Self Help Africa - Uganda Nutrition Strategy 2020

UGANDA

Nutrition Strategy selfhelpafrica.org

A Nutrition integration strategy and Plan of Action

1.0. INTRODUCTION

mission to support sustainable livelihoods for smallholder farmers.

T

development projects for close to 20 years with current programs

he Self Help Africa (SHA) Uganda Nutrition Strategy is based on a holistic causal analysis of the malnutrition situation in Uganda and forms a comprehensive approach

to address the underlying problems from a ‘farm to table’ to a food value chain perspective. Based on this analysis, strategic directions, implementation models and objectives have been defined. To address the immediate causes of under nutrition, the focus will be on improving nutrient intake and reducing infectious diseases that affect the biological utilization of food. To address the underlying causes (mainly at the household and community level), there is a need to improve food availability, utilization, and accessibility. These are facilitated by adequate childcare, best practices in infant and young child feeding, promoting support to cognitive stimulation for children, nutrition care and support for women during pregnancy and lactation and other vulnerable groups (as identified). Other important areas of focus will include food safety and quality, environmental health including safe drinking water and good sanitation which will impact positively on improvement on health outcomes. Strategies to address basic causes of malnutrition (mainly at the broader level) will also be included. These entails improving institutional and human capacity; the collection and dissemination of information; access to quality services; partnerships; as well as collaborative, learning and adaptation.

In a bid to recognising the complexity of improving the nutrition situation, the Government of Uganda developed a national multisectoral nutrition coordination framework that is outlined in the 2011-2016 Uganda Nutrition Action Plan (UNAP).* The UNAP aimed at addressing the high prevalence of malnutrition among women of reproductive age, infants, and young children, which was threatening the country’s health, education, and socio-economic development potential. It has since been updated with a similar goal of providing a framework for addressing the country’s nutrition issues. To align with the country vision, the breadth and depth of the proposed SHA Nutrition Strategy aims to fast track and break the current trends of malnutrition within SHA operational areas. In addition, the document stands to direct evidence-based nutrition integration models within the SHA Uganda operational areas to achieve the priority development goals as stated in the 2017-2021 Country Strategic plan.

1.1 Background

S

operating in the selected districts of the West Nile, South West, Eastern, Northern Regions and recently in the Karamoja region.

We work with and through local community-based organisations, government ministries, international NGOs, UN agencies, private sector partners and emerging social enterprises in Uganda. We believe that the most effective role that we can play is in bringing together and facilitating partnerships that will serve the needs of underdeveloped rural communities.

We aim to be a catalyst, developing collaborative approaches to meet specific local needs through effective, integrated, and sustainable solutions. In this way going forward, initiatives can continue to function without our support and have the potential to grow leading to sustainability. Our programmes link with the various national program strategies including Ministry of Agriculture, Animal Industry and Fisheries (MAAIF), Ministry of Health, Ministry of Gender, Labour and Social Development as well as other relevant ministries.

The 2017- 2021 SHA Uganda strategic plan earmarks the organization’s commitment to nutrition programming through an integrated approach. By the end of the five-year strategy period, the over-arching goal of SHA globally, is to support one million smallholder households. In Uganda, the nutrition strategic objective is to improve food and nutrition security by helping create sustainable income for 100,000 smallholder farming families. The strategies and activities to achieve this objective are centred on the four food security pillars namely access, availability, utilization, and stability.† On the other hand, SHA is committed to identifying and removing barriers that prevent inclusion of more vulnerable groups, and ensuring that neither age, disability, health status, tenure of land, nor gender should be a barrier to participating and benefitting from programmes.

2.0 UNDERSTANDING NUTRITION

N

utrition is a quintessential sustainable development goal.

As the Uganda Vision 2040 acknowledges, nutrition is a key driver of human capital development and inclusive

growth. Good nutrition is the foundation to proper human growth and development and with it, there are reduced risks for disease, improved cognitive development and physical growth leading to increased productivity and thus increased economic status at

elf Help Africa (SHA) is an International Non-

individual and/or household level.

Governmental Organisation (NGO) implementing rural

Malnutrition is a broad term which refers to all forms of poor

development, sustainable livelihoods, and food security

nutrition. It includes both undernutrition and overnutrition

programmes in nine countries in Sub-Saharan Africa. SHA’s vision is an economically thriving and resilient rural Africa with a

2

In Uganda, SHA has been implementing agriculture and rural

*. http://www.health.go.ug/docs/UNAP_11_16.pdf, Uganda Nutrition Action Plan2011–2016; Scaling Up Multi-Sectoral Efforts to Establish A Strong Nutrition Foundation for Uganda’s Development

(overweight/obesity). Both people with undernutrition and †. To enable smallholder farmer households, improve their income, food and nutrition security, SHA-Uganda will promote access to technologies for increased and sustainable agricultural productivity; Facilitate access to agricultural financial services; Promote adoption of positive nutrition and WASH practices; Strengthen farmer institutional capacities in agro-enterprise development

overnutrition often suffer from micronutrient deficiencies. Under nutrition is a state resulting from inadequate nutrient and energy intake needed to meet an individual’s dietary requirements essential for maintaining growth, immunity, and organ function.

Over nutrition on the other hand, results when the nutrient and energy intake exceed an individual’s dietary requirements. The triple burden of malnutrition (undernutrition, overnutrition and micro-nutrient deficiencies) is a major public health concern in Uganda that affects children and adults. During pregnancy and early childhood, malnutrition has many adverse consequences for child survival and long-term well-being. It also has far-reaching consequences for human capital, economic productivity, and

2.1 CAUSES OF UNDER NUTRITION

T

he causes of under nutrition are multi-factorial in nature although have been since updated as per the UNICEF 2020-2030 Maternal and Child Nutrition Strategy. The

immediate causes that included; inadequate food intake and/or diseases have since been changed to immediate determinants: ;underlying causes that included; inadequate care and feeding practices, unhealthy household environment, inadequate health services and household food insecurity (availability of or

overall national development.

access to safe, diverse, nutritious food) has since changed to

This guiding document will specifically deal with under nutrition

inadequate financial, human, physical, social capital; social,

(and not over nutrition) as well as micronutrient malnutrition, with a focus on how to address this through proposed country integrated implementation approaches.

underlying determinants: “and lastly basic causes that included; cultural, economic and political context as well as household access to adequate quantity and quality of resources has since been changed to reflect enabling determinants The causal factors linked to malnutrition are all inter-related and thus, call for multisectoral approaches to address malnutrition(See Figure 1 for details).

3

3.0 UGANDA NUTRITION LANDSCAPE 3.1 PREVALENCE OF UNDER NUTRITIONUGANDA

A

Angela Atim, Kapelebyong, Teso, Uganda.

3.2 PREVALENCE OF MICRONUTRIENT MALNUTRITION

M

icronutrient malnutrition, a term used to refer to diseases linked to a deficiency of vitamins or minerals in the diet (poor dietary diversity) and is

predominantly in developing countries, Uganda inclusive.

Vitamin A deficiency, Iron deficiency anaemia, Iodine deficiency

t national level, early childhood stunting, the key indicator

and Zinc deficiency disorders are the most common forms

for chronic under nutrition has emerged as critical factor

of micronutrient malnutrition of specific public health concern

contributing to slowed Uganda’s economic and social

worldwide. In Uganda, iron and Vitamin A deficiencies

development. Stunting, the measure of linear growth retardation

contribute significantly to the burden of disease among

and cumulative growth deficits in children is less visible and more

children below 5 years. In general, micronutrient malnutrition

difficult to diagnose and yet poses a detrimental effect on cognitive

has long-term impact on health, learning ability and

development. The periodic Uganda Demographic and Health

productivity and is a major contributor to childhood morbidity

survey (UDHS)* findings for all forms of under-nutrition prevalence

and mortality.

are summarised below (See Figure 2).

Anaemia:

Children in rural areas are more likely to be stunted than those in urban areas at 30% and 24% respectively. Moreover, the proportion of children who are stunted decreases with increasing mother’s education. About 35% stunting rate among children was reported among mothers that had no education at all compared to 10% stunted children among mothers with more than secondary education level. There are numerous well documented consequences of childhood under nutrition on an individual’s

WHO estimates that around 50% of all anaemia cases are due to lack of iron in the diet.* Lack of iron in the diet leads to a reduction in the production of haemoglobin which is essential to carry oxygen around the body leading to tiredness, breathlessness, and lack of concentration, and in very severe cases may lead to death. Anaemia can be caused by many other issues such as haemorrhaging or bone marrow disease.

physical and mental development. In Uganda, it is estimated that

The most dramatic health effects of anaemia are increased

54% of the working population is stunted due to early childhood

risk of maternal and child mortality due to severe anaemia,

malnutrition. †

have been well documented.† Anaemia can impair cognitive

As seen from the graph above malnutrition in Uganda is reducing which is extremely positive (down from 45% in 2001 to 29% in 2016) but there is considerable work to be done still, to reduce

development in children, with associated long-term health and economic consequences. The prevalence of anaemia among 6-59 months children in Uganda as per the UDHS has remained extremely high at 53% although declining somewhat between 2006 and 2016 (See Figure 3 overleaf) .

Of note is that the 2016 anaemia prevalence decreased with increasing mother’s education and household wealth.

Furthermore, it was also higher among younger children (age 6-23 months) than the older children (age 24-59 months), with a peak prevalence of 78% among children age 9-11 months.

In addition, rural areas showed a higher prevalence of anaemia than urban areas at 54% and 48% respectively.

Further, a regional variation exists; with Acholi region at 71%, West Nile at 56%, Karamoja at 68%, Bunyoro at 55%, Ankole at 31%, Lango at 61%, Kigezi at 32%, compared with 51% of children in Kampala central.

†

https://dhsprogram.com/pubs/pdf/FR333/FR333.pdf, Uganda Demographic and Health Survey 2016 UgandaThe Cost of Hunger in Uganda: Implications on National Development and Prosperity https://documents.wfp.org/stellent/groups/public/ documents/newsroom/wfp263404.pdf?_ga=2.222563355.1085429386.15568645971714979251.1492603860

4

Angella Atim, Kapelebyong, Teso, Uganda.

*

WHO – Focusing on anaemia, towards and integrated approach to effective anaemia control -2004

Anaemia is a major public health issue among women of reproductive age (15-49 years) in Uganda, leading to increased maternal mortality and poor birth outcomes as well as reduction in work productivity. There has been little reduction on prevalence of anaemia between 2001 and 2016, only reducing from 37% to 32% in a 15year period (See Figure 4). Pregnant (38%) and breastfeeding women (34%) are more likely to be anaemic than women who are neither pregnant nor breastfeeding (30%).

Similarly, there is regional variation in the prevalence, from 17% in Kigezi region to 47% in Acholi region. Also, the prevalence of anaemia decreases with increasing wealth, from 41% among women in the lowest wealth quintile to 25% among those in the highest quintile.

High levels of anaemia in pregnant and lactating women is possibly a contributing factor to the high levels of anaemia in young children (reduced iron stores in young children).

5

Vitamin A Deficiency: Severe vitamin A deficiency (VAD) can cause eye damage and is the leading cause of childhood blindness. The deficiency is common in dry environments where fresh fruits and vegetables are not readily available. It is reported to increase the severity of infections such as measles and diarrheal disease in children while slowing recovery from illness. In the 2016 UDHS, children whose mothers had more than a secondary education and children from households in the highest wealth quintile were less likely than other children to have VAD. Also, VAD was highest among children 2-4 years of age as well as children in rural areas compared to those in urban areas (21% vs. 15%). Furthermore, VAD among children was 15 % or less in Kampala, Western, and Southwest regions and highest in East Central region (32%). Children in internally displaced camps (IDP’s) and Karamoja were at very low risk for VAD (9% and 6 %, respectively) and this may be related to the public health strategy

3.3 RECOMMENDED INFANT AND YOUNG CHILD FEEDING PRACTICES

A

ppropriate national level infant and young child feeding (IYCF) practices include initiation of breastfeeding in the first hour of birth/life; exclusive breastfeeding in the first

6 months of life; introduction of solid and semi-solid foods at age 6 months (complementary feeding); continued breastfeeding through age 2 or beyond, and gradual increase in the amount of food given and frequency of feeding as the child gets older.

Complementary feeding, also defined as the transition period from exclusive breastfeeding to family food is the most critical period for children, as during this time, they are most vulnerable to becoming undernourished.

of six-monthly Vitamin A supplementation leading to high rates of

The process should be timely; that is, foods in addition to breast

vitamin A supplementation among children in these areas.

milk must start from 6 months onwards. Other key aspects to

Table 1 below summarizes the UDHS VAD findings accordingly.

consider include frequency of the feeding; food being adequate; with appropriate texture; be of variety (comprise of all the food groups); ensuring active feeding for the child and lastly food being hygienically prepared.

As per WHO standards, it is critical that young children receive a diverse diet containing food items derived from at least four of the seven food groups identified by WHO to address their increasing

Iodine deficiency: Iodine deficiency is one of the main causes of impaired cognitive development in children. The deficiency can start before birth, can impair children’s mental health and often their very survival.

According to WHO, iodine deficiency is one of the most prevalent yet easily preventable cause of brain damage. However, as per

nutrition needs. The seven WHO food groups include; 1) grains, roots and tubers, 2) legumes and nuts, 3) dairy products (milk, yoghurt and cheese, 4) flesh foods (meat, fish, poultry, and liver/ organ meats), 5) eggs, 6) vitamin A rich fruit and vegetables and 7) other fruit and vegetables. By giving at least four of the seven food groups above ensures young children receive a good source of protein in their diet.

WHO reports, there is global progress in eliminating the deficiency

The recognised Minimum Acceptable Diet (MAD) which includes

in the recent years, an achievement that will be hailed as a major

recommended diversity of diet* and frequency of meals† should

public health triumph.

be followed to ensure appropriate growth and development. In

Critical to mention is that Uganda has had numerous multifaceted interventions to address iodine deficiency including universal salt iodisation; advocacy and networking at regional and national level (iodine global network; national micronutrient technical working groups) with improved coverage of iodised salt intake. As per the 2016 UDHS, a total of 99% of the households whose salt was tested had iodine in it. Critical to mention is that the Karamoja region still stands as a high-risk location for potential iodine deficiency.

For instance, as per the most recent 2016 UDHS Karamoja had the highest proportion of households not having any salt present at time of the survey (32.4%).

the absence of adequate diversity and meal frequency, infants and young children are highly vulnerable to undernutrition, especially stunting and micronutrient deficiencies, as well as increased morbidity and mortality. The WHO MAD recommendation, which is a combination of minimum dietary diversity and minimum meal frequency, is different for breastfed and non-breastfed children. * Minimum dietary diversity means feeding the child food from at least four food groups. The four groups should come from a list of seven food groups: grains, roots, and tubers; legumes and nuts; dairy products (milk, yogurt, and cheese); flesh foods (meat, fish, poultry, and liver/organ meat); eggs; vitamin A-rich fruits and vegetables; and other fruits and vegetables. The cut off four food groups is associated with better-quality diets for both breastfed and non-breastfed children.

† A pre lacteal feed is any food except mother’s milk provided to a newborn before initiating breastfeeding. Pre lacteal feeding is a major barrier to exclusive breastfeeding.

6

3.3.1 UGANDA INFANT FEEDING STATISTICS

Regarding the MAD indicator among children aged 6-23 months, UDHS 2016 findings are as summarized in Table 4 below.

The proportion of children age 6-23 months fed the minimum

T

acceptable diet is similar among non-breastfed (13%) and

initiating breastfeeding varied too with urban children having more

Furthermore, the regional variation in the proportion of children

likelihood to start breastfeeding within 1 hour of birth (71%) and to

age 6-23 months receiving the MAD was observed; from 3%

receive a pre lacteal feed (32%) than rural children (65% and 25%,

in Acholi region to 27% in Ankole region. Important to note is

respectively).

that the proportion of children aged 6-23 months receiving the

he 2016 UDHS showed that a lower proportion (66%) of children were breastfed within 1 hour of birth among the surveyed households while one quarter of children (27%)

received a pre-lacteal feed . The background characteristics for

There is also regional variation in the initiation of breastfeeding; for instance, 9 in 10 (93%) children in Karamoja region start breastfeeding within 1 hour of birth, as compared with 5 in 10 (50%) children in Bukedi region. Key to mention is that the survey showed that initiation of breastfeeding within 1 hour of birth decreased as mother’s education increased. Furthermore,

breastfed (15%) children. This indicates that IYCF practices are extremely poor in Uganda in general and are likely to contribute to UDHS the high levels of malnutrition in young children.

MAD rose with increasing mother’s education, from 10% among children whose mothers have no education to 26% among those whose mothers have more than a secondary education. This is indicative of adherence to the recommended IYCF behavioural practices once mother has some level of education to ably comprehend the IYCF choices to take.

the proportion of children who received a pre-lacteal feed increased with increasing mother’s education and household wealth.* The rate of exclusive breastfeeding has remained relatively stable over the years as summarised in Table 2. Median durations of exclusive breastfeeding are similar among rural and urban children (4.0 and 3.9 months, respectively). However, overall exclusive breastfeeding as per 2016 findings declined with age, from 83% among children age 0-1 months to 69% among

4.0 SELF HELP AFRICA GLOBAL NUTRITION IMPLEMENTATION SCOPE

S

elf Help Africa’s current strategic plan 2017-2021 “Embracing Change” places nutrition at the centre of

those age 2-3 months and 43% among those age 4-5 months.

The proportion of children who were breastfeeding while consuming complementary foods increased with age (peaking at 87% among children age 9-11 months) and then fell among children age 12-23 months, as older children stopped breastfeeding. Median durations of any breastfeeding have undergone mild fluctuations over the past 16 years as summarized in Table 3. Children in rural areas breastfeed for longer (20.4 months) than those in urban areas (17.8 months).

In addition, children in the lowest wealth quintile breastfeed for longer (21.2 months) than those in the highest wealth quintile (17.2 months).

our work. It is one of our core pillars of work alongside

agriculture and enterprise. We are striving to improve food, nutrition, and income security among smallholder farmer beneficiaries with our overall vision “an economically thriving rural Africa”. Within our policy document “Linking Nutrition to Agriculture Production” - 2013 we state that we expect to improve nutrition outcomes through a combination of addressing seasonal hunger gaps and dietary diversity.

SHA recognises that hunger disproportionately affects rural small holder farmers and their families’. Lack of appropriate knowledge on good nutrition, lack of availability of a varied diet leading to poor dietary diversity and high levels of post-harvest losses are some of the aspects leading to the current high levels of chronic food insecurity and undernutrition. Addressing the following two core principles – “Seasonality and Dietary Diversity” will support improved nutrition within the populations addressed by SHA interventions (See summary in Figure 4).

* Last-born children who were born in the 2 years before the survey constituted the sample size

Mary Asele, Kapelebyong in Teso, Uganda.

7

4.0 SELF HELP AFRICA GLOBAL NUTRITION IMPLEMENTATION SCOPE

S

elf Help Africa’s current strategic plan 2017-2021 “Embracing Change” places nutrition at the centre of our work. It is one of our core pillars of work alongside

agriculture and enterprise. We are striving to improve food, nutrition, and income security among smallholder farmer beneficiaries with our overall vision “an economically thriving rural Africa”. Within our policy document “Linking Nutrition to Agriculture Production” - 2013 we state that we expect to improve nutrition outcomes through a combination of addressing seasonal hunger gaps and dietary diversity.

greater variety of nutritious foods as well as the main staple for good health and nutrition.

Enabling Processes: SHA recognises that there are three critical aspects to achieving these outcomes which include investment, knowledge, and organisation.

Investment: Self Help Africa will support the process of improving nutrition throughout its programmes with several different initiatives.

Where necessary, baseline studies will be conducted to inform communities on the most appropriate interventions to improve nutrition. Tools will be developed to support programme staff and beneficiaries better understand core elements of good nutrition, dietary diversity, food utilisation/processing, preserving and

SHA recognises that hunger disproportionately affects rural small

storage. SHA will facilitate access to resources, services, and

holder farmers and their families’. Lack of appropriate knowledge

capital across programmes.

on good nutrition, lack of availability of a varied diet leading to poor dietary diversity and high levels of post-harvest losses are

Knowledge:

some of the aspects leading to the current high levels of chronic

SHA will support staff and communities to have access to relevant

food insecurity and undernutrition. Addressing the following two

current knowledge on improving nutrition outcomes throughout

core principles – “Seasonality and Dietary Diversity” will support

its agriculture and livelihoods programmes with skills training and

improved nutrition within the populations addressed by SHA

linking to relevant institutions and knowledge forums. SHA will

interventions (See summary in Figure 4).

collate and disseminate information on its programming including

Address Seasonality: Many rural communities are affected by cyclical food insecurity termed as the “hunger gap”. This is multi-factorial. Main staples are generally only grown on an annual basis therefore one

successes and failures, lessons learned, and approaches taken.

Knowledge will be shared cross country, and with SHA head office and externally.

Organisation:

main harvest season. The period prior to the harvest is often

SHA’s strength is supporting and working with rural smallholder

considered the “hunger gap” as food availability is scarce. Post-

farmer communities over the last thirty years to build up resilience

harvest small holder households are usually required to sell a

with a varied model. Support includes capacity building of

considerable portion of their produce for low prices to pay for

smallholder farming groups in various skills to maximise returns

expenses accumulated during the hunger period.

from different enterprises.

Furthermore, poor processing practices and the lack of proper

These skills include the following: training on group dynamics,

storage facilities can lead to substantial losses of the harvest (up

financial management and legal requirements among other skills.

to 20-30%). Frequently off-season cropping practices are limited

The SHA focus is on supporting marginalised groups with a

for small holder farmers. By improving processing and storage

specific gender bias, supporting women’s groups, especially as

then crops can be sold later at higher value and improve income.

they are the dominant agriculture produces. As SHA is already

Off season cropping can increase production of other food groups

working with rural smallholder communities and has strong

as well as cereals. Supporting markets and the “value chain”

relations with these populations by strengthening the nutrition

will potentially increase incomes and support reduction in food

component this will assist in improving dietary diversity and

insecurity.

reducing hunger especially seasonal hunger.

Dietary Diversity: Poor people are mainly dependent on the staples (maize, wheat, rice) for their main dietary intake and to relieve hunger. A relish is often all that is added to give some flavour but is not necessarily very nutritious. Increased wealth may improve dietary diversity, but this is not an absolute given. Knowledge on the value and use of a Gladys Otiru, West Nile, Uganda. varied nutritious diet is fundamental to improving dietary diversity.

8

It is essential that smallholder farmers produce and consume a

8

4.1 KEY COMPONENTS TO ADDRESS NUTRITION WITHIN SHA PROGRAMS

•

foods including drying (dehydrating, sun-drying, air drying, smoking, or baking), pickling or caning •

Support and resource communities to develop locally appropriate ways of storing produce that prevents spoilage

Nutrition Education:

Bio-fortified Crop Production:

In many communities where there are high levels of food insecurity there are strong links with poverty, low literacy levels,

Micro-nutrient deficiencies are a public health issue and affect

and poor access to key services such as health care and safe

large proportions of the population in developing countries

drinking water. The lack of knowledge on appropriate caring

including Uganda as aforementioned. Food fortification and

practices (health and nutrition) during pregnancy and especially

vitamin/mineral supplementation have been the main strategy

for children up to 23 months leads to high levels of acute and

for addressing micro-nutrient deficiencies, however the reach

chronic malnutrition.

of these initiatives is often limited to more urban settings. Rural

Lack of knowledge on food preparation and processing especially when new foods are introduced may reduce the perceived value of important nutritious foods. There may be subtle changes in

communities in developing countries often do not purchase fortified foods or supplements where micronutrient deficiencies are of the most concern.

diet that considerably affect nutrition, such as the lack of access

A new technique is being developed- “bio-fortification” whereby

to wild foods and/or game which may have substantial seasonal

scientists are developing/breeding staple crops and some pulses

negative impact on nutrition outcomes. SHA, when supporting

with higher micro-nutrient concentrations. This may be particularly

initiatives to improve livelihoods and food security there is a

valuable in rural communities with mainly the consumption of their

need to ensure there is a component of nutrition education in all

own produce. Promising results have been achieved in fortification

interventions.

of orange fleshed sweet potato with vitamin A, orange maize (vitamin A) and zinc and iron in rice and wheat. Different varieties

This should be a combination of information sharing sessions, cooking demonstrations and information on good hygiene when

of beans are also being fortified with iron and zinc.

preparing meals. Where women’s groups include mothers with

SHA works with vulnerable rural smallholder communities. In

young children, SHA must ensure these mothers are aware of

certain countries, bio-fortification is being researched and piloted.

good caring practices for young children. SHA can either conduct

Where appropriate, SHA is an operational partner in some

trainings or link with others with this technical capacity. SHA

of these research initiatives: SHA will actively support these

programmes should consider:

initiatives to include:

•

•

Nutrition education/awareness as a core component of all

•

Linking/engaging with relevant institutions and where opportunities exist support research into further development

SHA interventions

of bio-fortification

Target vulnerable groups for increased knowledge sharing on selected topics around improved nutrition such as mothers

•

Ensuring SHA staff and all stakeholders (communities, CBO’s)

with young children, who need to know good practices on

remain current in advancements in terms of different research

care and dietary needs for these children

being conducted in reducing micro-nutrient deficiencies and hunger

Reduction in Post-Harvest Losses: •

Post-harvest losses are substantial particularly in the least developed countries where processing and preserving is limited.

Storage facilities are often poor also which leads to damage from pests, moisture damage etc. It is estimated that main staple loss can be between 15-25% of cereal production in Africa. This is shocking in a continent where hunger and food insecurity is so pervasive.

Where appropriate promote these new crop varieties within communities advocating for their nutritional benefits in reducing micro-nutrient deficiencies

Intra-household food access: In general, when looking at household food security we make assumptions that the nutrition needs of all household members are similar. This is a myth. Small children (under 2 years) require

SHA works with and supports smallholder farmers as they

more frequent high-density nutritious meals as they grow

are the main producers of food for their own use and for sale.

rapidly during these first two years. There are often cultural

SHA supports communities with selected initiatives including

taboos around the use of certain foods with children and during

training and resource support to improve practices in harvesting,

pregnancy. Women during pregnancy and lactation require a more

processing, preservation, and storage of foods.

nutritious diet however in some cultures certain nutritious foods are avoided. Traditionally in some cultures, men and boys eat first

Some of these initiatives may include:

9

Increasing knowledge on different techniques for preserving

Agnes Katushabe, Uganda

and receive the most nutritious foods. ,

9

Therefore, there may be huge inequalities within the household in the nutrition context. As SHA works with communities and households there is an opportunity to support capacity building/ information sharing on the importance of a nutritious diet for all household members with special considerations for young children, the sick, elderly, and pregnant/lactating women. Within the SHA

Food Security exists: “when all people at all times have physical, social and economic access to sufficient safe and nutritious food that meets their dietary needs and

programmes it is important to:

food preferences for an active and healthy life”

•

Conduct baseline studies (if not already existing) in some

Four main pillars to addressing Food Security

communities to ascertain what cultural norms and practices

include:

exist around the diet within the household (HH) and also within

1) Access to food

specific members, with this knowledge develop material to

2) Availability of food

support improvement in household dietary intake (within the

3) Utilisation of food

HH and intra HH)

4) Stability

•

Conduct periodic HH dietary diversity and individual dietary diversity surveys to track behavioural change

•

•

Nutrition Security exists when “food security is combined with adequate health services, a sanitary

Incorporate nutrition specific data questions/data collection

environment, and caring capacity that is proper care

within the IHM (individual household method) tool for collecting

and feeding practices to ensure a healthy life for all

baseline data

household members.”

Share knowledge and information with all community members on ways of achieving a balanced diet and importance of specific dietary requirements for different HH members

, Plot 44 Ministers’ Village, Ntinda, Kampala Tel: +256 414 286 305 E-mail: uganda@selfhelpafrica.org July 2020

10

Evalyne Akampurira, Uganda Photo credit: Arjen Van de Merwe 2014

5.0 PROPOSED COUNTRY NUTRITION INTEGRATION APPROACHES

potential for agriculture to make a lasting positive impact on nutrition is substantial.

Thus, to realize this potential requires continued commitment and significant investments in nutrition-sensitive agriculture. There is enormous evidence that Nutrition-sensitive agriculture can help unlock the potential of millions of food insecure people around the world, enabling them to live healthy, productive lives. Agriculture can play a significant role in addressing the causes of malnutrition

5.1 NUTRITION INTEGRATION THROUGH AGRICULTURE

A

griculture is the main source of both livelihoods and food for most people who struggle to get enough food to eat.

Globally, at least 70% of all food insecure people live in

rural areas and most of them are dependent on agriculture for their sustenance.* Similarly, in Uganda approximately 69% of the population are employed by the agricultural sector. Smallholder farmers are among those most likely to be food insecure. The

* http://www.fao.org/3/a-i7695e.pdf, The State of Food Security and Nutrition in the World, FAO

while also tackling underlying systemic issues such as social and economic underdevelopment as well as inequality. Production of diverse nutritious foods among these farmers is essential for their own household consumption and helps supply rural markets.

There is a new emphasis on trying to address global hunger with a more holistic approach looking at “healthy and sustainable diets for future generations”.

For this to work, a “Food Systems Approach” is required whereby one works on the food supply chains and also the food environments as both are needed to be well functioning to address food and nutrition security† (See Figure 5). Where possible and where needs are identified, SHA will work across various elements of both the food supply chains and food environments. What is key to this success is a well-functioning † Nutrition and food systems, A report by the High-Level panel of Experts on Food Security and Nutrition, September 2017

11

SHA, within its global strategy Embracing Change 2017-2021,

recommendations which are also aligned to the SHA guidance on

has committed to nutrition being a core pillar within all country

incorporating COVID 19 response in SHA programming* as we

programmes. This translates to incorporating nutrition at project

strive to do no harm to staff and the communities served.

design within all proposals and budgeted appropriately. As stated in the Uganda country strategic plan, there is organizational commitment to explore creative measures to address nutrition and integrate it in every project.

In some of SHA’s programmes going forward as well as a nutrition sensitive agriculture approach there will also be Nutrition Specific Interventions. Within certain programmes, vulnerable members of the household will receive specific nutrition attention. These

There are two basic approaches that can be taken where

will include pregnant and lactating women and children under

appropriate, or a combination of both for Uganda context. At

two years, and this will contribute to addressing the high levels

a basic level SHA commits to a Nutrition Sensitive Approach

of stunting within rural households in the rural communities in

to Agriculture whereby interventions will be developed to

Uganda where SHA works. This is an approach SHA has piloted

improve dietary diversity and reduce the hunger gap. In terms of

in Zambia with considerable success in nutrition outcomes. An

production, this equates to

adolescent nutrition component will be incorporated as well as

•

A strong nutrition promotion/education element will be embedded within the programmes

•

Producing more diversity and more nutritious quality crops at household level for both consumption and markets (intensification)

•

per Uganda national priorities where appropriate.

The Zambia Community Integration of Nutrition within Agriculture Programming (CINAP) model incorporates a strong element of maternal health and nutrition combined with improved Infant and Young Child feeding (IYCF) practices at community level supported by both the Ministry of Health and Agriculture. Key

Water, sanitation, and hygiene promotion component

persons (mainly women with some male nutrition champions

(WASH)

also) within the farmer groups receive intensive training (training of trainers) on general nutrition as well as nutrition during the first

The nutrition education component will include a focus on

1000 days (during pregnancy & lactation for women and nutrition

understanding of food groups and the need for a balanced

for young children). A component of WASH is also incorporated

diet, food utilization, combining foods and how to prepare new

in the training. Promotion of essential WASH practices among

foods with cooking demonstrations where possible using locally

supported farmers as part of meeting the need for a multi-

developed recipes. As post-harvest loss has substantial impact

sectoral approach. The WASH component is necessary to

on food insecurity where appropriate an element to address this

minimise gastric related illness which further exacerbate

will also be factored in.

malnutrition. These trainers then conduct cascade training

The promotion of bio-fortified crops will be encouraged where appropriate and SHA’s good agricultural practices of climate smart agriculture and production/promotion of good quality seed will also benefit improved quality and quantity of food.

with others in their community (10 persons) and form mother to mother support groups (care groups). The combination of intensive nutrition practical training and improvement in household food security through the various agriculture interventions support behavioural change and improve nutrition outcomes. The nutrition

Where appropriate SHA will also promote small livestock as the

specific interventions within the CINAP model will entail a strong

nutritional and economic benefits can be substantial especially for

component of promotion of IYCF practices .

the most vulnerable in the household.

well as good hygiene practices around food. Where applicable,

5.2 COMPLEMENTARY NUTRITION RELATED ACTIVITIES FOR THE COUNTRY PROGRAM

demonstrations on how to make a local ‘tippy-tap’ and local

•

The WASH component will include personal, household, community hygiene and sanitation including topics on essential WASH actions such as: critical times for hand washing, the need for a clean environment; how to safely dispose of waste including human excreta; and how to keep water safe for drinking as

latrines will be included in the modular WASH trainings. SHA will collaborate and/or build partnerships where possible to establish links with relevant government departments and other stakeholders to support the WASH hardware element in the project operational areas.

A special focus will be made to specific practices in relation to the Coronavirus Pandemic (COVID-19) as WASH behaviour practices are of particular importance in the reduction of the spread of the

12

disease to communities. This will be in a bid to uphold the WHO

Where appropriate such as where projects have a strong nutrition component, empowering farmer group representatives, mothers and/or care takers to conduct routine nutrition assessment for their children aged up to 5 years with use of colour coded Mid Upper Arm Circumference (MUAC) tapes and checking for nutritional oedema. This will be embedded within existing small holder farmer structures thus serving to play a key preventive role

* https://selfhelpafrica.org/ie/wp-content/uploads/sites/4/2020/04/SHA-COVID19Guidelines-web.pdf

•

Reinforcement of referral pathways for nutrition will be fostered through working with existing government structures

•

repeated screens with focus during peak months

and nutrition-health partners as per the SHA Uganda stakeholder mapping in place as well as district engagement by teams on ground •

Sensitization on early seeking of health care services among supported farmer households for cases including disease

Early detection of acute malnutrition requires of malnutrition especially rainy season

•

MUAC better identifies children at highest risk of death from common childhood illness

•

MUAC offers many advantages including the fact that it is simple to understand and use

management; treatment of moderate and severe acute malnutrition; micronutrient supplementation among others •

Encouraging beneficiaries to attend their nearest health centre at critical times such as during pregnancy for routine antenatal care, post-partum period for required postnatal care and during the child’s first 2 years of life for scheduled growth monitoring and immunization procedures

•

Capacity building of farmers on understanding local causes of malnutrition using the FAO problem-solution tree using a

•

actions within the project life cycle (See details in Figure 6). The Uganda National Nutrition Planning guidelines exist and serve as reference for partners as they outline principles, processes, stakeholders, and timelines involved in planning, as well as nutrition interventions that sectors and local governments can consider. Importantly, district involvement is paramount during all project planning as well as the entire project life cycle.

Regarding project participant identification, better to work

Supporting farmer groups to develop a food availability

within existing structures of farmer groups for better layering

understanding at community level what foods are available in what food groups throughout the year and thus help in decision making around what foods to grow at different times

•

within SHA operations, it is critical to have clear stepwise

TOT approach

seasonal calendar as a core component to improve

•

Furthermore, when planning for whatever nutrition interventions

and leverage. While establishing community nutrition support/ care groups, a gender lens needs to be factored so groups can mainly have predominately female participation. However, it is also important to have some male community influencers to

of the year

ensure family and community buy in of the various components

Provision of tailored nutrition sensitive job aides and

ultimately behavioural change at different levels of food systems.

preferably translated into the project specific local languages

Work with respective government ministries to adapt standard

Leveraging with core nutrition actors in the SHA project operational areas to create synergies beneficial for the

of improving agriculture, nutrition choices and practices and

nutrition related training material and identify accredited trainers to build capacity of the structures established.

farmers and the country program at large (nutrition coordination committees.

13

14

Uganda Nutrition Integration Strategy and Plan of Action 2020

P.O BOX 34429, Plot 44 Ministers’ Village, Ntinda, Kampala, Uganda Tel. +256 414 286305 Email: uganda@selfhelpafrica.org

15