The process towards development of an integrated National Nutrition Policy framework for Lesotho
Background and motivation: This thesis was prompted by the deteriorating health and economic status in Lesotho. The country is experiencing the double burden of disease including HIVIAIDS, communicable and non-communicable diseases, as well as micronutrient deficiencies. The situation is compounded by the prevailing food insecurity due to climatic shocks and stresses surging through Southern Africa. The deteriorating health burden is drawing heavily on limited resources in the country. As a medium term measure towards realisation of the longer-term vision 2020, the Government of Lesotho (GOL) has recently developed the national Poverty Reduction Strategy Programme (PRSP). Health is the fifth of the eight priority areas of the PRSP. One of the proposed strategies is reduction of nutrition related illness to be achieved through the development of a coherent nutrition policy. The aim: This thesis has attempted to produce a framework towards development of an integrated nutrition policy. The approach used follows standard procedures towards development of a policy. The specific objectives to be fulfilled by this thesis include problem identification and definition; analysing the magnitude of the problem and population groups affected; existing systems for reducing the impact of the problem among vulnerable groups; defining a framework that will articulate the desired output to be achieved by the proposed policy; a strategy articulating mechanisms to be implemented to achieve the output and a system for monitoring and evaluating the desired impact. The methods: Permission to proceed in defining the integrated national nutrition policy framework for Lesotho was obtained from relevant authorities in the country. A consultative process to define the process and solicit support from stakeholders within nutrition in Lesotho was engaged throughout the development of this thesis. The United Nations Children's fund's (UNICEF) conceptual framework depicting the causality of malnutrition was used to describe the nutrition related problems and their causes in Lesotho. In this thesis only the immediate causal factors of malnutrition are addressed. Other underlying causal factors contributing to these immediate causes can be pursued elsewhere when designing relevant specific interventions. This thesis describes the magnitude of disease experienced in Lesotho using secondary data generated from the World Health Organization (WHO) and the Ministry of Health and Social Welfare (MOHSW). Existing information on food security was obtained from studies undertaken in Lesotho, including the inter-agency assessment of the prevailing food shortage humanitarian crisis currently facing Southern African, vulnerability assessments, dietary intake and micronutrient deficiency studies. Selected elements of the existing national nutrition programme have been used in this thesis, taking cognizance of the problem, its size and location. The framework for developing a suitable nutrition policy for Lesotho is suggested. The suggested process will be participatory to include all stakeholders in an attempt to build components of sustainability. Results: Analysis of the prevailing situation confirms the double burden of disease, where infectious diseases are more prevalent in the younger age groups. In the older population, chronic illnesses are more prevalent. Both data sets used reflect that the burden of disease is a result of higher mortality rates compared to morbidity. HIV/AIDS, respiratory and other infections are causing a major proportion of the disease burden. The male population is more affected relative to the females, with the exception of females at the age of 15 to 29 years, probably because of maternal related complications. Analysis by age indicates the population group from 5 to 14 years old has lower rates of morbidity and mortality. This age group is the window of hope for correcting nutrition-related diseases. If the right interventions are targeted at this group, there is hope of attaining the national goal for vision 2020. It should be appreciated that this information reflects the burden of disease of those who seek health care within the health service delivery facilities. Both the exact magnitude of diseases and their causal factors can he confirmed by undertaking relevant research covering representative samples of the total population in Lesotho. The food security situation in Lesotho is far from optimal. Poor breastfeeding and infant feeding practices, such as early introduction of other foods besides breastfeeding, early cessation of breastfeeding, low nutrient (including energy) dense weaning foods and reduced feeding during illness and recuperation are ascertained as causal factors contributing to malnutrition amongst children in Lesotho. The mountain areas are identified as highly susceptible areas to food insecurity, followed by the southern districts. The vulnerability and high risk factors of populations in these locations are further confirmed by the high prevalence of chronic malnutrition and under-weights compared to the rest of the country. Indicators that were associated with vulnerability to food insecurity were households that were either widow or elderly headed, those engaging in multiple income earning mechanisms or relying on farming, herding, informal business or/and casual labour for income and those with a high ratio of dependents. The Food and Agriculture Organisation/World Food Programme (FAOIWFP) cereal production forecast for the 2003/04 period predicted that 45% of the total population in Lesotho would require food assistance in varying quantities. The livelihoods vulnerability assessment undertaken in 2003 estimated a nationwide food/income deficit ranging from 10 to 47%. The FAONFP report suggested improved soil husbandry and extension practices. The vulnerability assessment report suggested livelihood-based interventions, together with direct food and income transfers as relevant interventions. Analysis of the existing food and nutrition programme in Lesotho looked at main components that would strongly influence the integrated nutrition policy. The approach was borrowed from the European Union nutrition programme. In this thesis only the three elements of the national nutrition programme that would directly influence the nutritional outcomes were studied. These were nutrition security, food security and trade issues. On analysis, these elements reveal a fragmented implementation of nutrition interventions. This situation exists despite efforts by the GOL to establish a coordination office mandated with synchronizing all nutrition stakeholders countrywide on policy, programme, monitoring, evaluation and research issues. As a result of the fragmented non-cohesive approach and inefficient utilisation of resources, especially the scanty human resource, the national nutrition programme has not realised a positive impact on the prevalence of malnutrition in Lesotho. The main elements to constitute the policy will consider core values and principles of the nutrition profession and programme in Lesotho. This thesis assumes the national nutrition programme will embrace the common national vision 2020 and will share the similar mission reiterated by the Food and Nutrition Coordinating Office (FNCO) in the poverty reduction thematic nutrition paper. The nutrition policy advisory committee in Lesotho would, however, confirm this assumption or design alternative statements. The processes towards identifying relevant objectives and strategies have been defined in this thesis and will have to be undertaken by the committee, which will also define implementation mechanisms including financing, monitoring and evaluation mechanisms. The national nutrition programme has identified the need for technical support in some areas. The author, therefore, suggests that the WHO and the United Nations1 Standing Committee on Nutrition (UNISCN) can be approached for this support. Conclusions: The GOL demonstrated commitment towards the nutrition policy. The process toward defining the integrated nutrition policy for Lesotho should be completely participatory. This thesis has addressed the first component of the framework, which is the situation analysis and description of the main policy components. The situation analysis has portrayed a need for an integrated nutrition policy to address the double burden of disease compounded by HIVIAIDS and chronic food shortage. This adverse situation can be curbed through a coherent cost-effective food and nutrition programme. The FNCO, mandated with nutrition policy design, therefore, has to revitalize the policy advisory committee to carry the policy defining processes forward. A framework to be used in this process has been developed and presented in this thesis. Recommendations The stakeholders in nutrition should agree on systemic issues to be changed or maintained. The process for policy definition should state the institutional arrangements, such as stakeholders' analysis, financial mechanisms and management and coordination. The programme implementation arrangements should define the beneficiaries, realistic objectives aligned with the Poverty Reduction Strategy Paper (PRSP), strategies, prioritize cost-effective nutrition interventions and agree on coordination, monitoring and evaluation mechanisms. The nutrition policy will mainstream the cross-cutting issues such as HIVIAIDS, gender, environment and governance. On completion of this thesis the author will present it to the relevant authorities in Lesotho for the policy development processes to continue in line with the proposed time frame and implementation plan given in Chapter 5.
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