1. Do you have any general comments on the draft Framework for Action?
· Malnutrition, as rightly acknowledged in parts of the paper, has multiple - often overlapping - causes. While food and food systems play an important role in addressing malnutrition, and should be part of a comprehensive approach to addressing the current nutrition crisis, the draft Framework for Action (FFA) is unbalanced in the emphasis it gives to the role of food. At the same time it does not equally, nor adequately, recognize the role of other sectors in improving nutrition. We recommend the FFA includes a set of more balanced priority actions and all the factors that underline the nutrition crisis – including, but not limited to, greater focus throughout on water sanitation and hygiene (WASH), breastfeeding practices, education, and access to health care.
· Clarification and definition needed on what the FFA means by ‘healthy diets’. Emphasis should be put on a diet with adequate and balanced vitamins and minerals—not just enough calories.
· Whilst the FFA is aligned with the WHA nutrition targets for 2025, in order to align with the global community timeframe and level of ambition of the proposed post-2015
development agenda, any nutrition targets should be extended to 2030. Millions more children can be reached between 2025 and 2030 with a new global effort based on the
principle of ‘no one left behind’ if new international nutrition targets to 2030 are agreed
and long-terms plans developed. Ending malnutrition in all its forms and meeting other Sustainable Development Goals including targets such as that on ending preventable child deaths will not be met without 2030 nutrition targets.
· In addition we recommend the FFA makes stronger recommendations on the post-2015 development framework. – specifically the need for nutrition to be appropriately prioritised, as a stand-alone goal with ambitious targets on stunting and wasting. While the current FFA recognises the role of universal health coverage (UHC) in improving nutrition outcomes, and specifically the need for (UHC) to be integrated into the post-
2015 development framework, it does not make any reference to the need for nutrition to be prioritized in the 2015 development agenda. We recommend the FFA makes
stronger references on the post-2015 development agenda, specifically the need for a stand-alone goal on nutrition, with ambitious targets to address all forms of
malnutrition by 2030. Furthermore, we recommend that the stand alone goal on
Health and UHC (Goal #3) makes mention of malnutrition as a global impediment to improve the health of the most vulnerable, and of the overall population by 2030 – as of the last draft from the OWG, nutrition is not mentioned in Goal #3. Likewise, recommendations from the Open Working Group (OWG) presented in their final draft of proposed SDGs should be highlighted in the Framework for Action for purposes of alignment and continuity in what Member States are asked to commit to.
· Do you have any comments on chapter 1-2?
1.1. Backgrounda.
a. The draft FFA makes reference to ‘inappropriate diets’, ‘unhealthy diets’ and ‘healthy diets’. However, the language is ambiguous and unclear. It would be useful to have further clarification, or clearer definitions, about what constitutes ‘inappropriate’, ‘unhealthy’ and ‘healthy’ diets.
The current language around ‘inappropriate’ and ‘unhealthy’ diets could imply that diet – and by extension malnutrition – is a matter of choice, risking perpetuating blame and stigma around malnutrition. While it is possible to get all the required nutrients need from food, not all people are able to access diverse foods due to a number of factors, including purchasing power, lack of access to education, cultural norms, and discrimination. We recommend the language around ‘inappropriate’ and ‘unhealthy’ diets is reviewed and revised to reflect the more complicated reality of varying personal and collective agency, country and regional level, and situational context.
b. The FFA should recognise that the challenge goes beyond improving global and national food systems. The emphasis given to food systems in the current drafts seems to suggest that malnutrition is primarily a food issue and does not adequately reflect the complexity of the condition. Malnutrition is a result of multiple factors working together, including, but not limited to, water and sanitation, breastfeeding practices, education and access to health care. It is not possible to address malnutrition through food intake alone. Many people who do have access to diverse nutritious foods are still at risk from malnutrition if their bodies are unable to absorb the vital nutrients due to loss of appetite from or illness (e.g. diarrheal disease). The World Bank suggests that up to 50% of malnutrition is caused by diarrhea from a lack of access to clean safe water and sanitation. In future drafts we would like to see a FFA that recognizes the complex and multi-sectoral nature of nutrition that includes but goes beyond the role of food systems.
The framework recognizes that the implementation of National Plans of Action on Nutrition (NPANs), in some cases, have been uneven and slow. While the reasons for this are context-specific, the FFA should make specific reference to some of the key issues relating to slow implementation, and guidance on how to overcome the issues. For example, it should be clearer what national budgets were attached to these plans to show country commitment to implementation, as well as demonstrated issues of resources, capacity, or governance.
1.2 Framework for Action
a. Whilst the FFA is aligned with the WHA nutrition targets for 2025, in order to align the global community with the timeframe and level of ambition of the proposed Post-2015 Development agenda, new global nutrition targets to address all forms of malnutrition by 2030 are needed.
b. Millions more children can be reached between 2025 and 2030 with a new global effort based on the principle of ‘no one left behind’ if new international nutrition targets to 2030 are agreed and long-terms plans developed. Ending malnutrition in all its forms and meeting other Sustainable Development Goals including targets such as that on ending preventable child deaths will not be met without nutrition targets that extend to 2030.
c. While the FFA aims to provide guidance for developing and updating NPANs, there is a risk of duplicating efforts already started under the Scaling up Nutrition (SUN) Movement, which has been supporting countries to develop context specific nutrition plans. While the FFA may be useful for countries not yet part of SUN, or who have not yet developed or updated their NPAN, it should be recognized that many countries are beyond the assessment stage and the need now is to resource their action plans so they can begin implementation.
2.1 Enabling environment
a. We are pleased the FFA recognizes the need to create an enabling environment for improving nutrition outcomes. An enabling environment is also critical for successful behavior change, which the FFA recognizes as a key policy and programme option (3.3.4).
b. Creating an enabling environment requires recognising all the key barriers to achieving nutrition security. We agree with the FFA’s four key elements: political will, leadership, evidence and capacity. We recommend the inclusion of a fifth key element – equity. Although there has been progress in terms of child mortality and malnutrition, this progress has been matched with widening inequities. However recent process and technological innovations have provided effective options to reach those most in need.
2.2. Better governance for nutrition
Institutional arrangements that encourage effective multi-sector working
a. We welcome the recommendation of ‘multi-sector working.’ Too often the responsibility for tackling malnutrition falls on the Ministries of Health (MoH). But no single Ministry can shoulder the all the responsibility for reducing malnutrition. The conceptual framework on the determinants of a child’s nutrition status emphasizes the need for a comprehensive and coordinated effort to improve the nutrition status of a population. All Ministries are responsible for some elements that impact nutrition status. Often the potential impact of one set of interventions delivered by one sector is undermined by the lack of interventions in another. We recommend the FFA encourages the adoption of explicit nutrition objectives and nutrition-related performance indicators for all key line Ministries.
b. We recommend that implementation be delivered in a coordinated and joined up way that the addresses multiple causes of malnutrition through collaboration within sectors and across a variety of sectors that impact nutrition.
c. We recommend that as well as encouraging multi-sector coordination, cooperation, and collaboration at the national level, institutional arrangements encourage multi-sector working to extend to district, municipal and village levels. Donors must recognize that improving coordination and collaboration requires resources and ample staffing.
d. Additional priority actions should include:
i. Encourage and foster wide civil society participation in the debate and negotiation of the FFA process, both at the global and national level. Civil society must have an ongoing seat on the bodies that monitor implementation of the Framework for Action.
Assessment and accountability
a. We welcome the recommendation of regular assessments of progress. We recommend that transparency be at the heart of assessment and accountability processes. Transparency is key holding governments, and others responsible for nutrition, to account. Assessments, and subsequent data, should be easily accessible and released in an open format.
b. The FFA recommends that assessments take into account such factors as climate change and political conflict, among others. We recommend that assessments take into account inequality, rights-based, and social factors, which also perpetuate malnutrition.
2.3 Financing for improved nutrition outcomes
a. We recommend the FFA include commitments by donor countries (such as Nutrition for Growth, SUN, country bilateral and multilateral support for nutrition, and others), especially in cases where budget support is necessary for policy and implementation effectiveness. Stable, transparent and predictable financial commitment can help enhance policy coherence, coordination, country ownership, budget tracking and multi-stakeholder participation.
b. The health sector has a vital role to play in delivering better nutrition. Investment in strengthening health systems must go hand-in-hand with implementing nutrition interventions, especially those that are primarily delivered through health systems (e.g. community management of acute-malnutrition (CMAM), vitamin A supplementation, support for early imitation of breastfeeding, etc.). The overall impact, and cost-effectiveness, of nutrition interventions depends on the strength of the health system through which they are being delivered. For example, weak health systems in high-burden countries are currently a major constraint to the expanding treatment of severe acute malnutrition and one reason why global coverage rates remain unacceptably low. We recommend the FFA recognize, within its priority actions, the necessary role of health systems strengthening in achieving better results for nutrition and the need to finance health systems strengthening alongside efforts to scale up nutrition interventions.
c. Additional priority actions should include:
i. Financing for strengthening health systems that puts a focus on nutrition- specific interventions and their inherent ties to other health interventions within smartly interlinked health systems.
· Do you have any comments on chapter 3 (3.1 Food systems, 3.2 Social Protection; 3.3
Health; 3.4 International trade and investment)?
3.1 Food systems
a. While the FFA recognizes that obesity contributes to the burden of non- communicable disease (NCDs), it should also recognize the role of undernutrition in perpetuating NCDs. Undernutrition is a precursor to a number of NCDs that are often associated with obesity and overnutrition, including diabetes and coronary heart disease.
b. The FFA recognizes that economic growth at the macro level and income growth at the micro level can improve nutrition status. However, the FFA should be careful not to overplay the role of economic growth. Economic growth does not necessarily lead to improved nutrition. The Lancet Global Health, reported on the largest study to date to examine this issue with data from 1990-2011 in 36 LMIC including India, Colombia, Nigeria and many sub-Saharan countries and suggests that increases in Gross Domestic Product (GDP) over the two decades have generally not been associated with improvements in child nutritional status as economic growth can be unequally distributed, not spent in ways to enhance nutrition, and increases in household income may not be accompanied by the necessary public services and societal infrastructure to improve childhood nutritional status, e.g. additional income may be spent on non-food items. In regards to the role of economic growth, the FFA should reflect that the greatest impact is seen when efforts to improve economic growth are done in conjunction with other nutrition and health efforts. For example, India has experienced steady economic growth over the years, but rates of undernutrition have stagnated. Yet, the recent case of the Indian state, Maharashtra, shows what can be achieved when modest progress on a number of fronts (e.g. economic growth, empowering women and improving their maternal health; a committed government and improving services) combine. It is important to recognise that economic growth on its own has not been sufficient in leading to improved nutrition outcomes.
c. The FFA states that it is important ‘to meet basic nutrition needs.’ It would be useful to have further clarification, or clearer definitions, about what constitutes ‘basic nutrition.’
d. We are pleased the FFA recognizes the need for nutrition education to be combined with other efforts to improve nutrition. We recommend the FFA expand on this to specify the inclusion of nutrition within the national curriculum, in primary and secondary schools, as well as nutrition education targeted to adults, including women and men. We recommend nutrition education should be broad and, as well as teaching children about ‘appropriate diets’, should include other aspects of nutrition such as WASH and disease control.
e. We welcome the FFA recognition of the importance of gender-sensitive interventions for improving nutrition. However, the current draft does not mention the role of men in improving nutrition. For instance, educating fathers about the benefits of breastfeeding is critical in creating an enabling and empowering environment for mothers to breastfeed their children. It helps overcome cultural norms and myths that can inhibit mothers from feeding infants colostrum and breastfeeding exclusively. We recommend the FFA recognise the role of men in decision-making and the need to make men more nutrition aware. We recommend that gender-sensitive interventions be targeted at both men and women.
f. We are pleased that the FFA recognizes the importance of preventing acute malnutrition through building resilience to shocks. However, acute malnutrition is not a condition that is exclusive to emergencies. Many donors are actively bridging the gap between humanitarian and long-term development funding for the treatment of acute malnutrition, recognizing that many children are at risk during periods of stability and that governments need long-term funding to plan and implement strategies to address acute malnutrition.
g. While prevention is the first step towards management of severe
acute malnutrition (SAM), urgent action is needed to minimize and avoid the risk of death. In many poor countries the majority of children who have SAM are never brought to health facilities. However, recent adoption of Community-based Management of Acute Malnutrition (CMAM) has proved to be successful in treating the condition.
h. The FFA recommends integrating explicit nutrition objectives into agricultural strategy policy and programme design and implementation. We recommend the FFA encourages the adoption of explicit nutrition objective in all strategies and policies that impact nutrition status.
3.2 Social Protection
a. We question whether all social protection strategies can be effectively “country- owned” when some marginalization may be exacerbated by government policy, actions, or reinforcing of the status quo. While government leadership on social protection is a vital component of this area of the work, outside evaluation is also needed and, we feel, can be an effective component of country ownership work on nutrition.
b. The ‘first 1000 days’ between pregnancy and the second birthday of a child are noted to be crucial—and we agree. But we must remember that effective interventions for the health of the child start with ensuring the overall health of women of reproductive age even long before they consider beginning a family.
3.3 Health
a. We are pleased the FFA recognizes the vital role the health sector pleased in delivering better nutrition. However, too often the responsibility for tackling malnutrition falls solely on the health sector, through Ministries of Health. But no single sector can reduce malnutrition working alone. The conceptual framework on the determinants of a child’s nutrition status emphasizes the need for a comprehensive and coordinated effort to improve the nutrition status of a population. All sectors – health, education, WASH, agriculture – are responsible for some elements that impact nutrition status. Often the potential impact of one set of interventions delivered by one sector is undermined by the lack of interventions in another.
c. We are pleased the FFA recognizes the need for universal health coverage to be integrated in the post-2015 development agenda. We recommend that FFA also recognize need for nutrition to present as a stand-alone goal and the inclusion of nutrition in the goal on health, with appropriately ambitious targets to reduce both stunting and wasting, that are in line with the WHA targets for 2025 and extend proportionately to 2030.
d. Additional priority actions to address wasting should include:
i. A wasting target in the post-2015 development framework, under the nutrition stand-alone goal.
ii. Establishing national wasting targets to help focus efforts on tackling acute malnutrition, which includes a target for reducing the global rate of acute malnutrition to below 5% by 2025 (WHA targets see above). Building on this, all high-burden countries should establish national wasting targets, which would help focus domestic attention on this task and help ensure a joined-up effort across a range of sectors.
iii. Strengthening health systems to enable long-term expansion and affordability of CMAM.
e. Additional priority actions to address stunting should include:
i. A stunting target in the post-2015 development framework, under a nutrition stand-alone goal.
3.3.1 Delivery of nutrition interventions
a. There is a large body of evidence on the most effective direct interventions – the fortification of food and treatment for acute malnutrition, for example. It is widely acknowledged that micronutrient fortification schemes are extremely cost-effective and can be delivered at scale.
b. Any gains made through these types of nutrition-specific interventions can be undermined without progress also on the underlying factors, those that need to be addressed through nutrition-sensitive interventions. We recommend the FFA detail the supporting role of nutrition-sensitive interventions and supporting stakeholders in achieving nutrition-specific work, and the need to build the evidence base for nutrition sensitive interventions.
c. We recommend the FFA provide a platform which improves the ‘nutrition sensitivity’ of existing programmes including, but not limited to, agriculture, early child development, social protection and primary and secondary education.
3.3.3 Breastfeeding
a. We are pleased the FFA recognizes the importance of breastfeeding in improving nutrition outcomes. However, the draft does not recognise the barriers that inhibit women from breastfeeding according to WHO recommendations. Priority actions should endeavor to provide mother with an enabling environment to breastfeed, which require addressing:
· The critical shortage of skilled health workers to support mothers to breastfeed in the first hour and to continue breastfeeding exclusively for the first 6 months. Evidence suggests that mothers are twice as likely to breastfeed within the first hour after birth if a skilled health worker is present. However, the shortage of global health workers means that too many mothers are not given the support to breastfeed in the critical first hour after giving birth.
· The lack of legislation to support mothers in breastfeeding, particularly around maternity leave. A mother’s choice to return to work should not affect her ability to breastfeed.
· The unsupportive work environments for breastfeeding mothers. They are not often conducive to help mother breastfeed. If mothers do make the decision to return to work employers need to provide safe clean environments for mothers to breastfeed, including on-site day-care and facilities for mothers to express and store breast milk.
· The EFA should support governments to be stronger in standing up to multinational infant feeding companies that flout the code of practice on breastfeeding and the promotion of infant formulas.
· The FFA should support the inclusion of Breastfeeding in the standalone goal on nutrition. Leaving breastfeeding out of the standalone goal, undermines the fundamental role that breastfeeding plays in child survival, early development, and in achieving the WHA’s nutrition target for 2025 and natural extensions of these targets for 2030.
3.3.3 Nutrition education for behavior change
a. Education is not enough on its own to lead to behavior change. For example, many mothers may want to exclusively breastfeed their babies, aware of the nutritional and health benefits of breast milk; however, the environment is often not enabling to allow them to enact that behavior change. Short maternity leave and unsupportive work environments are major barriers for breastfeeding mothers. We recommend the FFA recognize the importance of providing an enabling environment for effective behavior change, and the priority actions reflect barriers to creating an enabling environment.
· Do you have any comments on chapter 4-5?
Accountability Mechanisms
4.1.1 National Level
a. While government reporting on implementation progress of national plans is a part of measuring progress for vulnerable groups, outside evaluation and monitoring is also needed to ensure accountability and standards of measurement across governments. Th SUN structures have a critical role to play in M&E of national progress.
4.2 International Level
a. While the actors named should indeed take into consideration the final FFA, the document will be strongest and most likely to be used as an accountability tool if it begins by taking into account corresponding recommendations in existing international frameworks. For example, the FFA would be greatly strengthened through incorporation of targets in the finalized Open Working Group draft of the Sustainable Development Goals. Alignment with UN frameworks and processes is further underlined through the recommended by the stated want to use UNGA as a moment to update on progress against the FFA each year.
b. The annual Global Nutrition Report will be a fundamental tool for accountability. The FFA must be aligned with global accountability mechanisms already set in motion and with the post-2015 development agenda and its targets for nutrition, food security, and broader health.
2. Does the Framework for Action adequately reflect the commitments of the Rome Declaration on Nutrition, and how could this be improved?
3. Does the Framework for Action provide sufficient guidance to realize the commitments made?
In future drafts, further guidance and more clarity should be given to targets and timelines to implement and realize the commitments made.
4. Are there any issues which are missing in the draft Framework for Action to ensure the effective implementation of the commitments and action to achieve the objectives of the ICN2 and its Declaration?
Our comments on this are integrated into the above points.
Kate Goertzen
1. Do you have any general comments on the draft Framework for Action?
· Malnutrition, as rightly acknowledged in parts of the paper, has multiple - often overlapping - causes. While food and food systems play an important role in addressing malnutrition, and should be part of a comprehensive approach to addressing the current nutrition crisis, the draft Framework for Action (FFA) is unbalanced in the emphasis it gives to the role of food. At the same time it does not equally, nor adequately, recognize the role of other sectors in improving nutrition. We recommend the FFA includes a set of more balanced priority actions and all the factors that underline the nutrition crisis – including, but not limited to, greater focus throughout on water sanitation and hygiene (WASH), breastfeeding practices, education, and access to health care.
· Clarification and definition needed on what the FFA means by ‘healthy diets’. Emphasis should be put on a diet with adequate and balanced vitamins and minerals—not just enough calories.
· Whilst the FFA is aligned with the WHA nutrition targets for 2025, in order to align with the global community timeframe and level of ambition of the proposed post-2015
development agenda, any nutrition targets should be extended to 2030. Millions more children can be reached between 2025 and 2030 with a new global effort based on the
principle of ‘no one left behind’ if new international nutrition targets to 2030 are agreed
and long-terms plans developed. Ending malnutrition in all its forms and meeting other Sustainable Development Goals including targets such as that on ending preventable child deaths will not be met without 2030 nutrition targets.
· In addition we recommend the FFA makes stronger recommendations on the post-2015 development framework. – specifically the need for nutrition to be appropriately prioritised, as a stand-alone goal with ambitious targets on stunting and wasting. While the current FFA recognises the role of universal health coverage (UHC) in improving nutrition outcomes, and specifically the need for (UHC) to be integrated into the post-
2015 development framework, it does not make any reference to the need for nutrition to be prioritized in the 2015 development agenda. We recommend the FFA makes
stronger references on the post-2015 development agenda, specifically the need for a stand-alone goal on nutrition, with ambitious targets to address all forms of
malnutrition by 2030. Furthermore, we recommend that the stand alone goal on
Health and UHC (Goal #3) makes mention of malnutrition as a global impediment to improve the health of the most vulnerable, and of the overall population by 2030 – as of the last draft from the OWG, nutrition is not mentioned in Goal #3. Likewise, recommendations from the Open Working Group (OWG) presented in their final draft of proposed SDGs should be highlighted in the Framework for Action for purposes of alignment and continuity in what Member States are asked to commit to.
· Do you have any comments on chapter 1-2?
1.1. Backgrounda.
a. The draft FFA makes reference to ‘inappropriate diets’, ‘unhealthy diets’ and ‘healthy diets’. However, the language is ambiguous and unclear. It would be useful to have further clarification, or clearer definitions, about what constitutes ‘inappropriate’, ‘unhealthy’ and ‘healthy’ diets.
The current language around ‘inappropriate’ and ‘unhealthy’ diets could imply that diet – and by extension malnutrition – is a matter of choice, risking perpetuating blame and stigma around malnutrition. While it is possible to get all the required nutrients need from food, not all people are able to access diverse foods due to a number of factors, including purchasing power, lack of access to education, cultural norms, and discrimination. We recommend the language around ‘inappropriate’ and ‘unhealthy’ diets is reviewed and revised to reflect the more complicated reality of varying personal and collective agency, country and regional level, and situational context.
b. The FFA should recognise that the challenge goes beyond improving global and national food systems. The emphasis given to food systems in the current drafts seems to suggest that malnutrition is primarily a food issue and does not adequately reflect the complexity of the condition. Malnutrition is a result of multiple factors working together, including, but not limited to, water and sanitation, breastfeeding practices, education and access to health care. It is not possible to address malnutrition through food intake alone. Many people who do have access to diverse nutritious foods are still at risk from malnutrition if their bodies are unable to absorb the vital nutrients due to loss of appetite from or illness (e.g. diarrheal disease). The World Bank suggests that up to 50% of malnutrition is caused by diarrhea from a lack of access to clean safe water and sanitation. In future drafts we would like to see a FFA that recognizes the complex and multi-sectoral nature of nutrition that includes but goes beyond the role of food systems.
The framework recognizes that the implementation of National Plans of Action on Nutrition (NPANs), in some cases, have been uneven and slow. While the reasons for this are context-specific, the FFA should make specific reference to some of the key issues relating to slow implementation, and guidance on how to overcome the issues. For example, it should be clearer what national budgets were attached to these plans to show country commitment to implementation, as well as demonstrated issues of resources, capacity, or governance.
1.2 Framework for Action
a. Whilst the FFA is aligned with the WHA nutrition targets for 2025, in order to align the global community with the timeframe and level of ambition of the proposed Post-2015 Development agenda, new global nutrition targets to address all forms of malnutrition by 2030 are needed.
b. Millions more children can be reached between 2025 and 2030 with a new global effort based on the principle of ‘no one left behind’ if new international nutrition targets to 2030 are agreed and long-terms plans developed. Ending malnutrition in all its forms and meeting other Sustainable Development Goals including targets such as that on ending preventable child deaths will not be met without nutrition targets that extend to 2030.
c. While the FFA aims to provide guidance for developing and updating NPANs, there is a risk of duplicating efforts already started under the Scaling up Nutrition (SUN) Movement, which has been supporting countries to develop context specific nutrition plans. While the FFA may be useful for countries not yet part of SUN, or who have not yet developed or updated their NPAN, it should be recognized that many countries are beyond the assessment stage and the need now is to resource their action plans so they can begin implementation.
2.1 Enabling environment
a. We are pleased the FFA recognizes the need to create an enabling environment for improving nutrition outcomes. An enabling environment is also critical for successful behavior change, which the FFA recognizes as a key policy and programme option (3.3.4).
b. Creating an enabling environment requires recognising all the key barriers to achieving nutrition security. We agree with the FFA’s four key elements: political will, leadership, evidence and capacity. We recommend the inclusion of a fifth key element – equity. Although there has been progress in terms of child mortality and malnutrition, this progress has been matched with widening inequities. However recent process and technological innovations have provided effective options to reach those most in need.
2.2. Better governance for nutrition
Institutional arrangements that encourage effective multi-sector working
a. We welcome the recommendation of ‘multi-sector working.’ Too often the responsibility for tackling malnutrition falls on the Ministries of Health (MoH). But no single Ministry can shoulder the all the responsibility for reducing malnutrition. The conceptual framework on the determinants of a child’s nutrition status emphasizes the need for a comprehensive and coordinated effort to improve the nutrition status of a population. All Ministries are responsible for some elements that impact nutrition status. Often the potential impact of one set of interventions delivered by one sector is undermined by the lack of interventions in another. We recommend the FFA encourages the adoption of explicit nutrition objectives and nutrition-related performance indicators for all key line Ministries.
b. We recommend that implementation be delivered in a coordinated and joined up way that the addresses multiple causes of malnutrition through collaboration within sectors and across a variety of sectors that impact nutrition.
c. We recommend that as well as encouraging multi-sector coordination, cooperation, and collaboration at the national level, institutional arrangements encourage multi-sector working to extend to district, municipal and village levels. Donors must recognize that improving coordination and collaboration requires resources and ample staffing.
d. Additional priority actions should include:
i. Encourage and foster wide civil society participation in the debate and negotiation of the FFA process, both at the global and national level. Civil society must have an ongoing seat on the bodies that monitor implementation of the Framework for Action.
Assessment and accountability
a. We welcome the recommendation of regular assessments of progress. We recommend that transparency be at the heart of assessment and accountability processes. Transparency is key holding governments, and others responsible for nutrition, to account. Assessments, and subsequent data, should be easily accessible and released in an open format.
b. The FFA recommends that assessments take into account such factors as climate change and political conflict, among others. We recommend that assessments take into account inequality, rights-based, and social factors, which also perpetuate malnutrition.
2.3 Financing for improved nutrition outcomes
a. We recommend the FFA include commitments by donor countries (such as Nutrition for Growth, SUN, country bilateral and multilateral support for nutrition, and others), especially in cases where budget support is necessary for policy and implementation effectiveness. Stable, transparent and predictable financial commitment can help enhance policy coherence, coordination, country ownership, budget tracking and multi-stakeholder participation.
b. The health sector has a vital role to play in delivering better nutrition. Investment in strengthening health systems must go hand-in-hand with implementing nutrition interventions, especially those that are primarily delivered through health systems (e.g. community management of acute-malnutrition (CMAM), vitamin A supplementation, support for early imitation of breastfeeding, etc.). The overall impact, and cost-effectiveness, of nutrition interventions depends on the strength of the health system through which they are being delivered. For example, weak health systems in high-burden countries are currently a major constraint to the expanding treatment of severe acute malnutrition and one reason why global coverage rates remain unacceptably low. We recommend the FFA recognize, within its priority actions, the necessary role of health systems strengthening in achieving better results for nutrition and the need to finance health systems strengthening alongside efforts to scale up nutrition interventions.
c. Additional priority actions should include:
i. Financing for strengthening health systems that puts a focus on nutrition- specific interventions and their inherent ties to other health interventions within smartly interlinked health systems.
· Do you have any comments on chapter 3 (3.1 Food systems, 3.2 Social Protection; 3.3
Health; 3.4 International trade and investment)?
3.1 Food systems
a. While the FFA recognizes that obesity contributes to the burden of non- communicable disease (NCDs), it should also recognize the role of undernutrition in perpetuating NCDs. Undernutrition is a precursor to a number of NCDs that are often associated with obesity and overnutrition, including diabetes and coronary heart disease.
b. The FFA recognizes that economic growth at the macro level and income growth at the micro level can improve nutrition status. However, the FFA should be careful not to overplay the role of economic growth. Economic growth does not necessarily lead to improved nutrition. The Lancet Global Health, reported on the largest study to date to examine this issue with data from 1990-2011 in 36 LMIC including India, Colombia, Nigeria and many sub-Saharan countries and suggests that increases in Gross Domestic Product (GDP) over the two decades have generally not been associated with improvements in child nutritional status as economic growth can be unequally distributed, not spent in ways to enhance nutrition, and increases in household income may not be accompanied by the necessary public services and societal infrastructure to improve childhood nutritional status, e.g. additional income may be spent on non-food items. In regards to the role of economic growth, the FFA should reflect that the greatest impact is seen when efforts to improve economic growth are done in conjunction with other nutrition and health efforts. For example, India has experienced steady economic growth over the years, but rates of undernutrition have stagnated. Yet, the recent case of the Indian state, Maharashtra, shows what can be achieved when modest progress on a number of fronts (e.g. economic growth, empowering women and improving their maternal health; a committed government and improving services) combine. It is important to recognise that economic growth on its own has not been sufficient in leading to improved nutrition outcomes.
c. The FFA states that it is important ‘to meet basic nutrition needs.’ It would be useful to have further clarification, or clearer definitions, about what constitutes ‘basic nutrition.’
d. We are pleased the FFA recognizes the need for nutrition education to be combined with other efforts to improve nutrition. We recommend the FFA expand on this to specify the inclusion of nutrition within the national curriculum, in primary and secondary schools, as well as nutrition education targeted to adults, including women and men. We recommend nutrition education should be broad and, as well as teaching children about ‘appropriate diets’, should include other aspects of nutrition such as WASH and disease control.
e. We welcome the FFA recognition of the importance of gender-sensitive interventions for improving nutrition. However, the current draft does not mention the role of men in improving nutrition. For instance, educating fathers about the benefits of breastfeeding is critical in creating an enabling and empowering environment for mothers to breastfeed their children. It helps overcome cultural norms and myths that can inhibit mothers from feeding infants colostrum and breastfeeding exclusively. We recommend the FFA recognise the role of men in decision-making and the need to make men more nutrition aware. We recommend that gender-sensitive interventions be targeted at both men and women.
f. We are pleased that the FFA recognizes the importance of preventing acute malnutrition through building resilience to shocks. However, acute malnutrition is not a condition that is exclusive to emergencies. Many donors are actively bridging the gap between humanitarian and long-term development funding for the treatment of acute malnutrition, recognizing that many children are at risk during periods of stability and that governments need long-term funding to plan and implement strategies to address acute malnutrition.
g. While prevention is the first step towards management of severe
acute malnutrition (SAM), urgent action is needed to minimize and avoid the risk of death. In many poor countries the majority of children who have SAM are never brought to health facilities. However, recent adoption of Community-based Management of Acute Malnutrition (CMAM) has proved to be successful in treating the condition.
h. The FFA recommends integrating explicit nutrition objectives into agricultural strategy policy and programme design and implementation. We recommend the FFA encourages the adoption of explicit nutrition objective in all strategies and policies that impact nutrition status.
3.2 Social Protection
a. We question whether all social protection strategies can be effectively “country- owned” when some marginalization may be exacerbated by government policy, actions, or reinforcing of the status quo. While government leadership on social protection is a vital component of this area of the work, outside evaluation is also needed and, we feel, can be an effective component of country ownership work on nutrition.
b. The ‘first 1000 days’ between pregnancy and the second birthday of a child are noted to be crucial—and we agree. But we must remember that effective interventions for the health of the child start with ensuring the overall health of women of reproductive age even long before they consider beginning a family.
3.3 Health
a. We are pleased the FFA recognizes the vital role the health sector pleased in delivering better nutrition. However, too often the responsibility for tackling malnutrition falls solely on the health sector, through Ministries of Health. But no single sector can reduce malnutrition working alone. The conceptual framework on the determinants of a child’s nutrition status emphasizes the need for a comprehensive and coordinated effort to improve the nutrition status of a population. All sectors – health, education, WASH, agriculture – are responsible for some elements that impact nutrition status. Often the potential impact of one set of interventions delivered by one sector is undermined by the lack of interventions in another.
c. We are pleased the FFA recognizes the need for universal health coverage to be integrated in the post-2015 development agenda. We recommend that FFA also recognize need for nutrition to present as a stand-alone goal and the inclusion of nutrition in the goal on health, with appropriately ambitious targets to reduce both stunting and wasting, that are in line with the WHA targets for 2025 and extend proportionately to 2030.
d. Additional priority actions to address wasting should include:
i. A wasting target in the post-2015 development framework, under the nutrition stand-alone goal.
ii. Establishing national wasting targets to help focus efforts on tackling acute malnutrition, which includes a target for reducing the global rate of acute malnutrition to below 5% by 2025 (WHA targets see above). Building on this, all high-burden countries should establish national wasting targets, which would help focus domestic attention on this task and help ensure a joined-up effort across a range of sectors.
iii. Strengthening health systems to enable long-term expansion and affordability of CMAM.
e. Additional priority actions to address stunting should include:
i. A stunting target in the post-2015 development framework, under a nutrition stand-alone goal.
3.3.1 Delivery of nutrition interventions
a. There is a large body of evidence on the most effective direct interventions – the fortification of food and treatment for acute malnutrition, for example. It is widely acknowledged that micronutrient fortification schemes are extremely cost-effective and can be delivered at scale.
b. Any gains made through these types of nutrition-specific interventions can be undermined without progress also on the underlying factors, those that need to be addressed through nutrition-sensitive interventions. We recommend the FFA detail the supporting role of nutrition-sensitive interventions and supporting stakeholders in achieving nutrition-specific work, and the need to build the evidence base for nutrition sensitive interventions.
c. We recommend the FFA provide a platform which improves the ‘nutrition sensitivity’ of existing programmes including, but not limited to, agriculture, early child development, social protection and primary and secondary education.
3.3.3 Breastfeeding
a. We are pleased the FFA recognizes the importance of breastfeeding in improving nutrition outcomes. However, the draft does not recognise the barriers that inhibit women from breastfeeding according to WHO recommendations. Priority actions should endeavor to provide mother with an enabling environment to breastfeed, which require addressing:
· The critical shortage of skilled health workers to support mothers to breastfeed in the first hour and to continue breastfeeding exclusively for the first 6 months. Evidence suggests that mothers are twice as likely to breastfeed within the first hour after birth if a skilled health worker is present. However, the shortage of global health workers means that too many mothers are not given the support to breastfeed in the critical first hour after giving birth.
· The lack of legislation to support mothers in breastfeeding, particularly around maternity leave. A mother’s choice to return to work should not affect her ability to breastfeed.
· The unsupportive work environments for breastfeeding mothers. They are not often conducive to help mother breastfeed. If mothers do make the decision to return to work employers need to provide safe clean environments for mothers to breastfeed, including on-site day-care and facilities for mothers to express and store breast milk.
· The EFA should support governments to be stronger in standing up to multinational infant feeding companies that flout the code of practice on breastfeeding and the promotion of infant formulas.
· The FFA should support the inclusion of Breastfeeding in the standalone goal on nutrition. Leaving breastfeeding out of the standalone goal, undermines the fundamental role that breastfeeding plays in child survival, early development, and in achieving the WHA’s nutrition target for 2025 and natural extensions of these targets for 2030.
3.3.3 Nutrition education for behavior change
a. Education is not enough on its own to lead to behavior change. For example, many mothers may want to exclusively breastfeed their babies, aware of the nutritional and health benefits of breast milk; however, the environment is often not enabling to allow them to enact that behavior change. Short maternity leave and unsupportive work environments are major barriers for breastfeeding mothers. We recommend the FFA recognize the importance of providing an enabling environment for effective behavior change, and the priority actions reflect barriers to creating an enabling environment.
· Do you have any comments on chapter 4-5?
Accountability Mechanisms
4.1.1 National Level
a. While government reporting on implementation progress of national plans is a part of measuring progress for vulnerable groups, outside evaluation and monitoring is also needed to ensure accountability and standards of measurement across governments. Th SUN structures have a critical role to play in M&E of national progress.
4.2 International Level
a. While the actors named should indeed take into consideration the final FFA, the document will be strongest and most likely to be used as an accountability tool if it begins by taking into account corresponding recommendations in existing international frameworks. For example, the FFA would be greatly strengthened through incorporation of targets in the finalized Open Working Group draft of the Sustainable Development Goals. Alignment with UN frameworks and processes is further underlined through the recommended by the stated want to use UNGA as a moment to update on progress against the FFA each year.
b. The annual Global Nutrition Report will be a fundamental tool for accountability. The FFA must be aligned with global accountability mechanisms already set in motion and with the post-2015 development agenda and its targets for nutrition, food security, and broader health.
2. Does the Framework for Action adequately reflect the commitments of the Rome Declaration on Nutrition, and how could this be improved?
3. Does the Framework for Action provide sufficient guidance to realize the commitments made?
In future drafts, further guidance and more clarity should be given to targets and timelines to implement and realize the commitments made.
4. Are there any issues which are missing in the draft Framework for Action to ensure the effective implementation of the commitments and action to achieve the objectives of the ICN2 and its Declaration?
Our comments on this are integrated into the above points.