Making the health system work for the delivery of nutrition interventions

Implementation of School Nutrition Policies to Address Noncommunicable Diseases in Uzbekistan and Kyrgyzstan

Noncommunicable diseases (NCDs), including cardiovascular diseases, cancer, and diabetes, account for over 80% of mortality in Uzbekistan and Kyrgyzstan in 2019, and unhealthy dietary behaviors are a major risk factor for NCDs in both countries. In 2021, national stakeholders, in consultation with the World Health Organization, identified school nutrition policies (SNPs) as a major approach to reducing the burden of NCDs in both countries. The SNPs included interventions implemented through a multistakeholder and multisectoral arrangement that aimed to improve the health and nutrition status of children and young people by providing healthy food/beverages and restricting unhealthy foods or beverages in schools. We used a multimethod approach of document review, participatory workshops, and key informant interviews to generate theories of change for the large-scale implementation of SNPs and describe the implementation processes to date, including key implementation and health system challenges, salient implementation strategies, and implementation outcomes in both countries. Multiple pathways for enacting and implementing SNPs successfully were identified. However, significant health system challenges, such as the lack of accountability for contracting and tender processes and coordination among different sectors, continue to hamper the large-scale implementation of these policies in both countries. The pathways, theories, and implementation outcomes identified will facilitate the development of implementation strategies and systematic learning and evaluation around SNPs for NCD prevention and control programs in the Central Asian region and other low- and middle-income countries more broadly.

Co-coverage of reproductive, maternal, newborn and child health interventions shows wide inequalities and is associated with child nutritional outcomes in Ethiopia (2005-2019)

The health system is the primary vehicle for the delivery of nutrition-specific interventions that aim to reduce maternal and child malnutrition. The integration of nutrition interventions into existing health interventions is promising, but to ensure that no one is left behind requires that access to essential health services is equitably distributed. This study aims to assess trends and socioeconomic inequalities in coverage of reproductive, maternal, newborn and child health (RMNCH) and assess its association with child nutritional outcomes in Ethiopia. Using the Ethiopian Demographic and Health Survey (2005, 2011, 2016, and 2019), we estimated the coverage of RMNCH interventions in Ethiopia using the co-coverage index, which is a count of the number of interventions accessed. We assessed the trend and inequalities in co-coverage and evaluated its association with child nutritional outcomes like stunting, wasting, and minimum dietary diversity (MDD). The national co-coverage index has shown a significant increase over the 2005-2019 period. However, all of the RMNCH interventions constituting the co-coverage index showed a pro-rich and pro-urban distribution (p < 0.05). The highest inequality, based on the slope index of inequality (SII), was observed for skilled assistance during delivery (SII: 80.4%), followed by access to an improved source of drinking water (SII: 62.6%), and antenatal care visits (SII: 55.5%). The low coverage in RMNCH and the observed inequality were associated with stunting, wasting, and MDD. Reducing socioeconomic inequality in RMNCH is key to achieve the health, nutrition and equity-related goals of the Sustainable Development Goals.

Impact of Suaahara, an at-scale multisectoral nutrition programme, on health workers' maternal and child health, and nutrition knowledge and skills in Nepal

Suaahara, an at-scale multisectoral nutrition programme in Nepal, aimed to advance knowledge and skills of frontline health workers to improve the quality of nutrition and health services at health facility and community levels. This study assessed the impact of Suaahara interventions on knowledge and skills of health facility workers and Female Community Health Volunteers (FCHVs). The study used a quasi-experimental design in which four Suaahara intervention districts were compared with pair-matched comparison districts. One health facility worker and three FCHVs from each survey cluster were included. Baseline survey consisted of 93 health facility workers (2015) and 118 FCHVs (2012), and endline survey (2022) consisted of 40 health facility workers and 120 FCHVs. Difference-in-differences regression models employing intent-to-treat analysis, accounting for clustering at the district level, assessed the impact of intervention. The intervention, relative to comparison, had no effect on health facility workers' knowledge. There was a positive effect, however, on FCHVs' knowledge in intervention relative to comparison areas on exclusive breastfeeding, timing of introduction of complementary feeding, sick child feeding and growth monitoring and promotion (GMP) for children under 2 years. Health facility workers and FCHVs in intervention versus comparison districts had higher endline scores for skills related to measuring the weight of children and pregnant women, measuring the height/length of children, conducting GMP for children under 2 years and identifying malnourished children. Suaahara interventions improved the capacity of health workers, particularly nutrition-related knowledge among FCHVs and GMP-related skills of both health facility workers and FCHVs.

Connecting the food and agriculture sector to nutrition interventions for improved health outcomes

To achieve the Sustainable Development Goal of zero hunger, multi-sectoral strategies to improve nutrition are necessary. Building towards this goal, the food and agriculture sector must be considered when designing nutritional interventions. Nevertheless, most frameworks designed to guide nutritional interventions do not adequately capture opportunities for integrating nutrition interventions within the food and agriculture sector. This paper aims to highlight how deeply connected the food and agriculture sector is to underlying causes of malnutrition and identify opportunities to better integrate the food and agriculture sector and nutrition in low and middle income countries. In particular, this paper: (1) expands on the UNICEF conceptual framework for undernutrition to integrate the food and agriculture sector and nutrition outcomes, (2) identifies how nutritional outcomes and agriculture are linked in six important ways by defining evidence-based food and agriculture system components within these pathways: as a source of food, as a source of income, through food prices, women’s empowerment, women’s utilization of time, and women’s health and nutritional status, and (3) shows that the food and agriculture sector facilitates interventions through production, processing and consumption, as well as through farmer practices and behavior. Current frameworks used to guide nutrition interventions are designed from a health sector paradigm, leaving agricultural aspects not sufficiently leveraged. This paper concludes by proposing intervention opportunities to rectify the missed opportunities generated by this approach. Program design should consider the ways that the food and agriculture sector is linked to other critical sectors to comprehensively address malnutrition. This framework is designed to help the user to begin to identify intervention sites that may be considered when planning and implementing multi-sectoral nutrition programs.

Leveraging water, sanitation and hygiene for nutrition in low- and middle-income countries: A conceptual framework

In low‐ and middle‐income countries (LMICs), access to water, sanitation and hygiene (WASH) is associated with nutritional status including stunting, which affects 144 million children under 5 globally. Despite the consistent epidemiological association between WASH indicators and nutritional status, the provision of WASH interventions alone has not been found to improve child growth in recent randomized control trials. We conducted a literature review to develop a new conceptual framework that highlights what is known about the WASH to nutrition pathways, the limitations of certain interventions and how future WASH could be leveraged to benefit nutritional status in populations. This new conceptual framework will provide policy makers, program implementors and researchers with a visual tool to bring into perspective multiple levels of WASH and how it may effectively influence nutrition while identifying existing gaps in implementation and research.

Making the health system work for the delivery of nutrition interventions

Addressing malnutrition requires strategies that are comprehensive and multi‐sectoral. Within a multi‐sectoral approach, the health system is essential to deliver 10 nutrition‐specific interventions, which, if scaled up, could substantially reduce under‐5 deaths in high‐burden countries through improving maternal and child undernutrition. This study identifies the health system components required for the effective delivery of these interventions, highlighting opportunities and challenges for nutrition programmes and policies. We reviewed implementation guidance for each nutrition‐specific intervention, mapping the delivery process for each intervention and determining the health system components required for their delivery. We integrated the components into a single health systems framework for nutrition, illustrating the pathways by which health system components influence household‐level determinants of nutrition and individual‐level health outcomes. Nutrition‐specific interventions are typically delivered in one of four ways: (i) when nutrition interventions are intentionally sought out, (ii) when care is sought for other, unrelated interventions, (iii) at a health facility after active community case finding and referral, and (iv) in the community after active community case finding. A health system enables these processes by providing health services and facilitating care seeking for services, which together require a skilled and motivated health workforce, an effective supply chain, demand for services and access to services. The nutrition community should consider the processes by which nutrition‐specific interventions are delivered and the health system components required for their success. Programmes should encourage the delivery of nutrition interventions at every client–provider interaction and should actively generate demand for services—in general, and for nutrition services specifically.