“ESSENTIAL NUTRITION ACTIONS” APPROACH - basics

“ESSENTIAL NUTRITION ACTIONS”APPROACHMrs WANE Coudy LYNutrition ADVISORBASICS— SENEGALAPRIL 2009

JUSTIFICATIONS‣ Malnutrition : one of the most serious public healthissues in developing countries :contributes to near 50 % of infant mortality.Increases risks of mortality due to certain diseases/ measles , diarrhea, malaria, ARI.

OBJECTIVES OF ENA‣ The main objective of ENA approach is to contributeto reduce maternal and infant morbidity andmortality‣ Its specific objectives are:increase coverage of Essential Nutrition Actions(80% coverage for each action)Improve quality of services

LES ACTIONS ESSENTIELLES DENUTRITIONNutritionEBF ACFSick child /malnurishedIodineVitamin AIron/ folic acid anddiet

JUSTIFICATIONS‣ Key behaviors selected based on: Proven impact on morbidity and mortality throughepidemiological data Their feasibility Their cost effectiveness Their performance

JUSTIFICATIONS‣ Lancet series 2003,confirmed Optimal breastfeeding , an adequate complementary feeding,vitamin A deficiency control and Zinc supplementation can reduceinfant mortality by 25% in developing countries optimal breastfeeding on its own can reduce that mortality by 13%

TECHNICAL JUSTIFICATIONS OF THE ENA‣ Advantages of exclusive breastfeeding and the risks ofpremature complementary food intake before age of 6months (risks of deaths due to diarrhea, ARI, otherinfections)Foods offered are rarely as nutritious as breastmilk.‣ Need of an adequate complementary feeding rich ofenergy protein vitamins and minerals at 6 months‣ Need of continuous breastfeeding up to 24 months toprevent nutrition deficiencies.

TECHNICAL JUSTIFICATIONS OF THE ENA‣ Impact of vitamin A on infant and maternal mortality :reduction of 23 to 34 %‣ Impact of anemia on pregnancy and the risks ofmaternal and neonatal mortality, low birth weight

TECHNICAL JUSTIFICATIONS OF THE ENA‣ Appropriate nutritional management of the childduring and following sickness reduces the consequencesof the disease and risks of malnutrition‣ Consequences of iodine deficiency (mental disorders,impaired physical and cognitive development of children,abortions, premature deliveries in women and goiter) arereduced with iodized salt consumption

Contacts clef du cycle de la viePrenatal visit: diet,iron/folic acid ,EBF, malariacontrol, deworming, iodizedsaltAccouchement: EBF, diet,vitamin A, iron/folic acid,iodized saltPost natal: EBF, diet,iron/folic acid, iodized saltImmunization: BF, ACF,vitamin A, deworming, iodizedsaltWell child visits: GMP,assess and counseling on BF,ACF, vitamin A, deworming,iodized saltSICK CHILD VISIT:monitoring of growth , diet,treatment according to IMCI,feeding counseling, treatmentof anemia, check for vitamin Asupplementation, deworming

IMPLEMENTATION STRATEGIES‣ Integration into health services‣ Partnership with the community‣ Communication plan

PAIN IN SENEGAL‣ 1997: Implementation of a CommunityNutrition program in the district of Dioffior: Weighing of children 0 to 3 years by community relays Assessment of children growth Feeding counseling (EBF, ACF, hygiene, etc…) Nutritional management of moderate malnutrition Referral to the health facilities

CONTEXTE / HISTORIQUE PAIN AU SENEGAL‣ 1997: Implementation of PMN (Minimum Package ofNutrition) at health facilities in the districts of Sokoneand Koungheul Advocacy near Ministry of health Joint situational analysis (national, regional and district) Review and update of norms and protocols:‣ Duration of EBF‣ Adoption of WHO recommendations on vitamin Asupplementation Adaptation of existing : registers

CONTEXTE (suite)‣ 1998: Rapid assessment of the two experiences.‣ 1998: Workshop on sharing results Good introduction of nutrition activities in the healthfacilities More nutrition actions promoted in the PMN (iron, vitaminA, iodine) Good community base in the GMP program‣ Integration of the two approaches‣ Birth of PAIN (Package of Integrated Nutrition Actions) in1998 adopted as national strategy by MSP

LES ACTIONS ESSENTIELLES DENUTRITIONIron/ folic acid anddietEBFACFNutritionSick child /malnurishedVitamin AIodineGrowth monitoringand promotion

INTEGRATION OF PAIN INTO HEALTH FACILITIES‣ Review of interventions by contact‣ Set up and use of adapted management materials‣ Capacities development of health workers(training and supervision)‣ Planning of community extension

INTEGRATION OF PAIN AT COMMUNITY LEVEL‣ Identification of exciting community groups: WG,CHW, matrons, Community Relays,‣ Negotiation for their involvement‣ Use of Community GMP activities as vehicles

INTEGRATION OF PAIN AT COMMUNITY LEVEL‣ Capacities building of community workers‣ Set up of adapted management tools(registers, report sheets, etc..)‣ Provide materials (scales, IEC tools, iodinetesting kits ...)

COMMUNICATION PLAN‣ Review of existing IEC/BC strategies and materials inSenegal‣ Identification of missing informations (nutrition ofpregnant women, complementary feeding)‣ Complementary qualitative research‣ Development of messages (behaviors to promote,targets and channels)

COMMUNICATION PLAN Development of IEC materials PRINTED MATERIALS• Counseling cards,• posters,• Job aids RADIO• Radio Spots in local languages• Audio cassettes• Development of Profiles Application for Senegal forNutrition advocacy,

COMMUNICATION PLANDevelopment of other tools in the integration with community IMCI (PIC):PRINTED MATERIALS Child Survival Counseling cards, Integrated Health card , Messages guide Posters‣ RADIO Radio series in 2 versions‣ ORAMEDIA5 Sketches of about 10–15 mn (live spectacle /film)Songs / jingle2 poems

OTHER NUTRITION ACTIVITIES TO REINFORCE PAIN‣ Breastfeeding : Baby friendly Health Centers,Breastfeeding Week.‣ Vitamin A: JNV, JNM, Integration in Bamako Initiative ,Child Health and Nutrition Week, JLM‣ Positive Deviance : (Koungheul) Strengthening of thenutritional management of the malnourished child atthe community level‣ New concepts of Community Monitoring and Promotionof Growth of children 0 to 2 years

SCALING UP OF PAIN 2 districts test in 1997 In 2006: 5/11 regions; 22/ 52 districts, 341 health posts;114 local collectivities (BASICS) 891 health workers; 4594 community relays trained 235 Salter scales , 2173 counseling cards distributed Partnership with NGO (WV, CCF, PI, APSPC), InternationalOrganizations (UNICEF, PRN/WB) In total, 10/11 regions, 46/52 districts were implementingPAIN in 2006

Nutritional Status of children 0 to 5 years in Senegal252015105UnderweightStuntingWasting0EOI 96MICS2000EDS IV2005

Exclusive breastfeeding in Senegal35302520151050EDS 92 EIO 96 MICS2000EDS IV2005EBF

EBF: Results of BASICS evaluations50454035302520151050DHS 97Eval 99RAP 2003

Vitamin A Supplementation of children 6-59 months100908070605040302010National0eBASICSEIO96JNM2000JNM2001JNM2002JLM2004JLM2005JLM2006

MAJOR ACHIEVEMENTS‣ PAIN adapted as national strategy andintroduced into Nutrition national policy‣ Integration of vitamin A in Bamako Initiative‣ Development of Norms and Protocols inNutrition

MAJOR ACHIEVEMENTS‣ Multiplication of contacts for Nutrition activities‣ Increase of coverage of services: Coverage ofmore than 80% with vitamin A throughorganization of JNM, JLM, Health and NutritionWeeks‣ 11 Health Centers and 4 regional Hospitals 1998

MAJOR ACHIEVEMENTS‣ Development of Senegal Profiles Applicationfor Nutrition Advocacy‣ Development of IEC strategies and tools (PIC)‣ Use of training and IEC materials by partnersfor scaling up

MAJOR ACHIEVEMENTS‣ Integration with other health programs :‣ PAIN used as entry point for community IMCI‣ PAIN integrated to Perinatal and neonatalhealth

MAJOR ACHIEVEMENTS‣ Facilitated the adaptation of Global strategy ofInfant and Young Child in Senegal‣ Development of the national strategic plan forfoods fortification with micronutrients inSenegal.

LESSONS LEARNED‣ It is essential to involve all the concerned actorsin particular the policy makers and communityleaders in all steps of implementation forappropriate ownership of the approach‣ Different levels of instruction of communityworkers should be taken into account : Adapt trained and management tools And/or support alphabetization

LESSONS LEARNED‣ Integration of the nutrition programs : Infant and young child Nutrition Maternal Nutrition Micronutrients‣ A better synergy and rationalization of costs(training for example)

LEÇONS APPRISES‣ AEN facilitates integration of Nutritionactions to other health programs– IMCI– Neonatal Health

LESSONS LEARNED‣ Develop effective communication strategies withintensification of messages through differentchannels (printed materials, radio, televisiontheaters, etc.…) constitute important element ofsuccess‣ Partnership with community helps : Increase coverage Cost sharing

LEÇONS APPRISES‣ Work with existing community networkfacilitates implementation‣ ONG play an important role in quick scaling upin the community

LEÇONS APPRISES‣ For sustainability of activities, it is importantto: Identify and adopt motivation systems specific toeach community Identify local sources of financing activities(training, furniture and materials)

PERSPECTIVES‣ ZincBased on new evidences Zinc supplementation appearsto have proven impact certain on nutrition and mortalityoutcomes. Zinc will probably be included in thepackage.‣ Integration in other sectors: Food Security Water, sanitation, hygiene Family Planning

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