THE 2016 AND THIRD TANZANIA JOINT MULTISECTORAL NUTRITION. REVIEW ..... selected sectoral programs, specifically: .... still unacceptably high and that the NMNAP is a good platform that allows all nutrition ...... The Collective Warehouse Based Marketing (COWABAMA) Big Results Now (BRN) Initiative is another.
UNITED REPUBLIC OF TANZANIA
PRIME MINISTER’S OFFICE REPORT ON THE 2016 AND THIRD TANZANIA JOINT MULTISECTORAL NUTRITION REVIEW Held at Julius Nyerere International Convention Centre, Dar es Salaam, 26-28th October 2016
CONVENED BY THE HIGH LEVEL STEERING COMMITTEE ON NUTRITION
By Dr Festo P. Kavishe, Independent Human Development Consultant
TFNC Report Number 2240
Dar es Salaam, November 2016
Suggested citation Kavishe F. P. (2016): Report on the 2016 and Third Tanzania Joint Multisectoral Nutrition Review. TFNC report number 2240, Dar es Salaam, Tanzania, November 2016.
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TABLE OF CONTENTS EXECUTIVE SUMMARY................................................................................................................. 5 Objectives ............................................................................................................................................ 5 Structure of the report ......................................................................................................................... 6 Recommendations ............................................................................................................................... 6
SECTION 1: INTRODUCTION ......................................................................................................... 8 1.1 1.2
Strategic context ....................................................................................................................... 8 Methodology of the Review....................................................................................................... 8
SECTION 2: PROCEEDINGS OF DAY ONE: 26TH OCTOBER 2016 ....................................................... 9 2.1 Session 1: Opening session ....................................................................................................... 9 2.1.1 Welcome remarks by TFNC .......................................................................................................... 9 2.1.2 Statements from key partner representatives............................................................................. 9 2.1.3 Opening speech by Guest of honour .......................................................................................... 10 2.1.4 Launch of the SBCC kit (Mkoba wa siku 1,000) .......................................................................... 10 2.1.5 Presentation on objectives and agenda of the meeting ............................................................ 10 2.2 Session 2: Endline review of the National Nutrition Strategy (NNS) 2011/12 – 2015/16 ............ 10 2.2.1 Progress on the implementation status of the 2015 JMNR2 recommendations ...................... 10 2.2.2 Review of the implementation of the 2011-2016 National Nutrition Strategy by LGA and MDA 10 2.2.3 Results of bottleneck analysis (BNA) of selected nutrition interventions at LGA level ............. 12 2.2.4 Successful experiences by LGAs in the implementation of the NNS 2011-2016 ....................... 13
SECTION 3: PROCEEDINGS OF DAY TWO: 27TH OCTOBER 2016 .................................................... 16 3.1 Session 3: Introducing the National Multisectoral Nutrition Action Plan 2016/17 – 2020/21 ...... 16 3.1.1 Overview of the National Multisectoral Nutrition Action Plan (NMNAP).................................. 16 3.1.2 Overview of the NMNAP Common Results, Resources and Accountability Framework (CRRAF) 22 3.1.3 The NMNAP execution strategy ................................................................................................. 24 3.2 Session 4: In memory of Mr. Benedict Jeje and Ms Helen Semu ................................................ 27 3.3 Session 5: Group work and feedback ........................................................................................ 27 3.3.1 Introduction to group work ........................................................................................................ 27 3.3.2 Reports on group work ............................................................................................................... 27
SECTION 4: PROCEEDINGS OF DAY THREE: 28TH OCTOBER 2016 .................................................. 34 4.1 Session 6: Strengthening the synergies between nutrition and sectoral programmes ................ 34 4.1.1 Nutrition program mapping: Who is doing what and where? ................................................... 34 4.1.2 Nutrition and TASAF’s Productive Social Safety Net (PSSN) program ....................................... 36 4.1.3 Nutrition and Agriculture, Livestock and Fisheries .................................................................... 38 4.1.4 Biofortification: A double edged sword to fight food insecurity and hidden hunger................ 40 4.1.5 Nutrition and Education ............................................................................................................. 41 4.1.6 Integrating water, sanitation and hygiene (WASH) into nutrition ............................................. 42 4.2 Session 7: A tribute to the late Dr. Urban Jonsson .................................................................... 43 4.3 Session 8: Development and adoption of recommendations ..................................................... 45 4.4 Session 9: Closing session ........................................................................................................ 45
Section 5: APPENDIXES .............................................................................................................. 46 Appendix 1: Members of the organizing committee for the 2015 JMNR ............................................... 46 3
Appendix 2: list of participants to the 2016 JMNR3.............................................................................. 47 Appendix 3: Agenda for The 2016 Joint Multisectoral Nutrition Review (JMNR3) ................................. 57 Appendix 4: Objectives, methodology and key findings of the review of the National Nutrition Strategy (NNS) 2011/12 – 2015/16 ................................................................................................................... 62 Appendix 5: Welcome remarks by the Tanzania Food and Nutrition Centre .......................................... 65 Appendix 6: Opening remarks by UNICEF on behalf of the United Nations ........................................... 67 Appendix 7: Opening speech by President’s Office –Regional Administration and Local Government .... 69 Appendix 8: Closing speech by President’s Office –Regional Administration and Local Government...... 74
Tables Table 1: Recommendations of the 2016 and Third Joint Multisectoral Nutrition Review (JMNR3) ................... 7 Table 2: The NMNAP key targets to be achieved by 2021 ................................................................................. 18 Table 3: Investment plan for the NMNAP 2016-2021 ........................................................................................ 19 Table 4: NMNAP funding gap ............................................................................................................................. 19 Table 5: NMNAP resource mobilization plan ..................................................................................................... 20 Table 6: Example of CRRAF using key result area of MIYCAN ............................................................................ 22 Table 7: NMNAP implementation: Feedback from group work on stakeholder contributions
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Figures Figure 1: Before and after impact of Mwanzo Bora “nourish a child program” in Mbulu district Council. ...... 15 Figure 2: NMNAP Coordination structure .......................................................................................................... 20 Figure 3: NMNAP Monitoring, evaluation and learning framework .................................................................. 21 Figure 4: Example of multisectoral nutrition score card .................................................................................... 23 Figure 5: The two execution phases of the NMNAP .......................................................................................... 25 Figure 6: The NMNAP three ONES ..................................................................................................................... 25 Figure 7: The car analogy in the implementation of the NMNAP ...................................................................... 26 Figure 8: NMNAP implementation - functional capacity criticality.................................................................... 26 Figure 9: Coverage of nutrition interventions by district ................................................................................... 35 Figure 10: Distribution of nutrition field implementers 2015/16 ...................................................................... 35 Figure 11: Geographical distribution of funders of nutrition activities
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EXECUTIVE SUMMARY This report1 summarizes the key outcomes of the 2016 and third Tanzania Joint Multi-Sectoral Nutrition Review (JMNR3) held at Julius Nyerere International Convention Centre (JNICC) in Dar es Salaam on 26-28th October 2016. The Review was convened by the Prime Minister’s Office (PMO) High Level Steering Committee on Nutrition (HLSCN) with the organizational support by the Tanzania Food and Nutrition Centre (TFNC) and financial support of several development partners (see title page for list of sponsors). A multisectoral organizing committee chaired by TFNC (see appendix 1 for list of members), provided overall coordination. The 2016 JMNR is the third in a series of joint Government and development partner reviews started in 2014 to monitor progress on nutrition in Tanzania and aiming at addressing any identified challenges and utilizing emerging opportunities to address the unacceptably high levels of malnutrition. The JMNR3 drew a total of over 150 participants from Ministries, Departments and Agencies (MDA), all Regional Nutrition Officers (RNuOs) and selected District Nutrition Officers (DNuOs) from Tanzania Mainland. Representatives from Zanzibar Ministry of Health Department of Nutrition also participated. Others were development partners including donors, United Nations agencies, NGOs, private sector and research and academic institutions. Members of the media participated and ensured key messages from the JMNR3 were delivered to the public (see appendix 2 for list of participants). Objectives The broad objectives of the 2016 and third Joint Multisectoral Nutrition Review (JMNR3) were: i. To review the end-of-term implementation of the National Nutrition Strategy (NNS) 2011–2016, ii. To disseminate the newly approved National Multisectoral Nutrition Action Plans (NMNAP) 20162021 with key stakeholders; iii. To ensure that key stakeholders understand how to strengthen the synergies between nutrition and selected programs; and iv. To facilitate stakeholders to discuss and recommend how they can contribute to the successful implementation of the NMNAP. The specific objectives were: 1) To review the implementation of the NNS 2011-16 paying special attention to: The implementation status of the recommendation of the 2015 JMNR2; Endline review of the overall NNS 2011-2016; and Share experiences of success stories from the implementation of the NNS 2011-2016. 2) To ensure that key stakeholders understand: The expected results and strategies of the NMNAP 2016-2021; Define their roles and responsibilities for successful implementation of the NMNAP 2016-2021; What are the critical elements for successful implementation of NMNAP? 3) To ensure that key stakeholders understand how to strengthen the synergies between nutrition and selected sectoral programs, specifically: Social Protection: Tanzania Social Action Fund (TASAF) Productive Social Safety Net (PSSN) Program; Health: Nutrition in the Health Sector Strategic Plan (HSSP IV); Water, Sanitation and Hygiene (WASH); 1 This report written by Dr. Festo Kavishe, an Independent Human Development consultant and Lead Facilitator for the Multisectoral
Nutrition Action Plan (NMNAP) and the JMNR3, incorporates notes taken by Mr. Adam Hancy of TFNC and the following TFNC rapporteurs: Luitfrid Nnally, Ruth Mkopi, Dr. Ladislaus Kasankala and Julieth Itatiro.
Agriculture, Livestock and Fisheries; Education and early childhood development; and Environment and climate Change Additionally, the JMNR3 was used to launch the 1,000 days SBCC Kit - Mkoba wa Siku 1,000, and pay tribute to the legacy of a giant champion of nutrition – Dr. Urban Jonsson who passed on in March 2016. The agenda The agenda shown in annex 3 was used to ensure that the objectives of the JMNR3 were met using a multisectoral approach that brought together nutrition specific, nutrition sensitive and enabling environment sectors and programmes. Facilitation Dr. Festo Kavishe, an Independent Human Development Consultant and Prof. Andrew Swai, the chairman of the Tanzania Non-Communicable Diseases Alliance (TNCDA) and the Tanzania Diabetic Associations (TDA) cofacilitated the meeting. Structure of the report The report is divided into five sections. Section 1 is an introduction that provides the strategic context of the JMNR3 and the methodology used. Sections 2, 3 and 4 reports on the daily proceedings of the review summarizing the key messages from the session presentations and discussions. Each day was started with a recap of the previous day. Section 5 is an appendix that provides the list of the organizing committee, list of participants, the agenda, the detailed findings of the review of the NNS 2011-2016, and some key speeches made at the JMNR3 that were made available. Recommendations The key output from the JMNR3 meeting was 14 recommendations as shown in table 1 below. The recommendations indicate those responsible for follow up and the timeline to complete the actions.
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Table 1: Recommendations of the 2016 and Third Joint Multisectoral Nutrition Review (JMNR3)
No. 1 2 3 4 5 6 7 8 9
10
11
12. 13. 14.
Recommendations of the 2016 JMNR Continue to follow up on developing regulations to support implementation of the Tanzania Food and Nutrition (TFN) Act no 24 of 1973 as amended in 1995. Follow up on the approval of the revised Food and Nutrition Policy
Responsible institution2 TFNC and MOHCDGEC
Timeline June 2017
TFNC, MOHCDGEC
June 2017
Develop a reader friendly summary of the NMNAP and translate into Kiswahili. Disseminate, advocate for, and communicate the NMNAP at various levels and with nutrition sensitive sectors and other stakeholders. Adopt and use standardized monitoring tools for NMNAP e.g. Multisectoral nutrition score card. Review and harmonize supervision tools for multisectoral nutrition activities for Regional Secretariats and Local Government Authorities (LGA) Roll out “Mkoba wa Siku 1000” (Advocacy package for the 1,000 days window of opportunity) to cover all regions in the country. Develop a resources mobilization strategy for the NMNAP and use it to mobilize resources. Develop a performance based review and rewarding system for good nutrition performing Ministries Departments and Agencies (MDA); Regional Secretariats; Local Government Authorities; private sector, media, CSOs and individuals. Issue a circular to Regional Secretariats and Councils to include in their plans and budgets TZS 1,000 per child underfive years for the financial year (FY) 2017/2018 to support nutrition activities. Use Common Results, Resources and Accountability Framework (CRRAF) reports to inform discussions and decisions in the Joint Multisectoral Nutrition Reviews (JMNRs), Multisectoral Technical Working Groups and High Level Steering Committee on Nutrition (HLSCN) Prepare a consolidated report on review of the implementation of the NNS 2011/122015/16 Prepare report on the 2016 and third Joint Multisectoral Nutrition Review (JMNR3). Disseminate the key findings and recommendations of the JMNR3 during the process for planning and budgeting for 2017/18
TFNC PO RALG, TFNC, PANITA
June 2017 June 2017
PO RALG, TFNC, PANITA
June 2017
PO RALG
June 2017
TFNC, PMO and LGAs
June 2017
TFNC Multi-sectoral Technical Working Group for Nutrition
February 2017 April 2017
PO RALG
By January 2017
PMO, TFNC, RSs and LGAs
On Going
TFNC
June 2017
Facilitators TFNC
November 2016 December 2016
2 Donors, UN Agencies, CSOs, private sector and NGOs will be included in the implementation of the recommendations as needed where relevant.
SECTION 1: INTRODUCTION 1.1
Strategic context
The 2016 and third Joint Multisectoral Nutrition Review (JMNR3) was held against the backdrop of three key nutrition relevant developments in Tanzania: first, the start of the Five-Year Development Plan two (FYDP-II) 2016-2021, which is the first FYDP of the fifth phase Government, whose theme is industrialization and human capital development; second the endline of the 2011-2016 National Nutrition Strategy (NNS), and third the adoption by the High Level Steering Committee on Nutrition (HLSCN) of the five year National Multisectoral Nutrition Action Plan (NMNAP) 2016-2021. It should be recalled that the 2015 JMNR2 assessed the progress made, and challenges in the implementation of the NNS 2011-16 for the first four years of implementation, made several recommendations and adopted a roadmap for the development of the NMNAP 2016-2021 to succeed the NNS. Thus, in addition to reviewing the implementation status of the 2015 JMNR2 recommendations, the 2016 JMNR3 provided an opportunity for endline review of the NNS, and gave stakeholders further in-depth understanding of the NMNAP and an opportunity to plan for their contributions in its successful implementation. 1.2
Methodology of the Review
As for previous JMNRs (2014-2015) and in order to achieve the planned objectives, the 2016 JMNR3 was planned in three phases as follows: -
Phase 1: The pre-workshop period (July – October 2016) entailed intensive preparations to ensure smooth facilitation and engaged participation in the workshop. An organizing committee under the chair of TFNC led this phase. Deliverables included: 1) Preparation of JMNR3 concept note and agenda; 2) Identification of participants, dignitaries and presenters and sending out invitations; 3) Finalization of JMNR3 budget and mobilization of funds; 4) Collection and analysis of data for Financial Year (FY) 2015/16 on implementation of nutrition activities by Regional Secretariats (RS), Local Government Authorities (LGA) and nutrition sensitive Ministries, Departments and Agencies (MDA); 5) Conducting Bottleneck Analysis (BNA) of selected nutrition interventions for FY 2015/16; 6) Calling for abstracts and selecting successful experiences from regions and councils for presentation in JMNR3; 7) Preparation of speeches, presentations and terms of reference for group work; 8) Preparation of exhibitions; and 9) Preparation of other workshop logistics including identification of venue.
1) 2) 3)
Phase 2: The Joint Multisectoral Nutrition Review Meeting (26-28 October 2016). Three days meeting attended by over 150 participants Venue: Mwalimu Nyerere International Convention Centre, Dar es Salaam Exhibition: by interested stakeholders for all three days.
Phase 3: Post JMNR3 actions 4) Preparation of this 2016 JMNR3 report (Lead Facilitator) 5) Dissemination of 2016 JMNR3 report (TFNC) 6) Follow up on JMNR3 recommendations (TFNC)
SECTION 2: PROCEEDINGS OF DAY ONE: 26TH OCTOBER 2016 Arrival, registration of participants and setting up exhibitions Participants were registered on arrival. On invitation by the organizing committee, several stakeholders displayed exhibitions of their work. Those who did so included: TFNC, Mwanzo Bora and COUNSENUTH
2.1
Session 1:
Opening session
The session was started by the TFNC Acting Managing Director introducing the dignitaries followed by selfintroductions by participants. 2.1.1 Welcome remarks by TFNC In her welcome note, Dr. Joyceline Kaganda, the Acting Managing Director of the Tanzania Food and Nutrition Centre (TFNC), welcomed the guests and mentioned the main objectives of the JMNR-3 as (a) to review end-ofterm implementation of the National Nutrition Strategy (NNS) 2011/12–2015/16; (b) to disseminate the National Multi-sectoral Nutrition Action Plan (NMNAP) 2016/17-2020/21 to participants; and (c) to discuss how to strengthen the synergies between nutrition and key nutrition sensitive sectors (health, agriculture, social protection, education and early child development, water, sanitation and hygiene (WASH), and environment and climate change. She then briefly reviewed the current nutrition situation in Tanzania looking at trends, consequences of undernutrition in the early years and how it affects nutrition in later life in terms of education performance and work productivity. Dr. Kaganda noted that the JMNR3 marked the official review of the NNS 2011-2016, thanked all stakeholders who supported its implementation and noted that the end of the NNS in June 2016 paved the way for the start of the NMNAP 2016-2021 that was approved by the High Level Steering Committee on Nutrition (HLSCN) on 21st October 2016. Lastly, Dr. Kaganda thanked the Prime Minister’s Office (PMO) for steering the process for the development of the NMNAP, TFNC for coordinating the process and all stakeholders who participated in the extensive consultations. Noting funding and implementation as the biggest challenges ahead, she requested the support and commitment of all stakeholders in joining hands with TFNC to support its implementation. To end, she thanked the guest of honour for coming and wished the meeting a fruitful outcome. Her full speech is shown in appendix 5. 2.1.2 Statements from key partner representatives Several key nutrition partners made motivational remarks including the UNICEF Rep on behalf of the UN, Irish Aid on behalf of the Donor Network, PANITA representing CSOs and GAIN representing the Business Network. All congratulated the Government for convening the third JMNR where the implementation of the freshly HLSCN approved NMNAP 2016/17-2021 will be discussed and pledged continued support by their organizations in its implementation. The full speech made by Ms Maniza Zaman, UNICEF Representative on behalf of the United Nations is reproduced in full in appendix 6 as it captures the key messages expressed by all other partners. In summary, Ms Maniza praised the Government for institutionalizing the annual joint multisectoral reviews (JMNR) initiated in 2013 and thanked partners who have sponsored these annual events. She noted that Tanzania has built a strong foundation to address the problem of malnutrition through progressive policies, strategies and plans and mentioned the recently approved National Multisectoral Nutrition Action Plan (NMNAP) 2016/17 – 2020/21 as an excellent example. She also noted that despite good progress made in addressing malnutrition, the levels are 9
still unacceptably high and that the NMNAP is a good platform that allows all nutrition stakeholders to come together to address the nutrition challenge collaboratively using a multisectoral approach with strong Government leadership. She reiterated the United Nations commitment and support to nutrition in Tanzania through the NMNAP. 2.1.3 Opening speech by Guest of honour Dr. Zainab Chaulla, Deputy Permanent Secretary (Health), President’s Office Regional Administration and Local Government (PO-RALG) officially opened the meeting. She noted that the meeting was timely not only in terms of reviewing the progress Tanzania has made in the implementation of the National Nutrition Strategy 20112016, but also to incorporate into national plans several nutrition relevant global commitments that Tanzania is a party to including Agenda 2030 on Sustainable Development Goals (SDGs), the UN Decade of Action on Nutrition 2016-2025, the World Health Assembly nutrition targets for 2025, the 2025 voluntary NonCommunicable diseases targets and the Comprehensive Implementation Plan on Infants and young child nutrition, among others. She was happy that the recently Government approved National Multisectoral Nutrition Action Plan (2016-2021) reflects both the global and national nutrition agenda and is aligned with the national Five Year Development Plan II (FYDP II) whose theme is “nurturing an industrial economy and human development”. She was delighted that this theme was also reflected in the meeting’s theme “Nutrition for human capital development: Invest now for future prosperity”. Dr. Chaulla reiterated Government’s commitment to support nutrition, noting recent government actions as follows: mainstreaming nutrition in the FYDP II (2016/17 – 2020/21), setting up of multisectoral coordinating committees at all levels, increasing budget allocation and spending on nutrition by Councils and the Government’s directive to Councils to increase the budget for nutrition from TZS 500 to TZS 1,000 per child under five years in the 2017/18 budget. She ended by calling on all stakeholders to support the Government’s efforts in addressing the unacceptably high levels of malnutrition in the country through the National Multisectoral Nutrition Action Plan 2016-2021 and thanked all those who provided resources to make the meeting a success. 2.1.4 Launch of the SBCC kit (Mkoba wa siku 1,000) The guest of honour then handed over the Nutrition Social Behavioural Change Communication (SBCC) kit (Mkoba wa siku 1,000) from Mwanzo Bora Nutrition Programme to the National Nutrition Alliance. 2.1.5 Presentation on objectives and agenda of the meeting Representatives from the PMO reminded the participants of the key objectives of JMNR3 as shown in the executive summary.
2.2
Session 2:
Endline review of the National Nutrition Strategy (NNS) 2011/12 – 2015/16
2.2.1 Progress on the implementation status of the 2015 JMNR2 recommendations Ms Maria Msangi of TFNC presented progress on the 10 recommendations of the 2015 and second JMNR2. She noted that 8 of the 10 recommendations were fully implemented and the remaining two were still work in progress. These were the recommendations on the updating of the 1992 Food and Nutrition Policy and Review of TFNC Act, which are at various stages of implementation. A revised (2016) Nutrition Policy is awaiting acclimatization with new leadership at the MoHCDGEC for submission to cabinet and discussions on the revision of the TFNC Act 1973 and development of related regulations is ongoing. 2.2.2 Review of the implementation of the 2011-2016 National Nutrition Strategy by LGA and MDA Mr. Geofrey Chiduo of TFNC reviewed the implementation status of the NNS 2011/12-2015/16 by Local Government Authorities (LGA) and Ministries, Departments and Agencies (MDA). Since this is an endline review, the objectives, methodology and key findings of the NNS review are reproduced in appendix 4 as a record of the review, which to a large extent can be considered as an end-evaluation of the NNS 2011/16 – 2015/16. Briefly, 10
the presentation provided an overview of the NNS and its implementation plan, the objectives of the NNS assessment, the methodology used, the key findings in terms of physical and financial implementation and alignment of activities with the NNS, a summary of the key findings, limitations of the assessment and suggested a way forward. The broad objective was to review implementation of the NNS by LGAs and MDAs from 2011/12 to 2015/16 in order to assess progress made, gaps and challenges. The data collection process was overseen by a task team formed in 2014 from TFNC with technical support from UNICEF for the purpose of collecting data on the implementation of the NNS for use in the JMNRs of 2014-2015. For the 2016 JMNR3, the task team used the same data collection tools developed in 2014 and trained data collectors who were Regional Nutrition Officers (RNuOs), District Nutrition Officers (DNuOs) and Focal Persons at Ministries, Departments and Agencies (MDAs) levels in July 2016. The data was received by Individual Regional Secretariats, Councils and MDAs in excel databases in August 2016, after which it was cleaned, consolidated and analyzed as basis for developing the presentation in appendix 4. There were several key findings: 1) There was continuous increase in the average number of planned and completed activities although not all planned activities were completed. 2) Although there was a progressive increase in the funding and spending on nutrition activities by LGAs, actual spending was lower than planned budget (only 61% was spent) due to late disbursement of funds among others. 3) Sectors that had high spending of their allocated budget were planning, coordination and budgeting (96%); education (80%); health and social welfare (72%); agriculture and food security (72%); and community development gender and children (52%). 4) The largest proportion of funds were planned (56%) and spent (66%) at the Council level an indication that both budgeting and spending occurred at a level closest to the community. 5) There was not adequate alignment of spending on nutrition with the burden of malnutrition. For example, regions with high caseload of stunting spent less than those with low caseloads. 6) There was poor alignment between the NNS and the activities implemented by the LGAs. Most were of low nutrition impact and did not fit well in any of the 8 objectives of the NNS. The main limitations of the review of the NNS were: There is no standard list of nutrition-sensitive interventions. Some activities that are in the database might have no proven impact on reducing malnutrition Questionnaires were self-administered and the orientation of respondents was limited. This can lead to non-harmonized classification of activities into different categories by respondents. Most nutrition related activities that were not included in district plans were not captured in the assessment by LGAs (i.e. projects directly implemented by development partners, in kind donations and supplies).
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The main recommendations were: 1)
The National Multisectoral Nutrition Action Plan (NMNAP) 2016-2021 should address the key weaknesses of the NNS 2011-16. This was done including (i) using the principle of three ONES to ensure a common plan, a harmonized stakeholder coordinating system and a common results, resources and accountability framework. Moreover, the NMNAP has a clear costing which was developed through a detailed activity based budget, the inclusion of key nutrition sensitive sectors as well as a list of key nutrition sensitive activities.
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2)
3)
A new review tool for the JMNRs be developed and adapted to the NMNAP. Its design should be in collaboration with the President’s Office – Regional Administration and Local Government (PORALG) and TFNC. To have the full picture, as a start, a parallel review should be done for activities directly implemented by development partners, led by the development partners group on nutrition (DPGN) and PANITA and find ways to incorporate them into the three ONES principle as required by the NMNAP.
2.2.3 Results of bottleneck analysis (BNA) of selected nutrition interventions at LGA level Mr. Mwita Waibe from PORALG Dodoma, made this presentation, looking at the purpose of the BNA, the methodology used, the key findings and the way forward for the next 15 months. The five critical interventions for young child and maternal nutrition selected for the BNA and their current coverage were: (i) counselling on appropriate minimum adequate diet for infant and Young Child Feeding - IYCF (20% coverage); (ii) treatment of severe acute malnutrition (SAM) among children (10% coverage) (iii) Vitamin A Supplementation (VAS) for children (72% coverage), and (iv) iron-folic acid (IFA) supplementation for pregnant women (8.3% coverage). The main reason for doing the BNA was to systematically assess the main determinants of effective coverage of the selected nutrition interventions in order to design evidence based strategies for scaling-up. The methodology used the Tanahashi model on the six determinants of health coverage, looking at the six determinants of coverage. These were: (i) quality and impact (ii) continuity and completion (iii) utilization at first contact of multi-contact services, (iv) physical accessibility of services, (v) availability of human resources, and (vi) availability of essential health commodities. A bottleneck is defined as a significant drop in the coverage of any of these determinants comparing the expected coverage and the observed coverage. The BNA used 5 steps: step 1 – define indicators, identify information sources and then collect coverage data; step 2 – from the data collected identify bottlenecks; step 3 – analyse the causes of the bottlenecks; step 4 - determine solutions at all levels; and step 5 – feed the findings and solutions into corrective plans and actions. The BNA was overseen by a TFNC task team with UNICEF technical support and was carried out May – September 2016. Out of expected responses from 181 councils 137 (76%) responded. The main limitations of the methodology were: (i) poor integration of some indicators in the district health information system (DHIS2), (iii) poor quality of data provided by the district nutrition officers (DNuOs), and (iii) poor participation and understanding by council level planners of the importance of the BNA. Results of BNA: Significant bottlenecks (of below 30% coverage), were noted as follows: Insufficient trained human resources are the main bottleneck across all interventions and in all regions. The main reason for this bottleneck is inadequate training and human resources management. Strengthening supervision and in-service and pre-service training is likely to improve the situation.
Low quality coverage is a major bottleneck in almost all regions for IFA supplementation, SAM treatment and IYCF interventions. Main cause of low quality of services is the inadequate training of Community Health Workers (CHWs), negative attitudes by service providers of some services provided, and erratic availability of some services. Low quality services can be improved through developing positive attitude and capacity of health facility workers to provide quality services (e.g. through training, client oriented services); ensure continuity of services (commodities available consistently, reasonable geographical access etc.).
Frequent stock-outs of commodities is a bottleneck mainly for IYCF and SAM treatment. Geographical accessibility is a bottleneck mainly for SAM treatment; 12
SAM treatment is the only intervention that is significantly affected by all six determinants and in all regions. In terms of follow up, it was proposed that within the next 15 months to (a) share the BNA results with the councils and discuss with the relevant staff the meaning of those results and support application of proposed actions; (b) Councils should use these results to plan for future quality data collection; (c) identify selected interventions based on the NMNAP and start collection of data for presentation and discussion during the 2017 and 4th JMNR, which will be the first to monitor the NMNAP. 2.2.4 Successful experiences by LGAs in the implementation of the NNS 2011-2016 Success stories from two councils and one regional hospital were presented as follows: Iringa District Council: Hospital based Management of Acute Malnutrition Iringa Municipal Council: Partnership for Nutrition action Arusha RAS: Mainstreaming nutrition education and counseling in management of diet related noncommunicable disease (DRNCDs) Mbulu District Council: Managing of severe acute malnutrition through education to mothers using locally made therapeutic foods 2.2.4.1 Experience on management of severe acute malnutrition (SAM) at Tosamaganga Hospital, Iringa Mr. Jeremiah Mwambange, DNuO of Iringa District Council (DC) presented the experience of managing severe acute malnutrition at Tosamaganga hospital, which is the hospital that provides inpatient treatment and management of SAM in Iringa DC. Severely malnourished children are admitted to the special ward called NURU (an abbreviation for Nutrition Rehabilitation Unit). NURU means a “beam of light” in Kiswahili. Despite the international volunteers from CUAMM (an Italian NGO) assisting with the management of SAM, staff is not sufficient in case of emergencies. Treatment is done using F-75, F-100 and Ready to use Therapeutic Food (RUTF) with the amount given depending on the body weight and medical complications of the child. Improved management of SAM at the hospital reduced the mortality rate of children underfive by 50% from a before rate of 14% in 2014/15 to 7% in 2015/16. The main reasons for reduction of mortality were timely distribution of therapeutic foods, regular supervision and improved human resource capabilities in terms of skills, experience and commitment. The main challenge was recurrence of SAM as about 25% of the children treated in 2014/15 were readmitted again with SAM in 2015/16. The main reasons for recurrence was failure to provide enough food of good nutritive value due to: (i) lack of knowledge on food preparation, (ii) Insufficient diversified food at home, (iii) Inadequate support and care to women and children, (iv) Lack of active feeding of children, (v) Negative attitude towards the use of nutrient supplement, and (vi) failure to comprehend nutrition knowledge gained from hospital to their local environment. To address these causes, a Social Behavioural Change Communication (SBCC) follow up project was initiated in order to provide practical knowledge on: (i) How to utilize local available foods, (ii) Food preservative techniques, (iii) Blending of locally available food to make nutritious food for under-fives, (iv) motivate mothers and caregivers to actively feed their children, and (vi) simple home gardening and how to process/add value to the garden produce. The Iringa DC is seeking a partner who could assist to establish a unit at the hospital to help the community change behaviour towards dealing with nutrition problems at family level. 2.2.4.2 Experience on strategic use of limited resources to effectively deliver interventions in Iringa Municipal Council The Municipal Nutritionist, Ms Anzaely Msigwa, made the presentation. The Iringa Municipal Council is implementing several nutrition specific and sensitive interventions including nutrition education, hand washing with soap during the critical hygienic periods (after going to the toilet, during food preparation and when 13
eating), keeping of small animals for food, nutrition supportive supervision, education and inspection of sale and use of iodated salt, production of pond fish for food, vitamin A supplementation, deworming and screening for acute malnutrition using mid-upper arm circumference (MUAC) method. There are several stakeholders supporting nutrition activities in Iringa Municipal Council and they include: UNICEF as main funder, Tanzania Home Economics Association (TAHEA), MWANZO BORA, CUAMM, PAPA YOHANE 23, KIPEPEO, TUNAJALI and ALAMANO. Due to poor coordination of their activities, the Iringa MC facilitated a stakeholders meeting where they agreed to work collaboratively. IMC, TAHEA and Mwanzo Bora did joint activities and supervision from January – September 2016 with regard to meal planning, preparation, developing vegetable gardens and supervision based on the community assessing the performance of community health workers (CHWs) on how they deliver nutrition education using the “mkoba wa siku 1000”. CUAMM provides RUTF for management of severe acute malnutrition. When the council has limited resources to distribute the RUTF, PAPA Yohane 23 distribute the RUTF to the health facilities. The key challenge in distributing RUTF is availability of transport. TUNAJALI provided funding for training of health providers on nutrition assessment, counselling and support (NACS) and for joint supportive supervision of NACS at the health facilities. A joint COUNSENUTH, TFNC, TUNAJALI and IMC supportive supervision was successfully done in August 2016. The overall challenge in doing nutrition work in Iringa Municipal Council is inadequate financial resources and the council is calling for more support from the partners. To facilitate transparency, the resources should be reflected in the Council’s budget and disbursed as planned. 2.2.4.3 Experience on a nutrition education programme for patients with hypertension and diabetes at Arusha Mt. Meru Referral hospital Mr. Prosper Mushi presented their experience at Mt. Meru Regional Hospital in Arusha on a “Nutrition Education Programme and dietary counselling for patients with hypertension and type 2 diabetes. On average, the hospital caters for around 200 clients with diabetes and hypertension every month. Seeing that the counselling was not comprehensive because of human resource constraints, the Regional Nutritionist decided to provide nutrition education to the medical practitioners who were treating such patients, emphasizing the importance of giving patients dietary guidelines relevant to their condition of hypertension or diabetes. The guideline is based on the integration of 4 basic principles; (1) dealing with food groups, (2) glycaemic index (GI) concept, (3) limiting salt (sodium) intake and encouraging use of spices, and (4) lifestyle modification. The introduction of continuous nutrition education to the health care providers increased the referral hospital’s capacity to provide dietary/lifestyle counselling to more than 180 (90%) diabetes/hypertension each month as compared to an initial patient load of 40 per month. The nutrition education programme has been running for about a year and it has been observed that through the health care providers, the programme impacted positively on the quality of life of patients with hypertension and diabetes without the continuous need for the Nutritionist. Moreover, even in the absence of the Nutrition Officer, it was possible to provide nutrition counselling, not only to patients with hypertension and diabetes, but also to patients suffering from other dietrelated non-communicable diseases (DRNCDs). 2.2.4.4 Experience on “NOURISH A CHILD PROGRAM” in Mbulu district council, Manyara region Mr. Magesa Japhari (Mbulu DC) presented on the results of a USAID funded nutrition program in Mbulu DC through Mwanzo Bora. The nutrition program, was started due to the high levels of stunting in Manyara region. TDHS data showed that the levels of stunting, which had declined from a prevalence of 45.8% in 2010 to a prevalence of 36% in 2015/16 was still categorized as severe, and thus the “Nourish a child program. 14
The experience presented was based on an In-depth interview with Zawadi Paulo (the mother of a child called Lucy Boay), who benefited from the “Nourish a Child” program. The interview identified that Lucy’s parents lacked knowledge on: infant and young child feeding, the frequency of feeding a child, complementary food diversification, proper food preparation methods, food hygiene and water sanitation hygiene. The program then supported the following interventions: To the child: child Complementary feeding practices, vitamin A supplementation and de-worming To the parents: iron-folic acid supplementation, de-worming and SP for malaria prevention, and provided knowledge on the following: exclusive breastfeeding for the first six months, home gardening, small livestock keeping, and hygiene and sanitation i.e. use of toilets, water treatment and tippy taps- for hand washing after toilet visits. After two months, the results were spectacular: Lucy who before the program was 23 months and weighed only 5 kg was bouncing and weighed 10 kg at 25 months. The before and after photos below speak for themselves. Lucy’s mother attributed the improvement to her following the advice given: “I followed their advice, and my child is doing well now, unlike in the past. I am very grateful for the assistance from the Mwanzo Bora project for their services that helped to save my child’s life”. The key conclusion from this experience is that “appropriate nutrition, health and care practices during the early years of a child’s life is crucial for improving the child’s nutritional status. Figure 1: Before and after impact of Mwanzo Bora “nourish a child program” in Mbulu district Council.
Held by her mother Zawadi Paulo, Lucy Boay is now an energetic 2-year old with the help of the Mwanzo Bora Nutrition Program
Discussion and issues emerging from the successful stories
Appreciation for innovation and commitment to scale nutrition services using scarce resources Lessons learnt: Problem identification, finding local solutions and sharing challenges and successes is important Proposal: Motivate best performing districts, wards and villages Promote multi-sectoral sharing of success stories (Business, CSOs etc.)
A key question that emerged from the discussion was: “Why do some men run away when there is a serious problem at the household, only to come back when the issue is resolved? I think they should run away when things are good and come back when there is problem” – presenter.
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SECTION 3: PROCEEDINGS OF DAY TWO: 27TH OCTOBER 2016 Recap of day 1 The eyes and ears for day 1 provided a recap of the first day. The recap summarized succinctly the content of the sessions and the key issues identified. These have been incorporated into the report under each session.
3.1
Session 3: Introducing the National Multisectoral Nutrition Action Plan 2016/17 – 2020/21
3.1.1 Overview of the National Multisectoral Nutrition Action Plan (NMNAP) Dr. Joyceline Kaganda, the Ag. Managing Director of TFNC presented a succinct summary of the NMNAP. She outlined the main reasons for developing the NMNAP; the approaches used; the conceptual framework and theory of change; the expected results and strategies; the coordination system; the monitoring, evaluation, accountability and learning framework; the investment plan; and concluded with a few remarks on the usefulness of the NMNAP. Dr. Kaganda cited the main reasons for developing the NMNAP as: 1) 2) 3)
To succeed the National Nutrition Strategy (NNS) of June 2011- June 2016. To implement the 2016 National Food and Nutrition Policy (FNP) and its 10-year Implementation Strategy (2016-2026), which updated the 1992 FNP and its implementation plan. To align the current national nutrition plans and strategies, inter alia, with: o The National Five Year Development Plan II (FYDP-II) of 2016-2021); o The 2025 global nutrition targets adopted by the World Health Assembly; o The 2025 Global Non-Communicable Disease (NCD) targets; o The 2030 Sustainable Development Goals (SDGs) nutrition relevant targets; o The Regional nutrition strategies (African Union - AU, Southern Africa Development CommunitySADC, and the East African Community - EAC).
The NMNAP is a strategic plan document that: 1) Provides the latest national level narrative on nutrition showing the key nutrition trends, the causes, impact, challenges and the evidence base for prioritized actions; 2) Defines the conceptual framework for the proposed interventions and the theory of change; 3) Proposes the expected results, targets and the key strategies to be used; 4) Identifies results-based key activities, workplans and the costs of their implementation in seven key result areas (KRAs): Maternal, Infant, Young Child and Adolescent Nutrition (MIYCAN); Micronutrients; Integrated Management of Acute Malnutrition (IMAM); Diet Related Non-Communicable Diseases (DRNCDs); Multisectoral Nutrition Governance (MNG); Multisectoral Nutrition Sensitive Interventions (MNSI); and Multisectoral Nutrition Information System (MNIS). 5) Proposes a governance and management structure for the NMNAP; 6) Develops a framework for monitoring, evaluation and learning; 7) Develops a strategic investment plan; and 8) Identifies the key risks and mitigation measures in its implementation. Dr. Kaganda explained the process for developing the NMNAP as being guided by a roadmap that was adopted by the 2015 Joint Multisectoral Nutrition review (JMNR2). The process was steered by the PMO, coordinated by TFNC as the engine, and facilitated by Dr. Festo Kavishe, an Independent Human Development Consultant, as Lead Facilitator, who also drafted the NMNAP document. KRA task team facilitators and chairs supported the 16
development of their respective KRA logical frameworks, results frameworks, result based action plans, and result based budgets. UNICEF facilitated orientation on results-based management (RBM), costing and theory of change in defining SMART results. Facilitators and chairs met every two weeks to strategize, harmonize and monitor progress. The process involved extensive participation of stakeholders who included the PMO, PORALG, MDAs, Regions, LGAs, development partners, national and international NGOs, United Nations Agencies, Academia and research institutions and the private sector and individual stakeholders not affiliated with any institution. The NMNAP’s desired change (impact) is that “Children, adolescents, women and men in Tanzania are better nourished leading to healthier and more productive lives that contribute to economic growth and sustainable development”. The conceptual framework and theory of change used was based on the 2013 Lancet Series on Maternal and Child Undernutrition, which divided interventions into those that are (i) nutrition specific (ii) nutrition sensitive and (iii) enabling environment. In order to achieve the desired change (impact), the NMNAP identified seven outcome results, which is one outcome per KRA. The expected outcome results categorized by type of interventions are: (a) Nutrition specific outcome results: 1. Increased proportion of adolescents, pregnant women and mothers/caregivers of children under two years who practice optimal maternal, infant and young child nutrition behaviours; 2. Increased micronutrient consumption by children, adolescents and women of reproductive age (15-49 years); 3. Increased coverage of Integrated Management of Acute Malnutrition (IMAM). 4. Communities in Tanzania are physically more active and eat healthier diet. (b) Nutrition sensitive outcome results: 5. Increased coverage of nutrition sensitive interventions from: i. Agriculture and Food Security; ii. Health and HIV; iii. Water, Sanitation and Hygiene; iv. Education and Early Childhood Development; v. Social Protection and vi. Environment and Climate Change. (c) Enabling environment outcome results: 6. Improved effectiveness and efficiency of nutrition Governance (including coordination and leadership) and response across all sectors, actors and administrative levels; 7. Increased access to quality nutrition related information to allow Government of Tanzania and partners to make timely and effective evidence informed decisions.
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Table 2: The NMNAP key targets to be achieved by 2021
NMNAP Key targets by 2020/21 1.
Reduction in the prevalence of stunting among children under five years from 34 percent in 2015 (TDHS 2015/16) to 28 percent in 2021 (WHA indicator target 1); 2. Reduction in the prevalence of anaemia in women of reproductive age (15-49 years) from 45 percent in 2015 (TDHS 2015/16) to 33 percent in 2021 (WHA indicator target 2); 3. Reduction in the prevalence of low birthweight from 7 percent in 2010 (TDHS 2010) to 5 percent in 2021 (WHA indicator target 3); 4. Increase in the rate of exclusive breast feeding (0-
