A few countries have demonstrated how improvements in nutrition can be achieved. Notable 76
among these are Rwanda, Malawi and Peru .
Rwanda
The District Plans to Eliminate Malnutrition (DPEM) models in Rwanda and the process by which they are developing have useful lessons for Zambia's new First 1000 Most Critical Days programme. The development of a national template for a multisector decentralised response to the prevention of stunting proved to be a necessary step in guiding district level plans. The need for advocacy at provincial and district levels and multisector orientation on how to effectively use the templates also proved important. Rwanda's system of Community Health Workers (4 per village) is a major asset. Funding from UNICEF and others supported key national meetings; workshops and technical assistance that helped introduce and facilitate district work on the DPEMS.
The Rwanda experience demonstrates the importance and impact of on-going commitment by senior government officials. In national efforts to effectively treat acute malnutrition, while setting up the more complex measures to prevent stunting in young children, this commitment is clearly found in Rwanda, in the leadership of the current Health Minister, Dr. Agnes Binagwaho. In her former position as MoH Permanent Secretary, she led and followed up continually on the development of these nutrition programmes. She guided donors and assured necessary intersector collaboration was adhered to at all stages. Now in the position of Health Minister and this bodes well for Rwanda national efforts to substantially lower the prevalence of stunting among children less than two years of age
Malawi
The main messages of the SUN 1000 Special Days in Malawi relate to the Essential Nutrition Actions (ENA). These are well developed in several Eastern African countries and in Zambia as well. The strategy calls for innovative monitoring displays linked closely to cross-sector planning and programme adjustment at district level. However, progress on the operational side of the Malawi project has been slow with a lower than anticipated level of coordinated funding.
In both Malawi and Rwanda there is strong consensus that the SUN package of interventions includes what is needed for national programmes to prevent stunting. Many of these interventions are already in place in each country although gaps exist in terms of effectiveness and in some cases scale. The overall set of interventions can best be viewed as the responsibility of multiple sectors in terms of related services. However, these interventions often have an “intrasector” characteristic as well. This is found when such services are in the domain of more than one department of ministries such as health, rural development and agriculture. Coordination and collaboration efforts need to consider this. Coordination and visible, high-level leadership and commitment are both important to the successful development and operations of such programmes.
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UNICEF. Tracking Progress..
Strengthening and integrating their delivery, increasing community awareness, knowledge, participation and commitment to the actions and services needed to prevent stunting in children are necessary elements of a national SUN programme. While accepted, as important, monitoring systems need to be operational at all levels from national to the community. Information obtained needs to be linked not only to policy makers and donors but also into the on-going operational regular discussions and decisions, particularly at decentralised levels.
Building national ownership of such multisector efforts requires champions inside and often outside government in NGOs and Civil Society. There is great room for media creativity and private sector participation. 1000 Days, 1000 Special Days, 1000 Precious Days in the Land of 1000 Hills and First 1000 Most Critical Days each give a human face to national efforts to Scale up Nutrition and prevent stunting in young children.
Peru
One reason for the continued high prevalence of stunting in Peru is the perception that undernutrition is primarily a food security issue. But in some regions of the country, more holistic, community-based efforts to improve basic health practices have led to an reduction in stunting levels among young children.
In 1999, the programme 'A Good Start in Life' was initiated in five regions – four in the Andean highlands and one in the Amazon region – as a collaboration between the Ministry of Health, USAID and UNICEF. Efforts focused on reaching pregnant and lactating women. Methods included such community-based interventions as antenatal care, promotion of adequate food intake during pregnancy and lactation, promotion of exclusive breastfeeding of infants under 6 months of age and improved complementary feeding from six months, growth promotion, control of iron and vitamin A deficiency, promotion of iodised salt, and personal and family hygiene. Programme teams were led by local government, which worked with communities, health facility staff and local non- governmental organisations. The programme emphasised strengthening the capacity and skills of female counsellors and rural health promoters.
By 2004, it covered the inhabitants of 223 poor, rural communities, including approximately 75,000 children under 3 years old, and 35,000 pregnant and lactating women. A comparison between 2000 and 2004 shows that in the communities covered by the programme the stunting rate for children under 3 years old declined from 54 per cent to 37 per cent, while anaemia rates dropped from 76 per cent to 52 per cent. The total cost of the programme was estimated to be US$116.50 per child per year. 'A Good Start in Life' inspired the design and implementation of a national programme, which has since been associated with reduced stunting rates.
There are many additional lessons to be learned from early work on developing, implementing and scaling up these programmes. Support is needed for innovative operationally focused documentation and information sharing within and across such national scale efforts.