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Black: indicates evidence for implementation in countries with a high burden of undernutrition

Grey: indicates evidence for implementation in specific contexts

* in addition to the Lancet Series list

** in partnership with other sectors

Cost-Effectiveness92(US$ per DALY averted)

Cost Estimate93
(US$)

Nutrition-specific interventions

Promoting good nutritional practices

Breastfeeding

3 - 11

5 – 15$/year
(included in a community nutrition programme)

Complementary feeding for infants older than 6 months

Improved hygiene practices, including hand washing

3

Increased intake of vitamins and minerals

Periodic vitamin A supplements (6 – 59 months)

6 - 12

1.2$/child/year

Therapeutic zinc supplements in diarrhoea management

73

1 $/child/year

Multiple micronutrients powder (6 – 23 months)*

1.8 – 3.6 $/child/year

De-worming in children (to reduce nutrient losses)

0.25 $/child/year

Iron-folic acid supplements for pregnant women

2 $/pregnancy

Maternal iodine supplements/iodised oil capsules

2.16 $/person/year

Salt iodisation**

34 - 36

0.05 $/person/year

Iron fortification of staple food 94 **

66 - 70

0.2 $/person/year

Therapeutic feeding for malnourished children with special foods

Prevention/treatment of moderate undernutrition
(6 – 23 months)

40 – 80 $/child/year

(using fortified foods)

Treatment of severe acute undernutrition with ready-to-use therapeutic foods

200 $/child/episode (community-based management)

Other health interventions

Intermittent preventive treatment for malaria

Insecticide-treated bed nets

11 (Sub-Saharan Africa)

Reducing tobacco consumption or indoor air pollution

Delayed cord clamping

Related interventions

Conditional cash transfers with nutrition components

156 – 432 $/household/year

Some interventions recommended by the Lancet Series have not been included as there are no cost-estimates available (e.g. preventive zinc supplements, maternal calcium supplements, maternal micronutrient supplements, maternal supplements of balanced energy/ protein).

Annex 6: Nutrition situation analysis

Note: Italics denote explanations/sections to be completed according to specific circumstances

1. Background

When taking action on nutrition, the starting point should be to undertake an analysis of the local nutrition situation and its determinants, including household food security, poverty and social issues. This analysis should form the basis for national policies, legislative frameworks and strategies that make the best use of local resources. Policy guidance and technical documentation on international norms already established can facilitate policy design and choice of implementation strategy.

(Give a brief overview of the country, its current socio-political situation, nutrition situation and Government responses and/or other donors, in the field of nutrition).

2. Objectives

The main objective of the nutrition situation analysis is to identify and assess the situation in order to:

  • better understand the nutrition problem – levels, trends, people worst affected, causes etc.;

  • better understand the country’s involvement in nutrition;

  • better design an appropriate response within the cooperation objectives/strategies;

  • provide decision makers in the partner country clear information on the nutrition situation and raise awareness.

The situation analysis describes the key links between nutrition and poverty reduction. It helps focus political dialogue and cooperation with the country on key areas of concern as well as raising awareness among policy makers.

It constitutes an important source of baseline information to provide a basis for discussion, justification, priorities for action and provide a benchmark against which to measure future trends in nutrition, essential for evaluating the results of the action taken, and for making improvements to on-going programmes.

3. Results

The nutrition situation analysis delivers the following results:

  • an assessment of the key nutrition factors and trends:

  • nature, trends, severity and distribution of maternal and child malnutrition problems

  • an assessment of the main links between nutrition and human development, in its multiple dimensions (income, consumption, health, security, vulnerability, …);

  • an assessment of national nutrition policy, institutional structures and capacity, and the involvement of civil society in nutrition issues:

  • commitment to resolve these problems

  • capacity to resolve these problems

  • an overview of past and ongoing national and international cooperation in the field of nutrition.

4. Issues to be assessed

4.1 Country nutrition factors and trends

This chapter identifies the state and trends of key nutrition issues in the country (see further reading below).

As appropriate, reference should be made to nutritional indicators that could be used for monitoring changes in the studied country. To the extent that data are available, trends in MDGs 1, 4 and 595 indicators should be provided; trends in additional indicators related to country-specific nutrition issues can also be provided, as available, to highlight those that are significant.

The concluding paragraphs should summarise the main problems identified (which nutritional conditions are causes of concern and what is their prevalence (e.g. stunting, wasting, obesity), described in terms of situations or trends. The information could be organised according to eco-geographical subdivisions as well as administrative boundaries.

Sources of further information

TRACKING PROGRESS ON CHILD AND MATERNAL NUTRITION A survival and development priority, UNICEF, 2009 /nutrition/index_51688.html

World Health Statistic 2009, WHO, t/whosis/whostat/

Inter-agency Group for Child Mortality Estimation (IGME), ChildInfo, UNICEF 2009, /mortality_igme.html

Health, Nutrition and Population Statistics, HNP statistics, World Bank 2009, /WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/EXTDATASTATISTICSHNP/EXTHNPSTATS/0,,print:Y~isCURL:Y~contentMDK:21187239~menuPK:3342157~pagePK:64168445~piPK:64168309~theSitePK:3237118,00.html/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/EXTDATASTATISTICSHNP/EXTHNPSTATS/0,,contentMDK:21563582~menuPK:3385544~pagePK:64168445~piPK:64168309~theSitePK:3237118~isCURL:Y,00.html

The State of the World’s Children, statistics UNICEF 2009, /rightsite/sowc/statistics.php

4.2 Country nutrition key issues and causes

The main key issues in terms of nutrition and major causes of malnutrition should be identified, assessing the three broad levels of nutritional status: immediate, underlying and basic,using theLancet conceptual framework (see Figure 5).

The concluding paragraphs should set out the key issues deriving from malnutrition (e.g. decline in active workforce, reduced performance at school). The main links between nutrition and human development (in its multiple dimensions: income, consumption, health, security, vulnerability etc.) should be highlighted, in the form of a nutrition causal model.

4.3 National nutrition policy, institutional structures and capacity

A brief description and review of the strengths and weaknesses of the following aspects should be provided, with their associated evaluation criteria shown below for guidance:

Aspect

Evaluation criteria

Policies96

Existence of national policies, strategies and action plans.

Important measures taken by the government to solve nutritional concerns and types of policy instruments used for implementation.

Effectiveness in achieving targets.

Institutions with nutrition responsibilities

Identity, number and quality of institutions (involved in policy making, planning, monitoring and enforcement).

Level of coordination and decentralisation.

Strength and capacity of individual institutions.

Influence on other institutions.

Good governance practices.

Capabilities, means, functioning of nutrition-related services (health, agriculture, water/sanitation, education).

Major NGOs, institutes or other organisations involved in nutrition programme or policy.

Public participation

Transparency and access to information.

Role of NGOs and civil society in nutrition-related issues ‘decision-making.

Effective participation.

Participation by women and traditionally less-represented groups.

Services and infrastructures

Health and agriculture services: number, areas, relevance, and effectiveness.

Sanitation and waste infrastructure.

Nutrition education at school (curricula).

Emergency response mechanisms.

Nutrition monitoring system

Relevance of selected indicators (with reference to MDG1, 4 and 5).

Measurement of the indicators: periodicity, liability.

Integration in the general development indicators.

This section should briefly review the past and current steps taken by the government to tackle malnutrition. Where information is available, the impacts or potential risks of past or ongoing actions should be identified for the benefit of future programmes. The results of existing evaluations/reviews should be summarised.

4.4 Integrating nutrition concerns into the main policies and sectors

The assessment should examine the integration of nutrition concerns in the overall development policy and in sectors/areas that have key links with nutrition issues and which may be identified for support, taking into account the options for future cooperation. This section should examine whether there is a nutrition assessment for the national development strategy or the Poverty Reduction Strategy and for the sectors of interest. The main legislation and institutional arrangements and measures of the sector which address nutrition issues should be examined.

4.5 Government’s response to malnutrition

Based on the results of Section 4.3, this section should briefly review the past and current steps taken by the government to tackle malnutrition. Where information is available, the effectiveness of past or ongoing actions should be evaluated for the benefit of future programmes. The results of existing evaluations/reviews should be summarised.

4.6 Stakeholders’ response to malnutrition

This section should review the past and current involvement of donors (in particular EU Member States, but other significant donors should also be included) and their experience in the country, and include a list of recent and planned projects/programmes with a focus or anticipated impact on nutrition. It should assess the mechanisms to coordinate between donors on issues of nutrition.

5. Conclusions and recommendations

The conclusion should identify, as clearly as possible, the key aspects of nutrition factors and trends in the country, including policy, regulatory and institutional constraints and challenges. They may be presented in a matrix, comparing nutrition concerns and the main sectors or policies.

Based on a comprehensive assessment of available information and on consultations with stakeholders, conclusions and recommendations should be formulated on how the government and stakeholders can best address the identified nutrition challenges, taking into account current action and any pre-identified options for future cooperation. Conclusions and recommendations should feed into the country analysis, response strategy and possibly the identification of focal cooperation sectors97. They should address (but not necessarily be limited to) the following aspects:

  1. Rationale for considering nutrition in areas of cooperation, in order to address nutrition constraints and opportunities as appropriate. Safeguards may include, for example, proposals for institutional strengthening and capacity building.

  2. Recommendations to ensure that nutrition concerns are taken into consideration when identifying new projects and programmes in different cooperation sectors. Information gaps preventing this work from being accomplished should be identified.

  3. Opportunities for coordination on nutrition issues with other donors, seeking to achieve complementarities and synergies in order to more effectively deliver development objectives.

  4. Proposals for nutrition-relevant indicators to be considered during the formulation of cooperation actions. The proposed indicators should be chosen taking account of the availability of data and actual capacity to monitor their evolution.

Individual recommendations should be clearly articulated and linked to the problems to be solved and grouped according to the sector concerned or institutional stakeholder. The relative priority of the recommendations and an indication of the challenges to their implementation should be given.

6. Work plan

The work plan should include but not necessarily be limited to the following activities:

  • Consultations with relevant officials, stakeholders involved in nutrition issues and a selection of national and local authorities, key national and international civil society actors operating in nutrition-related field.

  • Review of key documents and reports, including relevant national documents; evaluation reports, existing assessments (particularly those concerning potential focal sectors); nutrition or nutrition-related policies, information on monitoring and nutrition indicators.

  • Field visits to sites of key nutrition concern and (if possible) the organisation of a national workshop for national authorities, development partners, experts and representatives of civil society, with the aim of clarifying and validating key nutrition concerns.

  • On the basis of the outline work plan and time schedule given in these Terms of Reference, a detailed work plan should be proposed.

7. Expertise required

The proposed mission should be conducted by a team of (two) experts with the following profile:

  • Expert level I or level II - team leader - with at least 10 years experience in nutrition, including: institutional aspects; international policies; nutrition assessments and experience in rapidly assessing information and developing recommendations.

  • Expert level II with 10 years experience and with a nutrition background complementary to the team leader.

  • Previous working experience in the country/region is requested for at least one team member.

  • Experience in undertaking nutritional analyses and preparing development programmes is an asset.

  • Experience of participatory planning processes and gender awareness is an advantage.

The experts should have excellent skills in … and …. (knowledge of …. is an asset). … will be the working language and the final report must be written in ….

8. Reporting

The results of the study should be presented in the format given in Section 10 of these ToR. The draft situation analysis, in (number) hard copies and electronic version (Microsoft Word), should be presented to () by (date) at the latest. Within () weeks, comments on the draft report will be received from the contracting agency. The consultants will take account of these comments in preparing the final report (maximum 40 pages excluding appendices). The final report in (language) and(number) copies is to be submitted by (date).

9. Time schedule (example)

Expert I

Expert II

Desk analysis, briefing to the team leader

5

2

Field phase including travel and possible workshop

20

20

Report finalisation

3

2

Debriefing in (place)-not later than (date)

1

Final report end (date)

1

1

Total days

30

25

10. Report format for a nutrition situation analysis

Maximum length (excluding appendices): 45 pages.

The following text appears on the inside front cover of the report:

This report is financed by (name of the contracting authority) and is presented by (name of consultant) for the … (national institution). It does not necessarily reflect the opinion of …

1. Summary

The summary should succinctly and clearly present the key issues described in the report following the order of headings 2 to 6 given below. The summary should not exceed 6 pages.

2. Country nutrition factors and trends

3. Country nutrition key issues and causes

4. National nutrition policy, institutional structures and capacity

5. Government’s response to malnutrition

6. Stakeholders’ response to malnutrition

7. Conclusions and recommendations

8. Technical appendices

I. Nutrition map of the country

II. Reference list of nutrition-related policy documents, statements and action plans, and other relevant technical information.

9. Other appendices

I. Study methodology/work plan (1–2 pages)

II. Consultants’ itinerary (1–2 pages)

III. List of persons/organisations consulted with their affiliation and contact details (1–2 pages)

IV. List of documentation consulted (1–2 pages)

V. Curricula vitae of the consultants (1 page per person)

VI. Terms of Reference for the nutrition situation analysis

Annex 7: Terms of reference for evaluating programmes for nutrition outcomes

Note: Italics denote explanations/sections to be completed according to specific circumstances

1. Background section

Describe the nutrition environment of the country/region, the rationale and objectives of the programme, its main activities/services, institutional arrangements and timeframe

Nutrition and nutrition-related programmes all too often fail to meet their objectives – usually because they are based on a weak understanding of the main causes of undernutrition, are poorly supervised and managed and inadequately financed.

Evaluating programmes/projects with nutrition outcomes requires understanding the undernutrition problem and associated causes in the context of the area(s) targeted. This should be based on a nutrition situation analysis (see Annex 6 for details) determining the immediate and underlying causes and identifying the most appropriate responses. The required programme activities and inputs should follow on from this, and indicators of project efficiency and effectiveness be chosen.

The project/programme needs to include plans for future evaluation. This will be based on indicators built in to the design of the monitoring system, which span four levels: inputs, outputs, outcomes and impacts.

  • Input indicators measure the financial, administrative and regulatory resources provided. These include items to be delivered such as food, micronutrient supplements, equipment and training of project personnel.

  • Output indicators measure the immediate and concrete consequences of the measures taken and resources used, such as the number of pregnant and lactating mothers who received a cash transfer.

  • Outcome indicators measure the results in terms of target group benefits, such as the improved diet of children as a result of a cash transfer.

  • Impact indicators measure the long-term consequences of the outcome. For nutrition, impact is usually assessed by measuring change in nutrition status using anthropometric or indicators of micronutrient status.

There may well be broader benefits that emerge because the impacts combine with other factors in an anticipated way. Similarly, there may be unintended negative consequences that need also to be examined (i.e. increased workload for women hence less time to care for the children).

2. Evaluation objectives

Present the type of evaluation (process or impact) plus the general and specific objectives e.g. coverage, improvements in nutritional status, increased wealth, diversified diet, improved knowledge about child care and feeding practices or reduction/eradication of specific micronutrient deficiencies.

Evaluations look at the relevance, efficiency and effectiveness of the programme in contributing to achieving sustainable nutrition-relevant impacts. Recommendations are also included to feed into current programme design or future plans or policies.

One of the major difficulties in evaluating nutrition-relevant programmes is attributing any changes (outcomes) to specific inputs as other external factors may have had a role.

Depending on the type of evaluation, the following should be explored:

Process evaluation:

  • the quantity, quality, timeliness and adequacy of programme inputs;

  • verify that inputs were transformed, through activities, into outputs that generated results;

  • examine targeting criteria and their application;

  • identify any operational constraints to programme effectiveness, giving recommendations;

  • determine whether a process or service meets national or international standards;

  • how did the programme stakeholders contribute to the programme outcomes when the programme was being implemented?

Impact evaluation:

  • determine what effect the program had on the target population and whether the effects are justifiably attributed to the interventions or to extraneous factors. Were the outcomes/objectives met? Were the needs met?

  • assess either positive or negative benefits on the community.

  • take account of any factors that threaten the validity of the programme – such as spill-over, substitution or selection bias. Have the needs changed?

  • analyse the timeliness and time-frame of the programme.

  • how effective were the strategies and systems used in the programme?

  • what is the level of participation of various stakeholders?

  • what lessons have been learned from the project/programme?

  • what changes would have occurred in the absence of the programme and what changes are actually a result of the programme?

  • are there other external factors influencing any changes seen?

3. Indicators and expected outcomes: Outline the indicators that should be used

Process evaluation

In order to determine whether the intervention is being implemented as intended, barriers to effective implementation need to be identified and strategies designed to overcome them.

The following are examples of indicators that can be incorporated in process evaluations:

  • performance targets;

  • intermediate inputs and outputs that play a central role in the implementation process (e.g. number of home visits by community workers, nutrition demonstration sessions, community participation, distribution of foods or micronutrients);

  • administrative data; poverty levels; prevalence estimates of malnutrition and diseases among children; coverage and targeting of other existing nutrition programmes;

  • monitoring data and end-user satisfaction surveys: proportion of communities/families targeted by the programme that actually participate, the socioeconomic background of these families, characteristics of those who dropped out, access to and quality of services.

Impact evaluation

The next step when assessing programme performance is to draw credible conclusions about its causal effects on a target population. To establish the effect of an intervention, indicators need to be carefully selected that match the project’s purpose and design (Annex 3 provides a useful reference for this).

In addition, the TOR’s can set out a range of expected outcomes. For example, programme designers may argue that after two years of implementation, the rate of malnutrition in the target population should have decreased by x%.

Cost-benefit analysis

Rigorous cost information allows comparisons to be made of different interventions and informs policy makers of the financial feasibility of scaling up programmes. Key aspects to guide the identification and estimation of the costs (or savings) and benefits within the context of evaluations are:

  • savings of resources devoted to neonatal care;

  • savings of resources devoted to the treatment of illnesses related to low birthweight;

  • reduced costs associated with lower morbidity among young children;

  • increased productivity due to improved health status and better cognitive and motor skills.

4. Evaluation methods. Present the evaluation methods and specify why this specific method ill be used.

The TOR should establish certain minimum standards for the methods to be employed in the evaluation. Furthermore, it should identify key information required to undertake the evaluation – in terms of primary data (sample size, sampling methods, level of precision, power, etc.) or secondary data (censuses, household surveys, etc.) as well as the characteristics necessary to conduct a survey.

An evaluation must employ data collection and analysis procedures that provide useful and valid information on the effects of a project. The evaluation design (needs to be developed prior to project initiation, permitting collection of baseline data), should include the collection of information on both participant and control groups.

5. Deliverables. Present the expected result of the evaluation under 6 evaluation criteriaas defined by the Organisation for Economic Cooperation and Development (OECD).98Specify the types of analyses required, the datasets and the number of reports to be delivered both during and at the end of the assessment.

Periodic evaluations are necessary to draw conclusions about the effects of the project on target populations. Evaluation results should serve to determine the extent to which desired changes in term of nutrition have occurred, and whether the project is responsible for such changes. The information presented should allow those who plan, implement and fund projects with nutrition objectives to make sound judgments on the future of the project.

6. Evaluation team. Specify the minimum qualifications, experience and expertise required for each member of an external evaluation team

Possible roles include:

  • an evaluation director, responsible for coordinating the planning and implementation of the evaluation and supervising the team;

  • a nutritionist, to provide technical expertise and help develop strong recommendations;

  • other resource people including project/programme staff members, social scientists or a statistician.

  • The evaluation team would need to refer to a small (internal) group who will be responsible for planning, supervising, and analysing evaluation information.

7.Time schedule. Define dates and deadlines for all the activities to be accomplished by the evaluation.

8. Report format

Title

The following text appears on the inside front cover of the report:

This report is financed by (name of the contracting authority) and is presented by (name of consultant) for the … (national institution). It does not necessarily reflect the opinion of…

Acknowledgments

Table of Contents

List of tables

List of figures

List of abbreviations

List of definitions

1. Executive Summary

A summary of the key issues, structured under the report’s headings (2 to 5 below).

2. Introduction

Background to the evaluation

Programme description

Literature review (programme documents)

Evaluation objectives

Evaluation questions and sub-questions

3. Methodology

Evaluation design

Data collection methods used

Methods of data analysis

4. Findings

Data presentation and description

5. Conclusions and recommendations

Bibliography

Appendices

Map of the evaluation site or area

Further details on methodology, data collection and analytical instruments used

List of people contacted

List of organisations or institutions visited

List of team members

Timetable of evaluation

Other detailed findings or results

Letters related to the programme or evaluation

Sources of further information

Monitoring and Evaluation. A Guidebook for Nutrition Project Managers in Developing Countries. Human Development Network, the World Bank, Sept 1999

/NUTRITION/Resources/Tool8-fulltext.pdf

OECD, Development Assistance Committee (DAC), Evaluating Development Cooperation. Summary of Key Norms andstandards

/media/k2/attachments/41612905.pdf

Monitoring and evaluation of nutrition and nutrition-related programmes. A training manual for programme managers and implementers. The Applied Nutrition Programme, University of Nairobi School of Nutrition Science and Policy, Tufts University, Aug 2000

http://www.globa/tool_docs/63/m&e_training_manual.pdf

Sphere, 2011: Humanitarian Charter and Minimum Standards in Humanitarian Response. /component/option,com_docman/task,cat_view/gid,70/Itemid,203

1 This was one of the conclusions of an expert panel of economists at the Copenhagen Consensus of 2008 .

2 World Bank, 2006. Repositioning Nutrition as Central to Development - A Strategy for Large-Scale Action.

3 Horton and Ross, 2003. The economics of iron deficiency. Food Policy 28 (2003) 51–75.

4 The figures are sourced from UNICEF, 2009. Tracking Progress on Child and Maternal Nutrition.

5 Sixty-third World Health Assembly Resolutions, 21 May 2010

t/mediacentre/news/releases/2010/wha_closes_20100521/en/index.html .

6 For instance, ‘The neglected crisis of undernutrition: DFID’s strategy’( /tna/20100423085705/http://dfid.gov.uk/Documents/publications/nutrition-strategy.pdf) and the French Government strategy: Nutrition dans les Pays en Développement – Document d’Orientation Stratégique (http://www.diplomatie.gouv.fr/fr/ministere_817/publications_827/enjeux-planetaires-cooperation-internationale_3030/documents-strategie-sectorielle_20004/les-pays-developpement-nutrition_87987.html).

7 UNICEF definition is used here.

8 Bryce J. et al, 2008: Maternal and Child Undernutrition 4. Maternal and child undernutrition: effective action at national level. The Lancet.

9 Statistics are sourced from the Lancet Series on Maternal and Child Undernutrition, 2008, unless otherwise stated.

10 Source: Lancet Series 2008, Global deaths and disability-adjusted life years (DALYs) in children under 5 years of age attributed to nutritional status measures and micronutrient deficiencies in 2004.

11 Vitamin A deficiency in children can cause blindness and increases the risk of disease and death from severe infections.

12 Zinc deficiency in children results in increased risk of diarrhoea, pneumonia and malaria.

13 Iron deficiency in children increases the risk of morbidity and impairs physical and cognitive development. For adults, it increases the risk of poor pregnancy outcomes and reduces work productivity.

14 Iodine deficiency impairs children’s cognitive development. Severe iodine deficiency during pregnancy can lead to stillbirth, spontaneous abortion and congenital abnormalities such as cretinism.

15 Grantham-McGregor et al, 2007. Child development in developing countries 1. Developmental potential in the first 5 years for children in developing countries. Lancet 2007; 369: 60–70. Excerpts from page 63.

16 Ibid, page 63.

17 World Bank, 2006. Repositioning Nutrition as Central to Development. A Strategy for Large-Scale Action. International Bank for Reconstruction and Development, Washington.

18 World Bank, 2006. Repositioning Nutrition as Central to Development - A Strategy for Large-Scale Action.

19 Data from 50 countries. Gwatkin R.D. et al., 2007. Socio-economic differences in health, nutrition, and population within developing countries – An overview. World Bank.

20 Horton and Ross, 2003. The economics of iron deficiency. Food Policy 28 (2003) 51–75.

21 Ibid.

22 This was one of the conclusions of an expert panel of economists at the Copenhagen Consensus of 2008 .

23 SCN, 2004. 5th Report on the World Nutrition Situation.

24 The figures in this section are sourced from UNICEF, 2009. Tracking Progress on Child and Maternal Nutrition.

25 From /idd_status.html (data from 2003 - 2008).

26 India, Pakistan, Bangladesh, Nigeria, China, Ethiopia, Indonesia, DRC, Philippines and Afghanistan.

27 Communication from the Commission to the Council, The European Parliament, The European Economic and Social Committee and The Committee of the Regions. Towards an EU Response to Situations of Fragility - Engaging in Difficult Environments for Sustainable Development, Stability and Peace. Brussels, 25.10.2007 COM(2007) 643 final. http://ec.europa.eu/development/icenter/repository/COM_2007_0643_EN.pdf. Page 5.

28 The Lancet list of countries was compared to the OECD’s list, given in: Resource Flows to Fragile and Conflict-Affected States. Annual Report 2008. OECD.

29 UNICEF, 2010. Progress for Children. Achieving the MDGs with Equity. Number 9, September 2010. Page 16.

30 IDS, 2007. Greater DFID and EC Leadership on Chronic Malnutrition: Opportunities and Constraints. A. Sumner et al. Institute of Development Studies, commissioned by Save the Children UK. Pages 4 and 33.

31 UNICEF 2010. Progress for Children. Achieving the MDGs with Equity. Number 9, September 2010. Page 17.

32 Ibid, page 17.

33 Black et al, 2008. Maternal and Child Undernutrition 1. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet, 2008, page 15.

34 The distinction between direct and indirect interventions has been made previously, including in the EC’s Concept Note: Enhancing EC’s Contribution to Address Maternal and Child Undernutrition and its Causes. January 2009. http://ec.europa.eu/europeaid/infopoint/publications/europeaid/183a_fr.htm.

35 (2005) http://ec.europa.eu/development/icenter/repository/european_consensus_2005_en.pdf.

36 (2007) http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:C:2008:025:0001:0012:EN:PDF.

37 Indicators for assessing infant and young child feeding practices – Part 1 – Definitions, WHO et al., 2008 and Guidelines for measuring household and individual dietary diversity, FAO/FANTA, 2008 and World Health Statistics - Indicator compendium - Interim version, WHO, 2010 and Nutrition Landscape Information System – Country profiles – Interpretation guide, WHO, 2010. Sphere, 2011: Humanitarian Charter and Minimum Standards in Humanitarian Response.

38 t/nutrition/topics/wha_nutrition_iycn/en/index.html.

39 t/gb/ebwha/pdf_files/WHA63/A63_R23-en.pdf.

40 The Lancet is the world’s leading independent general medical journal. The journal’s coverage is international in focus and extends to all aspects of human health.

41 /journals/lancet/article/PIIS0140673607616936/fulltext.

42 Esrey, SA (1996). Water, waste and well-Being. A multi-country Study, American Journal of Epidemiology, Vol 43, No 6, 608 – 623.

43 Source MICS surveys dated 2006: /mics3_surveys.html.

44 School Feeding for Improving the Physical and Psychosocial Health of Disadvantaged Students, Kristjansson B. et al., Campbell Systematic Reviews, 2006. See also: School feeding: Outcomes and costs, Galloway R. et al., Food and Nutrition Bulletin, vol. 30, No. 2, 2009.

45 A non-contributory scheme is one into which the eventual beneficiary is not required to make a direct personal financial contribution.

46 The Lancet Series qualified its conclusion to ‘specific contexts’ since most examples reviewed were from Latin America.

47 Sources: ‘External Evaluation of Oportunidades 2008. 1997-2007: 10 Years of Intervention in Rural Areas

Executive Synthesis’. Secretaría de Desarrollo Social Coordinación Nacional del Programa de Desarrollo Humano Oportunidades, 2008.Skoufias E., 2005, ‘PROGRESA and its Impacts on the Welfare of Rural Households in Mexico, IFPRI and Basset L., 2008, ‘Can Conditional Cash Transfer Programs Play a Greater Role in Reducing Child Undernutrition?’, World Bank.

48 World Food Summit Plan of Action, 1996.

49 World Bank, ‘From Agriculture to Nutrition – Pathways, Synergies, and Outcomes’, 2007.

50 Animal products are an excellent source of protein and micronutrients. Micronutrients tend to be more easily absorbed by the human body when they come from an animal source than from plants.

51 Nelson et al., Climate change impact on agriculture and costs of adaptation, IFPRI, 2009.

52 Johns et al., ‘A Foundation for Development – Nutrition and the Environment’, SCN, 2002.

53 Nutrition information can be highly politicised or politically charged.

54 The charter of the UN, the International Covenant of Economic, Social and Cultural Rights, the Convention of the Elimination of Discrimination Against Women and the Convention on the Rights of the Child.

55 t/nutrition/publications/code_english.pdf.

56 Guidance on entry points can be found in the Voluntary Guidelines to support the progressive realisation of the right to adequate food in the context of national food security (FAO, 2004). /docrep/meeting/009/y9825e/y9825e00.HTM.

57 The FAO has put together a ‘Methodological Toolbox on the Right to Food’ which includes:- 1. Guide on legislating for the right to food; 2. Methods to monitor the human right to adequate food – Vol.I; Methods to monitor the human right to adequate food – Vol.II; 3. Guide to conducting a right to food assessment; 4. Right to food curriculum outline; 5. Budget work to advance the right to food. /righttofood/publi_02_en.htm.

58 Paragraph 5 of the Preliminary Study of the Human Rights Council Advisory Committee on discrimination in the context of the right to food. Human Rights Council 22 February 2010.

59 Copenhagen Consensus 2008 – Results. Five of the top nine strategies endorsed by a panel of expert economists concerned undernutrition.

60 Report on High Level Meeting on Nutrition, organised by the UN Standing Committee on Nutrition and hosted by the European Commission. 23-24 November 2009, Brussels. See page 3.

/files/Annual_Sessions/2009_Brussels/Brussels_High_Level_Nutrition_Meeting_report__final.pdf

61 Edited excerpts from World Bank, 2006, page 108. Repositioning Nutrition as Central to Development. A Strategy for Large-Scale Action./NUTRITION/Resources/281846-1131636806329/NutritionStrategy.pdf.

62 Adapted from World Bank 2006. Scaling Up Nutrition. What will it cost? Horton S. et al. Page 106.

63 Demographic and Health Surveys (DHS) are nationally-representative household surveys that provide data on a wide range of monitoring and impact evaluation indicators in the areas of population, health, and nutrition. /aboutsurveys/dhs/start.cfm.

64 UNICEF assists countries in collecting and analysing data to fill data gaps in monitoring the situation of children and women through its international household survey initiative, the Multiple Indicator Cluster Surveys (MICS). /statistics/index_24302.html.

65 World Bank, The Living Standards Measurement Study (LSMS) was established by the Development Economics Research Group (DECRG) to explore ways of improving the type and quality of household data collected by statistical offices in developing countries. /WBSITE/EXTERNAL/EXTDEC/EXTRESEARCH/EXTLSMS/0,,contentMDK:21610833~pagePK:64168427~piPK:64168435~theSitePK:3358997.00.html

66 For example, the model of Managing for Development Results Framework could be used. /.

67 /document/18/0,3343,en_2649_3236398_35401554_1_1_1_1,00.html.

68 http://www.goodh/gns/principles-good-practice-ghd/overview.aspx .

69 Principles for Good International Engagement in Fragile States & Situations. OECD/DAC, April 2007, Paris. /dataoecd/61/45/38368714.pdf.

70 Principles for Good International Engagement in Fragile States & Situations. OECD/DAC, April 2007, Paris. /dataoecd/61/45/38368714.pdf.

71 COM(2007) 643. Communication from the Commission to the Council, the European Parliament, the European Economic and Social Committee and the Committee of the Regions: Towards an EU response to situations of fragility - engaging in difficult environments for sustainable development, stability and peace. http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=COM:2007:0643:FIN:EN:PDF.

72 Whilst humanitarian actors are guided by the humanitarian imperative to save lives and to respond to suffering without discrimination of any kind, development actors tend to be guided more by the need to maximise growth and development by building national capacities, cooperating closely with national governments and assisting people who have viable potential as opposed to the most vulnerable and most in need.

73 ECHO internal Reflection paper on nutrition in emergencies. May 2010.

74Excerpts from the ECHO Interim Position on Nutrition (IPN) paper, 2010.

75 Excerpt from the ECHO Interim Position on Nutrition (IPN) paper, 2010.

76 WHO, 2010.

77 WHO, 2010. Nutrition Landscape Information System (NLIS). Country profile indicators: interpretation guide. t/nutrition/nlis_interpretation_guide.pdf.

78 Ibid.

79 Nutrition and Diet Therapy Reference Dictionary. Rosalinda T. Lagua and Virginia S. Claudio. New York: Chapman & Hall, 1995.

80 Gross, R. et al. (1998): Community Nutrition: Definition and Approaches. Encyclopaedia of human nutrition. Ed. by M. Sadler, S. Strain and B. Caballero. London.

81 Note that WFL is used for children under 85cm (meaning children are measured when lying down); WFH is used for children measuring 85cm and over (meaning they are measured when standing).

82 Black et al, 2008.Lancet series.

83 World Bank, 2006. Scaling Up Nutrition. Stunting estimates for the 32 countries come from 2003-2008 figures, presented in UNICEF, 2009: Tracking Progress on Child and Maternal Nutrition.

84 UNICEF 2009. Tracking Progress on Child and Maternal Nutrition.

85 World Bank 2008 Poverty Reduction Strategies. /WBSITE/EXTERNAL/TOPICS/EXTPOVERTY/EXTPRS/0,,menuPK:384207~pagePK:149018~piPK:149093~theSitePK:384201,00.html.

86 Cited in SCN, 2009. SCN News No 37: Landscape Analysis on Countries’ Readiness to Accelerate Action on Nutrition /layout/modules/resources/files/scnnews37.pdf.

87 EC AID Delivery methods, project cycle management guidelines, p138.

88 There is the potential for confusion over what is meant by a ‘result’: In the Commission’s ‘input -output-outcome-impact’ typology, it would correspond to an ‘outcome’, such as primary school enrolment. The amount spent on primary education would be classified as an ‘input’; the number of primary teachers trained would be an ‘output’, and literacy rates would be an ‘impact’. Thus the terms ‘result’ and ‘outcome’ should be treated as synonymous.

89 Composite indicators can be broken down and do not necessary need to be used in their entirety.

90 WHO/UNICEF 1989. Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services, a joint WHO/UNICEF Statement. /newsline/tenstps.htm.

91 UNICEF 2009, tracking progress on child and maternal nutrition.

92 DFID, 2010.

93 World Bank, 2010.

94 Lancet Series cites evidence for implementation in specific contexts, but World Bank, 2010 suggests: ‘given the high prevalence of iron deficiency anaemia and low costs of iron fortification, a wider application is justified’.

95 See /mdg/.

96Note: Climate-related policies and strategies may be described here but are also covered in more detail in Section 4.4.

97 Taking into account that other factors intervene in the choice of cooperation sectors, including past cooperation areas and the ‘division of labour’ between development partners in the context of the Paris Declaration.

98 OECD, Development Assistance Committee (DAC), Evaluating Development Cooperation. Summary of Key Norms andstandards /media/k2/attachments/41612905.pdf.



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