SIXT TY-FIFTH W WORLD HEA ALTH ASS SEMBLY Prov visional age enda item 13.

A65/11 26 April 2012 2

Nutrit tion
Matern infan and yo nal, nt oung child nutriti ion: draft compreh c hensive im mplementation pl lan
Repo by the Secretariat ort S t

1. At the 130t session of the Executiv Board in January 2012, the draft i th f ve implementati plan was ion s ia, discu ussed.1 In dec cision EB130 0(2), inter ali the Direc ctor-General was requeste to conduc as soon as ed ct, s possible, further consultatio r ons regardin the targ ng gets within the existin draft com ng mprehensive e imple ementation p plan via a web-based p w process open to all Mem n mber States, as well as multilateral l organ nizations, to provide fur rther guidanc in the fin ce nalization of the compre f ehensive imp plementation n plan. This consu ultation was held 627 F February 2012.2 The dra plan refle aft ects the outc come of the e consu ultation (see Annex). In May 201 the Healt Assembly in resolution WHA63.23 on infant a young ch nutrition 2. 10, th y n and hild n reque ested the Dir rector-Genera to develo a compreh al op hensive implementation p plan on infan and young nt g child nutrition as a critical com mponent of a global multisectoral nutrition frame ework. In Ja anuary 2011, , the E Executive Bo oard noted th preparato work on such a plan making se he ory n, everal suggestions on its s conte including revising its name to cover mater ent, rnal nutrition and payin more atte n ng ention to the e le doubl burden of undernutriti and over f ion rweight.3 In May 2011 th Health As M he ssembly note the report ed t on the subject and the revised outline of th plan.4 d d he 3. In the cou urse of 2011, five region consulta nal ations to collect feedbac on the ou ck utline of the e comp prehensive implementati ion plan we convene in the African Regi ere ed A ion, the Region of the e Amer ricas, and the South-East Asian, East t tern Mediter rranean and Western Pac cific regions. Altogether, . , the co onsultations were attende by represe ed entatives of different gov vernment sec ctors (health, agriculture, , , socia welfare, e al education, trade, financ environm t ce, ment and in ndustry) fro 92 Mem om mber States, , organ nizations in t United Nations system developm banks, donors and civ society. the m, ment ivil

See docume EB130/10 an the summary records of the second and nin meetings in document ent nd y e nth n EB130 0/2012/REC/2. Comments w received by ten Member States and six multilateral org were b m ganizations. The background paper and the e summa of the comm ary ments received and the respons provided by the Secretariat are available a ses y at http://w www.who.int/n nutrition/events/ /2012_consulta ation_proposed_ _globaltargets/e en/index.html (a arch accessed 21 Ma 2012).
3 4 2

See docume EB128/18 and EB128/201 ents a 11/REC/2, summ mary record of the tenth meetiing.

See the sum mmary record of the fourth mee f eting of Commi ittee B, section 5 of the Sixty-f fourth World Health H Assem mbly.

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4. The a annexed dra implemen aft ntation plan integrates all comments provided b Member States a s by during meet tings of WHOs governin bodies an the regiona consultatio It brings together relevant ng nd al ons. s elements from the glob strategy for infant an young-chi feeding,1 the Global Strategy on Diet, bal f nd ild n Physical Ac ctivity and H Health,2 and th action pla for the glo strategy for the prev he an obal vention and control of noncomm municable d diseases.3 WH HOs framew work for pri iority action for HIV an infant feeding, n nd issued in 20 003, has been recently up n pdated to ref flect the revised WHO gu uidelines for the prevent r tion of mother-to-c child transmission of HIV 4 V. 5. Sever related r ral regional stra ategies and plans have been consid dered in pre eparing this draft comprehens sive plan: the African Un e nions Revise African Regional Nutritional Strat ed R tegy (20052 2015), the Second European A Action Plan for Food and Nutrition Policy (2007 f d 2012),5 the Strategy and Plan d of Action fo the Reduc or ction of Chro onic Malnutr rition,6 the Regional strategy on nutr R rition 20102 2019,7 the regional nutrition str l rategy for So outh-East As 8 and the Framework for Action on Food Security in sia F f n 9 the Pacific. 6. The draft compr rehensive im mplementatio plan sets out its rationale, nam on mely the fact that, t worldwide, nutrition challenges are multifaceted effective nutrition actio exist but are not expanded d, n ons t sufficiently, and that ne initiatives have been launched. Th plan defin its object , ew s he nes tives and set five ts global targe and a tim frame. It further propo ets me f oses a series of five high s h-priority ac ctions for Me ember States, the S Secretariat an internatio partners, and lists eff nd onal , ffective health interventio and non-health h ons activities th affect nutr hat rition as well as indicator for monito l rs oring the imp plementation of the plan. n

New initia atives in nu utrition

7. The o optimal strategy to ensur rapid impr re rovement of nutrition req quires the im mplementatio of a on set of specif nutrition interventions and the inte fic egration of nutrition into health, agric n culture, educ cation, employmen social we nt, elfare and development programme The Scal d es. ling Up Nut trition move ement, launched in 2010, has brought toge n ether govern nment author rities from countries wit high burd of c th den malnutrition and a glob coalition of partners. It calls for intensive eff n bal i forts to scale up nutrition over e n the period 2 20132015 th hrough such a strategy. P h Partners in the movemen have comm t nt mmitted themselves to work tog gether to mo obilize resources, provide technical support, perf e s form high-le evel advocac and cy develop inn novative partn nerships.

1 2 3 4

Endo orsed in 2002 by the Health As y ssembly in reso olution WHA55 5.25. Endo orsed in 2004 by the Health As y ssembly in reso olution WHA57 7.17. Endo orsed in 2008 by the Health As y ssembly in reso olution WHA61.14.

Antir retroviral drugs for treating pregnant women and preventin HIV infectio in infants: re s p n ng on ecommendation for a ns public health approach 20 version. Geneva, World H 010 G Health Organiz zation, 2010; WHO, UNAIDS UNFPA, UN W S, NICEF. Guidelines on HIV and infan feeding. 2010 Principles an recommenda nt 0. nd ations for infant feeding in the context of HIV and a e V summary of ev vidence. Geneva World Health Organization, 2010. a, h ,
5 6 7 8

Adop in 2007 by the Regional Committee for E pted y C Europe in resolution EUR/RC5 57/R4. Endo orsed in 2010 by PAHOs Dire y ecting Council i resolution CD in D50.R11. Endo orsed in 2010 by the Regional Committee for the Eastern Me y editerranean in resolution EM//RC57/R.4.

Endo orsement by Me ember States of this strategy w urged in 201 by the Regio Committee for South-East Asia f was 11 onal e t in resolution S SEA/RC64/R4.
9 The P Pacific Islands Forum Secretar reported the endorsement of the action plan by the Pacif Food Summi 2010 riat e fic it (Port Vila, Van anuatu, 2123 A April 2010), see http://www.for rumsec.org/pag ges.cfm/newsroo om/press-statem ments/2010/fina aloutcomes-of-f food-summit-1.h html (accessed 27 March 2012 2).

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8. In order to respond to the challen o nges to succe essful coordination, orga anizations in the United n d Natio system h ons have commit tted themselv to better align their activities at global level through the ves r e reform of the Un m nited Nation Standing Committee on Nutrition and at co ns ountry level through the e Renewed Efforts against Child Hunger an Undernutr nd rition (REAC initiative CH) e. 9. ive e of n nd ng h The initiati for the elimination o new HIV infections in children an improvin the health and s survival of H HIV-infected mothers1 su d upports the improvemen of the nutr nt tritional state of mothers e s and th children heir n. 10. At regiona level, a successful e al s example of partnership is the Pan American Alliance for A r Nutri ition and Development for the Achie f evement of the Millenniu Developm t um ment Goals, launched in n 2009. 11. The draft c comprehensiv implemen ve ntation plan contributes to the global initiatives by identifying c o y g globa targets and priority acti al d ions in the h health sector and defining roles for con g oncerned part ties. Specific c discu ussions have been organiz with this purpose. zed s

IMP PLEMENTA ATION OF THE IN O NTERNAT TIONAL CODE OF MARKETING OF C F F BRE EAST-MILK SUBSTI ITUTES
12. In response to the requ e uirement for biennial rep porting,2 this report also provides inf formation on n progr ress made by countries in the implem y mentation of the Internat f tional Code of Marketin of Breastng milk Substitutes. The compre ehensive imp plementation plan also covers this a n c area and proposes future e activi ities. 13. The implem mentation of the Internat f tional Code of Marketing of Breast-m Substitu o g milk utes, adopted d by th Health A he Assembly in resolution WHA34.22, and of su n ubsequent re elated Health Assembly h y resolu utions is not consistent among coun t ntries. Statutory regulati ions have be put in place in 103 een p 3 Mem mber States an have been drafted in nine. Some 37 Member States rely o voluntary compliance nd n on y e by in nfant formula manufactu a urers and 25 Member Sta have no taken actio to enforc the Code; ates ot on ce ; inform mation is missing for 20 Member Sta 3 ates. 14. Among th Member States with legislation, most have provisions on the prohibition of he , e s f prom motion of desi ignated prod ducts to the g general public and health workers and in health-ca facilities, c d are , as w well as prov visions on labelling re equirements. Fewer Member State have provisions on . es n conta amination wa arnings, and bans on nutr rition and hea claims. alth 15. Less than 50% of cou untries with legal meas sures also ha legal pr ave rovisions on monitoring n g imple ementation o the Code Only 37 countries have establis of e. h shed function oning monito oring and/or r enfor rcement mechanisms, and limited inf d formation on the composition, manda and funct n ate tions of such h mech hanisms is av vailable.

Global plan towards the el n limination of ne HIV infections among child ew dren by 2015 an keeping their mothers alive, nd r , 2011 2015. Geneva, UNAIDS, 2011. Article 11.7 of the International Code; inf 7 formation is col llected periodically from Mem mber States by questionnaire, q the latest surveys of t status of imp the plementation be eing issued in 2008 and 2010. 2
3 Information from UNICEF these countrie also include all Member Sta that reporte on Code imp n F; es ates ed plementation, uired under Cod Articles 11.6 and 11.7. Que de 6 estionnaires wer sent to Member States in 20 and 2009 an the results re 007 nd as requ were s summarized in d documents A61 1/17 Add.1, sec ction F, and A63 3/9. 2

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16. Inform mation on im mplementatio of the Cod is also pro on de ovided by reg gional office in collabo es, oration with partne in government an the Unit ers nd ted Nations system. A recent PA AHO review on w implementa ation of the C Code in the period 1981 p 2011 indica that 16 countries ha legal mea ates ave asures and six of th regulate the implem hem e mentation of t law.1 In 2007 a review by UNICE of 24 We and the 2 w EF est Central Afr rican countri reported that half th ies hose countri had com ies mprehensive l legal measu ures in place.2 17. An an nalysis by th Secretaria of nutritio policies in Member States in 201 03 highlighte the he at on n ed following challenges: le egislation can only be ap n pplied in pub health facilities, does not provide clear blic s e operational guidance, is poorly enforced and inadequat e d tely monitor red; health workers ar not re adequately t trained; and the public is not adequat s tely informed d.

ACTION BY THE H HEALTH ASSEMBLY A Y

18. The H Health Assem mbly is invite to endorse the compre ed e ehensive imp plementation plan on mat n ternal, infant and y young child n nutrition.

1 30 a del Cdigo en Amrica La os atina: Un recorr rido sobre diver experiencia de aplicacin del Cdigo rsas as n Internacional d Comercializacin de Suced de dneos de la Lec Materna en la Regin entre 1981 y 2011. Washington DC, che n D PAHO, 2011.

Soko E, Aguayo V, Clark D. Prote ol ecting breastfee eding in West and Central Africa: 25 years im a mplementing the International C Code of Market ting of Breast-m Substitutes Dakar, UNICEF Regional Office for West a Central Afr milk s. and rica, 2007. See h http://www.who o.int/nutrition/E EB128_18_Bac ckgroundpaper1 1_A_review_of_ _nutritionpoliciies.pdf (accesse ed 27 March 2012 2).
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ANNE EX DR RAFT COM MPREHEN NSIVE IMP PLEMENT TATION PL LAN ON MATERNA INFAN AND YO M AL, NT OUNG CHI ILD NUTR RITION

RAT TIONALE Glob nutritio challenge are mult bal on es tifaceted

1. Adequate p provision of nutrients, b f beginning in early stage of life, is crucial to ensure good n es s d physi and men developm and lon ical ntal ment ng-term healt Poor avail th. lability or ac ccess to food of adequate d e nutrit tional quality or the expo y osure to cond ditions that impair absor i rption and us of nutrien has led to se nts o large sections of t worlds population b the p being underno ourished, hav ving poor vit itamin and mineral status m s or be eing overweig and obes with large differences among pop ght se, e s pulation grou These co ups. onditions are e often present simu n ultaneously and are inter a rconnected. 2. In women, both low body mass i , b index and sh hort stature are highly p prevalent in low-income e count tries, leading to poor fet developm g tal ment, increas risk of complication in pregnan sed c ns ncy, and the e need for assisted delivery.1 In some coun n ntries in sou uth-central Asia, more th 10% of women aged han w d 1549 years are shorter than 145 cm. In sub-Sahara Africa, so 9 n n an outh-central and south-e eastern Asia, , more than 20% o women ha a body m of ave mass index le than 18.5 kg/m2 and this figure is as high as ess 5 i s 40% in Banglade Eritrea and India. Co esh, a onversely, an increased proportion of women star pregnancy n p f rt y with a body mass index greater than 30 kg 2 leading to increased risk of com s g/m, g mplications in pregnancy i y and d delivery as w as heavie birth weigh and increa well er ht ased risk of obesity in chi o ildren. 3. Iron-deficie ency anaemi affects 30 women of reproduct ia 0% tive age (46 million), and 42% of 68 f pregn nant women (56 million). Maternal an naemia is associated with reduced bir weight an increased h irth nd d risk o maternal m of mortality. An naemia rates have not imp proved appre eciably over the past two decades.2 4. Every year an estimate 13 million children ar born with intrauterine growth restriction3 and r ed n re h e d 4 about 20 million with low birth weight. A child bo with low birth weig has a gre t n b orn w ght eater risk of f morb bidity and m mortality and is also mo likely to develop noncommuni d ore o n icable diseas ses, such as s diabe and hype etes ertension, lat in life. ter 5. In 2010 about 115 million children worldwide were underw w weight, 55 mi illion had low weight for w r 5 their height and 171 million under the age of five years had stunted grow n wth. The pr roportion of f childr under th age of fiv years in d ren he ve developing countries wh were unde c ho erweight is estimated to o
1 Black RE et al. Maternal an Child Under t nd rnutrition Study Group. Matern and child un y nal ndernutrition: global and g region exposures an health consequences. Lance 2008; 371:24 nal nd et, 43-260. Data ar also taken fro the Monitor and re om ring Evalua ation to Assess and Use Result Demographic and Health Su ts c urveys (MEASU DHS) proj URE oject (http:// /www.measuredhs.com/Data/, accessed 27 M , March 2012). 2 United Nations System Sta anding Committ on Nutrition Progress in nutrition: Sixth report on the world nutrition tee n. n w situati ion. Geneva, Un nited Nations System Standing Committee on Nutrition Secr g n retariat, 2010.

de Onis M, Blssner M, Vi illar J. Levels a patterns of intrauterine growth retardation in developing countries. and i n f tion, 1998; 52(S Suppl.1):S5-S15 5. European Journal of Clinical Nutrit United Nati ions Childrens Fund and Wo s orld Health Org ganization, Low birthweight: country, regional and global w l ates. New York, United Nation Childrens Fu ns und, 2004. estima
5 4

lth Underweigh and stunting, in: World Heal Statistics 20 Geneva, World Health Or ht 010, W rganization, 201 10.

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Annex A

have declin from 29% to 18% between 1990 and 2010, a rate that is still inade ned % 0 i equate to me the eet Millennium Developme Goal 1, Target 1.C of halving levels of un m ent nderweight b between 1990 and 2015. Suffic cient decline took place in Asia and L e i Latin Americ but considerable effor are still needed ca, rts n in Africa. In addition, i 2010, 43 million presc n in m chool children in develo oping and de eveloped cou untries were overw weight or obe 1 The prevalence of c ese. childhood obesity in low- and middle e-income cou untries has been ac ccelerating in the past 10 years; WHO estimates that in 2015 the rate will reach 11%, close n O t l , to the prevalence in up pper-middle-income coun untries (12%) Obese chi ). ildren are lik kely to grow into w obese adult have an i ts; increased risk of type 2 diabetes, liv disease and sleep-ass ver a sociated brea athing disorders; a have dim and minished chan nces of socia and econom performa al mic ance in adult life. t 6. Anae emia affects 47.4% (293 million ch 3 hildren) of th preschool-age popula he ation,2 and 33.3% 3 3 (190 million of the pres n) school-age population gl obally is def p ficient in vita amin A. 7. Nutri itional status is also infl s luenced by s several envir ronmental fa actors. In co ountries where the prevalence of HIV infec ction is high, HIV infecti has both a direct imp on the nu , ion pact utritional sta of atus women and children w are infec d who cted and an indirect effe through alterations i household food ect in d security and inappropri iate choices of infant-fe feeding pract tices in orde to preven mother-to er nt o-child transmission of HIV. P n Poor food sec curity also i increases risk k-taking beh haviour by w women that places p them at inc creased risk of becoming infected w HIV. To g with obacco use (both smokin and smok ( ng keless tobacco) du uring pregnan adversely affects feta health. Dir materna smoking as well as exp ncy y al rect al s posure to second-h hand smoke during pregn nancy increa ases the risk of complica ations in pre egnancy, incl luding low birth w weight and preterm birt More pe th. eople are sm moking in many low- t middle-in m to ncome countries, in particular y n young girls and women o reproductive age. Altho a of ough the pro oportion of women w smoking is low in man countries, women and their offspring still fac substantia risks of ad ny d ce al dverse pregnancy outcomes because of th heir exposur to second re d-hand smok Use of t ke. tobacco tran nsmits tobacco co ontaminants to the fetu through t us the placenta and to ne a eonates thro ough breast milk. Expenditure on tobacco also limits the capacit of familie to provide better nutri e o s ty es e rition for pre egnant women and children. d 8. Child dhood malnu utrition is th underlying cause of death in an estimated 3 he g 35% of all deaths d among child dren under th age of five years. Mor than two million childr die each year as a res of he re m ren sult undernutriti before th age of five years and i ion he e iron-deficien anaemia is estimated to contribut to a ncy d te significant n number of m maternal deat every yea in low- an middle-in ths ar nd ncome countr ries. Materna and al child undern nutrition acc count for 11% of the glob burden of disease.4 % bal f 9. Maln nutrition has a negative impact on cognitive developme s e n ent, school performance and e productivity Stunting and iodine and iron deficiencies combined with inad y. e s, d dequate cog gnitive stimulation, are leading risk factors contributing to the failu of an esti , g g ure imated 200 m million child dren to attain their full develop pment poten ntial. Each 1 increase in adult he 1% eight is asso ociated with a 4%

de Onis M, Bloessn M, Borghi E. Global preval ner E lence and trends of overweight and obesity am t mong preschool l children. Am J Clin Nutr 2010;92:125764.
2 De B Benoist B, McLe E, Egli I, Cogswell M (Ed Worldwide prevalence of anaemia 19932 ean C ds). p a 2005: WHO glo obal database on an naemia. Genev World Health Organization 2008, pp.140 va, n, 0. 3 Glob prevalence o vitamin A def bal of ficiency in popu ulations at risk 19952005: WHO global data W abase on vitami A in deficiency. Ge eneva, World H Health Organizat tion, 2009.

Black RE et al. Mat k ternal and Child Undernutrition Study Group. Maternal and child undernutr d n . c rition: global an nd regional expos sures and health consequences Lancet. 2008; 371:243-260. h s. ;

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increa in agricu ase ultural wages1 and elimi inating anaem would lead to an in mia ncrease of 5% to 17% in % n adult productivity Malnutrit y. tion is an im mpediment to the progr ress towards achieving Millennium s m Deve elopment Go oals 1 (Eradicate extre eme poverty and hunge 2 (Ach y er), hieve univer rsal primary y educa ation), 3 (Pro omote gende equality an empower women), 4 (Reduce chil mortality), 5 (Improve er nd ( ld e mater health) a 6 (Comb HIV/AID malaria an other dise rnal and bat DS, nd eases).

Effec ctive nutrit tion actions exist but a not imp s are plemented on a suffici iently large scale e
10. A review a policy analysis of M and a Member Stat in 2009 tes 20102 indica ated that mo countries ost s have a range of p policies and programmes on nutrition However, such policies are often in p n. s nadequate in n face of the comp plexity of th challenges of materna infant an young chi nutrition and do not he s al, nd ild n t produ the expec impact. uce cted 11. Even when nutrition policies exist, they have not always been officiall adopted, often do not n , n b ly t articu ulate operati ional plans and program mmes of wo with clear goals and targets, tim ork d melines and d delive erables; they do not spe y ecify roles an responsib nd bilities for th hose involved or identif workforce d, fy e and c capacity need and they do not includ process an outcome evaluation. ds; d de nd e 12. The policy review ind y dicated that correcting maternal un ndernutrition was not a priority in n n count tries with a h high burden of maternal m o mortality. Fe of the 36 countries wi the greate burden of ew ith est f under rnutrition im mplement on a national s scale the ful set of effe ll ective interv ventions to prevent child p d under rweight and maternal und dernutrition a to foster early child development and r d t. 13. Interventio that can be managed directly by the health sector lack detailed imp ons d y plementation n guida ance and are only partia impleme e ally ented where health syste ems are wea Many countries have ak. e at adopt ted integrate strategies for mater ed s rnal, newbor and child health tha incorpora nutrition rn d ate n interv ventions, but the actual delivery of nu t d utrition supp in health services is o port often inadequ and few uate w indica ators are ava ailable to mea asure the cov verage. 14. National de evelopment strategies do not give due considera o d ation to nutr rition. Nation food and nal d nutrit tion policies often focus on informat tion and info formed-choice models an give little attention to nd o struct tural, fiscal a regulator actions aim at chang and ry med ging unfavou urable food e environments s. 15. Programme implement e tation is not well coordin nated among different ac ctors. In all regions most r t coord dination and administration of policie occurred within health ministries, with variable input from es w h m minis stries of edu ucation, agric culture, food and welfar Policy an programm implemen d re. nd me ntation often n depen on extern funding and is not sus nds nal a stainable. Monitoring of activities is either not regularly done e or is p poorly done. . 16. The implem mentation of the Intern national Cod of Market de ting of Brea ast-milk Sub bstitutes and d subse equent related Health Assembly r resolutions is not cons sistent amon countries. Statutory ng y regul lations have been put in place in 10 Member States and have been dr n 03 h drafted in 9; 37 Member r

Haddad L, B Bouis HE. The impact of nutrit i tional status on agricultural productivity: wa evidence fro the n age om Philipp pines. Warwick (United Kingd k dom of Great B Britain and Nort thern Ireland), Development E D Economics Rese earch Centre. Papers No. 97, 1989. s, . See http://w www.who.int/nu utrition/EB128_ _18_Backgroun ndpaper1_A_rev view_of_nutritiionpolicies.pdf (accessed 27 Ma arch 2012).
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Annex A

States rely o voluntary compliance by infant fo on y e ormula manu ufacturers, an 25 Memb States hav not nd ber ve taken action to enforce t Code; inf n the formation is missing for 20 Member States.1 17. In mo of those 103 Member States, th legislation makes pro ost he n ovisions for t prohibiti of the ion promotion o designated products to the general public and health worke and in hea of d o h ers alth-care faci ilities, and sets lab belling requi irements. Fe ewer Membe States hav provisions on contam er ve mination warnings, and bans on nutrition an health clai n nd ims. 18. Less than 50% o countries with legal measures also have leg provision on monitoring of a gal ns implementa ation of the Code. Only 37 of thos countries have establ y se lished functi ioning monitoring and/or enfo orcement mec chanisms, an limited in nd nformation on the compo osition, mand date and fun nctions of such mec chanisms is a available. 19. Regio onal offices continue to update the i information on implementation of th Code. A recent he r PAHO review on imple ementation over the peri 198120112 indicated that 16 co o iod d ountries have legal e measures a six of th and hem regulate the implem e mentation of the relevan law. In a review in 2007, f nt 3 UNICEF fo ound that, o 24 West and Centra African countries, half had com of al c h mprehensive legal measures in place. n

OBJECTI IVE, TARG GETS AND TIME FR D RAME

20. The p plan aims to alleviate the double b o t burden of malnutrition in children, starting from the m i earliest stag of devel ges lopment. Substantial ben nefits can be obtained by concentra b ating efforts from ut conception through the first two yea of life, bu at the sam time a life ars me e-course app proach needs to be s considered so that good nutritional status can be maintained. s 21. Progr can be m ress made in the short term, an most nutr nd rition challen nges can be re esolved with the hin current generation. For example, cu urrently avail lable nutritio interventions should b able to av at on be vert 4 least one thi of the cas of stuntin in the sho term. However, full elimination o some cond ird ses ng ort e of ditions may require a longer t e time frame and commitm a ment for a decade of in d nvestment to expand nutrition o intervention should be made, with the aim of a ns averting one million child deaths per year. Takin into r ng account the need to alig the imple e gn ementation o the plan to other development fram of o meworks tha also at consider nu utrition, it is proposed tha this plan h a 13-yea time frame (2012202 Reportin will at has ar e 25). ng nnially until 2022 and th last report will be done in 2025. be done bien he e al 22. Globa targets ar important to identify priority areas and to ca re atalyse globa change. Global al G targets may inspire choi y ices of priori ities and amb bitions establ lished at cou untry level. T They are not meant to dictate th choices o individual countries a regions. Global targ may be used to me he of and . gets e easure
Infor rmation from U UNICEF; these countries also include all Me ember States tha reported on iimplementation of the at n Code, as requ uired its Article 11.6 and 11.7 Questionnair were sent to Member Stat in 2007 and 2009 and the results es 7. res tes d were summari ized in documen A61/17 Add section F, a A63/9. nts d.1, and
2 Soko E, Aguayo V, Clark D. Prote ol ecting breastfee eding in West and Central Africa: 25 years im a mplementing the International C Code of Market ting of Breast-m Substitutes Dakar, UNICEF Regional Office for West a Central Afr milk s. and rica, 2007. 1

30 a del Cdigo en Amrica La os atina: Un recorr rido sobre diver experiencia de aplicacin del Cdigo rsas as n Internacional d Comercializacin de Suced de dneos de la Lec Materna en la Regin entre 1981 y 2011. Washington DC, che n D PAHO, 2011. Bhut ZA et al. for the Maternal and Child Under tta a rnutrition Study Group. What works? Interve y entions for mate ernal and child unde ernutrition and survival. Lance 2008, 371:41 et, 17-440.
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achie evements and to develop accountabil framewo d p lity orks. Targets are needed for nutrition conditions s d s that a responsib for a large burden o nutrition-r are ble of related morbidity and mo ortality from conception m n throu ugh the first two years of life: st t s tunting, ma aternal anaem and low birth weight.1 Child mia w d under rweight of which stun f nting represe ents the large fraction is the larg est gest cause of deaths and f d disab bility-adjusted life years in children u d i under the age of five year and iron d e rs, deficiency co ontributes to o mater rnal mortali in low- and middle ity e-income co ountries. Suc targets w ch would comp plement and d under rpin Target 1.C of Millennium Dev velopment Goal 1 in relation to redu G ducing the pr revalence of f under rweight child dren. Under that Goal, a fourth targ on childh get hood overwe eight is warr ranted, given n the ra apid increas observed globally in the prevalen of that condition. T proposed targets are se nce c The d e based on country experiences and the exis d stence of effe ective interve entions. 23. Global tar rget 1: 40% reduction of the glo % n obal number of childre under fiv who are r en ve e stunt by 2025. This target implies a rel ted . lative reduct tion of 40% of the numbe of childre stunted by er en y the y year 2025, co ompared to the baseline of 2010. This would tran nslate into a 3.9% relativ reduction ve n per y year between 2012 and 20252 and implies redu n ucing the nu umber of stu unted children from the e 171 m million in 20 to appro 010 oximately 10 million, i. approxim 00 .e. mately 25 mil llion less tha what this an s numb would be if current trends are no changed.3 An analysis of 110 coun ber e t ot ntries for wh hich stunting g preva alence is ava ailable on at least two occ l casions in th 19952010 period4 rev he 0 veals that glo stunting obal g is dro opping at the rate of 1.8% per year ( e % (2.6% in cou untries with prevalence h p higher than 30%). In this 3 s period 20% of the countries have reduced stunting at a rate of 3.9 % or higher. e h 24. Global tar rget 2: 50% reduction of anaemia in women of reproduc % ctive age by 2025. This y s target implies a r t relative reduc ction of 50% of the num % mber of non-p pregnant wom of repro men oductive age e (154 years) af 49 ffected by anaemia by the year 20 a 025, compar to a bas red seline set in the period n d 1993 2005 and u used as a refe erence startin point. Th would translate into a 5.3% relativ reduction ng his ve n per y year between 2012 and 20 and impl reducing the number of anaemic non-pregnan women to 025 lies g r nt o appro oximately 23 million. Several count 30 tries have de emonstrated a reduction i anaemia prevalence in in p n non-p pregnant women, as indicated by re epeated natio onal surveys reported in the Sixth re eport on the e world nutrition si d ituation of th United Na he ations Standi Committee on Nutriti 5 China from 50% to ing ion: f o 19.9% in 21 year (19812002); Nepal f % rs from 65% to 34% in 8 years (1998 o 2006); Sri Lanka from m 59.8% to 31.9% in 13 years (19882001 ); Cambodia from 56.2% to 44.4% in 6 years (2 % a % 20002006); ; Viet N Nam from 40% to 24.3% in 14 years (19872001 and Guatemala from 3 % s 1); 35% to 20.2% in 7 years s (1995 52002). The estimates point to a 4 to 8% relative reduction per year. ese s 4% 25. Global tar rget 3: 30% reduction of low birth weight by 2025. The target implies a relative % h y e reduc ction of 40% of the num % mber of infan born wit a weight lower than 2 nts th 2500 grams by the year r 2025, compared to a baseline set in 200 062010 and used as a reference sta d r arting point. This would d transl late into a 3 3.9% relative reduction p year betw e per ween 2012 and 2025. In Bangladesh and India, a n , where around half the worlds children w low bir weight ar born, the prevalence of low birth e with rth re h weigh decreased respectivel from 30.0 to 21.6% (between 1998 and 20 ht d, ly 0% % 006) and fro 30.4% to om o
The develop pment of global targets has bee requested by Member States during region consultation Draft targets l en y nal n. have b been discussed a the regional consultations in the Region of the Americas and the Eastern Mediterranean Region but at c n f a n broade discussion with Member Sta is required at the Executiv Board and through electroniic consultation. er ates ve
2 3 1

r = ln(P1/P P2)/t.

de Onis M, Bloessner M, Borghi E. Preva B alence and trend of stunting am ds mong pre-schoo children, 199 ol 902020. Public Health Nutriti c ion, 2012, 15:14 42148.
4 5

Obtained fro 430 data po om oints. United Nations Standing Committee on N C Nutrition. Sixth report on the world nutrition s r w situation. Genev 2010. va,

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28.0% (betw ween 1999 a 2005). Reduction in the prevalen of low birth weight h been obs and R nce has served in El Salvad (from 13 to 7% bet dor 3% tween 1998 and 2003), South Africa (15.1% to 9 S 9.9% from 19 to 998 2003), and the United R Republic of Tanzania (fr rom 13.0% to 9.5% betw ween 1999 an 2005). In these nd n examples, th recorded reductions are in the ord of 1% to 12% per ye The high reduction rates he a der o ear. her n have been o observed in c countries wh here a large p proportion of the low bir weight is accounted for by o rth s intrauterine growth restr riction, whic is more am ch menable to re eduction than pre-term bi n irth. 26. Glob target 4: No increas in childho overwe bal se ood eight by 202 The targe implies th the 25. et hat global prevalence of 6.7 (95% co 7% onfidence int terval (CI) 5.67.7) estim mated for 20 10 should no rise ot to 10.8% (in 2025) as p current trends1 and th the number of overwe n per hat eight children under five years n should not i increase from 43 million to approxim m n mately 70 million as it could be fore m c ecast. The ra of ates increase are variable in different pa of the w e n arts world, with more rapid increases in countries th are m i hat rapidly expa anding their food system such as in North Afric In higher income coun ms, n ca. ntries national and regional lev informat vel tion indicate that highe socioecon e er nomic group have a l ps lower increa in ase childhood o obesity. Lifes style and env vironmental intervention used in su circumsta ns uch ances can be used e as an examp of good practice. In low- and mi ple iddle-income countries little program e mmatic exper rience exists. Prog grammes aim at curbin childhood obesity hav mainly tar med ng d ve rgeted schoo age children.2 It ol would also be importa to preve an incre o ant ent ease in chil ldhood over rweight in c countries tha are at addressing t reduction of stunting. the n 27. Glob target 5: Increase ex bal xclusive brea astfeeding rates in the first six mon f nths up to at least t 50% by 20 025. This targ implies that the curre global av get t ent verage, estim mated to be 3 37% for the period p 20062010, should incr , rease to 50% by 2025. Th would inv his volve a 2.3% relative incr % crease per yea and ar would lead to approxim mately 10 mil llion more ch hildren being exclusively breastfed u g y until six mon of nths age. Globa ally, exclusiv breastfeeding rates i ve increased from 14% in 1985 to 3 8% in 1995 but 5, decreased s subsequently in most regions. How y r wever, rapid and substantial increa d ases in exclusive breastfeedin rates, oft exceedin the propo ng ten ng osed global target, have been achie e eved in indiv vidual countries in all regions, such as Ca n , ambodia (fro 12% to 60% between 2000 and 2 om 6 n 2005), Mali (from 8% to 38% between 199 and 2006) and Peru (fr 96 ) from 33% to 64% betwee 1992 and 2 en 2007). 28. Glob target 6: Reducing and maintai bal a ining childhood wasting to less tha 5%. This target g an should be reduced implies that the global p t prevalence of childhood w wasting of 8.6% estimate for 2010 s 8 ed to less than 5% by 202 and maint n 25 tained below such levels 3 In the pe w s. eriod 20052 2010, 53 cou untries reported ch hildhood w wasting rates above 5% at least once. Was s % sting reduct tion require the es implementa ation of prev ventive inter rventions su as impro uch oved access to high-qua ality foods and to a health care improved nutrition and health knowledge and practic e; d a ces; promot tion of exclusive breastfeedin for the fir six month and promo ng rst hs otion of impr roved comple ementary fee eding practic for ces all children aged 624 months; and improved w n d water and sa anitation syst tems and hy ygiene practices to protect child dren against communicab diseases. Large numb of childr with seve wasting can be ble bers ren ere c treated in t their commu unities witho being ad out dmitted to a health faci ility or a th herapeutic fe eeding

1 de O Onis M, Bloess sner M, Borghi E. Global pre i evalence and tr rends of overw weight and obe esity among pre eschool children. Amer rican Journal of Clinical Nutr rition, 2010, 92: :12571264. 2 Popu ulation-based p prevention strat tegies for child dhood obesity: report of a WHO forum an technical meeting, : W nd m Geneva, 1517 December 20 7 009.

WHO global and regional trend est O timates for child malnutrition, see http://www d w.who.int/nutgro rowthdb/ estimates/en/in ndex.html (acce essed 23 April 2012). 2

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centre 1 For mode e. erate acute malnutrition, t m treatment sh hould be base on optima use of loca available ed al ally e food, complemen when necessary by sp , nted pecially form mulated supp plementary fo oods.

ACT TIONS
29. This action plan illustr n rates a serie s of priority actions tha should be jointly impl y at lemented by y Mem mber States an international partners. Specific reg nd . gional and co ountry adapt tation will be needed, led e d by the relevant na ational and re egional instit tutions. ACT environmen for the im TION 1: To create a supportive e o s nt mplementati tion of comp prehensive food and nutrit d tion policies 30. Progress to owards nutrition goals r requires hig gh-level policy commitm ment and br road societal l suppo Existing food and nu ort. utrition polic need to be reviewed so that they comprehen cies d y nsively meet t all m main nutrition challenges and deal with the distribu n a th ution of thos problems w se within society. A further r aim o such review is to ensur that nutriti is placed centrally in other sector policies an in overall of re ion d ral nd l devel lopment poli Crucial factors for th successful implementa icy. f he l ation of these policies are (a) official e e: l adopt tion by rele evant govern nmental bod dies; (b) the establishm e ment of an i intersectoral governance e mech hanism; (c) the engage ement of d development partners; and (d) the involveme of local a e ent l comm munities. Th private sector may a he also contribute to a be etter food su upply and to increased t d emplo oyment and therefore in d ncome. Ade equate safeg guards to pre event potent tial conflicts of interest s t shoul be put in p ld place. 31. Proposed a activities for Member S r States (a) revis nutrition policies so that they comprehensiv se c vely address the double burden of s e f malnutritio with a hum rights-b on man based approa and an official endor ach rsement of parliament or p r governmen nt; (b) inclu nutrition in the count ude trys overall developmen policy, Pov nt verty Reduct tion Strategy y ies; Papers and relevant sec d ctoral strategi (c) estab blish effectiv intersecto governan mechanisms for imp ve oral nce plementation of nutrition n policies at n national and local levels that contribu towards policy integr ute p ration across sectors; (d) enga local gov age vernments a commun and nities in the design of pl lans to expa nutrition and n actions and ensure their integration in existing community programmes; d r c p ; (e) estab blish a dialo ogue with re levant nation and international pa nal arties and form alliances s adequate me and partner rships to exp pand nutritio actions wi the establ on ith lishment of a echanisms to o safeguard a against poten ntial conflicts of interest. s

1 Community y-based management of severe acute malnutrition. A Joint St tatement by the World Health Organization, the Wo Food Programme, the United Nations Sy orld ystem Standing Committee on Nutrition and tthe United Nations Childrens Fund. WHO, Geneva 2007. a,

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32.

Prop posed activities for the Secretariat S (a) provide sup pport to Mem mber States, on request, in strengthen i ning national nutrition po l olicies and strategies, and nutritio compone on ents of oth her sectoral policies in ncluding na ational devel lopment poli icies and Pov verty Reducti Strategy Papers; ion (b) improve ac ccess to norm mative and po olicy guideli ines, knowledge products tools and expert s, e netwo orks.

33.

Prop posed activities for inter rnational par rtners (a) implement global advocacy initiat ncrease publ awarenes of the ne to lic ss eed tives that in expan actions on nutrition; nd n (b) strengthen international cooperation on nutrition in order to harmonize s n n standards, po olicies and a actions throu adequate mechanism and inter ugh ms rgovernmental bodies, su as the World uch W Healt Assembly the Comm th y, mittee on Wo orld Food Se ecurity and the United N t Nations Econ nomic and S Social Counc cil; (c) engage in international coordinatio mechanisms or partne l on erships, inclu luding the Scaling Up N Nutrition mov vement and the United N t Nations System Standing Committee o Nutrition. m C on

ACTION 2: To include all required effective health inte e erventions with an imp w pact on nutrition in nationa nutrition p al plans 34. Many diverse int y terventions aimed at cha a anging beha aviours, prov viding nutrit tional suppor and rt reducing th exposure to several environmenta risk facto have bee shown to be effectiv and he e al ors en o ve should be c considered f impleme for entation at n national scal Tables 1a and 1b lis effective direct le. a st nutrition in nterventions and health intervention that have an impact on nutrition and that can be ns n c delivered by the health system. The lists includ interventi y de ions that nee to be con ed nsidered eith for her selected po opulation gro oups or in special circ cumstances, including emergencies.. Analysis of the e o evidence is summarized in a backg d ground paper to this plan1 and repor r n rted in the W WHO e-Libra of ary Evidence fo Nutrition Actions2. WHOs guid for n W deline process ensures that evidenc is continu t ce uously updated and that gaps in research ar identified. Such interv d n re . ventions are intended as options that could be impleme ented on the b basis of coun needs. ntry 35. The g greatest bene efits result fr rom improvin nutrition in the early stages of life However, a lifeng s e. course appr roach to imp proving nutr rition is also needed, with activities targeting o o s older childre and en , adolescents besides infa ants and you children, in order to ensure the best possible environme for ung o e ent mothers be efore concep ption so as to reduce th incidence of low bi he e irth weight and to brea the ak

Esse ential nutrition actions. Impro oving maternal l-newborn-infant and young child health an nutrition. Geneva, nd G World Health Organization, 2 2011.
2

http:/ //www.who.int/ /elena/en/ (acce essed 27 March 2012). h

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interg generational cycle of malnutrition. Managemen of childho overwei m nt ood ight would also require e action throughout the school years.1 n t y 36. Interventio should be integrated i ons e into existing health-care systems to t extent po g the ossible. They y shoul be linked to existing programm and delivered as packages, in order to im ld d g mes mprove cost t effici iency. Imple ementation of WHOs a o approaches and interven a ntions Inte egrated Man nagement of f Child dhood Illnes Integrate Managem ss, ed ment of Adolescent and Adult Illness and Integrated A a d d Mana agement of Pregnancy and Childbi irth will be essential. Furthermor strengthe b re, ening health h system forms a c ms central eleme of a succe ent essful nutriti strategy. ion 37. The design of packag of interv n ges vention can be based on country needs and the level of o t f inves stment. Com mmunity-base programm that inte ed mes egrate different direct nu nutrition inte erventions in n prima care, wit systems to ensure univ ary th o versal access should be prioritized as being costs, p s -effective. A group of organiz p zations in the United N t Nations sys stem has joi intly produc ced the Uni ited Nations s OneH Health Costin Tool sof ng ftware that c easily be adapted to different coun contexts 2 can d ntry s. 38. Proposed a activities for Member S r States interventions relevant fo the countr in materna child and (a) inclu all prove nutrition i ude en s or ry al, d adolescent health servic and ensu universal access; ces ure (b) refle the Globa Strategy o Infant and Young Chi Nutrition the Global Strategy on ect al on d ild n, n Diet and Ph hysical Activ and the W vity WHO nutriti guideline in national policies; ion es l (c) stren ngthen health systems, p h promote univ versal covera and prin age nciples of pri imary health h care; elop or whe necessary strengthen legislative regulatory and/or oth effective ere y n e, y her e (d) deve measures to control the marketing of breast-mi substitute in order to ensure imp e ilk es o plementation n of the Inte ernational Code of Mar C rketing of Breast-milk Substitutes a B S and relevant resolutions t s adopted by the Health Assembly; y A (e) 39. enga in vigoro campaign to promote breastfeedi at the loc level. age ous ns e ing cal

Proposed a activities for the Secreta r ariat (a) revie update and expand W ew, a WHOs guid dance on and tools for eff ffective nutri ition actions, , highlight g good practice of delivery mechanisms and dissemi s inate the info ormation; (b) apply cost-effect y tiveness analy to health interventio with an im lysis h ons mpact on nut trition;

(c) prov vide support to Member S t States, on request, in imp plementing p policies and programmes s aimed at im mproving nut tritional outc comes;

1 Population-based prevent tion strategies f childhood obesity: repor of a WHO fforum and tech for rt hnical meeting, , Genev 1517 Decem va, mber 2009. Gen neva, World He ealth Organizat tion, 2010.

http://www. .internationalhe ealthpartnership p.net/CMS_files s/userfiles/OneH Health%20leafl flet%20May2011.pdf (accessed 27 March 2 2012).

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(d) provide su upport to Member State on reque in their efforts to d es, est, develop or where neces ssary strength and mon hen nitor legislat tive, regulato and other effective m ory r measures to control mark keting of brea ast-milk subs stitutes; (e) 40. convene a m meeting with academic p h partners to de evelop a prio oritized resea arch agenda.

posed activities for inter rnational par rtners Prop (a) align plans for developm assistan to nutriti actions re ment nce ion ecognized as effective; s

(b) support the nutrition co e omponents o health stra of ategies for maternal and child health such m h, as the Integrated M e Maternal Ne ewborn and C Child Health Strategy. ACTION 3: To stimu ulate develop pment polic and prog cies grammes ou utside the he ealth sector that recognize and include nutrition e 41. Secto developm oral ment strategies that are sensitive to issues of nu utrition are n needed in or rder to reduce the d double burde of undern en nutrition and overweight; these shoul aim to pro ; ld omote the de emand for and supp of health food and to eliminat constraints to its access and to use of healthier food. ply hier d te s r Many secto should b engaged, but mainly agriculture, food proces ors be ssing, trade, social prote ection, education, l labour and p public inform mation. Cro oss-cutting is ssues such as gender eq a quality, qual of lity governance and instituti ions, and pea and secu ace urity should also be consi a idered. These matters cou be e uld considered in the development and implement d tation of a framework akin to the W f a WHO Frame ework Convention on Tobacco Control, wh has prov n o hich vided substan ntial impetus to the contr of tobacco use. s rol o 42. The C Committee o World Food Security is preparin a global strategic fra on y ng amework on food n security and nutrition. I the mean d In ntime, a serie of genera principles can be deriv from ex es al ved xisting policy fram meworks, co ountry expe erience and analysis of the evide o ence. For e example, ch hronic malnutrition has been s n successfully reduced in s some countri in Southies -East Asia a Latin Am and merica thanks to th simultane he eous implem mentation of policies an programm aimed a improving food f nd mes at g security, red ducing pover and socia inequalities and enhan rty al s, ncing materna education.. al 43. For fo security increased access to foo of good nutritional qu food y, a ods n uality1 should be ensured in all d d local marke at an af ets ffordable pri all year round, par ice r rticularly thr rough suppo to smallh ort holder agriculture and women involvem ns ment but with considerati being gi h ion iven to the p potential negative impact of l labour-displa acing mecha anization and cash-crop production and of pres d ssure on womens time. In foo manufact od ture, the nut trient profile including better micro e, onutrient con ntent and reduced fats, needs to be improv content of s salt, sugar a saturated and trans-f and d t ved. In the a area of educ cation, better wom mens educati and impr ion rovements in water and sanitation ar associated with better child n re d r nutrition. 44. Empl loyment poli icies are cru ucial to hous sehold food security, bu labour po ut olicies should also d ensure adeq quate mater rnity protect tion and tha employee could wo in a be at es ork etter environ nment, including pr rotection fro second-hand smoke, and access to healthy fo om t ood. An adeq quate environ nment should be c created in the workplace for breastfe e eeding mothe Social protection is needed to re ers. p edress inequalities and must re each the mos vulnerable . Cash transf to the po are used to guarantee food st fers oor e
Food with high nutr d rient density and low concentra d ations of nutrients associated with increased r of w risk noncommunic cable diseases.
1

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needs Conditiona cash transfers, linking the receipt of cash to br s. al o ringing childr to health centres and dren h d schoo can have a positive impact on ch ol, i hildrens nut tritional statu including increase in height and us, g n d birth weight. 45. Trade mea asures, taxes and subsid s dies are an important means of g guaranteeing access and d enabl ling healthy dietary ch y hoices. They can be powerful tools when as y ssociated wi adequate ith e inform mation for co onsumers thr rough nutriti labelling and respons ion g sible food ma arketing, and with social d l mark keting and pro omotion of healthy diets and healthy lifestyles. h 46. Table 2 pro ovides examp of polic measures that engage different rele ples cy evant sectors which may s y be co onsidered. 47. activities for Member S r States Proposed a (a) revie sectoral policies in a ew p agriculture, social protec s ction, educat tion, labour and trade to o ors determine their impac on nutrit ct tion and in nclude nutrit tion indicato in their evaluation r n framework ks; (b) estab blish a dialo ogue between health and other gove n d ernment secto in order to consider tors r r policy mea asures that could impro the nutri c ove itional status of the pop pulation and to address d s potential c conflict betw ween current sectoral po t olicies and health polici aimed at improving h ies a g nutrition; lement the re ecommendat tions on the marketing of foods and non-alcoholic beverages s (c) impl to children (resolution WHA63.14) . W 48. activities for the Secreta r ariat Proposed a (a) deve elop methodo ological guid delines on th analysis of the health and nutritio impact of he o h on f sectoral po olicies, including that on different so n ocioeconomi and other vulnerable groups (e.g. ic r . indigenous peoples); s (b) ident and disse tify eminate exam mples of goo practice of sectoral po od olicy measure benefiting es g nutrition. 49. activities for internation partners r nal s Proposed a (a) enga in consu age ultations in order to an nalyse the health and n h nutrition imp plications of f existing po olicies involv ving trade, a agriculture, la abour, educa ation, and so ocial protecti ion, with the e aim of iden ntifying and describing po d olicy options to improve nutritional o s outcomes; (b) analy evidence of effectiv yse e veness of in nterventions aimed at im mproving fo security, ood , social welf and educ fare cation in low w-income cou untries. ACT TION 4: To provide su o ufficient hu man and financial reso ources for t impleme the entation of nutr rition interv ventions 50. Technical a manager capabiliti are neede for implem and rial ies ed mentation of nutrition pro f ogrammes at t full s scale and fo the design and imple or n ementation of multisecto policies . Capacity development o oral d t shoul be an int ld tegral part of plans to extend nutr o rition interventions. The availability of human e y n
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resources li imits the exp pansion of nu utrition actio ons, and the proportion of primary ca workers to the o are population is a major determinant of program t mme effectiv veness. Capacity buildin in nutrition is ng required in b both the health sector at all levels and other secto d ors. ion interven 51. More financial r e resources ar needed t increase the coverag of nutriti re to ge ntions. Currently, n nutrition pro ogrammes rec ceive less th 1% of ov han verall develo opment assis stance. The World W Bank has ca alculated tha US$ 10 50 million w at 00 would be nee eded each year to implem ment on a na ational scale top-pr riority nutriti intervent ion tions in the c countries with the highest burden of m t maternal and child d undernutriti 1 Further ion. rmore, predictable resou urces are es ssential to sustain an in s ncreased lev of vel programme delivery. 52. Joint efforts are r required of both governm b ments and do onors. Increased resource may come from es e innovative financing m mechanisms, such as the ones discus ssed in the context of m c maternal and child health. 53. Gove ernments nee to establish a budget line for nut ed trition progra ammes and identify fina ancing targets for n nutrition pro ogrammes. Excise taxes ( (for example on tobacco and alcoho may be used to e, o ol) establish na ational funds to expand nu utrition inter rventions. 54. At th internatio he onal level, mechanisms considered for maternal and child health prom m l motion dvance mar include an internationa financing facility, ad al g rket commitments to fu und research and h developmen a De-T nt, Tax to earm mark a shar of valuere -added taxes on goods and service for s es developmen and volun nt, ntary solidar contribu rity utions throug electronic airline ticke sales or mobile gh et m phone contr racts. Results s-based fund ding as an in ncentive to ac chieve target has also be consider by ts een red donors. 55. From the expense side, greate efficiency needs to be sought in fu m e er y unding progr rammes, incl luding better align nment of don nors investm ments with n national prior rities, and measures to r m reduce the cost of c micronutrie supplements and ready ent y-to-use ther rapeutic food also by red d, ducing patent nting fees. 56. Finan ncial monito oring and tr ransparency in the use of resource will be n es needed for better accountability and incre eased efficien ncy. 57. posed activities for Mem mber States Prop (a) identify an map capacity needs, a include capacity-dev nd and velopment in plans to expand n tion actions; nutrit (b) implement a comprehensive app proach to capacity bu uilding, incl luding work kforce devel lopment as well as leadership d l development academic institution t, c nal strengthe ening, organ nizational development and partnersh hips; (c) cost the ex xpansion pla and quan an ntify the exp pected benefits, includin the proportion ng neede for capaci developm and stren ed ity ment ngthening th delivery of services; he f (d) provide su upport to lo ocal commu unities for the implementation of community t y-level nutrit tion actions;

Horto S, et al. Scal on ling up nutrition What will it c n. cost? Washingt DC, The World Bank, 201 ton, W 10.

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(e) (f) 58.

estab blish a budge line and na et ational financial targets for nutrition; f chan funds ob nnel btained from excise taxes to nutrition intervention s ns.

Proposed a activities for the Secreta r ariat (a) supp port workfor developm rce ership, techn nical and m managerial capacities in c n ment, leade nutrition in Member St n tates through workshops distance learning and c h s, communities of practice, s , and provisi of trainin materials; ion ng (b) make available refined tool for capaci building, and suppo the capac e ls ity , ort city-building g efforts of M Member State es; (c) prov costing tools for nutr vide t rition interve entions.

59.

Proposed a activities for internation partners r nal s (a) follo the princi ow iples of the P Paris Declara ation on Aid Effectivenes and the Accra Agenda ss a for Action, and align do onor support at country level; t nternational competency standards, specific to th developm y he ment of the public health p h (b) set in nutrition w workforce, tha recognize different tie in the wor at ers rkforce (fron ntline worker managers rs, s and specia alists) and di ifferent cont texts for pol licy (i.e. cap pacities for i intersectoral action) and d practice (i. the double burden o f malnutritio .e. on), and sup pport revisio of curric ons cula for preservice and in-service training of al levels of he d ll ealth workers; (c) estab blish academ alliance aimed at providing institutiona support to capacity mic es a al y developme in Membe States; ent er (d) explo innovativ financing tools for fun ore ve nding the exp pansion of nu utrition prog grammes.

ACT TION 5: To monitor an evaluate t impleme o nd the entation of policies and programme p es 60. A well-def fined monitor ring framewo is needed to assess progress mad towards th objectives ork p de he s of th comprehe he ensive implementation p plan. The fra amework ha to provide accountab as e bility for the e action implemen ns nted, resourc and resu ces ults. Table 3 lists propos indicator for input (policy and sed rs d legisl lative frame eworks and human r d resources), output and outcome (nutrition programme d e imple ementation a food secu and urity) and im mpact (nutritio status an mortality) onal nd y). 61. The propos set of ind sed dicators need to be adap to the co ds pted ountry contex and priorities, but will xt l be ret tained for as ssessment pu urposes at the global leve Additional indicators s e el. should be co onsidered for r monitoring progre in interse ess ectoral action n.

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62. Surve eillance syst tems should be establish to ensur regular fl hed re low of infor rmation to policyp makers. Rep porting time should be in line with na n ational priori ities and the requirement of the gove ts erning bodies.1 63. posed activities for Mem mber States Prop (a) develop or strengthen surveillance systems for the collection of inform r r mation on selected input output/outc t, come and im mpact indicato ors; (b) implement the WHO Child Growth Standards to monitor individual gr C h rowth pattern and ns popul lation levels of stunting, wasting and overweight; d ; (c) ensure that nutrition indicators ar adequately reported in the annua review pr t i re y i al rocess recom mmended by the Comm y mission on Information and Accountability fo Womens and n for Child drens Health in countrie with lowe income and highest burden of m h es est a maternal and child d death and that so hs ocial differen ntials are ade equately high hlighted. 64. Prop posed activities for the Secretariat S (a) provide me ethodologica support for the collect al r tion of select input, ou ted utput/outcom and me impac indicators, including protocols and design of su ct p d urveillance systems; (b) ut, utcome and im mpact indica ators; establish a database of selected inpu output/ou

(c) report on global prog gress in de eveloping, st trengthening and imple g ementing na ational nutrit tion plans, po olicies and programmes; (d) 65. support Me ember States in implemen nting the WH Child Gr HO rowth Standa ards.

posed activities for inter rnational par rtners Prop (a) adopt the p proposed fra amework of indicators as a tool to monitor the i s m implementati of ion lopment activ vities; devel (b) support the collection and exchang of informa e a ge ation betwee organizati en ions, with th aim he of ensuring globa coverage of the databas of input, output/outco and imp indicator al o ses ome pact rs.

1 Repo orting implemen ntation of the plan could be co ombined with th biennial repo he orting to the Hea Assembly called alth for in Article 1 11.7 of the Inter rnational Code of Marketing o Breast-milk Substitutes, ado of S opted by the He ealth Assembly in resolution WH HA34.22.

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Table 1a. Effective direct nutrition interventions that can be expanded for delivery through the health system1
All women of reproductive age Iron and folic acid supplementation daily for pregnant women intermittent in non-anaemic pregnant women intermittent in menstruating women living in settings where anaemia is a public health concern Nutrition counselling through foodbased dietary guidelines Calcium supplementation for the prevention and management of preeclampsia and eclampsia Women in special circumstances Appropriate care of women with low body mass index All children aged 0 to 24 months Counselling and support for optimal breastfeeding (early initiation, exclusive breastfeeding for the first six months and continued breastfeeding up to two years of age or beyond) Children in special circumstances Integrated management of severe acute malnutrition through facility- and community-based interventions

Nutritional care and support for HIVinfected pregnant and lactating women Nutritional care and support in emergencies multiple micronutrient supplementation for pregnant women Iodine supplementation (in case iodized salt is unavailable)

Counselling and support for appropriate complementary feeding Implementation of the Baby-friendly Hospital Initiative

Treatment of moderate acute malnutrition Nutritional care and support for HIVpositive children

Implementation of the International Code of Marketing of Breast-milk Substitutes and relevant resolutions of the World Health Assembly after resolution WHA34.22 Vitamin A supplementation for children from six months to five years of age in vitamin A-deficient populations Iron supplementation for children aged under five years

Nutritional care and support in emergencies

Counselling and support for appropriate infant feeding in the context of HIV infection Counselling and support for appropriate feeding of low-birthweight infants

Based on individual country needs.

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All women of reproductive age

Women in special circumstances

All children aged 0 to 24 months Zinc supplementation for the management of diarrhoea Nutrition counselling for the adequate care of sick children Home fortification of foods intended for young children Vitamin A administration as part of treatment for measles-related pneumonia for children older than six months

Children in special circumstances

Table 1b. Effective health interventions with an impact on nutrition that can be expanded for delivery through the health system Women of reproductive age Prevention of adolescent pregnancy Pregnancy spacing Intermittent preventive treatment of malaria in pregnant women in high transmission areas Provision of insecticide-treated bednets Children aged 0 to 24 months Properly-timed cord clamping at birth Deworming of children Provision of insecticide-treated bednets Intermittent preventive treatment of malaria in infants, in areas of high transmission in sub-Saharan Africa where plasmodial resistance to sulfadoxine-pyrimethamine is not high Hand washing with soap, and other hygienic interventions

Prevention of exposure to second-hand smoke and cessation of direct tobacco use, alcohol and drug consumption by pregnant women Reduction of indoor air pollution Prevention and control of occupational risks in pregnancy Prevention and control of genitourinary infections in pregnancy Deworming of pregnant women

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Table 2. Sector Agriculture

Non-health interventions with an impact on nutrition Intervention Agricultural activities that generate employment Small-scale agriculture Production of nutrient-rich foods and of staple foods of the poor1 Home gardening and large-scale fruit and vegetable production Micronutrient-rich crop varieties (e.g. orange-flesh sweet potatoes) Diversified food production, and improved storage and processing of food Nutrition counselling integrated into agricultural extension programmes Womens role in agriculture supported Local production of fortified foods, including fortified flour, oil, salt, sugar, soy and fish sauce, and fortified blended foods Local production of high nutritional quality complementary food with provisions to allow access to all sectors of the population Micronutrient fortification of complementary foods Salt iodization Improvement of the nutritional quality of foods (reduction of the content of salt, fats and sugars, and elimination of trans-fatty acids) Improvement of water supply Improvement of sanitation Womens primary and secondary education Provision of healthy food in schools and pre-schools Nutrition and physical activity education in school Employment-support policies Healthy nutrition in the workplace Maternity protection in the workplace (through adopting and enforcing the ILO Maternity Protection Convention, 2000 (No. 183) and Recommendation (No. 191)) Smoke-free workplaces Conditional cash transfers Unconditional cash transfers Support for socially disadvantaged groups to access healthy foods Healthy built environments

Food manufacturing

Water and sanitation Education

Labour policies

Social protection

Urban planning

World development report 2008: agriculture for development. Washington, DC, World Bank, 2008. Spielman DJ, Pandya-Lorch R. Millions fed: proven successes in agricultural development. Washington, DC, International Food Policy Research Institute, 2009. Agricultural production contributes to food security, and hence indirectly to redressing undernutrition, both by increasing food availability and by increasing livelihoods and incomes of poor people, so increasing their capacity to feed their families.

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Sector Trade

Intervention Food-price regulatory measures Agricultural subsidies Offer of food in public institutions and private food outlets Food-labelling schemes Regulation of advertising food and beverages to children Implementation of International Code of Marketing of Breast-milk substitutes Use of excise taxes on tobacco and alcohol to finance expansion of nutrition programmes Social marketing for breastfeeding promotion, use of fortified foods, healthy diet and physical activity

Finance Social mobilization

Table 3. Indicators for monitoring the realization of the comprehensive implementation plan Inputs Policy/strategy environment for nutrition: nutrition governance score Human resources: ratio of community health workers to total population Outputs/outcomes Prevalence of children aged under six months who are exclusively breastfed Proportion of children aged under five years who have received two doses of vitamin A supplements1 Impact Incidence of low birth weight

Proportion of stunted children below five years of age Proportion of wasted children below five years of age

Legal frameworks: adoption Proportion of households with and effective implementation of consumption of iodized salt International Code of Marketing of Breast-milk Substitutes Proportion of population with sustainable access to an improved water source Individual food consumption score

Proportion of thin women2 of reproductive age Proportion of children below five years of age with haemoglobin concentration of <11 g/dl Proportion of women of reproductive age (1549 years) with haemoglobin concentration of <12 g/dl

Proportion of children receiving a minimum acceptable diet at 623 months of age

1 2

Children aged 659 months in settings where vitamin A deficiency is a public health problem. Women with body mass index <18.5 kg/m2.

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Inputs

Outputs/outcomes Prevalence of children (aged 0 59 months) with diarrhoea who received oral rehydration therapy and therapeutic zinc Proportion of pregnant women receiving iron and folic acid supplements

Impact Median urinary iodine concentration (g/l) in children aged 612 years Maternal mortality ratio (per 100 000 live births) Infant mortality rate (per 1000 live births) Under-five year mortality rate (per 10 000/day)

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