Building National Nutrition Coordination from the Field Up: Lessons Learnt From the Afghan Reconstruction By Charlotte Dufour, 11th Horwitz Lecture, February 2006

Session Plan Introduction: A few questions… Part 1: Building national nutrition coordination in a transition from relief to development Part 2: Building national nutrition coordination through community and provincial- level action Conclusion: Some thoughts and suggestions…

Rebuilding from scratch in a post- devastation / partial conflict situation Intensive capacity-strengthening process, from which we can learn Transition from Relief to Development, with regular crises Why Afghanistan ?

Great regional diversity

The nutritional situation Very high mortality: 26% children die before age 5 +/- 50% of chronic malnutrition 6-10% acute malnutrition, seasonality linked to disease patterns High rates of micronutrient deficiencies (MOPH, 2004) –Iron deficiency: ≥ 70% of children (38% anemic) and 48% of women (25% anemic) –Vitamin A (night blindness): 20% women –Vitamin C: up to 10% in some areas; scurvy epidemics 2002 & 2003

Causes of malnutrition Underlying Causes: –low diet diversity –improper feeding practices –poor hygiene & access to health services Basic causes: –Destroyed economic, natural, physical and social capital –Limited access to land & water –Low level of education –Poor condition of women –High unemployment –Conflict and lack of governance –Etc. Chronic poverty, compounded by regular shocks

Nutrition coordination… Why? Nutrition: a sector… or a core development objective that brings together different sectors? For whom? - For agencies and government institutions? - For donors? - For families and communities? How?

Coordination: How? Information sharing Common strategy Joint planning and implementation No communication Institutional/ formal Personal/ informal

Part 1 Building national nutrition coordination in a transition from relief to development: A complex process driven by population needs and institutional agendas…

EmergencyTransition Development (with regular crises) Large increase in food aid (drought, IDPs, returnees.) and SFCs Some TFCs Food security interventions Food aid SFC/TFC in Kabul, Herat & IDP camps. Small-scale agricultural projects “No” gov’t agencies; Few NGOs; UN in Islamabad MOPH Public Nutrition Strategy Capacity-strengthening of MOPH PND; some in MoAg and MRRD Integrated Public Nutrition approach USI Integration of TFCs in provincial hospitals; IYCF; supplementation in BPHS; community-based food security interventions flour fortification; nutrition education integrated in various programs Punctual relief interventions: targeted food aid CB cont’d, but end of Tufts support Nutrition not in ANDS: : Parliamentary elections; London Conf & ANDS Presidential elections Establish’t of gov’t : Taliban 2002: Establishment of Interim Govern’t 2007: ANDS National Action Plan for Nutrition ??? Arrival of NGOs, UN & donors Public Nutrition Depart in MOPH Active coordination: Nutrition Task Force; 6 working groups Coordination easy Some working groups stop; coordination less active ↑↑??

Evolving government and donor priorities Obj: to address malnutrition & food insecurity But how is food security defined? Emergencies: Key outcome = survival & nutritional status Type of aid: project support through grants Target groups & areas: the most vulnerable & poorest Development: Key outcome = economic growth Type of aid: budgetary support through grants & loans Target groups & areas: ‘enterpreneurs’ & productive areas or politically important

Evolving government structures and capacities Low capacity, esp. at provincial level Evolving government structures, varying importance and unclear relationships Inter-ministerial competition High staff turnover Public Nutrition Unit in MOPH → difficult to coordinate and influence other ministries → Coordination relies on key individuals

The costs of coordination Time costs: when do we do technical / field work?! Difficulty of coordinating workplans → delays in action No resources for coordination (tea & sweets, internet…) Coordination is seen as essential… But not a funding priority!

Inadequate availability and use of information Information for advocacy Information for planning at district and community levels Information to document and capitalize on lessons learnt

National nutrition coordination is fragile… What can we do to strengthen it?

Part 2 Building national coordination by mainstreaming nutrition in household, provincial and central level action: Some tools and examples

The key to success: 2 way coordination Policy & technical support Local knowledge, information & experience Central authorities Provincial Depart. Communities HealthEtc.Economy & social affairs EducationAgricultureRural devt Families

Integrating nutrition in local development FAO & Aga Khan Foundation Collaboration in Bamyan Province

Integrate sectors through malnutrition problem & solution trees

Integrate nutrition education in community activities CHWs Literacy classes Child to child learning Community Play

Communities design their own nutrition project Nutrition education through CHWs and child-to-child learning Greenhouses Livestock group for women Wells

Initial Results Nutrition ‘demystified’ Staff and families’ motivation and confidence to address malnutrition enhanced Integration of sectors supported Increased effectiveness / impact of existing resources → Plan to use nutrition at provincial level to strengthen integration of AKF activities

CONCLUSION What recommendations can we harvest from the Afghan experience? Mainstreaming Nutrition to support integrated and people-centered development

Coordination… how? Information sharing Common strategy Joint planning and implementation No communication Without shared objectives, and a shared understanding of people’s needs, we cannot go beyond information sharing! ?

Find the balance between benefits and costs… Define clear & realistic objectives / expectations Prioritize Estimate & allocate resources Advocate

Strengthen capacity for an integrated nutrition approach A common capacity-building strategy, to build ownership of nutrition across sectors Capacity-building efforts at all levels: -family -community -provincial -National Common nutrition education strategy

We need donor commitment to… Integrate pro-poor strategies in economic development (twin-track approach) Provide sustained and long-term funding for capacity-development for nutrition Support civil service reform (salaries) Support coordination Allow flexibility in programme design and implementation

Adapt information and planning methods Understand the causality of malnutrition at household and community level Use available information for advocacy Integrate flexibility in national planning to accommodate regional variations and evolutions Invest in communication between community, provincial and national-levels Capitalise on and use lessons learnt

And, most importantly…

Have fun and do lots of field visits! The only way to ensure people are at the heart of our work!