Ramadhani Abdallah Noor
Complementary feeding for children 6 months to 2 years of age: context matters.
Refinement Updates
Feedback to questions shared:
1.
Where in Tanzania will this idea be implemented;
This project will be implemented in Dodoma region, Chamwino district. Dodoma region has been chosen due to poor health indicators data in maternal as well as child health.
Dodoma is a predominantly rural region situated in the Central zone of Tanzania and covers an area of over 41,000 km
2
. Approximately 2 million people live in the Dodoma region. The region is made up of 6 administrative Districts, 28 Divisions, 177 Wards, and 457 Villages covering a total of 41,310 square meters. The region has 7 hospitals of which 5 are government and 2 are faith-based. There are 25 Health Centers of which 5 are faith-based facilities, in addition to the designated district hospitals.
According to Regional Annual reports, the regional facility based data indicates that the MMR in
2010 it was 110/100,000 and in 2009 it was 124/100,000. Available data indicate that 69% of births are attended by skilled personnel. There is also a 66% unmet need for family planning.
The reported antenatal attendance proportion is 98% while immunization coverage is 97%.
According to the region’s 2010 health report, the IMR is 95/1000, while the under five MR is
154/1000. The crude birth rate (CBR) is estimated at 40/1000 persons. There is also a noticeable shortage of health facilities and health care workers aggravated by some gaps in service implementation.
According to the 2013 Central Zone Reproductive and Child Health Report, 16% of the total population is 0-5 years of age and 24% is 15-49 years of age. Most sociodemographic and health indicators in Dodoma and in broader Central region are poor in comparison to the national average. The 2010 DHS reported that the median duration of formal education among men and women aged 15-49 years is 6.2 and 6.1 years, respectively. The vast majority of both men and women in Dodoma are employed in the agricultural. The total fertility rate in the Central zone is
6.5 per woman and the crude birth rate in rural areas of Tanzania, such as Dodoma, is 39.0 per
1,000 people. The 2010 Tanzania demographic survey shows that rates of child under nutrition in Dodoma are strikingly high: the prevalence of stunting, wasting and underweight among children under five is 56%, 5.2%, and 26.8%, respectively. In children less than 5 ages, anemia is reported at 48%, Iron deficiency 29% and Vitamin A deficiency at 30%.
Correcting these poor health indicators with existing weaknesses in Health system requires integrated community approach and prioritizing nutrition interventions; which are both the basis of the proposed LisheKwanza program.
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Ramadhani Abdallah Noor
Geographical description:
Source: Dodoma RMO office
Most of Dodoma residents are peasants, agriculture and livestock being their major economic activities. Dodoma is frequently faced by drought and therefore food scarcity. The region is classified as a food insecure region. As a result, Dodoma has a high burden of maternal and child health death and illnesses primarily caused by poor nutritional health.
This project will be conducted in Chamwino district; The projected population for the year 2014 is
330,543 (TBSD 2013) with a population density of 34 people per square kilometer. The District has a total area of 8,742 sq.km
2 with 777 hamlets, 78 villages and 32 wards which together aggregate into five
(5) divisions.
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Ramadhani Abdallah Noor
2.
Are there existing women groups plan to be included?
In collaboration with the district authorities we have already identified potential women groups at the district. There are over 10 women groups, most of them are micro financing groups and 3 special groups that work closely with district hospital in providing community based care, e.g. Health sensitization programs for vaccinations, HIV and TB home based care support, etc. These later groups have systems in place that bridge health facilities and communities, as well as outreach capacity / services to the level of households. We plan to work with 2 selected groups to start with covering 4 villages.
3.
What are the household approaches to local farming and processing?
This implies small scale farming and food processing; more specifically homestead food production through home gardening and/or backyard farms which is a common practice in rural parts of
Tanzania, like Dodoma. This approach is motivated by increased production (yield) from small pieces of land as a result of adequate adoption of technology and agricultural expert advice. Similarly, un favorable gender balance when it comes to land ownership and decisions to bigger family farms makes this approach more promising to start with, while gradually shifting to bigger farms as women gets empowered and men involvement into LisheKwanza program grows.
4.
Innovation (in the space that I work on)
The organization and collaborative efforts that I am involved, focuses on maternal and child health.
We do so through research, training and practice related activities. Our main area of interest is on
Nutrition health, before pregnancy, during pregnancy, post delivery and breastfeeding as well as early child nutrition. Our approach to prevention of malnutrition has been primarily on targeted micronutrient supplementation, iron in pregnant women, Vitamin A in newborns etc; all with weak to none significant effects or low impact in correcting existing deficiencies. Our group is currently, changing strategy and looks into avenues that adequately integrates agriculture nutrition and health; specifically targeting interventions across the value chain that impacts nutrition of women and children at the household level. Proposed project goes a step further, emphasizes on the role of women and context when it comes to child nutrition and optimal thriving.
Our collaborating partners in Dodoma, the Government through the district authorities and the
Ministry of Health; have traditionally emphasized on supporting community health workers, agriculture extension officers and now have introduced a new cadre, District Nutritionist; all in an effort to strengthen nutrition health especially for women and children. This approach inadvertently has continued to place women (target beneficiaries) on a receiving end and more so as second or third party when it comes to ownership of efforts. Disregard of context in most cases, has made these efforts less effective in enhancing nutrition value of traditional practices that women share across generations.
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Ramadhani Abdallah Noor
Similarly, “medicalized” solutions lead by health facilities, nutritionists; community health workers through cancelling and/or micronutrient supplements e.g iron and folate for pregnant women have proven limited effectiveness due to frequent stockouts, low compliance rates etc. in most cases, when we spoke to women they emphasize need for healthy food and not tablets as a primary intervention. Supplements should continue to be emphasized, but access to nutrient rich foods is necessary.
LisheKwanza program therefore seeks place purpose, ownership, responsibility and accountability primarily to women; and through peer support from LisheKwanza groups empower women to produce, create demand, market, and purchase power all necessary for sustainability of the program. The program bridges the weak health care system and community, while placing women at the forefront of improving child nutrition practices. This approach has more potential to influence intergeneration’s practices for women and child nutrition.
5.
Collaborations and expertise available.
Our team is primarily based at the Africa Academy of Public Health (AAPH), based in Tanzania.
Through related activities in this area, we have made strong collaborations with various partners, bring in diverse expertise. Below are some of the collaborations in place that will benefit proposed program.
Harvard School of Public Health (USA); collaboration mainly through Department of Nutrition and Global Health, allows technical support especially in designing and implementing health evaluations. Together, we are collaborating with Ifakara Health institute, Sokoine university of
Agriculture (SUA) in establishing a joint agriculture nutrition and health forum. This forum brings on board various stakeholders from the country as well as the region in discussing ways for integrating the three sectors and maximizing impact at the level of household. For this project,
HSPH will provide technical support on planned evaluations and scientific aspects related to nutrition products and nutrition monitoring. Through collaboration with HSPH, our team has already developed food composition tables for Tanzania which will be used in assessing nutritional value of traditional recipes in this program.
University of Dodoma: University of Dodoma shall provide local technical support in areas of data management, local technical support in research and training related activities of the program.
Chamwino District: Through the regional Health Management Team, we collaborate with the
Chamwino district authorities especially the office of District Medical Officer. Together with
HSPH and University of Dodoma; we are at advanced stages of establishing a demographic health survey (DSS) starting with Chamwino district. The DSS will allow integration of nutrition surveys as well as evaluation for program indicators as part of DSS survey, hence requiring minimal resources from the program. Through district authorities, we shall be able to work with
District nutritionist, agriculture extension officers and community health workers, all necessary for this program.
6.
Further collaborations to solicit:
We need to work with Microfinance experts who will support the LisheKwanza groups to draw business plans and attain needful entrepreneurial skills. This is key strategy for sustainability, as without enhanced markets, demand and production is likely to fall, hence threatening scalability
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Ramadhani Abdallah Noor of the program. We have identified potential partners from the University of Dar Es Salaam as well as micro finance institutions in Dodoma. Existing women microfinance groups in Dodoma provides a modal to succeed in this area.
We need to work with small scale industry experts in food processing. Our target is obtain low cost locally built machines for the LisheKwanza groups to use for semi processing of the selected nutrient rich foods into low cost infant feeding products. We have identified, Small Industries
Development Organization in Tanzania (SIDO) to support on such capacity
( http://www.sido.go.tz/Web/Index.aspx
)
Quality assurance and Quality Control – in Food processing and packaging; we have identified the following government patners whom we have to work with; Tanzania Bureau of Standards
(TBS) and the Tanzania Food and Drugs Authority (TFDA). We are exploring a few potential partnerships with expertise and support in renewable energy, needs of LisheKwanza groups.
7.
Prototyping
We have undertaken initial survey to explore what women and various district officials think about this idea, with positive feedback.
First, we have learnt about common nutrition deficiencies as well as common infant feeding practices. In this community, complimentary infant feeding starts early normally around 3-4 months old for most children. Main recipes are based on energy dense foods, the staples – e.g. maize flour porridge, millet and a few reported baobao tree leaves as vegetables, and bao bao seeds powder porridge. There is limited diversity in terms of other nutrients, for both mother and child nutrition.
Most families produce other varieties e.g. sesame seeds, groundnuts from their farms but these are mainly reserved for commercial purpose. Most women feel less able and less supported to produce needful varieties for their households. The following are key concerns and/or observations learnt from preliminary surveys;
Perishability – lack of low cost food processing technologies has had negative influence on production of foods like fruits and vegetables resulting into limited access due to unavailability and high prices.
Affordability; most families cannot afford to buy diversified types of foods especially those needed for child nutrition. For example, though Dodoma people are peasants and keep livestock, milk and meat consumption has remained very low in these communities.
Accessibility – communities in food in secured regions like Dodoma, generally have poor access to many nutritious foods.
Existing Behaviour / food culture: it is very difficult and often unsustainable to change food culture and traditions e.g. infant feeding practices – type of foods and recipes.
Knowledge; low literacy rates makes conventional knowledge transfer mechanisms e.g. nutrition counseling in adequate to achieve desired behaviors.
Hence this program has taken into consideration on the above raised concerns and reasons for failure of existing interventions; necessitating novel approaches across the value chain.
Incorporating aspects of food processing will enhance the shelf life for most foods, and improve affordability and accessibility. Use of peer women groups and transfer of knowledge and skills in practice through supported interactions with other women in LisheKwanza groups is expected to
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Ramadhani Abdallah Noor be more effective especially when done in addition to conventional methods. Enhancing nutrition value within the local context e.g. traditional crops, recipes and feeding practices is a novel way to positively influence food culture sustainably.
8.
Further Consultation (Literature as well as discussions at the Tanzanian Joint forum in Agriculture,
Nutrition and Health) – informing design of the proposed program.
Current literature on maternal and child health and nutrition makes a compelling case for the implementation of interventions that focus more holistically on preventing the occurrence of malnutrition through agricultural practices. The literature suggests two primary pathways exist through which agricultural interventions can impact to nutrition: (1) Own Production → Food Consumption, and
(2) Income Generation → Food Consumption. However the evidence base for these relationships is poor. Nonetheless, growing concerns about food security and its effect on the health and nutritional status of individuals residing in low- and middle-income countries has resulted in renewed interest in the efficacy of nutrition sensitive agricultural interventions to support and enhance current health and development initiatives.
Until recent, link between agriculture nutrition and health had not been well explored. Though, the agriculture, nutrition and health interrelation is now gaining appreciation; in practice the sectorial approach has not provided much integration. At the community level, these sectors don’t exists and thus need to integrate and share a holistic approach with a common ultimate goal. There are challenges at present, especially at the level of community – to mention a few, for example; Community Health
Workers and Agriculture Extension workers have different reporting lines, often don’t necessarily meet or work together etc.
The minimum 42 nutrients that we need cannot come from Maize alone, or Beans or any of the staple foods that we have emphasized over the recent past. We need a combination and varieties of foods. The question is, how much variety, and how many nutrients can we get from unit square area of land, that is not just promoting agriculture revolution but focusing more on Nutrition Sensitive Agriculture. Thus we need to explore and measure agriculture performance along these measures.
There are gaps and ongoing initiatives don’t reach out all those in need; There are no blanket recommendations, we need to take context into consideration; for example, asking ourselves what foods are locally available to provide needful nutrients. Proposed project and the like, will allow us an opportunity to think of how other sectors can support Agriculture, Nutrition, and Health continuum I.e. water for agriculture, water for health or Education for agriculture or Education for Health. We need to think on how this integrated approach can be accommodated by the systems – Health systems, for example etc. – the best way to learn all this is by doing, by implementing programs like LisheKwanza.
9.
Supportive / enabling/ concerning environment for the project:
A number of enabling factors have been realized for successful implementation of LisheKwanza program / project;
(policy) Kilimo kwanza policy led by Hon. President Mrisho Jakaya Kikwete revamps the agriculture sector and promote the Green Revolution in Tanzania. This policy provides emphasis in terms of agriculture extension package; formulating and contextualize the agenda coming
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Ramadhani Abdallah Noor from higher up (donor funding authorities) with inputs from farmers. Kilimo kwanza policy provides an opportunity to influence multisectoral efforts beyond agricultural value chain, to impact the whole continuum – i.e. nutrition and health.
Agriculture extension workers (AEO’s): a new cadre of agriculture community level officers has been rolled out across the country. The problem is that Agriculture extension officers are still few and spread thin compare to the needs on the ground. They are presently based at the ward level, whereas Nutrition Disctrict officers (DNO’s) (also a new cadre is based at the district) and the Community Health workers (CHW) (another new cadre is based at the village level. This to a great extent defeats the smooth integration expected at the ground level. To compliment this effort and cover the gaps, there is need to undertake careful evaluation of existing modals and/or develop novel modals that will enhance/amplify impact of these cadres at the community level. “Shamba darasa” i.e. central farm was cited as one of the potential modals whereas nutrition as well as health sensitive interventions can be integrated along the design – the question is therefore, how we promote this modal and bring in women for example as leaders rather than end users/beneficiaries alone. Further thoughts, are needed in exploring how these platforms and investments can be used to promote, integrate and scale up technologies e.g. nutrient rich crops e.g . vitamin A rich potatoes, protein rich maize etc
Subsidies (fertilizer and seeds): Subsidies are essential in supporting small scale farmers and examples where given on where subsidies have shown to work – promoting better seeds, use of fertilizers etc. Subsidies have provided Tanzania with a mechanism to promote production of staple foods (food security). The questions and the focus should now be on how do we incorporate varieties like, fruits and vegetable into this system – so far, vegetables and fruits are not subsidized by the government schemes i.e. in terms of seeds and fertilizer. Expanding subsidies and other financial schemes, e.g. microcredits to women and youth; to support production of nutrient diverse foods like fruits, vegetables, milk, eggs, meat, fish etc will go a long way in expanding the agriculture extension package and promote production of nutrient rich foods beyond commercial needs, i.e. for household’s consumption.
Income generation: Regions rich in food production in Tanzania, are no exception when it comes to malnutrition and some of these regions are leading in terms of stunting. This is a good example on how agriculture affects nutrition – issues starting with policies (what subsidies support) , gender and flow of information / knowledge, care (women prioritizing men more than children in food preparation at household level), can be best addressed into context with strong community and gender focused modals like LisheKwanza.
Food safety (mycotoxins eg. Aflatoxin + a number of toxins affecting – maize, cassava, ground nuts); impacts mother and child health, and remain as an important cause of stunting. Aflatoxin promoting – agriculture practices, climate change and food processing (e.g during value addition processes for commercial purposes e.g. commercial baby foods production) have been widely implicated and provide an opportunity to intervene as far as research, training and practice concerns.
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Ramadhani Abdallah Noor
Value addition is an important link between agriculture production and nutrition: How do we train, advocate and support producers; when we talk of food production per square hectar – how do we support smallholder women farmers on what to produce, how much land to support post-harvest processes, enhancing nutrition (value adding activities), and income generation for households. Ongoing green revolution across the country, provides an avenue for technology transfer and adoption for coordinated programs like LisheKwanza.
Gender issues: Male involvement – need to use approaches promoting production of cash crops, to promote production of nutrients rich food products. Increasing need to empower women with financial mechanisms, land ownership, etc; and make an impact in agriculture production, and household income to support nutrition, education and health needs at household level.
This program is designed based on wide consideration based on the local context. Implementing this idea provides an opportunity for novel and comprehensive approach towards elimination of mother and child malnutrition, enabling parents to ensure optimal thriving for their children during the critical window period 6 to 24 months, and through the first 5 years of life. LisheKwanza, built on local capacities caries high potential to be replicated at scale in similar settings like Dodoma.
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