1. Do you have any general comments on the draft Framework for Action?
Concern welcomes the opportunity to comment on the Framework for Action (FFA). A tremendous amount of work and consideration has gone into the draft and its focus on malnutrition in all its forms and its comprehensive nature is to be commended. We welcome the balanced consideration between the food, health and care environment dimensions that are crucial to addressing the underlying determinants of malnutrition.
· Do you have any comments on chapter 1-2?
1.2 Framework for Action
Ensure nutrition security and the eradication of malnutrition will require collective and aligned efforts by all stakeholders, with all having their respective roles to play. As such, we recommend that the second paragraph be expanded to read as follows: ‘… led by the UN General Assembly and taken forward by Member States in partnership and collaboration with all stakeholders’.
2.2 Better governance for nutrition
Coherent government endorsed policies with explicit targets and situation-specific strategies
The reference and focus on nutrition justice is most welcomed. To establish the requisite policies and incentivize actions to address the causes and underlying determinants of malnutrition will require commitment and ownership of all stakeholders. While it is encouraging that reference is made to the development of strategies through regular consultations among all implementing partners, this language could be stronger. It should go beyond regular consultation – strategies should be developed in collaboration with and among all implementing partners. Participation of civil society as well as participation of communities and those most affected, is vital to the formulation of policies that are locally appropriate and socially inclusive.
Institutional arrangements that encourage effective multi-sectoral working
Increased collaboration including joint planning, implementation and monitoring among ministries will be crucial for realising synergies and sustainable impact on nutrition outcomes. What gets measured gets done – the FFA should emphasis the need for explicit nutrition objectives and indicators to be adopted for all key ministries that have an impact on nutritional status.
The involvement of the private sector also should come out more and their responsibility and ability to influence e.g. the consumption of sugary drinks on the negative side and fortification on the positive side.
2.3 Financing for improved nutrition outcomes
Priority action for financing for improved nutrition outcome
The creation of a central, public, and updated database within each national government that can account for all off-budget allocations to nutrition i.e. from civil society, private sector, donors, should also be considered.
· Do you have any comments on chapter 3 (3.1 Food systems, 3.2 Social Protection; 3.3 Health;
3.4 International trade and investment)?
3.1 Food Systems
- We welcome the clear emphasis on the critical role women play in nutrition, as well as the implication and importance of raising women’s income. It would also be important to stress the need for equal access and control over other productive assets/resources (i.e., land, agricultural inputs, and agricultural services).Improving women’s land and property rights also help improve food and nutrition security.
- Men also have an important role to play in improving nutrition. As such the FFA should recognise the role of men in decision making and need to raise their awareness about nutrition.
- The private sector, like other stakeholders, has a role to play in food and nutrition security.
We welcome the emphasis on appropriate regulation and the subsequent reference to the Code of Marketing of Breast milk substitutes. The SUN movement has developed a Reference Document on Preventing and Managing Conflicts of Interest which is currently being piloted. It contains a number of key principles that should govern engagement in the movement. While focused on the SUN, it could also provide a useful reference, and guide action on engagement of the private sector, and all actors, during roll out and implementation of the FFA.
- One of the priority actions outlined is to ‘support extension services to support dietary diversity in collaboration with researchers, small scale farmers and local communities’. We would propose that this be expanded, or an additional priority action be added, to include improving coordination and collaboration between agricultural extension workers/services and Community Health Volunteers/health services. This point could alternatively be added under 3.3 on Health.
- There is little focus on actual fresh foods, with language more focused on processing, etc. We recommend this be amended. Similarly, there is a strong focus on plant foods and less on animal source foods, which, however, play an important part in fulfilling micronutrient requirements. Affordable ways to produce, access, and ultimately consume animal source foods by all household members in an equitable way, should be emphasized.
- While the 1,000 days features in other parts, it would be important to also consider this within food systems in relation to targeting. The highly prioritized school-related activities (near top of the list) might need to be slightly deprioritized.
- In terms of food environments, focus should not only be on nutrient related considerations stemming from the NCD Action Plan and rather be widened to include fertilizer or pesticide residues, preservatives with harmful side-effects, etc.
- Capacity within the Government system needs to be considered, ensuring adequate nutrition staffing within the Ministry of Agriculture, at national/ provincial/ district levels, who are nutrition experts.
- Stunting: ‘Stunting begins in utero, and it results from a complex web of individual, household, environmental,…’ It would be good to add ‘individual’ given the mother’s physiological/ nutrition status also plays a role and that is not necessarily well described by a household’s situation. In addition, increasing attention is drawn to also ensuring optimal nutrition status among adolescent girls (who are likely to get pregnant at some point in the future) and programmatic focus on that is likely to increase further over the course of the FFA. The priority actions should be adjust to span across pre-pregnancy, pregnancy, lactation and early life of the child.
- The monitoring of stunting as a priority action is very much welcomed. This will require further health capacities, equipment and motivation to ask the mother to visit the health facility beyond the usual period when immunization is being administered. Flexible systems will need to be designed for that, which allow detection of length growth faltering at the same time. This action should not be a standalone one but requires tailored and one-on one counselling, an aspect currently missing.
- Anaemia: we recommend to mention micronutrient powders/ home fortification so that the door is at least open for that. We assume this is not considered as ‘fortification’ or ‘supplementation’ and meant to be included among those. Establishing such a system might have additional benefits for similar systems for children, beyond the current focus on maternal anaemia.
Section 3.3.1 delivery of effective nutrition interventions
- The priority actions under this section only refer to three focus areas of the WHA Nutrition targets and should approach this more holistically. For example control of all major micronutrient deficiencies and for women, children (and men) instead of focusing on anaemia in women of reproductive age.
Section 3.3.2 Delivery of health interventions with an impact on nutrition
- It would be good to recognize the currently discussed important issue of environmental enteropathy, which might also require health systems to react. The trials that are currently on-going will be concluded at the early stages of the period this FFA will cover. A provisional priority action, pending the outcome of the trials, should be included.
Section 3.3.4 Nutrition education for behaviour change
- It would be good to change the language from a very ‘message’/‘education’ dominated focus towards an approach that promotes optimal behaviours through behaviour change. There is wide-spread acceptance now that ‘educating’ people by giving them ‘information’ does not work, and that more tailored approaches are required to enable an individual/ household/community to change their behaviours. The work of non-governmental organisations as well as large scale research projects on infant and young child feeding provide ample examples for this, which have the potential to influence national level delivery approaches. A mere focus on nutrition education and information campaigns would be a too ineffective approach to change maternal, infant and young child nutrition behaviours.
Overall section 3.3 Health: It would be good to revise the structure of the sub-sections of 3.3. They vary from very broad (e.g. 3.3.2, 3.3.5) to very specific (e.g. 3.3.6 (where addressing AMR seems to be a key concern) or 3.3.3 – and how is breastfeeding on a same level of importance as AMR), from addressing symptoms/special forms of malnutrition (3.3.1), to approaches to promote good nutrition (3.3.4).
· Do you have any comments on chapter 4-5?
4. Accountability Mechanisms
- The FFA proposes the production of a biannual report as well as international meetings to help guide interventions. Following the Nutrition for Growth event in London in June 2013 it was agreed that a Global Nutrition Report (GNR) would be produced annually. This report is intended to be comprehensive, capturing overall progress and trends on nutrition, progress against the WHA 2012 nutrition targets and in SUN countries, monitor commitments made by all stakeholders, as well as analyse data and propose recommendations. In a number of respects, the GNR has the potential to be the global monitoring and accountability framework for nutrition. The FFA should clearly lay out how its reporting approach will align with existing processes such as the GNR and seek to minimise the reporting requirements of states and other stakeholders so as not to over burden those who have a responsibility to account for nutrition impacts and outcomes.
- There is a clear need for additional resources for nutrition, with the 2013 Lancet Series on Maternal and Child Nutrition estimating a funding gap of $9.6 billion. As such, we welcome the idea of a global trust fund to mobilise resources. We would suggest considering a feasibility study for such a global fund, and potential for integrating such a fund within an existing mechanism such as GAFSP. RESULTS UK current research exploring the optimal aid architecture could be useful in this regard.
4.1 Responsibilities for Action
There are now over 53 countries that have agreed to scale up nutrition interventions and have joined the SUN movement. These countries are already working on establishing multistakeholder platforms, appointing Country Focal Points, developing or updating nutrition plans and costing same, and updating sector strategies/policies. In addition, at the Nutrition for Growth summit June 2013, a Global Nutrition for Growth Compact was endorsed by a total of 94 stakeholders, including 26 Governments addressing undernutrition. Fifteen Governments committed to increase the domestic resources for scaling up nutrition, and 12 Governments announced national stunting-reduction targets. The FFA should draw on and reflect these existing processes rather than creating a parallel process and mechanism.
5. Recommendations for follow up
We welcome the suggestion of periodic reports on overall follow up to ICN2 and would suggest that this in fact goes beyond this to consider hosting follow up ICN meetings and reviews in 5 to 10 years.
It would be useful to clarify how the Intergovernmental Panel on Nutrition could/should link with the Stakeholder group of the Global Nutrition Report, and the work that the Independent Expert Group that that group is overseeing.
2. Does the Framework for Action adequately reflect the commitments of the Rome Declaration on Nutrition, and how could this be improved?
3. Does the Framework for Action provide sufficient guidance to realize the commitments made?
We welcome the commitment to a Decade of Action on Nutrition. The FFA however fails to provide additional clarity on what this would entail and what it could look like and include. Key priorities that should be considered under such a Decade of Action include i) ensuring that nutrition prominently and adequately features in the Post-2015 framework, through a dedicated goal as well as integrated within other relevant goals as targets and indicators, ii) ensuring sustained political will and action on nutrition through support for local and global campaigns, and iii) the potential hosting of an ICN3 and regular reviews of ICN2 outcomes.
4. Are there any issues which are missing in the draft Framework for Action to ensure the effective implementation of the commitments and action to achieve the objectives of the ICN2 and its Declaration?
More practical actions and emphasis could have been placed on WASH as well as obesity; we therefore recommend that the FFA goes beyond focusing on food systems and address other complex and important issues such as these.
With over 60 ‘priority actions’ throughout the FFA, some guidance and clarification should be provided on which should actually be prioritised, as well as by whom, considering the different roles and responsibilities of different actors. Being clearer as to timelines and responsibilities around priorities will help ensure effective implementation.
While there is reference to the WHA 2025 targets and a Decade of Action it will be imperative that the momentum and ambition is sustained through 2030, aligning with and helping support and feed into the transformational change being sought through the Post-2015 framework. Much more emphasis is needed in the FFA on Post-2015, and particularly on the need for nutrition to be prioritised within the new framework, with a stand-alone goal and inclusion of ambitious targets to address all forms of malnutrition by 2030.
Second Draft of the Rome Declaration on Nutrition
Concern Worldwide, Helen Keller International and the SUN Civil Society Network welcome the opportunity to feedback on the latest iteration of the Rome Declaration. Progress has been made which is welcome, but many significant issues remain to be addressed. We offer the below as organisations committed to realising the best outcome and potential from ICN2 and hope that it proves helpful in finalising the Rome Declaration.
- In addition to restricting the attainment of human potential and impacts on physical and cognitive development, as the Cost of Hunger Study in Africa1 highlighted, undernutrition can cost a country as much as 16.5 percent of its GDP. Outlining the economic consequences of undernutrition is important and further emphasises the urgency and imperative to act. This omission has still not been rectified in the latest iteration of the Rome Declaration.
- Reference to the World Health Assembly targets is still lacking. Member States’ continued commitment and support of the WHA targets should be explicitly articulated, as well as recognising the need for commitments that go beyond the WHA 2025 targets.
- Gender and the issue of equality are not addressed and this omission should be rectified.
Ensuring an end to all forms of gender discrimination, recognising this as one of the greatest causes of undernutrition. Action to end hunger must transform societal norms that result in girls eating last and least, that keeps girls out of school, limits women’s income, voice and productivity, and that lead to child marriage. Improving women’s status and role, their access to education as well as their access to and control over resources is key (i.e. land, income, agricultural inputs and agricultural services).
- The second draft of the Rome Declaration continues to have a bias toward a food system approach. Many social and environmental factors such as gender, environmental health, optimal caring and feeding practices are key determinants. Other drivers and determinants of malnutrition need to be acknowledged and addressed. There is significant space and need for further promoting a balance between food systems approaches, nutrition sensitive interventions and nutrition specific interventions.
- It would be useful to explicitly mention the three underlying causes of malnutrition (Food, Care and Health) in the text to show the importance of all three being satisfied if nutritional status is to be improved.
- There is no mention of the vast transformation that urbanization will have on food systems and nutrition outcomes.
- We would suggest that mention is made that as food systems change and families, including the poor, utilize commercially produced complementary foods for children, explicit normative guidance will be required to help countries operationalize and enforce necessary steps to ensure the appropriate marketing of these products for children 6-24 months while at the same time protecting and promoting optimal breastfeeding. This is an issue that the WHA is addressing during its 67th Session, thus of utmost importance. See
Lancet Series 2013 Paper 4 by Gillespie et. al.
- The Outcome declaration should also push for having coding for nutrition-sensitive efforts as a first step towards thinking of normative guidance for nutrition sensitive efforts and to contribute to comparable data across countries.
- In relation to the second bullet under paragraph 5, poverty is indeed a major contributor to malnutrition, but also vice versa - malnutrition is also a contributor to poverty.
- Point 7 suggest adding – ‘Recognise the environmental, societal changes, and economic and gender disparities have an impact on dietary and physical patterns, …’
- While 12 d) recognises that public investments and appropriate market regulations in food, agriculture and other sectors are crucial to overcoming malnutrition, the Code on Marketing of Breastmilk Substitutes is conspicuously missing and should be explicitly referenced.
- Under paragraph 12:
o A point should be made on the importance of/encourage the integration of a multi- stakeholder approach to ensure food and nutrition security.
o Support the alignment behind national needs from all stakeholders and clear processes for making this happen.
o Highlight the importance of diversification and the central role of small holder farmers as the main producers of food.
- Under a ‘vision for global action to end all forms of malnutrition’, the need to support coordinated action of different actors is mentioned as well as the need for global and national policy coherence. The need and importance of coherence and consistency between the various global frameworks and initiatives on nutrition and food security should also be stressed, such as the Nutrition for Growth, WHA framework against the 6 targets, and SUN.
- We would encourage additional clarity/specificity on the commitments referenced, there is still work needed to make them SMARTER, in relation to what is and will be ‘measurable’ specifically, which also encompasses the timeliness.
- The commitment to action could be strengthened by adding ‘ensuring universal access to safe drinking water, sanitation, and hygiene for households, schools, and health facilities. WASH is critical to addressing malnutrition, preventing infections and diseases such as diarrhoea’.
- In commitment section, we further suggest adding a point on:
o Generating more evidence on nutrition-sensitive programming and policies to inform scale up and integration in policies, strategies, plans of government (multi- sectoral) and various line ministries.
- We support the idea of pushing for a Decade of Action, but this should not be UN only. It needs to be owned by multiple stakeholders.
- A commitment should be made to plan for accountability in a way that is aligned with the broader nutrition architecture (e.g. GNR, WHA, N4G)- to ensure efficient monitoring which begins as soon as possible after commitments
- In relation to the above point - a commitment and reference to learn from current experience should be mentioned.