child health clinic, expanded programme on immunization (EPI) clinics, child health days and communitybased management of acute malnutrition (CMAM), although only 3 countries (Madagascar, Ghana and Mauritania) indicated CMAM. Countries that have IYCF counseling taking place within in the top five maternal and child health contacts 6 (Table 2c) included, Turkmenistan (CEE/CIS), Mozambique (ESAR), Sudan (MENA), Niger, Senegal and Nigeria (WCAR). Table 2e. Health system level action: IYCF health service counseling Health system actions Selected indicators Results, n (%) IYCF counseling activities within the health facilities at relevant maternal and child health contacts Countries with IYCF counseling currently taking place within the health service level 59 (90.8%) Countries with IYCF counseling taking place within the top five maternal and child health contacts # 6 (9.2%) System integration: IYCF counseling within the top five maternal and child health contacts Countries in which IYCF counseling is currently taking place within the IMCI Countries in which IYCF counseling is currently taking place within the PMTCT Countries in which IYCF counseling is currently taking place within the GMP Countries in which IYCF counseling is currently taking place within the ANC Countries in which IYCF counseling is currently taking place within the ENA 46 (78.0%) 44 (75.9%) 34 (57.6%) 33 (55.9%) 15 (25.4%) Development & implementation of supervision/quality assurance system for IYCF services in the health system Countries with routine monitoring of health workers skills Countries with routine monitoring of quality of counselling 18 (34.6%) 10 (19%) % of countries with regular supportive supervision provided by managers 24 (44.0%) Countries that routinely monitor the or conducted routine monitoring of other process indicators 20 (35.1%) # Top five maternal and child health contacts identified included, Antenatal care, Prevention of mother to child transmission of HIV/AIDS, Growth monitoring and promotion, Integrated management of childhood illnesses and essential nutrition action programmes 6 The top five maternal and child health programme where counseling on IYCF takes place the most frequently included antenatal care, prevention of mother to child transmission of HIV, growth monitoring and promotion, integrated management of childhood illness and essential nutrition action programmes 19

26 Institutionalizing the Ten steps to successful breastfeeding" in all maternity facilities/hospitals The assessment included a question on the proportion of the target population reached with IYCF counselling services in the health system, and the proportion of districts where IYCF counseling services are provided, but no countries were able to provide a response. This represents a major gap in programme monitoring, as it is not possible to determine whether IYCF counselling is actually being provided and the scale of services. BABYFRIENDLY HOSPITAL INITIATIVE The BFHI was launched by WHO and UNICEF in 1991, following the joint WHO/UNICEF statement on breastfeeding in the maternity services in 1989 and the adoption of the Innocenti Declaration in 1990 [10]. The BFHI promotes the implementation of the Ten Steps to successful breastfeeding practices with the primary objective of creating an environment conducive for breastfeeding [11]. Maternal and infant experience in health care services exerts a strong influence on breastfeeding initiation and later infant feeding behaviour. Table 2f. Health system level action: Babyfriendly Hospital Initiative Health system actions Indicators Results, n (%) Countries with at least one hospital/ maternity facility ever certified as Baby Friendly 55 (84.6%) Certification of hospitals/ maternity facilities Baby Friendly Average proportion* of hospitals / maternity facilities ever certified Baby Friendly 22.7% (range 1.0% 100%) Recertification of hospital/ maternity facilities Babyfriendly Countries with at least one hospital / maternity facility ever recertified as BabyFriendly since 2006 Average proportion* of hospitals/ maternity facilities ever recertified Baby Friendly since (33.9%) 5.6% (range 1.0% 76%) Based on the responses from 65 countries, 55 countries (85%) had evercertified at least one hospital or maternity facility as babyfriendly, but only 22 countries (34%) had recertified at least one hospital or maternity facility. The average proportion of hospitals/maternity facilities ever certified was reported to be 22.7%, with a range of 1.0% to 100%. This is in line with the global reported average of around 27% at the time. And the average proportion of hospitals/maternity facilities ever recertified was extremely low at 5.6%, with a range of 1.0% to 76%. The low rate of certification, in particular recertification, highlights the difficulty of rapidly scaling up the BFHI in the traditional vertical manner and of sustaining the intervention. At the regional level, all of the countries (n=8) in CEE/CIS had evercertified at least one hospital/maternity facility, while only 63% of the countries (n=5) had at least one hospital/maternity facility recertified babyfriendly. Although the average proportion of maternity facilities evercertified is 49%, with a range of 1% (in Tajikistan) to 100% (in Kosovo). In EAPR region, only Vanuatu had no hospitals ever certified babyfriendly and only 4 countries (29%) [Vietnam, Papua New Guinea, Fiji and Thailand] had recertified babyfriendly hospitals. Not all countries reported the number of facilities in their countries, however, of Box 6. Summary of BFHI status in the 65 countries assessed The average proportion of hospitals/maternity facilities ever certified BabyFriendly was 22.7%, with a range of 1.0% to 100%. And the average proportion of hospitals/maternity facilities ever recertified BabyFriendly was 5.6%, with a range of 1.0% to 76%. The low rate of certification, in particular recertification highlights the difficulty of scaling up rapidly the BFHI in the traditional vertical manner. A sustainable option might be to institutionalize the BFHI principles within the health services. 20

27 those who did, only Fiji (100%) Philippines (83%) and Thailand (67%) certification rates were above 50%. Over half (52%) of babyfriendly designated hospitals in Fiji were recertified, about 10% for Thailand and 0% for Philippines. ESAR (16%), ROSA (15%) and WCAR (16%) regions had similar average proportion of hospitals/maternity facilities certified. However, recertification was only 0% (in ROSA), while ESAR (87.5%) of its countries hospitals/maternity facilities certified babyfriendly. However, recertification rate was even lower, as none of the facilities in ROSA were recertified, 5.6% in WCAR and 4.3% in ESAR. MONITORING AND EVALUATION OF IYCF COUNSELING ACTIVITIES As noted above, there is generally a serious problem of low reporting with respect to the coverage of IYCF counseling activities taking place within the maternal and child health contacts. The absence of routine and mandatory monitoring/reporting system on IYCF counselling is a major constraint. Inclusion of questions in household surveys or rapid assessments that would enable coverage to be determined is also generally assumed not to happen. Only 35% (n=18) of countries health system routinely monitored health worker skills. Only 10 (19%) had routine monitoring of the quality of counselling taking place in their health system. Fortyfour per cent (n=24) had managers that provided regular supportive supervision. None of the countries in MENA monitored health workers skills or quality of counselling routinely. In CEE/CIS, neither Kazakhstan nor Tajikistan conducted routine monitoring of health worker performance. Only Cambodia in EAPR conducted both performance monitoring activities and was the only country that conducted managerial supportive supervision. Box 5. Summary of IYCF counseling / monitoring within the health service in the 65 countries assessed Almost all of the countries that responded (43) had an IYCF standalone counseling training incountry during Very few countries monitored health workers skills routinely or monitored the quality of counseling taking place within the health service level. number of facilities carrying out IYCF counselling activities. In ESAR, only Malawi and Rwanda conducted regular monitoring of health worker skills. In ROSA only Sri Lanka, Bangladesh and India did and in WCAR six countries (Nigeria, DRC, Togo, Senegal, CAR and Gabon routinely monitored health workers skills. Among these countries only Tajikistan, Rwanda, India, Sri Lanka, Gabon, Togo, DRC and Nigeria carried out regular support supervision. Approximately 35.1% (20) of the countries reported conducting monitoring of other process indicators. Those mentioned included number of health workers trained, number of trainings conducted and HEALTH SERVICE LEVEL IYCF ACTIONS SCORE The average IYCF health service level IYCF action score was approximately 5 indicating a low level of IYCF action at the health system level for countries as a whole (Figure 2). Regional averages were mostly 5 (CEE/CIS, WCAR, EAPR and ESAR) or 4 (ROSA and MENA) (See Annex 5i). Romania and Bosnia Herzegovina. in CEE/CIS, Myanmar, Indonesia, Korea, Vietnam and Timor Leste in EAPR, Botswana and Somalia in ESAR, Yemen and South Sudan in MENA, Afghanistan, Nepal and Bangladesh in ROSA and Congo, Cote d Ivoire, Gabon, Liberia and Sierra Leone in WCAR had very low IYCF health service level activity scores and were rated as having very poor IYCF health system actions. Overall, 12% of the countries were rated Good, 57% Fair and 31% Poor on the health service IYCF actions. 21

28 Kyrgyzstan Tajikistan Turkmenistan Kazakhstan Uzbekistan Kosovo Bosnia Herz. Romania Fiji Lao P.Dem. Rep. P.N.Guinea Thailand Cambodia Mongolia China Philippines Vanuatu Korea Vietnam Indonesia Myanmar TimorLeste South Africa Tanzania Kenya Rwanda Zambia Zimbabwe Ethiopia Malawi Mozambique Uganda Angola Madagascar Namibia Swaziland Burundi Botswana Somalia North Sudan Yemen South Sudan Sri Lanka Bhutan India Afghanistan Bangladesh Nepal Nigeria Togo D.Rep.Congo Ghana Niger Senegal Burkina Faso Mali Mauritania Benin C. Afr. Rep. Gambia Congo Brazzaville Gabon Cote d'ivoire Sierra Leone Liberia Score Figure 2: Health service IYCF actions score* CEE/CIS EAPR ESAR MENA ROSA WCAR *The scores were measured on a scale of 0 to 10 The countries for which profiles were developed are indicated with the striped bars (see page 45) COLOUR KEY VERY GOOD GOOD FAIR POOR High number of key IYCF actions or intervention implemented Medium number of key IYCF actions or intervention implemented Low number of key IYCF actions or intervention implemented Very Low number of key IYCF actions or intervention implemented 22

29 Implementation of communitybased IYCF counseling services Establishment of integrated IYCF Counseling services at the communitylevel 3.4 COMMUNITY LEVEL IYCF ACTIONS Communitybased IYCF programmes and activities should build upon existing health and nutrition programmes to the extent possible. Community level breastfeeding and complementary feeding promotion and support can be effective in improving optimal infant and young child feeding, particularly for those disadvantaged and vulnerable groups with low access to health services. COMMUNITY LEVEL IYCF ACTIVITIES Based on the responses received, established communitybased IYCF activities were carried out in 53 countries (84%). Countries without established communitybased IYCF activities were Kazakhstan, Romania and Uzbekistan in CEE/CIS; Mongolia and Myanmar in EAPR; Angola, Botswana and Burundi in ESAR, Bhutan in ROSA and Congo in WCAR. Table 2g. IYCF actions at the community service level: Communitybased IYCF activities Health system actions Selected indicators Results, n (%) IYCF counseling activities at the community level Countries with established communitybased IYCF counseling activities 53 (84.1%) Countries with standalone communitybased IYCF activities 11 (20.3%) System integration: IYCF counseling taking place within other relevant selected communitybased programmes Countries in which IYCF counseling is currently taking place within CIMCI Countries in which IYCF counseling is currently taking place within the ANC Countries in which IYCF counseling is currently taking place within the GMP 12 (30.0%) 9 (22.5%) 7 (17.5%) Development and implementation of communitybased programmes Countries in which IYCF activities are carried out by multipurpose community health workers Countries in which IYCF activities are carried out by dedicated community health workers 34 (62.9%) 29 (53.7%) Countries in which IYCF activities are carried out by mother support groups 26 (47.3%) Korea and Thailand in EAPR provided no response. About 20% of the countries (n=11) indicated that the communitybased IYCF activities was standalone. One country in MENA (Sudan), ROSA (Afghanistan), and WCAR (Niger); two countries in CEE/CIS (Bosnia and Herzegovina and Turkmenistan) and EAPR (China and Vanuatu) and four in ESAR (Madagascar, Mozambique, Somalia and Uganda) had standalone IYCF activities. Countries without standalone IYCF communitybased activities indicated in which package IYCF was included. Some countries had standalone communitybased IYCF activities; however, they also indicated that IYCF was also included in other community activity packages. Twelve countries (30%) had IYCF within the community IMCI programme, 23% of the countries (n=9) had it included in ANC, 18% (n=7) in GMP, 13% (n=5) in ENA, 13% (n=5) in mother to mother programmes and 3% (n=1) in PMTCT programme. Only one country (Afghanistan) reported that IYCF activities were included within the CMAM programme. 23

30 Box 7. Summary of community level IYCF activities in the 65 countries assessed Almost 84% of the countries (n=53) indicated carrying out communitybased IYCF activities, but only 11 countries (20%) indicated had an established standalone IYCF activities. Approximately 60% of the countries (n=27) had a communitybased IYCF training and specific communication skills capacity building. Of the countries that responded, only 13 routinely monitored their community health workers skills and very few countries [13% (n=6)] monitored the quality of community health workers counselling skills. The monitoring systems need to be substantially strengthened. None of the countries responded on the proportion of districts implementing community IYCF interventions. The majority of IYCF community activities were being carried out by multipurpose community health workers [63% (n=34)] who conducted group education sessions as a part of child survival packages. Dedicated IYCF community health workers or counsellors who provided group counselling/promotion and individual counselling and support to mothers were reported in about 54% of the countries (n=29), with 47% of the countries (n=26) mentioning mother support groups. Only 17% of the countries IYCF community activities were conducted by traditional birth attendants (TBAs) or traditional health practitioners (THPs). Other groups listed as IYCF activity implementers were volunteers; secular and community groups (see Annex 5l for a complete list). About 68% of the countries (n=44) had data available to calculate the coverage of the IYCF communitybased activities. The average coverage was 65.3%, ranging from 3% to 100%. Thirteen countries had less than 25% of their districts covered with IYCF activities. 38 countries (59%) were not able to report the proportion of the population targeted by the IYCF activities. However, the proportion ranges from 7% to 100% among countries that were able to report on the proportion of the population living in the target districts (See Annex 5k which provides the coverage details as provided by the countries). Capacity development and routine monitoring of community health worker skills Not all countries had information on the communitybased IYCF trainings that took place in their Table 2h. IYCF at the community system level: Capacity development of community health workers skills Communitybased actions Selected indicators Results, n (%) Countries in which community health workers are trained on communitybased IYCF counseling since (66.1%) Training of community health workers on communitybased IYCF counseling Countries in which the capacity building on communication skills are conducted for community health workers 27 (60.0%) Community level monitoring system Average proportion of community health workers trained on IYCF counseling since 2006 Average proportion of district covered by the training on IYCF counseling Countries in which community IYCF activities are routinely monitored 25.6% [<1% 73%] No information 15.0 (31%) Countries in which community health workers counselling skills are routinely monitored 13 (27.1%) Countries in which community health workers counselling qualities are routinely monitored Countries with supportive supervision of community health workers Countries with recognition mechanism for wellperforming workers 6 (13.0%) 23 (50.0%) 5 (19.2%) 24

31 countries since Approximately 66% of the countries (n=39) had a communitybased IYCF training while about 60% (n=27) out of the 45 countries that responded had capacity building on communication skills for community health workers (see Annex 5j). Regionally, WCAR [81% (n=39)], ESAR [77% (n=13)] and EAPR [67% (n=8)] had the most countries that conducted community based IYCF trainings. IYCF Trainings occurred in two countries in MENA (Yemen and Sudan). Only Sri Lanka in ROSA, Turkmenistan and Kyrgyzstan in CEE/CIS had training on IYCF. About 60% of the countries (n=27) acknowledged that community health workers participated in specific communication skill capacity building, with WCAR region having the highest number of countries [86% (n=12)] that had specific skillbuilding capacity development for their community health workers. Only 17 countries (26%) were able to report on the proportion of community health workers trained since The average proportion of community health workers trained on communitybased IYCF counseling since 2006 is 26%, with a range of <1% (in Indonesia) to 73% (in South Africa) [See Annex 5k]. None of the countries responded on the questions related to the proportion of districts implementing community IYCF interventions. This reveals a major gap in information about geographic coverage and indeed the question was a very general one, not even about the proportion of the population that has access to IYCF services at community level. The assessment tool did not attempt to assess coverage for the target population of communitybased IYCF interventions, as it was assumed that this information would not be available. Neverthess, this represents a key area of work: to develop or strengthen community information systems to be able to measure performance, quality and coverage of IYCF interventions and to explore feasible assessment modalities including small surveys (e.g. through LQAS) and qualitative methods to complement the information systems. Monitoring communitybased IYCF activities Only 15 countries (31%) indicated that that routine monitoring of IYCF communitybased activities was being conducted. Neither of CEE/CIS or MENA regions conducted routine monitoring of IYCF activities in their region. Only Cambodia in EAPR and Somalia, Rwanda, Madagascar, South Africa and Kenya in ESAR; as well as Afghanistan in ROSA and 8 countries in WCAR reportedly conduct routine monitoring of IYCF community activities (based only on countries that responded). Furthermore, only 13 countries (27%) indicated that the counseling skills of community health workers were routinely monitored and only 6 countries (13%) routinely monitored the quality of counselling conducted by Community health workers. However, more countries [23 (50%)] conducted supportive supervision of the community health workers. Only Kyrgyzstan, Fiji, Kenya, CAR and Nigeria indicated that there was a recognition mechanism for well performing community health workers in their countries. Taken together, the monitoring systems of communitybased IYCF activities in most countries need to be substantially strengthened. Community level IYCF actions score The average communitybased IYCF actions score was very low: 3 (Annex 5j); all of the regions were either rated very low (CEE/CIS, EAPR, ROSA) or low (ESAR) for their performance on communitybased IYCF activities. Eight countries had a score of 0: Romania and Uzbekistan (CEE/CIS); Myanmar, Mongolia, Indonesia, Thailand (EAPR); Angola (ESAR) and Bhutan (ROSA). All of these countries responded that no communitybased IYCF activities existed incountry. Four countries (Senegal, Togo, Cote I voire, Nigeria and CAR), all in the WCAR region had scores of 7 or 8, based on how they completed the assessment matrix. They all received a rating of good for their communitybased IYCF activity level. However, in some cases this status reported in the matrix may reflect a more positive picture than the actual situation on the ground, based on other sources, reports and experience. All other countries were either "Poor 13 or "Fair 46 regarding incountry communitybased IYCF actions. Comparatively, WCAR was the only region with a score of 5 (denoting a medium level of communitybased IYCF activities). Overall, only 8% of the countries were rated Good, 31% Fair and 61% Poor on the communitybased IYCF actions. 25

32 Kyrgyzstan Bosnia and Herz. Tajikistan Turkmenistan Kazakhstan Kosovo Romania Uzbekistan Cambodia Vietnam P. N. Guinea Fiji China Philippines Lao P. D. Rep. Korea Vanuatu TimorLeste Thailand Myanmar Mongolia Indonesia Rwanda Somalia Madagascar Kenya Tanzania Zimbabwe Zambia Uganda South Africa Mozambique Malawi Swaziland Namibia Ethiopia Burundi Botswana Angola Yemen North Sudan South Sudan Afghanistan Sri Lanka Bangladesh India Nepal Bhutan Nigeria C. Afr. Rep. Cote D'Ivoire Senegal Togo Liberia Mauritania Sierra Leone Niger Benin Burkina Faso Gambia Dem. Rep. Congo Congo Brazzaville Gabon Ghana Mali Score. 10 Figure 3: Community level IYCF actions score* CEE/CIS EAPR ESAR MENA ROSA WCAR *The scores were measured on a scale of 0 to 10 The countries for which profiles were developed are indicated with the striped bars (see page 45) COLOUR KEY VERY GOOD GOOD FAIR POOR High number of key IYCF actions or intervention implemented Medium number of key IYCF actions or intervention implemented Low number of key IYCF actions or intervention implemented Very Low number of key IYCF actions or intervention implemented 26

33 Implementation of comprehensive communication strategy on IYCF 3.5 COMMUNICATION ON IYCF Communication broadly encompasses advocacy, social mobilization, social marketing, and behaviour and social change communication. Communication on IYCF is a researchbased consultative process of addressing the knowledge, attitudes and practices that are intrinsically linked to programme goals on IYCF. Formative research identifies both positive and problematic behaviours and motivators related to IYCF. It also identifies, analyses, and segments socalled participant groups who influence infant and young child feeding behaviours and practices, as well as the communication channels which particular communities and groups are most likely to use to receive information and to dialogue on IYCF. An effective communication strategy uses a wide mix of channels appropriate to the identified participant groups, which may include interpersonal, group and mass media channels, as well as participatory methods and social marketing [3]. It also includes plan to implement communication activities at scale and on a continuous basis, rather than just focusing on a oneoff event such as World Breastfeeding Week alone. National level communication strategy on IYCF About 52% of the countries (n=33) had a standalone national IYCF communication strategy, while 47 countries (78%) had elements 7 of communication on IYCF included in the overall national IYCF or nutrition strategy. The elements included in most strategies were World Breastfeeding Week (WBW) [90% (n=37)], while child health days [63% (n=26)] and national campaigns [54% (n=22)] were present to a lesser extent in countries. Table 2i. Communication on IYCF Key actions Selected indicators Results, n (%) National level communication strategy on IYCF Communication on IYCF at the health service level Communication on IYCF at the community level IYCF communication channels* Countries with national level communication strategy on IYCF 33 (52.3%) Countries with ongoing health service level behavioural change communication activities 54 (91.5%) Countries with ongoing communitybased behavioural change communication activities 50 (84.7%) Countries in which behavioural change and communication activities are implemented through five or more communication channels 36 (55.4%) Countries in which behavioural change and communication activities are implemented through eight communication channels 5 (7.7%) Monitoring system for communication on IYCF Countries that routinely monitor ongoing communication on IYCF activities 16 (28.1%) Countries that routinely monitor the number of people reached through media messages 9 (19.6%) Countries that routinely monitor the quality of group messages 8 (18.2%) *The 8 most important IYCF communication channels used among the countries, included national TV, radio, campaigns and poster, interpersonal communication, and mobile phone messages as well as communication through indigenous leaders and community leader In some instances, countries that indicated that despite not having a national IYCF communication strategy, their country still participated in certain IYCF communication activities. For example, Kosovo did not have an IYCF strategy but celebrated WBW under their national plan of action for nutrition. 7 The key elements of communication on IYCF included in most national level communication strategy as captured by the assessment matrix, included World Breastfeeding Week, National campaigns and health days 27

34 Although 23 countries indicated that there was no national coordination mechanism present incountry, almost all (except Angola and Botswana) listed an implementing agency. In 13% of the countries, the national coordination mechanism was implemented by nongovernmental organisations and 11% by the government and 76% by both. Communication on IYCF at the health service level At the health system level, most of the countries [92% (n=54)] that responded had ongoing behaviour change and communication activities occurring in their health system. The three behaviour change and communication activities that occurred in most countries were distribution of posters and leaflets on IYCF [83% (n=47)] with coverage rates ranging from 20% to 100% (as reported in only 24 countries); health workers conducting IYCF group sessions [73% (n=44)] with coverage rates ranging from 2% to 100% (as reported in only 10 countries) and videos on IYCF [37% (n=22)] for communication on IYCF with coverage rates ranging from 20% to 100% (as reported in 13 countries). Communication on IYCF at the community level 8 About 85% of the countries (n=50) indicated that there were ongoing behaviour change and communication activities at community level. Countries that did not indicate having ongoing behaviour change and communication activities at community level were Thailand, Papua New Guinea, Vanuatu, Philippines, Zambia, Tanzania, Somalia, Afghanistan and Cote d Ivoire. Approximately 85% of the countries (n=40) who responded indicated that communitybased health workers conducted group sessions to promote IYCF, 80% (n=39) had mother support groups or other group sessions to promote IYCF but only 34% (n=15) were aware of traditional health practitioners conducting sessions on IYCF. Other examples of special groups that conducted IYCF sessions in communities were community volunteers in Uzbekistan, Myanmar, Yemen, Sri Lanka; community resource persons in Mali; community health nurses and dieticians in Fiji and associations and NGOs in Benin. IYCF communication channels, materials and monitoring and evaluation Behaviour change and communication channels The 8 most important IYCF communication channels used, included National TV, radio, campaigns, and posters, interpersonal communication, mobile phone messages, as well as communication through indigenous leaders and community leader. Only five countries (Cambodia, Senegal, Zambia, Tanzania and Mauritania) out of the ones that that responded indicated implemented behaviour change and communication through 8 or more multiple channels. The average number of channels used was 5 and roughly 60% of the countries used 5 or more communication channels. The messages were most often communicated through national television [88% (n=52)], national campaigns [81% (n=48)], interpersonal communication [81% (n=48)], community leaders [71% (n=42)] and religious leaders [58% (n=34)]. The least used behaviour change and communication methods were mobile phones [12% (n=7)] (Annex 5m). Behaviour change and communication materials Box 8. Summary of IYCF communication channels/ methods in the 65 countries assessed Roughly twothirds of the countries conducted behaviour change and communication (BCC) through 5 or more communication channels and at multiple levels incountry: national, health system and community levels. Almost all of the countries had BCC materials available in country. However, only about 30% of the countries conducted regular monitoring of IYCF communication activities. Behaviour change and communication materials were available in most [95% (n=61)] of the countries Posters and leaflets on breastfeeding [90% (n=52)] and on complementary feeding [83% (n=48)] were the most common materials used. Participatory materials on IYCF were the least used behaviour change and communication materials [29% (n=17)]. Zimbabwe, Botswana, Gabon and the CAR had 8 The assessment matrix did capture information on the coverage of communication activities at the community level. 28

35 no behaviour change and communication material available and Ethiopia s only materials were family health cards. Monitoring and evaluation of communication strategy About 16 countries (28%) routine monitored IYCF communication activities. Few countries [20% (n=9)] had system in place for monitoring the number of people reached through media messages as well as to monitor the quality of the group sessions [18% (n=8)]. This represents a significant gap. As described for the monitoring of community based activities, there is a need to develop feasible approaches for monitoring and evaluation of communication strategies to measure whether coverage and quality is being achieved and the activities are appropriate and effective. Communication on IYCF action scores This communication score took into account all actions or activity related to IYCF behaviour change and communication including communication on IYCF at the national, health service and community level in each country as well as the communication on IYCF monitoring system. The average Communication on IYCF score was 5 (See annex 5o). The highest scores were in WCAR (Burkina Faso, Mauritania, and Senegal) with a score of 8 (Figure 4). Seventeen countries communication on IYCF actions were rated as poor: 03. These countries were Romania and Tajikistan in CEE/CIS; Timor Leste, Philippines and Indonesia in EAPR; Ethiopia, Madagascar, Somalia, South Africa, Zimbabwe and Botswana in ESAR; Nepal in ROSA and DRC, Gabon, Cote d Ivoire, Liberia and CAR in WCAR. Furthermore, all of these countries except Zimbabwe and Timor Leste scored 0 on BCC monitoring actions. Overall, 12% of the countries were rated Good, 62% Fair and 26% Poor on the communication on IYCF actions. 29

36 Kazakhstan Uzbekistan Kyrgyzstan Turkmenistan Kosovo Bosnia Herz. Tajikistan Romania Korea Vanuatu Mongolia Lao PDR Cambodia Vietnam P. N.Guinea Thailand Myanmar Fiji China TimorLeste Philippines Indonesia Mozambique Kenya Tanzania Uganda Rwanda Namibia Malawi Zambia Swaziland Burundi Angola South Africa Somalia Madagascar Ethiopia Zimbabwe Botswana North Sudan Yemen South Sudan Sri Lanka India Bangladesh Bhutan Afghanistan Nepal Senegal Mauritania Burkina Faso Nigeria Ghana Togo Sierra Leone Niger Congo Brazzaville Mali Gambia Benin Liberia Gabon D. Rep. Congo Cote D'Ivoire Cen. Afr. Rep. Score 10 Figure 4: Communication on IYCF actions score* CEE/CIS EAPR ESAR MENA ROSA WCAR *The scores were measured on a scale of 0 to 10 The countries for which profiles were developed are indicated with the striped bars (see page 45) COLOUR KEY VERY GOOD GOOD FAIR POOR High number of key IYCF actions or intervention implemented Medium number of key IYCF actions or intervention implemented Low number of key IYCF actions or intervention implemented Very Low number of key IYCF actions or intervention implemented 30

37 3.6 COMPLEMENTARY FEEDING INTERVENTIONS/COMPONENTS Quality counseling of mothers/caregivers and appropriate behavioural change and communication are essential for improving complementary feeding practices among children 6 to 24 months and beyond. In addition, provision of complementary food supplements (e.g. industrially and locally produced fortified foods, micronutrient powders or lipidbased nutrient supplements) may be needed to fill nutrient gaps when locally available foods alone cannot satisfy nutritional requirements. Strategies to improve complementary feeding in different contexts may also encompass various social protection measures such as cash transfers or vouchers, and nutritionsensitive measures in the agriculture sector. Table 2j. Complementary feeding interventions Key components Selected indicators Results, n (%) IYCF counseling of mothers/caregivers in relation to home preparation of complementary foods Countries in with caregivers/mothers are counselled on home preparation of complementary foods 37 (59.7%) Countries that counsel mothers through counseling cards on food preparation (for health system) 21 (56.8%) Countries that counsel mothers through counseling cards on food preparation (for community base) 15 (44.1%) Provision of complementary feeding supplements Countries providing micronutrient supplements to improve complementary foods of children 6 to 24 months 51 (78.5%) Countries providing targeted food supplements to improve complementary foods of children 6 to 24 months 40 (61.5%) Counseling of mothers/caregivers on home preparation of complementary foods About 59.7% of the countries (n=37) indicated that counseling of caregivers/mothers in home preparation of complementary foods was provided to improve complementary feeding practices of children 6 24 months. More countries counsel mothers through food preparation demonstration on TV [60% (n=22)] and health system counseling cards [57% (n=21]. Very few countries provide food preparation demonstrations on TV or radio [8% (n=3)] or cooking classes [15% (n=5)]. Regionally, counseling of mothers/caregivers on home preparation of complementary foods was similar for ESAR [69% (n=11)], ROSA [67% (n=4)], WCAR [65% (n=11)]; but less than twothirds for EAPR [58% (n=7)] and CEE/CIS [25% (n=2)]. Provision of complementary food supplements It must be noted that the assessment of the use of supplements was intended to be a general overview, and a much more detailed survey was undertaken by UNICEF and CDC on the use of various types of products 9. 9 This section is not intended to be comprehensive. In 2011 CDC and UNICEF conducted a detailed assessment of programmatic interventions related to home fortification in 162 countries (the survey covers the coverage and scale of use among young children). 31

38 Fiftyone (79%) countries reported that micronutrient supplements 10 were provided to improve complementary feeding of children 624 months old. Approximately twothirds of these countries provided both single micronutrients [68% (n=34)] and multiple micronutrients [62% (n=31)]. Supplements were most often available in nonemergency settings [73% (n=38)] with about 33% of the countries (n=17) provided them during emergencies. Targeted food supplements were provided in 62% (n=40) of the countries to improve the nutritional quality of complementary foods for children 6 to 24 months. Specifically, unfortified and fortified local complementary foods are available in 41% (n=16) and 26% (n=10) of the countries, respectively; while unfortified and fortified industriallyblended complementary foods were provided in 21% (n=7) and 58% (n=19), respectively. In addition, only few countries [19% (n=6)] provided lipidbased nutrient supplements to improve complementary feeding of children 6 to 24 months. The matrix contained questions aiming to assess how targeting of complementary feeding supplements was undertaken and the coverage achieved, but none of the countries responded on these aspects. Regionally, all countries (n=6) in ROSA had some type of micronutrient supplements available followed by CEE/CIS region [88% (n=7)], WCAR [82% (n=14)], EAPR [71% (n=10)], ESAR [71% (n=12)] and MENA (66.7%). Countries that indicated that multiple or single micronutrients were not provided/available for children 6 to 24 months, included Tajikistan in CEE/CIS, Fiji, Papua New Guinea, TimorLeste and Myanmar in EAPR, Botswana, Ethiopia, Zimbabwe, Angola and Rwanda in ESAR, South Sudan in MENA and Mali, DRC and Sierra Leone in WCAR. Not all countries Box 9. Summary of the complementary feeding interventions status in the 65 countries assessed Only about 60% of the countries counsel mothers/caregivers in home preparation of complementary foods for children 6 to 24 months. 42 countries responded that targeted food supplements were provided. Most countries did not have coverage estimates for supplement distribution in their countries. were aware if social protection programmes with food security component are available in their country; however, 40% (n=22) of those that responded did have such programmes. Complementary feeding interventions/components score The average complementary feeding component/interventions action score was 4. This score is ranked as fair and is indicative that actions to strengthen complementary feeding through counselling to caregivers/mothers as well as provision of complementary food supplements are low across countries (Figure 5 & Annex 5p). One of the regions had an average complementary feeding action score of 6 (EAPR) and ROSA had 4. Three regions (ESAR, MENA and WCAR) had an average of 3 and CEE/CIS average of 2; these regions are ranked as poor. The complementary feeding components/interventions actions score for 36 countries (55%) were ranked as poor. Overall, 11% of the countries were rated Very good, 4% Good, 36% Fair, and 49% Poor on the complementary feeding interventions/components. 10 The limitation of the assessment matrix pertaining to the reported use of micronutrient supplements is that it was difficult to differentiate countries that use micronutrient supplements added to complementary foods from other supplements that are taken directly (e.g. Vitamin A or Zinc supplements) because of the way the assessment matrix questionnaire was framed. 32

39 Turkmenistan Kosovo Bosnia and Herz. Kazakhstan Kyrgyzstan Romania Uzbekistan Tajikistan Mongolia Vietnam Cambodia China Philippines Indonesia P. New Guinea Myanmar Korea Thailand Lao D. Rep. Vanuatu Fiji TimorLeste Malawi South Africa Tanzania Mozambique Uganda Zimbabwe Madagascar Zambia Namibia Kenya Somalia Swaziland Botswana Burundi Rwanda Ethiopia Angola North Sudan South Sudan Yemen India Sri Lanka Bangladesh Nepal Afghanistan Bhutan Senegal Burkina Faso Nigeria Togo Mali Liberia Ghana Cote d'ivoire Benin Mauritania Gambia Niger Sierra Leone Cen.Afr.Rep. Congo Brazzaville Gabon D. Rep. Congo Score Figure 5: Complementary feeding components/interventions score* CEE / CIS EAPR ESAR MENA ROSA WCAR *The scores were measured on a scale of 0 to 10 The countries for which profiles were developed are indicated with the striped bars (see page 45) COLOUR KEY VERY GOOD GOOD FAIR POOR High number of key IYCF actions or intervention implemented Medium number of key IYCF actions or intervention implemented Low number of key IYCF actions or intervention implemented Very Low number of key IYCF actions or intervention implemented 33

40 Infant feeding programming within the context of HIV 3.7 IYCF IN DIFFICULT CIRCUMSTANCES HIV and infant feeding IYCF in the context of HIV poses significant challenges. Updated HIV and infant feeding guidance was issued by WHO in These new guidelines fundamentally transforms the landscape in which decisions on infant feeding are made by mothers and caregivers, health providers and national health authorities. The latter establish a single national public health recommendation: either breastfeeding and ARVs or replacement feeding. With the provision of ARVs for HIVpositive mothers and their infants, the standard breastfeeding practices can be recommended for the entire population and different recommendations for HIVexposed infants are no longer needed. Counseling on individual choice of feeding options is also no longer necessary unless the mother chooses to opt out of the national policy that has been set. The challenge countries face is to ensure the updated guidelines are widely disseminated and properly understood. Fiftyfour (84%) countries had a policy or guidance on HIV and infant feeding and 89% of those countries (n=48) had HIV and infant feeding policy or guidance included in their national IYCF policies (Table 2k & Annex 5q). Almost all of countries [93% (n=53)] had guidance on HIV and infant feeding included in their PMTCT policy but only 74% of the countries (n=42) had their infant feeding policy based on the WHO 2010 recommendation on HIV and infant feeding [12]. Regionally, in the CEE/CIS, Kosovo, Bosnia, Romania, Kazakhstan reported having no policy or guidance on HIV and infant feeding in place. In the other regions, countries without guidance were Korea and Timor Leste in EAPR, Botswana in ESAR, and Yemen in MENA, India in ROSA and DRC and Liberia in WCAR. Counselling of HIV positive mothers on appropriate infant feeding is reported to be in place in 48 countries (72%). All the countries in MENA and onethirds of the countries (n=4) in the ROSA region (Nepal, Sri Lanka, Afghanistan and Bangladesh) had no infant feeding counselling activities for HIV+ mothers. Approximately 87% (n=40) of the countries that had counseling activities for mothers in place also had IYCF counselling materials that included HIV and IF and only 31 countries (76%) had training materials updated based on the most recent HIV and infant feeding guidance. Table 2k. IYCF in difficult circumstances: HIV and infant feeding Action area Selected indicators Results, n (%) Policy on HIV and infant feeding Countries with policy or guidance on HIV and infant feeding Countries in which the national IYCF policy include guidance on HIV and infant feeding 54 (84.4%) 47 (88.7%) Capacity development Countries in with the prevention of mother to child transmission of HIV policy include guidance on HIV and infant feeding Countries with established training activities for health workers on HIV and infant feeding Countries in which health workers are trained on HIV and infant feeding counselling 53 (93.0%) 45 (83.3%) 44 (74.6%) Counseling activities for HIV+ mothers Countries with established counseling activities for HIV positive mothers on infant feeding 47 (72.3%) Countries with followup and continuous support for HIV + mothers on infant feeding in place 38 (66.7%) 34

41 Infant and young child feeding in emergency contexts Countries with system in place for monitoring infant feeding practices among HIV+ mothers 17 (27.4%) Countries that provide free breastmilk substitute to HIV+ mothers 35 (58.3%) Almost all of the countries [90% (n=55)] that responded had PMTCT training materials that included infant feeding and 76% (n=38) of these were updated. The exceptions were Cote d Ivoire, South Sudan, Mongolia, Korea, Sierra Leone, Sri Lanka and Indonesia. HIV and infant feeding job aids and counselling cards were available in 63% (n=36) of the countries that responded and 74% (n=23) of these had their materials updated based on the recent HIV and infant feeding guidance. Approximately 83% (n=45) of the countries that responded had training for health workers on HIV and infant feeding and 44 countries (75%) trained health workers on HIV and infant feeding counselling. Infant feeding counseling was integrated into the PMTCT services in 86% of the countries (n=50). Countries without their infant feeding counselling services integrated within the PMTCT programme were Mongolia, Indonesia and Timor Leste and Philippines in EAPR, Botswana in ESAR, North Sudan and South Sudan in MENA, Sri Lanka and Bangladesh in ROSA. Thirtyeight countries (67%) indicated that they provided support or followup for HIV+ mothers. Free infant formula was provided to HIV+ mothers in about 58% (n=35) of the countries that responded to the question. In general, formula was provided by most countries in CEE/CIS [88% (n=7)] except Kazakhstan, 60% of the countries (n=3) in ROSA region, 64% (n=9) in EAPR, 47% (n=7) in ESAR and only Yemen in MENA. Furthermore, based on the countries that responded, 42% (n=14) of the free formula came from the government and 64% (n=21) from nongovernmental organizations. Uzbekistan and Vietnam indicated that both entities distributed formula. Overall, only 27% (n=17) of the countries have a system in place for monitoring infant feeding practices among HIV+ mothers Infant feeding in emergencies The protection, promotion and support of good IYCF practices is essential in emergencies, when child mortality and malnutrition rates escalate and the risks of suboptimal IYCF practices are amplified. The response in terms of IYCF in emergencies is often less than adequate, starting from the preparedness, policy and planning aspects to the actual execution of the activities. An important starting point for an effective IYCF response in emergencies is the presence of a strong programme prior to the emergency, with high coverage of services and interventions and good availability of trained and skilled personnel, including those responsible for design, planning, management and decisionmaking. Approximately 41.3% of the countries (n=26) had a national IYCF policy which includes Infant feeding in emergencies. Additionally, 24 countries (40.7%) had national emergency preparedness plan which includes IYCF in emergencies and only 25.4% (n=15) of these were updated based on the latest edition of the guideline on infant feeding in emergencies [13]. Table 2l. IYCF in difficult circumstances: infant feeding and emergencies Action area Selected indicators Results, n (%) Policy on infant feeding in emergencies Countries in which the national IYCF policy includes infant feeding in emergencies Countries in which the national emergency preparedness plan include IYCF in emergencies 26 (41%) 24 (41%) Capacity Countries in which health providers and IYCF counsellors 14 (24%) 35

42 development are trained on infant feeding in emergencies Countries with uptodate training material on counseling on IYCF in emergencies 9 (33%) Provision of breastmilk substitute Countries in which breastmilk substitutes are provided during emergencies Countries in which the national government procures and distribute breastmilk substitutes during emergencies 15 (25%) 4 (13.8%) Regionally, in the CEE/CIS only Tajikistan has a national IYCF policy which includes IYCF in emergencies. In the other regions, 13 countries (46%) have a national policy in EAPR, 41% (n=7) in ESAR, 83% (n=6) in ROSA and 75% of the countries (n=12) in WCAR. Only few countries [33% (n=9)] indicated that an uptodate guideline or training materials on IYCF in emergencies are available. Additionally, only 24% of the countries (n=14) indicated that health workers or IYCF counsellors are trained on IYCF in emergencies. Overall IYCF in difficult circumstances score Similar to other IYCF action levels, the mean IYCF in difficult circumstances action score was 4 (Figures 6 and 7; Table 10c in Annex 2). This was indicative of a fair level of activity occurring in countries in this area. The overall score among all the countries was fair, only 2 countries (Ghana and Congo) received a rating of (7) good ; the rest have a score of 6 or lower. Regionally, WCAR scored 5; both ESAR and EAPR, scored 4; While CEE/CIS, MENA and ROSA had the lowest score of 3. Overall, about 78% of the countries assessed (n=51) were rated poor on the Infant feeding in emergency action scores. While only few countries were rated fair [17% (n=11) or good [5% (n=3). For IYCF within the context of HIV, 12% of the countries were rated Very good, 38% Good, 25% fair and 25% Poor. 36

43 Uzbekistan Turkmenistan Romania Tajikistan Kyrgyzstan Kosovo Kazakhstan Bosnia & Herz. Cambodia Vietnam China P. N. Guinea Lao PDR Fiji Philippines Vanuatu Myanmar Thailand Mongolia Timor Leste Indonesia Korea Rwanda Zimbabwe Zambia Mozambique Swaziland Uganda Tanzania Namibia South Africa Madagascar Somalia Malawi Kenya Ethiopia Botswana Burundi Angola Yemen S. Sudan N. Sudan Afghanistan Bhutan Bangladesh India Nepal Sri Lanka Benin Congo B. Ghana B. Faso CAR Cote D'Ivoire Gambia DRC Gabon Mali Niger Nigeria Mauritania Liberia Senegal S. Leone Togo Score Figure 7a: HIV and Infant Feeding score* CEE/CIS EAPR ESAR MENA ROSA WCAR *The scores were measured on a scale of 0 to 10 The countries for which profiles were developed are indicated with the striped bars (see page 45) COLOUR KEY VERY GOOD GOOD FAIR POOR High number of key IYCF actions or intervention implemented Medium number of key IYCF actions or intervention implemented Low number of key IYCF actions or intervention implemented Very Low number of key IYCF actions or intervention implemented 37

44 Uzbekistan Bosnia & Herz. Tajikistan Kyrgyzstan Romania Kosovo Kazakhstan Turkmenistan Philippines China Thailand Vanuatu Indonesia Vietnam Myanmar Korea Timor Leste Cambodia P. N. Guinea Fiji Lao PDR Mongolia Rwanda Malawi Swaziland South Africa Kenya Botswana Madagascar Uganda Tanzania Zimbabwe Ethiopia Mozambique Zambia Namibia Burundi Angola Somalia S. Sudan Yemen N. Sudan Sri Lanka Nepal Afghanistan Bangladesh Bhutan India Nigeria Senegal Togo Mali Congo B. Ghana Mauritania B. Faso CAR DRC Gambia Gabon Niger S. Leone Benin Cote D'Ivoire Liberia Score Figure 7b: Infant Feeding in emergencies score* CEE/CIS EAPR ESAR MENA ROSA WCAR *The scores were measured on a scale of 0 to 10 The countries for which profiles were developed are indicated with the striped bars (see page 45) COLOUR KEY VERY GOOD GOOD FAIR POOR High number of key IYCF actions or intervention implemented Medium number of key IYCF actions or intervention implemented Low number of key IYCF actions or intervention implemented Very Low number of key IYCF actions or intervention implemented 38

45 3.8 IYCF monitoring and evaluation In a broad sense, monitoring is assesses ongoing implementation and evaluation centres on taking stock of a programme or intervention. Quality monitoring is an ongoing programmed activity which helps to orient required adjustments at any stage of the programme cycle, and programme evaluation attempts to determine systematically and objectively (as much as possible) the worth or significance of a policy, strategy or intervention [14]. At the national level, monitoring and evaluation for IYCF was undertaken in about 64% of the countries (n=39). Regionally, countries that do not have a monitoring and evaluation strategy in place included; 5 countries (63%) in CEE/CIS [Bosnia, Romania, Kazakhstan, Turkmenistan and Kosovo]; 3 countries (27%) in EAPR [Fiji, Papua New Guinea Vanuatu]; 4 countries (24%) in ESAR [Angola, Swaziland, Tanzania and Burundi]; Yemen and South Sudan in MENA; 27% of the countries (Gabon, Cote d Ivoire, Benin and Niger) in WCAR. Only 31 countries (50%) routinely monitor ongoing IYCF activities and 56% (n=34) reported that there has been an overall evaluation or review of IYCF situation in the countries. Table 2m: Selected indicators on monitoring and evaluation of IYCF actions National level action Selected indicators Results, n (%) Monitoring, review and evaluation Countries with monitoring and evaluation for IYCF actions in place at the national level 39 (63.9%) Countries that routinely monitor ongoing IYCF activities 31 (50.0%) Countries in which there has been an overall evaluation or review of IYCF situation 34 (55.7%) IYCF monitoring and evaluation actions score The average monitoring and evaluation IYCF actions score for countries was low: 4 (Annex 5t). All the regions were either rated very low (03) [CEE/CIS, MENA] or low (46) [EAPR, ESAR, ROSA, WCAR) on their performance on monitoring and evaluation IYCF activities. In general, most of the countries were rated poor [31 countries (48%)] or fair [24 countries (37%)]. Only few countries were rated good [11% (7)] or very good [4% (3)]. The monitoring and evaluation system of most countries appears to be weak requiring substantial strengthening or reinforcement. 39

46 Tajikistan Kyrgyzstan Bosnia & Herz. Turkemnistan Uzbekistan Kazakhstan Kosovo Romania Cambodia Vietnam Mongolia Indonesia Myanmar Phillipines TimorLeste China Lao PDR Papua New Guinea Thailand Vanuatu Fiji Korea Rwanda Somalia Malawi Kenya Madagascar Mozambique Zambia South Africa Botswana Burundi Ethiopia Swaziland Tanzania Uganda Zimbabwe Angola Namibia North Sudan South Sudan Yemen India Sri Lanka Bangladesh Afghanistan Bhutan nepal Nigeria Togo DRC Ghana Mauritania Gambia Burkina Faso Senegal CAR Gabon Mali Sierra Leone Benin Liberia Niger Congo Brazaville Cote d'ivoire Score 10 9 Figure 8: IYCF monitoring and evaluation actions score* CEE/CIS EAPR ESAR MENA ROSA WCAR *The scores were measured on a scale of 0 to 10 The countries for which profiles were developed are indicated with the striped bars (see page 45) COLOUR KEY VERY GOOD GOOD FAIR POOR High number of key IYCF actions or intervention implemented Medium number of key IYCF actions or intervention implemented Low number of key IYCF actions or intervention implemented Very Low number of key IYCF actions or intervention implemented 40

47 3.9. CONCLUSIONS AND RECOMMENDATIONS The purpose of this assessment was to review the current scope, scale and status of IYCF key actions in 65 countries (Table 3; figure 9); with special focus on some 22 nutritionally vulnerable countries (see pages 48 to 92). As a whole, countries were rated Fair on average, indicating low implementation of comprehensive IYCF packages (Table 3). Individual countries performed strongly in some areas while they also had gaps in some other key action areas. In order to achieve the goal of having a comprehensive IYCF strategy at scale, countries will have to act in synergy by building upon or maintaining progress in areas where IYCF actions are already established while at the same time working to strengthen areas where actions are weak or nonexistent. National level IYCF actions Conclusions On average, countries were rated fair on their national level IYCF actions, indicating implementation of low number of key IYCF actions at the national level. Overall, 12% of the countries were rated Very good, 28% Good, 40% Fair and 20% Poor on the national IYCF actions. On the whole, more countries had IYCF policies than strategies and plan of action. An estimated 62% of the countries had national laws or regulations in place related to the International Code of Marketing of Breastmilk Substitutes and only 19 countries had the code monitoring or enforcement in place. Paid maternity leave existed in most of the countries (92%), but only about 52% of the countries provided paid nursing breaks for mothers after they returned to work. Recommendations Gaps at the policy level still need to be addressed. Although most countries had some form of IYCF policy (standalone/integrated), very few countries had a combination of policy, strategy and plan of action. IYCF policy comprehensiveness should be reviewed. National IYCF policies still did not reflect certain key IYCF practices or components. National IYCF policies should be comprehensive to ensure that all relevant health and community services protect, promote and support breastfeeding and ensure timely, safe and ageappropriate complementary feeding at 624 months as well as include guideline on ensuring appropriate IYCF in exceptionally difficult circumstances. More countries need to establish national legislation on the Code of Marketing of Breast milk Substitutes. Gaps existed with monitoring and enforcement systems for the Code, even for those countries with a law already in place. Regular independent monitoring is needed, which is free from commercial interests using standard protocols to document violations. Effective regulations and systems for enforcement are also needed. Maternity leave was provided in many countries but a large percentage of countries do not provide nursing breaks for mothers. Health service level IYCF actions Conclusions On average, countries were rated fair on their health service IYCF actions, indicating the implementation of low number of key IYCF actions at the health service level. Overall, 12% of the countries were rated Good, 57% Fair and 31% Poor on the health service IYCF actions. Preservice trainings for nurses and other health professionals on IYCF were more likely to occur than training for medical doctors. Only 51% of the countries conducted IYCFfocused preservice 41

48 trainings for medical doctors, and about 88% conducted preservice trainings for nurses and other health professionals. Inservice trainings occurred in about 60% of the countries. Further, an estimated 69% had job aids and counselling cards available for health professionals (medical doctors, nurses and other health professionals). Although 43 countries indicated that health workers were trained on IYCF counselling since 2006, only a few countries were able to report on the scale and coverage of counselling activities taking place within the maternal and child health centres. Among the 55 countries that indicated that at least one hospital/maternity facility ever certified as BabyFriendly, the average proportion evercertified is 23% (ranging from 1 to 100%). Among the 22 countries that indicated that at least one hospital/maternity facility ever recertified as Baby Friendly, the average proportion ever recertified is very low at 5.6% (ranging from 1 to 76%). Recommendations Inservice training and preservice education gaps in countries need to be comprehensively addressed. The standard preservice and inservice training curricula in countries should be based on the WHO 2009 IYCF model chapter for textbooks for medical students and allied professionals noting that the HIV and infant feeding chapter needs to be updated in line with the 2010 WHO recommendations on HIV and infant feeding. It is also vital to ensure that the capacities of health professionals are substantially strengthened in providing recommended IYCF counseling and support. Appropriate systems and structures to routinely deliver IYCF counselling services within the health system need to be developed. Supervision and performance monitoring mechanisms need to be in place to ensure sustained implementation, quality delivery and documentation of performance Given that the BabyFriendly Hospital Initiative was reported as having extremely low coverage of recertification of facilities, it must be properly institutionalized within the national health system in order to ensure continuity and sustainability. The Ten Steps and the tools to assess compliance with them need to be fully integrated within the standard operating procedures of health facilities and the supervisory, monitoring, quality assurance, accreditation systems. Monitoring of IYCF activities and outcomes in the health system needs to be substantially strengthened, based on the principle that what is monitored is more likely to be done. IYCF indicators need to be integrated within the health management information systems (HMIS), especially in countries where these systems function relatively well. Rapid assessment tools such as lot quality assurance sampling (LQAS), SMART and other nutrition surveys, health facility assessment tools and qualitative assessments can be used to measure coverage and quality of IYCF counseling, and established assessment and survey instruments need to integrate appropriate IYCF indicators. Community level IYCF actions Conclusions On average, countries were rated Poor on their communitybased IYCF actions, indicating the implementation of very low number of key IYCF actions at the community level. Overall, only 8% of the countries were rated Good, 31% Fair and 61% Poor on the communitybased IYCF actions. Eightyfour per cent of the countries (n=53) had established communitybased IYCF activities either as standalone and/or integrated within other programmes. Only 11 countries reported having standalone IYCF activities within the community. Some countries indicated integrating activities within other programmes [such as Integrated management of childhood illnesses (n=12), ante natal care (n=9), growth monitoring and promotion (n=7)]. About 66% of the countries indicated training community health workers on community IYCF counselling since 2006 and only 27 countries conducted specific capacity building on communication skills for community health workers. The average proportion of community health workers trained on IYCF counselling since 2006 is 26 % (ranging from 1 to 73%). Only 13 countries routinely monitored the counselling skills of the community health workers and very few monitored the counselling quality. 42

49 Recommendations Communitybased initiatives can extend the delivery of interventions, particularly important in countries that have a weak health infrastructure or low health facility delivery rates. However, current IYCF actions at the community level in most countries appear to be not as welldeveloped as the health service level. More effort is required to strengthen and scale up community level IYCF actions and ensure that IYCF is promoted and supported in communities. Communitybased IYCF activities and programmes should build upon existing health and nutrition programmes at community level to the extent possible. Training community health workers in communitybased IYCF counseling and communication skills should be intensified in countries and largescale coverage pursued. The distinction between promotive actions/communication and counselling and skilled support needs to be more clearly made, and the importance and complementarity of both underscored, as many countries do not yet pursue largescale actions related to counselling and support at the community level. Monitoring and evaluation of communitybased IYCF activities should be strengthened to include supportive supervision and a recognition mechanism for wellperforming workers in more countries. Additionally, monitoring systems should be comprehensive enough to be able to provide sufficient detail on the coverage, quality of training and counseling activities among others. A combination of routine data and rapid assessment and survey tools should be used to monitor coverage and quality of community IYCF interventions. Communication on IYCF Conclusions On average, countries were rated Fair on their communication on IYCF actions, indicating the implementation of low number of key communication on IYCF actions. Overall, 12% of the countries were rated Good, 62% Fair and 26% Poor on the communication on IYCF actions. Only 36 countries (55%) conducted communication on IYCF through five or more communication channels. Countries also indicated having communication strategies at the National (n=33), health service (n=54) and community (n=50) levels. Behavioural change and communication materials were available in most [95% (n=61)] of the countries. However, few countries have monitoring and evaluation system for communication on IYCF in place. Recommendations A comprehensive communication strategy on IYCF using multiple channels to reach priority audience with age and contextspecific messages should an integral part of any IYCF intervention. Gaps exist with respect to routine monitoring of ongoing communication on IYCF activities. Countries need to strengthen or develop appropriate system to monitor and evaluate communication activities, outcomes and impact on behaviour. Complementary feeding interventions/components Conclusions On average, countries were rated Fair on their complementary feeding interventions/components. Overall, 11% of the countries were rated Very good, 4% Good, 36% Fair and 49% Poor on the complementary feeding interventions/components. About 60% of the countries (n=37) indicated that caregivers/mothers were counselled on home preparation of complementary foods for children 624 months. Countries use varieties of counselling channels, such as counselling cards (at the health service and community level), cooking classes, published recipe guides for mothers and food preparation demonstration on TV. Micronutrient supplements (multiple/single) were provided to improve complementary feeding for children 624 months in about 79% of the countries (n=51). Furthermore, 58% of the countries (n=19) provided fortified industrially blended complementary foods, while only 26% of the countries (n=10) provided fortified local complementary foods. 43

50 Recommendations Counseling mothers or caregivers on optimal complementary feeding practices and using multiple communication channels will be crucial for improving mothers/caregivers knowledge and skills on home preparation of complementary foods for children 624 months. For some countries provision of complementary food supplements may be needed to fill the nutrient gap when locally available foods alone cannot satisfy nutrition requirement. Appropriate decisionmaking processes are needed to determine whether, when and for whom supplements are needed. Countries need to establish effective monitoring systems so the coverage and programmatic aspects of these products and the outcomes can be measured. The use of nutritionsensitive social protection schemes needs to be more widely tested and applied, as well as strengthened linkages with agriculture for the implementation of nutritionsensitive interventions to increase the availability of locally produced nutrient dense quality foods. IYCF in difficult circumstances HIV and infant feeding Conclusions On average, the countries were rated fair on their actions related to HIV and infant feeding interventions. Overall, 12% of the countries were rated Very good, 38% Good, 25% Fair and 25% Poor. HIV and infant feeding policy and guidance was available in about 84% of the countries (n=54). Approximately, 72% of the countries (n=47) provide infant feeding counselling for HIV positive mothers, while about 83% countries (n=45) train health workers on infant feeding and HIV. However, only about 67% (n=38) of the countries provided support on infant feeding for HIV positive mothers. Infant feeding and HIV training materials and job aids or counselling cards were updated with the WHO 2010 recommendations in approximately 76% (n=31), and 74% (n=23) of the countries, respectively. Only 27% (n=17) of the countries have a monitoring system on infant feeding practices among HIV positive mothers in place. Recommendations HIV and infant feeding recommendations, based on the latest 2010 guideline, need to be fully integrated within all the incountry IYCF guidelines, materials, training sessions and counselling contacts. These revised materials need to be thoroughly disseminated to all relevant health and community workers across the whole country, and systematic follow up and mentoring on quality and appropriate application is needed. More emphasis on the importance of providing support and followup for HIV positive mothers is required. Infant feeding in emergencies Conclusions On average the countries are rated poor on their actions related to infant feeding in emergencies. Overall, 4% of the countries were rated Good, 17% Fair and 78% Poor. Only 41% (n=26) of the countries indicated that their National IYCF policy includes infant feeding in emergencies. Similarly, just 24 countries (41%) also reported having a national emergency preparedness plan which includes IYCF in emergencies. About 24% of the countries (n=14) provide training for health providers or IYCF counsellors on infant feeding in emergency. Fifteen countries (25%) indicated that they provide breastmilk substitutes in emergencies. 44

51 Recommendations National policies should be updated to include infant feeding in emergencies and not wait until after emergency strikes before prioritizing infant feeding in emergencies in the national IYCF strategies. Capacities for the design, planning, management and monitoring of IYCF interventions in emergencies need to be strengthened among Governments, partners, NGOs and other institutions. Free breast milk substitutes were still provided in some of the countries. Actions should be taken to inform governments in advance (as part of emergency preparedness and planning) in these countries about the negative impact of accepting donations of these products on IYCF practices, and to ensure effective systems are in place to prevent, block and handle donations in case an emergency occurs. In situations where breast milk substitutes are necessary for eligible children then close control and monitoring is necessary. IYCF Monitoring and evaluation Conclusions On average, countries were rated Fair on the IYCF monitoring and evaluation action score. Overall, 4% of the countries were rated Very good, 11% Good, 37% Fair and 48% Poor. Evaluation or review of the IYCF situation only occurred in about two thirds of the countries. At the same time, monitoring and evaluation of national IYCF only occur in 39 countries (64%). Recommendations Routine monitoring and evaluation of ongoing IYCF activities and the monitoring of process indicators took place in about half of the countries. However, none of the countries were able to report on coverage of the health services, communitybased interventions and communication currently taking place in their countries. Monitoring and evaluation systems need to be substantially strengthened as evidenced by the low proportion of countries that were able to report on geographical scale, target population coverage and quality of IYCF interventions in the health services, at community level, on complementary feeding supplements and related to communication currently taking place in their countries. Steps to strengthen this aspect will involve a number of initiatives, for example to include IYCF indicators within HMIS systems where these systems are functioning well; to improve communitybased tallying and reporting by CHWs; to integrate IYCF indicators of outcome (IYCF practices) and programme performance (e.g. coverage of counselling and communication, coverage of complementary feeding supplements or social protection schemes; training received, counselling services provided, etc., within rapid assessment tools such as LQASbased small household surveys, CHW surveys and health facility surveys; and systematically integrating all IYCF indicators within household surveys such as SMART and MICS. The monitoring and evaluation system needs to be carefully designed from the onset to ensure that it comprehensively captures relevant information at key IYCF action areas. 45

52 Table 3: IYCF comprehensive action score (All countries) Region Country National level IYCF score Health services score Communitybased system score Communication on IYCF score IYCF in Difficult circumstances score CF Component SCORE Monitoring & evaluation score Overall IYCF Comprehensive actions score CEE/CIS Romania CEE/CIS Kosovo CEE/CIS Uzbekistan CEE/CIS Bosnia and Herz CEE/CIS Kazakhstan CEE/CIS Turkmenistan CEE/CIS Tajikistan CEE/CIS Kyrgyzstan MEAN EAPR TimorLeste EAPR Indonesia EAPR Myanmar EAPR Korea EAPR Fiji EAPR Thailand EAPR Vanuatu EAPR China EAPR Lao D. Rep EAPR Mongolia EAPR P. New Guinea EAPR Philippines EAPR Cambodia EAPR Vietnam MEAN ESAR Angola ESAR Burundi ESAR Ethiopia ESAR Botswana ESAR Namibia ESAR Swaziland ESAR Somalia ESAR Zambia ESAR Mozambique ESAR Madagascar ESAR South Africa ESAR Uganda ESAR Zimbabwe ESAR Rwanda ESAR Tanzania ESAR Kenya ESAR Malawi MEAN MENA South Sudan MENA Yemen MENA North Sudan MEAN ROSA Nepal ROSA Bhutan ROSA Bangladesh ROSA Afghanistan ROSA India ROSA Sri Lanka MEAN WCAR Liberia WCAR D. Rep. Congo WCAR Cote d'ivoire WCAR Gabon WCAR Congo Brazzaville WCAR Sierra Leone WCAR Benin WCAR Mali WCAR Niger WCAR Cen.Afr.Rep WCAR Gambia WCAR Burkina Faso WCAR Ghana WCAR Mauritania WCAR Senegal WCAR Togo WCAR Nigeria MEAN Colour key High / Very good Medium / Good Low / Fair Very Low / Poor 46

53 Senegal Nigeria Togo Vietnam Sri Lanka Philippines Mauritania Malawi Kyrgyzstan Ghana Cambodia Zimbabwe Zambia Uganda Tanzania Tajikistan South Africa Rwanda North Sudan Niger Mozambique Mongolia Mali Kenya India Gambia Congo Brazzaville Burkina Faso Benin Bangladesh Afghanistan Vanuatu Uzbekistan Turkmenistan Thailand Somalia Sierra Leone P. New Guinea Madagascar Lao D. Rep. Gabon China Cen.Afr.Rep. Bhutan Yemen Swaziland Nepal Namibia Myanmar Korea Kazakhstan Indonesia Fiji Ethiopia D. Rep. Congo Cote d'ivoire Botswana Bosnia and Herz. Romania Kosovo TimorListe Liberia Angola Burundi South Sudan Figure 9: Overall IYCF Comprehensive actions score *The scores were measured on a scale of 0 to 10 The countries for which profiles were developed are indicated with the striped bars (see page 45) COLOUR KEY VERY GOOD GOOD FAIR POOR High number of key IYCF actions or intervention implemented Medium number of key IYCF actions or intervention implemented Low number of key IYCF actions or intervention implemented Very Low number of key IYCF actions or intervention implemented 47

54 Table 4b: Nutritionally vulnerable country statistics Table 4b: Underfive mortality rankings in nutritionally vulnerable countries Country Under5 mortality rate (2009) Value Rank Democratic Republic of the Congo Sierra Leone Mali Somalia Burkina Faso Angola Niger Mozambique Nigeria Uganda Côte d'ivoire Liberia Malawi Sudan United Republic of Tanzania Ethiopia Kenya India Yemen Bangladesh Indonesia Philippines The above list ranks countries and territories in descending order of their estimated 2009 underfive mortality rate (U5MR), a critical indicator of the wellbeing of children. Source: UNICEF, Progress for Children: Achieving the MDGs with Equity, No, 9 New York,

55 Table 4c: Nutrition statistics: Nutritionally vulnerable countries Countries and territories Early initiation of breastfeeding (%) % of children ( *) who are: % of under fives ( *) suffering from: breastfed with underweight wasting still underweight (WHO) complementary (NCHS/WHO) (WHO) breastfeeding food exclusively breastfed * (<6 months) (6 9 months) (20 23 months) moderate & severe moderate & severe severe moderate & severe stunting (WHO) moderate & severe Angola x 77 x 37 x 16 y 7 y 8 y 29 y Bangladesh Burkina Faso Côte d'ivoire Democratic Republic of the Congo Ethiopia y India Indonesia Kenya Malawi Mali Mozambique Niger y 34 y 11 y 12 y 46 y Nigeria Philippines Sierra Leone Somalia Sudan Thailand Uganda United Republic of x 91 x 55 x Tanzania Yemen x 76 x Average SUMMARY INDICATORS BY REGION/GLOBAL Africa # Sub Saharan Africa # Eastern and Southern Africa West and Central Africa Middle East and North Africa Asia # South Asia East Asia and Pacific Developing countries Least developed countries World Source: UNICEF, Progress for Children: Achieving the MDGs with Equity, No, 9 New York,

56 References 1. UNICEF, Achieving the MDGs with equity: Progress for children, challenges and disparities. UNICEF: New York. 2. WHO/UNICEF, Global strategy for IYCF 2003 WHO/UNICEF Global Strategy for Infant and Young Child Feeding. World Health Organization: Switzerland, Geneva. 3. UNICEF, Programming guide: Infant and young child feeding. UNICEF: New York. 4. WHO & UNICEF Planning guide for national implementation of the global strategy for infant and young child feeding. World Health Organization: Switzerland, Geneva. 5. WHO International Code of Marketing of BreastMilk Substitutes. World Health Organization: Switzerland, Geneva. 6. WHO Infant and young child feeding: Model chapter for textbooks for medical students and allied professionals. 7. UNICEF Revised BFHI material 8. WHO/PAHO Guiding principles for complementary feeding of breastfeed child. 9. WHO Guiding principles for feeding nonbreastfed children 6 to 24 months. 10. WHO & UNICEF Innocenti declaration on the Protection, Promotion and Support for Breastfeeding. Online at: WHO & UNICEF, The BabyFriendly Hospital Initiative. Online at: WHO, UNICEF, UNAIDS, UNFPA Guidelines on HIV and infant feeding Principles and recommendation for infant feeding in the context of HIV and a summary of evidence. 13. IFE Core Group Infant and young child feeding in emergencies: Operational guidance. 14. UNICEF Programme policy and procedure manual: Programme operations 50

57 Section 4: IYCF PROFILES 22 countries*, with poor infant and young child feeding practices and large burdens of undernutrition among children less than five years, designated nutritionally vulnerable countries * IYCF and nutrition data reflects countries status for the year Source: UNICEF, Progress for Children: Achieving the MDGs with Equity, No, 9 New York,

58 ANGOLA Angola has a stunting prevalence rate of 29% among children under 5 years of age; while 16% and 8% are underweight and wasted, respectively. Recent reports on IYCF status indicate that the rate of early initiation of breastfeeding is currently at 55%, exclusive breastfeeding (< 6 months) at 11% and continued breastfeeding (20 23 months) at 37%. About 77% of children 6 to 9 months are breastfed with complementary food; the nutritional quality of complementary foods from most developing countries is usually poor or inadequate. KEYS Yes Part of the key IYCF actions/ interventions or practices implemented No Not part of the key IYCF actions or intervention implemented No information Poor Fair Good Very Good Very low number of key IYCF actions or intervention implemented Average number of key IYCF actions or intervention implemented Low number of the key IYCF actions or interventions implemented High number or all of the key IYCF actions or interventions implemented Overview of the scale, scope and status of comprehensive IYCF incountry actions are summarized below: NATIONAL POLICY, STRATEGY AND PLAN OF ACTIONS National policy, strategy and plan of action for a comprehensive IYCF strategy Overall national IYCF policy, strategy and plan of actions Poor Key practices reflected in the policy Early initiation of breastfeeding Exclusive breastfeeding Continued breastfeeding Complementary feeding IYCF LEGISLATION AND LAW The overall national IYCF legislation and law status seems fair ; it has some of the key components, including maternity protection law, maternity leave and paid nursing leave. However, more work is needed with respect to the CODE law, its monitoring and enforcement. HEALTH SYSTEM LEVEL ACTIONS Summary of IYCF health system level actions Overall IYCF health system level actions score Key action areas or components Fair Babyfriendly hospital initiative Poor IYCF health pre and inservice training curricula Fair IYCF health workers capacity development Fair IYCF health service counseling Good COMMUNITY SYSTEM LEVEL ACTIONS Selected key components reflected in the national IYCF policy Babyfriendly hospital initiative International code of marketing of breast milk substitute Behavioural change and communication HIV and infant feeding IYCF in emergency National IYCF strategy National IYCF plan of action Angola s overall national policy, strategy and plan of actions status appears to be poor. The country has very few of the building blocks for a comprehensive IYCF strategy and continued work on IYCF is required. At present the policy on IYCF reflected none of the key practices and only few of the key components. Summary of national IYCF legislation and law Overall national IYCF legislation Fair Key action areas CODE law CODE monitoring and enforcement Maternity protection law Maternity leave Paid nursing breaks The health system level actions appear to be fair. Although, the country seems to have adequate IYCF health service counseling, several other key components, including the BFHI, the pre and inservice training curricula and health workers capacity development activities need to be reinforced. National status of the Baby Friendly Hospital Initiative (estimated) Hospitals / maternity facilities ever certified Babyfriendly (%): < 2 Hospitals / maternity facilities recertified Babyfriendly (%): 0 Percentage of institutional delivery in the country (%) 42 Capacity building of health workers in delivering IYCF counseling (estimated) Health workers trained on IYCF counseling since 2006 (%) 0 Coverage of the training on IYCF counseling among health workers (%) 0 The IYCF community level actions may be poor. Strengthening IYCF activities within the communities should be a high priority action area. Key components, such as community system integration, community capacity development and training, as well as monitoring and evaluation require extensive attention. Summary of IYCF community system level actions Overall IYCF community system level actions score Key action areas or components IYCF community system integration IYCF community health workers capacity development Community monitoring and evaluation Poor Poor Poor Poor Selected key components of the IYCF community system level actions Community capacity development Training on community IYCF counseling since 2006 Capacity building on communication skills for community health workers Monitoring and evaluation Routine monitoring of IYCF activities Routine monitoring of skills of community health workers Routine monitoring of the quality of IYCF counseling Capacity building of community health workers (CHWs) in delivering communitybased IYCF counseling (estimated) Community health workers trained on community IYCF counseling since 2006 (%) 0 Coverage of community health workers providing IYCF counseling activities as part of other communitybased programme (%) 10 Proportion of the population living in the target area 26% 52

59 COMMUNICATION ON IYCF Overall national level communication on IYCF seems to fair. Several other key components are judged to be weak and may require extensive work, including the national IYCF behaviour change and communication strategy and the monitoring and evaluation of the effect of communication on IYCF behaviour. Summary of national level communication on IYCF Overall national level communication on IYCF Key action areas or component National IYCF behaviour change and communication strategy Fair Poor IYCF behaviour change and communication channels Good Behaviour change and communication materials on IYCF Good Monitoring and evaluating the effect of communication on behaviour Poor ADDITIONAL COMPLEMENTARY FEEDING INTERVENTIONS/COMPONENTS Summary of additional complementary feeding interventions/components Overall complementary feeding interventions / components score Selected key strategies IYCF counseling of caregivers in relation to home preparation of complementary foods Poor Provision of complementary food supplements score Selected key interventions in relation to provision of complementary food supplements Micronutrients supplements (single/multiple) are provided to improve CF for children 624 months Micronutrients supplements (single/multiple) provided in emergencies Micronutrients supplements provided in nonemergencies Targeted food supplements are provided to improve CF for children 624 months Fortified local complementary foods are provided Fortified industriallyblended complementary foods are provided Lipidbased nutrient supplements are provided IYCF IN EXCEPTIONALLY DIFFICULT CIRCUMSTANCES HIV AND INFANT FEEDING Overall national standing on HIV and infant feeding Selected key action areas Policy on HIV and infant feeding Poor National IYCF policy include guidance on HIV and infant feeding HIV and infant feeding in PMTCT policy Other selected key action areas Infant feeding policy updated based on 2010 WHO rapid advice Infant feeding counseling for HIV+ mothers IYCF training materials include HIV and infant feeding IYCF counseling materials which include HIV and infant feeding are updated Monitoring system on infant feeding practices among HIV+ mothers INFANT FEEDING IN EMERGENCIES Overall national standing on Infant feeding in emergencies Poor Selected key action areas National IYCF policy include IYCF in emergency National emergency preparedness plan includes IYCF in emergency National emergency preparedness plan updated based on the latest edition of IYCF in emergency Other selected key action areas Health workers and IYCF counsellors trained on IYCF in emergency Breast milk substitutes are provided during emergency Government procures/distribute breast milk substitutes Government accept donations of infant food IYCF MONITORING AND EVALUATION Summary of IYCF monitoring and evaluation score Overall IYCF monitoring and evaluation score Key action areas or components Poor Monitoring and evaluation for national IYCF Routine monitoring of ongoing IYCF Overall evaluation/review of IYCF situation Overall national level IYCF monitoring and evaluation appears to be poor and may require extensive attention. Additionally, more work is needed to strengthen the broader monitoring and evaluation system within the national legislation, community and health system levels as well as communication on IYCF and IYCF in exceptionally difficult circumstances. 53

60 BANGLADESH Bangladesh has a stunting prevalence rate of 43% among children under 5 years of age; while 41% and 17% are underweight and wasted, respectively. Recent reports on IYCF status indicate that the rate of early initiation of breastfeeding is currently at 43%, exclusive breastfeeding (< 6 months) at 43% and continued breastfeeding (20 23 months) at 91%. About 74% of children 6 to 9 months are breastfed with complementary food; the nutritional quality of complementary foods from most developing countries is usually poor or inadequate. Overview of the scale, scope and status of comprehensive IYCF incountry actions are summarized below: NATIONAL POLICY, STRATEGY AND PLAN OF ACTIONS National policy, strategy and plan of action for a comprehensive IYCF strategy Overall national IYCF policy, strategy and plan of actions Good Key practices reflected in the policy Early initiation of breastfeeding Exclusive breastfeeding Continued breastfeeding Complementary feeding IYCF LEGISLATION AND LAW The overall national IYCF legislation and law status seems fair ; it has some of the key components, including CODE law, maternity protection law, and maternity leave. However, more work may be needed with respect to the CODE monitoring and enforcement and provision paid nursing breaks. Bangladesh s overall national policy, strategy and plan of actions status appears to be good. The country seems to have adequate number of the building blocks for a comprehensive IYCF strategy. However, more work may be required to ensure that early initiation of breastfeeding is reflected in the national policy. HEALTH SYSTEM LEVEL ACTIONS Summary of IYCF health system level actions The health system level actions appear to be poor. Several key components, including the BFHI, health workers capacity development and the IYCF health service counseling activities may require strengthening. Overall IYCF health system level actions score Key action areas or components COMMUNITY SYSTEM LEVEL ACTIONS The IYCF community level actions seem poor. Strengthening IYCF activities within the communities should be a high priority action area. Key components, such as IYCF community system integration, community health workers capacity development, as well as monitoring and evaluation may require extensive attention. Poor Babyfriendly hospital initiative Poor IYCF health pre and inservice training curricula IYCF health workers capacity development Fair IYCF health service counseling Poor Selected key components reflected in the National IYCF policy Babyfriendly hospital initiative International code of marketing of breast milk substitute Behavioural change and communication HIV and infant feeding IYCF in emergency National IYCF strategy KEYS Yes Part of the key IYCF actions/ interventions or practices implemented No Not part of the key IYCF actions or intervention implemented No information Poor Fair Good Very Good Very low number of key IYCF actions or intervention implemented Average number of key IYCF actions or intervention implemented Low number of the key IYCF actions or interventions implemented High number or all of the key IYCF actions or interventions implemented National IYCF plan of action Summary of national IYCF legislation and law Overall national IYCF legislation Key action areas CODE law Fair CODE monitoring and enforcement Maternity protection law Maternity leave Paid nursing breaks National status of the Baby Friendly Hospital Initiative (estimated) Hospitals / maternity facilities ever certified Babyfriendly (%): 50 Hospitals / maternity facilities recertified Babyfriendly (%): 0 Percentage of institutional delivery in the country (%) 18 Capacity building of health workers in delivering IYCF counseling (estimated) Health workers trained on IYCF counseling since 2006 (%) Coverage of the training on IYCF counseling among health workers (%) Summary of IYCF community system level actions Overall IYCF community system level actions score Poor Key action areas or components IYCF community system Poor integration IYCF community health workers capacity development Fair Community monitoring and evaluation Poor < 1 Selected key components of the IYCF community system level actions Community capacity development Training on community IYCF counseling since 2006 Capacity building on communication skills for community health workers Capacity building of community health workers (CHWs) in delivering communitybased IYCF counseling (estimated) Monitoring and evaluation Routine monitoring of IYCF activities Routine monitoring of skills of community health workers Routine monitoring of the quality of IYCF counseling Community health workers trained on community IYCF counseling since 2006 (%) 3 Coverage of community health workers providing IYCF counseling activities as part of other communitybased programme (%) 25 Proportion of the population living in the target area 7% 3 54

61 COMMUNICATION ON IYCF Overall national level communication on IYCF seems fair. Some key components are judged to be weak and may require extensive work, including the IYCF behaviour change and communication channels and the monitoring and evaluation of the effect of communication on IYCF behaviour. Summary of national level communication on IYCF Overall national level communication on IYCF Key action areas or component National IYCF behaviour change and communication IYCF behaviour change and communication channels Behaviour change and communication materials on IYCF Monitoring and evaluating the effect of communication on behaviour Fair Good Fair Good Poor ADDITIONAL COMPLEMENTARY FEEDING INTERVENTIONS/COMPONENTS Summary of additional complementary feeding interventions/components Overall complementary feeding interventions / components score Selected key strategies IYCF counseling of caregivers in relation to home preparation of complementary foods Fair Poor Provision of complementary food supplements Fair Selected key interventions in relation to the provision of complementary food supplements Micronutrients supplements (single/multiple) are provided to improve CF for children 624 months Micronutrients supplements provided in emergencies Micronutrients supplements provided in nonemergencies Targeted food supplements are provided to improve CF for children 624 months Fortified local complementary foods are provided Fortified industriallyblended complementary foods are provided Lipidbased nutrient supplements are provided IYCF IN EXCEPTIONALLY DIFFICULT CIRCUMSTANCES HIV AND INFANT FEEDING Overall national standing on HIV and infant feeding Selected key action areas Policy on HIV and infant feeding National IYCF policy include guidance on HIV and infant feeding HIV and infant feeding in PMTCT policy Fair Other selected key action areas Infant feeding policy updated based on 2010 WHO rapid advice Infant feeding training/counseling for HIV+ mothers IYCF training materials include HIV and infant feeding IYCF counseling materials which include HIV and infant feeding are updated regularly Monitoring system on infant feeding practices among HIV+ mothers INFANT FEEDING IN EMERGENCIES Overall national standing on Infant feeding in emergencies Selected key action areas National IYCF policy include IYCF in emergency Poor National emergency preparedness plan includes IYCF in emergency National emergency preparedness plan updated based on the latest edition of IYCF in emergency Other selected key action areas Health workers and IYCF counsellors trained on IYCF in emergency Breast milk substitutes are provided during emergency Government procures/distribute breast milk substitutes Government accept donations of infant food IYCF MONITORING AND EVALUATION Summary of IYCF monitoring and evaluation score Overall IYCF monitoring and evaluation score Key action areas or components Fair Monitoring and evaluation for national IYCF Routine monitoring of ongoing IYCF Overall evaluation/review of IYCF situation Overall national level IYCF monitoring and evaluation appears to be fair and may require additional attention. Weaker aspects of the comprehensive IYCF monitoring and evaluation system should be strengthened, particularly at the national legislation, community and health system levels as well as communication on IYCF and IYCF in exceptionally difficult circumstances. 55

62 BURKINA FASO Burkina Faso has a stunting prevalence rate of 35% among children under 5 years of age; while 26% and 11% are underweight and wasted, respectively. Recent reports on IYCF status indicate that the rate of early initiation of breastfeeding is currently at 20% and exclusive breastfeeding (< 6 months) at 16%. The nutritional quality of complementary foods from most developing countries is usually poor or inadequate. Overview of the scale, scope and status of comprehensive IYCF incountry actions are summarized below: NATIONAL POLICY, STRATEGY AND PLAN OF ACTIONS National policy, strategy and plan of action for a comprehensive IYCF strategy Overall national IYCF policy, strategy and plan of actions Key practices reflected in the policy Early initiation of breastfeeding Exclusive breastfeeding Continued breastfeeding Complementary feeding Good IYCF LEGISLATION AND LAW The overall national IYCF legislation and law status seems good ; it has some of the key components, including CODE law, maternity protection law, maternity leave and paid nursing leave. However, more work is needed with respect to the CODE monitoring and enforcement. Burkina Faso s overall national policy, strategy and plan of actions status appears to be good. The country seems to have most of the building blocks for a comprehensive IYCF strategy. At present some of the key components are not reflected in the national IYCF policy and thus may require continued work in this area. HEALTH SYSTEM LEVEL ACTIONS Summary of IYCF health system level actions The health system level actions appear to be fair. Although, the country seems to have adequate IYCF health workers capacity development Overall IYCF health system level component, several other key components, including the BFHI, the pre and inservice training curricula and the IYCF health service counseling activities may actions score Fair Key action areas or components need strengthening. COMMUNITY SYSTEM LEVEL ACTIONS Babyfriendly hospital initiative Poor IYCF health pre and inservice training curricula Fair IYCF health workers capacity development Good IYCF health service counseling Fair Selected key components reflected in the national IYCF policy Babyfriendly hospital initiative International code of marketing of breast milk substitute Behavioural change and communication HIV and infant feeding IYCF in emergency National IYCF strategy KEYS Yes Part of the key IYCF actions/ interventions or practices implemented No Not part of the key IYCF actions or intervention implemented No information Poor Fair Good Very Good Very low number of key IYCF actions or intervention implemented Low number of the key IYCF actions or interventions implemented Average number of key IYCF actions or intervention implemented High number or all of the key IYCF actions or interventions implemented National IYCF plan of action Summary of national IYCF legislation and law Overall national IYCF legislation Key action areas CODE law National status of the Baby Friendly Hospital Initiative (estimated) Good CODE monitoring and enforcement Maternity protection law Maternity leave Paid nursing breaks Hospitals / maternity facilities ever certified Babyfriendly (%): < 2 Hospitals / maternity facilities recertified Babyfriendly (%): 0 Percentage of institutional birth in the country 76 Capacity building of health workers in delivering IYCF counseling (estimated) Health workers trained on IYCF counseling since 2006 (%) 10 Coverage of the training on IYCF counseling among health workers (%) 100 The IYCF community level actions may be fair. Strengthening IYCF activities within the communities should be a high priority action area. Key components, such as community system integration, community capacity development and training, as well as monitoring and evaluation require extensive attention Summary of IYCF community system level actions Overall IYCF community system level actions score Key action areas or components IYCF community system integration IYCF community health workers capacity development Community monitoring and evaluation Fair Poor Fair Fair Selected key components of the IYCF community system level actions Community capacity development Training on community IYCF counseling since 2006 Capacity building on communication skills for community health workers Monitoring and evaluation Routine monitoring of IYCF activities Routine monitoring of skills of community health workers Routine monitoring of the quality of IYCF counseling Capacity building of community health workers (CHWs) in delivering communitybased IYCF counseling (estimated) Community health workers trained on community IYCF counseling since 2006 (%) 66 Coverage of community health workers providing IYCF counseling activities as part of other communitybased programme (%) 100 Proportion of the population living in the target area (%)

63 COMMUNICATION ON IYCF Overall national level communication on IYCF seems good, However, to take advantage of the adequate communication on IYCF, other weaker aspects of the comprehensive IYCF programming should be reinforced, particularly at the health system and community levels, as well as IYCF monitoring and evaluation. Summary of national level communication on IYCF Overall national level communication on IYCF Key action areas or component National IYCF behaviour change and communication IYCF behaviour change and communication channels Behaviour change and communication materials on IYCF Monitoring and evaluating the effect of communication on behaviour Good Good Good Good Very Good ADDITIONAL COMPLEMENTARY FEEDING INTERVENTIONS/COMPONENTS Summary of additional complementary feeding interventions/components Overall complementary feeding interventions / components score Selected key strategies IYCF counseling of caregivers in relation to home preparation of complementary foods Provision of complementary food supplements Fair Fair Fair Selected key interventions in relation to the provision of complementary food supplements Micronutrients supplements (single/multiple) are provided to improve CF for children 624 months Micronutrients supplements (single/multiple) provided in emergencies Micronutrients supplements provided in non emergencies Targeted food supplements are provided to improve CF for children 624 months Fortified local complementary foods are provided Fortified industriallyblended complementary foods are provided Lipidbased nutrient supplements are provided IYCF IN EXCEPTIONALLY DIFFICULT CIRCUMSTANCES HIV AND INFANT FEEDING Overall national standing on HIV and infant feeding Selected key action areas Policy on HIV and infant feeding National IYCF policy include guidance on HIV and infant feeding HIV and infant feeding in PMTCT policy Good Other selected key action areas Infant feeding policy updated based on 2010 WHO rapid advice Infant feeding training/counseling for HIV+ mothers IYCF training materials include HIV and infant feeding IYCF counseling materials which include HIV and infant feeding are updated regularly Monitoring system on infant feeding practices among HIV+ mothers INFANT FEEDING IN EMERGENCIES Overall national standing on Infant feeding in emergencies Poor Selected key action areas National IYCF policy include IYCF in emergency National emergency preparedness plan includes IYCF in emergency National emergency preparedness plan updated based on the latest edition of IYCF in emergency Other selected key action areas Health workers and IYCF counsellors trained on IYCF in emergency Breast milk substitutes are provided during emergency Government procures/distribute breast milk substitutes Government accept donations of infant food IYCF MONITORING AND EVALUATION Summary of IYCF monitoring and evaluation score Overall IYCF monitoring and evaluation score Key action areas or components Monitoring and evaluation for national IYCF Fair Routine monitoring of ongoing IYCF Overall evaluation/review of IYCF situation Overall national level IYCF monitoring and evaluation appears to be fair and may require extensive attention. Additionally, more work is needed to strengthen the broader monitoring and evaluation system within the national legislation, community and health system levels as well as communication on IYCF and IYCF in exceptionally difficult circumstances. 57

64 COTE D IVOIRE Cote d Ivoire has a stunting prevalence rate of 40% among children under 5 years of age; while 16% and 8% are underweight and wasted, respectively. Recent reports on IYCF status indicate that the rate of early initiation of breastfeeding is currently at 25%, exclusive breastfeeding (< 6 months) at 4% and continued breastfeeding (20 23 months) at 37%. About 54% of children 6 to 9 months are breastfed with complementary food; the nutritional quality of complementary foods from most developing countries is usually poor or inadequate. Overview of the scale, scope and status of comprehensive IYCF incountry actions are summarized below: NATIONAL POLICY, STRATEGY AND PLAN OF ACTIONS National policy, strategy and plan of action for a comprehensive IYCF strategy Overall national IYCF policy, strategy and plan of actions Fair Key practices reflected in the policy Early initiation of breastfeeding Exclusive breastfeeding Continued breastfeeding Complementary feeding IYCF LEGISLATION AND LAW There is no information on the current status of the overall national IYCF legislation and law status. Additionally, there is no information on the current status of the key action areas or components including, CODE law, CODE monitoring and enforcement, maternity protection law, maternity leave and paid nursing breaks. HEALTH SYSTEM LEVEL ACTIONS Summary of IYCF health system level actions \ COMMUNITY SYSTEM LEVEL ACTIONS The IYCF community level actions may be good. Key components, such as community system integration as well as, monitoring and evaluation may require further strengthening. The community health workers capacity development and training activities may be adequate. Overall IYCF health system level actions score Poor Key action areas or components Babyfriendly hospital initiative Poor IYCF health pre and inservice training curricula Poor IYCF health workers capacity development Poor IYCF health service counseling Good Selected key components reflected in the National IYCF policy Babyfriendly hospital initiative International code of marketing of breast milk substitute Behavioural change and communication HIV and infant feeding IYCF in emergency National IYCF strategy National IYCF plan of action KEYS Yes Part of the key IYCF actions/ interventions or practices implemented No Not part of the key IYCF actions or intervention implemented No information Poor Fair Good Cote d Ivoire s overall national policy, strategy and plan of actions status appears to be fair. The country has some of the building blocks for a comprehensive IYCF strategy and continued work on IYCF is required. At present, there is no information on some of the key components as reflected in the national IYCF policy. The health system level actions appear to be poor. Although, the country seems to have adequate IYCF counseling service at the health system level, several other key components, including the BFHI, the pre and inservice training curricula and health workers capacity development activities may need to be reinforced. Very Good Very low number of key IYCF actions or intervention implemented Low number of the key IYCF actions or interventions implemented Average number of key IYCF actions or intervention implemented High number or all of the key IYCF actions or interventions implemented Summary of national IYCF legislation and law National status of the Baby Friendly Hospital Initiative (estimated) Overall national IYCF legislation Key action areas CODE law CODE monitoring and enforcement Maternity protection law Maternity leave Paid nursing breaks Hospitals / maternity facilities ever certified Babyfriendly (%): 9 Hospitals / maternity facilities recertified Babyfriendly (%): 0 Percentage of institutional birth in the country Capacity building of health workers in delivering IYCF counseling (estimated) Health workers trained on IYCF counseling since 2006 (%) Coverage of the training on IYCF counseling among health workers (%) Summary of IYCF community system level actions Overall IYCF community system level actions score Good Key action areas or components IYCF community system integration IYCF community health workers capacity development Community monitoring and evaluation Fair Very Good Fair Capacity building of community health workers (CHWs) in delivering communitybased IYCF counseling (estimated) Selected key components of the IYCF community system level actions Community capacity development Training on community IYCF counseling since 2006 Capacity building on communication skills for community health workers Monitoring and evaluation Routine monitoring of IYCF activities Routine monitoring of skills of community health workers Routine monitoring of the quality of IYCF counseling Community health workers trained on community IYCF counseling since 2006 (%) Coverage of trained community health workers providing IYCF counseling activities as part of other communitybased programme (%) Proportion of the population living in the target area 35% 58

65 COMMUNICATION ON IYCF Overall national level communication on IYCF seems poor. Several other key components are judged to be weak and may require extensive work, including the national IYCF behaviour change and communication strategy and channels, as well as the monitoring and evaluation of the effect of communication on IYCF behaviour. Summary of national level communication on IYCF Overall national level communication on IYCF Key action areas or component National IYCF behaviour change and communication strategy Poor Poor IYCF behaviour change and communication channels Poor Behaviour change and communication materials on IYCF Good Monitoring and evaluating the effect of communication on behaviour Poor ADDITIONAL COMPLEMENTARY FEEDING INTERVENTIONS/COMPONENTS Summary of additional complementary feeding interventions/components Overall complementary feeding interventions / components score Selected key strategies IYCF counseling of caregivers in relation to home preparation of complementary foods Provision of complementary food supplements Fair Poor Fair Selected key interventions in relation to the provision of complementary food supplements Micronutrients supplements (single/multiple) are provided to improve CF for children 624 months Micronutrients supplements (single/multiple) provided in emergencies Micronutrients supplements provided in non emergencies Targeted food supplements are provided to improve CF for children 624 months Fortified local complementary foods are provided Fortified industriallyblended complementary foods are provided Lipidbased nutrient supplements are provided IYCF IN EXCEPTIONALLY DIFFICULT CIRCUMSTANCES HIV AND INFANT FEEDING Overall national standing on HIV and infant feeding Selected key action areas Policy on HIV and infant feeding National IYCF policy include guidance on HIV and infant feeding HIV and infant feeding in PMTCT policy Good Other selected key action areas Infant feeding policy updated based on 2010 WHO rapid advice Infant feeding training/counseling for HIV+ mothers IYCF training materials include HIV and infant feeding IYCF counseling materials which include HIV and infant feeding are updated regularly Monitoring system on infant feeding practices among HIV+ mothers INFANT FEEDING IN EMERGENCIES Overall national standing on Infant feeding in emergencies Selected key action areas National IYCF policy include IYCF in emergency National emergency preparedness plan includes IYCF in emergency National emergency preparedness plan updated based on the latest edition of IYCF in emergency Other selected key action areas Health workers and IYCF counsellors trained on IYCF in emergency Breast milk substitutes are provided during emergency Government procures/distribute breast milk substitutes Government accept donations of infant food IYCF MONITORING AND EVALUATION Summary of IYCF monitoring and evaluation score Overall IYCF monitoring and evaluation score Key action areas or components Poor Monitoring and evaluation for national IYCF Routine monitoring of ongoing IYCF Overall evaluation/review of IYCF situation Overall national level IYCF monitoring and evaluation appears to be poor and may require extensive attention. Additionally, more work is needed to strengthen the broader monitoring and evaluation system within the national legislation, community and health system levels as well as communication on IYCF and IYCF in exceptionally difficult circumstances. 59

66 DEMOCRATIC REPUBLIC OF THE CONGO The Democratic Republic of the Congo (DRC) has a stunting prevalence rate of 46% among children under 5 years of age; while 25% and 10% are underweight and wasted, respectively. Recent reports on IYCF status indicate that the rate of early initiation of breastfeeding is currently at 48%, exclusive breastfeeding (< 6 months) at 36% and continued breastfeeding (20 23 months) at 64%. About 82% of children 6 to 9 months are breastfed with complementary food; the nutritional quality of complementary foods from most developing countries is usually poor or inadequate. KEYS Yes Part of the key IYCF actions/ interventions or practices implemented No Not part of the key IYCF actions or intervention implemented No information Poor Fair Good Very Good Very low number of key IYCF actions or intervention implemented Low number of the key IYCF actions or interventions implemented Average number of key IYCF actions or intervention implemented High number or all of the key IYCF actions or interventions implemented Overview of the scale, scope and status of comprehensive IYCF incountry actions are summarized below: NATIONAL POLICY, STRATEGY AND PLAN OF ACTIONS National policy, strategy and plan of action for a comprehensive IYCF strategy Overall national IYCF policy, strategy and plan of actions Key practices reflected in the policy Early initiation of breastfeeding Exclusive breastfeeding Continued breastfeeding Complementary feeding Very Good IYCF LEGISLATION AND LAW The overall national IYCF legislation and law status seems fair ; it has some of the key components, including CODE law, maternity protection law, and maternity leave. However, there are still gaps with respect to provision of paid nursing breaks and the CODE monitoring and enforcement. HEALTH SYSTEM LEVEL ACTIONS COMMUNITY SYSTEM LEVEL ACTIONS The IYCF community level actions are judged to be poor. Strengthening IYCF activities within the communities should be a high priority action area. Key components, such as community system integration, capacity development, as well as monitoring and evaluation require extensive attention. Summary of IYCF health system level actions Overall IYCF health system level actions score Fair Key action areas or components Babyfriendly hospital initiative Poor IYCF health pre and inservice training curricula IYCF health workers capacity development IYCF health service counseling Very Good Very Good Good Selected key components reflected in the national IYCF policy Babyfriendly hospital initiative International code of marketing of breast milk substitute Behavioural change and communication HIV and infant feeding IYCF in emergency National IYCF strategy National IYCF plan of action The DRC s overall national policy, strategy and plan of actions status appears to be very good. The country seems to have most of the building blocks for a comprehensive IYCF strategy in place. Nevertheless, more work may be needed in developing a comprehensive national IYCF strategy and plan of actions. Summary of national IYCF legislation and law Overall national IYCF legislation Key action areas CODE law Fair CODE monitoring and enforcement Maternity protection law Maternity leave Paid nursing breaks The health system level actions appear to be fair. Several key components, including the pre and inservice training curricula and health workers capacity development and health service counseling activities may be adequate. However, the BFHI need to be reinforced to take advantage of the good health system, particularly important with the percentage of institutional births currently at 64%. National status of the Baby Friendly Hospital Initiative (estimated) Hospitals / maternity facilities ever certified Babyfriendly (%): 4 Hospitals / maternity facilities recertified Babyfriendly (%): 0 Capacity building of health workers in delivering IYCF counseling (estimated) Percentage of institutional birth in the country 75 Health workers trained on IYCF counseling since 2006 (%) Coverage of the training on IYCF counseling among health workers (%) 5 Summary of IYCF community system level actions Overall IYCF community system level actions score Key action areas or components IYCF community system integration IYCF community health workers capacity development Community monitoring and evaluation Poor Poor Fair Poor Capacity building of community health workers (CHWs) in delivering communitybased IYCF counseling (estimated) Selected key components of the IYCF community system level actions Community capacity development Training on community IYCF counseling since 2006 Capacity building on communication skills for community health workers Monitoring and evaluation Routine monitoring of IYCF activities Routine monitoring of skills of community health workers Routine monitoring of the quality of IYCF counseling Community health workers trained on community IYCF counseling since 2006 (%) < 1 Coverage of trained community health workers providing IYCF counseling activities as part of other communitybased programme (%) 5 Proportion of the population living in the target area 8% 60

67 COMMUNICATION ON IYCF Overall national level communication on IYCF may be poor. All the key components are judged to be weak and may require extensive work, including the national IYCF behaviour change and communication strategy, channels and materials, as well as the monitoring and evaluation of the effect of communication on IYCF behaviour. Summary of national level communication on IYCF Overall national level communication on IYCF Key action areas or component National IYCF behaviour change and communication strategy ADDITIONAL COMPLEMENTARY FEEDING INTERVENTIONS/COMPONENTS Poor Poor IYCF behaviour change and communication channels Poor Behaviour change and communication materials on IYCF Fair Monitoring and evaluating the effect of communication on behaviour Poor Summary of additional complementary feeding interventions/components Overall complementary feeding interventions / components score Selected key strategies IYCF counseling of caregivers in relation to home preparation of complementary foods Poor Poor Provision of complementary food supplements Poor Selected key interventions in relation to the provision of complementary food supplements Micronutrients supplements (single/multiple) are provided to improve CF for children 624 months Micronutrients supplements (single/multiple) provided in emergencies Micronutrients supplements provided in nonemergencies Targeted food supplements are provided to improve CF for children 624 months Fortified local complementary foods are provided Fortified industriallyblended complementary foods are provided Lipidbased nutrient supplements are provided IYCF IN EXCEPTIONALLY DIFFICULT CIRCUMSTANCES HIV AND INFANT FEEDING Overall national standing on HIV and infant feeding Selected key action areas Good Policy on HIV and infant feeding National IYCF policy include guidance on HIV and infant feeding HIV and infant feeding in PMTCT policy Other selected key action areas Infant feeding policy updated based on 2010 WHO rapid advice Infant feeding training/counseling for HIV+ mothers IYCF training materials include HIV and infant feeding IYCF counseling materials which include HIV and infant feeding are updated regularly Monitoring system on infant feeding practices among HIV+ mothers INFANT FEEDING IN EMERGENCIES Overall national standing on Infant feeding in emergencies Poor Selected key action areas National IYCF policy include IYCF in emergency National emergency preparedness plan includes IYCF in emergency National emergency preparedness plan updated based on the latest edition of IYCF in emergency Other selected key action areas Health workers and IYCF counsellors trained on IYCF in emergency Breast milk substitutes are provided during emergency Government procures/distribute breast milk substitutes Government accept donations of infant food IYCF MONITORING AND EVALUATION Summary of IYCF monitoring and evaluation Overall IYCF monitoring and evaluation score Selected key action areas or components Monitoring and evaluation for national IYCF Routine monitoring of ongoing IYCF Overall evaluation/review of IYCF situation Good Overall national level IYCF monitoring and evaluation appears to be good. However, to take advantage of the current adequate IYCF monitoring and evaluation, other weaker aspects of the comprehensive IYCF monitoring and evaluation system should be strengthened, particularly at the national legislation, community and health system levels as well as communication on IYCF and IYCF in exceptionally difficult circumstances. 61

68 ETHIOPIA Ethiopia has a stunting prevalence rate of 51% among children under 5 years of age; while 33% and 12% are underweight and wasted, respectively. Recent reports on IYCF status indicate that the rate of early initiation of breastfeeding is currently at 69%, exclusive breastfeeding (< 6 months) at 49% and continued breastfeeding (20 23 months) at 88%. About 54% of children 6 to 9 months are breastfed with complementary food; the nutritional quality of complementary foods from most developing countries is usually poor or inadequate. Overview of the scale, scope and status of comprehensive IYCF incountry actions are summarized below: NATIONAL POLICY, STRATEGY AND PLAN OF ACTIONS National policy, strategy and plan of action for a comprehensive IYCF strategy Overall national IYCF policy, strategy and plan of actions Poor Key practices reflected in the policy Early initiation of breastfeeding Exclusive breastfeeding Continued breastfeeding Complementary feeding IYCF LEGISLATION AND LAW The overall national IYCF legislation and law status seems fair ; it has some of the key components, including maternity protection law, maternity leave. However, more work is needed with respect to the CODE law, its monitoring and enforcement and provision of paid nursing breaks. HEALTH SYSTEM LEVEL ACTIONS Summary of IYCF health system level actions Overall IYCF health system level actions score Fair Key action areas or components Babyfriendly hospital initiative Poor IYCF health pre and inservice training curricula IYCF health workers capacity development IYCF health service counseling Good Good Good COMMUNITY SYSTEM LEVEL ACTIONS The IYCF community level actions may be poor. Strengthening IYCF activities within the communities should be a high priority action area. Key components, such as community system integration, community capacity development and training, as well as monitoring and evaluation require extensive attention. Selected key components reflected in the national IYCF policy Babyfriendly hospital initiative International code of marketing of breast milk substitute Behavioural change and communication HIV and infant feeding IYCF in emergency National IYCF strategy National IYCF plan of action KEYS Yes Part of the key IYCF actions/ interventions or practices implemented No Not part of the key IYCF actions or intervention implemented No information Poor Fair Good Ethiopia s overall national policy, strategy and plan of actions status appears to be poor. The country has very few of the building blocks for a comprehensive IYCF strategy and continued work on IYCF is needed. At present the policy on IYCF reflected none of the key practices and there is no information on the status of most of the key components. The health system level actions appear to be fair. The country seems to be adequate in some of its key IYCF components. However, it may be essential to reinforce it weak BFHI. Very Good National status of the Baby Friendly Hospital Initiative (estimated) Very low number of key IYCF actions or intervention implemented Low number of the key IYCF actions or interventions implemented Average number of key IYCF actions or intervention implemented High number or all of the key IYCF actions or interventions implemented Summary of national IYCF legislation and law Overall national IYCF legislation Fair Key action areas CODE law CODE monitoring and enforcement Maternity protection law Maternity leave Paid nursing breaks Hospitals / maternity facilities ever certified Babyfriendly (%): 0 Hospitals / maternity facilities recertified Babyfriendly (%): 0 Percentage of institutional birth in the country 18 Capacity building of health workers in delivering IYCF counseling (estimated) Health workers trained on IYCF counseling since 2006 (%) 15 Coverage of the training on IYCF counseling among health workers (%) 21 Summary of IYCF community system level actions Overall IYCF community system level actions score Key action areas or components IYCF community system integration IYCF community health workers capacity development Community monitoring and evaluation Poor Poor Fair Poor Capacity building of community health workers (CHWs) in delivering communitybased IYCF counseling (estimated) Community health workers trained on community IYCF counseling since 2006 (%) Selected key components of the IYCF community system level actions Community capacity development Training on community IYCF counseling since 2006 Capacity building on communication skills for community health workers Monitoring and evaluation Routine monitoring of IYCF activities Routine monitoring of skills of community health workers Routine monitoring of the quality of IYCF counseling Coverage of trained community health workers providing IYCF counseling activities as part of other communitybased programme (%) Proportion of the population living in the target area 25,500,000 62

69 COMMUNICATION ON IYCF Overall national level communication on IYCF seems poor. Several key action areas are judged to be weak and may require extensive work, including the IYCF behaviour change and communication channels and materials, as well as the monitoring and evaluation of the effect of communication on IYCF behaviour. Summary of national level communication on IYCF Overall national level communication on IYCF Key action areas or component National IYCF behaviour change and communication strategy IYCF behaviour change and communication channels Behaviour change and communication materials on IYCF Monitoring and evaluating the effect of communication on behaviour Poor Good Poor Poor Poor ADDITIONAL COMPLEMENTARY FEEDING INTERVENTIONS/COMPONENTS Summary of additional complementary feeding interventions/components Overall complementary feeding interventions / components score Selected key strategies IYCF counseling of caregivers in relation to home preparation of complementary foods Poor Poor Provision of complementary food supplements Poor Selected key interventions in relation to the provision of complementary food supplements Micronutrients supplements (single/multiple) are provided to improve CF for children 624 months Micronutrients supplements (single/multiple) provided in emergencies Micronutrients supplements provided in nonemergencies Targeted food supplements are provided to improve CF for children 624 months Fortified local complementary foods are provided Fortified industriallyblended complementary foods are provided Lipidbased nutrient supplements are provided IYCF IN EXCEPTIONALLY DIFFICULT CIRCUMSTANCES HIV AND INFANT FEEDING Overall national standing on HIV and infant feeding Selected key action areas Policy on HIV and infant feeding National IYCF policy include guidance on HIV and infant feeding HIV and infant feeding in PMTCT policy Fair Other selected key action areas Infant feeding policy updated based on 2010 WHO rapid advice Infant feeding training/counseling for HIV+ mothers IYCF training materials include HIV and infant feeding IYCF counseling materials which include HIV and infant feeding are updated regularly Monitoring system on infant feeding practices among HIV+ mothers INFANT FEEDING IN EMERGENCIES Overall national standing on Infant feeding in emergencies Poor Selected key action areas National IYCF policy include IYCF in emergency National emergency preparedness plan includes IYCF in emergency National emergency preparedness plan updated based on the latest edition of IYCF in emergency Other selected key action areas Health workers and IYCF counsellors trained on IYCF in emergency Breast milk substitutes are provided during emergency Government procures/distribute breast milk substitutes Government accept donations of infant food IYCF MONITORING AND EVALUATION Summary of IYCF monitoring and evaluation score Overall IYCF monitoring and evaluation score Key action areas or components Monitoring and evaluation for national IYCF Poor Routine monitoring of ongoing IYCF Overall evaluation/review of IYCF situation Overall national level IYCF monitoring and evaluation appears to be poor and may require extensive attention. Additionally, more work is needed to strengthen the broader monitoring and evaluation system within the national legislation, community and health system levels as well as communication on IYCF and IYCF in exceptionally difficult circumstances. 63

70 INDIA India has a stunting prevalence rate of 48% among children under 5 years of age; while 43% and 20% are underweight and wasted, respectively. Recent reports on IYCF status indicate that the rate of early initiation of breastfeeding is currently at 41%, exclusive breastfeeding (< 6 months) at 46% and continued breastfeeding (20 23 months) at 77%. About 57% of children 6 to 9 months are breastfed with complementary food; the nutritional quality of complementary foods from most developing countries is usually poor or inadequate. Overview of the scale, scope and status of comprehensive IYCF incountry actions are summarized below: NATIONAL POLICY, STRATEGY AND PLAN OF ACTIONS National policy, strategy and plan of action for a comprehensive IYCF strategy Overall national IYCF policy, strategy and plan of actions Poor Key practices reflected in the policy Early initiation of breastfeeding IYCF LEGISLATION AND LAW The overall national IYCF legislation and law status seems good ; it has most of the key components, including the CODE law, its monitoring and enforcement, maternity protection law, maternity leave. However, more work is needed with respect to the provision of paid nursing breaks. HEALTH SYSTEM LEVEL ACTIONS COMMUNITY SYSTEM LEVEL ACTIONS Exclusive breastfeeding Continued breastfeeding Complementary feeding Summary of IYCF health system level actions Overall IYCF health system level actions score Fair Key action areas or components Babyfriendly hospital initiative Poor IYCF health pre and inservice training curricula Poor IYCF health workers capacity development IYCF health service counseling Good Good Selected key components reflected in the national IYCF policy Babyfriendly hospital initiative International code of marketing of breast milk substitute Behavioural change and communication HIV and infant feeding IYCF in emergency National IYCF strategy National IYCF plan of action KEYS Yes Part of the key IYCF actions/ interventions or practices implemented No Not part of the key IYCF actions or intervention implemented No information Poor Fair Good India s overall national policy, strategy and plan of actions status appears to be poor. The country has very few of the building blocks for a comprehensive IYCF strategy and continued work on IYCF is required. At present the policy on IYCF did not reflect most of the key practices and components. The health system level actions appear to be fair. Although, the country seems to have adequate IYCF counseling service and capacity development components at the health system level, other key components, including the BFHI, may need to be reinforced with institutional births currently at 41%. Very Good Very low number of key IYCF actions or intervention implemented Low number of the key IYCF actions or interventions implemented Average number of key IYCF actions or intervention implemented High number or all of the key IYCF actions or interventions implemented Summary of national IYCF legislation and law Overall national IYCF legislation Key action areas CODE law CODE monitoring and enforcement Maternity protection law Maternity leave National status of the Baby Friendly Hospital Initiative (estimated) Good Paid nursing breaks Hospitals / maternity facilities ever certified Babyfriendly (%): 10 Hospitals / maternity facilities recertified Babyfriendly (%): 0 Percentage of institutional birth in the country 41 Capacity building of health workers in delivering IYCF counseling (estimated) Health workers trained on IYCF counseling since 2006 (%) 12 Coverage of the training on IYCF counseling among health workers (%) The IYCF community level actions seem poor. Strengthening IYCF activities within the communities should be a high priority action area. Currently, it seems that all the key components require extensive attention. Summary of IYCF community system level actions Overall IYCF community system level actions score Key action areas or components IYCF community system integration IYCF community health workers capacity development Community monitoring and evaluation Poor Poor Poor Poor Selected key components of the IYCF community system level actions Community capacity development Training on community IYCF counseling since 2006 Capacity building on communication skills for community health workers Monitoring and evaluation Routine monitoring of IYCF activities Routine monitoring of skills of community health workers Routine monitoring of the quality of IYCF counseling Capacity building of community health workers (CHWs) in delivering communitybased IYCF counseling (estimated) Community health workers trained on community IYCF counseling since 2006 (%) 39 Coverage of trained community health workers providing IYCF counseling activities as part of other communitybased programme (%) 100 Proportion of the population living in the target area 100% 64

71 COMMUNICATION ON IYCF Overall national level communication on IYCF is fair, While some key action areas may be adequate including the national IYCF behaviour change and communication strategy and channels, other important key action areas need to be strengthened, including the behaviour change and communication materials, as well as the monitoring and evaluation of the effect of communication on IYCF behaviour. Summary of national level communication on IYCF Overall national level communication on IYCF Key action areas or component National IYCF behaviour change and communication strategy IYCF behaviour change and communication channels Behaviour change and communication materials on IYCF Fair Very Good Good Fair Monitoring and evaluating the effect of communication on behaviour Poor ADDITIONAL COMPLEMENTARY FEEDING INTERVENTIONS/COMPONENTS Summary of additional complementary feeding interventions/components Overall complementary feeding interventions / components score Selected key strategies IYCF counseling of caregivers in relation to home preparation of complementary foods Good Fair Provision of complementary food supplements Poor Selected key interventions in relation to the provision of complementary food supplements Micronutrients supplements (single/multiple) are provided to improve CF for children 624 months Micronutrients supplements (single/multiple) provided in emergencies Micronutrients supplements provided in nonemergencies Targeted food supplements are provided to improve CF for children 624 months Fortified local complementary foods are provided Fortified industriallyblended complementary foods are provided Lipidbased nutrient supplements are provided IYCF IN EXCEPTIONALLY DIFFICULT CIRCUMSTANCES HIV AND INFANT FEEDING Overall national standing on HIV and infant feeding Poor Selected key action areas Policy on HIV and infant feeding National IYCF policy include guidance on HIV and infant feeding HIV and infant feeding in PMTCT policy Other selected key action areas Infant feeding policy updated based on 2010 WHO rapid advice Infant feeding training/counseling for HIV+ mothers IYCF training materials include HIV and infant feeding IYCF counseling materials which include HIV and infant feeding are updated regularly Monitoring system on infant feeding practices among HIV+ mothers INFANT FEEDING IN EMERGENCIES Overall national standing on Infant feeding in emergencies Poor Selected key action areas National IYCF policy include IYCF in emergency National emergency preparedness plan includes IYCF in emergency National emergency preparedness plan updated based on the latest edition of IYCF in emergency Other selected key action areas Health workers and IYCF counsellors trained on IYCF in emergency Breast milk substitutes are provided during emergency Government procures/distribute breast milk substitutes Government accept donations of infant food IYCF MONITORING AND EVALUATION Summary of IYCF monitoring and evaluation score Overall IYCF monitoring and evaluation score Fair Key action areas or components Monitoring and evaluation for national IYCF Routine monitoring of ongoing IYCF Overall evaluation/review of IYCF situation Overall national level IYCF monitoring and evaluation appears to be fair and may require additional attention. Weaker aspects of the comprehensive IYCF monitoring and evaluation system should be strengthened, particularly the routine monitoring of ongoing community IYCF activities within the community, skills of community health workers or the quality of their skills. 65

72 INDONESIA Indonesia has a stunting prevalence rate of 37% among children under 5 years of age; while 18% and 14% are underweight and wasted, respectively. Recent reports on IYCF status indicate that the rate of early initiation of breastfeeding is currently at 44%, exclusive breastfeeding (< 6 months) at 32% and continued breastfeeding (20 23 months) at 50%. About 75% of children 6 to 9 months are breastfed with complementary food; the nutritional quality of complementary foods from most developing countries is usually poor or inadequate. Overview of the scale, scope and status of comprehensive IYCF incountry actions are summarized below: NATIONAL POLICY, STRATEGY AND PLAN OF ACTIONS National policy, strategy and plan of action for a comprehensive IYCF strategy Overall national IYCF policy, strategy and plan of actions Poor Key practices reflected in the policy Early initiation of breastfeeding Exclusive breastfeeding Continued breastfeeding Complementary feeding IYCF LEGISLATION AND LAW The overall national IYCF legislation and law status seems fair ; it has some of the key components, including maternity protection law, maternity leave. However, more work is needed with respect to the CODE law, its monitoring and enforcement as well as provision of paid nursing breaks. Indonesia s overall national policy, strategy and plan of actions status appears to be poor. The country may have none of the building blocks for a comprehensive IYCF strategy and continued work in developing a comprehensive IYCF policy and plan of actions may be required. HEALTH SYSTEM LEVEL ACTIONS Summary of IYCF health system level actions The health system level actions appear to be poor. All the key components, including the BFHI, health workers capacity development, the IYCF health Overall IYCF health system level services counseling and the IYCF pre and in service training curricula may need actions score Poor strengthening. Key action areas or components Babyfriendly hospital initiative IYCF health pre and inservice training curricula IYCF health workers capacity development IYCF health service counseling Poor Poor Poor Fair COMMUNITY SYSTEM LEVEL ACTIONS Selected key components reflected in the National IYCF policy Babyfriendly hospital initiative International code of marketing of breast milk substitute Behavioural change and communication HIV and infant feeding IYCF in emergency National IYCF strategy National IYCF plan of action KEYS Yes Part of the key IYCF actions/ interventions or practices implemented No Not part of the key IYCF actions or intervention implemented No information Poor Fair Good Very Good National status of the Baby Friendly Hospital Initiative (estimated) Very low number of key IYCF actions or intervention implemented Low number of the key IYCF actions or interventions implemented Average number of key IYCF actions or intervention implemented High number or all of the key IYCF actions or interventions implemented Summary of national IYCF legislation and law Overall national IYCF legislation Fair Key action areas CODE law CODE monitoring and enforcement Maternity protection law Maternity leave Paid nursing breaks Hospitals / maternity facilities ever certified Babyfriendly (%): < 1 Hospitals / maternity facilities recertified Babyfriendly (%): 0 Percentage of institutional birth in the country 46 Capacity building of health workers in delivering IYCF counseling (estimated) Health workers trained on IYCF counseling since 2006 (%) < 1 Coverage of the training on IYCF counseling among health workers (%) 2 The IYCF community level actions seem poor. Strengthening IYCF activities within the communities should be a high priority action area. Although, there are no information on some of the key action areas; however, all the key components may require extensive attention. Summary of IYCF community system level actions Overall IYCF community system level actions score Poor Key action areas or components IYCF community system integration IYCF community health workers capacity development Community monitoring and evaluation Poor Selected key components of the IYCF community system level actions Community capacity development Training on community IYCF counseling since 2006 Capacity building on communication skills for community health workers Monitoring and evaluation Routine monitoring of IYCF activities Routine monitoring of skills of community health workers Routine monitoring of the quality of IYCF counseling Capacity building of community health workers (CHWs) in delivering communitybased IYCF counseling (estimated) Community health workers trained on community IYCF counseling since 2006 (%) < 1 Coverage of trained community health workers providing IYCF counseling activities as part of other communitybased programme (%) 3 Proportion of the population living in the target area < 5 66

73 COMMUNICATION ON IYCF Overall national level communication on IYCF seems poor. All the key components are judged to be weak and may require extensive work, including the national IYCF behaviour change and communication strategy, channels and materials, as well as the monitoring and evaluation of the effect of communication on IYCF behaviour. Summary of national level communication on IYCF Overall national level communication on IYCF Key action areas or component National IYCF behaviour change and communication strategy IYCF behaviour change and communication channels Behaviour change and communication materials on IYCF Monitoring and evaluating the effect of communication on behaviour Poor Poor Fair Fair Poor ADDITIONAL COMPLEMENTARY FEEDING INTERVENTIONS/COMPONENTS Summary of additional complementary feeding interventions/components Overall complementary feeding interventions / components score Selected key strategies IYCF counseling of caregivers in relation to home preparation of complementary foods Fair Poor Provision of complementary food supplements Good Selected key interventions in relation to the provision of complementary food supplements Micronutrients supplements (single/multiple) are provided to improve CF for children 624 months Micronutrients supplements (single/multiple) provided in emergencies Micronutrients supplements provided in nonemergencies Targeted food supplements are provided to improve CF for children 624 months Fortified local complementary foods are provided Fortified industriallyblended complementary foods are provided Lipidbased nutrient supplements are provided IYCF IN EXCEPTIONALLY DIFFICULT CIRCUMSTANCES HIV AND INFANT FEEDING Overall national standing on HIV and infant feeding Poor Selected key action areas Policy on HIV and infant feeding National IYCF policy include guidance on HIV and infant feeding HIV and infant feeding in PMTCT policy Other selected key action areas Infant feeding policy updated based on 2010 WHO rapid advice Infant feeding training/counseling for HIV+ mothers IYCF training materials include HIV and infant feeding IYCF counseling materials which include HIV and infant feeding are updated regularly Monitoring system on infant feeding practices among HIV+ mothers INFANT FEEDING IN EMERGENCIES Overall national standing on Infant feeding in emergencies Fair Selected key action areas National IYCF policy include IYCF in emergency National emergency preparedness plan includes IYCF in emergency National emergency preparedness plan updated based on the latest edition of IYCF in emergency Other selected key action areas Health workers and IYCF counsellors trained on IYCF in emergency Breast milk substitutes are provided during emergency Government procures/distribute breast milk substitutes Government accept donations of infant food IYCF MONITORING AND EVALUATION Summary of IYCF monitoring and evaluation score Overall IYCF monitoring and evaluation score Fair Key action areas or components Monitoring and evaluation for national IYCF activities Routine monitoring of ongoing IYCF activities Overall evaluation/review of IYCF situation Overall national level IYCF monitoring and evaluation appears to be fair and may require additional attention. Weaker aspects of the comprehensive IYCF monitoring and evaluation system should be strengthened, particularly at the national legislation, community and health system levels as well as communication on IYCF and IYCF in exceptionally difficult circumstances. 67

74 KENYA Kenya has a stunting prevalence rate of 35% among children under 5 years of age; while 16% and 7% are underweight and wasted, respectively. Recent reports on IYCF status indicate that the rate of early initiation of breastfeeding is currently at 58%, exclusive breastfeeding (< 6 months) at 32% and continued breastfeeding (20 23 months) at 54%. About 83% of children 6 to 9 months are breastfed with complementary food; the nutritional quality of complementary foods from most developing countries is usually poor or inadequate. Overview of the scale, scope and status of comprehensive IYCF incountry actions are summarized below: NATIONAL POLICY, STRATEGY AND PLAN OF ACTIONS National policy, strategy and plan of action for a comprehensive IYCF strategy Overall national IYCF policy, strategy and plan of actions Very Good Key practices reflected in the policy Early initiation of breastfeeding Exclusive breastfeeding Continued breastfeeding Complementary feeding IYCF LEGISLATION AND LAW The overall national IYCF legislation and law status seems fair ; it has few of the key components, including maternity protection law and maternity leave. However, more work is needed with respect to the CODE law, it monitoring and enforcement and provision of paid nursing leave. HEALTH SYSTEM LEVEL ACTIONS COMMUNITY SYSTEM LEVEL ACTIONS Summary of IYCF health system level actions Overall IYCF health system level actions score Good Key action areas or components Babyfriendly hospital initiative IYCF health pre and inservice training curricula Good IYCF health workers capacity development IYCF health service counseling The IYCF community level actions may be fair. Strengthening IYCF activities within the communities should be a high priority action area. Important components, such as community system integration may require extensive action. Very Good Good Selected key components reflected in the National IYCF policy Babyfriendly hospital initiative International code of marketing of breast milk substitute Behavioural change and communication HIV and infant feeding IYCF in emergency National IYCF strategy KEYS Yes Part of the key IYCF actions/ interventions or practices implemented No Not part of the key IYCF actions or intervention implemented No information Poor Fair Good Kenya s overall national policy, strategy and plan of actions status appears to be very good. The country seems to have adequate number of the building blocks for a comprehensive IYCF strategy. However, more work may be required to ensure that early initiation of breastfeeding is reflected in the national policy. The health system level actions appear to be good. The country seems to have adequate IYCF health system level components. The country can take advantage of its strong health system level actions to further strengthen other weak action areas, such as the complementary feeding intervention. Very Good Very low number of key IYCF actions or intervention implemented Low number of the key IYCF actions or interventions implemented Average number of key IYCF actions or intervention implemented High number or all of the key IYCF actions or interventions implemented National IYCF plan of action Summary of national IYCF legislation and law National status of the Baby Friendly Hospital Initiative (estimated) Overall national IYCF legislation Fair Key action areas CODE law CODE monitoring and enforcement Maternity protection law Maternity leave Paid nursing breaks Hospitals / maternity facilities ever certified Babyfriendly (%): Hospitals / maternity facilities recertified Babyfriendly (%): Percentage of institutional birth in the country (%) 44 Capacity building of health workers in delivering IYCF counseling (estimated) Health workers trained on IYCF counseling since 2006 (%) Coverage of the training on IYCF counseling among health workers (%) 75 Summary of IYCF community system level actions Overall IYCF community system level actions score Fair Key action areas or components IYCF community system integration IYCF community health workers capacity development Community monitoring and evaluation Poor Very Good Good Capacity building of community health workers (CHWs) in delivering communitybased IYCF counseling (estimated) Selected key components of the IYCF community system level actions Community capacity development Training on community IYCF counseling since 2006 Capacity building on communication skills for community health workers Monitoring and evaluation Routine monitoring of IYCF activities Routine monitoring of skills of community health workers Routine monitoring of the quality of IYCF counseling Community health workers trained on community IYCF counseling since 2006 (%) 9 Coverage of trained community health workers providing IYCF counseling activities as part of other communitybased programme (%) 100 Proportion of the population living in the target area 15% 68

75 COMMUNICATION ON IYCF Overall national level communication on IYCF seems good. While most of the key action areas may be adequate, including the national IYCF behaviour change and communication strategy, channels and materials on IYCF; the monitoring and evaluation of the effect of communication on IYCF behaviour needs to be strengthened. Summary of national level communication on IYCF Overall national level communication on IYCF Key action areas or component National IYCF behaviour change and communication strategy IYCF behaviour change and communication channels Behaviour change and communication materials on IYCF Good Very Good Good Good Monitoring and evaluating the effect of communication on behaviour Poor ADDITIONAL COMPLEMENTARY FEEDING INTERVENTIONS/COMPONENTS Summary of additional complementary feeding interventions/components Overall complementary feeding interventions / components score Selected key strategies IYCF counseling of caregivers in relation to home preparation of complementary foods Poor Poor Provision of complementary food supplements Fair Selected key interventions in relation to the provision of complementary food supplements Micronutrients supplements (single/multiple) are provided to improve CF for children 624 months Micronutrients supplements (single/multiple) provided in emergencies Micronutrients supplements provided in non emergencies Targeted food supplements are provided to improve CF for children 624 months Fortified local complementary foods are provided Fortified industriallyblended complementary foods are provided Lipidbased nutrient supplements are provided IYCF IN EXCEPTIONALLY DIFFICULT CIRCUMSTANCES HIV AND INFANT FEEDING Overall national standing on HIV and infant feeding Selected key action areas Policy on HIV and infant feeding National IYCF policy include guidance on HIV and infant feeding HIV and infant feeding in PMTCT policy Fair Other selected key action areas Infant feeding policy updated based on 2010 WHO rapid advice Infant feeding counseling for HIV+ mothers IYCF counseling materials include HIV and infant feeding IYCF counseling materials which include HIV and infant feeding are updated regularly Monitoring system on infant feeding practices among HIV+ mothers INFANT FEEDING IN EMERGENCIES Overall national standing on Infant feeding in emergencies Poor Selected key action areas National IYCF policy include IYCF in emergency National emergency preparedness plan includes IYCF in emergency National emergency preparedness plan updated based on the latest edition of IYCF in emergency Other selected key action areas Health workers and IYCF counsellors trained on IYCF in emergency Breast milk substitutes are provided during emergency Government procures/distribute breast milk substitutes Government accept donations of infant food IYCF MONITORING AND EVALUATION Summary of IYCF monitoring and evaluation score Overall IYCF monitoring and evaluation score Fair Key action areas or components Monitoring and evaluation for national IYCF Routine monitoring of ongoing IYCF activities Overall national level IYCF monitoring and evaluation appears to be fair and may require additional attention. Weaker aspects of the comprehensive IYCF monitoring and evaluation system should be strengthened, particularly at the national legislation, community and health system levels as well as communication on IYCF and IYCF in exceptionally difficult circumstances. Overall evaluation/review of IYCF situation 69

76 MALAWI Malawi has a stunting prevalence rate of 53% among children under 5 years of age; while 15% and 4% are underweight and wasted, respectively. Recent reports on IYCF status indicate that the rate of early initiation of breastfeeding is currently at 58%, exclusive breastfeeding (< 6 months) at 57% and continued breastfeeding (20 23 months) at 72%. About 89% of children 6 to 9 months are breastfed with complementary food; the nutritional quality of complementary foods from most developing countries is usually poor or inadequate. Overview of the scale, scope and status of comprehensive IYCF incountry actions are summarized below: NATIONAL POLICY, STRATEGY AND PLAN OF ACTIONS National policy, strategy and plan of action for a comprehensive IYCF strategy Overall national IYCF policy, strategy and plan of actions Key practices reflected in the policy Early initiation of breastfeeding Exclusive breastfeeding Continued breastfeeding Complementary feeding Very Good IYCF LEGISLATION AND LAW The overall national IYCF legislation and law status seems good ; it has most of the key components, including the CODE law, its monitoring and enforcement, as well as the maternity protection law and maternity leave. However, more work is needed with respect to the provision of paid nursing breaks. HEALTH SYSTEM LEVEL ACTIONS COMMUNITY SYSTEM LEVEL ACTIONS Summary of IYCF health system level actions Overall IYCF health system level actions score Fair Key action areas or components Babyfriendly hospital initiative Poor IYCF health pre and inservice training curricula Poor IYCF health workers capacity development Very Good IYCF health service counseling Good The IYCF community level actions may be poor. Strengthening IYCF activities within the communities should be a high priority action area. All the key components within the community level may require extensive attention. Selected key components reflected in the National IYCF policy Babyfriendly hospital initiative International code of marketing of breast milk substitute Behavioural change and communication HIV and infant feeding IYCF in emergency National IYCF strategy National IYCF plan of action KEYS Yes Part of the key IYCF actions/ interventions or practices implemented No Not part of the key IYCF actions or intervention implemented No information Poor Fair Good Malawi s overall national policy, strategy and plan of actions status appears to be very good. The country seems to have adequate number of the building blocks for a comprehensive IYCF strategy. However, more work may be required in terms of developing a national IYCF plan of actions. The health system level actions appear to be fair. Although, the country seems to have adequate IYCF health service counseling activities; effort should be centred on reinforcing other weak key components within the health system level. Very Good Very low number of key IYCF actions or intervention implemented Low number of the key IYCF actions or interventions implemented Average number of key IYCF actions or intervention implemented High number or all of the key IYCF actions or interventions implemented Summary of national IYCF legislation and law Overall national IYCF legislation Key action areas CODE law CODE monitoring and enforcement Maternity protection law Maternity leave National status of the Baby Friendly Hospital Initiative (estimated) Good Paid nursing breaks Hospitals / maternity facilities ever certified Babyfriendly (%): 5 Hospitals / maternity facilities recertified BabyFriendly (%): < 2 Percentage of institutional birth in the country 72 Capacity building of health workers in delivering IYCF counseling (estimated) Health workers trained on IYCF counseling since 2006 [total number (%)] 6 Coverage of the training on IYCF counseling among health workers [total number (%)] 43 Summary of IYCF community system level actions Overall IYCF community system level actions score Poor Key action areas or components IYCF community system integration IYCF community health workers capacity development Community monitoring and evaluation Poor Fair Poor Capacity building of community health workers (CHWs) in delivering communitybased IYCF counseling (estimated) Selected key components of the IYCF community system level actions Community capacity development Training on community IYCF counseling since 2006 Capacity building on communication skills for community health workers Monitoring and evaluation Routine monitoring of IYCF activities Routine monitoring of skills of community health workers Routine monitoring of the quality of IYCF counseling Community health workers trained on community IYCF counseling since 2006 (%) 8 Coverage of trained community health workers providing IYCF counseling activities as part of other communitybased programme (%) 100 Proportion of the population living in the target area 100% 70

77 COMMUNICATION ON IYCF Overall national level communication on IYCF seems fair. Several important key components are judged to be weak and may require extensive work, including the IYCF behaviour change and communication channels and materials, as well as the monitoring and evaluation of the effect of communication on IYCF behaviour. Summary of national level communication on IYCF Overall national level communication on IYCF Key action areas or component National IYCF behaviour change and communication strategy IYCF behaviour change and communication channels Behaviour change and communication materials on IYCF Monitoring and evaluating the effect of communication on behaviour ADDITIONAL COMPLEMENTARY FEEDING INTERVENTIONS/COMPONENTS Fair Good Fair Fair Poor Summary of additional complementary feeding interventions/components Overall complementary feeding interventions / components score Selected key strategies IYCF counseling of caregivers in relation to home preparation of complementary foods Provision of complementary food supplements Fair Fair Good Selected key interventions in relation to the provision of complementary food supplements Micronutrients supplements (single/multiple) are provided to improve CF for children 624 months Micronutrients supplements (single/multiple) provided in emergencies Micronutrients supplements provided in nonemergencies Targeted food supplements are provided to improve CF for children 624 months Fortified local complementary foods are provided Fortified industriallyblended complementary foods are provided Lipidbased nutrient supplements are provided IYCF IN EXCEPTIONALLY DIFFICULT CIRCUMSTANCES HIV AND INFANT FEEDING Overall national standing on HIV and infant feeding Selected key action areas Policy on HIV and infant feeding National IYCF policy include guidance on HIV and infant feeding HIV and infant feeding in PMTCT policy Fair Other selected key action areas Infant feeding policy updated based on 2010 WHO rapid advice Infant feeding counseling for HIV+ mothers IYCF counseling materials include HIV and infant feeding IYCF counseling materials which include HIV and infant feeding are updated regularly Monitoring system on infant feeding practices among HIV+ mothers INFANT FEEDING IN EMERGENCIES Overall national standing on Infant feeding in emergencies Selected key action areas National IYCF policy include IYCF in emergency National emergency preparedness plan includes IYCF in emergency Poor National emergency preparedness plan updated based on the latest edition of IYCF in emergency Other selected key action areas Health workers and IYCF counsellors trained on IYCF in emergency Breast milk substitutes are provided during emergency Government procures/distribute breast milk substitutes Government accept donations of infant food IYCF MONITORING AND EVALUATION Summary of IYCF monitoring and evaluation score Overall IYCF monitoring and evaluation score Fair Key action areas or components Monitoring and evaluation for national IYCF Routine monitoring of ongoing IYCF activities Overall evaluation/review of IYCF situation Overall national level IYCF monitoring and evaluation appears to be fair and may require additional attention. Weaker aspects of the comprehensive IYCF monitoring and evaluation system should be strengthened, particularly the routine monitoring of counseling skills at community and health system levels. 71

78 MALI Mali has a stunting prevalence rate of 38% among children under 5 years of age; while 27% and 15% are underweight and wasted, respectively. Recent reports on IYCF status indicate that the rate of early initiation of breastfeeding is currently at 46%, exclusive breastfeeding (< 6 months) at 38% and continued breastfeeding (20 23 months) at 56%. About 30% of children 6 to 9 months are breastfed with complementary food; the nutritional quality of complementary foods from most developing countries is usually poor or inadequate. Overview of the scale, scope and status of comprehensive IYCF incountry actions are summarized below: NATIONAL POLICY, STRATEGY AND PLAN OF ACTIONS National policy, strategy and plan of action for a comprehensive IYCF strategy Overall national IYCF policy, strategy and plan of actions Fair Key practices reflected in the policy Early initiation of breastfeeding Exclusive breastfeeding Continued breastfeeding HEALTH SYSTEM LEVEL ACTIONS COMMUNITY SYSTEM LEVEL ACTIONS The IYCF community level actions may be poor. Strengthening IYCF activities within the communities should be a high priority action area. All key components require extensive attention and actions. There is no information on the status of some of the key action areas. Selected key components reflected in the National IYCF policy Babyfriendly hospital initiative International code of marketing of breast milk substitute Behavioural change and communication HIV and infant feeding IYCF in emergency National IYCF strategy KEYS Yes Part of the key IYCF actions/ interventions implemented No Not part of the key IYCF actions or intervention implemented No information Poor Fair Good Mali s overall national policy, strategy and plan of actions status appears to be fair. The country seems to have few of the building blocks for a comprehensive IYCF strategy and continued work on IYCF is required. The policy on IYCF reflected all the key practices, but very few of the key components. The health system level actions appear to be fair. The country may take advantage of some of its adequate IYCF health system level actions to reinforce other IYCF action areas, including BFHI, community system level actions, communication on IYCF. Very Good Very low number of key IYCF actions or intervention implemented Low number of the key IYCF actions or interventions implemented Average number of key IYCF actions or intervention implemented High number or all of the key IYCF actions or interventions implemented Complementary feeding National IYCF plan of action Summary of national IYCF legislation and law IYCF LEGISLATION AND LAW Overall national IYCF legislation Poor The overall national IYCF legislation and law status seems poor ; it has only one of the key components, the maternity leave. However, extensive work may be required Key action areas CODE law with respect to the CODE law, its monitoring and enforcement, as well as maternity CODE monitoring and enforcement protection law and the provision of paid nursing breaks. Maternity protection law Summary of IYCF health system level actions Overall IYCF health system level actions score Fair Key action areas or components Babyfriendly hospital initiative Poor IYCF health pre and inservice training curricula Good IYCF health workers capacity development Good IYCF health service counseling Good Maternity leave National status of the Baby Friendly Hospital Initiative (estimated) Paid nursing breaks Hospitals / maternity facilities ever certified Babyfriendly (%): 5 Hospitals / maternity facilities recertified Babyfriendly (%): 3 Percentage of institutional births in the country (%) 57 Capacity building of health workers in delivering IYCF counseling (estimated) Health workers trained on IYCF counseling since 2006 (%) < 1 Coverage of the training on IYCF counseling among health workers (%) 79 Summary of IYCF community system level actions Overall IYCF community system level actions score Key action areas or components IYCF community system integration IYCF community health workers capacity development Community monitoring and evaluation Poor Poor Poor Capacity building of community health workers (CHWs) in delivering communitybased IYCF counseling (estimated) Selected key components of the IYCF community system level actions Community capacity development Training on community IYCF counseling since 2006 Capacity building on communication skills for community health workers Monitoring and evaluation Routine monitoring of IYCF activities Routine monitoring of skills of community health workers Routine monitoring of the quality of IYCF counseling Community health workers trained on community IYCF counseling since 2006 (%) 0 Coverage of trained community health workers providing IYCF counseling activities as part of other communitybased programme (%) Proportion of the population living in the target area 72

79 COMMUNICATION ON IYCF Overall national level communication on IYCF seems fair. Several important key components are judged to be weak and may require extensive work, including IYCF behaviour change and communication channels and materials, as well as the monitoring and evaluation of the effect of communication on IYCF behaviour. Summary of national level communication on IYCF Overall national level communication on IYCF Key action areas or component National IYCF behaviour change and communication strategy IYCF behaviour change and communication channels Behaviour change and communication materials on IYCF Fair Very Good Fair Poor Monitoring and evaluating the effect of communication on behaviour Poor ADDITIONAL COMPLEMENTARY FEEDING INTERVENTIONS/COMPONENTS Summary of additional complementary feeding interventions/components Overall complementary feeding interventions / components score Selected key strategies IYCF counseling of caregivers in relation to home preparation of complementary foods Fair Fair Provision of complementary food supplements Poor Selected key interventions in relation to the provision of complementary food supplements Micronutrients supplements (single/multiple) are provided to improve CF for children 624 months Micronutrients supplements (single/multiple) provided in emergencies Micronutrients supplements provided in non emergencies Targeted food supplements are provided to improve CF for children 624 months Fortified local complementary foods are provided Fortified industriallyblended complementary foods are provided Lipidbased nutrient supplements are provided IYCF IN EXCEPTIONALLY DIFFICULT CIRCUMSTANCES HIV AND INFANT FEEDING Overall national standing on HIV and infant feeding Selected key action areas Policy on HIV and infant feeding National IYCF policy include guidance on HIV and infant feeding HIV and infant feeding in PMTCT policy Fair Other selected key action areas Infant feeding policy updated based on 2010 WHO rapid advice Infant feeding training/counseling for HIV+ mothers IYCF training materials include HIV and infant feeding IYCF counseling materials which include HIV and infant feeding are updated regularly Monitoring system on infant feeding practices among HIV+ mothers INFANT FEEDING IN EMERGENCIES Overall national standing on Infant feeding in emergencies Selected key action areas National IYCF policy include IYCF in emergency Fair National emergency preparedness plan includes IYCF in emergency National emergency preparedness plan updated based on the latest edition of IYCF in emergency Other selected key action areas Health workers and IYCF counsellors trained on IYCF in emergency Breast milk substitutes are provided during emergency Government procures/distribute breast milk substitutes Government accept donations of infant food IYCF MONITORING AND EVALUATION Summary of IYCF monitoring and evaluation score Overall IYCF monitoring and evaluation score Fair Key action areas or components Monitoring and evaluation for national IYCF Routine monitoring of ongoing IYCF Overall evaluation/review of IYCF situation Overall national level IYCF monitoring and evaluation appears to be good and may require additional attention. Weaker aspects of the comprehensive IYCF monitoring and evaluation system should be strengthened, particularly at the national legislation, community and health system levels, as well as communication on IYCF and in exceptionally difficult circumstances. 73

80 MOZAMBIQUE Mozambique has a stunting prevalence rate of 44% among children under 5 years of age; while 18% and 4% are underweight and wasted, respectively. Recent reports on IYCF status indicate that the rate of early initiation of breastfeeding is currently at 63%, exclusive breastfeeding (< 6 months) at 37% and continued breastfeeding (20 23 months) at 54%. About 84% of children 6 to 9 months are breastfed with complementary food; the nutritional quality of complementary foods from most developing countries is usually poor or inadequate. KEYS Yes Part of the key IYCF actions/ interventions implemented No Not part of the key IYCF actions or intervention implemented No information Poor Fair Good Very Good Very low number of key IYCF actions or intervention implemented Low number of the key IYCF actions or interventions implemented Average number of key IYCF actions or intervention implemented High number or all of the key IYCF actions or interventions implemented Overview of the scale, scope and status of comprehensive IYCF incountry actions are summarized below: NATIONAL POLICY, STRATEGY AND PLAN OF ACTIONS National policy, strategy and plan of action for a comprehensive IYCF strategy Overall national IYCF policy, strategy and plan of actions Poor Key practices reflected in the policy Early initiation of breastfeeding Exclusive breastfeeding Continued breastfeeding Complementary feeding IYCF LEGISLATION AND LAW The overall national IYCF legislation and law status seems good ; it has most of the key components, including the CODE, maternity protection law, maternity leave and the provision paid nursing breaks. However, more work is needed with respect to the CODE monitoring and enforcement. HEALTH SYSTEM LEVEL ACTIONS Summary of IYCF health system level actions Overall IYCF health system level actions score Fair Key action areas or components Babyfriendly hospital initiative Poor IYCF health pre and inservice training curricula Poor IYCF health workers capacity development Good IYCF health service counseling Very Good Selected key components reflected in the national IYCF policy Babyfriendly hospital initiative International code of marketing of breast milk substitute Behavioural change and communication HIV and infant feeding IYCF in emergency National IYCF strategy National IYCF plan of action Mozambique s overall national policy, strategy and plan of actions status appears to be poor. The country may have none of the building blocks for a comprehensive IYCF strategy and continued work in developing a comprehensive IYCF policy and plan of actions may be required. Summary of national IYCF legislation and law Overall national IYCF legislation Key action areas CODE law Good CODE monitoring and enforcement Maternity protection law Maternity leave Paid nursing breaks The health system level actions appear to be fair. Although, the country seems to have adequate IYCF counseling service and capacity development at the health system level; several other key components, including the BFHI, the pre and inservice training curricula and health workers capacity development activities need to be improved upon. National status of the Baby Friendly Hospital Initiative (estimated) Hospitals / maternity facilities ever certified Babyfriendly (%): 0 Hospitals / maternity facilities recertified Babyfriendly (%): 0 Percentage of institutional birth in the country 50 Capacity building of health workers in delivering IYCF counseling (estimated) Health workers trained on IYCF counseling since 2006 (%) 19 Coverage of the training on IYCF counseling among health workers (%) 100 COMMUNITY SYSTEM LEVEL ACTIONS The IYCF community level actions may be poor. Strengthening IYCF activities within the communities should be a high priority action area. Key components, such as community system integration, community capacity development and training, as well as monitoring and evaluation require extensive attention. Summary of IYCF community system level actions Overall IYCF community system level actions score Key action areas or components IYCF community system integration IYCF community health workers capacity development Community monitoring and evaluation Poor Poor Fair Poor Selected key components of the IYCF community system level actions Community capacity development Training on community IYCF counseling since 2006 Capacity building on communication skills for community health workers Monitoring and evaluation Routine monitoring of IYCF activities Routine monitoring of skills of community health workers Routine monitoring of the quality of IYCF counseling Capacity building of community health workers (CHWs) in delivering communitybased IYCF counseling (estimated) Community health workers trained on community IYCF counseling since 2006 (%) 0 Coverage of trained community health workers providing IYCF counseling activities as part of other communitybased programme (%) Proportion of the population living in the target area 74

81 COMMUNICATION ON IYCF Overall national level communication on IYCF seems good. While most of the key action areas may be adequate, including the national IYCF behaviour change and communication strategy, channels, as well as the monitoring and evaluation; the behaviour change and communication materials on IYCF needs extensive attention. Summary of national level communication on IYCF Overall national level communication on IYCF Key action areas or component National IYCF behaviour change and communication IYCF behaviour change and communication channels Behaviour change and communication materials on IYCF Monitoring and evaluating the effect of communication on behaviour Good Good Very Good Poor Very Good ADDITIONAL COMPLEMENTARY FEEDING INTERVENTIONS/COMPONENTS Summary of additional complementary feeding interventions/components Overall complementary feeding interventions / components score Selected key strategies IYCF counseling of caregivers in relation to home preparation of complementary foods Fair Poor Provision of complementary food supplements Fair Selected key interventions in relation to the provision of complementary food supplements Micronutrients supplements (single/multiple) are provided to improve CF for children 624 months Micronutrients supplements (single/multiple) provided in emergencies Micronutrients supplements provided in nonemergencies Targeted food supplements are provided to improve CF for children 624 months Fortified local complementary foods are provided Fortified industriallyblended complementary foods are provided Lipidbased nutrient supplements are provided IYCF IN EXCEPTIONALLY DIFFICULT CIRCUMSTANCES HIV AND INFANT FEEDING Overall national standing on HIV and infant feeding Selected key action areas Policy on HIV and infant feeding National IYCF policy include guidance on HIV and infant feeding HIV and infant feeding in PMTCT policy Good Other selected key action areas Infant feeding policy updated based on 2010 WHO rapid advice Infant feeding training/counseling for HIV+ mothers IYCF training materials include HIV and infant feeding IYCF counseling materials which include HIV and infant feeding are updated regularly Monitoring system on infant feeding practices among HIV+ mothers INFANT FEEDING IN EMERGENCIES Overall national standing on Infant feeding in emergencies Poor Selected key action areas National IYCF policy include IYCF in emergency National emergency preparedness plan includes IYCF in emergency National emergency preparedness plan updated based on the latest edition of IYCF in emergency Other selected key action areas Health workers and IYCF counsellors trained on IYCF in emergency Breast milk substitutes are provided during emergency Government procures/distribute breast milk substitutes Government accept donations of infant food IYCF MONITORING AND EVALUATION Summary of IYCF monitoring and evaluation score Overall IYCF monitoring and evaluation score Fair Key action areas or components Monitoring and evaluation for national IYCF Routine monitoring of ongoing IYCF Overall evaluation/review of IYCF situation Overall national level IYCF monitoring and evaluation appears to be Fair. Weaker aspects of the comprehensive IYCF monitoring and evaluation system should be strengthened, particularly at the national legislation, community and health system levels. For instance, routine monitoring of the quality of IYCF counseling at the community level need to be strengthened. 75

82 NIGER Niger has a stunting prevalence rate of 46% among children under 5 years of age; while 34% and 12% are underweight and wasted, respectively. Recent reports on IYCF status indicate that the rate of early initiation of breastfeeding is currently at 40%, exclusive breastfeeding (< 6 months) at 10%. About 52% of children 6 to 9 months are breastfed with complementary food; the nutritional quality of complementary foods from most developing countries is usually poor or inadequate. Overview of the scale, scope and status of comprehensive IYCF incountry actions are summarized below: NATIONAL POLICY, STRATEGY AND PLAN OF ACTIONS National policy, strategy and plan of action for a comprehensive IYCF strategy Overall national IYCF policy, strategy and plan of actions Fair Key practices reflected in the policy Early initiation of breastfeeding Exclusive breastfeeding Continued breastfeeding Complementary feeding IYCF LEGISLATION AND LAW The overall national IYCF legislation and law status seems fair ; it has some of the key components, including maternity protection law, maternity leave and provision of paid nursing leave. However, more work is needed with respect to the CODE law, as well as its monitoring and enforcement. HEALTH SYSTEM LEVEL ACTIONS Summary of IYCF health system level actions COMMUNITY SYSTEM LEVEL ACTIONS The IYCF community level actions may be fair. Strengthening IYCF activities within the communities should be a high priority action area. Key components, such as community system integration as well as monitoring and evaluation require extensive attention. Overall IYCF health system level actions score Fair Key action areas or components Babyfriendly hospital initiative Fair IYCF health pre and inservice training curricula Poor IYCF health workers capacity development Good IYCF health service counseling Very Good Selected key components reflected in the national IYCF policy Babyfriendly hospital initiative International code of marketing of breast milk substitute Behavioural change and communication HIV and infant feeding IYCF in emergency National IYCF strategy National IYCF plan of action KEYS Yes Part of the key IYCF actions/ interventions implemented No Not part of the key IYCF actions or intervention implemented No information Poor Fair Good Niger s overall national policy, strategy and plan of actions status appears to be fair. The country has few of the building blocks for a comprehensive IYCF strategy and continued work on IYCF is required. At present the policy on IYCF reflected most of the key practices, but very little number of the key components. The health system level actions appear to be good. Although, the country seems to have adequate health workers capacity development activities, IYCF counseling service and BFHI; several other key components, including the BFHI, the pre and inservice training curricula and need to be reinforced. Very Good Very low number of key IYCF actions or intervention implemented Low number of the key IYCF actions or interventions implemented Average number of key IYCF actions or intervention implemented High number or all of the key IYCF actions or interventions implemented Summary of national IYCF legislation and law National status of the Baby Friendly Hospital Initiative (estimated) Overall national IYCF legislation Fair Key action areas CODE law CODE monitoring and enforcement Maternity protection law Maternity leave Paid nursing breaks Hospitals / maternity facilities ever certified BabyFriendly (%): 11 Hospitals / maternity facilities recertified BabyFriendly (%): 4 Percentage of institutional birth in the country 30 Capacity building of health workers in delivering IYCF counseling (estimated) Health workers trained on IYCF counseling since 2006 (%) < 2 Coverage of the training on IYCF counseling among health workers (%) 12 Summary of IYCF community system level actions Overall IYCF community system level actions score Fair Key action areas or components IYCF community system integration Fair IYCF community health workers Very Good capacity development Community monitoring and evaluation Poor Capacity building of community health workers (CHWs) in delivering communitybased IYCF counseling (estimated) Selected key components of the IYCF community system level actions Community capacity development Training on community IYCF counseling since 2006 Capacity building on communication skills for community health workers Monitoring and evaluation Routine monitoring of IYCF activities Routine monitoring of skills of community health workers Routine monitoring of the quality of IYCF counseling Community health workers trained on community IYCF counseling since 2006 (%) 51 Coverage of trained community health workers providing IYCF counseling activities as part of other communitybased programme (%) 12 Proportion of the population living in the target area 15 76

83 COMMUNICATION ON IYCF Overall national level communication on IYCF seems fair. While some of the key action areas may be adequate, including the national IYCF behaviour change and communication strategy and channels, other important key components including behaviour change and communication materials on IYCF and the monitoring and evaluation of the effect of communication on IYCF behaviour needs to be strengthened. Summary of national level communication on IYCF Overall national level communication on IYCF Key action areas or component National IYCF behaviour change and communication IYCF behaviour change and communication channels Behaviour change and communication materials on IYCF Monitoring and evaluating the effect of communication on behaviour Fair Good Good Fair Poor ADDITIONAL COMPLEMENTARY FEEDING INTERVENTIONS/COMPONENTS Summary of additional complementary feeding interventions/components Overall complementary feeding interventions / components score Selected key strategies IYCF counseling of caregivers in relation to home preparation of complementary foods Poor Poor Provision of complementary food supplements Fair Selected key interventions in relation to the provision of complementary food supplements Micronutrients supplements (single/multiple) are provided to improve CF for children 624 months Micronutrients supplements (single/multiple) provided in emergencies Micronutrients supplements provided in nonemergencies Targeted food supplements are provided to improve CF for children 624 months Fortified local complementary foods are provided Fortified industriallyblended complementary foods are provided Lipidbased nutrient supplements are provided IYCF IN EXCEPTIONALLY DIFFICULT CIRCUMSTANCES HIV AND INFANT FEEDING Overall national standing on HIV and infant feeding Selected key action areas Policy on HIV and infant feeding National IYCF policy include guidance on HIV and infant feeding HIV and infant feeding in PMTCT policy Fair Other selected key action areas Infant feeding policy updated based on 2010 WHO rapid advice Infant feeding training/counseling for HIV+ mothers IYCF training materials include HIV and infant feeding IYCF counseling materials which include HIV and infant feeding are updated regularly Monitoring system on infant feeding practices among HIV+ mothers INFANT FEEDING IN EMERGENCIES Overall national standing on Infant feeding in emergencies Poor Selected key action areas National IYCF policy include IYCF in emergency National emergency preparedness plan includes IYCF in emergency National emergency preparedness plan updated based on the latest edition of IYCF in emergency Other selected key action areas Health workers and IYCF counsellors trained on IYCF in emergency Breast milk substitutes are provided during emergency Government procures/distribute breast milk substitutes Government accept donations of infant food IYCF MONITORING AND EVALUATION Summary of IYCF monitoring and evaluation score Overall IYCF monitoring and evaluation score Key action areas or components Monitoring and evaluation for national IYCF Poor Routine monitoring of ongoing IYCF Overall evaluation/review of IYCF situation Overall national level IYCF monitoring and evaluation appears to be poor and may require extensive attention. Additionally, more work is needed to strengthen the broader monitoring and evaluation system within the national legislation, community and health system levels as well as communication on IYCF and IYCF in exceptionally difficult circumstances. 77

84 NIGERIA Nigeria has a stunting prevalence rate of 43% among children under 5 years of age; while 24% and 11% are underweight and wasted, respectively. Recent reports on IYCF status indicate that the rate of early initiation of breastfeeding is currently at 38%, exclusive breastfeeding (< 6 months) at 13% and continued breastfeeding (20 23 months) at 32%. About 75% of children 6 to 9 months are breastfed with complementary food; the nutritional quality of complementary foods from most developing countries is usually poor or inadequate. Overview of the scale, scope and status of comprehensive IYCF incountry actions are summarized below: NATIONAL POLICY, STRATEGY AND PLAN OF ACTIONS National policy, strategy and plan of action for a comprehensive IYCF strategy Overall national IYCF policy, strategy and plan of actions Fair Key practices reflected in the policy Early initiation of breastfeeding Exclusive breastfeeding Continued breastfeeding Complementary feeding IYCF LEGISLATION AND LAW The overall national IYCF legislation and law status seems very good ; it is judged to have all the key components. However, to take advantage of the current adequate IYCF legislation and law; key components not reflected in the national IYCF policy may be strengthened, including the international code of marketing of breastmilk substitute, BCC, IYCF in emergency and infant feeding and IYCF. HEALTH SYSTEM LEVEL ACTIONS Summary of IYCF health system level actions Overall IYCF health system level actions score Good Key action areas or components Babyfriendly hospital initiative Poor IYCF health pre and inservice training curricula Very Good IYCF health workers capacity development Good IYCF health service counseling Very Good Selected key components reflected in the National IYCF policy Babyfriendly hospital initiative International code of marketing of breast milk substitute Behavioural change and communication HIV and infant feeding IYCF in emergency National IYCF strategy KEYS Yes Part of the key IYCF actions/ interventions implemented No Not part of the key IYCF actions or intervention implemented No information Poor Fair Good Nigeria s overall national policy, strategy and plan of actions status appears to be fair. The country seems to have some of the building blocks for a comprehensive IYCF strategy and continued work on IYCF is required. At present the policy on IYCF reflected most of the key practices, but very little number of the key components. The health system level actions appear to be good. Although, most of the key components seem to the adequate with the exception of the BFHI which needs more work. Further, there is need to strengthen the capacity of more health workers on IYCF counseling. Very Good Very low number of key IYCF actions or intervention implemented Low number of the key IYCF actions or interventions implemented Average number of key IYCF actions or intervention implemented High number or all of the key IYCF actions or interventions implemented National IYCF plan of action Summary of national IYCF legislation and law Overall national IYCF legislation Key action areas CODE law CODE monitoring and enforcement Maternity protection law Maternity leave Paid nursing breaks National status of the Baby Friendly Hospital Initiative (estimated) Very Good Hospitals / maternity facilities ever certified Babyfriendly (%): 8 Hospitals / maternity facilities recertified Babyfriendly (%): 0 Percentage of institutional birth in the country 39 Capacity building of health workers in delivering IYCF counseling (estimated) Health workers trained on IYCF counseling since 2006 (%) < 1 Coverage of the training on IYCF counseling among health workers (%) COMMUNITY SYSTEM LEVEL ACTIONS The IYCF community level actions may be good. Seem adequate, however strengthening the community system integration may be needed. Additionally, routine monitoring and evaluation of community health workers trained on IYCF counseling should be part of the routine monitoring of IYCF activities. Summary of IYCF community system level actions Overall IYCF community system level actions score Good Key action areas or components IYCF community system integration Fair IYCF community health workers Very Good capacity development Community monitoring and evaluation Very Good Selected key components of the IYCF community system level actions Community capacity development Training on community IYCF counseling since 2006 Capacity building on communication skills for community health workers Monitoring and evaluation Routine monitoring of IYCF activities Routine monitoring of skills of community health workers Routine monitoring of the quality of IYCF counseling Capacity building of community health workers (CHWs) in delivering communitybased IYCF counseling (estimated) Community health workers trained on community IYCF counseling since 2006 (%) Coverage of trained community health workers providing IYCF counseling activities as part of other communitybased programme (%) 100 Proportion of the population living in the target area 100% 78

85 COMMUNICATION ON IYCF Overall national level communication on IYCF seems good. While most of the key action areas may be adequate, including the national IYCF behaviour change and communication strategy, channels and materials; the monitoring and evaluation of the effect of communication in IYCF behaviour needs extensive attention. ADDITIONAL COMPLEMENTARY FEEDING INTERVENTIONS/COMPONENTS Summary of additional complementary feeding interventions/components Overall complementary feeding interventions / components score Selected key strategies IYCF counseling of caregivers in relation to home preparation of complementary foods Provision of complementary food supplements Fair Fair Fair Summary of national level communication on IYCF Overall national level communication on IYCF Key action areas or component National IYCF behaviour change and communication IYCF behaviour change and communication channels Behaviour change and communication materials on IYCF Good Very Good Good Good Monitoring and evaluating the effect of communication on behaviour Poor Selected key interventions in relation to the provision of complementary food supplements Micronutrients supplements (single/multiple) are provided to improve CF for children 624 months Micronutrients supplements (single/multiple) provided in emergencies Micronutrients supplements provided in nonemergencies Targeted food supplements are provided to improve CF for children 624 months Fortified local complementary foods are provided Fortified industriallyblended complementary foods are provided Lipidbased nutrient supplements are provided IYCF IN EXCEPTIONALLY DIFFICULT CIRCUMSTANCES HIV AND INFANT FEEDING Overall national standing on HIV and infant feeding Selected key action areas Policy on HIV and infant feeding National IYCF policy include guidance on HIV and infant feeding HIV and infant feeding in PMTCT policy Fair Other selected key action areas Infant feeding policy updated based on 2010 WHO rapid advice Infant feeding training/counseling for HIV+ mothers IYCF training materials include HIV and infant feeding IYCF counseling materials which include HIV and infant feeding are updated regularly Monitoring system on infant feeding practices among HIV+ mothers INFANT FEEDING IN EMERGENCIES Overall national standing on Infant feeding in emergencies Selected key action areas National IYCF policy include IYCF in emergency National emergency preparedness plan includes IYCF in emergency National emergency preparedness plan updated based on the latest edition of IYCF in emergency Good Other selected key action areas Health workers and IYCF counsellors trained on IYCF in emergency Breast milk substitutes are provided during emergency Government procures/distribute breast milk substitutes Government accept donations of infant food IYCF MONITORING AND EVALUATION Summary of IYCF monitoring and evaluation score Overall IYCF monitoring and evaluation score Key action areas or components Very good Monitoring and evaluation for national IYCF Routine monitoring of ongoing IYCF activities Overall evaluation/review of IYCF situation Overall national level IYCF monitoring and evaluation appears to be Very good. However, monitoring and evaluation of national IYCF actions at the national level need to be strengthened. For instance, proportion and coverage of community health workers trained on IYCF counseling skills need to be routinely monitored. 79

86 PHILIPPINES Philippines has a stunting prevalence rate of 32% among children under 5 years of age; while 22% and 7% are underweight and wasted, respectively. Recent reports on IYCF status indicate that the rate of early initiation of breastfeeding is currently at 54%, exclusive breastfeeding (< 6 months) at 34% and continued breastfeeding (20 23 months) at 34%. About 58% of children 6 to 9 months are breastfed with complementary food; the nutritional quality of complementary foods from most developing countries is usually poor or inadequate. Overview of the scale, scope and status of comprehensive IYCF incountry actions are summarized below: NATIONAL POLICY, STRATEGY AND PLAN OF ACTIONS National policy, strategy and plan of action for a comprehensive IYCF strategy Overall national IYCF policy, strategy and plan of actions Key practices reflected in the policy Early initiation of breastfeeding Exclusive breastfeeding Continued breastfeeding Complementary feeding Good IYCF LEGISLATION AND LAW The overall national IYCF legislation and law status seems very good. However, to take advantage of the current adequate IYCF legislation and law; key components not reflected in the national IYCF policy may be strengthened, including the international code of marketing of breast milk substitutes, BCC as well as the national plan of actions on IYCF. HEALTH SYSTEM LEVEL ACTIONS Summary of IYCF health system level actions COMMUNITY SYSTEM LEVEL ACTIONS Overall IYCF health system level actions score Fair Key action areas or components Babyfriendly hospital initiative Fair IYCF health pre and inservice training curricula IYCF health workers capacity development IYCF health service counseling Poor Good Poor Selected key components reflected in the National IYCF policy Babyfriendly hospital initiative International code of marketing of breast milk substitute Behavioural change and communication HIV and infant feeding IYCF in emergency National IYCF strategy National IYCF plan of action KEYS Yes Part of the key IYCF actions/ interventions implemented No Not part of the key IYCF actions or intervention implemented No information Poor Fair Good Philippines overall national policy, strategy and plan of actions status appears to be good. The country has adequate number of the building blocks for a comprehensive IYCF strategy. At present the policy on IYCF reflected some of the key IYCF components, while more work is needed with some others. The health system level actions appear to be fair. Although, the country seems to have adequate IYCF health worker capacity development, several other key components, including the BFHI, the pre and inservice training curricula and IYCF health service counseling activities need to be reinforced. Very Good Very low number of key IYCF actions or intervention implemented Low number of the key IYCF actions or interventions implemented Average number of key IYCF actions or intervention implemented High number or all of the key IYCF actions or interventions implemented Summary of national IYCF legislation and law Overall national IYCF legislation Key action areas CODE law CODE monitoring and enforcement Maternity protection law Maternity leave Paid nursing breaks National status of the Baby Friendly Hospital Initiative (estimated) Very Good Hospitals / maternity facilities ever certified Babyfriendly (%): 83 Hospitals / maternity facilities recertified Babyfriendly (%): 0 Percentage of institutional birth in the country 40 Capacity building of health workers in delivering IYCF counseling (estimated) Health workers trained on IYCF counseling since 2006 (%) 82 Coverage of the training on IYCF counseling among health workers (%) 100 The IYCF community level actions may be poor. Strengthening IYCF activities within the communities should be a high priority action area. Key components, such as community integration, community capacity development and training, as well as monitoring and evaluation require extensive attention. Summary of IYCF community system level actions Overall IYCF community system level actions score Key action areas or components IYCF community system integration IYCF community health workers capacity development Community monitoring and evaluation Poor Poor Fair Poor Selected key components of the IYCF community system level actions Community capacity development Training on community IYCF counseling since 2006 Capacity building on communication skills for community health workers Monitoring and evaluation Routine monitoring of IYCF activities Routine monitoring of skills of community health workers Routine monitoring of the quality of IYCF counseling Capacity building of community health workers (CHWs) in delivering communitybased IYCF counseling (estimated) Community health workers trained on community IYCF counseling since 2006 (%) 13 Coverage of trained community health workers providing IYCF counseling activities as part of other communitybased programme (%) 100 Proportion of the population living in the target area 80

87 COMMUNICATION ON IYCF Overall national level communication on IYCF seems poor. Several important key components are judged to be weak and may require extensive work, including IYCF behaviour change and communication channels and materials, as well as the monitoring and evaluation of the effect of communication on IYCF behaviour. ADDITIONAL COMPLEMENTARY FEEDING INTERVENTIONS/COMPONENTS Summary of national level communication on IYCF Overall national level communication on IYCF Key action areas or component National IYCF behaviour change and communication IYCF behaviour change and communication channels Behaviour change and communication materials on IYCF Monitoring and evaluating the effect of communication on behaviour Poor Good Fair Poor Poor Summary of additional complementary feeding interventions/components Overall complementary feeding interventions / components score Selected key strategies IYCF counseling of caregivers in relation to home preparation of complementary foods Fair Poor Provision of complementary food supplements Fair Selected key interventions in relation to the provision of complementary food supplements Micronutrients supplements (single/multiple) are provided to improve CF for children 624 months Micronutrients supplements (single/multiple) provided in emergencies Micronutrients supplements provided in non emergencies Targeted food supplements are provided to improve CF for children 624 months Fortified local complementary foods are provided Fortified industriallyblended complementary foods are provided Lipidbased nutrient supplements are provided IYCF IN EXCEPTIONALLY DIFFICULT CIRCUMSTANCES HIV AND INFANT FEEDING Overall national standing on HIV and infant feeding Selected key action areas Policy on HIV and infant feeding National IYCF policy include guidance on HIV and infant feeding HIV and infant feeding in PMTCT policy Good Other selected key action areas Infant feeding policy updated based on 2010 WHO rapid advice Infant feeding training/counseling for HIV+ mothers IYCF training materials include HIV and infant feeding IYCF counseling materials which include HIV and infant feeding are updated regularly Monitoring system on infant feeding practices among HIV+ mothers INFANT FEEDING IN EMERGENCIES Overall national standing on Infant feeding in emergencies Selected key action areas National IYCF policy include IYCF in emergency Fair National emergency preparedness plan includes IYCF in emergency National emergency preparedness plan updated based on the latest edition of IYCF in emergency Other selected key action areas Health workers and IYCF counsellors trained on IYCF in emergency Breast milk substitutes are provided during emergency Government procures/distribute breast milk substitutes Government accept donations of infant food IYCF MONITORING AND EVALUATION Summary of IYCF monitoring and evaluation score Overall IYCF monitoring and evaluation score Key action areas or components Monitoring and evaluation for national IYCF Routine monitoring of ongoing IYCF activities Overall evaluation/review of IYCF situation Fair Overall national level IYCF monitoring and evaluation appears to be fair and may require additional attention. Weaker aspects of the comprehensive IYCF monitoring and evaluation system should be strengthened, particularly at the community and health system levels as well as communication on IYCF and IYCF in exceptionally difficult circumstances. 81

88 SIERRA LEONE Sierra Leone has a stunting prevalence rate of 36% among children under 5 years of age; while 21% and 10% are underweight and wasted, respectively. Recent reports on IYCF status indicate that the rate of early initiation of breastfeeding is currently at 51%, exclusive breastfeeding (< 6 months) at 11% and continued breastfeeding (20 23 months) at 50%. About 73% of children 6 to 9 months are breastfed with complementary food; the nutritional quality of complementary foods from most developing countries is usually poor or inadequate. Overview of the scale, scope and status of comprehensive IYCF incountry actions are summarized below: NATIONAL POLICY, STRATEGY AND PLAN OF ACTIONS National policy, strategy and plan of action for a comprehensive IYCF strategy Overall national IYCF policy, strategy and plan of actions Key practices reflected in the policy Early initiation of breastfeeding Exclusive breastfeeding Continued breastfeeding Complementary feeding Very Good IYCF LEGISLATION AND LAW Selected key components reflected in the National IYCF policy Babyfriendly hospital initiative International code of marketing of breast milk substitute Behavioural change and communication HIV and infant feeding IYCF in emergency National IYCF strategy National IYCF plan of action The overall national IYCF legislation and law status seems fair ; it has some of the key components, including maternity protection law, maternity leave. However, more work is needed with respect to the CODE law, its monitoring and enforcement as well as the provision of paid nursing breaks. KEYS Yes Part of the key IYCF actions/ interventions implemented No Not part of the key IYCF actions or intervention implemented No information Sierra Leone s overall national policy, strategy and plan of actions status appears to be very good. The country has most of the building blocks for a comprehensive IYCF strategy, but continued work on IYCF is required. In particular, more work may be needed with respect to IYCF in emergency and national IYCF plan of action. HEALTH SYSTEM LEVEL ACTIONS Summary of IYCF health system level actions The health system level actions appear to be poor. All the key components may require extensive actions. In particular, BFHI, pre and inservice training curricula and IYCF health service counseling activities. Overall IYCF health system level actions score Key action areas or components Babyfriendly hospital initiative IYCF health pre and inservice training curricula IYCF health workers capacity development IYCF health service counseling Poor Poor Poor Fair Poor Poor Fair Good Very Good Very low number of key IYCF actions or intervention implemented Low number of the key IYCF actions or interventions implemented Average number of key IYCF actions or intervention implemented High number or all of the key IYCF actions or interventions implemented Summary of national IYCF legislation and law National status of the Baby Friendly Hospital Initiative (estimated) Overall national IYCF legislation Fair Key action areas CODE law CODE monitoring and enforcement Maternity protection law Maternity leave Paid nursing breaks Hospitals / maternity facilities ever certified Babyfriendly (%): 0 Hospitals / maternity facilities recertified Babyfriendly (%): 0 Percentage of institutional birth in the country 25 Capacity building of health workers in delivering IYCF counseling (estimated) Health workers trained on IYCF counseling since 2006 (%) 0 Coverage of the training on IYCF counseling among health workers (%) COMMUNITY SYSTEM LEVEL ACTIONS The IYCF community level actions may be fair. Strengthening IYCF activities within the communities should be a high priority action area. Key components, such as community system integration, as well as monitoring and evaluation require extensive attention. Summary of IYCF community system level actions Overall IYCF community system level actions score Fair Key action areas or components IYCF community system integration Poor IYCF community health workers Very Good capacity development Community monitoring and evaluation Capacity building of community health workers (CHWs) in delivering communitybased IYCF counseling (estimated) Fair Selected key components of the IYCF community system level actions Community capacity development Training on community IYCF counseling since 2006 Capacity building on communication skills for community health workers Monitoring and evaluation Routine monitoring of IYCF activities Routine monitoring of skills of community health workers Routine monitoring of the quality of IYCF counseling Community health workers trained on community IYCF counseling since 2006 (%) Coverage of trained community health workers providing IYCF counseling activities as part of other communitybased programme (%) 100 Proportion of the population living in the target area 100% 82

89 COMMUNICATION ON IYCF Overall national level communication on IYCF seems fair. While most of the key action areas may be adequate, the national IYCF behaviour change and communication strategy may need extensive attention. Summary of national level communication on IYCF Overall national level communication on IYCF Key action areas or component National IYCF behaviour change and communication strategy IYCF behaviour change and communication channels Behaviour change and communication materials on IYCF Monitoring and evaluating the effect of communication on behaviour Fair Poor Good Good Good ADDITIONAL COMPLEMENTARY FEEDING INTERVENTIONS/COMPONENTS Summary of additional complementary feeding interventions/components Overall complementary feeding interventions / components score Selected key strategies IYCF counseling of caregivers in relation to home preparation of complementary foods Poor Fair Provision of complementary food supplements Poor Selected key interventions in relation to the provision of complementary food supplements Micronutrients supplements (single/multiple) are provided to improve CF for children 624 months Micronutrients supplements (single/multiple) provided in emergencies Micronutrients supplements provided in nonemergencies Targeted food supplements are provided to improve CF for children 624 months Fortified local complementary foods are provided Fortified industriallyblended complementary foods are provided Lipidbased nutrient supplements are provided IYCF IN EXCEPTIONALLY DIFFICULT CIRCUMSTANCES HIV AND INFANT FEEDING Overall national standing on HIV and infant feeding Selected key action areas Policy on HIV and infant feeding National IYCF policy include guidance on HIV and infant feeding HIV and infant feeding in PMTCT policy Fair Other selected key action areas Infant feeding policy updated based on 2010 WHO rapid advice Infant feeding training/counseling for HIV+ mothers IYCF training materials include HIV and infant feeding IYCF counseling materials which include HIV and infant feeding are updated regularly Monitoring system on infant feeding practices among HIV+ mothers INFANT FEEDING IN EMERGENCIES Overall national standing on Infant feeding in emergencies Poor Selected key action areas National IYCF policy include IYCF in emergency National emergency preparedness plan includes IYCF in emergency National emergency preparedness plan updated based on the latest edition of IYCF in emergency Other selected key action areas Health workers and IYCF counsellors trained on IYCF in emergency Breast milk substitutes are provided during emergency Government procures/distribute breast milk substitutes Government accept donations of infant food IYCF MONITORING AND EVALUATION Summary of IYCF monitoring and evaluation score Overall IYCF monitoring and evaluation score Fair Key action areas or components Monitoring and evaluation for national IYCF Routine monitoring of ongoing IYCF Overall evaluation/review of IYCF situation Overall national level IYCF monitoring and evaluation appears to be fair and may require extensive attention. Additionally, more work may be needed to strengthen the broader monitoring and evaluation system within the national legislation, community and health system levels as well as IYCF in exceptionally difficult circumstances. 83

90 SOMALIA Somalia has a stunting prevalence rate of 42% among children under 5 years of age; while 32% and 13% are underweight and wasted, respectively. Recent reports on IYCF status indicate that the rate of early initiation of breastfeeding is currently at 26%, exclusive breastfeeding (< 6 months) at 9% and continued breastfeeding (20 23 months) at 35%. About 15% of children 6 to 9 months are breastfed with complementary food; the nutritional quality of complementary foods from most developing countries is usually poor or inadequate. Overview of the scale, scope and status of comprehensive IYCF incountry actions are summarized below: NATIONAL POLICY, STRATEGY AND PLAN OF ACTIONS National policy, strategy and plan of action for a comprehensive IYCF strategy Overall national IYCF policy, strategy and plan of actions Fair Key practices reflected in the policy Early initiation of breastfeeding Exclusive breastfeeding Continued breastfeeding Complementary feeding IYCF LEGISLATION AND LAW Selected key components reflected in the National IYCF policy Babyfriendly hospital initiative International code of marketing of breast milk substitute Behavioural change and communication HIV and infant feeding IYCF in emergency National IYCF strategy National IYCF plan of action The overall national IYCF legislation and law status seems poor and may require extensive work. It has none of the key components or action areas, including the CODE law, it monitoring and enforcement as well as the maternity protection law, maternity leave and the provision of paid nursing breaks. KEYS Yes Part of the key IYCF actions/ interventions implemented No Not part of the key IYCF actions or intervention implemented No information Poor Fair Good Very Good Very low number of key IYCF actions or intervention implemented Low number of the key IYCF actions or interventions implemented Average number of key IYCF actions or intervention implemented High number or all of the key IYCF actions or interventions implemented Somalia s overall national policy, strategy and plan of actions status appears to be fair. The country has few of the building blocks for a comprehensive IYCF strategy and continued work on IYCF is required. At present the policy on IYCF reflected most of the key practices, but only one of the key components. Summary of national IYCF legislation and law Overall national IYCF legislation Poor Key action areas CODE law CODE monitoring and enforcement Maternity protection law Maternity leave Paid nursing breaks HEALTH SYSTEM LEVEL ACTIONS Summary of IYCF health system level actions Overall IYCF health system level actions score Poor Key action areas or components Babyfriendly hospital initiative Poor IYCF health pre and inservice training curricula Poor IYCF health workers capacity development IYCF health service counseling Good Poor The health system level actions appear to be poor. Although, the country seems to have adequate health workers capacity development activities at the health system level; other key components, including the BFHI, the pre and inservice training curricula and counseling activities need to be strengthened. National status of the Baby Friendly Hospital Initiative (estimated) Hospitals / maternity facilities ever certified Babyfriendly (%): < 1 Hospitals / maternity facilities recertified Babyfriendly (%): 0 Percentage of institutional birth in the country 9 Capacity building of health workers in delivering IYCF counseling (estimated) Health workers trained on IYCF counseling since 2006 [total number (%)] Coverage of the training on IYCF counseling among health workers [total number (%)] 2 COMMUNITY SYSTEM LEVEL ACTIONS The IYCF community level actions may be fair. Strengthening IYCF activities within the communities should be a high priority action area. Key components, such as community system integration, as well as monitoring and evaluation require extensive attention. Summary of IYCF community system level actions Overall IYCF community system level actions score Fair Key action areas or components IYCF community system integration Fair IYCF community health workers Very Good capacity development Community monitoring and evaluation Fair Selected key components of the IYCF community system level actions Community capacity development Training on community IYCF counseling since 2006 Capacity building on communication skills for community health workers Monitoring and evaluation Routine monitoring of IYCF activities Routine monitoring of skills of community health workers Routine monitoring of the quality of IYCF counseling Capacity building of community health workers (CHWs) in delivering communitybased IYCF counseling (estimated) Community health workers trained on community IYCF counseling since 2006 (%) Coverage of trained community health workers providing IYCF counseling activities as part of other communitybased programme (%) 16 Proportion of the population living in the target area 84

91 COMMUNICATION ON IYCF Overall national level communication on IYCF seems poor. Several important key components are judged to be weak and may require extensive work, including National IYCF behaviour change and communication strategy, channels, materials and, as well as the monitoring and evaluation of the effect of communication on IYCF behaviour. Summary of national level communication on IYCF Overall national level communication on IYCF Key action areas or component National IYCF behaviour change and communication IYCF behaviour change and communication channels Behaviour change and communication materials on IYCF Monitoring and evaluating the effect of communication on behaviour Poor Poor Poor Good Poor ADDITIONAL COMPLEMENTARY FEEDING INTERVENTIONS/COMPONENTS Summary of additional complementary feeding interventions/components Overall complementary feeding interventions / components score Selected key strategies IYCF counseling of caregivers in relation to home preparation of complementary foods Poor Fair Provision of complementary food supplements Poor Selected key interventions in relation to the provision of complementary food supplements Micronutrients supplements (single/multiple) are provided to improve CF for children 624 months Micronutrients supplements (single/multiple) provided in emergencies Micronutrients supplements provided in nonemergencies Targeted food supplements are provided to improve CF for children 624 months Fortified local complementary foods are provided Fortified industriallyblended complementary foods are provided Lipidbased nutrient supplements are provided IYCF IN EXCEPTIONALLY DIFFICULT CIRCUMSTANCES HIV AND INFANT FEEDING Overall national standing on HIV and infant feeding Selected key action areas Policy on HIV and infant feeding National IYCF policy include guidance on HIV and infant feeding HIV and infant feeding in PMTCT policy Good Other selected key action areas Infant feeding policy updated based on 2010 WHO rapid advice Infant feeding training/counseling for HIV+ mothers IYCF training materials include HIV and infant feeding IYCF counseling materials which include HIV and infant feeding are updated regularly Monitoring system on infant feeding practices among HIV+ mothers INFANT FEEDING IN EMERGENCIES Overall national standing on Infant feeding in emergencies Poor Selected key action areas National IYCF policy include IYCF in emergency National emergency preparedness plan includes IYCF in emergency National emergency preparedness plan updated based on the latest edition of IYCF in emergency Other selected key action areas Health workers and IYCF counsellors trained on IYCF in emergency Breast milk substitutes are provided during emergency Government procures/distribute breast milk substitutes Government accept donations of infant food IYCF MONITORING AND EVALUATION Summary of IYCF monitoring and evaluation score Overall IYCF monitoring and evaluation score Good Key action areas or components Monitoring and evaluation for national IYCF Routine monitoring of ongoing IYCF Overall evaluation/review of IYCF situation Overall national level IYCF monitoring and evaluation appears to be good and may require additional attention. Weaker aspects of the comprehensive IYCF monitoring and evaluation system should be strengthened, particularly at the national legislation, community and health system levels as well as communication on IYCF and IYCF in exceptionally difficult circumstances. 85

92 SOUTH SUDAN South Sudan has a stunting prevalence rate of 31% among children under 5 years of age; while 28% and 23% are underweight and wasted, respectively. Recent reports 11 on IYCF status indicate that the rate of exclusive breastfeeding (< 6 months) is currently at 45% and about 21% of children 6 to 8 months are breastfed with complementary food; the nutritional quality of complementary foods from most developing countries is usually poor or inadequate. Overview of the scale, scope and status of comprehensive IYCF incountry actions are summarized below: NATIONAL POLICY, STRATEGY AND PLAN OF ACTIONS National policy, strategy and plan of action for a comprehensive IYCF strategy Overall national IYCF policy, strategy and plan of actions Poor Key practices reflected in the policy Early initiation of breastfeeding Exclusive breastfeeding Continued breastfeeding Complementary feeding IYCF LEGISLATION AND LAW Selected key components reflected in the National IYCF policy Babyfriendly hospital initiative International code of marketing of breast milk substitute Behavioural change and communication HIV and infant feeding IYCF in emergency National IYCF strategy National IYCF plan of action The overall national IYCF legislation and law status seems poor ; and may require extensive work. It has none of the key components or action areas, including the CODE law, it monitoring and enforcement as well as the maternity protection law, maternity leave and the provision of paid nursing breaks. KEYS Yes Part of the key IYCF actions/ interventions implemented No Not part of the key IYCF actions or intervention implemented No information Poor Fair Good Very Good Very low number of key IYCF actions or intervention implemented Low number of the key IYCF actions or interventions implemented Average number of key IYCF actions or intervention implemented High number or all of the key IYCF actions or interventions implemented South Sudan s overall national policy, strategy and plan of actions status appears to be poor. The country has very few of the building blocks for a comprehensive IYCF strategy and continued work on IYCF is required. At present it had none of the key components and very few of the IYCF practices are reflected in the policy. Summary of national IYCF legislation and law Overall national IYCF legislation Poor Key action areas CODE law CODE monitoring and enforcement Maternity protection law Maternity leave Paid nursing breaks HEALTH SYSTEM LEVEL ACTIONS Summary of IYCF health system level actions The health system level actions appear to be poor. Although, the country seems to have adequate IYCF counseling service at the health system level; Overall IYCF health system level several other key components, including the BFHI, the pre and inservice actions score Poor training curricula and health workers capacity development activities need to be Key action areas or components reinforced. Babyfriendly hospital initiative IYCF health pre and inservice training curricula IYCF health workers capacity development IYCF health service counseling Poor Poor Poor Good National status of the Baby Friendly Hospital Initiative (estimated) Hospitals / maternity facilities ever certified Babyfriendly (%): 0 Hospitals / maternity facilities recertified Babyfriendly (%): 0 Percentage of institutional birth in the country 12 Capacity building of health workers in delivering IYCF counseling (estimated) Health workers trained on IYCF counseling since 2006 (%) 0 Coverage of the training on IYCF counseling among health workers (%) COMMUNITY SYSTEM LEVEL ACTIONS The IYCF community level actions may be poor. Strengthening IYCF activities within the communities should be a high priority action area. The community system integration component may require extensive attention. There is no information on most of the other key components. Summary of IYCF community system level actions Overall IYCF community system level actions score Key action areas or components IYCF community system integration IYCF community health workers capacity development Community monitoring and evaluation Poor Poor Capacity building of community health workers (CHWs) in delivering communitybased IYCF counseling (estimated) Selected key components of the IYCF community system level actions Community capacity development Training on community IYCF counseling since 2006 Capacity building on communication skills for community health workers Monitoring and evaluation Routine monitoring of IYCF activities Routine monitoring of skills of community health workers Routine monitoring of the quality of IYCF counseling Community health workers trained on community IYCF counseling since 2006 (%) 0 Coverage of trained community health workers providing IYCF counseling activities as part of other communitybased programme (%) Proportion of the population living in the target area 86

93 COMMUNICATION ON IYCF Overall national level communication on IYCF seems fair. Several key components are judged to be weak and may require extensive work, including the national IYCF behaviour change and communication strategy and channels, as well as monitoring and evaluation of the effects of communication on behaviour. Summary of national level communication on IYCF Overall national level communication on IYCF Key action areas or component National IYCF behaviour change and communication strategy IYCF behaviour change and communication channels Behaviour change and communication materials on IYCF Monitoring and evaluating the effect of communication on behaviour Fair Poor Fair Good Poor ADDITIONAL COMPLEMENTARY FEEDING INTERVENTIONS/COMPONENTS Summary of additional complementary feeding interventions/components Overall complementary feeding interventions / components score Selected key strategies IYCF counseling of caregivers in relation to home preparation of complementary foods Provision of complementary food supplements Poor Poor Poor Selected key interventions in relation to the provision of complementary food supplements Micronutrients supplements (single/multiple) are provided to improve CF for children 624 months Micronutrients supplements (single/multiple) provided in emergencies Micronutrients supplements provided in nonemergencies Targeted food supplements are provided to improve CF for children 624 months Fortified local complementary foods are provided Fortified industriallyblended complementary foods are provided Lipidbased nutrient supplements are provided IYCF IN EXCEPTIONALLY DIFFICULT CIRCUMSTANCES HIV AND INFANT FEEDING Overall national standing on HIV and infant feeding Poor Selected key action areas Policy on HIV and infant feeding National IYCF policy include guidance on HIV and infant feeding HIV and infant feeding in PMTCT policy Other selected key action areas Infant feeding policy updated based on 2010 WHO rapid advice Infant feeding training/counseling for HIV+ mothers IYCF training materials include HIV and infant feeding IYCF counseling materials which include HIV and infant feeding are updated regularly Monitoring system on infant feeding practices among HIV+ mothers INFANT FEEDING IN EMERGENCIES Overall national standing on Infant feeding in emergencies Poor Selected key action areas National IYCF policy include IYCF in emergency National emergency preparedness plan includes IYCF in emergency National emergency preparedness plan updated based on the latest edition of IYCF in emergency Other selected key action areas Health workers and IYCF counsellors trained on IYCF in emergency Breast milk substitutes are provided during emergency Government procures/distribute breast milk substitutes Government accept donations of infant food IYCF MONITORING AND EVALUATION Summary of IYCF monitoring and evaluation score Overall IYCF monitoring and evaluation score Key action areas or components Poor Monitoring and evaluation for national IYCF Routine monitoring of ongoing IYCF Overall evaluation/review of IYCF situation Overall national level IYCF monitoring and evaluation appears to be poor and may require extensive attention. Additionally, more work is needed to strengthen the broader monitoring and evaluation system within the national legislation, community and health system levels as well as communication on IYCF and IYCF in exceptionally difficult circumstances. 87

94 SUDAN North Sudan has a stunting prevalence rate of 35% among children under 5 years of age; while 32% and 16% are underweight and wasted, respectively. Recent reports on IYCF status indicate that the rate of early initiation of breastfeeding is currently at 73%, exclusive breastfeeding (< 6 months) at 41%. About 53% of children 6 to 23 months are breastfed with complementary food; the nutritional quality of complementary foods from most developing countries is usually poor or inadequate. Overview of the scale, scope and status of comprehensive IYCF incountry actions are summarized below: NATIONAL POLICY, STRATEGY AND PLAN OF ACTIONS National policy, strategy and plan of action for a comprehensive IYCF strategy Overall national IYCF policy, strategy and plan of actions Fair Key practices reflected in the policy Early initiation of breastfeeding Exclusive breastfeeding Continued breastfeeding Complementary feeding IYCF LEGISLATION AND LAW The overall national IYCF legislation and law status seems fair ; it has some of the key components, including maternity protection law, maternity leave and provision of paid nursing leave. However, more work is needed with respect to the CODE law, its monitoring and enforcement. HEALTH SYSTEM LEVEL ACTIONS Summary of IYCF health system level actions COMMUNITY SYSTEM LEVEL ACTIONS Overall IYCF health system level actions score Fair Key action areas or components Babyfriendly hospital initiative Poor IYCF health pre and inservice training curricula Fair IYCF health workers capacity development Good IYCF health service counseling Very Good Selected key components reflected in the National IYCF policy Babyfriendly hospital initiative International code of marketing of breast milk substitute Behavioural change and communication HIV and infant feeding IYCF in emergency National IYCF strategy KEYS Yes Part of the key IYCF actions/ interventions implemented No Not part of the key IYCF actions or intervention implemented No information Poor Fair Good North Sudan s overall national policy, strategy and plan of actions status appears to be fair. The country seems to have most of the building blocks for a comprehensive IYCF strategy. However, more work is required in strengthening its BFHI and IYCF in emergency. The health system level actions appear to be fair. Although, the country seems to be adequate in some of the key components; however, there is need to further strengthen its BFHI and training curricula. Very Good Very low number of key IYCF actions or intervention implemented Low number of the key IYCF actions or interventions implemented Average number of key IYCF actions or intervention implemented High number or all of the key IYCF actions or interventions implemented National IYCF plan of action Summary of national IYCF legislation and law National status of the Baby Friendly Hospital Initiative (estimated) Overall national IYCF legislation Fair Key action areas CODE law CODE monitoring and enforcement Maternity protection law Maternity leave Paid nursing breaks Hospitals / maternity facilities ever certified Babyfriendly (%): 12 Hospitals / maternity facilities recertified Babyfriendly (%): 12 Percentage of institutional birth in the country 19 Capacity building of health workers in delivering IYCF counseling (estimated) Health workers trained on IYCF counseling since 2006 (%) Coverage of the training on IYCF counseling among health workers (%) 62 The IYCF community level actions may be poor. Strengthening IYCF activities within the communities should be a high priority action area. All the key components may require extensive attention. Summary of IYCF community system level actions Overall IYCF community system level actions score Key action areas or components IYCF community health workers capacity development Poor IYCF community system integration Fair Fair Community monitoring and evaluation Poor Selected key components of the IYCF community system level actions Community capacity development Training on community IYCF counseling since 2006 Capacity building on communication skills for community health workers Monitoring and evaluation Routine monitoring of IYCF activities Routine monitoring of skills of community health workers Routine monitoring of the quality of IYCF counseling Capacity building of community health workers (CHWs) in delivering communitybased IYCF counseling (estimated) Community health workers trained on community IYCF counseling since 2006 (%) Coverage of trained community health workers providing IYCF counseling activities as part of other communitybased programme (%) 60 Proportion of the population living in the target area 88

95 COMMUNICATION ON IYCF Overall national level communication on IYCF is fair. Some key components are judged to be weak and may require extensive work, including behaviour change and communication materials on IYCF, as well as the monitoring and evaluation of the effect of communication on IYCF behaviour. Summary of national level communication on IYCF Overall national level communication on IYCF Key action areas or component National IYCF behaviour change and communication IYCF behaviour change and communication channels Behaviour change and communication materials on IYCF Monitoring and evaluating the effect of communication on behaviour Fair Good Good Fair Poor ADDITIONAL COMPLEMENTARY FEEDING INTERVENTIONS/COMPONENTS Summary of additional complementary feeding interventions/components Overall complementary feeding interventions / components score Selected key strategies IYCF counseling of caregivers in relation to home preparation of complementary foods Fair Fair Provision of complementary food supplements Fair Selected key interventions in relation to the provision of complementary food supplements Micronutrient supplements (single/multiple) are provided to improve CF for children 624 months Micronutrients supplements (single/multiple) provided in emergencies Micronutrients supplements provided in nonemergencies Targeted food supplements are provided to improve CF for children 624 months Fortified local complementary foods are provided Fortified industriallyblended complementary foods are provided Lipidbased nutrient supplements are provided IYCF IN EXCEPTIONALLY DIFFICULT CIRCUMSTANCES HIV AND INFANT FEEDING Overall national standing on HIV and infant feeding Poor Selected key action areas Policy on HIV and infant feeding National IYCF policy include guidance on HIV and infant feeding HIV and infant feeding in PMTCT policy Other selected key action areas Infant feeding policy updated based on 2010 WHO rapid advice Infant feeding training/counseling for HIV+ mothers IYCF training materials include HIV and infant feeding IYCF counseling materials which include HIV and infant feeding are updated regularly Monitoring system on infant feeding practices among HIV+ mothers INFANT FEEDING IN EMERGENCIES Overall national standing on Infant feeding in emergencies Poor Selected key action areas National IYCF policy include IYCF in emergency National emergency preparedness plan includes IYCF in emergency National emergency preparedness plan updated based on the latest edition of IYCF in emergency Other selected key action areas Health workers and IYCF counsellors trained on IYCF in emergency Breast milk substitutes are provided during emergency Government procures/distribute breast milk substitutes Government accept donations of infant food IYCF MONITORING AND EVALUATION Summary of IYCF monitoring and evaluation score Overall IYCF monitoring and evaluation score Fair Key action areas or components Monitoring and evaluation for national IYCF Routine monitoring of ongoing IYCF Overall evaluation/review of IYCF situation Overall national level IYCF monitoring and evaluation appears to be fair and may require additional attention. Weaker aspects of the comprehensive IYCF monitoring and evaluation system should be strengthened, particularly at the national legislation, community and health system levels as well as communication on IYCF and IYCF in exceptionally difficult circumstances. 89

96 UGANDA Uganda has a stunting prevalence rate of 38% among children under 5 years of age; while 16% and 6% are underweight and wasted, respectively. Recent reports on IYCF status indicate that the rate of early initiation of breastfeeding is currently at 42%, exclusive breastfeeding (< 6 months) at 60% and continued breastfeeding (20 23 months) at 54%. About 80% of children 6 to 9 months are breastfed with complementary food; the nutritional quality of complementary foods from most developing countries is usually poor or inadequate. Overview of the scale, scope and status of comprehensive IYCF incountry actions are summarized below: NATIONAL POLICY, STRATEGY AND PLAN OF ACTIONS National policy, strategy and plan of action for a comprehensive IYCF strategy Overall national IYCF policy, strategy and plan of actions Fair Key practices reflected in the policy Early initiation of breastfeeding Exclusive breastfeeding Continued breastfeeding Complementary feeding IYCF LEGISLATION AND LAW Selected key components reflected in the National IYCF policy Babyfriendly hospital initiative International code of marketing of breast milk substitute Behavioural change and communication HIV and infant feeding IYCF in emergency National IYCF strategy National IYCF plan of action The overall national IYCF legislation and law status seems good ; it has some of the key components, including the CODE, its monitoring and enforcement, as well as maternity protection law and maternity leave. Nevertheless, more work is needed with respect to the provision of paid nursing breaks. KEYS Yes Part of the key IYCF actions/ interventions implemented No Not part of the key IYCF actions or intervention implemented No information Poor Fair Good Very Good Very low number of key IYCF actions or intervention implemented Low number of the key IYCF actions or interventions implemented Average number of key IYCF actions or intervention implemented High number or all of the key IYCF actions or interventions implemented Uganda s overall national policy, strategy and plan of actions status appears to be fair. The country has very few of the building blocks for a comprehensive IYCF strategy and continued work on IYCF is required. At present very few of the key IYCF components are reflected in the national policy. Summary of national IYCF legislation and law Overall national IYCF legislation Key action areas CODE law CODE monitoring and enforcement Maternity protection law Maternity leave Good Paid nursing breaks HEALTH SYSTEM LEVEL ACTIONS Summary of IYCF health system level actions COMMUNITY SYSTEM LEVEL ACTIONS The IYCF community level actions may be poor. Strengthening IYCF activities within the communities should be a high priority action area. All the key components are weak and may require extensive reinforcement. Overall IYCF health system level actions score Fair Key action areas or components Babyfriendly hospital initiative Poor IYCF health pre and inservice training curricula IYCF health workers capacity development IYCF health service counseling Good Good Fair The health system level actions appear to be fair. Although, the country seems to have adequate IYCF training curricula and health workers capacity development counseling service at the health system level, several other key components, including the BFHI and IYCF health service counseling may require to be reinforced. National status of the Baby Friendly Hospital Initiative (estimated) Hospitals / maternity facilities ever certified Babyfriendly (%): < 1 Hospitals / maternity facilities recertified Babyfriendly (%): 0 Percentage of institutional birth in the country 41 Capacity building of health workers in delivering IYCF counseling (estimated) Health workers trained on IYCF counseling since 2006 (%) 9 Coverage of the training on IYCF counseling among health workers (%) 36 Summary of IYCF community system level actions Overall IYCF community system level actions score Poor Key action areas or components IYCF community system integration IYCF community health workers capacity development Community monitoring and evaluation Poor Fair Poor Selected key components of the IYCF community system level actions Community capacity development Training on community IYCF counseling since 2006 Capacity building on communication skills for community health workers Monitoring and evaluation Routine monitoring of IYCF activities Routine monitoring of skills of community health workers Routine monitoring of the quality of IYCF counseling Capacity building of community health workers (CHWs) in delivering communitybased IYCF counseling (estimated) Community health workers trained on community IYCF counseling since 2006 (%) Coverage of trained community health workers providing IYCF counseling activities as part of other communitybased programme (%) 21 Proportion of the population living in the target area 90

97 COMMUNICATION ON IYCF Overall national level communication on IYCF seems fair. Several key components are judged to be weak and may require extensive work, including the national IYCF behaviour change and communication strategy and channels, as well as monitoring and evaluation of the effects of communication on behaviour. Summary of national level communication on IYCF Overall national level communication on IYCF Key action areas or component National IYCF behaviour change and communication Fair Poor IYCF behaviour change and communication channels Fair Behaviour change and communication materials on IYCF Very Good Monitoring and evaluating the effect of communication on behaviour Poor ADDITIONAL COMPLEMENTARY FEEDING INTERVENTIONS/COMPONENTS Summary of additional complementary feeding interventions/components Overall complementary feeding interventions / components score Selected key strategies IYCF counseling of caregivers in relation to home preparation of complementary foods Fair Fair Provision of complementary food supplements Poor Selected key interventions in relation to the provision of complementary food supplements Micronutrients supplements (single/multiple) are provided to improve CF for children 624 months Micronutrients supplements (single/multiple) provided in emergencies Micronutrients supplements provided in nonemergencies Targeted food supplements are provided to improve CF for children 624 months Fortified local complementary foods are provided Fortified industriallyblended complementary foods are provided Lipidbased nutrient supplements are provided IYCF IN EXCEPTIONALLY DIFFICULT CIRCUMSTANCES HIV AND INFANT FEEDING Overall national standing on HIV and infant feeding Selected key action areas Policy on HIV and infant feeding National IYCF policy include guidance on HIV and infant feeding HIV and infant feeding in PMTCT policy Good Other selected key action areas Infant feeding policy updated based on 2010 WHO rapid advice Infant feeding training/counseling for HIV+ mothers IYCF training materials include HIV and infant feeding IYCF counseling materials which include HIV and infant feeding are updated regularly Monitoring system on infant feeding practices among HIV+ mothers INFANT FEEDING IN EMERGENCIES Overall national standing on Infant feeding in emergencies Selected key action areas National IYCF policy include IYCF in emergency Poor National emergency preparedness plan includes IYCF in emergency National emergency preparedness plan updated based on the latest edition of IYCF in emergency Other selected key action areas Health workers and IYCF counsellors trained on IYCF in emergency Breast milk substitutes are provided during emergency Government procures/distribute breast milk substitutes Government accept donations of infant food IYCF MONITORING AND EVALUATION Summary of IYCF monitoring and evaluation score Overall IYCF monitoring and evaluation score Poor Key action areas or components Monitoring and evaluation for national IYCF Routine monitoring of ongoing IYCF Overall evaluation/review of IYCF situation Overall national level IYCF monitoring and evaluation appears to be poor and may require extensive attention. Additionally, more work is needed to strengthen the broader monitoring and evaluation system within the national legislation, community and health system levels as well as communication on IYCF and IYCF in exceptionally difficult circumstances. 91

98 UNITED REPUBLIC OF TANZANIA The United Republic of Tanzania has a stunting prevalence rate of 44% among children under 5 years of age; while 17% and 4% are underweight and wasted, respectively. Recent reports on IYCF status indicate that the rate of early initiation of breastfeeding is currently at 67%, exclusive breastfeeding (< 6 months) at 41% and continued breastfeeding (20 23 months) at 55%. About 91% of children 6 to 9 months are breastfed with complementary food; the nutritional quality of complementary foods from most developing countries is usually poor or inadequate. Overview of the scale, scope and status of comprehensive IYCF incountry actions are summarized below: NATIONAL POLICY, STRATEGY AND PLAN OF ACTIONS National policy, strategy and plan of action for a comprehensive IYCF strategy Overall national IYCF policy, strategy and plan of actions Poor Key practices reflected in the policy Early initiation of breastfeeding Exclusive breastfeeding IYCF LEGISLATION AND LAW The overall national IYCF legislation and law status seems very good. However, to take advantage of the current adequate IYCF legislation and law; key components not reflected in the national IYCF policy may need strengthening. HEALTH SYSTEM LEVEL ACTIONS COMMUNITY SYSTEM LEVEL ACTIONS The IYCF community level actions may be fair. Strengthening IYCF activities within the communities should be a high priority action area. More work is required with respect to reinforcing the IYCF community system integration as well as monitoring and evaluation activities. Continued breastfeeding Complementary feeding Summary of IYCF health system level actions Overall IYCF health system level actions score Good Key action areas or components Babyfriendly hospital initiative Poor IYCF health pre and inservice training curricula IYCF health workers capacity development IYCF health service counseling Very Good Very Good Good Selected key components reflected in the National IYCF policy Babyfriendly hospital initiative International code of marketing of breast milk substitute Behavioural change and communication HIV and infant feeding IYCF in emergency National IYCF strategy KEYS Yes Part of the key IYCF actions/ interventions implemented No Not part of the key IYCF actions or intervention implemented No information Poor Fair Good United Republic of Tanzania s overall national policy, strategy and plan of actions status appears to be poor. The country has very few of the building blocks for a comprehensive IYCF strategy and continued work on IYCF is required. At present there is no information on the status of most of the key IYCF components. The health system level actions appear to be good. The country may need to take advantage of its adequate IYCF actions at the health system level to further strengthen other IYCF action areas, several other key components, including the BFHI and health workers capacity development activities in delivering IYCF counseling need to be reinforced. Very Good Very low number of key IYCF actions or intervention implemented Low number of the key IYCF actions or interventions implemented Average number of key IYCF actions or intervention implemented High number or all of the key IYCF actions or interventions implemented National IYCF plan of action Summary of national IYCF legislation and law Overall national IYCF legislation Key action areas CODE law CODE monitoring and enforcement Maternity protection law Maternity leave Paid nursing breaks National status of the BabyFriendly Hospital Initiative (estimated) Very Good Hospitals / maternity facilities ever certified Babyfriendly (%) < 2 Hospitals / maternity facilities recertified Babyfriendly (%) < 1 Percentage of institutional birth in the country 50 Capacity building of health workers in delivering IYCF counseling (estimated) Health workers trained on IYCF counseling since 2006 (%) 6 Coverage of the training on IYCF counseling among health workers (%) 8 Summary of IYCF community system level actions Overall IYCF community system level actions score Fair Key action areas or components IYCF community system integration Fair IYCF community health workers Very Good capacity development Community monitoring and evaluation Poor Selected key components of the IYCF community system level actions Community capacity development Training on community IYCF counseling since 2006 Capacity building on communication skills for community health workers Monitoring and evaluation Routine monitoring of IYCF activities Routine monitoring of skills of community health workers Routine monitoring of the quality of IYCF counseling Capacity building of community health workers (CHWs) in delivering communitybased IYCF counseling (estimated) Community health workers trained on community IYCF counseling since 2006 (%) 0 Coverage of trained community health workers providing IYCF counseling activities as part of other communitybased programme (%) 42 Proportion of the population living in the target area 41 92

99 COMMUNICATION ON IYCF Overall national level communication on IYCF seems fair. While some of the key action areas may be adequate, other aspects including the IYCF behaviour change and communication channels as well as the monitoring and evaluation of the effect of communication on behaviour may need strengthening. Summary of national level communication on IYCF Overall national level communication on IYCF Key action areas or component National IYCF behaviour change and communication IYCF behaviour change and communication channels Behaviour change and communication materials on IYCF Fair Very Good Fair Good Monitoring and evaluating the effect of communication on behaviour Poor ADDITIONAL COMPLEMENTARY FEEDING INTERVENTIONS/COMPONENTS Summary of additional complementary feeding interventions/components Overall complementary feeding interventions / components score Selected key strategies IYCF counseling of caregivers in relation to home preparation of complementary foods Fair Poor Provision of complementary food supplements Fair Selected key interventions in relation to the provision of complementary food supplements Micronutrients supplements (single/multiple) are provided to improve CF for children 624 months Micronutrients supplements (single/multiple) provided in emergencies Micronutrients supplements provided in nonemergencies Targeted food supplements are provided to improve CF for children 624 months Fortified local complementary foods are provided Fortified industriallyblended complementary foods are provided Lipidbased nutrient supplements are provided IYCF IN EXCEPTIONALLY DIFFICULT CIRCUMSTANCES HIV AND INFANT FEEDING Overall national standing on HIV and infant feeding Selected key action areas Policy on HIV and infant feeding National IYCF policy include guidance on HIV and infant feeding HIV and infant feeding in PMTCT policy Good Other selected key action areas Infant feeding policy updated based on 2010 WHO rapid advice Infant feeding training/counseling for HIV+ mothers IYCF training materials include HIV and infant feeding IYCF counseling materials which include HIV and infant feeding are updated regularly Monitoring system on infant feeding practices among HIV+ mothers INFANT FEEDING IN EMERGENCIES Overall national standing on Infant feeding in emergencies Poor Selected key action areas National IYCF policy include IYCF in emergency National emergency preparedness plan includes IYCF in emergency National emergency preparedness plan updated based on the latest edition of IYCF in emergency Other selected key action areas Health workers and IYCF counsellors trained on IYCF in emergency Breast milk substitutes are provided during emergency Government procures/distribute breast milk substitutes Government accept donations of infant food IYCF MONITORING AND EVALUATION Summary of IYCF monitoring and evaluation score Overall IYCF monitoring and evaluation score Key action areas or components Poor Monitoring and evaluation for national IYCF activities Routine monitoring of ongoing IYCF activities Overall evaluation/review of IYCF situation Overall national level communication on IYCF appears to be poor and may require extensive attention. Additionally, more work is needed to strengthen the broader monitoring and evaluation system within the national legislation, community and health system levels as well as communication on IYCF and IYCF in exceptionally difficult circumstances. 93

100 YEMEN Yemen has a stunting prevalence rate of 58% among children under 5 years of age; while 43% and 15% are underweight and wasted, respectively. Recent reports on IYCF status indicate that the rate of early initiation of breastfeeding is currently at 30% and exclusive breastfeeding (< 6 months) at 12%. About 76% of children 6 to 9 months are breastfed with complementary food; the nutritional quality of complementary foods from most developing countries is usually poor or inadequate. KEYS Yes Part of the key IYCF actions/ interventions implemented No Not part of the key IYCF actions or intervention implemented No information Poor Fair Good Very Good Very low number of key IYCF actions or intervention implemented Low number of the key IYCF actions or interventions implemented Average number of key IYCF actions or intervention implemented High number or all of the key IYCF actions or interventions implemented Overview of the scale, scope and status of comprehensive IYCF incountry actions are summarized below: NATIONAL POLICY, STRATEGY AND PLAN OF ACTIONS National policy, strategy and plan of action for a comprehensive IYCF strategy Overall national IYCF policy, strategy and plan of actions Fair Key practices reflected in the policy Early initiation of breastfeeding Exclusive breastfeeding Continued breastfeeding IYCF LEGISLATION AND LAW The overall national IYCF legislation and law status seems fair ; it has some of the key components, including the CODE law, maternity leave and provision of paid nursing breaks. However, more work is needed with respect to the CODE monitoring and enforcement as well as maternity protection law. Yemen s overall national policy, strategy and plan of actions status appears to be fair. The country has very few of the building blocks for a comprehensive IYCF strategy and continued work on IYCF is required. At present it had some of the key components, but more work is required in terms of the BFHI and HIV and infant feeding components. HEALTH SYSTEM LEVEL ACTIONS Summary of IYCF health system level actions The health system level actions appear to be poor. Although, the country seems to have adequate IYCF capacity development at the health system level, Overall IYCF health system level other key components, including the BFHI, the pre and inservice training actions score Poor curricula and IYCF health service counseling activities may need to be Key action areas or components reinforced. COMMUNITY SYSTEM LEVEL ACTIONS The IYCF community level actions may be poor. Strengthening IYCF activities within the communities should be a high priority action area. Extensive work is required to strengthen its weak IYCF community system integration, community capacity development and training, as well as monitoring and evaluation require extensive attention. Complementary feeding Babyfriendly hospital initiative IYCF health pre and inservice training curricula IYCF health workers capacity development IYCF health service counseling Poor Poor Good Fair Selected key components reflected in the National IYCF policy Babyfriendly hospital initiative International code of marketing of breast milk substitute Behavioural change and communication HIV and infant feeding IYCF in emergency National IYCF strategy National IYCF plan of action Summary of national IYCF legislation and law Overall national IYCF legislation Key action areas CODE law Fair CODE monitoring and enforcement Maternity protection law Maternity leave Paid nursing breaks National status of the Baby Friendly Hospital Initiative (estimated) Hospitals / maternity facilities ever certified Babyfriendly (%) 0 Hospitals / maternity facilities recertified Babyfriendly (%) 0 Percentage of institutional birth in the country 20 Capacity building of health workers in delivering IYCF counseling (estimated) Health workers trained on IYCF counseling since 2006 [total number (%)] Coverage of the training on IYCF counseling among health workers [total number (%)] 0 Summary of IYCF community system level actions Overall IYCF community system level actions score Key action areas or components Poor IYCF community system integration Fair Fair IYCF community health workers capacity development Community monitoring and evaluation Poor Selected key components of the IYCF community system level actions Community capacity development Training on community IYCF counseling since 2006 Capacity building on communication skills for community health workers Monitoring and evaluation Routine monitoring of IYCF activities Routine monitoring of skills of community health workers Routine monitoring of the quality of IYCF counseling Capacity building of community health workers (CHWs) in delivering communitybased IYCF counseling (estimated) Community health workers trained on community IYCF counseling since 2006 (%) Coverage of trained community health workers providing IYCF counseling activities as part of other communitybased programme (%) Proportion of the population living in the target area 94

101 COMMUNICATION ON IYCF Overall national level communication on IYCF seems fair. Several key components may need to be strengthened, including the national IYCF behaviour change and communication strategy and channels, as well as monitoring and evaluation of the effects of communication on behaviour. Summary of national level communication on IYCF Overall national level communication on IYCF Key action areas or component National IYCF behaviour change and communication IYCF behaviour change and communication channels Behaviour change and communication materials on IYCF Monitoring and evaluating the effect of communication on behaviour Fair Fair Fair Good Poor COMPLEMENTARY FEEDING INTERVENTIONS/COMPONENTS Summary of additional complementary feeding interventions / components Overall complementary feeding interventions / components score Selected key strategies IYCF counseling of caregivers in relation to home preparation of complementary foods Poor Poor Provision of complementary food supplements Poor Selected key interventions in relation to the provision of complementary food supplements Micronutrients supplements (single/multiple) are provided to improve CF for children 624 months Micronutrients supplements (single/multiple) provided in emergencies Micronutrients supplements provided in nonemergencies Targeted CF supplements are provided to improve CF for children 624 months Fortified local complementary foods are provided Fortified industriallyblended complementary foods are provided Lipidbased nutrient supplements are provided IYCF IN EXCEPTIONALLY DIFFICULT CIRCUMSTANCES HIV AND INFANT FEEDING Overall national standing on HIV and infant feeding Selected key action areas Poor Policy on HIV and infant feeding National IYCF policy include guidance on HIV and infant feeding HIV and infant feeding in PMTCT policy Other selected key action areas Infant feeding policy updated based on 2010 WHO rapid advice Infant feeding training/counseling for HIV+ mothers IYCF training materials include HIV and infant feeding IYCF counseling materials which include HIV and infant feeding are updated regularly Monitoring system on infant feeding practices among HIV+ mothers INFANT FEEDING IN EMERGENCIES Overall national standing on Infant feeding in emergencies Poor Selected key action areas National IYCF policy include IYCF in emergency National emergency preparedness plan includes IYCF in emergency National emergency preparedness plan updated based on the latest edition of IYCF in emergency Other selected key action areas Health workers and IYCF counsellors trained on IYCF in emergency Breast milk substitutes are provided during emergency Government procures/distribute breast milk substitutes Government accept donations of infant food IYCF MONITORING AND EVALUATION Summary of IYCF monitoring and evaluation score Overall IYCF monitoring and evaluation score Key action areas or components Poor Monitoring and evaluation for national IYCF Routine monitoring of ongoing IYCF Overall evaluation/review of IYCF situation Overall national level IYCF monitoring and evaluation appears to be poor and may require extensive attention. Additionally, more work is needed to strengthen the broader monitoring and evaluation system within the national legislation, community and health system levels as well as communication on IYCF and IYCF in exceptionally difficult circumstances. 95

102 Section 5: ANNEXES 96

103 ANNEX 1: Assessment Matrix Questionnaire 97

104 98

105 99

106 100

107 101

108 102

109 103

110 ANNEX 2: Completion of Assessment Matrix Region Version I Matrix Completed Version II Completed in Version II Matrix Completed Matrix Not Completed in WCAR Mauritania, Liberia, Cote Mali, Senegal, Gambia, Sierra Guinea (Conakry), Guinea d'ivoire, Burkina Faso, Leone, Congo Brazzaville, Gabon, Bissau, Chad, Cameroon, Ghana, Togo, Benin, D. Rep. Congo Equatorial Guinea, Central Nigeria, Niger, Congo African Rep. Brazzaville ROSA Sri Lanka, India, Nepal Afghanistan, Bhutan, Bangladesh Pakistan MENA North Sudan, South Sudan, Yemen ESAR Angola, Namibia, Botswana, South Lesotho, Comoros, Eritrea Africa, Malawi, Zambia, Zimbabwe, Mozambique, Madagascar, Tanzania, Burundi, Uganda, Kenya, Ethiopia, Somalia, Swaziland, Rwanda EAPR Thailand, Lao People's Dem. Rep., Cambodia, China, Korea, Indonesia, TimorLeste, Papua New Philippines, Vietnam, Malaysia Guinea, Fiji, Myanmar, Vanuatu, Mongolia CEE/CIS Bosnia and Herzegovina, Kazakhstan, Kosovo, Romania, Tajikistan, Turkmenistan, Uzbekistan Nutritionally vulnerable countries are shown in red Kyrgyzstan Albania, Armenia, Azerbaijan, Belarus, Croatia, Georgia, Moldova, Montenegro, Serbia, Turkey, Ukraine TOTALS Response rate Result WCAR ESAR ROSA EAPR CEE/CIS MENA TOTAL Number of countries (#received by countries matrix) Number of matrices Completed (Other Countries) na 43 Number of Matrices completed (Nutritionally vulnerable Countries) na 3 22 Total number of matrices completed (All countries) Response Rate for other countries (%) na 69.3 Response Rate for the Countries designated Nutritionally Vulnerable y (%) na Total Response Rate (%) Na= not applicable i.e. no country in the region fell in this category. 104

111 ANNEX 3: Key IYCF interventions and indicators Components and Interventions for a comprehensive IYCF strategy National action level Policy/Advocacy Development & enforcement of national legislation on the marketing of BMS Development & enforcement of national legislation on maternity protection Health system action level Development/updating of IYCF integrated curriculum for health provider preservice and inservice education Capacity development on IYCF for health providers/lactation counsellors Establishment of integrated IYCF counseling services in health facilities at relevant MCH contacts in primary health care services Development & implementation of supervision/quality assurance system for IYCF services in the health system Institutionalization of the Ten Steps to Successful Breastfeeding in all maternities (BFHI) Community action level Establishment of community based integrated IYCF counseling services at community level Capacity development of CHW and IYCF counseling services at community level Creation of mother support groups for IYCF in the community Communication Implementation of communication for behaviour and social change through multiple channels Additional Complementary feeding Components Improving the quality of complementary foods through locally available ingredients Provision of nutrition supplements and foods for complementary feeding (MNPs, LNS, fortified complementary foods) in foodinsecure populations Social protection schemes with nutrition component complementary feeding. (e.g. in kind complementary foods, vouchers, cash transfers) Indicators % of countries with national standalone IYCF policy, strategy and plan of action % of countries with all key IYCF elements in National IYCF Policy % of countries with existing ICMBS law or regulation % of countries with system of monitoring and enforcement of ICMBS law in place % of countries with maternity protection laws or regulations in place % of countries with paid maternity leave % of countries with paid nursing breaks provided for mothers after return to work % of countries with updated preservice and inservice curricula % of countries with all 3 elements of a comprehensive IYCF package in preservice curricula for health professionals % of countries with preservice and inservice training % of countries with IYCF job aids and counseling cards for health professionals % of countries with health workers trained in standalone IYCF counseling course % of countries with routine performance monitoring % of countries with IYCF counseling taking place in the health system % of countries with caregivers helped or trained in homepreparation of CF % of countries with routine monitoring on skills of HW % of countries with routine monitoring of quality of counseling %of countries with regular supportive supervision provided by managers % of countries with ever certified BF facilities % of countries with BF facilities recertified since 2006 % of countries with established communitybased activities in country % of countries with stand alone communitybased IYCF activities % of countries with CHW trained with a standalone IYCF counseling % of countries with specific capacity building on communication skills for HWs. % of countries with routine monitoring of community health worker skills % of countries with supportive supervision of CHW % of countries monitoring quality of counseling skills of CHW % of countries with recognition mechanism for wellperforming workers % of countries with mother support groups (or other groups) conducting sessions to promote IYCF % of countries with 8 multiple communication channels % of countries with communication at multiple channels ( national, health system, community levels ) % of countries with BCC materials available % of countries with national level communication Strategy % of countries with national coordination mechanism % of countries with IYCF communication elements in IYCF/national strategy % of countries with routine monitoring of IYCF communication activities % of countries providing micronutrient supplements for CF (624 months) % of countries providing local CF (unfortified) % of countries providing fortified local CF % of countries providing targeted food supplements % of countries providing industriallyblended CF (unfortified) % of countries with providing fortified industriallyblended CF % of countries with providing lipid based supplements % of countries with social protection program available with food security component 105

112 IYCF in difficult circumstances HIV and infant feeding IYCF in emergencies % of countries with IF and PMTCT addressed in IYCF national policy % of countries with complete, adequate training and counseling on IF and HIV % of countries with adequately trained HW on HIV and IF % of countries with followup and continuous support for HIV + mothers % of countries with IYCF policy whcich includes infant feeding in emergencies % of countries with complete, adequate training and counseling on infant feeding in emergencies % of countries with BMS provided during emergencies Monitoring and Evaluation Monitoring, review and evaluation % of countries with overall evaluation or review of IYCF situation in the country % of countries with monitoring of process indicators 106

113 ANNEX 4: Country Descriptions Region Country Date Completed Contact Person (S) Position(S)/Title(S) Organization Addresses CEE/CIS Kosovo 09/24/2010 Agron Gashi Health And Nutrition UNICEF Officer Tajikistan 11/15/2010 Mutrib Bakhruddinov Nutrition Officer UNICEF Bosnia And 10/18/2010 Selena Bajraktarevic Health Nutrition Ecd UNICEF Herzegovina Officer Uzbekistan 09/30/2010 Bakhodir Rahimov Nutrition Officer UNICEF Turkmenistan 09/30/2010 Shafag Rahimova Health And Nutrition UNICEF Org Specialist Romania 10/12/2010 Anemona Munteanu Health And Nutrition UNICEF Consultant Kyrgyzstan 03/15/2011 Damira Abakirova Health And Nutrition UNICEF Officer Kazakhstan 11/26/2009 Aigul Nurgabilova Nutrition Officer UNICEF EAPR Korea NA Sawasan Rawas Nutrition Specialist UNICEF Vanuatu 03/19/2010 Jennifer Timothy Nutrition And Ministry Of Health Dietetics Coordinator. Cambodia 03/16/2010 Multiple Na Na China 03/18/2010 Lilian Selenje And Chang Nutrition Specialist UNICEF Suying Indonesia 03/16/2010 Sonia Blaney Nutrition Manager UNICEF Mongolia 03/22/2010 Batjargal Jamiyan Director Of Nutrition Nutrition Research Research Center Center Of Public Health Institute Myanmar 03/18/2010 Dr. Kyaw Win Sein Nutrition Specialist UNICEF Papua New Guinea 03/18/2010 Lazarus Dawa And Clementine Yaman TimorLeste 03/09/2010 Dirce M. Soares/ Faraja Chiwile Nutrition Project Officer And Nutrition Officer Head Of Nutrition Department/ Nutrition Specialist Thailand 03/19/2010 Pornthida Padthong Communication Officer Department Of Health And UNICEF Ministry Of Health/UNICEF UNICEF Thailand Lazarus Dawa And 107

114 Region Country Date Completed Contact Person (S) Position(S)/Title(S) Organization Addresses ESAR Vietnam 03/01/2011 Roger Mathisen, Do Hong Phuong Nutrition Specialist / Health And Nutrition Policy Officer UNICEF [email protected], [email protected] Philippines 03/15/2011 Vicenta E. Borja Supervising Health Department Of [email protected] Program Officer Health Fiji 03/18/2010 Ms Jimaima Schultz Manager National Food And [email protected] Nutrition Centre, Ministry Of Health, Fiji Lao People's Democrati c Republic 03/19/2011 Dr Khamseng Philavong Senior Officer, MCH Center MOH [email protected] Madagasc 01/20/2011 Amal Bennaim Nutrition Specialist UNICEF [email protected] ar Burundi 01/20/2011 Hedy Ip Nutrition Specialist UNICEF [email protected] Zambia 01/31/2011 Ruth Siyandi Nutrition Officer UNICEF [email protected] Angola 01/02/2011 Vandana Agarwal Nutrition Specialist UNICEF [email protected] Somalia 02/03/2011 Erin McCloskey Nutrition Specialist UNICEF Somalia [email protected] IYCF & Micronutrients Mozambiq 03/01/2011 Maaike Arts Nutrition Specialist UNICEF [email protected] ue Botswana 02/04/2011 Patrick Codjia Nutrition Specialist UNICEF [email protected] Ethiopia 02/21/2011 Abebe Hailemariam Nutrition Specialist UNICEF [email protected] Tanzania 01/20/2011 Elizabeth Macha Ecd/Nutrition UNICEF [email protected] Specialist Rwanda 03/18/2010 Deborah Kortso Collison UNICEF Nutrition UNICEF [email protected] Officer South Africa 02/02/2011 Joan Majti Senior Nutrition And Child Survival Specialist UNICEF [email protected] Swaziland 06/06/2009 Makhosini Mamba Health Specialist UNICEF [email protected] Uganda 02/17/2011 Dr. Mbonye Andrew Commissioner Ministry Of Health [email protected], Community Health 108

115 Region Country Date Completed Contact Person (S) Position(S)/Title(S) Organization Addresses Namibia 01/28/2011 Steve Okokwu Health Specialist UNICEF Zimbabwe 03/22/2011 Fitsum Assefa Nutrition Manager UNICEF Malawi 04/14/2011 Benson M. Kazembe Micronutrient Officer UNICEF Benson M. Kazembe Kenya 05/06/2011 Linda Beyer Nutrition Specialist, UNICEF IYCN And HIV Mena Yemen 01/25/2011 Rajia Sharahan, Nagib Abdulbaqi Nutrition Officer UNICEF South 02/16/2011 Bertha Jackson Nutrition Specialist UNICEF Sudan North 03/08/2011 Mara Nyawo Nutrition Surveillance UNICEF Sudan Rosa Bangladesh 03/18/2010 Dr. Mohsin Ali Nutrition Specialist UNICEF India 03/03/2010 Dr. Kajali Paintal Nutrition Specialist UNICEF Nepal 03/17/2010 Pragya Mathema Nutrition Specialist UNICEF WCAR Sri Lanka 03/15/2010 Dr. (Ms) H. S. Jayawickrama Programme Manager, Child Health Family Health Bureau, Ministry Of Healthcare & Nutrition Afghanista 03/07/2011 Zakia Maroof Nutrition Officer UNICEF n Bhutan 04/01/2011 Chandralal Mongar And Ugyen Zangmo Health And Nutrition Officer And Nutrition Programme Officer Respectively UNICEF And Ministry Of Health Respectively And Congo 02/02/2011 Isabelle Mouyokani Nutrition Officer UNICEF Brazzaville Mauritania 02/04/2011 Mohamed Ag Nutrition Specialist UNICEF Bendech/ Ines Lezama C. African 02/04/2011 Benedict Mbeng Nutrition Consultant UNICEF Rep. Gambia 02/08/2011 Mathew Baldeh/Bakary Jallow EPI Specialist/Principal Programme Officer UNICEF/National Nutrition Agency (Nana) 109

116 Region Country Date Completed Contact Person (S) Position(S)/Title(S) Organization Addresses WCAR Senegal 02/03/2011 Acajou Doom Et Dr. Nutrition Specialist UNICEF/MOH Mama Madame Dionne Ghana 02/02/2011 Ernestina Agyepong Nutrition Specialist UNICEF Gabon 02/09/2011 Ayang Ebang Michel Nutritionist Centre National De Nutrition Togo 02/11/2011 Amina Bangana (En Collaboration Avec Le Service National De Nutrition/Ministère De La Santé) Nutritionist/Nutrition Officer UNICEF Benin 03/01/2011 AnneSophie Le Dain Nutrition Specialist UNICEF Niger 11/04/2009 Gwénola Desplats Nutrition Specialist UNICEF Sierra 02/20/2011 Rashid Abdulai Nutrition Officer UNICEF Leone D. Rep. Congo UNICEF And Pronanut 03/21/2011 Moïse Kabongo (Nutrition Officer), Simeon Nanama (Nutrition Manager), Kamanda Augustin (National Nutrition Program) Nutrition Officer, Nutrition Manager, Pronanut Rdc Mali 03/24/2011 Anne Marie Dembele Nutrition Officer UNICEF Nigeria 04/11/2011 Stanley Citekwe OIC Chief Of Nutrition UNICEF Burkina 04/21/2011 Fatoumata Lankoande Specialiste En Nutrition UNICEF Faso Liberia Na Na Na Na Na Cote d'ivoire Na Na Na Na Na 110

117 ANNEX 5a: IYCF Policy, Strategy and Plan of actions COUNTRY EBF Stand alone/not stand alone policy Initiati on BF Contin ued BF CF Initiatio n of CF BFHI 10 Steps Commu nity Actions ICMBS Matern al Nutritio n Mother Support Groups BCC HIV/ IF IYCF in Emerge ncies Strategy POA Policy, Strategy, POA SubScore CEE/CIS Bosnia and d Herz. Kosovo na na na na na na na na na na na na na na na Romania 0 na na na na na na na na na na na na na na Turkmenistan na na Uzbekistan Tajikistan d Kazakhstan d Kyrgyzstan d n M N % EAPR Cambodia China Fiji c Indonesia na na na na na na na na na na Korea na Lao D.Rep Mongolia c na na na na na na na na na Myanmar c P. New Guinea c na 0 na na na Philippines Thailand na TimorLeste c na na na na na na na na na na na na na na Vanuatu Vietnam c n M N % ESAR Angola d Botswana a Burundi c Ethiopia c na na na na na na na na na Kenya

118 COUNTRY Stand alone policy Initiat ion BF EBF Conti nued BF CF Initiati on of CF BFHI 10 Steps Comm unity Actions ICMB S Matern al Nutriti on Moth er Supp ort Grou ps BCC HIV/ IF IYCF in Emerge ncies Strategy POA Policy, Strategy, POA SubScore Madagascar c Malawi Mozambique na na na na na na na na na Namibia Rwanda c Somalia e South Africa Swaziland 0 na na na na na na na na na na na na na na Tanzania na na na na na na na na na Uganda Zambia 1,c Zimbabwe a n M N % MENA North Sudan c South Sudan f Yemen na na n M N % ROSA Afghanistan c Bangladesh Bhutan India c Nepal Sri Lanka c,d n M N % WCAR Gambia c Benin d

119 COUNTRY Stand alone policy Initiat ion BF EBF Conti nued BF CF Initiati on of CF BFHI 10 Steps Comm unity Actions ICMB S Matern al Nutriti Mothe r Suppor BCC HIV/ IF IYCF in Emerge ncies Strategy POA Policy, Strategy, POA SubScore on t Groups Burkina Faso c,d Cen.Afr.Rep. d Congo c Brazzaville Cote d'ivoire c na na 1 na na na 1 1 na na 5 D. Rep. Congo d Gabon d Ghana d Liberia c,d na na na na na na na na na na na na na na na na 1 Mali 1,c Mauritania c Niger c Nigeria Senegal Sierra Leone c Togo n M N % COUNTRY TOTAL n M N % na= no response/ data not available/ not applicable a= BEING DRAFTED, b= PLANNED, c= PART OF NUTRITION POLICY, d=part OF HEALTH POLICY, e=part OF THE NUTRITION STRATEGY, f= MENTIONED IN DRAFTED NUTRITION HEALTH POLICY; M=mean 1= Yes, 0=No Nutritionally vulnerable countries are highlighted in yellow 113

120 ANNEX 5b: IYCF Legislation and law Region COUNTRY CODE LAW CODE Monitoring & Enforcement Maternity Protection Law Maternity Leave Paid Nursing Breaks LEGISLATION SUBSCORE CEE/CIS Romania CEE/CIS Kazakhstan CEE/CIS Kyrgyzstan CEE/CIS Bosnia and Herz CEE/CIS Turkmenistan CEE/CIS Kosovo CEE/CIS Tajikistan CEE/CIS Uzbekistan a na n N M % EAPR P. N.Guinea EAPR Vietnam EAPR Philippines EAPR Mongolia EAPR Vanuatu EAPR Lao PDR EAPR China EAPR Cambodia 1 na EAPR Thailand EAPR Korea 0 na EAPR Myanmar 0 na EAPR Indonesia 0 na EAPR Fiji EAPR TimorLeste 0 na n M N % ESAR Zimbabwe ESAR Tanzania ESAR Botswana ESAR Zambia ESAR Uganda ESAR Mozambique ESAR Malawi ESAR Swaziland ESAR Madagascar 0 na ESAR Angola 0 na ESAR South Africa 0 na ESAR Kenya 0 na ESAR Ethiopia 0 na ESAR Burundi 0 na ESAR Namibia 0 na ESAR Somalia 0 na ESAR Rwanda 0 na n M N % MENA North Sudan 0 na MENA Yemen MENA South Sudan 0 na 0 na 0 0 n M N % ROSA Afghanistan ROSA India ROSA Sri Lanka ROSA Bhutan 0 na Region COUNTRY CODE CODE Monitoring & Maternity Protection Maternity Leave Paid Nursing LEGISLATION 114

121 law Enforcement Law Breaks SUBSCORE ROSA Bangladesh 1 na ROSA Nepal n M N % WCAR Ghana WCAR Nigeria WCAR Senegal WCAR Burkina Faso WCAR Gabon WCAR Mauritania WCAR Gambia WCAR Niger 0 na WCAR Togo 0 na WCAR Cen.Afr.Rep. 0 na WCAR Benin WCAR Sierra Leone 0 na WCAR Congo Brazzavill e 0 na WCAR Mali 0 na WCAR D. Rep. Congo WCAR Cote d'ivoire na na na na na NI WCAR Liberia na na na na na NI n M N % COUNTRY TOTAL n M N % na= no response, not available, not applicable. M= mean. NI= No Information. Nutritionally vulnerable countries are highlighted in yellow 115

122 ANNEX 5c: National level IYCF action score Region COUNTRY Policy, Strategy, Plan of actions SUBSCORE LEGISLATION SUBSCORE NATIONAL level actions SCORE CEE/CIS Bosnia and Herz CEE/CIS Kazakhstan CEE/CIS Kosovo CEE/CIS Kyrgyzstan CEE/CIS Romania CEE/CIS Tajikistan CEE/CIS Turkmenistan CEE/CIS Uzbekistan Mean EAPR Cambodia EAPR China EAPR Fiji EAPR Indonesia EAPR Korea EAPR Lao D. Rep EAPR Mongolia EAPR Myanmar EAPR P. New Guinea EAPR Philippines EAPR Thailand EAPR TimorLeste EAPR Vanuatu EAPR Vietnam Mean ESAR Angola ESAR Botswana ESAR Burundi ESAR Ethiopia ESAR Kenya ESAR Madagascar ESAR Malawi ESAR Mozambique ESAR Namibia ESAR Rwanda ESAR Somalia ESAR South Africa ESAR Swaziland ESAR Tanzania ESAR Uganda ESAR Zambia ESAR Zimbabwe Mean MENA North Sudan MENA South Sudan MENA Yemen Mean ROSA Afghanistan ROSA Bangladesh ROSA Bhutan ROSA India ROSA Nepal ROSA Sri Lanka Mean WCAR Togo WCAR Sierra Leone WCAR Senegal WCAR Nigeria WCAR Niger WCAR Mauritania WCAR Mali WCAR Liberia 1 NI 0 WCAR Ghana WCAR Gambia WCAR Gabon

123 Region COUNTRY Policy, Strategy, Plan of actions SUBSCORE LEGISLATION SUBSCORE NATIONAL level actions SCORE WCAR D. Rep. Congo WCAR Cote d'ivoire 5 NI 2 WCAR Congo Brazzaville WCAR Cen.Afr.Rep WCAR Burkina Faso WCAR Benin Mean Total Mean NI= No information.. Nutritionally vulnerable countries are highlighted in yellow 117

124 ANNEX 5d: IYCF health service pre and inservice training curricula COUNTRY IYCF ELEMENTS MEDICAL TRAINING PACKGE Baby Friendly Practice s Appropri ate BF Approp riate CF IYCF ELEMENTS NURSES/ OTHER HEALTH PROFESSIONALS TRAINING PACKAGE REFERENCES MEDICAL DOCTORS REFERENCES HEALTH PROFESSIONALS INSERVICE REFS. Baby Friendly Practice s nurses/ HP Approp riate BF nurses/ HP Approp riate CF nurses/ HP Global Strategy DOCS Revised BHI DOCS Guiding Principles Breastfed DOCS CEE/CIS Kosovo na na na na na na na na na na na na na na Romania na na na na na na na na na na na na na na na 1 Bosnia Herz Uzbekistan Kyrgyzstan Kazakhstan Turkmenistan Tajikistan n M N % EAPR Cambodia na na na na na na na na China na na na na na na na na Myanmar na na na na na na na na na na na na na na TimorLeste na na na na na na na na na na na na na na na na na na 0 Philippines na na na na na na na na na na na na na na Lao P.Dem. Rep na na na na Korea Indonesia na na na na na na na na 3 Thailand Vietnam Fiji P.N.Guinea Vanuatu na na na na 7 Mongolia n M N % ESAR Somalia na na na na na na na na na na na na 1 Mozambique na na na na na na na na 3 Botswana na na na na na na na na na na na na na na na 2 Guiding Principles for Feeding Non Breastfed DOCS Global Strategy (Nurses) Revised BHI (Nurses) Guiding Principles Breastfed (Nurses) Guiding Principles Non Breastfed (Nurses) Global Strate gy Inservic e Revise d BHI Inservic e Guiding Principl es BF Inservice Guiding Principles for Feeding NonBF Inservice CURRIC ULA SUBSCO RE 118

125 COUNTRY IYCF ELEMENTS MEDICAL TRAINING PACKGE Baby Friendly Practice s Appropri ate BF Approp riate CF IYCF ELEMENTS NURSES/ OTHER HEALTH PROFESSIONALS TRAINING PACKAGE REFERENCES MEDICAL DOCTORS REFERENCES HEALTH PROFESSIONALS INSERVICE REFS. Baby Friendly Practice s nurses/ HP Approp riate BF nurses/ HP Approp riate CF nurses/ HP Global Strategy DOCS Revised BHI DOCS Guiding Principles Breastfed DOCS Namibia na na na na na na na Malawi na na na na na na na na Madagascar South Africa Swaziland Burundi Angola na na na na 4 Kenya Zambia Tanzania Ethiopia Uganda Rwanda Zimbabwe n M N % MENA Yemen na na na na na na na na na na na South Sudan na na na na 3 North Sudan n M N % ROSA Bangladesh na na na na na na na na na na na na na na na na na na na India na na na na Nepal na na na na Afghanistan na na na na na na na na na na na na 1 Bhutan na na na na Sri Lanka n M N % WCAR Gambia na na na na na na na Niger na na na na na na na na na na na na 3 Sierra Leone na na na na na na na na Cote d'ivoire na na na na na na na na na na na na na na na 1 Liberia na na na na na na na na na na na na na na na 0 Congo Guiding Principles for Feeding Non Breastfed DOCS Global Strategy (Nurses) Revised BHI (Nurses) Guiding Principles Breastfed (Nurses) Guiding Principles Non Breastfed (Nurses) Global Strate gy Inservic e Revise d BHI Inservic e Guiding Principl es BF Inservice Guiding Principles for Feeding NonBF Inservice CURRIC ULA SUBSCO RE 119

126 COUNTRY IYCF ELEMENTS MEDICAL TRAINING PACKGE Baby Friendly Practice s Appropri ate BF Approp riate CF IYCF ELEMENTS NURSES/ OTHER HEALTH PROFESSIONALS TRAINING PACKAGE REFERENCES MEDICAL DOCTORS REFERENCES HEALTH PROFESSIONALS INSERVICE REFS. Baby Friendly Practice s nurses/ HP Approp riate BF nurses/ HP Approp riate CF nurses/ HP Global Strategy DOCS Revised BHI DOCS Guiding Principles Breastfed DOCS Brazzaville Gabon na na na na 3 Benin na na na na na na Ghana Senegal Mali Burkina Faso na na na na 6 C. Afr. Rep na na na na na na na na na na na 4 Togo Mauritania D.Rep.Congo Nigeria n M N % COUNTRY TOTAL n M N % Nutritionally vulnerable countries are highlighted in yellow Guiding Principles for Feeding Non Breastfed DOCS Global Strategy (Nurses) Revised BHI (Nurses) Guiding Principles Breastfed (Nurses) Guiding Principles Non Breastfed (Nurses) Global Strate gy Inservic e Revise d BHI Inservic e Guiding Principl es BF Inservice Guiding Principles for Feeding NonBF Inservice CURRIC ULA SUBSCO RE 120

127 ANNEX 5e: IYCF health workers capacity development PRE SERVICE TRAINING MEDICAL INISERVICE TRAINING HEALTH PROF. INSERVICE TRAINING IYCF job aids/counseling cards for health professionals IYCF Training 2006 HW trained stand alone counseling Capacity Development SubScore COUNTRY CEE/CIS Kosovo 0 na Romania na 3 Bosnia Herz na 2 Uzbekistan Kyrgyzstan Kazakhstan 1 na Turkmenistan Tajikistan n M N % EAPR Cambodia China 1 na Myanmar 0 na TimorLeste 0 na Philippines 0 na Lao P.Dem. Rep Korea 0 na na Indonesia 0 na na 2 Thailand 0 na Vietnam 0 na Fiji na 7 P.N.Guinea Vanuatu Mongolia n M N % ESAR Somalia 1 na Mozambique Botswana 0 na na 3 Namibia 0 1 na 1 0 na 3 Malawi Madagascar 0 na South Africa Swaziland 0 na Burundi na 3 Angola 1 1 O 1 0 na 5 Kenya Zambia Tanzania Ethiopia Uganda 1 na Rwanda Zimbabwe n M 121

128 PRE SERVICE TRAINING MEDICAL INISERVICE TRAINING HEALTH PROF. IYCF job aids/counseling cards for health professionals IYCF Training 2006 HW trained stand alone counseling Capacity Development SubScore INSERVICE COUNTRY TRAINING N % MENA Yemen South Sudan North Sudan n M N % ROSA Bangladesh India na 8 Nepal na 3 Afghanistan Bhutan Sri Lanka n N M % WCAR Gambia Niger na 7 Sierra Leone na 5 Cote d'ivoire 0 na na 2 Liberia 0 na 0 na 0 na 0 Congo Brazzaville 1 na na 3 Gabon 0 na na Benin Ghana Senegal na 7 Mali na 7 Burkina Faso C. Afr. Rep Togo Mauritania D.Rep.Congo Nigeria n M N % COUNTRY TOTAL n N M % N=NUMBER, n= Total, %=percentage, M= Mean, na=not available, not applicable, no answer, Nutritionally vulnerable countries are highlighted in yellow 122

129 ANNEX 5f: Training of health providers on IYCF counseling Country No of HPs trained on standalone IYCF counseling course since 2006 Total number of HPs in the Country % of HPs trained on IYCF counselling course since 2006 Total no of districts/province/region covered by the IYCF training Total number of district /province/region in the country Coverage (% of district / province / region covered by the training) Coverage of IYCF counseling currently taking place within the Health system (%) CEE/CIS Kosovo NI Tajikistan NI 30 BOSNIA AND NI NI NI NI HERZEGOVINA UZBEKISTAN Turkemnistan Romania NI NI NI NI KYRGYZSTAN KAZAKASTAN EAPR Korea , Vanuatu NI NI NI NI Mongolia 60 NI MYANMAR NI NI NI Indonesia < 5 Papua New Guinea 138 NI Cambodia 500 NI China NI NI NI 2800 Thailand 200 NI NI NI 95 TIMORLESTE 100 NI NI NI South Africa 600 NI VIETNAM Philippines 28,063 34, Fiji NI NI Lao People's Democratic Republic ESAR Madagascar 1800 NI Burundi Zambia 6207 NI Angola Somalia NI NI Mozambique 3700 NI Botswana NI NI NI NI 94 UGANDA NAMIBIA NI NI NI NI Tanzania SWAZILAND 300 NI RWANDA NI 30 NI

130 Country No of HPs trained on standalone IYCF counseling course since 2006 Total number of HPs in the Country % of HWs trained on IYCF counselling since 2006 Total no of districts/province/region covered by the IYCF training Total number of district/province/region in the country Coverage (% of district / province / region covered by the training) Coverage of IYCF counseling currently taking place within the Health system (%) Ethiopia Malawi NI Zimbabwe Kenya MENA YEMEN 105 NI North Sudan 500 NI South Sudan 0 NI NI NI NI ROSA BANGLADESH India NI 642 Nepal NI Sri Lanka ~ 80 AFGHANISTAN NI Bhutan WCAR Congo Brazzaville NI CAR Gambia 118 NI Ghana GABON 37 NI Togo BENIN NIGER NI Sierra Leone MAURITANIA Senegal NI NI NI NI 60 DRC MALI NI NI NI 60 Nigeria NI 774 Burkina Faso Cote d'ivoire NI NI NI NI Liberia NI NI NI NI Nutritionally vulnerable countries are highlighted in yellow, NI= No information

131 ANNEX 5g: IYCF Health System Counselling IYCF health service counselling Counseling in health system ANC PMTCT GMP IMCI ENA COUNSELLING SUBSCORE COUNTRY CEE/CIS Kosovo 1 na na na na na 2 Romania 0 na na na na na 0 Bosnia Herz Uzbekistan Kyrgyzstan Kazakhstan Turkmenistan Tajikistan n M N % EAPR Cambodia China Myanmar TimorLeste 1 na na na na na 2 Philippines Lao P.Dem. Rep Korea Indonesia Thailand Vietnam Fiji P.N.Guinea Vanuatu Mongolia n M N % ESAR Somalia 0 na na na na na 0 Mozambique Botswana Namibia Malawi Madagascar South Africa Swaziland Burundi Angola Kenya Zambia Tanzania Ethiopia Uganda Rwanda Zimbabwe

132 IYCF health service counselling COUNTRY Counseling in health system ANC PMTCT GMP IMCI ENA COUNSELLING SUBSCORE n M N % MENA Yemen South Sudan North Sudan n M N % ROSA Bangladesh India Nepal Afghanistan Bhutan Sri Lanka n M N % WCAR Gambia Niger Sierra Leone 0 na na na na na 0 Cote d'ivoire 1 1 na Liberia 0 0 Congo Brazzaville Gabon Benin Ghana Senegal Mali Burkina Faso C. Afr. Rep Togo Mauritania D.Rep.Congo Nigeria n N M % COUNTRY TOTAL n N M % n= number, N= Total, %=percentage Nutritionally vulnerable countries are highlighted in yellow, 1=Yes, 0= No 126

133 ANNEX 5h: BabyFriendly Hospital Initiative HSCOUNTRY CEE/CIS Ever Certified hospitals Ever recertified % of institutional Births % ever certified Baby Friendly Hospital % recertified Baby Friendly Hospital Uzbekistan Turkmenistan Tajikistan Romania Kyrgyzstan Kosovo Kazakhstan Bosnia and Herz n 8 5 BFHI SUB SCORE N 8 8 M M M % EAPR China NI 0 Cambodia Fiji Indonesia Korea 1 0 NI NI 0 Lao PDR Mongolia NI 0 Myanmar 1 0 NI NI 0 Papua New Guinea Philippines Thailand Timor Leste 1 0 NI NI 0 Vanuatu Vietnam n 13 4 N M M M % ESAR Zimbabwe Zambia Uganda

134 HSCOUNTRY Ever Certified hospitals Ever recertified % of institutional Births % ever certified Baby Friendly Hospital % recertified Baby Friendly Hospital BFHI SUB SCORE Tanzania Swaziland South Africa Somalia Rwanda Namibia Mozambique Malawi Madagascar Kenya NI Ethiopia Burundi Botswana Angola n 14 6 N M M M % MENA Yemen South Sudan 0 0 NI North Sudan n 1 1 N 3 3 M M M % ROSA India Sri Lanka Nepal Bhutan Bangladesh Afghanistan n 5 0 N 6 6 M M M % WCAR Benin

135 HSCOUNTRY Ever Certified hospitals Ever recertified % of institutional Births % ever certified Baby Friendly Hospital % recertified Baby Friendly Hospital Burkina Faso 1 0 NI C. Afr. Rep Congo Brazzaville Cote d'ivoire 1 0 NI D. Rep. Congo Gabon 1 0 NI NI 0 Gambia 0 0 NI Ghana Liberia 0 0 NI Mali 1 1 NI Mauritania Niger Nigeria Senegal Sierra Leone Togo n 14 5 BFHI SUB SCORE N M M M % ALL Countries n M M M N % N= number, N= Total, %= percent, na=data not available/no answer, not applicable; NI= No information. Nutritionally vulnerable countries are highlighted in yellow 129

136 ANNEX 5i: Health system level IYCF actions score COUNTRY CEE/CIS BFHI SUB SCORE CIRRICULA SUB SCORE CAPACITY DEVELOPMENT SUBSCORE COUNSELLING SUBSCORE HEALTH SYSTEM ACTIONS SCORE Uzbekistan Turkmenistan Tajikistan Romania Kyrgyzstan Kosovo Kazakhstan Bosnia Herz MEAN EAPR China 0 Cambodia 1 Fiji 8 Indonesia 0 Korea 0 Lao P.Dem. Rep. 2 Mongolia 0 Myanmar 0 P.N.Guinea 1 Philippines 4 Thailand 4 TimorLeste 0 Vanuatu 0 Vietnam 0 MEAN ESAR Zimbabwe Zambia Uganda Tanzania Swaziland South Africa Somalia Rwanda Namibia Mozambique Malawi

137 BFHI SUB COUNTRY SCORE Madagascar 0 Kenya 0 Ethiopia 0 Burundi 0 Botswana 0 Angola 0 MEAN 0 CIRRICULA SUB SCORE CAPACITY DEVELOPMENT SUBSCORE COUNSELLING SUBSCORE HEALTH SYSTEM ACTIONS SCORE MENA Yemen 0 South Sudan 0 North Sudan 1 MEAN ROSA India 0 Sri Lanka 1 Nepal 0 Bhutan 0 Bangladesh 2 Afghanistan 0 MEAN na WCAR Benin Burkina Faso C. Afr. Rep Congo Brazzaville Cote d'ivoire D.Rep.Congo Gabon Gambia Ghana Liberia 0 0 na na na Mali Mauritania Niger Nigeria Senegal Sierra Leone Togo MEAN Total Mean Nutritionally vulnerable countries are highlighted in yellow 131

138 ANNEX 5j: Communitybased IYCF actions Country COMMUNITYBASED PROGRAMMES WHICH INCLUDE IYCF ACTIVITIES / IMPLEMENTATION Communitylevel CD Communitylevel M &E Commun Moth COMM. Train Capa. COMM. Routine Routine Routine Supportiv Recogn M&E itybased Multi ers SYSTEM ing buildin CD monitorin monitori monitori e ition SUBS Com Activi Dedica Mother TBA supp INTEGRAT on g on SUBSC g of IYCF ng of ng of supervisio mecha CORE System m. ty PMT ted purp ANC GMP IMCI ENA to or ort ION SUB IYCF comm. ORE activities skills of quality n CHW nism actions Activ stand CT IYCF ose Mother THP grou SCORE 2006 skills CHW of Score ity alone CHWs CHW ps for counseli s CHW ng CEE/CIS Bosnia and Herz Kazakhstan Kosovo 1 na na na na na na na na na na na 1 0 na 0 na na na na na 0 0 Kyrgyzstan Romania 0 na na na na na na na na na na na 0 na na 0 0 na na na na 0 0 Tajikistan na 0 3 Turkmenista n na na na 5 na na na na na 0 2 Uzbekistan 0 0 na na na na na na na na 0 na na na na na 0 0 n M 2 3 M M M N % EAPR Vietnam na na na na 1 na 2 5 Vanuatu 1 1 na na na na na na na na na TimorLeste na Thailand na na na na na na na na na na na na 0 na na 0 na na na na na 0 0 Philippines 1 na na na na na na 2 3 P. N. Guinea na 0 4 Myanmar 0 na na na na na na na na na na na 0 0 na 0 0 na na na na 0 0 Mongolia 0 na na na na na na na na na 0 0 Lao P. D. Rep na 5 na na na na na 0 3 Korea na na na na na na na na 1 na na na 1 1 na 5 na na na na na 0 2 Indonesia 1 0 na na na na na na na na na na 1 na na 0 na na na na na 0 0 Fiji na China 1 1 na na na na na na na 0 4 Cambodia 1 0 na na na na na na n M 8 4 M M M N % ESAR Zimbabwe Zambia DK na na na 0 3 Uganda Tanzania na 0 4 Swaziland South Africa 1 0 na na na na na na na na 4 3 Somalia na 4 5 Rwanda Namibia

139 Country COMMUNITYBASED PROGRAMMES WHICH INCLUDE IYCF ACTIVITIES Communitybased CD Communitybased M &E Com Activit PMTCT ANC GMP IMCI ENA Mother IYCF Multi TBA Moth COMM. Train Capa. COMM. Routine Routin Routine Supporti m. y to CHWs or ers SYSTEM ing buildin CD monitori e monitoring ve Activi standal Mother purp TH supp INTEGR on g on SUBSC ng of monito of quality of supervis ty one ose P ort ATION IYCF comm. ORE IYCF ring of counseling ion CHW CHW grou SUB 2006 skills activities skills s ps SCORE for of CHW CHW Recognit ion mechani sm M&E SUBS CORE Commu nitybased System actions Score ESAR Mozambiq ue na na na na na na Malawi na na na na 0 3 Madagasca r 1 1 na na na na na na na 8 5 Kenya Ethiopia na 0 2 Burundi na 0 1 Botswana 0 0 na na na na na na na 0 na na na na na 0 1 Angola 0 0 na na na na na na n M 13 5 M M M N % MENA Yemen 1 0 na na na na na na South Sudan 1 0 na na na na na na na na 0 na na na na na 0 2 North Sudan n M 2 0 M M M N % ROSA Afghanista n na na na na na na 0 0 na 5 Banglades h 1 3 Bhutan 0 na na na na na na na na na na na India na 0 1 Nepal Sri Lanka na 2 5 n M 1 3 M N M M % WCAR Benin na 0 4 Burkina Faso na 4 4 C. Afr. Rep Congo Brazzaville Cote D'Ivoire 1 na na na na na na na na 6 7 Dem. Rep. Congo Gabon 1 na na na na na na na na na na na 0 na na na na na 0 1 Gambia na na na na 0 4 Ghana na 2 na na 0 na na na na na

140 COMMUNITYBASED PROGRAMMES WHICH INCLUDE IYCF ACTIVITIES Communitybased CD Communitybased M &E Country Com m. Activ ity Activi ty stand alone PMTCT ANC GMP IMCI ENA Mother to Mother IYCF CHW s Multipurpos e CHWs TBA or THP Moth ers supp ort grou ps COMM. SYSTEM INTEGR ATION SUB SCORE Traini ng on IYCF 2006 Capa. buildin g on comm. skills for CHW COM M. CD SUBS CORE Routine monitori ng of IYCF activities Routine monitori ng of skills of CHW Routine monitorin g of quality of counselin g Suppor tive superv ision CHW Reco gnitio n mech anis m M&E SUBSC ORE Communitybased actions Score Liberia 1 na na na na na na na na 6 6 Mali na 0 na na na na na 0 1 Mauritania 1 0 na na na na na na na 6 6 Niger Nigeria Senegal na NA 6 7 Sierra Leone 1 0 na na na na na na Togo na 8 7 n N M M M M % COUNTRY TOTAL n M M M M N % na= not applicable/ no answer/no data available, M=Mean, 1= yes, 0=no. Nutritionally vulnerable countries highlighted in yellow 134

141 ANNEX 5k: Capacity development and coverage of community based IYCF actions COUNTRY Training of community health workers on communitybased IYCF IYCF Communitybased activity coverage CEE/CIS No of IYCF CHWs trained on communitybased IYCF since 2006 No of Community health workers trained in IYCF as part of another health course Total number of community health workers in the country % CHW trained on Communitybased IYCF since 2006 % CHW trained in IYCF as part of another health course Total number of districts/region/municipalities implementing CHW programmes with IYCF included Total number of districts/regions/m unicipalities etc... in the country Coverage (% of district implementing CHW programmes including IYCF) Kosovo NI NI NI NI Proportion of the population living in target districts Tajikistan NI NI CHILDREN BOSNIA AND HERZEGOVINA NI NI 620 NI NI NI UZBEKISTAN NI NI NI NI NI NI Turkemnistan NI NI NI Romania NI NI 400 NI NI NI KYRGYZSTAN NI NI KAZAKASTAN NI NI 0 NI NI NI EAPR VIETNAM NI 10,000 10, NI Vanuatu NI NI NI Cambodia 1200 NI NI China 300 NI NI NI 2800 NI Mongolia NI NI 0 NI NI NI MYANMAR NI NI NI NI NI NI Papua New Guinea NI 20 30% TIMORLESTE NI NI NI NI Thailand NI NI NI NI NI NI VIETNAM TOO NI NI NI Philippines NI NI NI NI Fiji NI NI NI NI Indonesia < 1 < < 5 Korea NI NI NI NI Lao People's Democratic Republic ESAR NI NI NI Madagascar 6000 NI NI 5555 NI 33 Burundi NI NI NI Zambia NI NI NI NI Angola % Somalia NI NI NI 20 NI NI NI Mozambique 0 NI NI Botswana NI NI NI % Ethiopia 55,800 50, ,500,000 Tanzania % RWANDA

142 COUNTRY Training of community health workers on communitybased IYCF IYCF Communitybased activity coverage No of IYCF CHWs trained on communitybased IYCF since 2006 No of Community health workers trained in IYCF as part of another health course Total number of community health workers in the country % CHW trained on Communitybased IYCF since 2006 % CHW trained in IYCF as part of another health course Total number of districts/region/municipalities implementing CHW programmes with IYCF included Total number of districts/regions/m unicipalities etc... in the country Coverage (% of district implementing CHW programmes including IYCF) Proportion of the population living in target districts South Africa 1165 NI NI UGANDA NI NI 90, NI NAMIBIA NI NI NI % SWAZILAND % Zimbabwe NI NI NI % Malawi 400 NI % Kenya 4000 NI % MENA YEMEN NI NI 0 NI 334 NI South Sudan NI NI NI NI NI NI North Sudan NI NI NI NI ROSA India NI % Nepal NI NI NI Sri Lanka NI NI NI AFGHANISTAN NI NI NI NI NI Bhutan NI NI 1200 NI NI NI BANGLADESH 4500 NI % WCAR Congo Brazzaville NI MAURITANIA NI 3800 NI % CAR NI % Gambia 400 NI NI % Senegal NI NI Ghana ,000 16, NI GABON NI NI NI NI NI NI Togo % BENIN NI 7190 NI % NIGER 1898 NI % Sierra Leone NI 2205 NI % DRC NI NI % MALI NI NI NI NI Nigeria NI 95 40, % Burkina Faso 700 NI % Liberia 0 NI NI NI NI NI Cote D'Ivoire NI NI NI 6 NI 35% "" Dash= Value could not be calculated because there was no information provided, NI= No information. Nutritionally vulnerable countries are highlighted in yellow 136

143 ANNEX 5l: IYCF community activity implementer Other groups conducting IYCF communitybased actions Region/ Country Groups CEE/CIS Kosovo Volunteers of Red Cross of Kosovo are providing counseling/promotion to parents about breastfeeding and child nutrition MENA Yemen Through CBPHC volunteers EAPR TimorLeste There are no CHW in TimorLeste but there are volunteers (Mother Support Group members) who conducts and have been trained on counseling ESAR South Africa the mothers to mothers programme provides this support to a limited extent EAPR China provided by all sorts of groups including local government and also companies in the cities WCAR Mali PMTCT, Mother to Mother and IMCI WCAR Cote d Ivoire PEV CPN WCAR Niger not at national scale ROSA Afghanistan NGOs who implement CMAM ESAR Angola National catholic church train the activist for counseling of mothers on IYCF CEE/CIS Bosnia And IBFAN Local branch Herzegovina WCAR Car health workers ESAR Madagascar growth monitoring ESAR Uganda Diverse community groups, small scale projects ROSA India Community volunteers called (ASHA) WCAR Nigeria Community Resource Persons, provide individual counseling and support to mothers on KHHP including IYCF WCAR Mauritania Community nutrition centers, BCC community agents, supplementary feeding centers for MAM ESAR Kenya Community health strategy, mother to mother support groups and workplace support initiative with private sector (better business practices for children). EAPR Fiji Community Health Nurses and Dieticians WCAR Ghana community based volunteers 137

144 ANNEX 5m: Communication on IYCF IYCF communication channels COUNTR Y CEE/CIS Nation al radio Nation al TV Nation al Campa ign Poster s BCC Channels BCC Health System Mass media BCC Community BCC Interp ersona l Comm unicati on Mobile Phone Messa ges Other Chann els Religio us Leader s Comm unity Leader s BCC HS Uzbekistan na na na na 6 Turkmenista n Tajikistan na 0 na na 0 na na 3 Romania Kyrgyzstan na na na 1 na 5 Kosovo na 1 na 5 Kazakhstan Bosnia Herz na na na na 5 n N % EAPR Poster s and leaflet s Vietnam na na na na na na na 5 Vanuatu Timor Leste na Thailand Philippines P.N.Guinea Myanmar Mongolia Lao PDR Korea Indonesia na na na na na Fiji na China na Cambodia n N M % ESAR Zimbabwe na na na 3 Zambia Uganda Videos on IYCF HW grp. IYCF sessio ns Mass media Mass media WBF week. Mass media freque ntly/o n an ongoin g Nation al Campa igns Ongoi ng comm unity BCC CHWs conduc t group sessio ns Mothe r suppor t groups /other groups TBAs or traditi onal health practiti oners CHAN NELS SUBSC ORE 138

145 IYCF communication channels Nation al radio Nation al Campa ign BCC Channels BCC Health System Mass media BCC Community BCC Interp ersona l Comm unicati on Mobile Phone Messa ges Other Chann els Religio us Leader s Comm unity Leader s Poster s and leaflet s COUNTR Nation Poster BCC Mass Y al TV s HS media Tanzania Swaziland South Africa Somalia Rwanda Namibia na na na na na na 0 na na Mozambique Malawi na na 6 Madagascar na Kenya na 8 Ethiopia na na na na 3 Burundi Botswana na Angola n N M % MENA Yemen South Sudan North Sudan n N M % ROSA Sri Lanka Nepal India Bhutan na 7 Bangladesh Afghanistan n N M % WCAR Togo Sierra Leone Videos on IYCF HW grp. IYCF sessio ns 0 Mass media WBF week. Mass media freque ntly/o n an ongoin g Nation al Campa igns Ongoi ng comm unity BCC CHWs conduc t group sessio ns Mothe r suppor t groups /other groups TBAs or traditi onal health practiti oners CHAN NELS SUBSC ORE 5 139

146 IYCF communication channels Nation al radio Nation al Campa ign BCC Channels BCC Health System Mass media BCC Community BCC Interp ersona l Comm unicati on Mobile Phone Messa ges Other Chann els Religio us Leader s Comm unity Leader s Poster s and leaflet s COUNTR Nation Poster BCC Mass Y al TV s HS media Senegal Nigeria Niger Mauritania Mali Liberia na na na na na na na na na 0 na na na na na na 1 Ghana Gabon Dem. Rep na na na na na na na na na na na na Congo 2 Cote D'Ivoire na na na na na na 0 na na Congo B C. Afr. Rep na na na na na na 0 na na 1 1 na na Burkina Faso Benin Gambia na n N M % Videos on IYCF HW grp. IYCF sessio ns Mass media WBF week. Mass media freque ntly/o n an ongoin g Nation al Campa igns Ongoi ng comm unity BCC CHWs conduc t group sessio ns Mothe r suppor t groups /other groups TBAs or traditi onal health practiti oners CHAN NELS SUBSC ORE Country Totals n N M % M=Mean, n=number, N=total, %= percent, na= not applicable, data not available, no response; Nutritionally vulnerable countries are highlighted in yellow 140

147 ANNEX 5n: Communication on IYCF: Strategy, materials and monitoring/evaluation National BCC, M and E and BCC materials NATIONAL communication on IYCF* Behaviour change and communication M & E Behaviour change and communication materials Comm. Strate gy on IYCF WB W Healt h Days National Campaig ns Comm. Strat. on IYCF in Natl IYCF / Nutri strate gy Cord. Mechanism implementi ng agency NATION AL BCC SUBSCO RE Monitoring IYCF comm.activit ies Monitori ng people reached media message s Monitori ng quality grp sessions BCC MONTORI NG COMMS SUBSCORE COUNTRY other CEE/CIS Bosnia Herz Kazakhstan na 7 Kosovo na na na 5 Kyrgyzstan na na 8 Romania na na na 5 Tajikistan na 3 Turkmenist an na 5 Uzbekistan na na na 3 n N M M M % EAPR Vietnam na na na na 7 Cambodia na 8 China na 5 Fiji 0 na na na na 5 Indonesia 0 na na na na 5 Korea na 3 Lao PDR na na na 8 Mongolia 0 na na na na 7 Myanmar na 5 P.N.Guinea na na na 8 Philippines na na 0 1 na na na na 1 3 Thailand na 5 Timor Leste 0 na na na na 1 2 na na na na na na 2 Vanuatu na 7 n N M M M % BCC materia ls BF Poste rs / leafle ts CF Poster s /leafle ts Flipchar ts for group sessions Participato ry materials BCC Materia ls SUBSco re 141

148 National BCC, M and E and BCC materials NATIONAL communication on IYCF* Behaviour change and communication M & E Behaviour change and communication materials Comm. Strate gy on IYCF WB W Healt h Days National Campaig ns Comm. Strat. on IYCF in Natl IYCF / Nutri strate gy Cord. Mechanism implementi ng agency NATION AL BCC SUBSCO RE Monitoring IYCF comm.activit ies Monitori ng people reached media message s Monitori ng quality grp sessions BCC MONTORI NG COMMS SUBSCORE COUNTRY other ESAR Zimbabwe 0 na na na na na 3 0 na na na na na 0 Zambia 0 na na na na 7 Uganda 0 na na na na na Tanzania na 8 Swaziland na 3 South 0 na na na na Africa Somalia 0 na na na na na na 7 Rwanda 0 na na na na 8 Namibia na 8 Mozambiq ue na 3 Malawi na na 5 Madagasca r na 5 Kenya na 7 Ethiopia na na 1 na na na na 1 3 Burundi 0 na na na Botswana 0 na na na na na na na na 0 Angola 0 na na na na n N M M M % MENA Yemen na na 7 South Sudan 0 na na na na 7 North Sudan na na na na 5 n N M M M % ROSA Sri Lanka Nepal 0 na na na na na 7 India na 5 Bhutan 0 na na na na 5 BCC materia ls BF Poste rs / leafle ts CF Poster s /leafle ts Flipchar ts for group sessions Participato ry materials BCC Materia ls SUBSco re 142

149 National BCC, M and E and BCC materials NATIONAL communication on IYCF* Behaviour change and communication M & E Behaviour change and communication materials Comm. Strat. on IYCF in Natl IYCF / Nutri strate gy Monitori ng people reached media message COUNTRY Comm. Strate gy on IYCF WB W Healt h Days National Campaig ns Cord. Mechanism implementi ng agency NATION AL BCC SUBSCO RE Monitoring IYCF comm.activit ies s Monitori ng quality grp sessions BCC MONTORI NG COMMS SUBSCORE BCC materia ls BF Poste rs / leafle ts CF Poster s /leafle ts Flipchar ts for group sessions Participato ry materials other Bangladesh na 7 Afghanista 0 na na na na na n n N M M M % WCAR Togo na na 8 Sierra Leone 0 na na na na 8 Senegal na 8 Nigeria na 8 Niger Mauritania na 7 Mali na 3 Liberia na na na na na na 0 0 na na na 7 Ghana Gabon 0 na na na na na 0 na na na na na na 0 D. Rep. Congo 0 na na na na na na 5 Cote'd'Ivoire na na na na na na 0 0 na na na 7 Congo Brazzaville na 3 C.Afr. Rep na na na na na 0 Burkina Faso na 8 Benin na 3 Gambia na na na na 5 n N M M M % Country Totals n N M % na= not available/not applicable/ no response M= Mean, 1=Yes, 2=No, Nutritionally vulnerable countries are highlighted in yellow *36 countries with 5 or more communication on IYCF channels and 4 countries with 8 communications on IYCF channels BCC Materia ls SUBSco re 143

150 ANNEX 5o: Communication on IYCF actions score COUNTRY CEE/CIS BCC MONTORING COMMS SUBSCORE CHANNELS SUBSCORE NATIONAL BCC SUBSCORE BCC Materials SUBSCORE Communication on IYCF actions SCORE Uzbekistan Turkmenistan Tajikistan Romania Kyrgyzstan Kosovo Kazakhstan Bosnia Herz Mean EAPR Vietnam Vanuatu TimorLeste Thailand Philippines P. N.Guinea Myanmar Mongolia Lao PDR Korea Indonesia Fiji China Cambodia Mean

151 COUNTRY ESAR BCC MONTORING COMMS SUBSCORE CHANNELS SUBSCORE NATIONAL BCC SUBSCORE BCC Materials SUBSCORE Communication on IYCF actions SCORE Zimbabwe Zambia Uganda Tanzania Swaziland South Africa Somalia Rwanda Namibia Mozambique Malawi Madagascar Kenya Ethiopia Burundi Botswana Angola Mean MENA Yemen South Sudan North Sudan Mean ROSA Sri Lanka Nepal India Bhutan

152 COUNTRY BCC MONTORING COMMS SUBSCORE CHANNELS SUBSCORE NATIONAL BCC SUBSCORE BCC Materials SUBSCORE Communication on IYCF actions SCORE Bangladesh Afghanistan Mean WCAR Togo Sierra Leone Senegal Nigeria Niger Mauritania Mali Liberia Ghana Gabon D. Rep. Congo Cote D'Ivoire Congo Brazzaville Cen. Afr. Rep Burkina Faso Benin Gambia Mean TOTAL Mean Nutritionally vulnerable countries highlighted in yellow 146

153 ANNEX 5p: Complementary feeding components / intervention COUNTRY Micron utrient supple ments ( single/ multi) Single micron utrient Multimicro nutrie nt In emerg ency nonemerg ency Targete d food supplem ents Local CFs ( unfortif ied) Industr ially blende d CFs unfortifie d Fortif ied local CFs Fortifie d industri allyblende d CFs Lipi d bas ed CEE/CIS Bosnia Herz na Kazakhstan na na na na na Kosovo na na na na na Kyrgyzstan Romania na na na na na Tajikistan 0 na na na na 0 na na na na na Turkmenistan Uzbekistan na na na na na n M M M N % EAPR Cambodia China Fiji 0 na na na na Indonesia Korea na 1 na na Lao People's Democratic Republic na na na na na Mongolia Myanmar 0 na na na na Papua New Guinea 0 na na na na 0 na na na na na Philippines na 1 na na Thailand na na na na na TimorLest 0 na na na na na Vanuatu na na na na na Vietnam na n M M N % ESAR Angola 0 na na na na na na na na Botswana 0 na na na na Burundi na na na na na Ethiopia 0 na na na na 0 na na na na na na Kenya na Madagascar 1 na na Malawi na Mozambique na Namibia na 1 na na Rwanda 0 na na na na 0 na na na na na Somalia na na na na na na South Africa Swaziland Tanzania Social protec tion progra m Prov. of CF suppl. Sub score Caregi vers couns elled in home prep. of CF Co oki ng Cla sse s Food prep arati on demo nstra tions on TV Food preparatio n demonstr ations on radio Local food events Publis hed recipe guides for mother s Couns eling cards on food prepar ation ( for health system ) Couns eling cards on food prepar ation ( for comm unity) CF coun selin g sub score CF Score 147

154 COUNTRY Micron utrient supple ments ( single/ multi) Single micron utrient Multimicro nutrie nt In emerg ency nonemerg ency Targete d food supplem ents Local CFs ( unfortif ied) Industr ially blende d CFs unfortifie d Fortif ied local CFs Fortifie d industri allyblende d CFs Lipi d bas ed Uganda na na na na na Zambia na na na na na Zimbabwe 0 na na na na na na na n M M M N % MENA North Sudan South Sudan 0 na na na na Yemen na na n M M M N % ROSA Afghanistan na na na na na Bangladesh Bhutan India na 1 na Nepal Sri Lanka n M M M N % ## Social protec tion progra m Pro v. of CF sup pl. Sub sco re Care giver s coun selle d in home prep. of CF Cookin g Classes Food prep arati on demo nstra tions on TV Food preparatio n demonstr ations on radio Local food events Publis hed recipe guides for mother s Counse ling cards on food prepara tion ( for health system ) Counse ling cards on food prepara tion ( for commu nity) CF couns eling sub score CF Score WCAR Benin na na na na na Burkina Faso C. Afr. Rep na na na na na na Congo Brazzaville na na na na na na Cote d'ivoire na 1 1 na na na DR. Congo 0 na na na na 0 na na na na na Gabon na na na na na Gambia na na na na na na Ghana na na Liberia na na na na Mali 0 na na na na 1 na Mauritania Niger Nigeria Senegal na Sierra Leone 0 na na na na Togo na na n M M M N % Country Total n M M M N % M=Mean, n=number, N=Total, %=percent, na=data not available, Nutritionally vulnerable countries highlighted in yellow 148

155 IF and HIV policy IF & HIV in national IYCF policy IF & HIV in PMTCT IF policy updated based on WHO2010 guideline IF training/counselin g for HIV + mothers HIV & IF in IYCF materials Job aids on HIV & IF Job aids updated HW trained on IF & HIV? HW trained on HIV & IF counseling IF counseling integrated in PMTCT HIV+ mothers support on IF Free infant formula to HIV +mothers Infant Formula provided by Government Infant formula provided by NGOs Monitoring system on IF practices among HIV+ mothers ANNEX 5q: IYCF in difficult circumstances IYCF in difficult circumstances (HIV and infant feeding) Country CEE/CIS POLICY TRAINING/ COUNSELLING BMS IF & HIV IYCF mater ials updat ed IF in PMTC T mater ials PMT CT mat erial s upd ated Uzbekistan Romania 0 na na Kosovo 0 na na na na na na 4 Kazakhstan na na 1 1 na na na 1 na na 0 na na 0 2 Bosnia & Herz. 0 na na na 1 na na na na na na 1 na na na Turkmenist an 1 na na 8 Tajikistan na Kyrgyzstan na na HIV and IF SCORE Number Total Percent M=6 EAPR Vietnam na Philippines na na China na Thailand na na 1 1 na na na Vanuatu na 1 na na na 0 7 Indonesia na na 0 na 0 na na na 0 2 Myanmar na na Korea 0 na na na 0 na na 0 na na na na 0 na na P. N. Guinea na Lao PDR na na 1 8 Mongolia na na 0 na 0 na na na 0 3 Fiji Timor Leste 0 na na 1 1 na 1 1 na na na 0 3 Cambodia na na

156 IF and HIV policy IF & HIV in national IYCF policy IF & HIV in PMTCT IF policy updated based on WHO2010 guideline IF training/counselin g for HIV + mothers HIV & IF in IYCF materials Job aids on HIV & IF Job aids updated HW trained on IF & HIV? HW trained on HIV & IF counseling IF counseling integrated in PMTCT HIV+ mothers support on IF Free infant formula to HIV +mothers Infant Formula provided by Government Infant formula provided by NGOs Monitoring system on IF practices among HIV+ mothers IYCF in difficult circumstances (HIV and infant feeding) POLICY TRAINING/ COUNSELLING BMS IF & PMT HIV CT IYCF IF in mat mater PMTC erial ials T s updat mater upd Country ed ials ated Number Total Percent ESAR 7 Rwanda Zimbabwe Mozambiq ue na na Zambia 1 na Malawi na na na na na na 6 Swaziland Namibia na 0 na 1 na South Africa na na Kenya na na 0 6 Ethiopia na na 0 5 Botswana 0 na na na 1 0 na na na na 0 3 Madagasca r na 1 1 na 1 1 na 0 na na 1 7 Burundi na na na na na 0 3 Angola na na na na na 0 3 Uganda na na 1 8 Tanzania na na 0 8 Somalia na na na 0 7 Number Total Percent M=7 MENA Yemen 0 na na na na na na 1 0 na na na na 0 3 S. Sudan na na 0 na 0 na na N. Sudan na na na na 0 na na na na 0 3 Number na na na na Total na na na na Percent na na na na M=3 ROSA Afghanista 0 na na na na n Banglades na na HIV and IF SCORE 150

157 IF and HIV policy IF & HIV in national IYCF policy IF & HIV in PMTCT IF policy updated based on WHO2010 guideline IF training/counselin g for HIV + mothers HIV & IF in IYCF materials Job aids on HIV & IF Job aids updated HW trained on IF & HIV? HW trained on HIV & IF counseling IF counseling integrated in PMTCT HIV+ mothers support on IF Free infant formula to HIV +mothers Infant Formula provided by Government Infant formula provided by NGOs Monitoring system on IF practices among HIV+ mothers IYCF in difficult circumstances (HIV and infant feeding) POLICY TRAINING/ COUNSELLING BMS IF & HIV IYCF mater ials updat ed IF in PMTC T mater ials PMT CT mat erial s upd ated Country h Bhutan India 0 na na na 1 0 na na na na 0 3 Nepal na na na 0 0 na 1 na na na 0 3 Sri Lanka na na 0 na 0 na na na 1 3 Number Total Percent WCAR Benin B. Faso na na 1 8 CAR Congo B na 9 Cote na na 8 D'Ivoire DRC 0 na na na 0 7 Gabon 1 1 na na na 6 Gambia na na 1 8 Ghana Liberia 0 na na na na na na 4 Mali na na Mauritania na na na na 0 5 Niger na 1 na 0 na na 0 na na 1 6 Nigeria na 1 na na na Senegal na na na na 4 S. Leone na na na 0 na na na na 0 na 0 4 Togo na na na na na na na na na na na na na 1 3 Number Total Percent ALL Number Total Percent M=6 na= no response /not applicable, 1=Yes, 0= No; Nutritionally vulnerable countries highlighted in yellow HIV and IF SCORE M=4 M=6 151

158 National IYCF policy includes IYCF in Emerg. National Emerg.preparedness plan include IYCF in Emerg. National Emerg. Prep. Plan updated* Uptodate guidelines/training materials on IYCF in Emerg. HWs/IYCF counsellors trained on IYCF in Emerg. Training materials pretested Effectiveness of messages tested Baseline on KAP conducted Postintervention of KAP conducted BMS provided in emergencies Govt procures/distribute BMS during emergencies Govt accept donations of infant foods IF in Emergencies SCORE ANNEX 5r: IYCF in difficult circumstances IYCF in difficult circumstances (Infant feeding in emergency) CEE/CIS Country Uzbekistan 0 0 na na 0 na 0 na na Romania 0 0 na na 0 na na na na 0 na Na 0 Kosovo na na na na 0 na na na na 0 na na 0 Kazakhstan 0 0 na na 0 na 0 na na 0 na na 0 Bosnia & Herz. 0 0 na na 0 na Turkmenistan 0 na na na 0 na na na na 0 na na 0 Tajikistan Kyrgyzstan 0 0 na na 0 na Number M = 1.0 Total Percent EAPR Vietnam na 0 na 0 na na 0 na na 2 Philippines 1 na na na 1 na China 0 0 na na 1 1 na Thailand na na na na na na Vanuatu na na 4 Indonesia na 0 na na Myanmar na na 2 Korea na 1 na 1 na na na na na 0 na na 2 P. N. Guinea Lao PDR 0 0 na na na na 0 Mongolia 0 0 na na 0 na 0 na na 0 na na 0 Fiji 0 1 na 0 0 na na na 1 Timor Leste Cambodia na 0 na 0 na na 0 na na 2 Number Total M = 2.4 Percent ESAR Rwanda Zimbabwe 0 1 na na 0 na 0 na na 0 na na 1 Mozambique na 0 na 0 na na 0 na na 0 Zambia 0 0 na na 0 na 0 na na 0 na na 0 Malawi 1 1 na na 0 na 1 na na 0 na na 2 152

159 National IYCF policy includes IYCF in Emerg. National Emerg.preparedness plan include IYCF in Emerg. National Emerg. Prep. Plan updated* Uptodate guidelines/training materials on IYCF in Emerg. HWs/IYCF counsellors trained on IYCF in Emerg. Training materials pretested Effectiveness of messages tested Baseline on KAP conducted Postintervention of KAP conducted BMS provided in emergencies Govt procures/distribute BMS during emergencies Govt accept donations of infant foods IF in Emergencies SCORE IYCF in difficult circumstances (Infant feeding in emergency) Country Swaziland Namibia 0 0 na na 0 na 0 na na 0 na na 0 South Africa na Kenya na Ethiopia 1 0 na na 0 na na na na 0 na na 1 Botswana 0 0 na na 0 na 0 na na Madagascar na na na 0 na na 0 na na 2 Burundi 0 0 na na 0 0 na 0 na 0 na na 0 Angola 0 0 na na 0 na Uganda 1 0 na na na 2 Tanzania 1 1 na 1 0 na na na na 0 na na 2 Somalia 0 0 na na 0 na 0 na na 0 na na 0 Number Total M = 1.2 Percent MENA Yemen S. Sudan na na na 4 N. Sudan na na 3 Number Total M = 3.3 Percent ROSA Afghanistan na na na na Bangladesh na Bhutan na na na na 2 India 0 0 na na 0 na 0 na na 0 na na 0 Nepal 1 1 na na Sri Lanka na na na na na Number Total M = 2.3 Percent WCAR Benin 0 0 na na B. Faso 0 0 na na 0 na na na na 2 CAR na 0 na na 0 na na 2 Congo B na na na 5 Cote D'Ivoire na na na na na na na na na na na na 0 DRC Gabon 1 na na na na 0 na na na 1 Gambia na Ghana na na 5 153

160 National IYCF policy includes IYCF in Emerg. National Emerg.preparedness plan include IYCF in Emerg. National Emerg. Prep. Plan updated* Uptodate guidelines/training materials on IYCF in Emerg. HWs/IYCF counsellors trained on IYCF in Emerg. Training materials pretested Effectiveness of messages tested Baseline on KAP conducted Postintervention of KAP conducted BMS provided in emergencies Govt procures/distribute BMS during emergencies Govt accept donations of infant foods IF in Emergencies SCORE IYCF in difficult circumstances (Infant feeding in emergency) Country Liberia 0 na na na na na na na na na Mali 1 0 na Mauritania na na 1 5 Niger 1 0 na na 0 na 0 na na 0 na na 1 Nigeria Senegal na 0 na S. Leone 0 0 na na na na 1 Togo na na 7 Number Total Percent M =3.1 ALL Number Total Percent na= no response /not applicable, 1=Yes, 0= No, 1= yes, 0=no Nutritionally vulnerable countries highlighted in yellow. 154

161 ANNEX 5S: Overall IYCF in difficult circumstances Country HIV and IF SUBSCORE IF in Emergencies SUBSCORE IYCF in Diff. Circums. SCORE CEE/CIS Uzbekistan Romania Kosovo Kazakhstan Bosnia & Herz Turkmenistan Tajikistan Kyrgyzstan Mean EAPR Vietnam Philippines China Thailand Vanuatu Indonesia Myanmar Korea P. N. Guinea Lao PDR Mongolia Fiji Timor Leste Cambodia Mean ESAR Rwanda Zimbabwe Mozambique Zambia Malawi Swaziland Namibia South Africa Kenya Ethiopia Botswana Madagascar Burundi Angola Uganda Tanzania Somalia Mean Country HIV and IF IF in Emergencies IYCF in Diff. Circums. 155

162 SUBSCORE SUBSCORE SCORE MENA Yemen S. Sudan N. Sudan Mean ROSA Afghanistan Bangladesh Bhutan India Nepal Sri Lanka Mean WCAR Benin B. Faso CAR Congo B Cote D'Ivoire DRC Gabon Gambia Ghana Liberia Mali Mauritania Niger Nigeria Senegal S. Leone Togo Mean TOTAL MEAN na= no response /not applicable, 1=Yes, 0= No 156

163 ANNEX 5t: IYCF Monitoring and evaluation COUNTRY National level M&E system M&E at the health system level M&E at the Communitylevel Baseline M & E for national IYCF undertaken Baseline assessment of EBF rate available assessment of barriers and facilitators for breastfeeding available eg. KAP study Baseline assessment of CF situation available Ongoing food security surveillance system Ongoing nutrition surveillance system Routine monitoring of ongoing IYCF activities? Routine monitoring of skills of health workers? Routine monitoring of quality of counseling _e.g. KAP surveys of mothers_? Monitoring of other program process indicators _e.g. # HW trained) Evaluation or review of IYCF situation? Routine monitoring of ongoing IYCF activities in the community? Routine monitoring of quality Routine monitoring of skills of community health workers? of counseling by CHW _e.g. KAP surveys of mothers_? M&E Score CEE/CIS BOSNIA AND HERZEGOVINA 3 KAZAKASTAN Kosovo na na na na na na na na 1 KYRGYZSTAN 1 na Romania na na na na 0 Tajikistan na Turkemnistan na na na 3 UZBEKISTAN na na 3 n N M % EAPR Cambodia na na China Fiji Indonesia na na na na 4 Korea na na na na na na na na na na na 1 Lao People's na na na 3 157

164 National level M&E system M&E at the health system level M&E at the Communitylevel COUNTRY M & E for national IYCF undertaken Baseline assessment of EBF rate available Baseline assessment of barriers and facilitators for breastfeeding available eg. KAP study Baseline assessment of CF situation available Ongoing food security surveillance system Ongoing nutrition surveillance system Routine monitoring of ongoing IYCF activities? Routine monitoring of skills of health workers? Routine monitoring of quality of counseling _e.g. KAP surveys of mothers_? Monitoring of other program process indicators _e.g. # HW trained) Evaluation or review of IYCF situation? Routine monitoring of ongoing IYCF activities in the community? Routine monitoring of skills of community health workers? Routine monitoring of quality of counseling by CHW _e.g. KAP surveys of mothers_? M&E Score Democratic Republic Mongolia na na 5 MYANMAR na na na na 4 Papua New Guinea Philippines na na na 1 na na 0 na 4 Thailand na na na 1 na na na 0 na na na 3 TIMORLESTE na Vanuatu VIETNAM n N M % ESAR Angola Botswana 1 1 na na na 0 1 na na na 3 Burundi Ethiopia na na Kenya Madagascar Malawi na 6 Mozambique NAMIBIA na RWANDA

165 COUNTRY National level M&E system M&E at the health system level M&E at the Communitylevel Baseline M & E for national IYCF undertaken Baseline assessment of EBF rate available assessment of barriers and facilitators for breastfeeding available eg. KAP study Baseline assessment of CF situation available Ongoing food security surveillance system Ongoing nutrition surveillance system Routine monitoring of ongoing IYCF activities? Routine monitoring of skills of health workers? Routine monitoring of quality of counseling _e.g. KAP surveys of mothers_? Monitoring of other program process indicators _e.g. # HW trained) Evaluation or review of IYCF situation? Routine monitoring of ongoing IYCF activities in the community? Routine monitoring of quality Routine monitoring of skills of community health workers? of counseling by CHW _e.g. KAP surveys of mothers_? M&E Score Somalia South Africa SWAZILAND Tanzania UGANDA Zambia na na na 5 Zimbabwe n N M % MENA North Sudan South Sudan na na na 2 YEMEN n N M % ROSA AFGHANISTAN BANGLADESH Bhutan na na India na 1 na Nepal

166 COUNTRY National level M&E system M&E at the health system level M&E at the Communitylevel Baseline M & E for national IYCF undertaken Baseline assessment of EBF rate available assessment of barriers and facilitators for breastfeeding available eg. KAP study Baseline assessment of CF situation available Ongoing food security surveillance system Ongoing nutrition surveillance system Routine monitoring of ongoing IYCF activities? Routine monitoring of skills of health workers? Routine monitoring of quality of counseling _e.g. KAP surveys of mothers_? Monitoring of other program process indicators _e.g. # HW trained) Evaluation or review of IYCF situation? Routine monitoring of ongoing IYCF activities in the community? Routine monitoring of quality Routine monitoring of skills of community health workers? of counseling by CHW _e.g. KAP surveys of mothers_? M&E Score Sri Lanka n N M % WCAR Gambia BENIN Burkina Faso CAR Congo Brazzaville na na na Cote d'ivoire 0 na na na na na 0 na na na na na na na 0 DRC na na 7 GABON 0 1 na na na na 5 Ghana Liberia na na na na na na na 3 MALI MAURITANIA NIGER na Nigeria Senegal na na na 1 na Sierra Leone na Togo na n N M 160

167 COUNTRY National level M&E system M&E at the health system level M&E at the Communitylevel Baseline M & E for national IYCF undertaken Baseline assessment of EBF rate available assessment of barriers and facilitators for breastfeeding available eg. KAP study Baseline assessment of CF situation available Ongoing food security surveillance system Ongoing nutrition surveillance system Routine monitoring of ongoing IYCF activities? Routine monitoring of skills of health workers? Routine monitoring of quality of counseling _e.g. KAP surveys of mothers_? Monitoring of other program process indicators _e.g. # HW trained) Evaluation or review of IYCF situation? Routine monitoring of ongoing IYCF activities in the community? Routine monitoring of quality Routine monitoring of skills of community health workers? of counseling by CHW _e.g. KAP surveys of mothers_? M&E Score % ALL COUNTRY M n N %