Public Disclosure Authorized Public

Public Disclosure Authorized Public Child stunting in Lesotho: Trends and way forward

Dr. Masekonyela Sebotsa, Director, Food and Nutrition Coordinating Office, Office of the Prime Minister, Government of Lesotho

Early Childhood Nutrition in Southern Africa Public Disclosure Authorized Public Investing in healthy children for healthy countries October 2 – 3, 2018, Thaba Bosiu, Lesotho Public Disclosure Authorized Public 1. Situation analysis • Child stunting in Lesotho • Trends and determinants of child stunting

2. Multisectoral programme strengths, needs and Outline of the gaps • Policy environment to address child stunting presentation • Programmatic platforms to deliver nutrition interventions • Programmatic and policy strengths, needs and gaps

3. Proposed roadmap to improve child stunting in Lesotho • Proposed outline of interventions • Timeline and Goals Child stunting has reduced in Lesotho, but slowly

1. Child Stunting prevalence, Butha-Buthe Stunting 2004 Leribe prevalence, stunting in Berea Mokhotlong 2014

Lesotho Maseru Thaba-Tseka Butha-Buthe Leribe Mafeteng Mafeteng

Qacha's Nek Berea Mokhotlong Trends and determinants Mohale's Hoek

Quthing Maseru Thaba-Tseka

Mafeteng Mafeteng

StuntingChild Stunting Rate 2004 Qacha's Nek Mohale's Hoek ST2004Percent

35 Quthing 36 - 40

41 - 48 StuntingChild Stunting Rate 2014

49 - 61 ST2014Percent 25 - 35 36 - 40 41 - 48 49 - 61 Source: Lesotho Demographic and Health Surveys 2004, 2014 Child stunting is highest among poorest households in rural areas

Prevalence of Child Stunting by wealth quintiles 50% 45.6% 45%

40% 38.1% 34.8% Child stunting is higher among the 35%

30% 28.2% • Poorest households (45.6%) versus 13.4% richest; 25% % Stunting 20% • Rural (36%) versus urban (28%) areas; 15% 13.4%

10%

5%

0% Lowest Second Middle Fourth Highest Wealth Quintile

Source: Lesotho Demographic and Health Survey, 2014 Access to basic health and WASH services amongst the poor is low

Access to health services by Access to WASH services by wealth quintiles wealth quintiles 100 95.8 92.3 92.5 100 92.7 90 82.3 90 86.6 79.7 83.6 80 76.8 77.7 72.9 80 68.7 70.6 69.5 71.4 70 64.7 65.2 67.5 63.2 70 65.1 61 60 60 53.7 50.6 50 50

Percentage 40 37.5 Percentage 40 32 30 30 20 20 10 10 0 0 Poorest Poorer Middle Richer Richest Poorest Poorer Middle Rich Richest Wealth Quintiles Wealth quintiles Full Immunization ANC 4+ Visits Birth by Skilled birth attendant Toilet Safe drinking water

Source: Lesotho Demographic and Health Survey, 2014 Food insecurity affects majority especially in rural areas

100 7.9 15.1 12.3 90

80 27.5

70 34.4 38.7 60

50 Even among the food secure, 8% rural houses had high Percent Percent 40 dietary diversity indicating that majority have diets poor 64.6 30 in micronutrients 53.3 46.2 20

10

0 Rural Urban Total

Food secure Marginally food insecure Moderately food insecure Severely food insecure Maternal factors are highly correlated with child stunting

Prevalence of child stunting according to maternal education Prevalence of child according to maternal age at childbirth 50% 60% 40% 50% 30% 40% 20% teenage pregnancy 30% 10% older mothers Illiterate 0% 20% Primary Education Maternal age at child birth 10% Secondary education Higher 0% Maternal education Prevalence of child stunting according to maternal nutrition status 50% 50% 45% 45% 40% 40% 35% 35% Thin (BMI <18.5) 30% 30% 25% Height < 150 cm 25% Normal weight (BMI 20% Height 150+ cm 18.5-24.9) 20% 15% Overweight/Obese 15% 10% (BMI>25) 5% 10% 0% 5% Maternal height 0% Maternal BMI Source: Lesotho Demographic and Health Survey, 2014 Long term impact of child stunting in Lesotho

Health : • Under nourished children are likely to experience anemia, diarrhea, acute respiratory infection and fever; 19.5% of child deaths is associated with undernutrition. • For additional case of child illness, both the health system and family are faced with an additional economic cost.

Education : • On an average 14.1% stunted children repeat a grade compared to 5.8% healthy children Costs of grade repetitions associated with undernutrition Total public costs: 64.5 billion Maloti Total costs to Families/caretakers: 50.6 billion Maloti Total cost: 115.2 billion Maloti Cost of Hunger study 2017 Long term impact of child stunting in Lesotho (contd)

Productivity : An estimated 45.1% of the working age population were stunted as children

• Child undernutrition affects human capital and productivity Lower education Less qualified for levels and work 11.2 million USD lost as Undernourished income as non manual children labour (0.4% of the GDP) Reduced income- earning potential 18.6 million USD lost as income as manual labour (0.7% of the GDP Cost of Hunger study 2017 Policy and programme design 2. Multisectoral programme Institutional arrangements strengths, needs and gaps Governance

Programme management and monitoring gaps assessed Ministries 7in assessed gaps

Programmatic strengths, needs and and needs strengths, Programmatic Budgets - Lesotho Food and Nutrition Policy 2016/2017 - Kingdom of Lesotho: Poverty Reduction Strategy Prime Minister’s Office (Cabinet - Zero Hunger Strategic Plan - Disaster Risk Reduction Policy 2011

- Seed Policy (2015) - National Action Plan for Food Security (2006) - Lesotho food Security Policy and Strategic guidelines (2005) Ministry of Agriculture and Food Security - Plant Protection Policy - Agricultural sector strategy - Agricultural Marketing Act 26 of 1967 - Lesotho Micro small and medium enterprise policy 2016

- National Guidelines on Infant and Young Child Feeding (2013) - MOH Nutrition Strategy 2012/13-2018/19 - Lesotho National Guidelines for Integrated Management of Acute Malnutrition (2016) - Lesotho Nutrition and Poverty Programme (2002) - Expanded program on immunisation (EPI) Policy 2010 Ministry of Health - Reproductive, Maternal, Newborn, Child, Adolescent Health and Nutrition Strategy (RMNCAH & N) 2017- 2027 - Health Sector Policy and strategic Plan - HIV and AIDS Strategic Plan - Salt Iodisation Regulation of 1999 - Village Health Worker Guidelines - Non-communicable Diseases Strategy

- Lesotho National Social Protection Strategy (2014) - National Policy on Orphans and Vulnerable Children (2005) Ministry of Social Development - Child Act 1993 • National Strategic plan on Vulnerable Children 2012- 2017 - National Policy For integrated Early Childhood Care and Development (2013) Ministry of Education and Training - National School Feeding Policy (2015) • Lesotho Curriculum and Assessment Policy 2009 - National Water and Sanitation Policy (2007) Ministry of Water - Water Act no 15 of 2008 Strengths of existing policy and programme environment

• Government structures and systems in place to village level for implementing a comprehensive multisectoral programme.

• Some nutrition programme interventions implemented through the existing Ministries and departments.

• For programme implementation: • The vulnerable groups are mapped ; • District co-ordination structures are in place ; • Work force across all sectors are in position ; and • Programme monitoring and information systems in place for all the sectoral ministries. Challenges within the policy and programme environment Programme implementation challenges Possible solutions

Implementation structures are vertical resulting Ministries need to collaborate and not work in silos in duplication of efforts and resources The two separate nutrition units within Ministry • Need to co-ordinate and communicate of Agriculture and Ministry of Health work in silos • Nutrition Units needs to take a leadership role with minimal coordination Food and Nutrition Coordination Unit is weak Technical support and capacity development for effective multisectoral planning and co-ordination Ministry of Local Government: two parallel Streamline parallel governance systems into structures in communities and district level integrated political and administrative unit Greater focus on curative nutrition services and Support capacity development of workers across limited capacity of workforce to deliver sectors to deliver nutrition services preventive services Budgetary cutbacks within the government Nutrition related budgets re-examined for efficient resource allocation 3. Proposed roadmap to address child Higher GDP and stunting in Increased economic productivity growth and better Lesotho Increased wages school attendance and better Lowered learning child stunting Engaging multiple sectors towards improving child stunting

Improved child nutrition, growth and development

Improved nutrition of mothers and children Reduced disease incidence Increasingutilizationcreation demandand

Increased food access – quantity and Improved childcare, stimulation and Improved health service delivery and quality feeding practices WASH facilities

Social Protection: targeted support to vulnerable households Health, Education and WASH sectors : (infant grant). • Increased utilization of reproductive maternal and child health and nutrition services Agriculture, food security, livestock and livelihood : • Improved health/nutrition behaviours: feeding and - Increased agricultural diversification hygiene practices - Post harvest processing of food to minimise losses and • Increased utilization of ECCD services increase nutrition security - Improved market access and incomes; Improving supply and of quality services Improving Local Government Co-ordination:

FNCO: increased convergence and coverage of multisectoral services Targeting the poorest in rural, vulnerable and hard-to-reach households

THE DETERMINANTS ANALYSIS HIGHLIGHTS THE ACUTE NEEDS OF POOR, RURAL AND VULNERABLE HOUSEHOLDS

1) Targeted support and a package of essential services during the first 1,000 days to the vulnerable households through cash transfers and livelihood support; Rural households 2) Increased access and utilization of maternal and Districts child health, nutrition, early childhood stimulation Vulnerable with high Most poor and WASH services by incentivizing critical groups child behaviors improvements; stunting Women and 3) Ensuring food security and dietary diversity to the children < 2 years vulnerable households through improved linkages with agriculture and social protection; 4) Strengthening national and sub-national convergence and co-ordination between key sectors and Food and Nutrition Co-ordination Unit; Proposed programme interventions (contd)

Food and Nutrition Co-ordination Unit Local government co-ordination - Oversees multisectoral programme planning and co-ordination at national and district level - Tracks progress through multisectoral nutrition information system - Reports to PMO

Mins. Agriculture Min. Social Mins. Health and Min. of and food security, Development WASH Education and Livestock

Enhancing dietary Cash transfers to HH based Improving quality of Early childhood diversity through on poverty in districts with health care in health stimulation; horticultural production high stunting; facilities; IDA IDA and kitchen gardens; funds funds Support to working mothers at ECCD Livelihood support through Improving access to egg centers; agriculture and livestock Increased service and milk consumption; including access to utilization; marketing; Community-level Advocacy for parenting support; Incentivizing use of health, Community-based dietary nutrition and WASH nutrition, health and behavioural services with a focus on WASH support; change behavior change; Proposed roadmap for reducing child stunting in Lesotho

Multisectoral programme to reduce child stunting [Ministries of Health, Social Protection, Agriculture, Livestock, Education, WASH,

Long term Local government, Finance, with co-ordination from FNCO] (> 59 m)

Rolling out complementary programmes to reduce child stunting: - Enhanced social safety net and livelihood programmes [Min of Social Devt.] - Improved health sector service delivery programme [Min of Health] - Enhanced dietary diversity and homestead gardening involving women and communities [Min of Agriculture] Medium term (25 – 59 m) Analytical work on: Determinants of stunting & maternal and child mortality [FNCO & Min. of Health] Multisectoral nutrition programme strengths, needs and gaps [FNCO] Increased dietary diversity among subsistence farmers [Min of Agriculture] Short term Develop costed food and nutrition security strategy and action plan [FNCO] (6- 24 m) Technical Assistance to enhance budgetary allocations and efficiency in expenditure for nutrition [Min. of Finance] THANK YOU