Nutrition Marketplace

Nutrition Marketplace Profiling World Vision s Best Practices in Nutrition 1

World Vision is a Christian relief, development and advocacy organisation dedicated to working with children, families and their communities worldwide to reach their full potential by addressing the causes of poverty and injustice. World Vision serves all people, regardless of religion, race, ethnicity or gender. Copyright World Vision International 2010 2

Nutrition Marketplace Profiling World Vision s Best Practices In Nutrition for Advocacy and Programme Stakeholders 3

Publishing Information Acknowledgements 4

Introduction Table of Contents INTRODUCTION Icon Explanations...7 Foreword by Dave Toycen, President, World Vision Canada...8 Introduction by Martha Newsome, Partnership Leader, Global Health and WASH, World Vision International... 10 SECTION ONE ESTABLISHING NUTRITION AS A PRIORITY FOCUS...13 1.1 The Importance of Nutrition...14 1.1.1 From a Global Perspective... 14 1.1.2. From World Vision s Perspective... 17 1.2 World Visions s First Generation of Nutrition-Focused Programming...19 1.2.1 World Vision s First Nutrition-Focused Programme... 19 1.2.2 Growing Nutrition Capacity... 20 1. 2.3 Nutrition Centre Of Expertise... 20 1.3 Where Are We Going?...22 1.3.1 Global Nutrition Framework... 22 1.3.2 The Global Health And Nutrition Strategy... 24 SECTION TWO LEARNING FROM OUR BEST PRACTICES...31 2.1 Mothers and Children are Well Nourished...32 2.1.1 Appropriate Breastfeeding... 33 2.1.2 Complementary Feeding... 43 2.1.3 Supplementation... 55 2.1.4 Fortification... 72 2.1.5 Increasing Food Diversity... 89 2.1.6 Behaviour Change Modification...100 2.1.7 Nutrition in Emergency Settings...114 5

2.2 Mothers and Children Are Protected From Infection and Disease...127 2.2.1 Prevention and Treatment of Diarrhoea and Helminths...127 2.2.2 Prevention and Treatment of Malaria...136 2.3 Mothers and Children Access Essential Health Services...144 2.3.1 Training 145 2.3.2 Monitoring and Evaluation...153 2.3.3 Supply Chain...158 2.3.4 Advocacy...163 Report View...177 SECTION THREE WORKING AS A GLOBAL PARTNER...187 3.1 Global Partners...190 3.2 International Conferences...196 3.3 External Publications...201 SECTION FOUR NUTRITION PROJECT SUMMARIES...203 4.1 Our World Vision s Best Nutrition-Based Programs...204 4.1.1 Our Best Practices...204 4.1.2 Our Promising Practices...203 6

Introduction List of Icons List of Figures/Tables, Icon Explanations $ 7

Foreword by Dave Toycen Over the years, I have sat with mothers holding babies too sick to eat, I have seen children too weak to hold their own heads up, and spoken with fathers desperate to find ways to feed their children. At World Vision, we picture a world where every child has the opportunity for life in all its fullness. With 3.2 million children dying each year from under-nutrition, this will not happen unless a concerted effort is placed on child nutrition and health issues. We work among the poorest and most vulnerable people with millions of children in our programme areas malnourished and susceptible to a daunting array of health challenges. This is unacceptable and obligates us to place a greater emphasis on nutrition-related interventions as a critical step towards improving this situation. The Bible (or Jesus) makes it transparently clear that we are denying our faith if we deny help to the most vulnerable and innocent the world s children. While we are especially concerned with malnutrition rates in the areas in which we work, we are also committed to addressing hunger globally through our advocacy efforts. Malnutrition continues to be the world s most serious health problem and the single biggest contributor to child mortality. Under-nutrition accounts for 35% of global mortality in children under five-years of age and is also the largest risk factor in any age group for disease. Good nutrition is the number one health solution for children. A small number of costeffective and proven interventions have the potential to quickly prevent child deaths, and improve the health and quality of life in the countries where World Vision works. World Vision s focus on nutrition has been relatively recent, but of high calibre. I am delighted that World Vision Canada played a leading role in launching the first major nutrition-focused programme in 1995. Over 7 million people were reached across five African countries under the Micronutrient and Health Programme (MICAH), funded by the Canadian International Development Agency (CIDA). The project positioned World Vision with the expertise, reputation, and institutional linkages necessary to make nutrition a Partnership priority. In addition, I m pleased that World Vision Canada introduced the Positive Deviance/Hearth model to the World Vision Partnership in 1999, and that it has extended to more than 20 countries since that time. Most recently, our offices have 8

Introduction Foreword by Dave Toycen introduced the Community-based Management of Acute Malnutrition (2006), which has resulted in the treatment of thousands of severely malnourished children in emergency contexts. It is in this context that World Vision established the Nutrition Centre of Expertise (NCOE). The centre is headquartered in World Vision Canada but structurally positioned within the Partnership s Global Health and WASH Team. The NCOE aims to establish and maintain world-class leadership for nutrition programming throughout the World Vision Partnership by leading the effort to incorporate quality nutrition programming especially for children across the continuum of contexts, from emergency to development. Its establishment heralds a new era for World Vision competency and world-class expertise in an area essential for effective international development. Nutrition is a niche within the humanitarian arena that World Vision is uniquely positioned to fill. Few non-governmental humanitarian agencies have nutrition-focused programming of such high technical calibre, variety, and global reach at the community level. World Vision s nutrition team has been intentional about measuring and communicating the impact of its nutrition interventions and is able to demonstrate evidenced-based best practices which contribute to our programme quality and advocacy messages. The extent and degree of collaboration with other institutions technical, academic, multilateral, and operational is remarkable. The Nutrition Marketplace represents an exciting effort to capture in a single place our growing expertise and commitment to nutrition through programme interventions and advocacy initiatives. I am confident that you will be both encouraged and challenged as you read through the material and that together we can make a difference in the lives of children around the world. Blessings, Dave Toycen, President, World Vision Canada 9

Introduction by Martha Newsome Background/Rationale The primary goal of World Vision s programmes is sustained well being of children within families and communities, especially the most vulnerable. In order to achieve this, World Vision recognises the need to pay closer and more concerted attention to nutrition, because nutrition is absolutely fundamental for the survival, health, development, and well being of children. To ensure that this happens, World Vision has established nutrition as a central element in its Global Health and Nutrition Strategy (2008) and made nutrition an organisational priority. World Vision has a strong and solid foundation for incorporation of nutrition throughout Partnership programming but we need to invest significant time and resources to assimilate and broaden our renewed focus on nutrition within World Vision s programmes across the Partnership. Towards this end, the Partnership s Global Nutrition and Health Team will build on evidence-based best practices to advance the organisation s worldwide impact on nutrition and health for women and children. Organisational Strategy The Global Health and Nutrition Strategy refocuses World Vision s programming by expanding initiatives in community-based maternal and child nutrition and health, and promoting equitable access to quality primary health care to better achieve health outcomes. It is a disarmingly simple strategy aimed at ensuring that mothers and children: 1. Are well-nourished; 2. Are protected from infection and disease; and 3. Can access essential health services. This focus emphasizes World Vision s areas of comparative advantage while aligning with global best practices. It also equips World Vision to make more intentional decisions regarding what services to provide moving from doing many good practices to concentrating on a few best practices. The strategy is essentially a way to act our size and be an authoritative voice at all levels driving change (Strategic Mandate #4) on behalf of the world s many children with great health needs. Achieving of MDG Goals An organisational focus on nutrition puts World Vision in the forefront of humanitarian agencies contributing to achievement of the United Nations Millennium Development 10

Introduction Goals (MDG) including MDG 1 (reducing hunger), MDG 4 (reducing child mortality), MDG 5 (improving maternal health), and MDG 6 (combating HIV/AIDS, malaria, other diseases). Implementing the Right Interventions Interventions must be targeted to pregnant women and children during their first two years to prevent the irreparable, lifelong harm that results from early childhood undernutrition. World Vision s strategy is anchored in evidence-based practices, interventions that have been proven to make a difference. Called 7-11 the strategy entails an organization-wide scale-up of a minimum set of contextualized preventative interventions. These include seven (7) possible time-sensitive interventions for mothers and eleven (11) for children under 2 years, hence the name. Best Practices Over the past decade, World Vision has developed considerable expertise and learned many lessons about effective integrated nutrition programming. As you will see from the description of World Vision s Best Practices in Nutrition contained in the innovative Nutrition Marketplace on-line resource, there are numerous ways to successfully address nutritional issues at household, community, and national level: training healthcare workers, promoting appropriate infant and young child feeding practices, providing supplementation, enabling fortification, promoting dietary diversification, behaviour-change communication, protecting mothers and children from common infections and diseases such as malaria, and focusing on nutrition in emergency settings. Conclusion The fact remains, too many children and women are dying of preventable illnesses; and the lives of too many children and women are impaired by poor health, as well as damage to physical growth and brain development incurred through poor nutrition at critical life stages. By capitalising on its excellent implementation and results record in the specialized field of nutrition, and intentionally incorporating nutrition into programming, World Vision can make a significant positive contribution to ensuring life in all its fullness for millions of women and children around the world. Martha Newsome Partnership Leader, Health and WASH World Vision International 11

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1 Establishing Nutrition as a Priority Focus 1.1 The Importance of Nutrition 1.1.1 From a Global Perspective... 14 1.1.2. From World Vision s Perspective... 14 1.2 World Visions s First Generation of Nutrition-Focused Programming... 19 1.2.1 World Vision s First Nutrition-Focused Programme... 19 1.2.2 Growing Nutrition Capacity... 20 1. 2.3 Nutrition Centre Of Expertise... 20 1.3 Where Are We Going? 1.3.1 Global Nutrition Framework... 20 1.3.2 The Global Health And Nutrition Strategy... 24 13

SECTION 1 Establishing Nutrition as a Priority Focus 1.1 THE IMPORTANCE OF NUTRITION Did you know? Nutrition is a crosscutting intervention which influences positive outcomes in agriculture, water and sanitation, education, and health but is often ignored unless it is positioned as a central component of a national development agenda. 1.1.1 From A Global Perspective 1. Malnutrition is the NUMBER ONE HEALTH PROBLEM! Malnutrition continues to be the world s most serious health problem and the single biggest contributor to child mortality. 1 Undernutrition 2 contributes more to the global burden of disease than other factor, accounting for an estimated 15% of total disease burden in disability-adjusted life years (DALYs). 3,4 Even from conception, its importance extends beyond the role in survival and the mental and physical development of an individual, to include the platform from which future social and economic opportunities are provided for generations to come. Despite universal understanding of the minimum daily food requirements for survival, the importance of breastfeeding, and necessary micronutrient needs for growth, undernutrition still contributes to at least 3.5 million deaths each year and more than one-third of all deaths of children under five years. 5 Conservative estimates predict 138 million children under five years are stunted (chronically undernourished) and a further 19 million children are severely wasted (weak and emaciated), 6 although these figures were calculated prior to the global food crisis. 2. GOOD NUTRITION IS THE NUMBER ONE HEALTH SOLUTION FOR CHILDREN. FACT: Malnourished children are up to 12 times more likely to die from easily preventable and treatable diseases than are wellnourished children. The impact of nutrition upon health has been documented for many years (i.e. affecting quality of life and mortality rates), but there has been limited profiling of nutrition within the larger health care profession until recently, when the Maternal and Child Undernutrition Study Group released a series of papers in the influential medical journal, The Lancet (January 2008). The third paper in the series showed that in the 36 countries that have 90% of children chronically undernourished, implementing existing general nutrition interventions could reduce the number of deaths in children under three years by 13%, using existing micronutrient interventions could reduce child deaths by 12%, while disease control interventions would reduce deaths by just 3%. Thus, existing interventions for nutrition and disease prevention can reduce mortality between birth and 36 months by about one quarter. 7 14

The Importance Of Nutrition 1.1.1 From A Global Perspective 3. Micronutrient malnutrition will be a WIDESPREAD DEVASTATING CONSEQUENCE OF THE ECONOMIC CRISIS. Recent trends in commodity markets and the worldwide financial situation are accelerating the numbers of people at risk of vitamin and mineral deficiencies. In 2007, the Food and Agriculture Organisation s index of food prices rose by 24%, and rose again by 51% between October 2007 and October 2008. 8 In November of 2008, the World Bank estimated that high food and fuel prices had increased the number of extremely poor by at least 100 million people, and had set back seven years of progress in meeting the Millennium Development Goal (MDG) target for the reduction of poverty. 9 The World Bank also estimated that in 2008 alone, increased food prices may have been responsible for an additional 44 million children experiencing permanent physical and cognitive setbacks due to malnutrition. 4. Nutrition is CENTRAL TO NATIONAL DEVELOPMENT. Investments in micronutrients have higher returns than those from investments in trade liberalization, in malaria, or in water and sanitation No other technology offers as large an opportunity to improve lives as such low cost and in such a short time. Copenhagen Consensus (2008). Ensuring adequate nutrition is not only important for the survival, growth, and development of children, it is central to national development. Early malnutrition impairs motor and mental development, which decreases future adult productivity. 10 Malnutrition creates significant barriers for social and economic development such that it will prevent achievement of several Millennium Development Goals, specifically the aims to reduce extreme poverty and hunger, HIV/AIDS, malaria, child mortality, and to improve education. 11 Malnutrition contributes to higher child and general mortality rates, while also increasing morbidity (illness) in those who survive. 12 Recent meta-analysis research 13 re-emphasises the linkages between nutrition and agriculture, water and sanitation, education, and health. Governments are urged to implement and scale-up social policies associated with rapid improvements in nutritional status, including policies on health, poverty, trade, and agriculture. 5. Nutrition makes the MOST ECONOMIC SENSE IN TACKLING GLOBAL PROBLEMS. Nutrition programmes have high impact on economic growth and poverty reduction. Maternal and child undernutrition is associated with lower economic status in adulthood and has lasting effects on future generations. 14 Research also indicates that nutrition interventions can avert 65 million disability-adjusted life years (DALYs), compared to 6.6 million averted DALYs through disease control interventions. 15 6. Nutrition provides the FIRST AND BEST CHANCE FOR CHILD SURVIVAL AND DEVELOPMENT throughout life. The period from pregnancy to 24 months of age is a crucial window of opportunity for reducing undernutrition and its life time adverse effects. The damage to physical growth, brain development, and human capital formation that occurs during this critical period is extensive and largely irreversible. The World Health Organisation (WHO), United Nations Children s Fund (UNICEF), the World Bank, and academics across the globe advocate that programme efforts, as well as monitoring and assessment, should focus on this segment of the continuum of care. 16 Continuum of care refers to continuity of individual care which is necessary throughout the lifecycle (adolescence, pregnancy, childbirth, postnatal time, and childhood) and also between places of caregiving (households and communities, outpatient and outreach services, and clinical-care settings). The Lancet 2008 15

SECTION 1 Establishing Nutrition as a Priority Focus The 20 countries with the highest burden of undernutrition countries with stunting prevalence 20% in children under the age of 5 years that together account for >80% of the world s undernourished children. Source: Maternal and Child Undernutrition Series, Paper 4, Maternal and child undernutrition, effective action at national level. The Lancet 2008; published online Jan 17. DOI:10.1016/S0140-6736(07)61694-8 7. Nutrition programmes TARGETING JUST 20 COUNTRIES CAN IMPACT 80% OF THE WORLD S UNDERNOURISHED CHILDREN. Malnutrition is the world s number one health problem; yet 80% of the world s undernourished children live in just 20 countries. 17 Concerted effort to intensify nutrition programming in these countries can help achieve MDG 1 and greatly increase the chances of reaching MDG s 4 and 5. 8. SUSTAINED POLITICAL COMMITMENT CAN QUICKLY IMPROVE NATIONAL NUTRITIONAL STATUS of mothers and children. Evidence from countries such as Costa Rica, Cuba, Sri Lanka, Thailand and China shows that nutrition of mothers and children can be improved fairly quickly with sustained political will. 18 Yet just half of the countries where high proportions of the burden of disease are attributable to undernutrition had included nutrition policies or programmes in their national Poverty Reduction Strategy Papers (PRSPs), and even fewer had funding allocated to nutrition. Countries that did include nutrition in their PRSP and designated funds to nutrition programming reported that the PRSP had a positive effect on national nutrition. 9. CLIMATE CHANGE WILL SIGNIFICANTLY INCREASE THE THREAT OF MALNUTRITION TO CHILDREN, both in magnitude and global distribution and is set to create the worst possible conditions to reduce its current prevalence, especially in sub-saharan Africa and south Asia. 19 The United Nations Intergovernmental Panel on Climate Change (IPCC) estimates that climate change will 16

The Importance Of Nutrition 1.1.2 From World Vision s Perspective increase the number of malnourished people by 80 to 90 million, 20 and other projections calculate the number of hungry people because of climate change is expected to grow by more than two thirds by 2030. 21 For children, malnutrition is a doubled edged sword. As their body weakens from a lack of sustenance, their resistance to infection and resilience to trauma is compromised, increasing the risk of not surviving any threat to their health. Importantly, all underlying causes of malnutrition will be exacerbated from the effects of the changing climate system, including household food security, access to clean water and health services, infectious diseases, and adequate sanitation and shelter. 22,23 Extreme weather events and chronic droughts and floods will impact all these variables, but especially food production, affecting crops, forestry, livestock, fisheries, aquaculture, and water systems farmed and fished by small holder and subsistence farmers and traditional societies. 24 The recent global food crisis showed how malnourishment can escalate rapidly; without an adequate global response, climate change is poised to exacerbate malnutrition. Studies suggest that staple food sources will be severely affected, including cereal crops, which account for 70% of global food energy. 25 Other assessments of the impact on crop yields from 18 countries have forecast reductions in agricultural productivity of between 5-25% by 2080 in Africa and Latin America 26, whereas the IPCC has estimated that food production could decline by as much as 50% in some parts of Africa by 2020. 27 Notwithstanding the effects of these future projections, the food crisis of 2008 plunged an additional 40 million people into hunger 28, with estimates ranging from 100 million to 850 million more people suffering food insecurity. 29 The United Nations World Food Programme has reported a doubling of food emergencies over the past 20 years, rising from an average of 15 per year during the 1980s to now more than 30 annually. 30 1.1.2 From World Vision s Perspective World Vision (WV) has become increasingly aware of the fact that millions of children in its target communities are malnourished and vulnerable to a daunting array of health challenges. This is unacceptable. A greater emphasis on nutrition-related programming interventions is one important step toward improving this situation. World Vision works in over 1,400 Area Development Programmes (ADPs) 31 impacting more than 100 million people in 98 countries, with annual revenue of $2.5 billion (2008 figure). 32 Every World Vision development manager must strategically prioritise limited financial resources. Nutrition, a relatively new priority focus, can often be overlooked in development strategies. World Vision is now taking measures to ensure it is included as a vital component in its development approach. 17

SECTION 1 Establishing Nutrition as a Priority Focus Challenge of a WORLD focus World Vision focuses on projects that help communities address the root causes of poverty, not just the symptoms. There are several key types of projects, including: Sponsorship (children & families connected to sponsors through life-changing relationships); Child Crisis Partnerships (helping the world s most vulnerable children escape a life of horror); Food & Water Programmes (fresh water wells, seeds, tools, agricultural training and livestock); Health Care (immunisations, health clinics, HIV/AIDS awareness and prevention); Education (school fees, teachers, IS THERE ROOM FOR NUTRITION? tutoring, building & repairing schools, lifeskills training); Economic Development (microloans, business training, job skills, new markets for entrepreneurs); and Emergency Assistance (pre-positioned relief goods, family survival kits, disaster mitigation and shelter). Nutrition is central to a child s survival and development. We all know and believe in this and think we have been practicing it for over 50 years and yet based on our recent [Transformational Development Indicators] TDI data, it s evident too many of the 30,000 children that die every day are on World Vision s watch. We are missing the mark and without a deliberate and professionally guided commitment to nutrition interventions we will fail to protect children s God-given potential to develop and live life to the fullest. (WV Global Health Strategy 2007) World Vision has demonstrated impact on improving nutritional status in many of its grant funded programmes, however, the same impact is not evident across its ADPs. This is not to say change has not happened, but rather tracking of change, especially in nutritional levels across the partnership, has not been well documented. With a renewed commitment to ensure mothers and children are well nourished, combined with new technology, incorporation of Transformational Development Indicators (TDI) and Learning from Evaluation with Accountability and Planning (LEAP), training in monitoring nutritional status and a resolve to scale up some of its evidence-based nutrition interventions, combined with the launch of a global campaign entitled Child Health Now, World Vision is setting the stage to achieve significant nutritional impact worldwide. 18

World Vision s First Generation of Nutrition-Focused Programming 1.2.1 World Vision s First Nutrition Focused Programme 1.2 FIRST GENERATION NUTRITION-FOCUSED PROGRAMMING 1.2.1 World Vision s First Nutrition-Focused Programme Provision of food and implementation of health interventions have always been part of World Vision s ministry. Nutrition as a priority focus in World Vision s development programmes began in 1995 with World Vision Canada s implementation of a major nutritionfocused programme called MICAH (Micronutrient And Health). The MICAH Programme contributed to improved quality of life of women and children in five African nations over a 10-year period between 1996 and 2005. The programme was conducted in two phases, funded by the Canadian International Development Agency (CIDA), managed by World Vision Canada and implemented by World Vision offices in Ethiopia, Ghana, Malawi, Senegal, and Tanzania. The problem of micronutrient deficiencies (vitamin A, iron, and iodine) was addressed through integrated strategies and direct interventions that resulted in measurable positive effects. Quantitative and qualitative programme results affirm the contribution of MICAH s achievements towards the MDGs, and global nutrition and health targets. Examples from the MICAH programme can be found throughout Section 2: Learning from our Best Practices. MICAH aimed to improve the nutritional and health status of women and children through the most cost-effective and sustainable interventions. The three key objectives for reaching this goal were: Increasing intake and bioavailability of micronutrients (iron, iodine, and vitamin A); reducing the prevalence of diseases that affect micronutrient status (diarrhoeal, parasitic, and vaccine-preventable diseases); and building local capacity for delivery systems to improve micronutrient status. 19

SECTION 1 Establishing Nutrition as a Priority Focus 1.2.2 Growing Nutrition Capacity To facilitate MICAH, World Vision Canada built up a competent team of professional nutritionists. Staff worked closely with country implementing partners to expand the quality and reach of World Vision s nutrition programming and by 2008 initiated six separate programming models in over 30 countries. The subsequent increased implementation capacity increased World Vision s corporate credibility within the global nutrition professional community, enabling close collaboration with academic institutions and independent experts, and prompting the establishment of a World Vision Partnership Nutrition Task Force (January 2006 - August 2008) which evolved into the Nutrition Working Group. The expertise of technical staff on the Task Force shaped World Vision s Global Nutrition Framework. World Vision s nutrition programming is unique in several aspects. First, nutrition is something of a global niche there are only a few operational development NGOs that actually have nutrition-focused programming of such technical calibre, variety, and scale, and with a long-term commitment at the community level. Second, World Vision has been very intentional about the importance of measuring and communicating the impact of its nutrition interventions and is able to demonstrate evidenced-based best practices (as profiled in this report). Third, the nutrition sector has a commitment to operational research in order to improve the effectiveness of World Vision programmes. And fourth, the extent and degree of the nutrition sector collaboration with other institutions technical, academic, multilateral, and operational is remarkable in World Vision. WORLD VISION TERMINOLOGY A Centre of Expertise (COE) is a location-based team of particular sectoral expertise a centre of knowledge and research and development that is at the cutting edge worldwide in a particular sector. 20 1.2.3 Nutrition Centre Of Expertise (NCOE) The NCOE is the first of several Centres of Expertise (COE) proposed in the Children in Ministry strategic plan to provide the highest level of technical leadership for improving the programmes aimed at improving the well-being of children. With a 13-year track record in successful, focused programmes (see Section Two) World Vision s nutrition

World Vision s First Generation of Nutrition-Focused Programming 1.2.3 Nutrition Centre Of Expertise sector is pioneering the COE approach to improving Partnership-wide quality of service. The NCOE s role is to provide effective leadership for incorporating quality nutrition programming (especially for children) across the continuum of contexts, from emergency to development. The NCOE (located within the Global Health and WASH Team) is comprised of not only full NCOE positions, but also has several shared positions with World Vision Canada s Nutrition and Health Team. Technical staff on World Vision Canada s Nutrition and Health Team are responsible primarily for resource development, management, and technical support for World Vision Canada-funded programmes. Nutritionists assigned to the NCOE provide global leadership for nutrition strategy, capacity building, operational research, and advocacy/policy for the World Vision Partnership. While members of both teams have their respective roles and responsibilities, the two teams ensure that strategy, planning, capacity building, and advocacy efforts are aligned and duplication is avoided. Both teams seek to work in synergy complementing and leveraging each other s work. The NCOE staff also engages cross-functionally on various partnership endeavours including Policy Group, Sponsorship, Humanitarian and Emergency Affairs, and Livelihoods as well as more nutrition focused groups like the Emergency Nutrition Working Group and the Sponsorship Nutrition Working Group. NCOE GOAL: to establish and maintain world-class leadership for nutrition programming throughout the World Vision partnership. Nutrition COE Objectives 1. Define organisational strategy and provide programme guidance for implementation of evidence-based nutrition interventions, integrated with other relevant programming sectors (health, food security, economic development). 2. Document World Vision nutrition programming experience, incorporating learning from the field into strategy and programming, and communicating successes and learnings. 3. Build World Vision capacity at regional and country levels for improving nutrition services by strengthening civil society and government systems. 4. Lead operational research, evaluation, and advocacy initiatives for improved nutrition policies and programmes. 5. Represent World Vision externally and establish collaborative working agreements within the global nutrition arena. Formally established in November 2007 within the Global Health Team and hosted by World Vision Canada, the Nutrition Centre of Expertise (NCOE) heralds a new era for World Vision competency and world-class expertise in international development. 21

SECTION 1 Establishing Nutrition as a Priority Focus 1.3 WHERE ARE WE GOING? 1.3.1 Global Nutrition Framework The sketch below illustrates how nutrition is part of World Vision s integrated focus supporting the principal ministries of Humanitarian and Emergency Affairs Transformational Development, and Policy & Advocacy Christian, Community-based, Child-focused The core focus choices align with the Integrated Focus, supporting integration and effectiveness across multiple lines of ministry. Over the past few years, World Vision has put significant time, effort, and resources into realigning its integrated focus and organisational strategy to better articulate its understanding of child well-being. While the process is still unfolding, the emerging framework confirms that the primary goal of World Vision programmes should be the sustained well-being of children within families and communities, especially the most vulnerable. Bringing alignment of all ministries and technical sectors within such a large and diverse organisation to achieve this goal is no small task. Even within the World Vision s nutrition network, developing a cohesive strategy to improve the nutrition of children, women, and vulnerable groups marked a preliminary milestone. One of many off-shoots from MICAH was creation of World Vision s Taskforce on Nutrition, comprised of nutrition and health professionals from across the Partnership. In 2007 the Taskforce drafted World Vision s Global Nutrition Framework to guide the Partnership s efforts at improving nutrition globally; this document was further validated at the Asia sub-regional Nutrition Workshop in 2008. The Nutrition Framework (based on the UNICEF child well-being model) aims TD P&A to improve the nutrition of children under five years, women, and vulnerable groups by addressing the underlying causes of malnutrition through prioritising the following: 1) adequate household food security; 2) Adequate maternal and childcare practices; HEALTH & NUTRITION EDUCATION & LIFESKILLS and 3) Adequate health services and healthy environments. HEA CONFLICT SENSITIVITY & PEACEBUILDING WASH ECONOMIC STRENGTHENING RIGHTS, PROTECTION, INCLUSION 22

Where Are We Going? 1.3.1 Global Nutrition Framework World Vision Global Nutrition Framework Adequate household food security Quality of food for infants and young children; nutrient-dense food for families; sufficient quality/ quantity of food for families in crisis Adequate maternal & childcare practices Care of young children care of mothers response to child illness hygiene Adequate health services & healthy environment Community-based maternal-child healthcare access to essential (facility based) primary healthcare, a healthy physical environment The Nutrition Framework provides an over-arching structure to engage in nutritional programming on multiple fronts, which include not only health, but also agriculture, food security, education, and economic development. For example, the nutrition framework allows for exploring new frontiers in scaling up community-based nutrition interventions such as small-scale fortification. It also connects World Vision s front-line operational research with academic institutions and policy setting groups. Perhaps the biggest challenge is assimilating the nutrition framework into the organisation s own mammoth operational structure. Gradually this is happening as illustrated by the following: Prioritisation of nutrition programming in Area Development Programme designs: World Vision has established nutrition as a central element of its Global Health and Nutrition Strategy (2008). This priority reaches through subsequent regional and national strategy development to the ADP and community level. Implementing nutrition Threshold indicators in target communities: World Vision monitors six triggers for action at community level (stunting, wasting, underweight, iodine fortification, iron-deficiency anaemia, and vitamin A supplementation) as well as four indicators closely related to nutrition (related to diarrhoea, immunisation, breastfeeding, and access to improved water sources). Monitoring of Child Well-Being Outcome Indicators: Globally, every World Vision country programme evaluates impact using six core indicators. One of the six measures is stunting; the others are immunisation rates, access to improved water sources, management of diarrhoea, completion of formal education, and adoption of coping strategies. The direct and indirect incorporation of nutrition-related indicators into the central impact evaluation system for World Vision indicates World Vision s organisational support of nutrition. Mainstreaming evidence-based, best practice relief and development interventions: World Vision is scaling-up well known interventions and models such as Infant and Young Child Feeding, Positive Deviance/Hearth (PD/Hearth), Homebased Fortification (e.g. Sprinkles), Small-Scale Fortification (SSF), and Communitybased Management of Acute Malnutrition (CMAM). Why measure stunting and anaemia? Stunting and anaemia are good proxy indicators for global poverty and health inequality because they capture the multiple dimensions of a child s health and development, as well as the socioeconomic and environmental causes. Source: Beaton G, Kelly A, Martorell R, et al. Appropriate uses of anthropometric indices in children. Geneva: ACC/SCN, 1990. 23

SECTION 1 Establishing Nutrition as a Priority Focus Integrating with other World Vision sectors: The NCOE works crossfunctionally, actively participating on various World Vision Taskforces, Communities of Practice, Working Groups, and Interest Groups to strengthen nutrition components in food aid, emergency settings, food security, education, early childhood care and development, and livelihoods, in addition to its integral involvement within the Global Health and WASH Team. 1.3.2 The Global Health and Nutrition Strategy As part of the Global Health and WASH Team, the NCOE contributes nutrition expertise and technical guidance to World Vision s global health initiatives. The Global Health and Nutrition Strategy refocuses World Vision s programming by expanding communitybased maternal and child health and nutrition, and promoting equitable access to quality primary health care to better achieve health outcomes. It emphasises World Vision s areas of comparative advantage while aligning with global best practices. It also equips World Vision to make more intentional decisions regarding what services to provide moving from doing many good practices to concentrating on a few best practices. The strategy is essentially a way to act our size and be an authoritative voice at all levels driving change (Strategic Mandate 4) on behalf of the world s many children with great health needs. 1. Health and Nutrition Goal World Vision s Global Health and Nutrition Strategy refines the nutrition focus while expanding the overall health scope of the Nutrition Framework. World Vision is committed to improving the health and nutrition of women and children, and contributing to the global reduction of under five and maternal mortality. Therefore the strategy aims are stated in terms of three child well-being outcomes and ways to show whether or not the outcome has been achieved. 1. Mothers and children are well nourished (measured by rates of stunting and anemia). 2. Mothers and children are protected from infection and disease (measured by rates of malaria/illnesses, care-seeking for treatment of diarrhea and ARI, and immunisation rates). 3. Mothers and children access essential health services (measured by rate of skilled attendance at birth and antenatal care coverage). Achievement of the health and nutrition goal is dependant on achieving the full breadth of World Vision s child well-being outcomes, applied in an inter-generational life cycle. This can only be accomplished through effective integration of health outcomes within multiple sector and ministry interventions. 24

Where Are We Going? 1.3.2 The Global Health and Nutrition Strategy 2. Alignment with Millennium Development Goals A primary indicator for measuring success in improving health and nutrition for women and children is ensuring that they survive. This is demonstrated by mortality rates for both children under five years and women during delivery. As the world s largest private humanitarian agency, World Vision joins the global community in a commitment to the UN Millennium Development Goals. The following chart shows that although the world community has made progress in reducing child mortality, it still has a long way to go to meet the targets set for 2015. There are four key MDG with significant impact for child and maternal survival: MDG 1,2 - Reduce by half the proportion of people who suffer from hunger (includes the hidden hunger of micronutrient deficiencies). MDG 4 - Reduce child mortality MDG 5 - Improve maternal health MDG 6 - Combat HIV/AIDS, malaria and other diseases. 3. Window of Focus World Vision s Global Health and Nutrition Strategy takes a life-cycle approach, showing possible nutrition and related sector interventions throughout the life-cycle. The first phase targets child development from conception through the first two years (that is: -9 to +24 months). A significant proportion of undernutrition begins in utero and results in low birth weight, particularly in Asia. Undernutrition also commonly develops in the first two years of life (Asia, Africa, and Latin America regions). This period of development is the time with highest risk of child mortality, as well as the period of most rapid physical and brain growth. Inadequate food, health, & care Reduced physical labour capacity, lower educational attainment, restricted economic potential, shortened life expectancy OLDER PEOPLE Malnourished Reduced capacity to care for child WOMAN Malnourished PREGNANCY Low weight gain Higher maternal mortality Inadequate fetal nutrition CHILD MORTALITY Net under five mortality rate per 1,000 live births, 1990 and 2005 200 150 100 50 0 Higher mortality rate Inadequate food, health, & care Sub-Saharan Africa S Asia E Asia Lat Am & Carib SE Asia W Asia N Africa CIS Asia* BABY Low birthweight ADOLESCENT Stunted Impaired mental development Inadequate catch-up growth Reduced physical labour capacity, lower educational attainment Health and nutrition interventions intersect within the intergenerational life cycle. Source: adapted from ACC/SCN. 4th Report on the world nutrition situation - nutrition through the lifecycle. Geneva: ACC/SCN in collaboration with IFPRI, 2000. Increased risk of adult chronic disease CHILD Stunted 1990 2004 2015 Target CIS Europe** Oceania *Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, Uzbekiatan **Belarus, Russian Federation, Moldova, Ukraine *** Sub-Saharan Africa, SE Asia, Oceania, E. Asia, S. Asia, W. Asia, Latin America and Caribbean Untimely/inadequate weaning Frequent infections Inadequate food, health, & care Reduced mental capacity Inadequate food, health, and care Developing*** Regions SOURCE: UN 25

SECTION 1 Establishing Nutrition as a Priority Focus The Window of Opportunity for Addressing Undernutrition The window of opportunity for improving nutrition is small from pre-pregnancy through the first two years of life. There is consensus that the damage to physical growth, brain development, and human capital formation that occurs during this period is extensive and largely irreversible. Therefore interventions must focus on this window of opportunity. Any investments after this critical period are much less likely to improve nutrition. Source: Shrimpton and others (2001) Note:Estimates are based on WHO regions. Growth faltering generally starts about six months after birth and age-specific malnutrition rates increase until approximately two years of age before leveling off. Deficiencies in micronutrients also play a critical role in these early years and have similar long-term effects on physical and mental development. Did you know? Better infant feeding practices in the first two years of life could prevent the deaths of 5,500 children a day - almost one-fifth of all child deaths in the developing world Source: Phillips O, Donovan K. Poor feeding for children under two leads to nearly one-fifth of child deaths. Press Release by UNICEF, 1 August 2005: New York. Because these first two years are such a critical period for child development, undernutrition must be addressed within this window. And, interventions that aim to prevent undernutrition can be much more effective than those that target children who are already undernourished. In summary, nutrition interventions must be targeted to pregnant women and children during their first two years to prevent the irreparable, lifelong harm that results from early childhood undernutrition. 4. Implement the Right Interventions: 7-11 World Vision s strategy is anchored in evidence-based preventive practices, those practices that have been proven to make a difference. It entails an organisation-wide scaleup of the 7-11 minimum set of interventions. 7-11 is a menu of possible interventions which can be applied depending upon the particular socio-cultural and economic context it consists of 7 possible time-sensitive interventions for mothers and 11 for children under two years. Nutrition interventions within this 7-11 package are highlighted in the following chart. 26

Where Are We Going? 1.3.2 The Global Health and Nutrition Strategy Preventing Maternal and Child Undernutrition As part of the 7-11 Core Interventions Pregnant Women Single dose deworming after 4 mo. -9 mo. Children <2 yrs. Iron/folic acid during pregnancy Malaria Prevention 2 extra meals/day - 6 mo. - 3 mo. 0 6 mo. 9 mo. 12 mo. 18 mo. Initiate breastfeeding within 1st hour after birth Pregnant Women: -9 months 1. Adequate Diet 2. Iron/Folate Supplements 3. Tetanus Toxoid Immunization 4. Malaria Prevention and Intermittent Preventive Treatment 5. Healthy Timing and Spacing of Birth 6. Deworming 7. Facilitate access to Maternal Health Service: antenatal and postnatal care, skilled birth attendance, Prevention of Mother-to-Child Transmission, HIV/STI screening 1st dose of Vitamin A Exclusive breastfeeding Measles Immun. 2-3 feedings/day of complementary food 1st deworming 2nd Vit. A Ensure adequate Iron intake daily from 6-24 mo. Children: 0-24 months 1. Appropriate Breastfeeding 2. Essential Newborn Care 3. Hand Washing 4. Appropriate Complementary Feeding (6-24 months) 5. Adequate Iron 6. Vitamin A Supplementation 7. Oral Re-Hydration Therapy/Zinc 8. Care Seeking for Fever 9. Full Immunization for Age 10. Malaria Prevention 11. Deworming (+12 months) Continue breastfeeding Give ORS with zinc for diarrhea 2nd deworming 3rd Vit. A 3-4 feedings/day of complementary foods, increase food quantity as child ages, include variety of food 3rd deworming 4th Vit. A 24 mo. 5. Phased and Integrated Delivery World Vision s delivery for health and nutrition interventions start with the core and contextualised package of 7-11 interventions (Phase 1), and then build on integrated activities over time to address other local causes of illness and malnutrition (e.g. food insecurity, environmental issues) (Phase 2). In emergency contexts, delivery focuses on urgent survival needs, while maintaining focus on prevention and reduction of illness and death. For nutrition, the treatment and prevention of severe acute malnutrition through Community-based Management of Acute Malnutrition (CMAM) is the key model for delivery. 6. Multi-Level Approaches At the Household Level World Vision s delivery models focus on primary health and nutrition education and behaviour change at the household level, by empowering caregivers and children to keep themselves healthy. In addition, they include improving access to sufficient high quality foods (e.g. animals and gardens) and improving quality of existing foods (e.g. fortification). Did you know? Nutrition interventions aimed at women and children under two years are among the key strategies for achieving the millennium development goal of universal primary education by 2015. Weight gain in the first two years is strongly associated with longer schooling and higher performance in children. Source: Martorell R, Horta BL, Adair LS, et al. Weight gain in the first two years of life is an important predictor of schooling outcomes in pooled analyses from five birth cohorts from low- and middle-income countries. J Nutr. 2010 Feb;140(2):348-54. Epub 2009 Dec 9 27

SECTION 1 Establishing Nutrition as a Priority Focus At the Community Level World Vision s strategies build the capacity of community groups to address and monitor local causes of illness, death, and malnutrition, advocate for quality health service delivery, and monitor home-based care services. At the Government Level Recognising the importance of the national context and political will for sustainable nutritional improvement, World Vision emphasises partnership with national government and other stakeholders (such as the private business sector) to ensure delivery of quality health and nutrition services at community level. Did you know? Iodine deficiency is associated with an average 13.5 point reduction in IQ for a population. Reduced cognitive abilities, on the order of 1nstandard deviation, are associated with anaemia in both infants and school-age children with similar reductions in school performance. There is ample evidence that increased height, working both through physical capacity and through learning capacity and school performance, results in increased adult wages and productivity. Source: Jukes M, McGuire J, Method F, Sternberg R. Nutrition and Education (Brief 2 of 12). In Nutrition: A foundation for development. SCN. 2002. The WHO upholds that improvements in the iron status of affected populations can increase levels of national productivity by 20 percent. Source: Davidson F. Nutrition and Health (Brief 4 of 12). In Nutrition: A foundation for development. SCN. 2002. 28