Landscape Landscape AnalysisAnalysisBy: RAVELOHARISON By: RAVELOHARISON AmbinintsoaAmbinintsoa

National Coordinator of ONNNational Coordinator of ONN

Dr RAKOTONIRINA SimonDr RAKOTONIRINA SimonChief Unit of Nutrition Service Chief Unit of Nutrition Service ((MoHMoH))

MADAGASCAR

Genève, May 21, 2008

From 1997 to 2003*:

Significant reduction of under five mortality rate from 139 to 94 per 1,000 live births

Dramatic increase of Exclusive Breast Feeding from 42% to 64%EBF

Reduction of Stunting in children <3 years of age from 48% to 45%

Malnutrition among women 15-49 remain a serious problem in 2003:

19% (BMI < 18,5)

Anemia: 46%

From 1997 to 2003*:From 1997 to 2003*:

Significant reduction of under five mortality rate Significant reduction of under five mortality rate from 139 to 94 per 1,000 live birthsfrom 139 to 94 per 1,000 live births

Dramatic increase of Exclusive Breast Feeding Dramatic increase of Exclusive Breast Feeding from 42% to 64%EBFfrom 42% to 64%EBF

Reduction of Stunting in children <3 years of Reduction of Stunting in children <3 years of age from 48% to 45% age from 48% to 45%

Malnutrition among women 15Malnutrition among women 15--49 remain a 49 remain a serious problem in 2003:serious problem in 2003:

19% 19% (BMI < 18,5) (BMI < 18,5)

Anemia: 46%Anemia: 46%

HEALTH AND NUTRITION INDICATORSHEALTH AND NUTRITION INDICATORS

*Madagascar DHS 1997 & 2003

MAIN ACTIONSMAIN ACTIONSInstitutional framework:Institutional framework:

Nutrition/food security: MAP, Commit. 5; Challenge 7Nutrition/food security: MAP, Commit. 5; Challenge 7Adoption of the National Nutrition Policy (PNN) and implementatiAdoption of the National Nutrition Policy (PNN) and implementation of on of the National plan for nutrition actions (PNAN) the National plan for nutrition actions (PNAN) Operational Coordination mechanism /body : National Nutrition OfOperational Coordination mechanism /body : National Nutrition Office fice (ONN) , National Nutrition Council (CNN)(ONN) , National Nutrition Council (CNN)

Prevention:Prevention:Food and nutrition surveillanceFood and nutrition surveillancePromotion of breastfeedingPromotion of breastfeedingCommunity nutritionCommunity nutritionFight against all forms of micronutrient deficiency Fight against all forms of micronutrient deficiency Food security for vulnerable householdsFood security for vulnerable householdsSchool nutrition programSchool nutrition program

Treatment of severe malnutrition:Treatment of severe malnutrition:At health center (CSB) or community levelAt health center (CSB) or community levelAt clinical hospital levelAt clinical hospital levelNutrition during emergency situationNutrition during emergency situation

Communication strategy for nutritionCommunication strategy for nutrition

COVERAGE OF THE COMMUNITY NUTRITION PROJECTYear 2004:Year 2004:

3,470 nutrition 3,470 nutrition sitessites

Coverage: Coverage: 694,000 children 694,000 children under five (24% under five (24% of children <5)of children <5)

Year 2007:Year 2007:

5.550 sites/175005.550 sites/17500

Coverage: Coverage: 1.000.000 1.000.000 children under children under five (34% of five (34% of children <5)children <5)

SUCCES STORYSUCCES STORY

National level Vitamin A coverage rates improved since National level Vitamin A coverage rates improved since its initiation through mass campaign in 1998its initiation through mass campaign in 1998

Since 2005, the programme reached >90% of targeted Since 2005, the programme reached >90% of targeted children bichildren bi--annuallyannually

MICRONUTRIENTSMICRONUTRIENTS

Landscape Landscape ProcessProcess

Adjust standardized collection tools to fit Adjust standardized collection tools to fit within the national contextwithin the national contextInform key stakeholders and present the Inform key stakeholders and present the principles of landscape analysisprinciples of landscape analysisInterview and field visit: central and Interview and field visit: central and regional levelregional levelData consolidation and analysisData consolidation and analysisResults dissemination and Results dissemination and recommendationsrecommendations

STAKEHOLDERSTAKEHOLDERModerators:Moderators:

SCNSCNHKIHKIOMSOMSMINSANPFPSMINSANPFPSONNONNUNICEFUNICEF

Person interviewed:Person interviewed:Central levelCentral level

National Nutrition Council :National Nutrition Council :Office of the Prime MinisterOffice of the Prime MinisterDecentralizationDecentralizationFinanceFinanceAgricultureAgricultureEducation Education HealthHealthCivil SocietyCivil Society

Development partners :Development partners :World Bank World Bank United Nations Agencies : WFP, FAO, United Nations Agencies : WFP, FAO, UNICEF, WHO.UNICEF, WHO.USAIDUSAID

Private SectorPrivate Sector

Person interviewed :Person interviewed :Regional levelRegional level

••DRSDRS••DRDRDRDR••CRCR••DRENDREN••REGIONREGION••ONGSONGS

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SELECTED REGIONS

.. RRéégion gion AnosyAnosy

.. RRéégion gion AnalamangaAnalamanga

RRéégion gion BoenyBoeny ..

FINDINGSFINDINGSPerceptions of nutritional problems : Perceptions of nutritional problems :

Main determinants: Main determinants: •• PovertyPoverty•• Lack of foodLack of food•• Lack of information/ignoranceLack of information/ignorance•• Low incomeLow income•• Natural disastersNatural disasters•• Inadequate performance and coordinationInadequate performance and coordination

Underlying factors :Underlying factors :•• Inadequate maternal and infant feeding Inadequate maternal and infant feeding •• Micronutrient deficiencyMicronutrient deficiency•• Inadequate Hygiene and sanitation practiceInadequate Hygiene and sanitation practice

National Nutrition Policy and national plan for National Nutrition Policy and national plan for Nutrition Actions :Nutrition Actions :

Strengths:Strengths:•• Relatively well known by key stakeholdersRelatively well known by key stakeholders•• Address the main problems (as noted earlier)Address the main problems (as noted earlier)•• IntersectoralIntersectoral•• Anchored with the Anchored with the «« Madagascar Action PlanMadagascar Action Plan »»

Weaknesses:Weaknesses:•• Insufficient implementationInsufficient implementation•• Lack of clear definition of the roles and responsibility of Lack of clear definition of the roles and responsibility of

different key stakeholdersdifferent key stakeholders•• Divergence between strategic/priorities and supports from Divergence between strategic/priorities and supports from

development partnersdevelopment partners

FINDINGSFINDINGS

Financial Resources :Financial Resources :

Almost all respondents think they are Almost all respondents think they are insufficientinsufficient

How to increase them ?How to increase them ?•• Increase external resourcesIncrease external resources•• Reinforce financial commitment of the GovernmentReinforce financial commitment of the Government•• Integrate nutrition with development Plans at regional Integrate nutrition with development Plans at regional

and communal levelsand communal levels•• Reinforce public and private partnershipReinforce public and private partnership•• Financial contribution/participation of beneficiariesFinancial contribution/participation of beneficiaries

FINDINGSFINDINGS

Coordination :Coordination :StrengthsStrengths : :

•• Existing coordination bodyExisting coordination body•• Positioning of ONN under the Office of the Prime Minister and Positioning of ONN under the Office of the Prime Minister and

leadership dynamism of ONN leadership dynamism of ONN •• Multisectoral representationMultisectoral representation•• Harmonization of approachesHarmonization of approaches

Weaknesses : Weaknesses : •• Due to the fact that the coordination body is youngDue to the fact that the coordination body is young•• Lack of clarification of the roles and responsibilities of stakeLack of clarification of the roles and responsibilities of stakeholdersholders•• Confusion between coordination roles and implementationConfusion between coordination roles and implementation•• Frequent change with members of the permanent bureau of CNN and Frequent change with members of the permanent bureau of CNN and

lack of transfer of power in case of changelack of transfer of power in case of change•• ONN do not control some partners interventionsONN do not control some partners interventions

FINDINGSFINDINGS

Going to scaleGoing to scale

Madagascar has potential Madagascar has potential assets to go to scale in the assets to go to scale in the fight against malnutrition:fight against malnutrition:

Develop and appropriate the Develop and appropriate the vision of vision of «« Madagascar without Madagascar without MalnutritionMalnutrition»»Develop and follow a road map Develop and follow a road map to reach this visionto reach this visionImplement the formulated Implement the formulated recommendations from the recommendations from the landscape analysislandscape analysis

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Next STEPSNext STEPS

Consolidate nutrition information for decision Consolidate nutrition information for decision makingmaking

Reinforce the coordination and the leadership in all Reinforce the coordination and the leadership in all sectors and clarify roles and responsibilities of sectors and clarify roles and responsibilities of different actors;different actors;

Consider nutrition with the life cycle and link it with Consider nutrition with the life cycle and link it with other child survival interventions;other child survival interventions;

Ensure effective integration of nutrition with other Ensure effective integration of nutrition with other sectors, not only health: agriculture, educationsectors, not only health: agriculture, education……

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Next STEPSNext STEPS

Reinforce public Reinforce public –– private partnership for a better nutrition;private partnership for a better nutrition;

Extend the coverage of evidence based interventions already Extend the coverage of evidence based interventions already carried out: Community Nutrition , CMAM, Baby friendly carried out: Community Nutrition , CMAM, Baby friendly hospital; (34 hospital; (34 percperc to 100 to 100 percperc))

Reinforce the fight against micronutrient deficiencies;Reinforce the fight against micronutrient deficiencies;

Give greater priority to actions on SAM;Give greater priority to actions on SAM;

Reinforce nutrition in the operational health system; Reinforce nutrition in the operational health system;

14 STRATEGIC AXES OF THE PNAN14 STRATEGIC AXES OF THE PNANLeader Leader StrategiesStrategies Responsible Responsible

HealthHealth 1: BF, AC1: BF, AC ONN, Education, Justice, Population, Decentralization, ONN, Education, Justice, Population, Decentralization, Commerce, partnersCommerce, partners

3: Micronutrients3: Micronutrients ONN, Education, Decentralization, Commerce , partnersONN, Education, Decentralization, Commerce , partners

4: Health integration4: Health integration ONN ONN

5: Treatment5: Treatment ONN, partnersONN, partners

14: Emerging Prob.14: Emerging Prob. ONN, CNLS, partnersONN, CNLS, partners

ONNONN 2: Community2: Community Health, Agriculture, Education, Decentralization, partnersHealth, Agriculture, Education, Decentralization, partners

11: SAN11: SAN All Ministries, partnersAll Ministries, partners

AgricultureAgriculture 6: SAM6: SAM ONN, Decentralization, partnersONN, Decentralization, partners

EducationEducation 7: School based7: School based ONN, health, agricultureONN, health, agriculture

12: National capacity12: National capacity ONN, health ONN, health

CommunicationCommunication 8:Communication8:Communication ONN, health, decentralization, partnersONN, health, decentralization, partners

PlanPlan 9: Policy development9: Policy development ONN, all MinistriesONN, all Ministries

BNGRCBNGRC 10: Emergency10: Emergency ONN, cluster nutritionONN, cluster nutrition

CommerceCommerce 13: Norms13: Norms ONN, health, agriculture, partnersONN, health, agriculture, partners

BUDGET BUDGET (USD)(USD)20082008 20092009 20102010 20112011 TOTALTOTAL

NeedsNeeds 25.080.00025.080.000 31.700.00031.700.000 40.080.00040.080.000 45.600.00045.600.000 142.460.000142.460.000

Gov ContributionGov Contribution 6.386.0006.386.000 9.600.0009.600.000 10.280.00010.280.000 10.556.00010.556.000 36.822.00036.822.000

Donors/Partners Donors/Partners ContributionContribution

9.300.0009.300.000 9.300.0009.300.000

GAP 2008/2011GAP 2008/2011 9.397.0009.397.000 22.100.00022.100.000 29.800.00029.800.000 35.044.00035.044.000 96.338.00096.338.000

GAP 2009/2011GAP 2009/2011 22.100.00022.100.000 29.800.00029.800.000 35.044.00035.044.000 86.944.00086.944.000

THANK YOU VERY MUCH FOR YOUR THANK YOU VERY MUCH FOR YOUR ATTENTIONATTENTION

MISAOTRA TOMPOKOMISAOTRA TOMPOKO