7 STRATEGIES FOR NUTRITION IMPROVEMENT
To achieve its objectives, the National Nutrition Policy proposes the following strategies:
Reinforcement of the political commitment
Given the magnitude and persistence of nutrition problems in the country, their multi-causal factors and impact on different development sectors, Rwanda needs to strengthen its political commitment to improve the nutritional well-being of its people and make this a priority government action for its sustainable development. Some of the measures that can strengthen the political commitment are:
- Advocate for nutrition and concurrently disseminate the National Nutrition Policy
- Integrate nutrition in the socio-economic development indicators (EDPRS, Vision 2020)
- Include a nutrition component in all sectoral development programs
Allocate and/or mobilize adequate government or partner resources for the fight against nutritional problems, in particular, the financing of nutrition activities through the medium-term expenditure framework (MTEF).
Re-establish the training of nutritionists at A1 level and initiate undergraduate (A) and graduate nutrition degree programs in the university.
- Integration of nutrition in the curriculum of basic education at primary and secondary levels, and establish an in-service training program for health professionals;
- Allocate nutrition positions for each level in the health system.
- Develop and/or adopt, and/or implement national strategies and protocols related to nutrition (such as the Protocol for the treatment of acute malnutrition, Guidelines for the nutritional care and support of PLWHA, Strategy for the Control of Micronutrient deficiencies, strategy and guideline for community based nutrition projects, etc)
- Promote food security for households and production of local nutrient-rich foods at community level.
- Develop and/or strengthen policies for food processing, fortification and preservation.
- Develop and enforce national legislation on standards for food fortification.
- Implement all government nutrition-relevant policies such as the agricultural policy (especially the land reform policy for improved food security).
- Operationalize the one cow per one family strategy.
7.2 Promotion of optimal infant and young child feeding
Inappropriate breastfeeding and complementary feeding practices are major factors affecting infant and child mortality. Children from 0 to 6 months who are not breastfed have 7 and 5 times higher risk of dying from diarrhea and pneumonia, respectively. Promoting optimal child feeding makes it possible to reduce child deaths, the practice of breast-feeding and optimal complementary feeding respectively constitute the first and the 3rd most effective preventive interventions of child mortality. Breastfeeding is part of the Rwandan culture, however, it needs to be maintained and optimally practiced through the following strategies: 21
Promotion and protection of the exclusive breastfeeding in infants from birth up to six months, including infants born to HIV positive mothers who cannot meet the AFASS (Acceptable, Accessible, Feasible, Sustainable and Safe) conditions for replacement feeding,
- Protection of breastfeeding women who work in all (private and public) sectors by modifying the law in favor of breastfeeding (paid maternity leave periods, prolongation of maternity leaves, creation of breast-feeding space in the work place and public areas, etc.),
- Promotion of breastfeeding activities by establishing support groups at community level;
- Promotion of continuous breastfeeding up to twenty-four months or more, with an appropriate complementary feeding from six months,
- Institutionalize the celebration of the national breastfeeding week in the national calendar,
- Adoption and implementation of the National Code of Marketing of Breastmilk Substitutes.
- Development and adoption of a national strategy on infant and young child feeding (IYCF) in the context of HIV/AIDS in Rwanda,
- Integration of IYCF in the guidelines and protocol on voluntary counseling and testing (VCT), the prevention of mother-to-child transmission (PMTCT) of HIV/AIDS and pediatric care.
- Integration of IYCF in medical and para-medical training schools,
- Support to operational research on infant and young child feeding
- Promotion of the consumption of appropriate locally-produced complementary and weaning foods.
7.3 Scaling up of community-based nutrition programs
Certain simple actions, easy to be implemented by community workers, have a very positive impact on the nutritional status and the survival of the population. The Community–Based Nutrition Program (CBNP) is an approach that promotes equity and efficiency in the fight against malnutrition in a participatory manner. In addition, this approach will enable the link of nutrition services and the communities, and can constitute an entry point to child survival interventions such as integrated management of childhood illnesses (IMCI) at community level. Thus, the objective of the approach is achieving coverage of up to 80% of cells (umurenge) in all the districts of the country. In order to achieve this objective, the following activities are planned:
- Updating of the national CBNP protocol;
- Development/validation of training modules for health and community workers;
- Training of local administrative authorities and health workers involved in the CBNP;
- Development and implementation of district CBNP action plans;
- Mobilization of the required resources for the implementation of CBNP actions plans;
- Promotion of growth monitoring of children under five years at community level;
- Organization of community nutrition week, coupled with micronutrients supplementation, de-worming and promotion/preventive health activities;
- Support of income–generating activities at the household and cell level, in particular, for women associations;
- Social mobilization activities for the promotion of safe water, personal and environmental hygiene, the use of insecticide treated (impregnated) mosquito nets, family planning, HIV/AIDS prevention and community health insurance (Mutuelle de Santé);
- Mobilize communities to establish early childhood development (ECD) and school feeding programs to promote nutrition of preschoolers and school children,
- Development and production of communication tools (IEC) to ensure social behavioral change.
7.4 Food Fortification
Fortification is one of the approaches to provide essential micronutrients to a large proportion of any population using commonly consumed and easily accessible foods. In Rwanda, the only food that is fortified and widely consumed is table salt which is iodized. However, there is a potential to fortify other foods to combat micronutrient deficiencies. To achieve this objective, the following activities are planned:
- Carry out a technical and financial feasibility study on fortification of various local foods;
- Fortification of the identified foods;
- Development of national standards governing the fortification of local or imported foods coupled with promulgation of relevant legislation;
- Promotion of the consumption of iodized salt as part an integrated strategy to eliminate iodine deficiency disorders,
- Strengthen the capacity of the reference laboratory for monitoring adherence to national standards
- Study the health risks or implications of consuming Genetically Modified Foods and other technologically modified products.
7.5 Promotion of household food security
The following strategies can improve availability, accessibility and utilization of foods at all levels:
- Develop strategies that promote equitable inter-regional and intra-household food distribution,
- Promote production and consumption of locally produced micronutrient-rich foods,
- Promote income generating activities to improve the population’s purchasing power,
- Promote post-harvest processing, preservation and conservation techniques for food,
- Promote norms and standards for food and water and food hygiene measures,
- Promote trans-border trade of food products
- Promote appropriate dietary and feeding practices and a healthy life-style to prevent dietary excesses, alcohol abuse, tobacco use, etc,
- Implement pertinent policies that promote food production such as the agriculture and land reform policies, and those that promote women empowerment especially to access and control household resources,
- Implement a habitat policy which favors the promotion of settlement clusters (imidugudu), a better management of the environment, and freeing of land for agricultural use.
- Establishing a Food and Nutrition Surveillance System as part of a comprehensive Food Security and Early Warning System
7.6 Prevention and management of nutritional deficiency or excess-related diseases
The following strategies can promote prevention and management of malnutrition and related diseases:
- Regular growth monitoring of children aged between 0 to 5 years, at health center and community levels,
- Regular monitoring of weight gain for pregnant women, through the ANC at health center and community levels,
- Promotion of balanced and good nutrition among the population; especially in specific and vulnerable groups such as children under-five years, orphans and other vulnerable children, pregnant and lactating women, old people, refugees ,
- Monitoring the implementation of the strategy for micronutrient supplementation within the IMCI (immunization, de-worming, etc),
- Implement food fortification strategies as listed in section 7.4 above,
- Establish a nutrition monitoring system integrated in the HIS.
- Develop relevant IEC messages and materials on adequate nutrition to sensitize all population.
- Nutritional support and care to PLWHA and their families
Nutrition care and support is now integrated into the national strategy for prevention, treatment and care for PLWHA. In line with this, the government has developed and adopted guidelines and protocol giving practical recommendations for improving the nutritional well being of PLWHA. These guidelines are intended to be used by service providers, including those providing home based care. In order to meet the nutrition needs of PLWHA and their families, the following actions should be implemented:
- Ensure that service providers implement and utilize the guidelines and protocol,
- Mobilize resources for implementation of the minimum food package for PLWHA and affected people, including infants born to HIV infected mothers,
- Develop long term strategies to sustain nutrition support and care for PLWHA including income generating activities and improved agricultural production,
- Strengthen the capacity of service providers in nutrition support and care targeting:
Health professionals in nutrition centers and health facilities in nutritional assessment and counseling, management and follow up,
Community health workers in order to promote community based nutrition interventions for PLWHAs,
Associations to act as a forum for setting up community-based nutrition programs and as an agent of behavioral change.
7.8 Promotion of pre-school and school nutrition
In order to improve the children’s nutritional status and school performance, including HIV/AIDS orphans and vulnerable children, the following actions have to be taken:
- Screen preschoolers and school children for malnutrition,
- Install and/or maintain drinking-water points and hygienic toilets
- With the community’s help, establish and maintain school food stocks in order to ensure the sustainability of an adequate school diet,
- Establish school canteens to supplement children’s diet at schools,
- Provide micronutrient supplements to school children or fortified food rations,
- Establish and regularly systematically deworm school children,
- Promote school garden practices and small-livestock keeping.
7.9 Communication for behavior change
Because clinical symptoms associated with malnutrition appear in the advanced stages of deficiency, communication for behavior change should be reinforced at all levels. Communication should provide pertinent educational messages to trigger voluntary changes in dietary behavior and practices that impact on nutrition. Appropriate Communication channels should include the mass media, radio, televisions, audio-visual press, newspaper, conferences, plays, traditional media (street shouters, songs, sketches...) e.t.c and relevant messages passed through health facilities, community health or nutrition workers, schools, churches, CBOs, NGOs, etc… To reach rural populations, developed messages must be culturally appropriate and translated to the local language.