We can. overcome. Undernutrition: Niger. Case Study. International Cooperation and Development

Transcription

1 We can overcome Niger Case Study Undernutrition: International Cooperation and Development

2 2 W E C A N O V E R C O M E U N D E R N U T R I T I O N : N I G E R C A S E S T U D Y Undernutrition: a national priority requiring massive investment Reducing malnutrition in Niger one of the poorest countries in the world 1, prone to drought and increasingly insecure is an immense challenge. This challenge is made even greater by the population doubling every 20 years, thus multiplying the difficulties of providing Nigeriens with food and essential services. Stunting affects nearly one in two children and has a damaging impact on the human capital of the country. Faced with the extent of the challenge, the eradication of hunger and undernutrition in particular has become a national priority along with efforts to improve access to healthcare. However strong the political commitment, it needs to be accompanied by reinforced financial support, in order to scale up prevention initiatives and reverse trends that remain of considerable concern. A critical nutritional situation and alarming tendencies mirroring the country s prevailing social problems Targeted stunting reduction (million Under 5 s stunted children) Beginning prevalence (2012): 44.9% Target prevalence (WHA 2025): 16.6% Trend in stunting reduction estimated in 2012 = 1.91% 1,06 million The European Union (EU) has been working with the government for ten years, focusing as much on the management of food and nutrition crises as on the prevention of stunting. Between 2005 and 2014, the EU mobilised more than 200 million in order to combat undernutrition in Niger, contributing to the creation of a real sense of dynamism in the nutrition sector. 1,60 million Reduction needed to achieve WHA target 2 = 7.38% 0,96 million Effects of Stunting Children who suffer from chronic malnutrition fail to grow to their full genetic potential, both mentally and physically. It significantly increases the likelihood of premature death, and those that survive are prone to ill health and are less able to contribute to an active and productive life. The condition is measured by stunting shortness in height compared to others of the same age group which manifests itself in the early life cycle of children, and the effects of which are irreversible. 1 Niger is ranked 187 th out of 187 on the UN Human Development Index (HDI). Source: HDR, WHA: World Health Assembly Rate of population increase: 3.9% for the period Source: RGPH, Address delivered by Prime Minister Brigi Rafini on behalf of the President during the Nutrition For Growth event in London, June Cover page photo by: Hélène Berton Target Effort needed The annual reduction of stunting prevalence (1.9%) is too little with respect to the population increase (+3.9% annually 3 ). Today, approximately 1.6 million children under 5 are stunted. According to projections, there will be more than 2 million in Malnutrition, by its diversity, its scale and its severity, more than simply being a public health issue, represents a real problem of national development. S.E. Mahamadou Issoufou, President of the Republic of Niger 4

3 W E C A N O V E R C O M E U N D E R N U T R I T I O N : N I G E R C A S E S T U D Y 3 Prevalence of stunting in children under-five years of age, by region in Niger Food crises occur with an ever-increasing frequency requiring significant support from the State and its partners in order to avoid further erosion of human capital and the means of production. Food insecurity and a poor diet During the past 5 years 20 to 48% of Nigerien households have been affected by severe or moderate food insecurity. Children aged 6-23 months with minimum acceptable diet: 6%. Children aged 6-23 months with minimum diet diversity: 10%. Social problems exacerbated by rapid population growth Regional stunting rates Very high prevalence Medium prevalence A real public-health challenge High prevalence Low prevalence In 2014, the national prevalence of stunting was 45.5%. The level was especially high in the south and east of the country. In Maradi, the most densely populated part of the country, 56% of children are affected, despite the region having a level of agricultural production that is higher than the national average. Stunting is just one expression of undernutrition which can be manifested in many different forms. The Nigerien population is heavily affected by deficiencies in essential minerals (iodine, iron, and zinc) 5 and vitamins (A and folate). The proportion of children affected by wasting is just as alarming, with a national prevalence which each year approaches the WHO emergency threshold of 15% 6. The causes are multiple and interlinked; addressing them requires an approach which is both holistic and long-term. An inappopriate diet backed up by extensive poverty and vulnerability to climatic and economic shocks Approximately 80% of the Nigerien population is engaged in agriculture and pastoralism. However, because of scarce natural resources, many of these households cannot feed themselves from their own production. Rural households, especially the poorest, are increasingly dependent on the market to feed themselves. An unpredictable climate, the fluctuation of prices for foodstuffs and the difficulty of generating a living wage in a country where 49% of the population live below the national poverty threshold 7, results in widespread food insecurity. Children s food is insufficient in quantity as well as in quality. On top of the ever increasing economic difficulties can be added the disruption to child care and irregular and inappropriate feeding practices caused by mothers heavy workloads, their low education levels, and the burden of certain cultural norms (early marriage, underage pregnancies, insufficient child-spacing, etc.). Equally, children are exposed to a high level of infectious diseases which contributes significantly to their poor nutritional status: the inadequacy of health and sanitation infrastructure and poor access to clean drinking water for the entire Nigerien population especially in rural areas. In addition, with an average of more than seven births per woman, Niger holds the record for the highest fertility rate in the world. Each year, on top of making up its deficit in terms of development, Niger must cater for the needs (food, health and educational) of almost 700,000 additional Nigeriens. To add to these structural problems, increasing security challenges have arisen since 2012 due to the instability of neighbouring states (Mali, Libya, Nigeria). The additional spending necessary for defence and hosting refugees 8 represents an annual cost estimated at 1% of GDP 9. This reduces the resources that can be committed to socio-economic development. Female literacy: 14%. Social conditions of mothers Median age of first marriage: Women having first child before 18 years: 40.4%. Fecundity rate: 7.6. Exclusive maternal breastfeeding from 0 to 5 months: 23.3%. 5 Anaemia affects 73% of children aged 6 to 56 months and 72% of school-age children suffer from iodine deficiency. Source: Demographic and Health Survey of Niger EDSN-MICS 2012). 6 National prevalence of accute malnutrition: 14.8%. Source: National Survey on Nutrition of Children aged 0 to 59 months, Niger Institute of Statistics INS, Source: Niger - National Survey on Household Living Conditions and Agriculture 2011INS / World Bank, ,000 refugees and displaced persons in June Source: OCHA. 9 Source: World Bank, 2015.

4 4 W E C A N O V E R C O M E U N D E R N U T R I T I O N : N I G E R C A S E S T U D Y Niger s commitment to overcome undernutrition Recognising that malnutrition acts as a brake to the development of the country, Niger committed to reduce the prevalence of stunting of children under 5 to 25% 10 by Whilst drawing up the Economic and Social Development Plan (PDES) , Niger reinvigorated its commitment to the eradication of hunger, by launching the «3 N» Initiative (I3N) encouraged by the EU. «Nigeriens feeding Nigeriens» - I3N: the political ambition of a society free from hunger, more productive, more self-sufficient and more equitable Created under the impetus of President Mahamadou Issoufou, this initiative has as its objective to make the agriculture sector a vehicle to transform society and the means to increase economic growth. In addition, it aims to enhance the resilience of populations faced with food and nutrition crises. The improvement of the nutritional status of Nigeriens is one of the strategic axes. It comprises treatment, prevention and management of the sector and is administered by a Multi-Sector Steering Committee. The I3N endeavours to be an inclusive and mobilising framework that applies an ever-increasing effort towards achieving its objectives, by mobilising private and public funds, by ensuring multi-sectoral and multi-actor oversight and coordination, and, finally, by mobilising the entire Nigerien population around this aspiration. I3N has raised 1.8 billion between 2012 and 2015, of which 250 million is for nutrition. The PDES also signifies an important evolution in social policy. In 2013, a National Social Protection Policy (PNPS) was adopted and the social safety-net programme enlarged to encompass more than 80,000 vulnerable households until These households benefit from cash transfers and sensitisation on essential family practices to improve nutrition. In addition, the launching of a family-planning action plan ( ) intends to contribute to the challenge of population growth. AGIR: to reduce long-term household vulnerability to food and nutritional insecurity The vision for Niger of hunger reduction by increasing the resilience of populations matches that of the Global Alliance for Resilience (AGIR) 11 at the regional level. Within the framework of AGIR, Niger defined its Country Resilience Priorities PRP around the key activities of the National Social Protection Policy and the I3N. Efforts rewarded in the health domain Considerable progress has been achieved in the integrated treatment of wasting and Niger has one of the most efficient systems in the world 12. The scaling-up of therapeutic programmes across the whole country and efforts to improve healthcare access, especially through free at point of use healthcare services for pregnant women and young children, 13 have contributed to reducing under 5 mortality, in line with progress targets of the MDG They have also contributed to the reversal of upward trends in stunting observed between 1985 and Despite progress in the health sector, the overall effect has been limited by the scale and complexity of the challenges. Reinforcement of the multi-sectoral approach and scale-up of the First 1000-days approach In spite of these encouraging advances in child survival, stunting remains a major problem necessitating a more holistic approach. The Ministry of Public Health (Directorate of Nutrition) has developed a national preventative strategy for stunting within the framework of the National Nutrition Policy. The latter is under review and should be accompanied by a Plan of Action driven by the I3N in order to formalise the multisectorial commitments of different ministries on nutrition that go beyond the health sector. National strategy to prevent chronic malnutrition Drawn up in 2013, the strategy comprises a package of integrated activities within the frame of the First 1000-days approach ie from the stage of pregnancy to the end of a child s second year of life. Relying on a substantial community foundation, it targets behavioural change and improvement in the use of social services. It stimulates direct collaboration of participants in the areas of water and sanitation systems, and makes a direct link with social safety-nets and food security. The strategy promotes the development of partnerships in order to encourage the greater efficiency of interventions and fixes specific targets. Examples of progress expected between now and 2017 include: 3 Increase in the proportion of children aged 0-6 months exclusively breast-fed from 23 to 40%. 3 Reduction by 30% the prevalence of anaemia in children aged 6-23 months through the provision of micronutrient supplements. 3 Maintenance of 90% coverage for deworming of children aged months and vitamin A supplementation amongst children aged 6-59 months. 10 Commitment made at the Nutrition for Growth event in London in June Regional roadmap for AGIR: 12 Each year, more than 300,000 children affected by wasting are cared for by the health services. Source: UNICEF. 13 The policy of fee-waivered healthcare for pregnant women and under 5 s was put in place in User-attendance levels for under 5 curative care went from 59% in 2005 to 85% in 2009 and the figures for prenatal consultations rose from 42% to 90%. Source: Ministry of Public Health, DEP, Report on the Execution of the PDS , November Between 1998 and 2009, mortality rates have fallen by 5.1% going from an annual figure of 226 to 128 deaths per 1000 live births. Source: Lancet 2012, Reduction in child mortality in Niger: a Countdown to 2015 country case study.

5 W E C A N O V E R C O M E U N D E R N U T R I T I O N : N I G E R C A S E S T U D Y 5 Photo by: Hélène Berton. The European Union alongside Niger: 10 years of investment in nutrition and in the prevention and management of crises Towards an even more preventative approach Since 2005, the European Union (EU) has been supporting Niger, as much in the management of food and nutritional crises as in searching for long-term solutions to malnutrition. With that aim, the EU maintains a strong link between its humanitarian and development interventions, sustained by a common and continuous dialogue with the government. If the support has initially focused on the treatment of acute malnutrition, in reaction to occasional crises, it has subsequently been concerned with chronic malnutrition and its underlying causes. Between 2010 and 2015, the EU invested more than 58 million in ambitious preventative programmes. Complementarity between humanitarian and development assistance: from the local project to the institutional reform of the State From 2005 to 2014 the EU contributed 144 million of humanitarian aid to Niger with a strong emphasis on the scaling up of integrated treatment programmes for acute malnutrition. This effort with other development partners has increased ten-fold the treatment capacity of the regional state health structures and has highlighted the problem of malnutrition that had long been neglected. There are two clear challenges linked to the high number of malnourished children: (i) ensuring the treatment of acute malnutrition is fully institutionalised and part of the package of mother-child healthcare; and (ii) reducing the number of children affected by one form or another of malnutrition through greater focus on prevention measures. Through sustained political dialogue and significant budget support, the EU has helped the Niger government engage in institutional reforms to expand the package of multisectoral measures for nutrition. It is worth noting that the EU and the UK (DFID) 15 united their efforts in 2015 in order to shift their humanitarian programming towards a more preventative approach and towards further strengthening the resilience of local populations in the most affected areas. A reinforced commitment to reduce stunting in the 11 th EDF The Government of Niger and the EU are consolidating a systematic approach to malnutrition through the 11 th EDF 16. The National Indicative Programme (NIP) ensures the full support of the EU for the objectives of hunger reduction and social progress in Niger. For the period , the EU will provide 180 million support for I3N through a sectoral reform contract Food and nutrition security and resilience. Another sectoral reform contract of 200 million targets the Reinforcement of State capacity to put into effect social policies and should significantly impact the other causes of malnutrition (health, education, social equity and population control). 15 DFID: Department for International Development. 16 EDF: European Development Funds.

6 6 W E C A N O V E R C O M E U N D E R N U T R I T I O N : N I G E R C A S E S T U D Y Photo by: Hélène Berton. In line with the EC s Plan of Action on Nutrition, the EU is focusing on 3 strategic priorities: Strategic Priority 1: Enhancing mobilisation and political commitment for nutrition The EU is the donor convener of the SUN 17 movement, which Niger joined in It aims to co-ordinate the different interventions of other development partners and to ensure the division of labour, particularly amongst EU member States. Amongst others, the EC invests 3.5 million in support of coordination. This contributes to the co-ordination of Axis 4 (nutrition) of the I3N via the REACH initiative 18. Technical support of the EU to Coordination in the I3N The EU finances two key posts at the level of the I3N: the post of REACH Coordinator and an assistant technical support post in food security and social safety nets. In addition to their technical expertise, they play a support role in coordination and advocacy such that nutrition is mainstreamed in different sectors especially through the ministries responsible for pastoralism, agriculture, water infrastructure and sanitation, in addition to social protection. The support to REACH equally consists of facilitation work on nutrition at the level of the regions within the framework of I3N. This must nonetheless be reinforced by the implementation of more effective activities across the whole country. 17 SUN movement (Scaling Up Nutrition): 18 REACH: Renewed Efforts Against Child Hunger and undernutrition - Photo by: ECHO/Anouk Delafortrie.

7 W E C A N O V E R C O M E U N D E R N U T R I T I O N : N I G E R C A S E S T U D Y 7 Strategic Priority 2: Scaling up actions at country level The actions that have an impact on nutrition and increased resilience to crises are more concentrated at a national level and concern several sectors: 3 Agriculture: by supporting the productive capacities of the most vulnerable groups, notably through family-level irrigation schemes that aim to increase food availability and increase household income. 3 Water, hygiene and sanitation: by programmes of improved access to water and basic sanitation undertaken by the Ministry of Water Infrastructure and Sanitation, as well as by the promotion of essential practices at the level of the family. Initiative for accelerated achievement of Millenium Development Goals The EU finances the Government of Niger to the tune of 15.5 million over 4 years ( ) with the objective of accelerating the achievement of MDG 1 ( to reduce extreme poverty and hunger ). This project (put in place with UNICEF and the support of seven NGO s) assists the Ministry of Public Health in the application of the First 1000 days package for the prevention of malnutrition. It covers 17 communes, spread out over three regions (Zinder, Maradi and Tahoua). In total 300,600 children under 5 years of age (80% of children in the targeted areas) and 332,000 women of child-bearing age will benefit from sensitisation in essential practices at the level of the family via community platforms 19. The project is followed-up by a system of six-monthly monitoring using LQAS (Lot Quality Assurance Sampling) methodology. After an initial year setting up, significant results were achieved notably on childbirths, complementary feeding of breastfeeding children and the prevention of malaria. Regular follow-up of indicators by commune allow better targeting of the kind of message and the zones most in need in terms of implementation of good practices. A complementary programme of 25 million established by the Ministry of Water Infrastructure and Sanitation aims to improve access to drinking water at the village level in the same zones in order to accelerate the impact on nutritional status. 3 The Management and Prevention of food crises: by support to the organisation, management and implementation of activities by the National Plan for Prevention and Management of Catastrophes and Food Crises (DNPGCCA). EU support to the DNPGCCA The EU is the principal donor for the management and prevention of food crises in Niger. Between 2010 and 2014, the EU mobilised more than 150 million to support the annual national response plans of the DNPGCCA. This financing contributes to addressing the food gap experienced by the most vulnerable sectors of the population. Amongst other things, it has as an objective to ensure that operations are better programmed and are more effective. It also endeavours to support innovative response options to better address chronic food insecurity. 3 Social Protection and access to basic social services: by reinforcing the capacity of the State to put in place public policies with a good-governance oversight (budgetary programming and credibility, management, internal resource management, etc); by increasing equitable access to quality health and education services for the population; by promoting the integration of the treatment of acute malnutrition cases in the health system; by sustaining the utilisation of reproductive health services and family planning and by ensuring that girls remain within the basic education system; by sustaining the incorporation of the poorest and the most vulnerable groups in social protection programmes (social safety-net). Strategic Priority 3: Strengthening the expertise and the knowledge base Since 2007, the EU has sustained the food and nutritional vulnerability analysis (HEA 20, Harmonised Framework 21, SMART surveys 22, National System for Health Information). Following a need expressed by the Office of Nutrition, the EU envisages also investing more than 3 million to support Niger strengthen its information systems by establishing a National Information Platform on Nutrition (NIPN). The platform will collate and analyse information on the situation of nutrition, assess levels of investment in the sector and review the effectiveness and impact of the programmes with the aim of ensuring stronger accountability for nutrition. Photo by: Hélène Berton Essential family practices (PFE): 1. Exclusive breastfeeding; 2. Sleeping under a treated bednet; 3. Rehydrating the child with ORS; 4. Handwashing with soap; 5. Adding other nutritive foods from 6 months; 6. Ensuring preventive care for the child; 7. Bringing child to the health centre. 20 HEA: Household Economy Approach. 21 Harmonised framework for the identification of zones and populations faced with food insecurity. 22 SMART: Standardized Monitoring and Assessment of Relief and Transitions anthropometric survey and mortality rates.

8 MN EN-N European Union 2015 Published by Directorate-General International Cooperation and Development, Directorate Sustainable Growth and Development, August The contents of this publication do not necessarily represent the official position or opinion of the European Commission. Neither the European Commission nor any person acting on behalf of the Commission is responsible for the use which might be made of information in this publication. Directorate General International Cooperation and Development, Rue de la Loi 41, B-1049 Brussels. For further information: ISBN DOI /134286