Why ENA

1
ESSENTIAL NUTRITION ACTIONS

• Why ENA?
• What is ENA?
• How does it work ?

Tina G. Sanghvi, PhD Deputy Director (Tech.)
BASICS II USAID Global Health Mini-University
"Program Science in Action" May 10, 2004
2
Why ENA?
3
Trends in Child Malnutrition by Region
4
Prevalence of anemia 5
Major Causes of Death in

Associated with Malnutrition 60
Severe
Sources EIP/WHO, Caulfield LE, Black RE. Year
2000
6
Malnutrition and Infectious Diseases
Measles
7
Deaths in Children Preventive Interventions
Black Caulfield, From Jones et al, Lancet 2003
In 42 Countries with 90 of Global Deaths in 2000
8
Endemic Iodine Deficiency
IQ reduced by 13.5 points
Permanent!
9
Foundation for Achieving MDGs

• Poverty, productivity
• Mortality, health
• Education, cognition

10
Causes of malnutrition

• At birth, poor stores and limited growth
  potential
• Inadequate breastfeeding (
• Inadequate complementary feeding (6-23 m)
• Deficiencies vitamin A, iron, iodine, other
• Frequent infections and poor recovery

11
Essential Actions 6 Proven Interventions
12
Unmet Needs for ENA
The figure shows current levels of six key ENA
indicators in developing countries. The weight
for age indicator is a proxy for appropriate
complimentary feeding. Countries included in the
figure were selected from the 42 countries with
the highest numbers of child deaths, as
identified in Black et al, 2003. Countries with
sufficient and available DHS data (1998 to 2002)
for the key indicators were included India,
Tanzania, Uganda, Mali, Malawi, Zambia, Nepal,
Egypt, Cambodia, Rwanda. Data for iodized salt
was not available for Nepal and Tanzania. The
data for vitamin A supplementation in Egypt is
for children 12-23 months rather than 6-59.
13
Benefits and Costs of Interventions
Increase in DALYs (log scale)
Vitamin A
Breastfeeding promotion
Cost per intervention or per intervention-year
(log scale)
DALYs Disability adjusted life years
14
Return on Investment
Cost 1 US

• Low estimate

Benefit 8-20 US
PROFILES
15
What needs to be done? What is ENA?
16
Malnutrition Happens Early
Weight-for-Age by Region
Source DHS
17
How maternal and child nutrition are linked
18
Lines of Work - Essential Nutrition Actions
Family Practices and Demand

• Early initiation of BF
• Exclusive BF 6 m
• Appropriate CF (age, qty, qlty)
• Maternal diet work
• Compliance with supplements
• Use of iodized salt
• Use of nutrient dense foods
• Caring practices

Delivery/Access to Micronutrients
Care of Sick and Malnourished

• Vitamin A supplements
• (6-monthly)
• Iron /folic acid tablets
• (routine)
• Iodized salt
• Nutrient dense foods including fortified foods

• Increase BF
• Continuation of food
• Extra micronutrients
• Extra food and BF following acute phase
• Monitor return to normal grade
• Health care

19
Family Practices, Demand

• ISSUE Need to address motivations
• Caregivers/mothers interpersonal counseling
• Convince family/community decision-makers
• Shift community norms
• Food security may be an issue for 5-20 HH
• APPROACH Mass movement created in favor of
  desirable practices must reach large numbers of
  varied audiences with practical solutions to
  common barriers
• HOW Multiple channels, high intensity, sustained
  exposure, simple do-able actions

20
Delivery/Access to Micronutrients

• ISSUE Choice of fortification/supplements
• Supplements Health services driven, fixed
  facilities, outreach, market??
• Fortification Food processing industry driven,
  simple technology, access by poorest?, regulatory
  systems
• APPROACH Vitamin A biannual supplement
  distribution/ combined fort-supplements
• Iron Routine supplementation linked to
  IMCI/malaria/mmunization/ deworming,
  fortification
• Iodine Iodized salt
• HOW Collaboration with private sector,
  integration
• with health

21
Care of Sick and Malnourished Children

• ISSUE Linking communities with health services
• Detection care-seeking by HH for sick children,
  routine growth monitoring, surveys, HIV AIDS
  testing
• Treatment/care Community-based approaches, role
  of health workers, HIV and children of HIV
• APPROACH Hearth/Positive Deviants approach
  with referral and follow-up
• HOW Integration with primary health care and HIV
  AIDS programs

22
Main Components of ENA

• Community mobilization
• Communications
• Health services
• Policy
• Coordination and links
• Scale strategy

23
Essential Nutrition Actions 6-6-3

• Essential to achieving Millennium Development
  Goals
• Poverty and equity
• Health and survival
• Cognition and education
• The ENA package is cost-effective, feasible,
  measurable, and has high/immediate impact!
• Nutrition
• 6 priority interventions at 6 critical lifecycle
  stages

• WHY?

• WHAT?

• Priority Interventions
• Breastfeeding
• Complementary feeding/diet
• Care of sick, malnourished
• Vitamin A
• Iron
• Iodine

• Critical Lifecycle Stages
• Pregnancy
• Delivery
• Infants
• Young children
• During and after illness
• Adolescence/youth

Actions through 3 channels 1.   Community
structures 2. Communication networks 3. Health
and social services

• HOW?

24
Lessons Learned
25
Madagascar

• Problem
• Low coverage
• Capacity of the health system particularly
  following the move to decentralize health
  services
• Low community participation, access to basic
  health services
• Inadequate coordination among donors and NGOs
• Out-dated policies, processes, and frameworks
• Lack of preparedness for emergencies.

26
Guiding Principles

• Communities improve their own reproductive and
  child health practices
• Phased, bottom-up evidence
• Initial focus preventive household behaviors
• Integrated services for the convenience of
  families
• Maximize scale districts health teams and
  partners, engines of replication.
• Four-levels starting with communities, districts

27
Results

• Increases in the use of child survival
  interventions in the first implementation sites
  in two districts located within Antananarivo and
  Fianarantsoa provinces during 19961998
• Increases in the use of CS, RH, and nutrition
  interventions in the expanded program areas of
  Antananarivo and Fianarantsoa provinces during
  20002002
• Expansion in geographic scale from two districts
  to 23 districts during 19992002.
• Nationwide scaling up underway now.

28
Critical Step - Formation of Coordinating Body
GAIN

• More than 75 representatives from 50
  organizations
• Government ministries (health, finance,
  education, agriculture, trade, population)
• Donor Community
• NGOs
• Informal functioning with attendance driven by
  personal interest
• Action-oriented organization
• Support provided by USAID TA

Groupe dActions Inter-Sectoriel en Nutrition
29
Key Approaches

• High frequency and intensity of BCC
• Training health staff in clinical and counseling
  skills, ICP, and supervision
• Small, do-able actions for HH behaviors
• Support for CBOs, leaders and volunteers
• Many sectors
• Linked district to regional and national levels
• Advocacy (e.g. using PROFILES, celebs)
• Mass media and communications
• Systems strengthening protocols, supplies, M
  E, rapid assessments, training, pre-service
  education

30
Success Factors

• Consensus at all levels, networking, coalitions
• Partnerships public/private, govt./NGOs,
  university
• BF as the integrating intervention across CS and
  RH and entry point for health issues
• Use of existing CBOs to fast-track
• Investments in sustainability e.g. pre-service
  curricula reform and organizational capacity
• High level of expertise, credibility
• Continuity in technical and financial support
• Transforming threats and crises into
  opportunities
• Strong sense of volunteerism among the Malagasy
• Large number of grassroots organizations

31
India

• Program Context
• Enormous, diverse
• Stagnant indicators
• Difficult socio-cultural environment
• class, caste and gender discrimination
• Large community-based platform
• Poor coordination between the two important
  national programs (ICDS and RCH)
• Strong partner -CARE facilitator, catalyst and
  capacity builder

32
ENA Program Start-up

• Assessments need to re-focus on prevention
• Gaps Behavior change, counseling on infant
  feeding, Vitamin A and Iron
• Outdated, lack of basic information
• Process focus, not outcomes
• Mechanical activities - lack of content and
  quality
• Lack of coordination

33
Shift in Focus

• BEFORE
• Target Group Children under six
• Indicator of children in Grades 3 and 4
  malnutrition

• AFTER
• Children
• Impact Indicators
• Normal grade
• following feeding recommendations
• consuming IFA supplements
• receiving 5 doses of vitamin A

34
Intervention Focus

• BEFORE
• Food Distribution
• Antenatal, IFA distribution

• AFTER
• Individualized problem solving for
• Early initiation, EBF through 6 months
• Complementary Fdg. quality/quantity
• Feeding during and after illness
• Maternal and child IFA consumption
• 5 vitamin A doses (9-36 months)
• Promoting adequate weight gain

35
Approach

• BEFORE
• Meeting quotas for food dist.
• Detecting and follow up of severe grades of
  malnutrition
• 1 dose of vitamin A
• RCH not responsible for nutrition

• AFTER
• ICDS and RCH equally responsible
• Defined priorities of front line workers and
  supervisors

36
Priority Activities

• Effective counseling skills in promoters/providers
  
• BCC At least 5 different channels per village
  with action messages on specific do-able actions
• Monitoring Normal grade children 1-3 years,
  EBF/CF (through Supervisors checklist), vitamin A
  (1st and 2nd doses), IFA consumption in women and
  children 1-3 years
• Supplies Vitamin A, IFA, IEC materials for
  service providers and Change Agents
• Supervision emphasis on feeding practices,
  Normal grade, counseling skills and completion
  of Vitamin A and IFA doses
• Achieving SCALE

37
CARE/India Scale Strategy

• 1. Identify demonstration and replication sites
  19, DS distributed evenly
• 2. Accelerate 4 processes or Best Practices -
  vehicles for technical interventions
• 3. Deepen technical content once processes in
  place, sequencing by relative difficulty in
  achieving outcomes ENA, NBC, immunization, RH,
  HIV
• 4. Build capacity in govt., NGOs, address
  institutional issues
• 5. Documentation with evidence

38
Best Practice Example Nutrition and Health Day
Monthly outreach sessions in the village
39
Best Practice Example Change Agents
Volunteer promoters 120-25 households
extension of ICDS AWW 1200-250 households
40
Results from Early Learning Sites

• Exclusive Breastfeeding to 6 months
• 69.3 in ELS vs 59.6 in non-intervention sites
• Vitamin A (first dose)
• 59.5 in ELS vs 43.2 in non-intervention sites
• Consumption of 90 IFA
• 59.8 in ELS vs 41.1 in non-intervention sites
• Solid food initiated in 7th month
• 38.5 coverage in ELS vs 23.9 in
  non-intervention sites

41
What Has Not Worked

• Screening and treating
• Large/older age groups
• Vertical, isolated
• Intensive, small-scale projects
• Health systems-dominated, clinical
• Insufficient monitoring, communications, systems
  support
• Starting from scratch

42
What has Worked

• Preventive actions, universal coverage
• Youngest age groups
• Community platforms at scale, partnerships
• Removing barriers to desirable behaviors
• Links with CS and RH
• Systems support
• Building on what exists

43
Barriers to Scale

• Lack of a explicit strategy
• Lack of buy-in across key decision makers
• Strategies too complicated
• Lack of joint planning and coordination
• Inadequate readiness to replicate ID
  replicators, definition of core and flexible,
  tools
• Dilution during transition from early to
  expanded sites
• Capacity building and monitoring not linked to
  problem solving for scale
• Motivation and rewards critical for sustaining
  progress

44
Essential Nutrition Actions 6-6-3

• Essential to achieving Millennium Development
  Goals
• Poverty and equity
• Health and survival
• Cognition and education
• The ENA package is cost-effective, feasible,
  measurable, and has high/immediate impact!
• Nutrition
• 6 priority interventions at 6 critical lifecycle
  stages

• WHY?

• WHAT?

• Priority Interventions
• Breastfeeding
• Complementary feeding/diet
• Care of sick, malnourished
• Vitamin A
• Iron
• Iodine

• Critical Lifecycle Stages
• Pregnancy
• Delivery
• Infants
• Young children
• During and after illness
• Adolescence/youth

Actions through 3 channels 1.   Community
structures 2. Communication networks 3. Health
and social services

• HOW?

45
Package of Essential Nutrition Actions key to
major gains for maternal and child health,
education, productivity
For more information www.basics.org