74302 -1- -2- How to Protect and Promote the Nutrition of Mothers and Children: References, annexes and glossary in Latin America and the Caribbean Table of Contents Glossary 1 References 6 Annexes 13 Glossary Acute malnutrition: a condition characterized by referral, and treatment; this strategy enables the wasting that is generally caused by a recent shock, management of acute malnutrition to be moved from such as illness or lack of adequate food. Severe the facility to the community and can be applied in acute malnutrition (SAM) is defined according to a both stable and unstable times. weight-for-height Z-score (WHZ) <-3 and/or a mid- upper arm circumference <11.5 cm. Moderate acute Chronic malnutrition: occurs over time and results malnutrition (MAM) is defined according to a WHZ <-2 in stunting, whereby children are smaller and shorter and ≤ -3. Global acute malnutrition (GAM) is the sum but appear normal. To address stunting, interventions of the prevalence of SAM plus MAM, at a population need to be targeted at pregnant women and to level. children from birth to 18 months of age. Antiretroviral therapy (ART) and antiretroviral Complementary foods or supplements: foods that (ARV) drugs: a strategy and a means used to treat nutritionally complement breast milk and which HIV-infected individuals and to prevent mother-to- should be provided to infants after 6 months of age. child transmission of HIV/AIDS. These foods should be hygienically prepared, nutrient- dense, and easy to eat and digest. They may include Anemia: low level of hemoglobin in the blood, as basic food-aid commodities from general rations, evidenced by a reduced quality or quantity of red inexpensive locally available foods, micronutrient- blood cells; approximately 50% of anemia worldwide fortified cereal-legume blends, and ready-to-use is caused by iron deficiency. supplementary foods. Benchmarking: using points of reference, standards, Constant crisis: an ongoing state in which the poorest and recommended practices against which and most vulnerable groups in society have difficulty comparative measurements, assessments, and securing basic needs and obtaining social services evaluations can be made. and are exposed to high rates of hunger, crime, and physical displacement. Case study: an analysis of an experience stressing developmental factors in relation to the environment Crisis: a difficult period or time of danger that can be that provides lessons learned from the experience. precipitated by a shock, not as acute as an emergency, but a turning point that can result in sufficiently Cash transfer: a cash payment to poor households to precarious conditions that heighten vulnerability; supplement household income. Sometimes provision during crises, if a foundation of sound interventions of the cash is conditional upon on certain positive that build resilience was laid in stable times, these behaviors such as school attendance and routine can be scaled up for vulnerable households that lack health clinic visits. access to social services. Catastrophe: a disaster of great magnitude. Cross-cutting approach: a multi-sectoral intervention or strategy that supports the Community-based management of acute implementation of priority interventions (e.g. human malnutrition (CMAM): a comprehensive strategy resource development, monitoring and evaluation, that encompasses community outreach, screening, communication strategies). -1- Deworming: periodic preventive treatment with other hand, nutritional “insults� during this period anthelminthic drugs to children to reduce the worm can cause permanent disability, leading to fewer burden and prevent adverse effects on nutritional years of schooling, reduced adult productivity, lower status, growth, and development. lifetime earnings, and—by extension—diminished national productivity. Disaster: a serious disruption of the functioning of a community or a society that causes widespread Food crisis: constrained access to food due to human, material, economic, or environmental losses escalation or fluctuation of food prices. that exceed the ability of the affected community or society to cope using its own resources. Food insecurity: a situation that exists when people lack secure access to sufficient amounts of safe and Double burden of malnutrition: the co-existence of nutritious food for normal growth and development undernutrition (often in the form of child stunting and an active and healthy life. It may be caused by and/or micronutrient deficiencies) and overnutrition, the unavailability of food, insufficient purchasing in the same population. power, inappropriate distribution, or inadequate use of food at the household level. Food insecurity, poor Early warning and response system (EWARN): conditions of health and sanitation, and inappropriate provides information to detect and respond rapidly care and feeding practices are the major causes to outbreaks of diseases and malnutrition, especially of poor nutritional status. Food insecurity may be regarding the situation in vulnerable areas, which can chronic, seasonal or transitory. contribute to sound health and nutrition decisions. Food security: a situation in which people have Emergency: a state demanding decision and follow- access to sufficient, safe, and nutritious food to up in terms of extraordinary measures; it is usually maintain a healthy and active life. defined in time and space, requires threshold values to be recognized, and implies rules of engagement Food voucher: a coupon that is redeemable for and an exit strategy; calls for an immediate rescue food. Food vouchers can be exchanged for certain response that focuses on the most efficient means of food items that are provided to poor or food insecure preserving life, especially on the needs of children households in times of crisis or instability to help in the first 1,000 days of life to counter otherwise protect nutritional status. Vouchers are particularly longer-term consequences due to privation, even for useful where access to food is the problem, rather a relatively short time. than availability. Exit strategy: a graduation or transition plan to assist Gradual-onset crisis: more slowly developing event, individuals to return to stability after a shock and such as a drought. to enhance sustained recovery; includes provision of food and supplements to affected populations for a set Growth monitoring and promotion (GMP): program post-emergency period as well as transient, longer- based on measuring and interpreting growth, used to term support following the immediate response for prevent and screen for malnutrition and to enable families who have lost their housing, livelihoods, and referral for cases of acute malnutrition; in crises, relatives. GMP-related nutrition, health, and social protection services can be scaled up. First 1,000 days of life: a critical period, a “window of opportunity�—from conception to 2 years of Hazard: a possible threat or source of exposure to age— during which cost-effective, evidence-based injury, harm, or loss. interventions (e.g., micronutrients and infant and young child feeding) can be delivered to positively Healthy/safe motherhood: the desired outcome impact a child’s growth and development; on the of a set of interventions including antenatal and -2- postpartum services, promotion of proper weight are malnourished if their diet does not provide gain, birth planning for pregnant women, availability the right amount of vitamins, minerals, and other of skilled caregivers and essential equipment, and nutrients needed to maintain healthy tissues and use of infection-prevention measures. organ functions, or if they are unable to fully utilize the food they eat due to illness (undernutrition); Human capital: the stock of competencies, often takes the form of micronutrient deficiencies or knowledge, social skills, and personality attributes, stunting. including creativity, embodied in the ability to perform labor so as to produce economic value; an Micronutrients: essential vitamins and minerals that aggregate economic view of the human being acting are required by humans in small amounts for optimal within economies, which is an attempt to capture growth, development and overall health. the social, biological, cultural, and psychological complexity as they interact in explicit and/or Micronutrient deficiency: a condition caused by economic transactions. insufficient consumption of foods rich in vitamins and minerals. Micronutrient deficiencies are common in Humanitarian crisis: a complex emergency in a low- and middle-income countries, especially among country, region, or society where there is total or mothers and young children, who have increased considerable breakdown of authority resulting from requirements of several micronutrients. internal or external conflict (political instability, economic crisis, food insecurity, or rapid urbanization) Middle-upper arm circumference (MUAC): a measure and which requires an international response that to diagnose acute malnutrition using a simple color- goes beyond the mandate or capacity of any single or coded measuring tape, which enables community ongoing United Nations country program. members to be trained to diagnose cases and refer them for treatment. Infectious diseases: diseases resulting from the infection, presence and growth of pathogenic Moderate acute malnutrition (MAM): malnutrition biological agents such as bacteria, viruses, or in which a weight-for-height Z score that is ≥–3 SD parasites. These are also known as communicable and <–2 SD and/or a middle-upper arm circumference diseases and can be passed from person to person. that measures <12.5cm and ≥11.5cm. Several infectious diseases can compromise nutritional status. Monitoring and evaluation: the ongoing process of collecting and analyzing data to assess performance, Intergenerational cycle of poverty: poverty that effectively manage outcomes, inform decision- is passed from generation to generation and that making, and achieve results. deprives individuals of a happy, productive future and society of economic prosperity. Multiple micronutrient supplement: a supplement or powder (referred to as a multiple micronutrient Iodine-deficiency disorder (IDD): the most prevalent, powder) containing multiple essential vitamins and yet easily preventable cause of mental retardation minerals that are intended to prevent and/or treat worldwide, and a threat to child survival; can result micronutrient deficiencies in vulnerable subgroups. in children growing up stunted, apathetic, mentally Multiple micronutrient powders are often added retarded, and incapable of normal movement, to complementary foods in a process called home speech, and hearing. fortification in order to increase vitamin and mineral intake of young children. Malnutrition: a largely preventable cause of over one-third of all child deaths, this broad term is Multisectoral coordination: a comprehensive commonly used as an alternative to undernutrition, approach that encompasses the wide-ranging efforts but technically it also refers to overnutrition; people of various technical areas—e.g., health, nutrition, -3- agriculture, industry, water and sanitation—that in times of stability can build resilience and in times of Resilience: ability to withstand or recover from crisis and emergencies can maximize the capacity to shocks, be they external or internal in origin; enables deal with problems; the aim is to reduce duplication individuals and groups to withstand or moderate the and avoid gaps in technical cooperation. negative effects of shocks. Nutrition intervention: specific, substantive Safe haven/safe space: a place, a situation or an efforts—which can be short-, medium-, and long- activity where people can go and be protected. term—aimed at having a positive impact (e.g., In crises and emergencies, a place for women, promotion or protection) on a population; application especially mothers to feel secure to breastfeed in of interventions can vary, depending on whether the privacy, to provide pregnant and lactating women situation is stable, a crisis, or an emergency. support services, to shelter transient families, and to safeguard against violence. Oral rehydration salts (ORS): a simple treatment for dehydration associated with diarrhea consisting of a Safety nets: noncontributory transfer programs solution of salts and sugar that is taken by mouth. targeted in some manner to the poor and vulnerable WHO guidelines recommend that it be provided in to poverty and shocks. Analogous to the U.S. term conjunction with therapeutic zinc supplements. “welfare� and the European term “social assistance�. Overnutrition: a form of malnutrition in which Scaling up: a “surge� response; during a crisis, an nutrients are oversupplied relative to the amounts intensification and expansion of efforts to develop required for normal growth, development, and existing infrastructure and interventions that have metabolism; includes overweight and obesity, which previously been put in place, to counter the worsening results from caloric excess. of vulnerability and poverty. Policy guidance: a set of internationally vetted Severe acute malnutrition (SAM): malnutrition in and recommended interventions aimed at providing which a weight-for-height Z score that is < –3 SD and/ decision makers in countries information with respect or a middle-upper arm circumference that measures to how to effectively promote and protect the <11.5cm. population, especially its most vulnerable groups, and to assure the most profitable investment of limited Shock: a high-impact, low-probability event. national resources in both stable and unstable times. Social protection: a strategy that targets transient Ready-to-use formula: a form of artificial infant poor and vulnerable populations by providing safety feeding that does not require the addition of water. It net programs and services; following crises and should only be used as a breast-milk substitute after emergencies, efforts stress helping those who have careful assessment of needs, under strict medical lost their assets to return to productive activity. control, and in hygienic conditions. Stable times/stable settings/stability: period during Ready-to-use supplementary food (RUSF): specially which a foundation can be laid and long-term resiliency formulated, energy-dense, micronutrient-fortified can be built that will enable a population to deal spreads or pastes that require no refrigeration or with eventual economic, environmental, health, and preparation and can be consumed directly from the nutrition shocks in a timely manner; period for the package. design and creation of priority interventions, safety- net initiatives, sustainable development programs, Ready-to-use therapeutic food (RUTF): similar to and for the reservation of set-aside or “rainy-day� RUSF, but provides more calories and is used to treat resources. children with severe acute malnutrition. -4- Stunting: a condition of hindered growth, Universal salt iodization (USI): the fortification development, and progress that results from chronic with iodine of all salt used for human and animal malnutrition, often a result of poverty; measured in consumption; it is the main public health strategy for terms of height for age. eliminating iodine deficiency. Sudden-onset disaster: an emergency such as a Vector-borne diseases: diseases, such as malaria and hurricane, flood, landslide, or earthquake. dengue, the pathogens of which are transmitted by organisms, often mosquitoes, from reservoir to host; Targeting: in emergencies, a strategy to assure can seriously harm children and pregnant women, maximum effectiveness in protecting the population increasing the risk of anemia in mothers, delivery and, when resources are limited, to focus on the needs problems, and low birth weight; transmission of of the most vulnerable, taking into consideration these diseases increases during emergencies due to criteria for inclusion, conditions, approaches, and proliferation of vector-breeding sites. agents. Vitamin A deficiency (VAD): the leading cause of Toolkit: an assembly or collection of interventions preventable blindness in children, a cause of night and approaches designed to be used together to build blindness in pregnant women, and possibly a factor the capacity to deal with a social challenge and to contributing to maternal mortality. assess the readiness to meet that challenge. Vulnerability: a state resulting from exposure to Undernutrition: the outcome of insufficient food external shocks, the effects of which are aggravated intake and repeated infectious diseases; includes in the absence or the inadequacy of health, food, being underweight for one’s age, too short for one’s education, and other social goods and services. age (stunting), dangerously thin for one’s height (wasting), and deficient in vitamins and minerals Wasting: a process of deterioration that results from (micronutrient malnutrition). undernutrition and that is marked by weight loss and decreased physical vigor, appetite, and mental activity. In young children, it is defined according to a weight-for-height Z-score (WHZ) <-2. -5- References References for the Rationale and Introduction 1. Copenhagen Consensus. Expert Panel Findings. http://www.copenhagenconsensus.com/Projects/ CC12/Outcome.aspx. 2. Harmeling, S. Global Climate Risk Index 2012. Who Suffers Most from Extreme Weather Events? 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Management of moderate acute malnutrition – Module 12. www.en- nonline.net/.../m12-management-of-moderate-acute-malnutrition-technical-notes.docx 74. UNHCR/UNICEF/UNICEF/WHO. Food and nutrition needs in emergencies. Geneva, 2003. http://wh- qlibdoc.who.int/hq/2004/a83743.pdf 75. Inter-agency food and nutrition cluster in Indonesia. Contingency and preparedness plan. 2008. www. ochaonline.un.org 76. WHO. Outbreak communication: Best practices for communicating with the public during an out- break. Report of the WHO Expert Consultation on Outbreak Communications held in Singapore, 21–23 September 2004. http://www.who.int/csr/resources/publications/WHO_CDS_2005_32web.pdf 77. WHO. Outbreak communication planning guide. 2008 Edition. http://www.who.int/ihr/elibrary/ WHOOutbreakCommsPlanngGuide.pdf 78. WHO. Effective media communication during public health emergencies: A WHO handbook. WHO, 2005. 79. PAHO. Field guide for developing a risk communication strategy: from theory to action. 2011. 80. Institute for Nutrition of Central America and Panama (INCAP) and UNICEF. Diplomado virtual “Nu- - 10 - trición y Salud en emergencias�. Accessed on June 11, 2012. http://www.educacionincap.org/2011/08/ convocatoria-diplomado-virtual-nutricion-y-salud-en-situaciones-de-emergencia/ 81. ENN Emergency nutrition Networks. Accessed on June 11, 2012. http://www.ennonline.net/meetings 82. Nutrition in Emergencies, Center of International health and Development. Nutrition in emergencies regular training. Accessed on June 11, 2012. http://www.nietraining.net/ 83. Emergency Nutrition Networks. Nutrition intervention for crises: some worrying experiences. Accessed on June 11, 2012. http://fex.ennonline.net/16/nutrition.aspx 84. UNICEF. Nutrition in emergencies. Accessed on June 11, 2012. http://www.unicef.org/nutrition/train- ing/ 85. International Committee of Red Cross. Accessed on June 11, 2012. http://www.icrc.org/eng/resourc- es/result/index.jsp?txtQuery=training&sortBy=relevance&action=newSearch&searchType=simple 86. United Nations Office for Coordination of Humanitarian Affairs (OCHA). Accessed on June 11, 2012. http://www.unocha.org/what-we-do/coordination-tools/UN-CMCoord/training-partnerships%20 87. International Committee of Red Cross. Accessed on June 11, 2012. http://www.icrc.org/eng/resourc- es/documents/publication/p0820.html 88. FAO. Natural resources water and environmental department. Accessed on June 12, 2012. http://www. fao.org/nr/water/index.html 89. Institute of Medicine. Dietary reference intakes for water, potassium, sodium, chloride, and sulfate. Washington D.C. November, 2004. http://www.nap.edu/openbook.php?isbn=0309091691. 90. WHO/Water, Engineering, and Development Centre. Technical notes on drinking water, sanitation and hygiene in emergencies. How much water is needed in emergencies? Geneva, 2011. http://www.who. int/water_sanitation_health/publications/2011/tn9_how_much_water_en.pdf 91. Famine Early Warning Systems Network (FEWSNET). www.fews.net 92. FAO. Global Information and Early Warning System on Food and Agriculture (GIEWS). http://www.fao. org/giews/english/about.htm 93. WHO. Early warning surveillance and response in emergencies. 2009. http://whqlibdoc.who.int/ hq/2010/WHO_HSE_GAR_DCE_2010.4_eng.pdf 94. Standardized Monitoring and Assessment of Relief and Transitions. http://www.smartmethodology.org/ 95. WFP. Monitoring and evaluation guidelines. http://www.wfp.org/content/monitoring-and-evalua- tion-guidelines/ 96. Grosh M. et al. For protection and promotion: the design and implementation of effective safety nets. World Bank, 2008. 97. World Bank. Safety nets how to: a toolkit for practitioners. www.worldbank.org/safetynets/howto 98. WFP. Nutritional dimension of the social safety nets in Central America and the Dominican Republic. 2010. References for the Benchmarking Section 1. UNICEF. Current status of baby-friendly hospital initiative, March 2002. http://www.unicef.org/nutri- tion/files/nutrition_statusbfhi.pdf 2. UNICEF. State of the world’s children, 2012. 3. UNICEF. Situation analysis on fortified complementary foods for children between 6 and 36 Months of age in Latin America and the Caribbean region. September 2006. 4. FFI/GAIN/MI/USAID/WB/UNICEF. Global report: Investing in the future: a united call to action on vita- min and mineral deficiencies. 2009. 5. PAHO/UNICEF/UNAIDS. Situation analysis: elimination of mother-to-child transmission of HIV and con- genital syphilis in the Americas. 2010. - 11 - 6. http://new.paho.org/hq/index.php?option=com_content&task=blogcategory&id=987&Itemid=904 7. WHO. Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA, and the World Bank. 2007. http://www.who.int/whosis/mme_2005.pdf 8. UNFPA. http://www.unfpa.org/public/mothers/pid/4388 References for the Case Studies Haiti: Humanitarian Response to the 2010 Earthquake and Child Nutrition 1. Ministère de la Santé Publique et de la Population, Institut Haïtien de l’Enfance et Macro International Inc. Enquête Mortalité, Morbidité et Utilisation des Services (EMMUS), Haïti, 2005-2006. 2. Document de stratégie nationale de croissance et de réduction de la pauvreté (DSNCRP), 2008-10. 3. FAO. 2009. The state of food insecurity in the world: Economic crises – impacts and lessons learned. 4. UNICEF-Haiti, Country Office Annual Report 2010. 5. WFP Haiti, Standard Project Report, EMOP 2010. 6. MSPP, UNICEF, ACF, WFP, MDM, Terre des Hommes et Cluster Nutrition, Enquête Nutritionnelle Anthro- pométrique et de mortalité rétrospective chez les enfants de 6-59 mois dans les zones affectées par le séisme du 12 janvier 2010, Janvier 2011. 7. MSPP, Unicef, PAM, Concern, ACF, Terre des Hommes, MDM-France, Enquête Nutritionnelle Nationale avec la Méthodologie SMART, Mars 2012. Haiti: Tackling Malnutrition with Ready-to-use Local Food Products 1. Nutrition at a Glance – Haiti, World Bank, 2010 2. Lutter CK, Chaparro CM 2008. Malnutrition in infants and young children in Latin America and the Ca- ribbean: Achieving the Millennium Development Goals. Pan American Health Organization: Washington D.C. 3. Haiti Demographic And Health Survey 2005-2006 - Addendum to Chapter 11 - Nutritional Status. 4. For example, see: Allen L, and S. Gillespie. What Works? A Review of the Efficacy and Effectiveness of Nutrition Interventions. United Nations Administrative Committee on Coordination/ Standing Com- mittee on Nutrition, Nutrition Policy Paper No. 19, in collaboration with the Asian Development Bank; or Barker DJP. 1998. Mothers, Babies and Health in Later Life. Edinburgh, United Kingdom: Churchill Livingstone. 5. Horton, Shekar et al. Scaling Up Nutrition What Will it Cost? The World Bank, 2010. Honduras: Community Nutrition Volunteers Promote Child Health and Nutri- tion Services in the Wake of Hurricane Mitch 1. Huffman, S. et. al. 1989. Prevention of maternal malnutrition through a community kitchen in Peru: final report. Center to Prevent Malnutrition: Bethesda, MD. 2. Creed de Kanashiro, H., et. al. 1998. An intervention to improve dietary iron intake among women and adolescents through community kitchens in Lima, Peru: final report. MotherCare/JSI: Arlington, VA. 3. Garrett, J. 2001. Comedores Populares: lessons for urban programming from Peruvian community kitchens. CARE/IFPRI: Washington, DC. - 12 - Annexes Annex 1. Survey Questionnaires Purpose and scope of the questionnaires It was determined that the survey should target decision makers and technical personnel in each country as well as in- ternational experts, all of whom were expected to provide relevant information about practices in place that promote and protect the nutritional status of pregnant and lactating women and children <2 years of age. The survey included personnel in governments, UN agencies, NGOs, and academic institutions. Questionnaire 1 was used to survey people working in the field of nutrition in institutions that deal with crises and emergencies in the countries under study: Bolivia and Colombia in South America; El Salvador, Guatemala, Honduras, Nicaragua, and Panama in Central America; and Dominica, Grenada, Haiti, St. Lucia, and St. Vincent in the Caribbean. Questionnaire 2 was used to survey experts at international level. Introduction to the questionnaires A number of countries in the Latin America and Caribbean (LAC) region have been severely hit by food-price crises in 2008 and are still very vulnerable to food-price volatility experienced since late 2010. Humanitarian responses to high food prices, crises, shocks, or emergency situations should help the poor avoid the consequences of the reduced afford- ability of a basic food basket. This is especially crucial in the first 1,000 days of life (that is, children from pregnancy until they reach 2 years of age and breastfeeding women), since most of the physical and cognitive damages due to improper nutrition in this period are irreversible. The World Bank is leading a regional study on how to improve LAC country responses so as to protect the nutritional status of the poorest and most vulnerable in times of crises and emergencies. The countries covered by this study are Bolivia, Colombia, Dominica, El Salvador, Grenada, Guatemala, Haiti, Honduras, Nicaragua, Panama, St. Lucia, and St. Vincent. Your participation in this study is crucial, as it will contribute to the development of a policy guidance toolkit for high-level decision makers as well as to the building of capacity in the region through South–South regional knowledge sharing. The results of this study and the toolkit will be presented during a high-level event in late 2012. We kindly ask for your response to this survey, which will take you approximately eight minutes to complete. Thank you very much in advance for your collaboration. Dr. Jennifer Bernal (Consultant) Email: jbernal@usb.ve Phone: 0058-4143227182 - 13 - Questionnaire 1 (Country perspective) 1. Does the country have a policy or a strategy to protect the nutritional status of the population in times of crises or emergencies? 2. Does this policy have a special focus on children under 2 years of age? Yes____ No ___ (skip to question 4). 3. Please describe 3-5 aspects of the policy for the children. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 4. Does this policy have a special focus on the protection of pregnant and lactating women (e.g., nutrition supplement / cash transfer / incentives to use services, psychological counseling, etc.)? Yes____ No ___ (skip to question 6). 5. Please describe 3-5 aspects of the policy for the women. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 6. What are the food and nutrition recommendations you think should be implemented to protect pregnant, lactating mothers and infants in an emergency or crises? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 7. In your opinion, what are the current policy /intervention gaps in your country to protect the nutrition status of preg- nant, lactating mothers and infants in an emergency or crisis? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 8. Which institutions are handling the implementation of food security and nutrition recommendations for pregnant, lactating women and children in an emergency or crisis? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 9. Please indicate the name and e-mail address of any person in your country who you think could provide useful infor- mation regarding the nutritional protection of pregnant, lactating mothers and children in an emergency or crisis. Name ________________________ Name ________________________ Title__________________________ Title__________________________ Email_________________________ Email_________________________ Phone_________________________ Phone_________________________ - 14 - Questionnaire 2 (International expertise) 1. In your opinion, what are the best policies or interventions presently implemented to protect the nutritional status of pregnant, lactating women and children in case of an emergency/crisis in the world? (Indicate with numbers 1-5, where 5 is best) Exclusive breastfeeding____ Provision of infant formula feeding ____ Food rations _____ Community kitchen ____ Ready-to-use supplementary foods ____ Promotion of appropriate and timely complementary feeding _____ Micronutrients supplementation _____ (specify) Supply of seeds or livestock______ Cash transfer_____ Nutrition education _______ (specify) Promotion of hand washing ____ Others _____ (Please list). ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 2. Regarding the policies or interventions actually being implemented to protect the nutritional status of pregnant, lac- tating women and infants in case of an emergency/crisis should? Which one would you recommend? (Indicate with numbers 1-5, where 1 is low priority and 5 is top priority) Protection of breastfeeding ___ Rapid response of food supply______ Improve the quality/diversity of the food given_____ Increase the quantity of food given______ Provide food supplements ___ Provide micronutrients ___ Control of food prices / food subsidy_____ Intensification of the communications (radio in rural places)_____ Extend safety nets ____ Prioritizing nutrition of mothers and children in emergency response policies ___ Donor harmonization ___ Better targeting ___ Others ____ (please provide a list) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ - 15 - 3. What are your suggestions for implementing policies and interventions to protect the nutritional status of pregnant, lactating women and children during emergency/crisis in a low-income country? Create a nutritional entity to work more efficiently across ministries___ Diminish the gap between scientific knowledge and stakeholders ___ Learn from experiences in other countries____ Concentrate nutrition response in one ministry (please name which one)____ Others (specify) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 4. What should be done to put protection of nutrition of vulnerable groups on top of the policy agenda, especially in view of sustained high food prices and recurrent economic volatility? (Indicate with numbers 1-5, where 1 is low priority and 5 is top priority) Increase cash transfer _____ Scale up social safety nets ___ Raise awareness of high-level decision makers ___ Better multisectoral coordination ___ Strengthen of the capacities and knowledge in nutrition of policy makers_____ Strengthen of knowledge in food and nutrition) of the population_____ Others ____ (please provide a list) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 5. In your view, what are the main challenges that countries in Latin America and the Caribbean face to protect the nu- tritional status of mothers and young children in times of crises and emergencies? (Indicate with numbers 1-5, where 5 is the most important) Lack of knowledge / capacity at technical level ___ Lack of knowledge / capacity at highest level of decision ___ Lack of financial resources ___ Lack of coordination across key sectors of government ___ Lack of coordination of donors / international partners ___ Lack of availability / inappropriate nutritional guidelines to address the problem ___ Nutrition is not a priority ____ Lack of understanding on long-term impact of crisis on nutritional status and development outcome ___ Nutrition is seen as a health issue and not as a key factor in economic development of countries ___ Others (please specify) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ - 16 - ANNEX 2. LIST OF PEOPLE INTERVIEWED Country Name Title Agency Bolivia Lic. Adriana Espinoza Jefa, Unidad de Nutrición Ministry of Health Bolivia Ivette Sandino UNICEF Bolivia Coronel Nestor Torres Jefe, Unidad de Respuesta Despacho Viceministerio de Inmediata Defensa Civil Bolivia Coronel Pedro Severich Dirección de Alerta Tem- Secretaria Técnica del CO- prana NARADE, Despacho Vicemi- nisterio de Defensa Civil Bolivia Coronel Edilberto Quiroz Unidad de Respuesta Inme- Secretaria Técnica del CO- diata NARADE, Despacho Vicemi- nisterio de Defensa Civil Bolivia Lic. Gualberto Chávez Unidad de Gestión de Sumi- Secretaria Técnica del CO- Mamani nistros NARADE, Despacho Vicemi- nisterio de Defensa Civil Bolivia Lic. Franklin Condori Dirección General Preven- Secretaria Técnica del CO- ción y Reconstrucción NARADE, Despacho Vicemi- nisterio de Defensa Civil Bolivia Ing Heber Romero Belarde Unidad de Prevención. Secretaria Técnica del CO- NARADE, Despacho Vicemi- nisterio de Defensa Civil Bolivia Coronel Dim Reynaldo Tapia Unidad de Rehabilitación Secretaria Técnica del CO- Orosco NARADE, Despacho Vicemi- nisterio de Defensa Civil Bolivia Dr. Michele Thieren Representante PAHO/OMS Bolivia Dra. Martha Mejias PAHO/OMS Bolivia Lic. Isabel del Carpio PAHO/OMS Bolivia Jose Miguel Alarcon Jefe de Unidad de Salud Cruz Roja Boliviana Bolivia María Felix Delgadillo Directora Ejecutiva UDAPE (Unidad de Análisis de Políticas Sociales y Eco- nómicas) Bolivia Mirna Mariscal Subdirectora Política Macro- UDAPE (Unidad de Análisis economica de Políticas Sociales y Eco- nómicas) Bolivia Roland Pardo Subdirector Politica Social UDAPE (Unidad de Análisis de Políticas Sociales y Eco- nómicas) Bolivia Milton Carreon Subdirector Politica Multi- UDAPE (Unidad de Análisis sectorial de Políticas Sociales y Eco- nómicas) Bolivia Silvia Fernández Sector Agrícola UDAPE (Unidad de Análisis de Políticas Sociales y Eco- nómicas) Bolivia Ademir Esquivel Nutrición UDAPE (Unidad de Análisis de Políticas Sociales y Eco- nómicas) Bolivia Monica Viaña Oficial de Nutrición WFP - 17 - Country Name Title Agency Bolivia Juan Carlos Soria Desastres WFP Bolivia Marie France Beltrán Na- Directora CT-CONAN Comité Técnico varro del Consejo Nacional de Alimentación y Nutrición Bolivia Guy Vargas Director de Planificación CT-CONAN, Ministerio de Salud y Deportes Bolivia Sheila Montes CT-CONAN, SUPE Bolivia Lucy Alarcón Unidad Nutrición CT-CONAN Bolivia Odalis Caballero Unidad Desastres CT-CONAN Bolivia Henry Flores Desastres CT-CONAN Bolivia Oscar Mendieta CT-CONAN Bolivia Elizabeth Ascarrunz CT-CONAN, Minsiterio Plani- ficación Bolivia Patricia Alvarez WB Colombia Constanza Alarcón Coordinator Alta Conserjería Presiden- cial de Programas Especia- les, Comisión Intersectorial de la Primera Infancia Colombia Jennifer Andrea Gutiérrez Alta Conserjería Presiden- Sanchez cial de Programas Especia- les, Comisión Intersectorial de la Primera Infancia Colombia Liliana Peñaloza Ministerio de Salud y Pro- tección Social Colombia Bertha Forero Subdirectora Instituto Colombiano de Bienestar Familiar, Minis- terio de Salud y Protección Social Colombia Ana María Angel Instituto Colombiano de Bienestar Familiar, Minis- terio de Salud y Protección Social Colombia Herson Vasquez Instituto Colombiano de Bienestar Familiar, Minis- terio de Salud y Protección Social Colombia Clara Eugenia Hernández Instituto Colombiano de Bienestar Familiar, Minis- terio de Salud y Protección Social Colombia María Cecilia Cuartas Public Police Officer WFP Colombia Inka Himanen Program Officer WFP Colombia Profa. Sara Eloisa del Cas- Directora, Escuela de Nu- Food and Nutrition Observa- tillo trición tory, Universidad Nacional de Colombia Colombia Patricia Heredia Food and Nutrition Observa- tory, Universidad Nacional de Colombia Colombia Santiago Mazo Nutrition Cluster - Instituto Colombiano de Bienestar Familiar - 18 - Country Name Title Agency Colombia Clemencia Gomez Oficial de Salud y Nutrición Nutrition Cluster: UNICEF Colombia Sandra Estupinan Nutrition Cluster: FAO Colombia Angelica María Sanchez Executive Director Colombian Red Cross Dominica Sandra Charter-Rolle General Director of the Ministry of Health Civil Defense Commission Dominica Shirley Augustine Country Program Specialist PAHO Dominica Eleanor Lambert Ministry of Health Dominica Chamber Maryness Tit Nutritionist Ministry of Health and Dominica Food & Nutrition Council (DFNC) Dominica Don Corriette Program Officer National Emergency Pro- gram Office (NEPO) Dominica Representative USAID Dominica Kathleen Pinard-Byrne Director General Red Cross Grenada Mr. Benedict Peters National Disaster Coordi- National Disaster Manage- nator ment Agency (NADMA) Grenada Macia Cameron Executive Secretary Grenada Food and Nutrition Council/Ministry of Agri- culture Grenada Ms. Norma Purcell Product Development and Grenada Food and Nutrition Training Officer Council/Ministry of Agri- culture Grenada Mr. Oswald Charles Disaster Coordinator General Hospitals Grenada Nurse Francis Lidia Chief Community Health Ministry of Health Officer Grenada Nurse Nestor Edward Chief Nursing Officer Ministry of Health Grenada Daniel Lewis FAO Representative, Chief MOA/FAO of Agriculture Office at the Ministry of Agriculture Grenada Tessa Stroude PAHO Country Program PAHO Specialist Grenada Terry Charles Director General Red Cross Guatemala Maritza Oliva Nutrition Specialist WFP Guatemala Guy Gauvreau Country Director WFP Guatemala Lic. Carina Ramirez Nutritionist MINSA Guatemala M Licda. Maira Ruano Program Coordinator, Food MINSA Security and Nutrition Guatemala Dr Luis Roberto Escoto PAHO/WHO Guatemala Ian MacArthur Senior Specialist, Health IADB and Social Protection Guatemala Ramiro Quezada UNICEF Guatemala Maria Claudia Santizo Health and Nutrition Spe- UNICEF cialist Guatemala Maria Marta Tuna Cruz Roja Guatemala Dr. Rudy Cabrera AINM-C Coordinator MINSA Guatemala Luis Enrique Monterroso SESAN Guatemala Samayoa Luisa FAO Haiti Raphy Favre Aba Grangou Haiti Beatrice Turnier Aba Grangou - 19 - Country Name Title Agency Haiti Klaus Eberwein Aba Grangou Haiti Christophe Grosjean Aba Grangou Haiti Dr Mohamed AG Ayoya Chief of Nutrition UNICEF Haiti Myrta Kaulard Country Director WFP Haiti Michele Doura Nutrition Specialist WFP Haiti Meri Helantera Social Protection Specialist IDP Haiti Antoinette Traore Nutrition Specialist WHO Haiti A.Charlotte Scheider ACF Nicaragua Guillermo J. Gonzalez Director SINAPRED Nicaragua Carlos Jose Cuadra DEGCA Special Services MINSA Director Nicaragua Patricia Hallesven Nutrition Specialist MINSA Nicaragua Miriam Downs Advisor for RRD Humanita- Swiss Cooperation for Cen- rian Help tral America Nicaragua Guillermo Guevara Consultant SDE/PED PAHO Nicaragua Israel Rios Nutrition Consultant WFP Nicaragua Karla Somarriba Principal Program Assistant WFP Panama Dr. Reina Roa Sistema Institucional de Nutrition Department, MOH Salud para Emergencias y Desastres, Dirección Provi- sión Servicios de Salud Panama Flavia Fontes Departamento Salud Nutri- cional, MOH Panama Moises Abouganem Departamento Salud Nutri- cional, MOH Panama Lic Emilio Castillo Secretario Autoridad Panameña de Seguridad de Alimentos Panama Enrique Paz Nutrition Officer UNICEF/TACRO Panama Lic Aldo Mootoo Secretario SENAPAN Panama Dayaris Alvarez SENAPAN Panama Iris Ayarza SENAPAN Panama Vudia Donoso Bonos condicionales SENAPAN Panama Lic. Carolina Siu Directora INCAP Guatemala Panama Lic. Ana Atencio Directora Oficina INCAP Panamá y WHO Panama Dr. Dana van Alphen Regional Advisor on Disaster WHO Response Panama Jorge Dawson Director DICRE (Dirección de In- versiones, Concesiones y Riesgos del Estado) Panama Diego Ferrer Subdirector DICRE (Dirección de In- versiones, Concesiones y Riesgos del Estado) Panama Diego Galindo Jefe Inversiones, consecio- DICRE (Dirección de In- nes versiones, Concesiones y Riesgos del Estado) Panama Arturo Alvarado Director General SINAPROC Defensa Civil (Sistema Nacional de Pro- tección Civil) - 20 - Country Name Title Agency Panama Heriberto Chavez Director de Desastres SINAPROC Defensa Civil (Sistema Nacional de Pro- tección Civil) St. Lucia Dawn French Director National Emergency Mana- gement Office (NEMO) St. Lucia Mr. Claudie Prospere Chief Environmental Health Ministry of Health St. Lucia Lisa Hunt Chief Nutritionist Ministry of Health St. Lucia Nurse Ann Margaret Henry Head, Maternal and Child Ministry of Health Health Program St. Lucia Terrencia Gillard Red Cross St. Lucia Kerri Mills Health Disaster Coordinator Ministry of Health St. Lucia Director of Agriculture Ministry of Health St. Vincent Bernard Marksman Director General Red Cross St. Vincent Howie Prince National Disaster Coordi- National Emergency Mana- nator gement Office (NEMO) St. Vincent Ferosa Roache Senior Head, Child and Ministry of Health and Envi- Maternal Health ronment St. Vincent Andrea Robin Chief of Nutrition Ministry of Health and Envi- ronment St. Vincent Audrey Gittens- Gilkes Chief Nursing Officer Ministry of Health and Envi- ronment St. Vincent Annik Wilson Focal Point PAHO - 21 - Annex 3. Summary of Policy Guidance Recommendations for Priority Nutrition Interventions & Cross-Cutting Approaches Intervention In Stable Times Priority Nutritio • Promote optimal breastfeeding practices: initiation of exclu- sive breastfeeding within one hour of birth, exclusive breas- tfeeding until 6 months of age, and after 6 months sustained breastfeeding with appropriate complementary foods until 2 years of age and beyond. • Encourage appropriate complementary feeding practices starting at 6 months of age. Appropriate complementary foods should be adapted to the development of the child, nu- trient-dense, of the appropriate consistency, fed frequently, Assuring Maternal, Infant, and Young Child Nutrition varied, easy to chew and digest, appealing to children, help children transition to the family diet, prepared and fed in hygienic conditions, and fed responsively with patience and encouragement. • Ensure the International Code of Marketing of Breast-milk Substitutes is in place and complied with at all times. • Implement community-based nutrition programs that promo- te and support optimal maternal, infant, and young child fe- eding practices. • Implement growth monitoring and promotion (GMP) activities to prevent undernutrition by detecting growth faltering and improving household practices or seeking care for illness. • Integrate a referral system for cases of acute malnutrition detected through GMP and ensure that protocols for mana- gement of acute malnutrition are up-to-date with the latest recommendations. • If rates of acute malnutrition are above 5%, implement com- munity-based management of acute malnutrition (CMAM) Promoting Healthy Growth programs for children with acute malnutrition without com- plications, providing ready-to-use therapeutic food. • Ensure that GMP and CMAM programs integrate the most cost-effective interventions and products. - 22 - In Crisis In Emergency on Interventions • Intensify and scale up programs that educate, encourage, and • Ensure that mothers and families receive adequate su- support mothers and families to practice optimal infant-fee- pport, including provision of ongoing information and of ding practices, including sustained breastfeeding. a safe environment, to practice optimal infant feeding, • For households with pregnant women or children <2 years of including sustained breastfeeding. age, consider income support in response to constrained ac- • Provide, in situations where children cannot be breast- cess to affordable nutritious foods or specialized complemen- fed, artificial feeding in the form of ready-to-use infant tary food provision in response to constrained availability for formula, following WHO recommendations. those at risk of falling into poverty. • Ensure availability of safe havens where mothers can breastfeed. • Ensure that pregnant and lactating women receive ade- quate fluids and food to maintain hydration and sustain breastfeeding in order to support the additional nutritio- nal requirements of pregnancy and lactation. • Provide specialized complementary foods to children 6-24 months of age. • Scale up and strengthen GMP programs to ensure coverage and • Intensify GMP and, where it does not exist, put in place more frequent monitoring of young children with enhanced rapid screening for acute child malnutrition and undernu- vulnerability. GMP programs may be a good platform to scale trition in pregnant and post-partum women; target espe- up other health and social service programs. cially women and children in shelters. • Use an early warning surveillance system to target and monitor • Scale up CMAM or referral for acute malnutrition, ensu- rates of acute malnutrition. ring the supply of ready-to-use foods to prevent and treat • Use GMP as a platform to offer essential nutrition, health, and malnutrition. social protection interventions. • Use information from GMP programs or the early warning • Strengthen referral networks or initiate CMAM programs to in- surveillance system to inform nutrition-program decisions clude acutely malnourished children and those with increased over time following the emergency; closely monitor rates vulnerability, for example those who are losing weight. of moderate and severe acute malnutrition, particularly • Make sure a supply chain for CMAM supplies is in place. among the poorest individuals. • Provide supplementary food rations to young children with mo- derate acute malnutrition. • If the crisis is prolonged screen pregnant and post-partum wo- men for undernutrition and refer to supplementary feeding program as needed. Intervention In Stable Times • Promote consumption of a diverse diet rich in micronutrients. • As needed, establish micronutrient supplementation pro- grams for common deficiencies as a short-term strategy for eliminating micronutrient deficiencies: For children < 5 years, • vitamin A when vitamin A deficiency prevalence > 20% • iron when anemia prevalence is > 40% For girls and women of reproductive age, iron-folic acid when anemia prevalence is > 20%. • Establish food fortification programs, including universal salt iodization and fortification of complementary foods, as Preventing and Treating Micronutrient Deficiencies a long-term strategy for eliminating micronutrient deficien- cies. • Promote optimal breastfeeding practices. • Provide all pregnant women with daily iron-folic acid supple- ments for at least six months. • Provide daily iron-folic acid supplements to mothers for three months after delivery where anemia prevalence is ≥ 40%. • Provide deworming treatment to pregnant women, pres- chool-aged children, and school-aged children in areas where hookworms or soil-transmitted helminthes are prevalent. • Set up infrastructures that ensure access to safe water and hygienic environments. • Decide whether health services should counsel mothers to ei- ther breastfeed and receive ARV drugs or avoid all breastfee- ding. • Promote replacement feeding only if it is acceptable, feasi- ble, affordable, sustainable, and safe. • Recommend, in countries that choose to promote breastfee- ding with ARV interventions and where ARV drugs are availa- ble or are planned to be, that mothers known to be HIV-infec- ted exclusively breastfeed for six months and then continue Preventing and Treating Micronutrient Deficiencies breastfeeding with complementary foods at least until their children reach 12 months of age. • Use oral rehydration salts (ORS) and daily zinc supplements for the clinical management of acute diarrhea, as per WHO and UNICEF recommendation. • Implement robust malaria and dengue control programs that reduce vector breeding sites by encouraging clean environ- ments and, where relevant, sleeping under bed nets, espe- cially for pregnant women and young children. • Promote and protect breastfeeding, especially exclusive breastfeeding for the first six months of life. - 24 - In Crisis In Emergency • Scale up and strengthen programs to prevent, screen, and • As needed, provide fortified food rations, including iodi- treat micronutrient deficiencies, paying attention to women zed salt. and children whose diet quality or health care access may be • Provide pregnant and lactating women with a daily mul- limited. tiple micronutrient supplements; continue provision of • Monitor prevalence of micronutrient deficiencies in vulnerable iron-folic acid supplements. populations to see if the supplementation protocol should be • Provide children 6-59 months of age with a daily dose modified. of multiple micronutrient supplements when fortified ra- • Provide deworming treatment to pregnant women, pres- tions are not being given; when fortified rations are being chool-aged children, and school-aged children in areas where given, children in this age group should receive two doses hookworms or soil-transmitted helminthes are prevalent. per week. • Continue semi-annual vitamin A supplementation. • Expand and strengthen infectious disease control programs, • As needed, provide fortified food rations, including iodi- especially in vulnerable populations. zed salt. • Intensify the promotion and protection of optimal breastfee- • Provide pregnant and lactating women with a daily mul- ding practices. tiple micronutrient supplements; continue provision of • Ensure that emergency preparedness plans take into account iron-folic acid supplements. appropriate management of infectious diseases including the • Provide children 6-59 months of age with a daily dose provision of ART, ARV drugs, breast-milk substitutes (for those of multiple micronutrient supplements when fortified ra- countries that recommend that HIV-infected mothers avoid all tions are not being given; when fortified rations are being breastfeeding), and condoms. given, children in this age group should receive two doses • Enhance the surveillance of infectious diseases and scale up per week. programs where prevalence increases. • Continue semi-annual vitamin A supplementation. - 25 - Intervention In Stable Times • Set up infrastructures that ensure access to safe water and hygienic environments. • Decide whether health services should counsel mothers to ei- ther breastfeed and receive ARV drugs or avoid all breastfee- ding. • Promote replacement feeding only if it is acceptable, feasi- ble, affordable, sustainable, and safe. • Recommend, in countries that choose to promote breastfee- ding with ARV interventions and where ARV drugs are availa- ble or are planned to be, that mothers known to be HIV-infec- ted exclusively breastfeed for six months and then continue Preventing and Treating Infectious Diseases breastfeeding with complementary foods at least until their children reach 12 months of age. • Use oral rehydration salts (ORS) and daily zinc supplements for the clinical management of acute diarrhea, as per WHO and UNICEF recommendation. • Implement robust malaria and dengue control programs that reduce vector breeding sites by encouraging clean environ- ments and, where relevant, sleeping under bed nets, espe- cially for pregnant women and young children. • Promote and protect breastfeeding, especially exclusive breastfeeding for the first six months of life. • Follow WHO guidelines for antenatal and postpartum package of services. • Promote good nutrition for all girls and women of reproducti- ve age, and adequate weight gain during pregnancy. • Discuss birth plans with all pregnant women, and provide each with a safe delivery kit. • Ensure the availability of skilled professionals and essential Promoting Healthy Motherhood equipment. • Use infection prevention measures when caring for women and infants immediately after birth. • Ensure a sufficient number of delivery kits for the estimated number of deliveries in each area. • Integrate safe motherhood interventions into emergency plans. - 26 - In Crisis In Emergency • Expand and strengthen infectious disease control programs, • Ensure supplies of ART, ARV drugs, breast-milk substitutes especially in vulnerable populations. (if applicable), and condoms are included in emergen- • Intensify the promotion and protection of optimal breastfee- cy response kits and that health workers maintain blood ding practices. safety and infection control procedures; provide ARV as • Ensure that emergency preparedness plans take into account soon as feasible. appropriate management of infectious diseases including the • In emergency settings, recommend breastfeeding for all provision of ART, ARV drugs, breast-milk substitutes (for those mothers. countries that recommend that HIV-infected mothers avoid all • Guarantee adequate access to potable water and safe breastfeeding), and condoms. foods, prioritizing mothers and young children. • Enhance the surveillance of infectious diseases and scale up • Have soap readily available in the toilet areas of shelters programs where prevalence increases. and promote regular hand washing with soap. • Encourage hygienic food preparation and closely monitor food safety in shelters • Intensify vector control measures and follow WHO recom- mendations on diagnosis and treatment of infectious di- seases. • Identify women who are in advanced stages of pregnancy and • Link with other sectors to provide “safe havens� for preg- discuss birth plans, providing each with a safe delivery kit. nant and lactating women. • Consider cash transfers or vouchers for households in which • Ensure that pregnant and lactating women receive addi- pregnant mothers are unable to afford adequate services or tional rations of food and safe drinking water. diets. • Provide pregnant women with additional warm clothes, • Provide food transfers when affordable nutritious foods are not based on the climate. Provide baby clothes and blankets available. for infants. • Follow WHO recommendations for healthy childbirth du- ring an emergency, including ensuring the presence of female health workers and adequate security at the deli- very site. • Ensure that an evacuation plan is in place for women and newborns with pregnancy and health complications. - 27 - Intervention In Stable Times • Establish strong links between agricultural, food security, social protection and nutrition policies that can be used to inform a robust communication program regarding maternal diet and critical infant and young child feeding practices. • Support diversified agricultural production to increase avai- lability of nutrient-dense foods, particularly those of animal sources. • Target the most vulnerable geographic areas and, within them, the most vulnerable households: poor/food insecure households and smallholder farmers. Ensuring Food Security • Prioritize the needs of pregnant and lactating women (ado- lescent girls if appropriate), and infants and children <2 years of age. • Encourage procurement and use of locally produced products when possible. • Provide cash vouchers, food, or in-kind transfers to food-inse- cure individuals. • Ensure that, when foods products are offered, they are adap- ted to the nutritional needs of women and young children. • Preposition food and logistics in hard-to-reach areas. Cross-Cutting • Identify and map pockets of vulnerability using a variety of criteria: poverty, disaster-prone, marginalized population, geographic isolation, etc. • Define target groups according to the different realms of in- terventions implemented. • Define targeting strategy including categories and criteria for inclusion, conditions, approaches, and appropriate targeting Targeting agents. • Establish a system at the community and agency level for identifying vulnerable families and actions to reduce their vulnerability. • Ensure that the targeting strategy does not add stigma to beneficiaries. • Establish a comprehensive humanitarian coordination mecha- nism that will lead the functions of preparedness, response, leadership, policy, advocacy, information management, and humanitarian financing. • Establish operational “clusters� or subcommittees by tech- nical areas (such as health, nutrition, water, and sanitation) Multisectoral Coordination to avoid duplications and gaps and ensure coordination and clear leadership for each technical area. • Involve a wide range of organizations and actors in huma- nitarian coordination mechanisms, including governmental and non-governmental institutions, religious or humanitarian groups, and bilateral and multilateral partners. - 28 - In Crisis In Emergency • Scale up income support via cash transfers, vouchers or food • Provide cash, vouchers, fee waivers, food rations, to in- transfers to allow households to procure a sufficient food bas- dividuals in distress rapidly to enable them to meet their ket. daily nutritional needs. • Scale up the provision of micronutrient supplements to preg- • Provide safe water and address specifically the need to nant/lactating women and young children in households that continue breastfeeding with specific instructions about may be suffering from reduced dietary diversity and/or vulne- use of formula and artificial milk. rable to micronutrient deficiencies. • Make certain that adequate and hygienic cooking facili- ties are available to families who have lost access to their homes. g Approaches • Target based on nutritional needs, especially pregnant and lac- • Establish an ongoing targeting process throughout the tating women and children <2 years of age, if resources are emergency that is clear and acceptable to those who are limited. included. • Prioritize other vulnerable groups, including children 2-5 years • Balance inclusion and exclusion errors to minimize harm of age, people with disabilities, the elderly, and people living to affected individuals. in hard-to-reach areas. • Consider blanket distributions in sudden-onset disasters if all households have suffered similar losses or where targeting is not possible. • Intensify coordination mechanisms and ensure that core func- • Activate coordination mechanisms to ensure efficient tions are operating well and are ready to be activated. emergency response. • Enable coordination mechanisms to build shared situational • Ensure that these mechanisms perform their core func- awareness as well as common strategy, approaches, and im- tions, share information fluently, and implement the res- plementation plans. ponse cooperatively. - 29 - Intervention In Stable Times • Make fighting undernutrition a top priority, focusing on opti- mal nutrition during the first 1,000 days through education of and advocacy among senior policy makers. • Enlist nutrition experts to review existing policies and plans to ensure that they are up-to-date with regard to internatio- nal recommendations and best practices and that nutrition Policy Making and Planning has been mainstreamed into preparedness planning. • Orient local first-responders to translate central plans into decentralized action that reaches those most in need. • Develop a graduation strategy or transition plan to assist in- dividuals to return to stability after a shock and to build resi- lience. • Elaborate a comprehensive communication plan for crises and emergencies to efficiently inform the public about the si- tuation and what to do at both the central and decentralized levels and to provide accountability to the public. • Include, in planning, multiple channels of communication— hardwired and wireless networks, broadcast and satellite te- Emergency Communication levision, radio, mobile phone networks, Internet, social me- dia, and interpersonal networks. • Develop or adapt training strategy, curricula, and materials to ensure that they include protecting nutrition during the first 1,000 days, taking into account training resources that have been produced by UN agencies and other reputable or- ganizations. Human Resources and Training • Integrate nutrition into crisis and emergency response trai- ning curricula for workers at all levels. • Ensure that key personnel undertake training courses on basic concepts of humanitarian aid, management of undernutrition and emergency response. • Invest resources in WASH infrastructures, especially in disas- ter-prone and peri-urban areas, to minimize the effects of poor hygienic conditions and to avoid population-wide epide- mics. • Ensure that emergency and crisis plans include sections on WASH and comply with international best practices taken from WHO/WEDC guidelines. Water, Sanitation, and Hygiene • Promote culturally-specific good WASH practices. • Maintain a store of clean water to meet basic needs for the initial phase of an emergency in more remote disaster-prone areas. - 30 - In Crisis In Emergency • Intensify links with existing social protection systems to ad- • Follow-up the work of, and maintain communication dress the food and nutrition needs of the chronic and transient with, local responders to adapt the implementation of poor. policies and plans according to the situation. • Expand systems and programs that address food and nutrition • Evaluate the situation before closing a program or ma- insecurity, with an emphasis on meeting the needs of mothers king the transition to a new phase, to provide evidence of and children. improvement or identify suitable actors to take over the • Ensure that emergency response plans are up-to-date and that responsibility. resources are available to be rolled out rapidly. • Communicate the exit strategy to affected populations during the early stages of program implementation to en- hance sustained recovery. • Implement the communication plan, targeting the affected • Rapidly roll out emergency communication plan, main- population, to provide information on how to seek assistance tain open communication with the public to assure calm and on what to do. and order, and provide clear and practical information on • Monitor the situation and continually test the effectiveness what to do and how to seek assistance. of the communication system by regularly obtaining feedback • Ensure that the communication system accommodates from the field and collecting data. two-way communication in order to collect and analyze information coming in from the field and to be responsive to it as the nature of the emergency changes. • Once the emergency is over, continue communication re- levant to recovery and to preventing relapse. • Evaluate public communication strengths and weaknesses during and following events and adapt plan accordingly. • Provide refresher training to crisis and emergency response • Provide continuous training, support, and supervision to personnel to assure that their skills and knowledge are up-to- response personnel during and after an emergency. date, notably in nutrition. • Take stock of strengths and skill gaps to adapt training • Have trained human resources assist in scaling up programs, after an emergency. implementing communication and education campaigns, and participating in surveillance and monitoring activities. • Strengthen WASH infrastructures in areas that are the most • Promote exclusive breastfeeding for children <6 months vulnerable to shocks and where the population lives in condi- of age and appropriate hygiene practices related to com- tions of extreme poverty, such as peri-urban and rural areas. plementary feeding. • Scale up programs to educate the population on practices they • Supply adequate levels of safe drinking water, prioritizing need to follow to prevent water-borne diseases. young children and pregnant and lactating women in light • Promote exclusive breastfeeding and appropriate hygiene of their increased water needs. practices related to complementary feeding. • If the local water supply is compromised, distribute water purification technologies or products. • Ensure that the population has access to adequate sanita- tion facilities and the ability to maintain good hygiene. • Monitor the incidence of water-borne diseases, particu- larly diarrhea and infectious diseases. - 31 - Intervention In Stable Times • Develop early warning systems based on international best practices that enable the government to predict crises and their associated effects. • Establish responses to be made when food security and nutri- tional status indicators fall below crisis and emergency cutoff values. • Develop a monitoring and evaluation system for crises and Monitoring and Evaluation emergencies that can assess the effectiveness of the humani- tarian response, enable learning, and promote accountabili- ty. • Link the monitoring and evaluation system to relevant gover- nment management information systems. - 32 - In Crisis In Emergency • Activate early warning systems and intensify surveillance, es- • Intensify surveillance of the situation through early war- pecially in vulnerable areas. ning and response (EWARN) systems to detect and res- • Monitor closely the food security and nutrition situation in vul- pond rapidly to outbreaks of diseases and malnutrition. nerable areas (i.e. rural and peri-urban areas) among mothers • Monitor and evaluate the emergency response, notably to and young children, and provide relevant assistance in accor- assess the two most vital, basic public health indicators dance with the information collected. measuring severity: nutritional status of children <5 years • Evaluate periodically the impact of these programs, informing of age and mortality rate of the population. planners of the results of evaluation, so that strategies can be • Ensure that key data from the field are inputted into go- improved. vernment management information systems for easier analysis and communication. - 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