Nutrition situation worsening in the country Current Crisis - Yemen KEY FIGURES 22.2 million Total affected population 11.3 million Total affected children (<18) 2.9 million people (1 million children) Have been internally displaced 16.37 million / 51% children Need basic healthcare Nutrition situation worsening in the country 1 out of 3 children is at risk of acute malnutrition. 1 out of 5 PLW is at risk of acute malnutrition. 1 out of 2 children under 5 year is stunted. 9 in 10 children age 6-59 months (86 %) are anemic. (DHS – 2014 ) 7 in 10 women age 15-49 (71%) are anemic as well. (DHS – 2014 )

Current Crisis – General challenges affecting IYCF programming Humanitarian access remains a challenge Food Insecurity; 60% of total Yemeni population are food insecure Decline in resources and liquidity, increase of food and commodity prices and decline in fuel and basic food imports. Poor access to safe water and poor sanitation services. Large and dynamic displacement movements and conflicting priority of the families. Health system: Collapsing health system (almost half of health facilities partially functional) No / minimal operational cost for most of health facilities and salaries crisis. Frequent outbreaks (cholera, diphtheria, measles, …) more burden and changes the priorities. Nutrition program: Structural and personnel changes in MoPHP at different levels. Competing with other urgent priorities for local and health authorities. Limited number of partners with enough capacity.

Nutrition situation over years (Acute & Chronic Malnutrition) SMART data SMART DATA shows different stunting rates range to 70% stunting (≥40%) in 12 of the 18 governorates surveyed. four Governorates had more than 60% of under five year old children stunted (Rayma, 67.4%; Al-Mahweet, 63.3%; Hajja, 62.9% and Dhamar, 61.9%), with slightly lower figure for Amran (57.6%), Hodeidah (56.5%), Sana’a (54.7%) and Ibb (52.9%).

IYCF situational analysis 52.7% of newborns who had breastfeed initiated within the first hour of birth. (The proportion of EIBF is slightly lower among those delivered in health facility (46 %) than among those born at home (57 %) (This indicator increased from 30% in 2006 to 53% in 2013) (Two-thirds of newborns in Yemen received pre-lacteal feeds, this is more common among infants born in health facilities than those born at home) Only 10.3% of Infant under 6 months were exclusively breastfed Although 93.4% of infants (0 – 5 months) are currently breastfed, mixed feeding is also common practices for infant under 6 months of age. 6.6% of infant 0 - 5 months are not breastfed. (Currently no interventions for this group) Almost 1/3 of infants under 6 months are being fed other milks and another third are being fed with water in addition to breastmilk Continued breastfeeding at 1 year is 71% while only 45% of children continued breastfeeding at 2 year. The Median duration of any breastfeeding is 18.4 months. Highest in Hajjah (23 m) and lowest in Mareb (15 m). Shorter for children with educated mothers (17 m) than non educated mothers (20 m)

IYCF situational analysis 59.7% of 6- 8 months children who were given timely complementary foods. However, the Minimum Acceptable Diet was 17% among children 6-23 months of age. 27% of children had an adequately diverse diet (at least 4 food groups) (37% among non-breastfed children and 27% among breasted infants) 59% of children had been fed the minimum number of times appropriate for their age. However, 15% of Yemeni children age 6-23 months are fed in accordance with all three IYCF practices. 33% of no breastfed children age 6-23 months consumed foods rich in vitamin A, compared with 26% of breastfed children. 45.9% of children under one year were bottle-fed during the last 24 hours.

IYCF situational analysis – Cont. Polices / guidelines: National Nutrition Strategy - 2009 endorsed by Cabinet. (Includes IYCF, however, the part of complementary feeding is weak and also it not has sections for strategies in emergency contexts) Cabinet decree of breastfeeding protection and Code of Marketing of BMS – 2002. (Legal status: Full provisions in law) MoPHP decree on the national policy of breastfeeding protection & promotion - 2004 National strategy of IYCF – 2018 (not yet officially signed by MoPHP) Cabinet decree # 165 - 2001 on Food fortification (iron, folate, vitamin A & D)

IYCF situational analysis – Structure of MoPHP for IYCF / Nutrition Head of Nutrition Department IYCF coordinator Assistant of IYCF coordinator Micronutrient program CMAM Community program Central Primary health care manager Governorate Nutrition Coordinator IYCF focal point CHVs' focal point Governorate National Nutrition Cluster: IYCF TWG Sub national Nutrition cluster District health office manager District Nutrition coordinator District

IYCF Programming Health facility level: Community level: IYCF corners Integrated IYCF in CMAM program (TFCs & OTPs) Support IYCF in delivery rooms for early initiation and in post-natal wards for proper positioning and attachment. Community level: Provide IYCF counselling through networks of CHVs, CMWs and CHWs. 17,000 CHVs distributed in > 180 districts. 8,000 CMWs distributed in 333 districts. More than 800 CHWs (new program launched end of 2017) Support IYCF in home delivery by CMWs for early initiation and for proper positioning and attachment. Mobile clinics; Integrated outreach activities (National level, 5 rounds annually) Public Engagement: Communication campaigns through media (TV, Radio), public festivals and celebrations. Breast feeding weeks activities. IEC materials (flipcharts, poster) development and printing. Sensitization workshops for the press reporters, Imams and women associations.

IYCF Programming Guideline development Capacity development National Training Package for HWs on IYCF – 2010 (based on WHO/UNICEF guidelines) These guidelines include the support for non breasted infants & Include practical and demonstration parts. National guidelines for code monitoring and implementation. National guidance of MNP developed in 2018 Integrated IYCF in other guidelines; CMAM, CBMNC, maternal and neonatal care and IMCI. Training package of CHVs (IYCF is the main part of the package) Capacity development IYCF training for Health Workers (6 days course). IYCF training integrated in other programs training courses (CMAM, CBMNC, IMCI) IYCF-E training courses for MoPHP, GHOs and NGOS.

COMPLEMENTARY FEEDING IN EMERGENCIES Counselling and support for appropriate CF: Optimize use of local foods; Home grown (Shabiza promotion) Counselling and demonstration activities on safe and proper food preparation. Small scale project using positive deviate approach for support CF. Blanket Supplementary Feeding Program: Currently the program being implemented in 89 districts. 56% of 2018 target has been achieved so far. 100% of children 6 – 23 months in 107 districts are targeted by WFP with BSFP. Food security interventions: GFD & cash vouchers (focus in priority districts. Families of children with acute malnutrition are included as one of the selection criteria for GFD / vouchers which is 6 months support. PLW included in the criteria of selection

Complementary feeding – MN Micronutrient Interventions: Micronutrient powders (MNPs) supplementation for children U2 years Provision of iron/folate supplementation to pregnant and lactating women Vitamin A supplementation & Deworming for children under 5 years Delivery Platforms: Facility based interventions. Community based interventions: through integrated outreach, H&N integrated mobile teams, community health volunteers and workers. National Targets: 90% of children U5 received VAC twice a year. (in 2017; coverage was > 90%) 60% of children U5 received deworming twice a year. (in 2017; coverage was 25% 60% of children U5 received MNP supplementation. (in 2017; coverage was 56%) 60% of PLW received iron – folate supplementation. (in 2017; coverage was 63%)

IYCF Programming Code monitoring and implementation Existing legislations and policies; (full provision in law), but: Repeated violations of the code (public advertisements, support medical workshops, free sample distribution and contracting doctors and pediatricians) Some violations were from health officials and some NGOs. The monitoring system for violations is available but it is not active. Reporting mainly by the government HWs. Irregular monitoring system by MoPHP. Depends upon the support from agencies. However, couple of activities and follow up actions were implemented: Monitoring visits, Campaign on public and private hospitals and institutions Legal affair department follow up, Orientation workshops for cluster partners.

IYCF counselling and education Different approaches IYCF counselling through CHVs is the major contribution to IYCF achievement. In 2018, the outreach activities still not implemented fully (1 out of 5 rounds implemented so far) From 2017 – 18, HFs contributed to the counselling and messaging on OYCF through CMAM, ANC clinics.

IYCF Indicators Progress Based on SMART surveys from 17 out of the 22 Governorates. For the remaining 5 governorate, DHS results were taken)

Challenges specific to IYCF programming IYCF programming challenges and gaps: Unavailability of national evaluation data. Weak implementation of the national legislations especially with the conflicting authorities. Repeated violations of BMS code (some from the health workers and officials) Non-breastfed infants are not managed within current programming due to lack of data and capacity of the existing partners on this area. The coverage of community programs need more expansion (currently less than 50% of the CHVs coverage are achieved) Access to quality complementary food is a big challenge.

Challenges - Cont. Leadership and Coordination: Limited partners’ engagement and capacity in IYCF programming. Complexities of working with two authorities in term of endorsement and development of guidelines. Centralization of some activities. Adherence to the national guidelines of training and implemented approaches from some partners. Weak monitoring & supervision from central and governorate levels on IYCF programs due to multiple reasons (limited number of IYCF/Nutrition officers, conflicting priorities, …)  

Discussion points  How do we engage local partners sufficiently to build capacity on IYCF? Role of INGOs and NNGOs. IYCF-e capacity building activities. Private sector involvement. How can we better improve monitoring and impact assessment of IYCF interventions? How can we improve needs assessment for non-BF infants? What should we be doing to support non-BF infants in Yemen and how can we make that happen? How can we scale up complementary feeding response to improve access to adequate food?

Thank you  Thank you!