All Hands on Deck: Reducing Stunting Through Multisectoral Efforts in Sub-Saharan Africa ANNEX with 33 country-specific notes on the underlying determinants of stunting including maps of regional differences 1 Contents Uganda:.......................................................... 183 Country-specific briefs – introduction and Zambia: .......................................................... 189 caveats ............................................................... 1 Zimbabwe: ..................................................... 195 Angola: ............................................................... 3 Benin: ................................................................. 9 Burkina Faso: .................................................... 15 Burundi:............................................................ 21 Cameroon: ....................................................... 27 Chad: ................................................................ 33 Comoros: .......................................................... 39 Congo: .............................................................. 45 Cote d’Ivoire:.................................................... 51 DRC:.................................................................. 57 Ethiopia: ........................................................... 63 Gabon:.............................................................. 69 Gambia: ............................................................ 75 Ghana: .............................................................. 81 Guinea: ............................................................. 87 Kenya:............................................................... 93 Lesotho:............................................................ 99 Liberia: ........................................................... 105 Madagascar: ................................................... 111 Malawi: .......................................................... 117 Mali: ............................................................... 123 Mozambique: ................................................. 129 Namibia: ......................................................... 135 Niger:.............................................................. 141 Nigeria: ........................................................... 147 Rwanda: ......................................................... 153 Senegal: .......................................................... 159 Sierra Leone: .................................................. 165 Tanzania: ........................................................ 171 Togo: .............................................................. 177 2 Country-specific briefs – schedule of the country, its inclusion in the vaccination measure may be appropriate. Or if introduction and caveats it is known that certain types of health facilities provide low-quality services, then services (such As part of the effort to understand the as pre- or post-natal checkups) may not be underlying multisectoral nature of improving considered as adequate if provided by these nutrition outcomes in sub-Saharan Africa, facilities. Or there maybe additional and better stylized country specific analyses were carried measures of household food security collected out for the 33 countries in the study. The in a survey that allow for a more robust methodology used for the regional study was measure of access to food. Furthermore, if applied at the country level, and the results are animal excreta in the household environment is offered as a starting point for understanding common and the survey collected information and evaluating the multisectoral dimensions of on the extent of contact then this may be used nutrition in specific country contexts. The briefs as a component of access to WASH. For each layout the prevalence of stunting and access to determinant there are many additional aspects nutrition determinants in the country, for select to consider based on the specific context and subpopulations within the country, and the available information. The country specific regionally. While they depict the general indicators should reflect these considerations nutrition-related conditions and highlight the and most likely will differ from the measures heterogeneity within a country, they come with used in these briefs based on the regional important caveats. It was outside the scope of model. this analysis to dwell deeply into each country For a particular country, it may also be that context. While the general approach and adequate access is defined differently. For this framework is applicable at the country level, in regional report, for health and WASH the a carefully crafted country-specific analysis the fulfillment of at least three of five conditions is choices for components, definitions, and deemed adequate. For adequate access to subpopulations may differ from those used in food/care, access to minimum acceptable diet these briefs. and at least one of the two breastfeeding An ideal country specific determinant indicator components is required. These formulations may use a different set of components. Given were chosen to ensure better comparability the country’s cultural, political, economic, and across the different countries and to ensure environmental contexts components used to variability in access to determinants. For determine adequate access to household food example, not all surveys collected information security, child health, or household WASH may on post-natal checkups. To minimize the effect be different from those used in the regional of only some children having information for analysis. The definitions for the regional this component, the access measure is defined analyses are based on components readily so that it is not necessary to have a post-natal available and applicable to most of the checkup but acknowledging the possible countries in the study. However, in a specific benefits from post-natal checkups on nutrition context, additional or different components and allowing it “count� towards adequacy. One may be more informative. For example, if an drawback from requiring access to only a subset infectious disease is prevalent in a country and of the components, is the introduction of a vaccination for it is part of the vaccination substitutability among a determinant’s components. In fact, the WASH and health 1 measures give equal weight to each of the five internally displaced children separately may components and any combination of three of yield additional insights. Understanding of the the five is considered equal. This weighting may internal structures at work, not only guides the not reflect context specific definitions of decision of which subpopulations to study, but adequate access. In a particular case, a more also helps in interpreting the results. Given that appropriate measure may be along the lines of the framework only identifies correlations, the food/care measure where some some results may be surprising and here an components need to be met and other facets of understanding of the context is paramount. For the determinant are met if one of several example, if a breastfeeding campaign has been components are met. It may also be carried out targeting at risk infants then a determined that all the components need to be negative correlation between care—where met. However, as exemplified by the case study breastfeeding is a component—and nutrition of Tanzania in Chapter 6 of the main report, in outcomes may reflect the effectiveness of the many cases these stricter definitions result in campaign and not be a manifestation of insufficient number of children with access to breastfeeding leading to worse nutrition any determinant to make the exercise useful. outcomes. So, although the determinant definitions based Therefore, while the following briefs provide a on a subset of components may not capture all useful starting point for diving deeper into the aspects of what it means to be adequate (and interplay of multisectoral determinants and thus even though a child is identified as nutrition in a country, they are just that, a adequate they may in fact be lacking in some starting point. Carefully considering the details key aspect) they do identify children with of the framework as laid out above is necessary. greater access to underlying determinants and Expertise and understanding of country specific proxy, albeit imperfectly, for adequate access. context are critical components of any detailed However, in a detailed country specific analysis, analyses of multisectoral determinants and different criteria from those used here for nutrition. defining adequate access may be appropriate. In applying the methodology to a country, additional subpopulations may be of interest. In these country briefs, standard subpopulations are explored. Children are characterized by the locality of their residence and by the wealth of the household. However, there are many other populations of interest— such as those based on the mother’s educational attainment, family structure, region, etc—that are not included in these briefs. Countries with distinctions based on ethnicity, religion, or health status analysis of specific groups based on such delineations maybe illuminating. Furthermore, countries with large internally displaced populations (either from conflict or disasters), such as DRC, Nigeria, South Sudan and Somalia, analyzing the 2 Angola: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of malnutrition in interventions in these sectors will have to be Angola using data for children between 0 and able not only to address the key underlying 23 months of age, from the 2015/2016 determinants of nutrition effectively, but also Demographic and Health Survey (DHS). The contribute to enhancing the impacts of UNICEF (1990) conceptual framework views “nutrition-specific� interventions (Black et al., malnutrition as the consequence of a variety of 2013). interlinked factors. The causes of malnutrition are classified into three hierarchical categories: The effectiveness and ultimate success of (i) the immediate causes, (ii) the underlying nutrition-sensitive interventions in different causes, and (iii) the basic causes of sectors towards reducing stunting depends on malnutrition. In any given context having a more holistic view of the inequities and identification of the immediate causes of gaps in access to adequate levels of the malnutrition—disease or inadequate dietary underlying determinants of nutrition typically intake—is useful for guiding policy actions addressed by nutrition-sensitive interventions especially in situations of crises. In general, in: Food and Care, Health, and Environment. however, disease and inadequate dietary intake The interdependencies among the underlying are typically consequences of a variety of determinants of nutrition are usually beyond underlying drivers that are interrelated. the consideration of any given sector. The The variety of underlying causes of malnutrition integration of nutrition-related objectives in are grouped into three groups: (a) inadequate agricultural operations, for example, is unlikely household food security and care practices, (b) 3 unhealthy household environment (WASH), and 20%) and in the poorest (Bottom 20%) (c) inadequate health services. Adequate households. access to each of the three underlying drivers is Along similar lines, the panels in Figure 2 defined based on internationally accepted summarize the prevalence of simultaneous standards. Access to Food and Care is access to none, only one, two, or all three of the characterized as adequate if the child, drivers of nutrition. depending on its age, consumes a minimum acceptable diet (based on types of foods Figure 3 presents estimates of the extent to consumed and feeding frequency), whether which access to only one, or simultaneous breastfeeding was initiated within an hour of access to two, or to all three of the underlying birth, and whether the child is age appropriately drivers of nutrition is associated with better breastfed at the time of the survey. Access to nutritional outcomes (i.e., lower prevalence of Adequate Environment is characterized by the stunting). This is done both visually (i.e. in terms access to at least three of the five WASH of shift to the right in the density function of components: (1) access to an improved source height for age z-scores associated with access to of water for drinking, (2) access to basic none or one or more of the drivers of nutrition) sanitation in the dwelling, (3) access to proper and quantitatively (in terms of the marginal children’s feces disposal, (4) access to a hand decrease in the stunting rate relative to the washing station with soap, and (5) living in a stunting rate prevailing among children with community where less than 25 percent of the access to adequate level in none of the three households openly defecate. Access to health drivers of nutrition). is characterized as adequate if the child adheres to at least three of the following five health The figures are accompanied by a series of components: (1) mother used prenatal services maps helpful for targeting nutrition specific and at least four times while pregnant, (2) child nutrition sensitive interventions. The maps delivered by a skilled professional, (3) child summarize the prevalence of stunting rates, received a postnatal check within two months and access to adequate Food & Care, of birth, (4) child is compliant with national Environment, and Health, one at a time and vaccination schedule, and (5) child sleeps under simultaneously by region in Angola. a mosquito net. A necessary condition for guidance towards Notes on Angola: effective multi-sectoral policies for the reduction of undernutrition, is knowledge on n/a the extent to which infants and children are lacking access to adequate levels of these three drivers of undernutrition, independently (Figure 1) as well as simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the country, and for children in the wealthiest (Top 4 FIGURE 1 5 FIGURE 2 Percentage of children adequate in National Rural Urban None 37 59 22 Food/Care 10 16 5 WASH 10 6 13 Health 16 10 21 Food/Care & WASH 2 1 3 Food/Care & Health 6 5 8 WASH & Health 14 3 21 All 3 5 1 8 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 6 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 7 8 Benin: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Benin using data for children between 0 and 23 able not only to address the key underlying months of age, from the 2012 Demographic and determinants of nutrition effectively, but also Health Survey (DHS). The UNICEF (1990) contribute to enhancing the impacts of conceptual framework views undernutrition as “nutrition-specific� interventions (Black et al., the consequence of a variety of interlinked 2013). factors. The causes of undernutrition are classified into three hierarchical categories: (i) The effectiveness and ultimate success of the immediate causes, (ii) the underlying nutrition-sensitive interventions in different causes, and (iii) the basic causes of sectors towards reducing stunting depends on undernutrition. In any given context having a more holistic view of the inequities and identification of the immediate causes of gaps in access to adequate levels of the undernutrition—disease or inadequate dietary underlying determinants of nutrition typically intake—is useful for guiding policy actions addressed by nutrition-sensitive interventions especially in situations of crises. In general, in: Food and Care, Health, and Environment. however, disease and inadequate dietary intake The interdependencies among the underlying are typically consequences of a variety of determinants of nutrition are usually beyond underlying drivers that are interrelated. the consideration of any given sector. The The variety of underlying causes of integration of nutrition-related objectives in undernutrition are grouped into three groups: agricultural operations, for example, is unlikely (a) inadequate household food security and 9 care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment, and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Benin: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and 1. No differences in stunting rates by children are lacking access to adequate levels of subpopulations. these three drivers of undernutrition, 2. Children in urban areas without access independently (Figure 1) as well as to any are very likely to be stunted simultaneously (Figure 2). (pr=0.45) whereas in the rural areas the probability of being stunted without The panels in Figure 1 summarize the access to any is “only� 0.34. prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the country, and for children in the wealthiest (Top 10 FIGURE 1 50 40 Benin: Stunting rates by subpopulations 37 38 36 36 36 35 34 Stunting rate 32 30 20 10 0 National Urban/Rural Wealth Education Empowerment Subpoplation groups National Rural Bottom 20% Not Educated Not Empowered Urban Top 20% Educated Empowered Source: Author estimates based on Benin 2012 DHS. Benin: Components of Adequate WASH Benin: Components of Adequate Health 62 Improved 72 77 Prenatals 55 72 water 84 42 64 82 88 Basic 13 86 5 81 sanitation 23 Assisted 93 1 72 37 98 Feces 11 51 4 46 disposal 21 Postnatal 59 1 42 34 63 OD <25% 29 45 5 43 in community 2 63 Vaccinations 49 72 39 51 Handwash 8 79 5 78 facilities 12 Nets 81 5 75 16 85 0 20 40 60 80 100 0 20 40 60 80 100 Percentage of children who meet criteria Percentage of children who meet criteria National Rural Urban Bottom 20% Top 20% National Rural Urban Bottom 20% Top 20% Source: Author estimates based on Benin 2012 DHS. Source: Author estimates based on Benin 2012 DHS. Note: *Based on all households in the child's PSU. 11 FIGURE 2 Percentage of children adequate in Nationa Rural Urban l None 20 26 12 Food/Care 4 5 2 WASH 1 1 1 Health 47 49 44 Food/Care & WASH 0 0 1 Food/Care & Health 16 17 15 WASH & Health 9 2 19 All 3 3 1 6 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 12 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 13 14 Burkina Faso: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Burkina Faso using data for children between 0 able not only to address the key underlying and 23 months of age, from the 2010 determinants of nutrition effectively, but also Demographic and Health Survey (DHS). The contribute to enhancing the impacts of UNICEF (1990) conceptual framework views “nutrition-specific� interventions (Black et al., undernutrition as the consequence of a variety 2013). of interlinked factors. The causes of undernutrition are classified into three The effectiveness and ultimate success of hierarchical categories: (i) the immediate nutrition-sensitive interventions in different causes, (ii) the underlying causes, and (iii) the sectors towards reducing stunting depends on basic causes of undernutrition. In any given having a more holistic view of the inequities and context identification of the immediate causes gaps in access to adequate levels of the of undernutrition—disease or inadequate underlying determinants of nutrition typically dietary intake—is useful for guiding policy addressed by nutrition-sensitive interventions actions especially in situations of crises. In in: Food and Care, Health and Environment. The general, however, disease and inadequate interdependencies among the underlying dietary intake are typically consequences of a determinants of nutrition are usually beyond variety of underlying drivers that are the consideration of any given sector. The interrelated. integration of nutrition-related objectives in The variety of underlying causes of agricultural operations, for example, is unlikely undernutrition are grouped into three groups: 15 (a) inadequate household food security and country, and for children in the wealthiest (Top care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Burkina Faso: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and n.a. children are lacking access to adequate levels of these three drivers of undernutrition, independently (Figure 1) as well as simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the 16 FIGURE 1 Burkina Faso: Stunting rates by subpopulations 50 40 Stunting rate 31 30 27 26 26 25 23 20 19 17 11 10 0 National Urban/Rural Wealth Education Empowerment Subpoplation groups National Rural Bottom 20% Not Educated Not Empowered Urban Top 20% Educated Empowered Source: Author estimates based on Burkina Faso 2010 DHS. 17 FIGURE 2 Percentage of children adequate in National Rural Urban None 16 19 6 Food/Care 2 2 1 WASH 1 0 4 Health 63 67 43 Food/Care & WASH 0 0 1 Food/Care & Health 9 9 7 WASH & Health 8 2 33 All 3 1 0 6 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 18 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 19 20 Burundi: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Burundi using data for children between 0 and able not only to address the key underlying 23 months of age, from the 2016/2017 determinants of nutrition effectively, but also Demographic and Health Survey (DHS). The contribute to enhancing the impacts of UNICEF (1990) conceptual framework views “nutrition-specific� interventions (Black et al., undernutrition as the consequence of a variety 2013). of interlinked factors. The causes of undernutrition are classified into three The effectiveness and ultimate success of hierarchical categories: (i) the immediate nutrition-sensitive interventions in different causes, (ii) the underlying causes, and (iii) the sectors towards reducing stunting depends on basic causes of undernutrition. In any given having a more holistic view of the inequities and context identification of the immediate causes gaps in access to adequate levels of the of undernutrition—disease or inadequate underlying determinants of nutrition typically dietary intake—is useful for guiding policy addressed by nutrition-sensitive interventions actions especially in situations of crises. In in: Food and Care, Health, and Environment. general, however, disease and inadequate The interdependencies among the underlying dietary intake are typically consequences of a determinants of nutrition are usually beyond variety of underlying drivers that are the consideration of any given sector. The interrelated. integration of nutrition-related objectives in The variety of underlying causes of agricultural operations, for example, is unlikely undernutrition are grouped into three groups: 21 (a) inadequate household food security and country, and for children in the wealthiest (Top care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment, and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Burundi: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and n/a children are lacking access to adequate levels of these three drivers of undernutrition, independently (Figure 1) as well as simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the 22 FIGURE 1 23 FIGURE 2 Percentage of children adequate in National Rural Urban None 16 16 11 Food/Care 6 6 4 WASH 10 10 2 Health 22 22 19 Food/Care & WASH 3 3 3 Food/Care & Health 15 14 25 WASH & Health 18 18 19 All 3 11 10 17 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 24 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 25 26 Cameroon: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Cameroon using data for children between 0 able not only to address the key underlying and 23 months of age, from the 2011 determinants of nutrition effectively, but also Demographic and Health Survey (DHS). The contribute to enhancing the impacts of UNICEF (1990) conceptual framework views “nutrition-specific� interventions (Black et al., undernutrition as the consequence of a variety 2013). of interlinked factors. The causes of undernutrition are classified into three The effectiveness and ultimate success of hierarchical categories: (i) the immediate nutrition-sensitive interventions in different causes, (ii) the underlying causes, and (iii) the sectors towards reducing stunting depends on basic causes of undernutrition. In any given having a more holistic view of the inequities and context identification of the immediate causes gaps in access to adequate levels of the of undernutrition—disease or inadequate underlying determinants of nutrition typically dietary intake—is useful for guiding policy addressed by nutrition-sensitive interventions actions especially in situations of crises. In in: Food and Care, Health and Environment. The general, however, disease and inadequate interdependencies among the underlying dietary intake are typically consequences of a determinants of nutrition are usually beyond variety of underlying drivers that are the consideration of any given sector. The interrelated. integration of nutrition-related objectives in The variety of underlying causes of agricultural operations, for example, is unlikely undernutrition are grouped into three groups: 27 (a) inadequate household food security and country, and for children in the wealthiest (Top care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Cameroon: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and 1. Growth control information only available for children are lacking access to adequate levels of a smaller subset so excluded from the these three drivers of undernutrition, components independently (Figure 1) as well as simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the 28 FIGURE 1 29 FIGURE 2 Percentage of children adequate in National Rural Urban None 35 48 18 Food/Care 4 6 2 WASH 12 12 12 Health 24 22 27 Food/Care & WASH 2 2 2 Food/Care & Health 5 4 6 WASH & Health 16 6 29 All 3 3 1 6 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 4 components 30 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 4 components 31 32 Chad: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Chad using data for children between 0 and 23 able not only to address the key underlying months of age, from the 2014/2015 determinants of nutrition effectively, but also Demographic and Health Survey (DHS). The contribute to enhancing the impacts of UNICEF (1990) conceptual framework views “nutrition-specific� interventions (Black et al., undernutrition as the consequence of a variety 2013). of interlinked factors. The causes of undernutrition are classified into three The effectiveness and ultimate success of hierarchical categories: (i) the immediate nutrition-sensitive interventions in different causes, (ii) the underlying causes, and (iii) the sectors towards reducing stunting depends on basic causes of undernutrition. In any given having a more holistic view of the inequities and context identification of the immediate causes gaps in access to adequate levels of the of undernutrition—disease or inadequate underlying determinants of nutrition typically dietary intake—is useful for guiding policy addressed by nutrition-sensitive interventions actions especially in situations of crises. In in: Food and Care, Health, and Environment. general, however, disease and inadequate The interdependencies among the underlying dietary intake are typically consequences of a determinants of nutrition are usually beyond variety of underlying drivers that are the consideration of any given sector. The interrelated. integration of nutrition-related objectives in The variety of underlying causes of agricultural operations, for example, is unlikely undernutrition are grouped into three groups: 33 (a) inadequate household food security and adequate Food and Care, adequate care practices, (b) unhealthy household Environment (WASH), and adequate Health, environment (WASH), and (c) inadequate health among children 0-23 months of age, at the services. Adequate access to each of the three national level, for rural and urban areas in the underlying drivers is defined based on country, and for children in the wealthiest (Top internationally accepted standards. Access to 20%) and in the poorest (Bottom 20%) Food and Care is characterized as adequate if households. the child, depending on its age, consumes a Along similar lines, the panels in Figure 2 minimum acceptable diet (based on types of summarize the prevalence of simultaneous foods consumed and feeding frequency), access to none, only one, two, or all three of the whether breastfeeding was initiated within an drivers of nutrition. hour of birth, and whether the child is age appropriately breastfed at the time of the Figure 3 presents estimates of the extent to survey. Access to Adequate Environment is which access to only one, or simultaneous characterized by the access to at least three of access to two, or to all three of the underlying the five WASH components: (1) access to an drivers of nutrition is associated with better improved source of water for drinking, (2) nutritional outcomes (i.e., lower prevalence of access to basic sanitation in the dwelling, (3) stunting). This is done both visually (i.e. in terms access to proper children’s feces disposal, (4) of shift to the right in the density function of access to a hand washing station with soap, and height for age z-scores associated with access to (5) living in a community where less than 25 none or one or more of the drivers of nutrition) percent of the households openly defecate. and quantitatively (in terms of the marginal Access to health is characterized as adequate if decrease in the stunting rate relative to the the child adheres to at least three of the stunting rate prevailing among children with following five health components: (1) mother access to adequate level in none of the three used prenatal services at least four times while drivers of nutrition). pregnant, (2) child delivered by a skilled professional, (3) child received a postnatal The figures are accompanied by a series of check within two months of birth, (4) child is maps helpful for targeting nutrition specific and compliant with national vaccination schedule, nutrition sensitive interventions. The maps and (5) child sleeps under a mosquito net. summarize the prevalence of stunting rates, and access to adequate Food & Care, A necessary condition for guidance towards Environment, and Health, one at a time and effective multi-sectoral policies on Stunting, is simultaneously by region. knowledge on the extent to which infants and children are lacking access to adequate levels of these three drivers of undernutrition, Notes on Chad: independently (Figure 1) as well as simultaneously (Figure 2). The panels in Figure 1 summarize the n/a prevalence of access to the components of 34 FIGURE 1 35 FIGURE 2 Percentage of children adequate in National Rural Urban None 68 76 34 Food/Care 5 6 3 WASH 2 0 10 Health 20 17 34 Food/Care & WASH 0 0 0 Food/Care & Health 1 1 3 WASH & Health 3 0 16 All 3 0 0 1 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 36 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 37 38 Comoros: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Comoros using data for children between 0 and able not only to address the key underlying 23 months of age, from the 2012 Demographic determinants of nutrition effectively, but also and Health Survey (DHS). The UNICEF (1990) contribute to enhancing the impacts of conceptual framework views undernutrition as “nutrition-specific� interventions (Black et al., the consequence of a variety of interlinked 2013). factors. The causes of undernutrition are classified into three hierarchical categories: (i) The effectiveness and ultimate success of the immediate causes, (ii) the underlying nutrition-sensitive interventions in different causes, and (iii) the basic causes of sectors towards reducing stunting depends on undernutrition. In any given context having a more holistic view of the inequities and identification of the immediate causes of gaps in access to adequate levels of the undernutrition—disease or inadequate dietary underlying determinants of nutrition typically intake—is useful for guiding policy actions addressed by nutrition-sensitive interventions especially in situations of crises. In general, in: Food and Care, Health, and Environment. however, disease and inadequate dietary intake The interdependencies among the underlying are typically consequences of a variety of determinants of nutrition are usually beyond underlying drivers that are interrelated. the consideration of any given sector. The The variety of underlying causes of integration of nutrition-related objectives in undernutrition are grouped into three groups: agricultural operations, for example, is unlikely (a) inadequate household food security and 39 care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment, and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Comoros: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and n/a children are lacking access to adequate levels of these three drivers of undernutrition, independently (Figure 1) as well as simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the country, and for children in the wealthiest (Top 40 FIGURE 1 Comoros: Components of Adequate WASH Comoros: Components of Adequate Health 55 Improved 8286 Prenatals 55 57 water 93 41 81 66 86 Basic 27 86 23 83 sanitation 35 Assisted 95 27 66 38 96 Feces 17 35 15 32 disposal 24 Postnatal 43 20 23 20 40 OD <25% 100 70 100 70 in community 100 100 Vaccinations 68 100 57 75 Handwash 15 67 14 66 facilities 18 Nets 68 10 61 18 69 0 20 40 60 80 100 0 20 40 60 80 100 Percentage of children who meet criteria Percentage of children who meet criteria National Rural Urban Bottom 20% Top 20% National Rural Urban Bottom 20% Top 20% Source: Author estimates based on Comoros 2012 DHS. Source: Author estimates based on Comoros 2012 DHS. Note: *Based on all households in the child's PSU. 41 FIGURE 2 Percentage of children adequate in National Rural Urban None 17 19 13 Food/Care 1 1 0 WASH 8 9 6 Health 43 43 43 Food/Care & WASH 0 0 0 Food/Care & Health 6 6 4 WASH & Health 23 20 31 All 3 3 3 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 42 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 43 44 Congo: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Congo using data for children between 0 and 23 able not only to address the key underlying months of age, from the 2011/2012 determinants of nutrition effectively, but also Demographic and Health Survey (DHS). The contribute to enhancing the impacts of UNICEF (1990) conceptual framework views “nutrition-specific� interventions (Black et al., undernutrition as the consequence of a variety 2013). of interlinked factors. The causes of undernutrition are classified into three The effectiveness and ultimate success of hierarchical categories: (i) the immediate nutrition-sensitive interventions in different causes, (ii) the underlying causes, and (iii) the sectors towards reducing stunting depends on basic causes of undernutrition. In any given having a more holistic view of the inequities and context identification of the immediate causes gaps in access to adequate levels of the of undernutrition—disease or inadequate underlying determinants of nutrition typically dietary intake—is useful for guiding policy addressed by nutrition-sensitive interventions actions especially in situations of crises. In in: Food and Care, Health, and Environment. general, however, disease and inadequate The interdependencies among the underlying dietary intake are typically consequences of a determinants of nutrition are usually beyond variety of underlying drivers that are the consideration of any given sector. The interrelated. integration of nutrition-related objectives in The variety of underlying causes of agricultural operations, for example, is unlikely undernutrition are grouped into three groups: 45 (a) inadequate household food security and country, and for children in the wealthiest (Top care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment, and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Congo: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and 1. No feces disposal or handwashing children are lacking access to adequate levels of information so environment is based on having these three drivers of undernutrition, access to all three of improved water, basic independently (Figure 1) as well as sanitation and less than 25% of community simultaneously (Figure 2). using OD. The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the 46 FIGURE 1 47 FIGURE 2 Percentage of children adequate in National Rural Urban None 11 22 5 Food/Care 2 4 1 WASH 1 1 1 Health 68 59 74 Food/Care & WASH 0 0 0 Food/Care & Health 11 13 9 WASH & Health 6 2 8 All 3 1 0 2 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 3 components; Adequate Health: 3 of 5 components 48 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 3 components; Adequate Health: 3 of 5 components 49 50 Cote d’Ivoire: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Cote d’Ivoire using data for children between 0 able not only to address the key underlying and 23 months of age, from the 2011/2012 determinants of nutrition effectively, but also Demographic and Health Survey (DHS). The contribute to enhancing the impacts of UNICEF (1990) conceptual framework views “nutrition-specific� interventions (Black et al., undernutrition as the consequence of a variety 2013). of interlinked factors. The causes of undernutrition are classified into three The effectiveness and ultimate success of hierarchical categories: (i) the immediate nutrition-sensitive interventions in different causes, (ii) the underlying causes, and (iii) the sectors towards reducing stunting depends on basic causes of undernutrition. In any given having a more holistic view of the inequities and context identification of the immediate causes gaps in access to adequate levels of the of undernutrition—disease or inadequate underlying determinants of nutrition typically dietary intake—is useful for guiding policy addressed by nutrition-sensitive interventions actions especially in situations of crises. In in: Food and Care, Health and Environment. The general, however, disease and inadequate interdependencies among the underlying dietary intake are typically consequences of a determinants of nutrition are usually beyond variety of underlying drivers that are the consideration of any given sector. The interrelated. integration of nutrition-related objectives in The variety of underlying causes of agricultural operations, for example, is unlikely undernutrition are grouped into three groups: 51 (a) inadequate household food security and country, and for children in the wealthiest (Top care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Cote d’Ivoire: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and n.a. children are lacking access to adequate levels of these three drivers of undernutrition, independently (Figure 1) as well as simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the 52 FIGURE 1 53 FIGURE 2 Percentage of children adequate in National Rural Urban None 35 46 15 Food/Care 3 4 2 WASH 4 2 8 Health 41 39 43 Food/Care & WASH 0 0 0 Food/Care & Health 5 5 4 WASH & Health 11 3 24 All 3 2 0 4 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 54 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 55 56 DRC: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be DRC using data for children between 0 and 23 able not only to address the key underlying months of age, from the 2013 Demographic and determinants of nutrition effectively, but also Health Survey (DHS). The UNICEF (1990) contribute to enhancing the impacts of conceptual framework views undernutrition as “nutrition-specific� interventions (Black et al., the consequence of a variety of interlinked 2013). factors. The causes of undernutrition are classified into three hierarchical categories: (i) The effectiveness and ultimate success of the immediate causes, (ii) the underlying nutrition-sensitive interventions in different causes, and (iii) the basic causes of sectors towards reducing stunting depends on undernutrition. In any given context having a more holistic view of the inequities and identification of the immediate causes of gaps in access to adequate levels of the undernutrition—disease or inadequate dietary underlying determinants of nutrition typically intake—is useful for guiding policy actions addressed by nutrition-sensitive interventions especially in situations of crises. In general, in: Food and Care, Health, and Environment. however, disease and inadequate dietary intake The interdependencies among the underlying are typically consequences of a variety of determinants of nutrition are usually beyond underlying drivers that are interrelated. the consideration of any given sector. The The variety of underlying causes of integration of nutrition-related objectives in undernutrition are grouped into three groups: agricultural operations, for example, is unlikely (a) inadequate household food security and 57 care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment, and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on DRC: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and n/a children are lacking access to adequate levels of these three drivers of undernutrition, independently (Figure 1) as well as simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the country, and for children in the wealthiest (Top 58 FIGURE 1 DRC: Stunting rates by subpopulations 50 40 Stunting rate 32 32 30 29 30 28 28 23 21 20 18 10 0 National Urban/Rural Wealth Education Empowerment Subpoplation groups National Rural Bottom 20% Not Educated Not Empowered Urban Top 20% Educated Empowered Source: Author estimates based on DRC 2013 DHS. DRC: Components of Adequate WASH DRC: Components of Adequate Health Improved 31 47 47 82 41 water 27 Prenatals 59 84 39 59 Basic 17 84 17 78 sanitation 17 Assisted 96 20 76 16 98 Feces 14 16 14 14 disposal 15 Postnatal 22 17 26 13 21 OD <25% 79 47 71 41 in community 83 97 Vaccinations 62 94 42 3 68 Handwash 1 63 facilities 7 62 1 Nets 64 7 71 63 0 20 40 60 80 100 Percentage of children who meet criteria 0 20 40 60 80 100 Percentage of children who meet criteria National Rural Urban Bottom 20% Top 20% National Rural Urban Bottom 20% Top 20% Source: Author estimates based on DRC 2013 DHS. Note: *Based on all households in the child's PSU. Source: Author estimates based on DRC 2013 DHS. 59 FIGURE 2 Percentage of children adequate in National Rural Urban None 31 36 19 Food/Care 10 11 6 WASH 5 5 4 Health 31 27 39 Food/Care & WASH 1 1 1 Food/Care & Health 14 13 16 WASH & Health 7 5 11 All 3 3 2 4 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 60 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 61 62 Ethiopia: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of malnutrition in interventions in these sectors will have to be Ethiopia using data for children between 0 and able not only to address the key underlying 23 months of age, from the 2016 Demographic determinants of nutrition effectively, but also and Health Survey (DHS). The UNICEF (1990) contribute to enhancing the impacts of conceptual framework views malnutrition as “nutrition-specific� interventions (Black et al., the consequence of a variety of interlinked 2013). factors. The causes of malnutrition are classified into three hierarchical categories: (i) the The effectiveness and ultimate success of immediate causes, (ii) the underlying causes, nutrition-sensitive interventions in different and (iii) the basic causes of malnutrition. In any sectors towards reducing stunting depends on given context identification of the immediate having a more holistic view of the inequities and causes of malnutrition—disease or inadequate gaps in access to adequate levels of the dietary intake—is useful for guiding policy underlying determinants of nutrition typically actions especially in situations of crises. In addressed by nutrition-sensitive interventions general, however, disease and inadequate in: Food and Care, Health, and Environment. dietary intake are typically consequences of a The interdependencies among the underlying variety of underlying drivers that are determinants of nutrition are usually beyond interrelated. the consideration of any given sector. The The variety of underlying causes of malnutrition integration of nutrition-related objectives in are grouped into three groups: (a) inadequate agricultural operations, for example, is unlikely household food security and care practices, (b) 63 unhealthy household environment (WASH), and 20%) and in the poorest (Bottom 20%) (c) inadequate health services. Adequate households. access to each of the three underlying drivers is Along similar lines, the panels in Figure 2 defined based on internationally accepted summarize the prevalence of simultaneous standards. Access to Food and Care is access to none, only one, two, or all three of the characterized as adequate if the child, drivers of nutrition. depending on its age, consumes a minimum acceptable diet (based on types of foods Figure 3 presents estimates of the extent to consumed and feeding frequency), whether which access to only one, or simultaneous breastfeeding was initiated within an hour of access to two, or to all three of the underlying birth, and whether the child is age appropriately drivers of nutrition is associated with better breastfed at the time of the survey. Access to nutritional outcomes (i.e., lower prevalence of Adequate Environment is characterized by the stunting). This is done both visually (i.e. in terms access to at least three of the five WASH of shift to the right in the density function of components: (1) access to an improved source height for age z-scores associated with access to of water for drinking, (2) access to basic none or one or more of the drivers of nutrition) sanitation in the dwelling, (3) access to proper and quantitatively (in terms of the marginal children’s feces disposal, (4) access to a hand decrease in the stunting rate relative to the washing station with soap, and (5) living in a stunting rate prevailing among children with community where less than 25 percent of the access to adequate level in none of the three households openly defecate. Access to health drivers of nutrition). is characterized as adequate if the child adheres to at least three of the following five health The figures are accompanied by a series of components: (1) mother used prenatal services maps helpful for targeting nutrition specific and at least four times while pregnant, (2) child nutrition sensitive interventions. The maps delivered by a skilled professional, (3) child summarize the prevalence of stunting rates, received a postnatal check within two months and access to adequate Food & Care, of birth, (4) child is compliant with national Environment, and Health, one at a time and vaccination schedule, and (5) child sleeps under simultaneously by region in Ethiopia. a mosquito net. A necessary condition for guidance towards Notes on Ethiopia: effective multi-sectoral policies for the reduction of undernutrition, is knowledge on (1) No information on sleeping under the extent to which infants and children are mosquito nets, so component no included lacking access to adequate levels of these three in access to adequate health drivers of undernutrition, independently (Figure 1) as well as simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the country, and for children in the wealthiest (Top 64 FIGURE 1 65 FIGURE 2 Percentage of children adequate in National Rural Urban None 64 69 28 Food/Care 18 19 11 WASH 2 2 6 Health 8 6 22 Food/Care & WASH 1 1 2 Food/Care & Health 4 3 12 WASH & Health 2 0 11 All 3 1 0 9 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 4 components 66 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 4 components 67 68 Gabon: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Gabon using data for children between 0 and 23 able not only to address the key underlying months of age, from the 2012 Demographic and determinants of nutrition effectively, but also Health Survey (DHS). The UNICEF (1990) contribute to enhancing the impacts of conceptual framework views undernutrition as “nutrition-specific� interventions (Black et al., the consequence of a variety of interlinked 2013). factors. The causes of undernutrition are classified into three hierarchical categories: (i) The effectiveness and ultimate success of the immediate causes, (ii) the underlying nutrition-sensitive interventions in different causes, and (iii) the basic causes of sectors towards reducing stunting depends on undernutrition. In any given context having a more holistic view of the inequities and identification of the immediate causes of gaps in access to adequate levels of the undernutrition—disease or inadequate dietary underlying determinants of nutrition typically intake—is useful for guiding policy actions addressed by nutrition-sensitive interventions especially in situations of crises. In general, in: Food and Care, Health, and Environment. however, disease and inadequate dietary intake The interdependencies among the underlying are typically consequences of a variety of determinants of nutrition are usually beyond underlying drivers that are interrelated. the consideration of any given sector. The The variety of underlying causes of integration of nutrition-related objectives in undernutrition are grouped into three groups: agricultural operations, for example, is unlikely (a) inadequate household food security and 69 care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment, and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Gabon: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and 1. No information on handwashing facilities children are lacking access to adequate levels of and feces disposal, so not included as these three drivers of undernutrition, components of WASH independently (Figure 1) as well as simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the country, and for children in the wealthiest (Top 70 FIGURE 1 50 40 Gabon: Stunting rates by subpopulations Stunting rate 33 30 25 20 20 15 16 13 14 12 10 7 0 National Urban/Rural Wealth Education Empowerment Subpoplation groups National Rural Bottom 20% Not Educated Not Empowered Urban Top 20% Educated Empowered Source: Author estimates based on Gabon 2012 DHS. Gabon: Components of Adequate WASH Gabon: Components of Adequate Health 77 91 57 59 Prenatals 80 Improved 43 97 83 water 61 92 98 73 Assisted 95 62 33 97 Basic 11 54 37 43 sanitation Postnatal 56 1 36 61 53 25 98 24 Vaccinations 25 OD <25% 92 23 99 25 in community 90 59 60 100 Nets 59 56 52 0 20 40 60 80 100 Percentage of children who meet criteria 0 20 40 60 80 100 Percentage of children who meet criteria National Rural Urban Bottom 20% Top 20% National Rural Urban Bottom 20% Top 20% Source: Author estimates based on Gabon 2012 DHS. Note: *Based on all households in the child's PSU. Source: Author estimates based on Gabon 2012 DHS. 71 FIGURE 2 Percentage of children adequate in National Rural Urban None 21 39 17 Food/Care 1 3 1 WASH 6 2 6 Health 44 47 44 Food/Care & WASH 1 0 1 Food/Care & Health 4 3 4 WASH & Health 22 6 25 All 3 3 0 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 3 components; Adequate Health: 3 of 5 components 72 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 3 components; Adequate Health: 3 of 5 components 73 74 Gambia: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Gambia using data for children between 0 and able not only to address the key underlying 23 months of age, from the 2013 Demographic determinants of nutrition effectively, but also and Health Survey (DHS). The UNICEF (1990) contribute to enhancing the impacts of conceptual framework views undernutrition as “nutrition-specific� interventions (Black et al., the consequence of a variety of interlinked 2013). factors. The causes of undernutrition are classified into three hierarchical categories: (i) The effectiveness and ultimate success of the immediate causes, (ii) the underlying nutrition-sensitive interventions in different causes, and (iii) the basic causes of sectors towards reducing stunting depends on undernutrition. In any given context having a more holistic view of the inequities and identification of the immediate causes of gaps in access to adequate levels of the undernutrition—disease or inadequate dietary underlying determinants of nutrition typically intake—is useful for guiding policy actions addressed by nutrition-sensitive interventions especially in situations of crises. In general, in: Food and Care, Health, and Environment. however, disease and inadequate dietary intake The interdependencies among the underlying are typically consequences of a variety of determinants of nutrition are usually beyond underlying drivers that are interrelated. the consideration of any given sector. The The variety of underlying causes of integration of nutrition-related objectives in undernutrition are grouped into three groups: agricultural operations, for example, is unlikely (a) inadequate household food security and 75 care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment, and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Gambia: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and 1. Post-natal checkup information only available children are lacking access to adequate levels of for about 40 percent of the children, therefore, these three drivers of undernutrition, health is based on 3 of 4 components, excluding independently (Figure 1) as well as postnatal checkup. simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the country, and for children in the wealthiest (Top 76 FIGURE 1 Gambia: Stunting rates by subpopulations 50 40 Stunting rate 30 23 24 22 20 20 20 19 15 14 14 10 0 National Urban/Rural Wealth Education Empowerment Subpoplation groups National Rural Bottom 20% Not Educated Not Empowered Urban Top 20% Educated Empowered Source: Author estimates based on Gambia 2013 DHS. Gambia: Components of Adequate WASH Gambia: Components of Adequate Health Improved 83 89 79 80 water 96 Prenatals 77 81 79 98 89 Basic 37 67 30 49 sanitation 45 Assisted 88 20 44 68 87 Feces 26 73 27 75 disposal 25 Postnatal* 68 18 74 39 65 OD <25% 98 84 96 90 95 100 in community Vaccinations 78 89 100 81 Handwash 3 56 1 50 facilities 6 Nets 62 1 57 13 52 0 20 40 60 80 100 0 20 40 60 80 100 Percentage of children who meet criteria Percentage of children who meet criteria National Rural Urban Bottom 20% Top 20% National Rural Urban Bottom 20% Top 20% Source: Author estimates based on Gambia 2013 DHS. Source: Author estimates based on Gambia 2013 DHS. Note: *Based on all households in the child's PSU. Note: *Only for less than 50% of sample. Not used as a component. 77 FIGURE 2 Percentage of children adequate in National Rural Urban None 18 22 12 Food/Care 4 7 1 WASH 9 11 7 Health 29 28 30 Food/Care & WASH 3 2 4 Food/Care & Health 12 12 12 WASH & Health 18 13 25 All 3 6 4 9 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 4 components 78 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 4 components 79 80 Ghana: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Ghana using data for children between 0 and 23 able not only to address the key underlying months of age, from the 2014 Demographic and determinants of nutrition effectively, but also Health Survey (DHS). The UNICEF (1990) contribute to enhancing the impacts of conceptual framework views undernutrition as “nutrition-specific� interventions (Black et al., the consequence of a variety of interlinked 2013). factors. The causes of undernutrition are classified into three hierarchical categories: (i) The effectiveness and ultimate success of the immediate causes, (ii) the underlying nutrition-sensitive interventions in different causes, and (iii) the basic causes of sectors towards reducing stunting depends on undernutrition. In any given context having a more holistic view of the inequities and identification of the immediate causes of gaps in access to adequate levels of the undernutrition—disease or inadequate dietary underlying determinants of nutrition typically intake—is useful for guiding policy actions addressed by nutrition-sensitive interventions especially in situations of crises. In general, in: Food and Care, Health, and Environment. however, disease and inadequate dietary intake The interdependencies among the underlying are typically consequences of a variety of determinants of nutrition are usually beyond underlying drivers that are interrelated. the consideration of any given sector. The The variety of underlying causes of integration of nutrition-related objectives in undernutrition are grouped into three groups: agricultural operations, for example, is unlikely (a) inadequate household food security and 81 care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment, and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Ghana: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and n/a children are lacking access to adequate levels of these three drivers of undernutrition, independently (Figure 1) as well as simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the country, and for children in the wealthiest (Top 82 FIGURE 1 Ghana: Stunting rates by subpopulations 50 40 Stunting rate 30 20 20 18 13 14 13 11 12 10 7 8 0 National Urban/Rural Wealth Education Empowerment Subpoplation groups National Rural Bottom 20% Not Educated Not Empowered Urban Top 20% Educated Empowered Source: Author estimates based on Ghana 2014 DHS. Ghana: Components of Adequate WASH Ghana: Components of Adequate Health Improved 67 73 87 59 84 water 73 Prenatals 91 51 81 97 Basic 37 75 27 60 sanitation 49 Assisted 92 26 51 46 97 Feces 10 73 9 70 disposal 11 Postnatal 77 8 70 9 78 OD <25% 66 74 46 70 in community 35 90 Vaccinations 79 94 64 12 78 Handwash 7 51 facilities 18 58 1 Nets 43 27 55 38 0 20 40 60 80 100 Percentage of children who meet criteria 0 20 40 60 80 100 Percentage of children who meet criteria National Rural Urban Bottom 20% Top 20% National Rural Urban Bottom 20% Top 20% Source: Author estimates based on Ghana 2014 DHS. Note: *Based on all households in the child's PSU. Source: Author estimates based on Ghana 2014 DHS. 83 FIGURE 2 Percentage of children adequate in National Rural Urban None 9 14 3 Food/Care 3 4 2 WASH 2 3 2 Health 39 41 37 Food/Care & WASH 1 1 1 Food/Care & Health 21 22 19 WASH & Health 17 11 24 All 3 8 4 13 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 84 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 85 86 Guinea: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Guinea using data for children between 0 and able not only to address the key underlying 23 months of age, from the 2012 Demographic determinants of nutrition effectively, but also and Health Survey (DHS). The UNICEF (1990) contribute to enhancing the impacts of conceptual framework views undernutrition as “nutrition-specific� interventions (Black et al., the consequence of a variety of interlinked 2013). factors. The causes of undernutrition are classified into three hierarchical categories: (i) The effectiveness and ultimate success of the immediate causes, (ii) the underlying nutrition-sensitive interventions in different causes, and (iii) the basic causes of sectors towards reducing stunting depends on undernutrition. In any given context having a more holistic view of the inequities and identification of the immediate causes of gaps in access to adequate levels of the undernutrition—disease or inadequate dietary underlying determinants of nutrition typically intake—is useful for guiding policy actions addressed by nutrition-sensitive interventions especially in situations of crises. In general, in: Food and Care, Health, and Environment. however, disease and inadequate dietary intake The interdependencies among the underlying are typically consequences of a variety of determinants of nutrition are usually beyond underlying drivers that are interrelated. the consideration of any given sector. The The variety of underlying causes of integration of nutrition-related objectives in undernutrition are grouped into three groups: agricultural operations, for example, is unlikely (a) inadequate household food security and 87 care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment, and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Guinea: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and n/a children are lacking access to adequate levels of these three drivers of undernutrition, independently (Figure 1) as well as simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the country, and for children in the wealthiest (Top 88 FIGURE 1 Guinea: Stunting rates by subpopulations 50 40 Stunting rate 30 23 24 20 20 20 20 19 15 10 10 8 0 National Urban/Rural Wealth Education Empowerment Subpoplation groups National Rural Bottom 20% Not Educated Not Empowered Urban Top 20% Educated Empowered Source: Author estimates based on Guinea 2012 DHS. Guinea: Components of Adequate Health 56 48 Prenatals 77 42 76 40 25 Assisted 84 12 83 57 52 Postnatal 70 48 70 41 36 Vaccinations 53 34 55 34 34 Nets 36 34 32 0 20 40 60 80 100 Percentage of children who meet criteria National Rural Urban Bottom 20% Top 20% Source: Author estimates based on Guinea 2012 DHS. 89 FIGURE 2 Percentage of children adequate in National Rural Urban None 46 57 15 Food/Care 3 4 1 WASH 6 5 7 Health 29 25 40 Food/Care & WASH 1 0 1 Food/Care & Health 5 4 7 WASH & Health 10 5 26 All 3 1 0 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 90 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 91 92 Kenya: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Kenya using data for children between 0 and 23 able not only to address the key underlying months of age, from the 2014 Demographic and determinants of nutrition effectively, but also Health Survey (DHS). The UNICEF (1990) contribute to enhancing the impacts of conceptual framework views undernutrition as “nutrition-specific� interventions (Black et al., the consequence of a variety of interlinked 2013). factors. The causes of undernutrition are classified into three hierarchical categories: (i) The effectiveness and ultimate success of the immediate causes, (ii) the underlying nutrition-sensitive interventions in different causes, and (iii) the basic causes of sectors towards reducing stunting depends on undernutrition. In any given context having a more holistic view of the inequities and identification of the immediate causes of gaps in access to adequate levels of the undernutrition—disease or inadequate dietary underlying determinants of nutrition typically intake—is useful for guiding policy actions addressed by nutrition-sensitive interventions especially in situations of crises. In general, in: Food and Care, Health, and Environment. however, disease and inadequate dietary intake The interdependencies among the underlying are typically consequences of a variety of determinants of nutrition are usually beyond underlying drivers that are interrelated. the consideration of any given sector. The The variety of underlying causes of integration of nutrition-related objectives in undernutrition are grouped into three groups: agricultural operations, for example, is unlikely (a) inadequate household food security and 93 care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment, and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Kenya: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and 1. Only have dietary diversity information for 58 children are lacking access to adequate levels of percent of the sample. these three drivers of undernutrition, 2. Postnatal checkup for 47 percent of the independently (Figure 1) as well as simultaneously (Figure 2). children. Not used as a component of health. The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the country, and for children in the wealthiest (Top 94 FIGURE 1 Kenya: Stunting rates by subpopulations 50 40 Stunting rate 30 28 28 24 22 22 20 20 18 14 10 0 National Urban/Rural Wealth Education Empowerment Subpoplation groups National Rural Bottom 20% Not Educated Not Empowered Urban Top 20% Educated Empowered Source: Author estimates based on Kenya 2014 DHS. Kenya: Components of Adequate WASH Kenya: Components of Adequate Health Improved 54 63 55 82 49 water 43 Prenatals 66 84 43 20 72 Basic 16 66 sanitation 27 55 8 40 Assisted 86 15 35 Feces 14 94 disposal 18 7 72 26 68 OD <25% 80 Vaccinations 79 71 54 in community 44 97 83 99 66 Handwash 12 62 8 Nets 73 facilities 22 49 3 76 29 0 20 40 60 80 100 0 20 40 60 80 100 Percentage of children who meet criteria Percentage of children who meet criteria National Rural Urban Bottom 20% Top 20% National Rural Urban Bottom 20% Top 20% Source: Author estimates based on Kenya 2014 DHS. Source: Author estimates based on Kenya 2014 DHS. Note: *Based on all households in the child's PSU. Note: *Only collected for subsample of children, not included as a component. 95 FIGURE 2 Percentage of children adequate in National Rural Urban None 28 36 12 Food/Care 8 10 5 WASH 4 4 2 Health 28 27 31 Food/Care & WASH 3 2 3 Food/Care & Health 15 12 20 WASH & Health 9 6 16 All 3 5 3 10 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 4 components 96 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 4 components 97 98 Lesotho: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Lesotho using data for children between 0 and able not only to address the key underlying 23 months of age, from the 2014 Demographic determinants of nutrition effectively, but also and Health Survey (DHS). The UNICEF (1990) contribute to enhancing the impacts of conceptual framework views undernutrition as “nutrition-specific� interventions (Black et al., the consequence of a variety of interlinked 2013). factors. The causes of undernutrition are classified into three hierarchical categories: (i) The effectiveness and ultimate success of the immediate causes, (ii) the underlying nutrition-sensitive interventions in different causes, and (iii) the basic causes of sectors towards reducing stunting depends on undernutrition. In any given context having a more holistic view of the inequities and identification of the immediate causes of gaps in access to adequate levels of the undernutrition—disease or inadequate dietary underlying determinants of nutrition typically intake—is useful for guiding policy actions addressed by nutrition-sensitive interventions especially in situations of crises. In general, in: Food and Care, Health, and Environment. however, disease and inadequate dietary intake The interdependencies among the underlying are typically consequences of a variety of determinants of nutrition are usually beyond underlying drivers that are interrelated. the consideration of any given sector. The The variety of underlying causes of integration of nutrition-related objectives in undernutrition are grouped into three groups: agricultural operations, for example, is unlikely (a) inadequate household food security and 99 care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment, and Health, one at a time and compliant with national vaccination schedule, simultaneously by region in Lesotho. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Lesotho: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and 1. Handwash facilities available for only 50 children are lacking access to adequate levels of children (out of 600+) so not included in the these three drivers of undernutrition, WASH determinant independently (Figure 1) as well as simultaneously (Figure 2). 2. No information on mosquito nets so not included in the health determinant. The panels in Figure 1 summarize the prevalence of access to the components of 3. Small sample, only 547 observations. adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the country, and for children in the wealthiest (Top 100 FIGURE 1 Lesotho: Stunting rates by subpopulations 50 40 35 Stunting rate 30 30 27 28 25 22 23 20 20 11 10 0 National Urban/Rural Wealth Education Empowerment Subpoplation groups National Rural Bottom 20% Not Educated Not Empowered Urban Top 20% Educated Empowered Source: Author estimates based on Lesotho 2014 DHS. Lesotho: Components of Adequate WASH Lesotho: Components of Adequate Health 79 73 Improved 74 72 water 94 Prenatals 79 61 64 89 92 49 83 Basic 51 80 sanitation 44 Assisted 94 29 67 59 98 39 80 Feces 40 80 disposal 36 Postnatal 80 16 48 63 81 57 OD <25% 45 78 in community 96 76 26 Vaccinations 85 94 63 82 0 20 40 60 80 100 Percentage of children who meet criteria 0 20 40 60 80 100 Percentage of children who meet criteria National Rural Urban Bottom 20% Top 20% National Rural Urban Bottom 20% Top 20% Source: Author estimates based on Lesotho 2014 DHS. Note: *Based on all households in the child's PSU. Source: Author estimates based on Lesotho 2014 DHS. 101 FIGURE 2 Percentage of children adequate in National Rural Urban None 11 13 6 Food/Care 3 3 2 WASH 5 6 4 Health 31 31 33 Food/Care & WASH 2 3 0 Food/Care & Health 13 12 16 WASH & Health 26 24 33 All 3 9 10 5 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 4 components; Adequate Health: 3 of 4 components 102 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 4 components; Adequate Health: 3 of 4 components 103 104 Liberia: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Liberia using data for children between 0 and 23 able not only to address the key underlying months of age, from the 2013 Demographic and determinants of nutrition effectively, but also Health Survey (DHS). The UNICEF (1990) contribute to enhancing the impacts of conceptual framework views undernutrition as “nutrition-specific� interventions (Black et al., the consequence of a variety of interlinked 2013). factors. The causes of undernutrition are classified into three hierarchical categories: (i) The effectiveness and ultimate success of the immediate causes, (ii) the underlying nutrition-sensitive interventions in different causes, and (iii) the basic causes of sectors towards reducing stunting depends on undernutrition. In any given context having a more holistic view of the inequities and identification of the immediate causes of gaps in access to adequate levels of the undernutrition—disease or inadequate dietary underlying determinants of nutrition typically intake—is useful for guiding policy actions addressed by nutrition-sensitive interventions especially in situations of crises. In general, in: Food and Care, Health, and Environment. however, disease and inadequate dietary intake The interdependencies among the underlying are typically consequences of a variety of determinants of nutrition are usually beyond underlying drivers that are interrelated. the consideration of any given sector. The The variety of underlying causes of integration of nutrition-related objectives in undernutrition are grouped into three groups: agricultural operations, for example, is unlikely (a) inadequate household food security and 105 care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment, and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Liberia: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and 1. Red palm oil considered a vitamin A rich food children are lacking access to adequate levels of these three drivers of undernutrition, independently (Figure 1) as well as simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the country, and for children in the wealthiest (Top 106 FIGURE 1 Liberia: Stunting rates by subpopulations 50 40 Stunting rate 30 24 25 23 21 21 20 20 19 20 18 10 0 National Urban/Rural Wealth Education Empowerment Subpoplation groups National Rural Bottom 20% Not Educated Not Empowered Urban Top 20% Educated Empowered Source: Author estimates based on Liberia 2013 DHS. Liberia: Components of Adequate WASH Liberia: Components of Adequate Health Improved 59 71 80 82 75 water 56 Prenatals 85 80 68 86 Basic 12 66 4 56 sanitation 19 Assisted 75 3 46 33 85 Feces 5 68 2 65 disposal 8 Postnatal 72 1 69 15 70 OD <25% 34 59 4 56 in community 4 64 Vaccinations 62 71 47 66 Handwash 1 1 44 1 facilities 0 45 1 Nets 43 40 38 0 20 40 60 80 100 Percentage of children who meet criteria 0 20 40 60 80 100 Percentage of children who meet criteria National Rural Urban Bottom 20% Top 20% National Rural Urban Bottom 20% Top 20% Source: Author estimates based on Liberia 2013 DHS. Note: *Based on all households in the child's PSU. Source: Author estimates based on Liberia 2013 DHS. 107 FIGURE 2 Percentage of children adequate in National Rural Urban None 22 28 15 Food/Care 6 8 4 WASH 1 0 2 Health 48 43 52 Food/Care & WASH 0 0 0 Food/Care & Health 17 19 16 WASH & Health 6 1 10 All 3 1 1 1 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 108 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 109 110 Madagascar: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of malnutrition in interventions in these sectors will have to be Madagascar using data for children between 0 able not only to address the key underlying and 23 months of age, from the 2008/2009 determinants of nutrition effectively, but also Demographic and Health Survey (DHS). The contribute to enhancing the impacts of UNICEF (1990) conceptual framework views “nutrition-specific� interventions (Black et al., malnutrition as the consequence of a variety of 2013). interlinked factors. The causes of malnutrition are classified into three hierarchical categories: The effectiveness and ultimate success of (i) the immediate causes, (ii) the underlying nutrition-sensitive interventions in different causes, and (iii) the basic causes of sectors towards reducing stunting depends on malnutrition. In any given context having a more holistic view of the inequities and identification of the immediate causes of gaps in access to adequate levels of the malnutrition—disease or inadequate dietary underlying determinants of nutrition typically intake—is useful for guiding policy actions addressed by nutrition-sensitive interventions especially in situations of crises. In general, in: Food and Care, Health, and Environment. however, disease and inadequate dietary intake The interdependencies among the underlying are typically consequences of a variety of determinants of nutrition are usually beyond underlying drivers that are interrelated. the consideration of any given sector. The The variety of underlying causes of malnutrition integration of nutrition-related objectives in are grouped into three groups: (a) inadequate agricultural operations, for example, is unlikely household food security and care practices, (b) 111 unhealthy household environment (WASH), and 20%) and in the poorest (Bottom 20%) (c) inadequate health services. Adequate households. access to each of the three underlying drivers is Along similar lines, the panels in Figure 2 defined based on internationally accepted summarize the prevalence of simultaneous standards. Access to Food and Care is access to none, only one, two, or all three of the characterized as adequate if the child, drivers of nutrition. depending on its age, consumes a minimum acceptable diet (based on types of foods Figure 3 presents estimates of the extent to consumed and feeding frequency), whether which access to only one, or simultaneous breastfeeding was initiated within an hour of access to two, or to all three of the underlying birth, and whether the child is age appropriately drivers of nutrition is associated with better breastfed at the time of the survey. Access to nutritional outcomes (i.e., lower prevalence of Adequate Environment is characterized by the stunting). This is done both visually (i.e. in terms access to at least three of the five WASH of shift to the right in the density function of components: (1) access to an improved source height for age z-scores associated with access to of water for drinking, (2) access to basic none or one or more of the drivers of nutrition) sanitation in the dwelling, (3) access to proper and quantitatively (in terms of the marginal children’s feces disposal, (4) access to a hand decrease in the stunting rate relative to the washing station with soap, and (5) living in a stunting rate prevailing among children with community where less than 25 percent of the access to adequate level in none of the three households openly defecate. Access to health drivers of nutrition). is characterized as adequate if the child adheres to at least three of the following five health The figures are accompanied by a series of components: (1) mother used prenatal services maps helpful for targeting nutrition specific and at least four times while pregnant, (2) child nutrition sensitive interventions. The maps delivered by a skilled professional, (3) child summarize the prevalence of stunting rates, received a postnatal check within two months and access to adequate Food & Care, of birth, (4) child is compliant with national Environment, and Health, one at a time and vaccination schedule, and (5) child sleeps under simultaneously by region in Madagascar. a mosquito net. A necessary condition for guidance towards Notes on Madagascar: effective multi-sectoral policies for the reduction of undernutrition, is knowledge on n/a the extent to which infants and children are lacking access to adequate levels of these three drivers of undernutrition, independently (Figure 1) as well as simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the country, and for children in the wealthiest (Top 112 FIGURE 1 50 Madagascar: Stunting rates by subpopulations Madagascar: Components of Adequate Food/Care 16 44 44 Minimum 15 43 43 43 41 41 Acceptable 20 40 38 Diet 14 36 19 Stunting rate 30 79 Immediate 79 breastfeeding 82 79 20 80 76 10 Appropriate 76 breastfeeding 74 75 74 0 National Urban/Rural Wealth Education Empowerment Subpoplation groups 0 20 40 60 80 100 Percentage of children who meet criteria National Rural Bottom 20% Not Educated Not Empowered National Rural Urban Bottom 20% Top 20% Urban Top 20% Educated Empowered Source: Author estimates based on Madagascar 2009 DHS. Source: Author estimates based on Madagascar 2009 DHS. Note: *Exclusive for first 6 months and complementary 6 months to 23 months. Madagascar: Components of Adequate WASH Madagascar: Components of Adequate Health Improved 34 45 28 43 water 87 Prenatals 65 17 35 87 78 Basic 11 41 45 sanitation 0 7 Assisted 26 82 9 92 Feces 0 1 44 43 disposal 0 5 Postnatal 55 8 40 41 58 OD <25% 36 49 in community 85 47 26 Vaccinations 66 85 38 32 76 Handwash 29 53 facilities 52 52 18 Nets 68 67 47 74 0 20 40 60 80 100 Percentage of children who meet criteria 0 20 40 60 80 100 Percentage of children who meet criteria National Rural Urban Bottom 20% Top 20% National Rural Urban Bottom 20% Top 20% Source: Author estimates based on Madagascar 2009 DHS. Note: *Based on all households in the child's PSU. Source: Author estimates based on Madagascar 2009 DHS. 113 FIGURE 2 Madagascar: Adequate Access to Nutrition Drivers Madagascar: Simultaneous Access to Nutrition Drivers Percentage of children adequate in National, in 2009 National Rural Urban 100 2 None 43 47 12 Percentage of children who meet criteria 16 80 Food/Care 7 8 4 43 WASH 2 2 4 60 47 Health 30 30 28 40 39 Food/Care & WASH 1 0 1 16 20 13 Food/Care & Health 7 7 8 WASH & Health 9 6 34 0 Food/Care WASH Health Source: Author estimates based on Madagascar 2009 DHS. Zero One Two Three All 3 2 1 9 Source: Author estimates based on Madagascar 2009 DHS. Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 114 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 115 116 Malawi: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of malnutrition in interventions in these sectors will have to be Malawi using data for children between 0 and able not only to address the key underlying 23 months of age, from the 2016 Demographic determinants of nutrition effectively, but also and Health Survey (DHS). The UNICEF (1990) contribute to enhancing the impacts of conceptual framework views malnutrition as “nutrition-specific� interventions (Black et al., the consequence of a variety of interlinked 2013). factors. The causes of malnutrition are classified into three hierarchical categories: (i) the The effectiveness and ultimate success of immediate causes, (ii) the underlying causes, nutrition-sensitive interventions in different and (iii) the basic causes of malnutrition. In any sectors towards reducing stunting depends on given context identification of the immediate having a more holistic view of the inequities and causes of malnutrition—disease or inadequate gaps in access to adequate levels of the dietary intake—is useful for guiding policy underlying determinants of nutrition typically actions especially in situations of crises. In addressed by nutrition-sensitive interventions general, however, disease and inadequate in: Food and Care, Health, and Environment. dietary intake are typically consequences of a The interdependencies among the underlying variety of underlying drivers that are determinants of nutrition are usually beyond interrelated. the consideration of any given sector. The The variety of underlying causes of malnutrition integration of nutrition-related objectives in are grouped into three groups: (a) inadequate agricultural operations, for example, is unlikely household food security and care practices, (b) 117 unhealthy household environment (WASH), and 20%) and in the poorest (Bottom 20%) (c) inadequate health services. Adequate households. access to each of the three underlying drivers is Along similar lines, the panels in Figure 2 defined based on internationally accepted summarize the prevalence of simultaneous standards. Access to Food and Care is access to none, only one, two, or all three of the characterized as adequate if the child, drivers of nutrition. depending on its age, consumes a minimum acceptable diet (based on types of foods Figure 3 presents estimates of the extent to consumed and feeding frequency), whether which access to only one, or simultaneous breastfeeding was initiated within an hour of access to two, or to all three of the underlying birth, and whether the child is age appropriately drivers of nutrition is associated with better breastfed at the time of the survey. Access to nutritional outcomes (i.e., lower prevalence of Adequate Environment is characterized by the stunting). This is done both visually (i.e. in terms access to at least three of the five WASH of shift to the right in the density function of components: (1) access to an improved source height for age z-scores associated with access to of water for drinking, (2) access to basic none or one or more of the drivers of nutrition) sanitation in the dwelling, (3) access to proper and quantitatively (in terms of the marginal children’s feces disposal, (4) access to a hand decrease in the stunting rate relative to the washing station with soap, and (5) living in a stunting rate prevailing among children with community where less than 25 percent of the access to adequate level in none of the three households openly defecate. Access to health drivers of nutrition). is characterized as adequate if the child adheres to at least three of the following five health The figures are accompanied by a series of components: (1) mother used prenatal services maps helpful for targeting nutrition specific and at least four times while pregnant, (2) child nutrition sensitive interventions. The maps delivered by a skilled professional, (3) child summarize the prevalence of stunting rates, received a postnatal check within two months and access to adequate Food & Care, of birth, (4) child is compliant with national Environment, and Health, one at a time and vaccination schedule, and (5) child sleeps under simultaneously by region in Malawi. a mosquito net. A necessary condition for guidance towards Notes on Malawi: effective multi-sectoral policies for the reduction of undernutrition, is knowledge on n/a the extent to which infants and children are lacking access to adequate levels of these three drivers of undernutrition, independently (Figure 1) as well as simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the country, and for children in the wealthiest (Top 118 FIGURE 1 119 FIGURE 2 Percentage of children adequate in National Rural Urban None 12 12 11 Food/Care 2 2 2 WASH 11 12 6 Health 25 25 26 Food/Care & WASH 3 3 1 Food/Care & Health 11 10 20 WASH & Health 25 26 22 All 3 11 11 13 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 120 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 121 122 Mali: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Mali using data for children between 0 and 23 able not only to address the key underlying months of age, from the 2012/2013 determinants of nutrition effectively, but also Demographic and Health Survey (DHS). The contribute to enhancing the impacts of UNICEF (1990) conceptual framework views “nutrition-specific� interventions (Black et al., undernutrition as the consequence of a variety 2013). of interlinked factors. The causes of undernutrition are classified into three The effectiveness and ultimate success of hierarchical categories: (i) the immediate nutrition-sensitive interventions in different causes, (ii) the underlying causes, and (iii) the sectors towards reducing stunting depends on basic causes of undernutrition. In any given having a more holistic view of the inequities and context identification of the immediate causes gaps in access to adequate levels of the of undernutrition—disease or inadequate underlying determinants of nutrition typically dietary intake—is useful for guiding policy addressed by nutrition-sensitive interventions actions especially in situations of crises. In in: Food and Care, Health and Environment. The general, however, disease and inadequate interdependencies among the underlying dietary intake are typically consequences of a determinants of nutrition are usually beyond variety of underlying drivers that are the consideration of any given sector. The interrelated. integration of nutrition-related objectives in The variety of underlying causes of agricultural operations, for example, is unlikely undernutrition are grouped into three groups: 123 (a) inadequate household food security and country, and for children in the wealthiest (Top care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Mali: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and n.a. children are lacking access to adequate levels of these three drivers of undernutrition, independently (Figure 1) as well as simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the 124 FIGURE 1 125 FIGURE 2 Percentage of children adequate in National Rural Urban None 34 40 9 Food/Care 6 7 1 WASH 5 6 4 Health 32 32 31 Food/Care & WASH 1 1 1 Food/Care & Health 6 6 8 WASH & Health 12 7 38 All 3 3 2 9 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 126 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 127 128 Mozambique: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Mozambique using data for children between 0 able not only to address the key underlying and 23 months of age, from the 2011 determinants of nutrition effectively, but also Demographic and Health Survey (DHS). The contribute to enhancing the impacts of UNICEF (1990) conceptual framework views “nutrition-specific� interventions (Black et al., undernutrition as the consequence of a variety 2013). of interlinked factors. The causes of undernutrition are classified into three The effectiveness and ultimate success of hierarchical categories: (i) the immediate nutrition-sensitive interventions in different causes, (ii) the underlying causes, and (iii) the sectors towards reducing stunting depends on basic causes of undernutrition. In any given having a more holistic view of the inequities and context identification of the immediate causes gaps in access to adequate levels of the of undernutrition—disease or inadequate underlying determinants of nutrition typically dietary intake—is useful for guiding policy addressed by nutrition-sensitive interventions actions especially in situations of crises. In in: Food and Care, Health and Environment. The general, however, disease and inadequate interdependencies among the underlying dietary intake are typically consequences of a determinants of nutrition are usually beyond variety of underlying drivers that are the consideration of any given sector. The interrelated. integration of nutrition-related objectives in The variety of underlying causes of agricultural operations, for example, is unlikely undernutrition are grouped into three groups: 129 (a) inadequate household food security and country, and for children in the wealthiest (Top care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Mozambique: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and 1. Polio not given at birth in vaccination children are lacking access to adequate levels of schedule, but included in the measure as most these three drivers of undernutrition, children have followed 4 polio vaccination independently (Figure 1) as well as schedule. simultaneously (Figure 2). 2. No information on growth control visits so The panels in Figure 1 summarize the excluded from the health determinant. prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the 130 FIGURE 1 131 FIGURE 2 Percentage of children adequate in National Rural Urban None 38 46 17 Food/Care 13 15 7 WASH 5 3 9 Health 23 22 26 Food/Care & WASH 1 1 3 Food/Care & Health 8 7 10 WASH & Health 9 4 22 All 3 3 2 7 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 4 components 132 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 4 components 133 134 Namibia: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Nambia using data for children between 0 and able not only to address the key underlying 23 months of age, from the 2013 Demographic determinants of nutrition effectively, but also and Health Survey (DHS). The UNICEF (1990) contribute to enhancing the impacts of conceptual framework views undernutrition as “nutrition-specific� interventions (Black et al., the consequence of a variety of interlinked 2013). factors. The causes of undernutrition are classified into three hierarchical categories: (i) The effectiveness and ultimate success of the immediate causes, (ii) the underlying nutrition-sensitive interventions in different causes, and (iii) the basic causes of sectors towards reducing stunting depends on undernutrition. In any given context having a more holistic view of the inequities and identification of the immediate causes of gaps in access to adequate levels of the undernutrition—disease or inadequate dietary underlying determinants of nutrition typically intake—is useful for guiding policy actions addressed by nutrition-sensitive interventions especially in situations of crises. In general, in: Food and Care, Health, and Environment. however, disease and inadequate dietary intake The interdependencies among the underlying are typically consequences of a variety of determinants of nutrition are usually beyond underlying drivers that are interrelated. the consideration of any given sector. The The variety of underlying causes of integration of nutrition-related objectives in undernutrition are grouped into three groups: agricultural operations, for example, is unlikely (a) inadequate household food security and 135 care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment, and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Nambia: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and 1. The health determinant includes mosquito children are lacking access to adequate levels of nets. However, these are only used in northern these three drivers of undernutrition, regions, thus southern regions are effectively independently (Figure 1) as well as based on access to three of the other four simultaneously (Figure 2). components. The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the country, and for children in the wealthiest (Top 136 FIGURE 1 Namibia: Stunting rates by subpopulations 50 40 Stunting rate 30 24 20 19 19 16 14 13 12 12 10 10 0 National Urban/Rural Wealth Education Empowerment Subpoplation groups National Rural Bottom 20% Not Educated Not Empowered Urban Top 20% Educated Empowered Source: Author estimates based on Namibia 2013 DHS. Namibia: Components of Adequate WASH Namibia: Components of Adequate Health Improved 83 78 73 76 water 96 Prenatals 82 65 75 98 87 Basic 28 89 14 83 sanitation 46 Assisted 96 4 78 82 99 Feces 2 7 53 51 disposal 0 13 Postnatal 55 22 46 67 OD <25% 32 88 6 90 in community 2 65 Vaccinations 87 83 86 81 Handwash 42 9 28 10 facilities 60 Nets 8 19 13 71 10 0 20 40 60 80 100 0 20 40 60 80 100 Percentage of children who meet criteria Percentage of children who meet criteria National Rural Urban Bottom 20% Top 20% National Rural Urban Bottom 20% Top 20% Source: Author estimates based on Namibia 2013 DHS. Source: Author estimates based on Namibia 2013 DHS. Note: *Based on all households in the child's PSU. 137 FIGURE 2 Percentage of children adequate in National Rural Urban None 14 19 6 Food/Care 2 3 2 WASH 3 1 5 Health 43 55 26 Food/Care & WASH 1 1 2 Food/Care & Health 12 14 10 WASH & Health 19 6 38 All 3 6 2 13 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 138 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 139 140 Niger: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Niger using data for children between 0 and 23 able not only to address the key underlying months of age, from the 2012 Demographic and determinants of nutrition effectively, but also Health Survey (DHS). The UNICEF (1990) contribute to enhancing the impacts of conceptual framework views undernutrition as “nutrition-specific� interventions (Black et al., the consequence of a variety of interlinked 2013). factors. The causes of undernutrition are classified into three hierarchical categories: (i) The effectiveness and ultimate success of the immediate causes, (ii) the underlying nutrition-sensitive interventions in different causes, and (iii) the basic causes of sectors towards reducing stunting depends on undernutrition. In any given context having a more holistic view of the inequities and identification of the immediate causes of gaps in access to adequate levels of the undernutrition—disease or inadequate dietary underlying determinants of nutrition typically intake—is useful for guiding policy actions addressed by nutrition-sensitive interventions especially in situations of crises. In general, in: Food and Care, Health and Environment. The however, disease and inadequate dietary intake interdependencies among the underlying are typically consequences of a variety of determinants of nutrition are usually beyond underlying drivers that are interrelated. the consideration of any given sector. The The variety of underlying causes of integration of nutrition-related objectives in undernutrition are grouped into three groups: agricultural operations, for example, is unlikely (a) inadequate household food security and 141 care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Niger: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and 1. Information on the disposal of feces is children are lacking access to adequate levels of missing for ¾ of the sample, so adequate these three drivers of undernutrition, WASH does not include disposal independently (Figure 1) as well as component and is based on having at least three of the other four components. simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the country, and for children in the wealthiest (Top 142 FIGURE 1 143 FIGURE 2 Percentage of children adequate in National Rural Urban None 52 59 6 Food/Care 6 7 1 WASH 4 2 13 Health 23 24 13 Food/Care & WASH 1 0 4 Food/Care & Health 4 5 3 WASH & Health 8 2 47 All 3 2 1 13 Niger: Adequate Access to Nutrition Drivers Urban/Rural, in 2012 100 76 76 80 60 40 31 16 20 10 5 0 Rural Urban Food/Care WASH Health Source: Author estimates based on Niger 2012 DHS. Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 4 components; Adequate Health: 3 of 5 components 144 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 4 components; Adequate Health: 3 of 5 components 145 146 Nigeria: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Nigeria using data for children between 0 and able not only to address the key underlying 23 months of age, from the 2013 Demographic determinants of nutrition effectively, but also and Health Survey (DHS). The UNICEF (1990) contribute to enhancing the impacts of conceptual framework views undernutrition as “nutrition-specific� interventions (Black et al., the consequence of a variety of interlinked 2013). factors. The causes of undernutrition are classified into three hierarchical categories: (i) The effectiveness and ultimate success of the immediate causes, (ii) the underlying nutrition-sensitive interventions in different causes, and (iii) the basic causes of sectors towards reducing stunting depends on undernutrition. In any given context having a more holistic view of the inequities and identification of the immediate causes of gaps in access to adequate levels of the undernutrition—disease or inadequate dietary underlying determinants of nutrition typically intake—is useful for guiding policy actions addressed by nutrition-sensitive interventions especially in situations of crises. In general, in: Food and Care, Health and Environment. The however, disease and inadequate dietary intake interdependencies among the underlying are typically consequences of a variety of determinants of nutrition are usually beyond underlying drivers that are interrelated. the consideration of any given sector. The The variety of underlying causes of integration of nutrition-related objectives in undernutrition are grouped into three groups: agricultural operations, for example, is unlikely (a) inadequate household food security and 147 care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Nigeria: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and n.a. children are lacking access to adequate levels of these three drivers of undernutrition, independently (Figure 1) as well as simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the country, and for children in the wealthiest (Top 148 FIGURE 1 149 FIGURE 2 Percentage of children adequate in National Rural Urban None 43 55 20 Food/Care 6 7 4 WASH 15 16 14 Health 19 13 30 Food/Care & WASH 3 2 3 Food/Care & Health 5 3 9 WASH & Health 8 3 16 All 3 2 1 5 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 150 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 151 152 Rwanda: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Rwanda using data for children between 0 and able not only to address the key underlying 23 months of age, from the 2014/2015 determinants of nutrition effectively, but also Demographic and Health Survey (DHS). The contribute to enhancing the impacts of UNICEF (1990) conceptual framework views “nutrition-specific� interventions (Black et al., undernutrition as the consequence of a variety 2013). of interlinked factors. The causes of undernutrition are classified into three The effectiveness and ultimate success of hierarchical categories: (i) the immediate nutrition-sensitive interventions in different causes, (ii) the underlying causes, and (iii) the sectors towards reducing stunting depends on basic causes of undernutrition. In any given having a more holistic view of the inequities and context identification of the immediate causes gaps in access to adequate levels of the of undernutrition—disease or inadequate underlying determinants of nutrition typically dietary intake—is useful for guiding policy addressed by nutrition-sensitive interventions actions especially in situations of crises. In in: Food and Care, Health and Environment. The general, however, disease and inadequate interdependencies among the underlying dietary intake are typically consequences of a determinants of nutrition are usually beyond variety of underlying drivers that are the consideration of any given sector. The interrelated. integration of nutrition-related objectives in The variety of underlying causes of agricultural operations, for example, is unlikely undernutrition are grouped into three groups: 153 (a) inadequate household food security and country, and for children in the wealthiest (Top care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Rwanda: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and 1. Post-natal check-up information available children are lacking access to adequate levels of for only a subsample of children, and thus these three drivers of undernutrition, not used as a component of adequate health. independently (Figure 1) as well as simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the 154 FIGURE 1 155 FIGURE 2 Percentage of children adequate in National Rural Urban None 10 11 6 Food/Care 7 7 8 WASH 9 10 5 Health 17 15 25 Food/Care & WASH 7 8 5 Food/Care & Health 15 13 21 WASH & Health 18 19 17 All 3 17 18 15 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 4 components 156 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 4 components 157 158 Senegal: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Senegal using data for children between 0 and able not only to address the key underlying 23 months of age, from the 2015 Demographic determinants of nutrition effectively, but also and Health Survey (DHS). The UNICEF (1990) contribute to enhancing the impacts of conceptual framework views undernutrition as “nutrition-specific� interventions (Black et al., the consequence of a variety of interlinked 2013). factors. The causes of undernutrition are classified into three hierarchical categories: (i) The effectiveness and ultimate success of the immediate causes, (ii) the underlying nutrition-sensitive interventions in different causes, and (iii) the basic causes of sectors towards reducing stunting depends on undernutrition. In any given context having a more holistic view of the inequities and identification of the immediate causes of gaps in access to adequate levels of the undernutrition—disease or inadequate dietary underlying determinants of nutrition typically intake—is useful for guiding policy actions addressed by nutrition-sensitive interventions especially in situations of crises. In general, in: Food and Care, Health, and Environment. however, disease and inadequate dietary intake The interdependencies among the underlying are typically consequences of a variety of determinants of nutrition are usually beyond underlying drivers that are interrelated. the consideration of any given sector. The The variety of underlying causes of integration of nutrition-related objectives in undernutrition are grouped into three groups: agricultural operations, for example, is unlikely (a) inadequate household food security and 159 care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to Health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Senegal: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and n.a. children are lacking access to adequate levels of these three drivers of undernutrition, independently (Figure 1) as well as simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the country, and for children in the wealthiest (Top 160 FIGURE 1 Senegal: Stunting rates by subpopulations 50 40 Stunting rate 30 24 20 20 19 19 18 18 15 14 14 10 0 National Urban/Rural Wealth Education Empowerment Subpoplation groups National Rural Bottom 20% Not Educated Not Empowered Urban Top 20% Educated Empowered Source: Author estimates based on Senegal 2015 DHS. Senegal: Components of Adequate WASH Senegal: Components of Adequate Health Improved 64 70 40 47 water 84 Prenatals 60 51 29 84 60 Basic 43 54 34 44 sanitation 62 Assisted 73 3 32 83 75 Feces 35 84 30 78 disposal 47 Postnatal 95 2 60 69 96 OD <25% 70 66 56 60 in community 41 97 Vaccinations 76 95 50 15 79 Handwash 13 58 facilities 20 58 7 Nets 57 24 47 54 0 20 40 60 80 100 Percentage of children who meet criteria 0 20 40 60 80 100 Percentage of children who meet criteria National Rural Urban Bottom 20% Top 20% National Rural Urban Bottom 20% Top 20% Source: Author estimates based on Senegal 2015 DHS. Note: *Based on all households in the child's PSU. Source: Author estimates based on Senegal 2015 DHS. 161 FIGURE 2 Percentage of children adequate in National Rural Urban None 19 26 5 Food/Care 5 6 2 WASH 6 5 6 Health 29 30 26 Food/Care & WASH 1 1 0 Food/Care & Health 7 8 5 WASH & Health 26 17 45 All 3 8 7 11 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 162 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 163 164 Sierra Leone: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Sierra Leone using data for children between 0 able not only to address the key underlying and 23 months of age, from the 2013 determinants of nutrition effectively, but also Demographic and Health Survey (DHS). The contribute to enhancing the impacts of UNICEF (1990) conceptual framework views “nutrition-specific� interventions (Black et al., undernutrition as the consequence of a variety 2013). of interlinked factors. The causes of undernutrition are classified into three The effectiveness and ultimate success of hierarchical categories: (i) the immediate nutrition-sensitive interventions in different causes, (ii) the underlying causes, and (iii) the sectors towards reducing stunting depends on basic causes of undernutrition. In any given having a more holistic view of the inequities and context identification of the immediate causes gaps in access to adequate levels of the of undernutrition—disease or inadequate underlying determinants of nutrition typically dietary intake—is useful for guiding policy addressed by nutrition-sensitive interventions actions especially in situations of crises. In in: Food and Care, Health, and Environment. general, however, disease and inadequate The interdependencies among the underlying dietary intake are typically consequences of a determinants of nutrition are usually beyond variety of underlying drivers that are the consideration of any given sector. The interrelated. integration of nutrition-related objectives in The variety of underlying causes of agricultural operations, for example, is unlikely undernutrition are grouped into three groups: 165 (a) inadequate household food security and country, and for children in the wealthiest (Top care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment, and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Sierra Leone: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and n/a children are lacking access to adequate levels of these three drivers of undernutrition, independently (Figure 1) as well as simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the 166 FIGURE 1 Sierra Leone: Stunting rates by subpopulations 50 40 35 Stunting rate 32 33 32 32 31 30 30 28 28 20 10 0 National Urban/Rural Wealth Education Empowerment Subpoplation groups National Rural Bottom 20% Not Educated Not Empowered Urban Top 20% Educated Empowered Source: Author estimates based on Sierra Leone 2013 DHS. Sierra Leone: Components of Adequate WASH Sierra Leone: Components of Adequate Health Improved 45 54 87 79 86 water 38 Prenatals 91 79 85 9 92 Basic 6 61 sanitation 19 56 3 25 Assisted 79 55 7 82 Feces 4 70 disposal 14 70 2 Postnatal 69 19 66 OD <25% 59 66 75 in community 88 73 43 75 95 Vaccinations 69 7 75 Handwash 3 67 facilities 16 52 2 54 20 Nets 43 51 40 0 20 40 60 80 100 Percentage of children who meet criteria 0 20 40 60 80 100 Percentage of children who meet criteria National Rural Urban Bottom 20% Top 20% Source: Author estimates based on Sierra Leone 2013 DHS. National Rural Urban Bottom 20% Top 20% Note: *Based on all households in the child's PSU. Source: Author estimates based on Sierra Leone 2013 DHS. 167 FIGURE 2 Percentage of children adequate in National Rural Urban None 15 16 11 Food/Care 3 4 2 WASH 1 0 2 Health 57 60 51 Food/Care & WASH 0 0 0 Food/Care & Health 14 14 12 WASH & Health 8 5 19 All 3 1 1 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 168 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 169 170 Tanzania: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Tanzania using data for children between 0 and able not only to address the key underlying 23 months of age, from the 2015/2016 determinants of nutrition effectively, but also Demographic and Health Survey (DHS). The contribute to enhancing the impacts of UNICEF (1990) conceptual framework views “nutrition-specific� interventions (Black et al., undernutrition as the consequence of a variety 2013). of interlinked factors. The causes of undernutrition are classified into three The effectiveness and ultimate success of hierarchical categories: (i) the immediate nutrition-sensitive interventions in different causes, (ii) the underlying causes, and (iii) the sectors towards reducing stunting depends on basic causes of undernutrition. In any given having a more holistic view of the inequities and context identification of the immediate causes gaps in access to adequate levels of the of undernutrition—disease or inadequate underlying determinants of nutrition typically dietary intake—is useful for guiding policy addressed by nutrition-sensitive interventions actions especially in situations of crises. In in: Food and Care, Health and Environment. The general, however, disease and inadequate interdependencies among the underlying dietary intake are typically consequences of a determinants of nutrition are usually beyond variety of underlying drivers that are the consideration of any given sector. The interrelated. integration of nutrition-related objectives in The variety of underlying causes of agricultural operations, for example, is unlikely undernutrition are grouped into three groups: 171 (a) inadequate household food security and country, and for children in the wealthiest (Top care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Tanzania: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and n/a children are lacking access to adequate levels of these three drivers of undernutrition, independently (Figure 1) as well as simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the 172 FIGURE 1 Tanzania: Stunting rates by subpopulations 35 33 32 30 30 Stunting rate 28 27 26 25 21 20 18 15 National Urban/Rural Wealth Education Empowerment Subpoplation groups National Rural Bottom 20% Not Educated Not Empowered Urban Top 20% Educated Empowered Source: Author estimates based on Tanzania 2016 DHS. Tanzania: Components of Adequate WASH Tanzania: Components of Adequate Health Improved 45 56 48 83 42 water 40 Prenatals 64 87 39 64 Basic 15 64 8 55 sanitation 35 Assisted 88 1 46 52 94 Feces 13 36 6 34 disposal 30 Postnatal 41 1 32 43 43 OD <25% 81 69 77 63 in community 68 90 Vaccinations 84 97 58 4 86 Handwash 3 64 facilities 8 58 2 Nets 81 13 49 84 0 20 40 60 80 100 Percentage of children who meet criteria 0 20 40 60 80 100 Percentage of children who meet criteria National Rural Urban Bottom 20% Top 20% National Rural Urban Bottom 20% Top 20% Source: Author estimates based on Tanzania 2016 DHS. Note: *Based on all households in the child's PSU. Source: Author estimates based on Tanzania 2016 DHS. 173 FIGURE 2 Percentage of children adequate in National Rural Urban None 29 37 9 Food/Care 9 11 3 WASH 1 1 2 Health 34 32 41 Food/Care & WASH 0 0 0 Food/Care & Health 13 13 13 WASH & Health 10 4 24 All 3 3 1 8 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 174 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 4 components 175 176 Togo: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Togo using data for children between 0 and 23 able not only to address the key underlying months of age, from the 2013/2014 determinants of nutrition effectively, but also Demographic and Health Survey (DHS). The contribute to enhancing the impacts of UNICEF (1990) conceptual framework views “nutrition-specific� interventions (Black et al., undernutrition as the consequence of a variety 2013). of interlinked factors. The causes of undernutrition are classified into three The effectiveness and ultimate success of hierarchical categories: (i) the immediate nutrition-sensitive interventions in different causes, (ii) the underlying causes, and (iii) the sectors towards reducing stunting depends on basic causes of undernutrition. In any given having a more holistic view of the inequities and context identification of the immediate causes gaps in access to adequate levels of the of undernutrition—disease or inadequate underlying determinants of nutrition typically dietary intake—is useful for guiding policy addressed by nutrition-sensitive interventions actions especially in situations of crises. In in: Food and Care, Health, and Environment. general, however, disease and inadequate The interdependencies among the underlying dietary intake are typically consequences of a determinants of nutrition are usually beyond variety of underlying drivers that are the consideration of any given sector. The interrelated. integration of nutrition-related objectives in The variety of underlying causes of agricultural operations, for example, is unlikely undernutrition are grouped into three groups: 177 (a) inadequate household food security and country, and for children in the wealthiest (Top care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment, and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Togo: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and n/a children are lacking access to adequate levels of these three drivers of undernutrition, independently (Figure 1) as well as simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the 178 FIGURE 1 Togo: Stunting rates by subpopulations 50 40 Stunting rate 30 23 23 21 20 19 19 18 12 12 13 10 0 National Urban/Rural Wealth Education Empowerment Subpoplation groups National Rural Bottom 20% Not Educated Not Empowered Urban Top 20% Educated Empowered Source: Author estimates based on Togo 2013 DHS. Togo: Components of Adequate WASH Togo: Components of Adequate Health Improved 46 59 55 84 48 water 31 Prenatals 68 85 38 75 Basic 11 61 3 45 sanitation 25 Assisted 92 1 24 35 93 Feces 2 9 73 22 71 disposal 0 Postnatal 75 30 68 31 77 OD <25% 8 71 in community 74 69 2 Vaccinations 75 78 68 7 80 Handwash 2 47 facilities 17 50 1 Nets 41 20 48 42 0 20 40 60 80 100 Percentage of children who meet criteria 0 20 40 60 80 100 Percentage of children who meet criteria National Rural Urban Bottom 20% Top 20% National Rural Urban Bottom 20% Top 20% Source: Author estimates based on Togo 2013 DHS. Note: *Based on all households in the child's PSU. Source: Author estimates based on Togo 2013 DHS. 179 FIGURE 2 Percentage of children adequate in National Rural Urban None 22 28 10 Food/Care 9 13 2 WASH 1 0 2 Health 37 37 37 Food/Care & WASH 0 0 0 Food/Care & Health 21 20 22 WASH & Health 8 2 21 All 3 2 0 6 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 180 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 181 182 Uganda: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Uganda using data for children between 0 and able not only to address the key underlying 23 months of age, from the 2011 Demographic determinants of nutrition effectively, but also and Health Survey (DHS). The UNICEF (1990) contribute to enhancing the impacts of conceptual framework views undernutrition as “nutrition-specific� interventions (Black et al., the consequence of a variety of interlinked 2013). factors. The causes of undernutrition are classified into three hierarchical categories: (i) The effectiveness and ultimate success of the immediate causes, (ii) the underlying nutrition-sensitive interventions in different causes, and (iii) the basic causes of sectors towards reducing stunting depends on undernutrition. In any given context having a more holistic view of the inequities and identification of the immediate causes of gaps in access to adequate levels of the undernutrition—disease or inadequate dietary underlying determinants of nutrition typically intake—is useful for guiding policy actions addressed by nutrition-sensitive interventions especially in situations of crises. In general, in: Food and Care, Health, and Environment. however, disease and inadequate dietary intake The interdependencies among the underlying are typically consequences of a variety of determinants of nutrition are usually beyond underlying drivers that are interrelated. the consideration of any given sector. The The variety of underlying causes of integration of nutrition-related objectives in undernutrition are grouped into three groups: agricultural operations, for example, is unlikely (a) inadequate household food security and 183 care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment, and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Uganda: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and 1. Cannot take into account sample children are lacking access to adequate levels of stratification as not given. these three drivers of undernutrition, independently (Figure 1) as well as simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the country, and for children in the wealthiest (Top 184 FIGURE 1 Uganda: Stunting rates by subpopulations 50 40 Stunting rate 30 27 28 28 28 25 26 23 24 20 19 10 0 National Urban/Rural Wealth Education Empowerment Subpoplation groups National Rural Bottom 20% Not Educated Not Empowered Urban Top 20% Educated Empowered Source: Author estimates based on Uganda 2011 DHS. Uganda: Components of Adequate WASH Uganda: Components of Adequate Health Improved 73 71 48 89 46 water 74 Prenatals 58 85 44 65 Basic 13 59 12 53 sanitation 18 Assisted 92 3 39 32 87 Feces 13 29 12 28 disposal 18 Postnatal 38 3 40 30 42 OD <25% 88 53 86 50 in community 68 98 Vaccinations 73 98 51 8 68 Handwash 6 59 facilities 19 57 4 Nets 70 22 61 72 0 20 40 60 80 100 Percentage of children who meet criteria 0 20 40 60 80 100 Percentage of children who meet criteria National Rural Urban Bottom 20% Top 20% National Rural Urban Bottom 20% Top 20% Source: Author estimates based on Uganda 2011 DHS. Note: *Based on all households in the child's PSU. Source: Author estimates based on Uganda 2011 DHS. 185 FIGURE 2 Percentage of children adequate in National Rural Urban None 17 20 5 Food/Care 22 24 12 WASH 4 5 3 Health 22 20 27 Food/Care & WASH 3 3 0 Food/Care & Health 22 20 27 WASH & Health 8 5 18 All 3 4 2 8 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 186 FIGURE 3 Uganda: Cumulative Distribution of HAZ Uganda: Cumulative Distribution of HAZ Uganda: Cumulative Distribution of HAZ Children under 24 months, 2011 Rural Children under 24 months, 2011 Urban Children under 24 months, 2011 .8 .8 1 Access to Access to Access to 0 drivers Cumulative share of children's HAZ Cumulative share of children's HAZ 0 drivers 0 drivers 1 driver 1 drivers 1 drivers .8 .6 .6 2 drivers 2 drivers 2 drivers 3 drivers 3 drivers 3 drivers .6 .4 .4 .4 .2 .2 .2 0 0 0 -6 -5 -4 -3 -2 -1 0 Height-for-age Z-score -6 -5 -4 -3 -2 -1 0 -6 -5 -4 -3 -2 -1 0 Height-for-age Z-score Height-for-age Z-score Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 187 188 Zambia: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Zambia using data for children between 0 and able not only to address the key underlying 23 months of age, from the 2013/2014 determinants of nutrition effectively, but also Demographic and Health Survey (DHS). The contribute to enhancing the impacts of UNICEF (1990) conceptual framework views “nutrition-specific� interventions (Black et al., undernutrition as the consequence of a variety 2013). of interlinked factors. The causes of undernutrition are classified into three The effectiveness and ultimate success of hierarchical categories: (i) the immediate nutrition-sensitive interventions in different causes, (ii) the underlying causes, and (iii) the sectors towards reducing stunting depends on basic causes of undernutrition. In any given having a more holistic view of the inequities and context identification of the immediate causes gaps in access to adequate levels of the of undernutrition—disease or inadequate underlying determinants of nutrition typically dietary intake—is useful for guiding policy addressed by nutrition-sensitive interventions actions especially in situations of crises. In in: Food and Care, Health, and Environment. general, however, disease and inadequate The interdependencies among the underlying dietary intake are typically consequences of a determinants of nutrition are usually beyond variety of underlying drivers that are the consideration of any given sector. The interrelated. integration of nutrition-related objectives in The variety of underlying causes of agricultural operations, for example, is unlikely undernutrition are grouped into three groups: 189 (a) inadequate household food security and The panels in Figure 1 summarize the care practices, (b) unhealthy household prevalence of access to the components of environment (WASH), and (c) inadequate health adequate Food and Care, adequate services. Adequate access to each of the three Environment (WASH), and adequate Health, underlying drivers is defined based on among children 0-23 months of age, at the internationally accepted standards. Access to national level, for rural and urban areas in the Food and Care is characterized as adequate if country, and for children in the wealthiest (Top the child, depending on its age, consumes a 20%) and in the poorest (Bottom 20%) minimum acceptable diet (based on types of households. foods consumed and feeding frequency), Along similar lines, the panels in Figure 2 whether breastfeeding was initiated within an summarize the prevalence of simultaneous hour of birth, and whether the child is age access to none, only one, two, or all three of the appropriately breastfed at the time of the drivers of nutrition. survey. Access to Adequate Environment is characterized by the access to at least three of Figure 3 presents estimates of the extent to the five WASH components: (1) access to an which access to only one, or simultaneous improved source of water for drinking, (2) access to two, or to all three of the underlying access to basic sanitation in the dwelling, (3) drivers of nutrition is associated with better access to proper children’s feces disposal, (4) nutritional outcomes (i.e., lower prevalence of access to a hand washing station with soap, and stunting). This is done both visually (i.e. in terms (5) living in a community where less than 25 of shift to the right in the density function of percent of the households openly defecate. height for age z-scores associated with access to Access to health is characterized as adequate if none or one or more of the drivers of nutrition) the child adheres to at least three of the and quantitatively (in terms of the marginal following five health components: (1) mother decrease in the stunting rate relative to the used prenatal services at least four times while stunting rate prevailing among children with pregnant, (2) child delivered by a skilled access to adequate level in none of the three professional, (3) child received a postnatal drivers of nutrition). check within two months of birth, (4) child is compliant with national vaccination schedule, The figures are accompanied by a series of and (5) child sleeps under a mosquito net. maps helpful for targeting nutrition specific and nutrition sensitive interventions. The maps A necessary condition for guidance towards summarize the prevalence of stunting rates, effective multi-sectoral policies on Stunting, is and access to adequate Food & Care, knowledge on the extent to which infants and Environment, and Health, one at a time and children are lacking access to adequate levels of simultaneously by region. these three drivers of undernutrition, independently (Figure 1) as well as simultaneously (Figure 2). Notes on Zambia: n/a 190 FIGURE 1 Zambia: Stunting rates by subpopulations 50 42 40 39 39 39 37 34 35 Stunting rate 32 30 29 20 10 0 National Urban/Rural Wealth Education Empowerment Subpoplation groups National Rural Bottom 20% Not Educated Not Empowered Urban Top 20% Educated Empowered Source: Author estimates based on Zambia 2013 DHS. Zambia: Components of Adequate WASH Zambia: Components of Adequate Health Improved 45 59 54 88 53 water 37 Prenatals 54 95 49 64 Basic 22 69 18 57 sanitation 30 Assisted 92 14 53 52 96 Feces 18 56 14 52 disposal 25 Postnatal 63 11 53 42 62 OD <25% 72 52 59 43 in community 54 98 Vaccinations 71 96 39 10 75 Handwash 5 49 facilities 21 50 3 Nets 45 34 51 49 0 20 40 60 80 100 Percentage of children who meet criteria 0 20 40 60 80 100 Percentage of children who meet criteria National Rural Urban Bottom 20% Top 20% National Rural Urban Bottom 20% Top 20% Source: Author estimates based on Zambia 2013 DHS. Note: *Based on all households in the child's PSU. Source: Author estimates based on Zambia 2013 DHS. 191 FIGURE 2 Percentage of children adequate in National Rural Urban None 25 31 12 Food/Care 9 11 4 WASH 4 4 6 Health 30 29 31 Food/Care & WASH 2 2 2 Food/Care & Health 15 15 14 WASH & Health 10 6 20 All 3 6 3 11 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 192 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 193 194 Zimbabwe: to take into account the fact that water, All Hands on Deck: Reducing Stunting sanitation and hygiene (WASH) services and Through Multisectoral Efforts in Sub- facilities may be inadequate in the project Saharan Africa communities. As a consequence, the extent to which such nutrition-sensitive interventions in agriculture can ultimately impact on nutrition outcomes can be impeded considerably by the There is a wide consensus that economic absence of adequate WASH services. On the growth is not sufficient for improving nutrition other hand, the impacts of the same nutrition- outcomes. As a consequence, much of the sensitive agricultural interventions on nutrition effort to date has been focused on the costing, outcomes could be enhanced considerably if financing and impact of “nutrition-specific� they were to be accompanied by simultaneous interventions delivered mainly through the improvements in the water and sanitation health sector, for the purpose of reaching the services in the same project communities. Thus, global nutrition targets for stunting, anemia, a coordinated multi-sectoral approach to and breastfeeding, and interventions for “nutrition-sensitive� interventions in the water treating wasting (Shekar et al. 2016; Horton et and agricultural sectors is likely to be better al, 2010; and the forthcoming regional report able to address the key underlying “Reducing Stunting in Africa�). An acceleration determinants of nutrition effectively, as well as of the progress towards reducing stunting, reinforce the impacts of nutrition-specific requires enlisting more sectors, in addition to interventions. the health sector, such as agriculture, education, social protection, and water, This country note provides the essential sanitation, and hygiene in the effort to improve ingredients for more effective multi-sectoral nutrition. Large scale “nutrition sensitive� action for the reduction of undernutrition in interventions in these sectors will have to be Zimbabwe using data for children between 0 able not only to address the key underlying and 23 months of age, from the 2015 determinants of nutrition effectively, but also Demographic and Health Survey (DHS). The contribute to enhancing the impacts of UNICEF (1990) conceptual framework views “nutrition-specific� interventions (Black et al., undernutrition as the consequence of a variety 2013). of interlinked factors. The causes of undernutrition are classified into three The effectiveness and ultimate success of hierarchical categories: (i) the immediate nutrition-sensitive interventions in different causes, (ii) the underlying causes, and (iii) the sectors towards reducing stunting depends on basic causes of undernutrition. In any given having a more holistic view of the inequities and context identification of the immediate causes gaps in access to adequate levels of the of undernutrition—disease or inadequate underlying determinants of nutrition typically dietary intake—is useful for guiding policy addressed by nutrition-sensitive interventions actions especially in situations of crises. In in: Food and Care, Health, and Environment. general, however, disease and inadequate The interdependencies among the underlying dietary intake are typically consequences of a determinants of nutrition are usually beyond variety of underlying drivers that are the consideration of any given sector. The interrelated. integration of nutrition-related objectives in The variety of underlying causes of agricultural operations, for example, is unlikely undernutrition are grouped into three groups: 195 (a) inadequate household food security and country, and for children in the wealthiest (Top care practices, (b) unhealthy household 20%) and in the poorest (Bottom 20%) environment (WASH), and (c) inadequate health households. services. Adequate access to each of the three Along similar lines, the panels in Figure 2 underlying drivers is defined based on summarize the prevalence of simultaneous internationally accepted standards. Access to access to none, only one, two, or all three of the Food and Care is characterized as adequate if drivers of nutrition. the child, depending on its age, consumes a minimum acceptable diet (based on types of Figure 3 presents estimates of the extent to foods consumed and feeding frequency), which access to only one, or simultaneous whether breastfeeding was initiated within an access to two, or to all three of the underlying hour of birth, and whether the child is age drivers of nutrition is associated with better appropriately breastfed at the time of the nutritional outcomes (i.e., lower prevalence of survey. Access to Adequate Environment is stunting). This is done both visually (i.e. in terms characterized by the access to at least three of of shift to the right in the density function of the five WASH components: (1) access to an height for age z-scores associated with access to improved source of water for drinking, (2) none or one or more of the drivers of nutrition) access to basic sanitation in the dwelling, (3) and quantitatively (in terms of the marginal access to proper children’s feces disposal, (4) decrease in the stunting rate relative to the access to a hand washing station with soap, and stunting rate prevailing among children with (5) living in a community where less than 25 access to adequate level in none of the three percent of the households openly defecate. drivers of nutrition). Access to health is characterized as adequate if the child adheres to at least three of the The figures are accompanied by a series of following five health components: (1) mother maps helpful for targeting nutrition specific and used prenatal services at least four times while nutrition sensitive interventions. The maps pregnant, (2) child delivered by a skilled summarize the prevalence of stunting rates, professional, (3) child received a postnatal and access to adequate Food & Care, check within two months of birth, (4) child is Environment, and Health, one at a time and compliant with national vaccination schedule, simultaneously by region. and (5) child sleeps under a mosquito net. A necessary condition for guidance towards Notes on Zimbabwe: effective multi-sectoral policies on Stunting, is knowledge on the extent to which infants and 1. No information on polio vaccination at birth children are lacking access to adequate levels of and thus not used in the construction of these three drivers of undernutrition, vaccination record. independently (Figure 1) as well as simultaneously (Figure 2). The panels in Figure 1 summarize the prevalence of access to the components of adequate Food and Care, adequate Environment (WASH), and adequate Health, among children 0-23 months of age, at the national level, for rural and urban areas in the 196 FIGURE 1 Zimbabwe: Stunting rates by subpopulations 50 40 Stunting rate 31 30 25 25 26 25 24 24 20 15 10 0 National Urban/Rural Wealth Education Empowerment Subpoplation groups National Rural Bottom 20% Not Educated Not Empowered Urban Top 20% Educated Empowered Source: Author estimates based on Zimbabwe 2015 DHS. Zimbabwe: Components of Adequate WASH Zimbabwe: Components of Adequate Health Improved 66 75 74 96 74 water 57 Prenatals 75 100 71 87 Basic 29 83 26 78 sanitation 37 Assisted 95 11 74 52 96 Feces 24 83 24 81 disposal 25 Postnatal 88 10 79 32 87 OD <25% 58 85 41 83 in community 30 100 Vaccinations 88 93 80 9 89 Handwash 3 14 facilities 24 13 1 Nets 18 38 12 19 0 20 40 60 80 100 Percentage of children who meet criteria 0 20 40 60 80 100 Percentage of children who meet criteria National Rural Urban Bottom 20% Top 20% National Rural Urban Bottom 20% Top 20% Source: Author estimates based on Zimbabwe 2015 DHS. Note: *Based on all households in the child's PSU. Source: Author estimates based on Zimbabwe 2015 DHS. 197 FIGURE 2 Percentage of children adequate in National Rural Urban None 11 14 4 Food/Care 3 3 1 WASH 2 2 3 Health 44 46 37 Food/Care & WASH 1 1 1 Food/Care & Health 14 15 11 WASH & Health 19 14 31 All 3 7 5 13 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 198 FIGURE 3 Definitions used - Adequate Food/Care: MAD and at least one other component; Adequate WASH: 3 of 5 components; Adequate Health: 3 of 5 components 199 200