Aude Favre, Karin Gross and Marlene Heeb
The good news is that hunger is decreasing worldwide. The bad news is that malnutrition has increased. The Global Nutrition Report 2016 illustrated that nearly 800 million people experience hunger and suffer from calorie deficiency, 2 billion people worldwide suffer from micronutrient malnutrition and 2 billion people are overweight and obese. Nutrition has become more complex over the last decades with the apparition of the double burden of malnutrition: Many countries witness a simultaneous increase of undernutrition and overweight. In low- and middle-income countries, poor nutrition has led to a fast rise in childhood overweight and obesity while undernutrition still causes nearly half of deaths in children under five years old worldwide. Particularly, the globally changed dietary patterns, with an increasing consumption of meat, sugar, fats and processed food have led to a rapidly increasing proportion of overweight children world-wide. This is alarming since obese children are very likely to remain obese as they grow up and to be at high risk for non-communicable diseases (NCDs) like diabetes or heart diseases.
Malnutrition is a multi-faceted problem with multiple causes across a number of sectors. Single sector approaches do not work for nutrition interventions. The fight against malnutrition requires a multi-sectoral approach, covering aspects of health, water and sanitation, education, agriculture and many more.
In 2016, SDC invested 44.3 Mio
CHF in nutrition specific and nutrition sensitive projects such as the
project Nutrition in Mountain Agro-ecosystems (NMA) in Pakistan, Kyrgyz
Republic, Ethiopia, Peru and Nepal Photo: Marlene Heeb, Kyrgyz Republic, 2017.
How are our projects doing?
SDC’s Global Programme Food Security together with the Global Programme Health recently conducted a resource tracking exercise based on a methodology developed by the SUN Donor Network (Scaling Up Nutrition). At an international level, this exercise aims at increasing accountability for international development funding targeted at improving nutrition. At an SDC internal level, the exercise revealed that SDC supports many interventions in the health, water and agriculture domains, which are considered nutrition-sensitive. Interventions are nutrition-sensitive if their primary objective is not nutrition, but if they have the potential to improve the food and nutrition security of beneficiaries or address the underlying causes of malnutrition (e.g., by targeting agriculture and food security, health, care, education, water and sanitation).
In 2016, SDC invested 44.3 Mio CHF in nutrition specific and nutrition sensitive projects such as the project Nutrition in Mountain Agro-ecosystems (NMA) in Pakistan, Kyrgyz Republic, Ethiopia, Peru and Nepal Photo: Marlene Heeb, Kyrgyz Republic, 2017.
There is much untapped potential in agriculture, health and WASH projects
The review of project in the frame of the resource tracking exercise showed that most SDC projects in these domains do not tap their potential for improving nutrition. In most cases, there are no specific nutrition objectives or indicators defined. SDC’s agricultural engagement, for example, often works on improving agricultural value chains to increase income. Considering nutrition challenges already in the choice of value chains as well as the processing steps of the product can be a first effective way to increase their contribution to improved nutrition. Let’s take the example of health: SDC’s health engagement strongly focuses on health system strengthening at the primary health care level. Through this focus, we can improve health care services in general, but also put emphasis on nutrition advice and breastfeeding in prenatal and mother and child health programs, thereby contributing to improved nutrition and NCD diet-related risk factors. SDC has many programs which promote and facilitate access to clean drinking water, sanitation and hygiene facilities (WASH). These programs can be a great entry point for linking the importance of WASH facilities to improving nutrition, as it is often underestimated in its contribution or not incorporated clearly in the project design, implementation and monitoring.
Improving hygiene and sanitation has tremendous effects on well-being and increases the body’s ability to take up and use nutrients. In our projects, we can acknowledge and increase these benefits by programming in a more nutrition-sensitive manner. Photo: WaterAid / Marco Betti.
Improving hygiene and sanitation has tremendous effects on well-being
and increases the body’s ability to take up and use nutrients. In our projects,
we can acknowledge and increase these benefits by programming in a more
nutrition-sensitive manner. Photo: WaterAid / Marco Betti.
Acknowledging these untapped opportunities, the Working Group Nutrition would like to join forces with the domains health, water and agriculture and food security (A&FS) in order to enhance SDC’s projects’ impact for improved nutrition. Therefore, the working group encourages programme managers to take into consideration the following aspects when designing coopation strategies or planning new projects or follow-up phases:
Health: There is evidence that nutrition during the first 1000 days after conception is essential for the early development in life, but also for lifelong health. Improving pregnant women’s and mothers’ access to prenatal and maternal health care has a major positive impact on the nutritious status of women and their child (Lancet Series 2008 and 2013 on maternal and child nutrition). There are several entry points to be considered when defining objectives and indicators: By accessing prenatal and maternal health care services, women’s health can be checked; essential micro-nutrients (iron, folate, folic acids, etc.) can be prescribed; advice and counselling on breastfeeding, healthy diet and food diversity during and after pregnancy can be delivered; breastfeeding-initiation during the first hour can be promoted, and post-natal care can help counselling women on how to wean and introduce food to their toddlers etc.. All these interventions – with their potential to improve the mother’s and child’s nutrition and health – should be an integral part of SDC’s health system strengthening projects at the primary health care level.
Agriculture and Food Security: A crucial aim for nutrition-sensitive projects in the domain of A&FS is to facilitate healthy and diversified diet for everybody on a regular basis and throughout the entire lifetime. This requires looking at food value chains, food consumption habits, gender, food and agricultural policies. Improving nutrition through a food-based approach can start with the selection of value chains: Consider not only their economic potential, but also their contribution to improving nutrition. Working on fruit, vegetable and protein sources value chains like milk, eggs, insects, pulses and small livestock, can significantly contribute to tackle vitamin, mineral or protein deficiencies among consumers. Improving cold chains, preservation techniques and transformation of perishable nutritious food, such as fruits and vegetables, facilitates their availability throughout the year; a key challenge regarding malnutrition! Agricultural and food policies play an important role in facilitating availability, accessibility, utilization and stability of nutritious food for consumers. Policies promoting the cultivation of nutritious food, like fruits and vegetables, pulses etc. consider the consumers’ nutrient requirements rather than focusing only on their caloric need covered by staple crops like maize and rice.
Water and WASH: Improving access to water and sanitation for women, men, adolescent girls and boys also contributes to their nutritional status. By accessing clean drinking water and sanitation facilities, beneficiaries are less at risk for diseases like diarrhea and can therefore also retain the nutrients they consume better. Moreover, having access to proper sanitation and clean water tremendously reduces the risk of getting sick. This is especially important for the development and well-being of children. It increases their chances of survival and supports them in the development of important physical and cognitive functions. Improving water management in general can further avoid waterborne human diseases.
Keeping in mind – and even more importantly integrating – nutrition objectives and indicators in health, water and agriculture projects will strengthen nutrition, and thereby improve health, education, economic productivity and development. The resource tracking exercise revealed that there is huge potential to make projects and interventions more effectively towards the elimination of malnutrition!
Ask the working group on Nutrition at SDC about the resource tracking exercise and how they evaluated current SDC projects! The group can provide you with more detailed information on the analysis of projects and assist you upon demand with adapting your existing projects or designing new interventions to assure they leverage the full potential to fight malnutrition and thus contribute to SDG 1, 2, 3, 4, 5, 6 & more!
For information on health and WASH contact: Karin Gross, karin.gross@eda.admin.ch
For information on the Nutrition Working Group and the A&FS domain contact: Marlene Heeb, marlene.heeb@eda.admin.ch
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Erika Placella
Strong health governance ensures that health sector resources and funds achieve their intended results, including the provision of priority health services. According to WHO, “governance in the health sector refers to a wide range of steering and rule-making related functions carried out by governments/decisions makers as they seek to achieve national health policy objectives that are conducive to universal health coverage”.1
From a health systems strengthening perspective, there are five key aspects of governance that are important in explaining the ability of health systems to provide accessible, high-quality, equitable, affordable, efficient, and sustainable health care: transparency, accountability, participation, organizational integrity and policy capacity.2
Most of SDC health programs in Eastern Europe and Central Asia have strong good governance components and aim at increasing the equitable access to quality and affordable health care for all. To this end, an approach centered on transparency, accountability, inclusion and participation is introduced.
As regards transparency, one of the most important expected outputs of SDC programs in Ukraine is the effective and regular communication on health care reform progress from the Ministry of Health. It is expected that this communication is transparent, regular, strategic, and efficient, with clear definition of key target audience, proper preparation of key messages, and its delivery through defined communication channels. Strengthening public information on health policies, health expenditures and insurance entitlements is also a strong component of the SDC health portfolio in Moldova.
Transparent information on free-of-charge sexual and reproductive health services for youth in Moldova. Photo: SDC 2016
In Kyrgyzstan, transparency at central level is strongly promoted by SDC: as a result the Ministry of Health reports twice a year to the Parliament on progress of the reforms. Information on budget and expenditures is available on the Ministry of Finance website and key documents and progress reports of the Health Sector Strategy are posted on the Ministry of Health website. The Joint Annual Reviews receive high media coverage and the public can and does participate in them.
Accountability in health involves an understanding of how services will be supplied, financing to ensure that adequate resources are available to deliver services, performance around the supply of services, and receipt of relevant information to evaluate or monitor performance. In Eastern Europe, health services are still curative, hospital-centric and inefficient, despite substantial reforms introduced over the past years. They absorb most of the state budget and limited resources are allocated to health promotion and disease prevention which are recognized to be much more cost-effective. SDC health programs aim at improving the performance and efficiency of health services at the primary level, at strengthening disease prevention, and promoting healthy behaviors. In Kyrgyzstan, the budget support provided by Joint Financiers is discussed and agreed on an annual basis. The level and distribution of funds are adjusted annually, based on the performance, absorptive capacity, and identified needs. In Kosovo, through a Trust Fund, SDC is providing technical assistance to the Ministry of Health and the Health Insurance Fund in designing and implementing performance-based payments and DRG payments for hospitals. In Ukraine, SDC support aims at strengthening the capacities of the Ministry of Health to govern and deliver quality public health and result-oriented and inclusive health services. This implies assigning clear mandates according to the roles expected of actors in the health sector and in alignment with other sectors, to ensure that institutional and organizational arrangements fit with overarching goals, while minimizing overlaps, duplication or fragmentation in processes. Accountability should be properly measured and monitored by selecting specific indicators. SDC uses the WHO toolkit to define good governance indicators. It consists in rules-based indicators (i.e. existence of up-to-date national health strategy linked to national needs and priorities, existence of an essential medicines list updated within the last five years) and outcome-based indicators (i.e. proportion of government funds which reach district level, stock-out rates of essential drugs in health facilities, perception of quality of services by end-users, proportion of informal payments within public health care system).
SDC health programs aim at improving financial protection and reducing the financial burden on patients. In the case of Kyrgyzstan, the increased public funding and the strengthening of the Single Payer system and its national pooled resources allocated to the State Guaranteed Benefit Package has allowed greater access to care and to universal coverage for some basic services. Funds are allocated with greater regional equity and efficiency has improved: increasing share of funds are allocated to primary care, while in-patient care facilities are allocating more resources to direct medical costs, instead of maintenance of infrastructure. Decentralization of decision-making to local entities is central for good governance. In Kosovo, where the responsibility for the delivery of primary health care services is decentralized to local level, municipal governments are key partners. In order to improve the skills of health managers at both municipal and facility levels, a strong management training system has been developed. It focuses on facility and service management, basic health technology management, planning, financial management and budgeting, human resources, communication, and leadership. In Kyrgyzstan, an innovative program aims at improving the efficiency and quality of health care services by expanding the autonomy of service providers. The impact hypothesis is that by granting expanded autonomy to health facilities‘ managers, in combination with clear vision, adequate managerial capacity, appropriate accountability mechanisms and effective incentives, they will be able to provide health care services in a more efficient way and with better quality. A governing system at rayon level has been established to steer and monitor the work of decentralized health facilities within new accountability mechanisms and effective communication strategy.
Mental health service users-led health advocacy in Bosnia and Herzegovina. Photo: SDC 2017
Participation of users is central in SDC health programs. This involvement starts at the policy development stage and is ensured throughout the process. Local population is strongly involved in the elaboration and monitoring of business plans and budget allocated to health care facilities. Civic engagement in primary health care service delivery is supported through the development and institutionalization of feedback processes (complaint handling mechanisms, participatory planning and budgeting, quality audits) between communities and health services, as a basis for accountability and increased awareness on patients’ rights. Mental health programs in Bosnia and Herzegovina and Moldova aim at strengthening community-based mental health services, thus reinforcing the role of the community as service providers and advocacy actors. As regards organizational integrity, in Kyrgyzstan, the budget support aims at strengthening the capacity of the Ministry of Health in the implementation of Public Finance Management reforms in the Health Sector, more specifically to ensure that the Ministry of Health and the Mandatory Health Insurance Fund are capacitated to take an active part in the budget processes in conjunction with the Ministry of Finance. This includes support in financial reporting, procurement, contract management and the use of the medium term budget framework.
In Albania, management capacities at the primary health care level are developed to foster the autonomy of local government units, including on efficient resource allocation and corruption prevention. To better define the scope of intervention in anti-corruption, the program relies on a risk assessment generated by the EU-funded Project against Corruption. The promotion of citizen/patient information and the increase of their knowledge of entitlements, the set-up of patient complaints systems and the training of health workers in anti-corruption practices are the major key components of the intervention.
In Kosovo, the mobilization and role of civil society organizations for the purposes of developing social accountability and increasing awareness on patients’ rights, is strengthened. Particular attention is paid to supporting organizations that represent the concerns and needs of vulnerable groups (Roma, disabled, elderly). Health mediators have been trained to address the specific needs of Roma population.
As regards policy capacity, in Kyrgyzstan, Moldova, Ukraine, Kosovo and Albania, SDC is supporting health authorities to develop, implement and review national/sub-national policies and integrated strategic plans. It mainly consists in providing technical assistance to strengthen national health authorities’ leadership and stewardship to formulate and implement health reforms and to steer their health systems. In Kyrgyzstan, the budget support aims at strengthening Government's leadership and self-implementation of reforms without a separate project implementation unit. The overall objective is to ensure adequate funding, with fiduciary risks mitigated and financial management improved. As a result, the Government has increased its allocation to the health sector from 10.7% of the overall annual state budget in 2006 to 13% since 2010 and executed 95-97% of the health sector budget.
In Tajikistan, the skills and capacities of managers at health facility and rayon level to develop business plans are strengthened. Based on the business plan model, a performance measurement tool offering the possibility for rewards is also established.
Good governance is key to strong, resilient and equitable health systems. These good practices are well documented and can be shared and easily transposed to other contexts with similar challenges. 1: http://www.who.int/healthsystems/topics/stewardship/en/ 2: European Observatory on Health Systems and Policies Series, Strengthening Health System Governance. Better policies, stronger performance, ed. by Scott L. Greer, Matthias Wismar, Josep Figueras, 2016 3: WHO 2008, http://www.who.int/healthinfo/statistics/toolkit_hss/EN_PDF_Toolkit_HSS_Governance.pdf
Contact: enrichetta.placella@eda.admin.ch |
 Health
for All Project has completed the renovations of three health centers
in Dibër qark: Kastriot, Komsi, Maqellarë and Shupenzë. The newly
renovated facilities provide access to comprehensive primary healthcare
service for nearly 30.000 residents in the respective communes and their
surroundings. The renovation of these health centers was funded
by the Swiss Agency for Development and Cooperation of the Government of
Switzerland, with an approximate total cost of 386,000 euro.
Renovations included new roofs, floors, lighting and plumbing, painting,
installation of heating and cooling system, and fencing walls. The
improved facilities include reception, patient waiting areas, doctor's
rooms, nurse stations, emergency rooms, warehouses, offices, and
restrooms.
Since 2016, the Swiss founded project Health for All
has renovated in total six health centers in the Fier and Dibër qarks:
Libofsha and Cakran in Fier district and Kastriot, Komsi, Maqellarë and
Shupenzë in the district of Dibër. About the centers: Kastriot HC
– Offers primary health care to a population of 3625 of the commune of
Kastriot and its surrounding villages; it has 2 general practitioners
and 23 nurses/midwifes. Komsi HC—covers a community of 6023 residents, living in 11 villages and has a staff of 3 doctors and thirteen nurses/midwifes. Maqellare HC
– Offers 24-hours primary health care and medical emergency services,
seven days a week, to a community of 13.800 residents. The center is
staff with 3 general practitioners and 38 nurses/midwifes; they work in
the center and in its 19 health posts. Shupenzë HC
– Offers 24 hour primary health care service and medical emergency
services to a community of 6170 residents with a team composed of 1
general practitioner and 22 nurses/midwifes, who work in this center and
in 12 health posts. Health
for All Project has completed the renovations of three health centers
in Dibër qark: Kastriot, Komsi, Maqellarë and Shupenzë. The newly
renovated facilities provide access to comprehensive primary healthcare
service for nearly 30.000 residents in the respective communes and their
surroundings. The renovation of these health centers was funded
by the Swiss Agency for Development and Cooperation of the Government of
Switzerland, with an approximate total cost of 386,000 euro.
Renovations included new roofs, floors, lighting and plumbing, painting,
installation of heating and cooling system, and fencing walls. The
improved facilities include reception, patient waiting areas, doctor's
rooms, nurse stations, emergency rooms, warehouses, offices, and
restrooms. Since 2016, the Swiss founded project Health for All
has renovated in total six health centers in the Fier and Dibër qarks:
Libofsha and Cakran in Fier district and Kastriot, Komsi, Maqellarë and
Shupenzë in the district of Dibër. About the centers: Kastriot HC
– Offers primary health care to a population of 3625 of the commune of
Kastriot and its surrounding villages; it has 2 general practitioners
and 23 nurses/midwifes. Komsi HC—covers a community of 6023 residents, living in 11 villages and has a staff of 3 doctors and thirteen nurses/midwifes. Maqellare HC
– Offers 24-hours primary health care and medical emergency services,
seven days a week, to a community of 13.800 residents. The center is
staff with 3 general practitioners and 38 nurses/midwifes; they work in
the center and in its 19 health posts. Shupenzë HC
– Offers 24 hour primary health care service and medical emergency
services to a community of 6170 residents with a team composed of 1
general practitioner and 22 nurses/midwifes, who work in this center and
in 12 health posts. Further information:
http://www.hap.org.al/qendra-shendetsore
Contact: Ina Xhani, Ina.xhani@hap.org.al |
