Moving towards multi-sector programming       in Mauritania 

Mohamed Ould Saleck is the coordinator of the National Nutrition Programme at the Ministry of Social Affairs, Childhood and Women in Mauritania.

Background

A vast country with a landmass of 1.03 million km, Mauritania has a population of over 3.5 million. The country has significant natural resources: iron ore, gold and copper, small reserves of offshore oil and gas, and one of the world’s largest fishing stocks (the coast is almost 750 km long). Mauritania’s economy, however, is extremely vulnerable to exogenous shocks and climate change; the effects of the latter are becoming increasingly evident.

Over the past 15 years the Government has made significant efforts to improve healthcare in terms of its national training programme, recruitment system, infrastructure and equipment, and in making healthcare services more accessible. It has also taken steps to fight disease by developing and implementing the National Health Development Plan (PNDS) for the period 2012-2020. After four years of implementation, the Ministry of Health (MoH) launched a mid-term evaluation of this plan to refocus the 2016-2020 phase in line with the first SCAPP (French acronym for Strategie de croissance accelerée et de prosperité partagée or ‘Strategy for accelerated growth and shared prosperity’) Action Plan. The first stage of SCAPP comprises 15 strategic projects and 59 priority interventions (reforms, projects and activities).

Despite the progress made, malnutrition remains a major public health issue in Mauritania. Prevalence of wasting among children under five (CU5) is very high at 15 per cent (GNR 2017) and CU5 stunting prevalence is little changed in the last ten years (29 per cent in 2007 and 28 per cent in 2017 (GNR 2017). Moreover, the country is off course to meet under-5 overweight global World Health Assembly targets, with 8 per cent prevalence (GNR 2017). However, the country has made progress in increasing rates of exclusive breastfeeding, albeit from a very low base of 11 per cent in 2007 to 27 per cent in 2011 (GNR 2017).

A lack of multi-sector and malnutrition prevention programmes (the focus has been on emergency interventions) may have contributed to the stagnation of stunting rates in the country over the last decade. Added to this, a causal analysis carried out by ACF and the French Red Cross in Gorgol (Mauritania) and Matam (Senegal), which are separated by the Senegal river, shows that these border areas are subjected not only to major shocks (floods and drought) but also frequent micro-shocks, which the affected communities have difficulty in anticipating and withstanding.

Developing nutrition policies and programmes

Mauritania has made a number of policy and governance- related efforts to improve the nutrition situation, such as the creation of the National Nutrition Development Council (CNDN), linked to a Standing Technical Committee; the adoption of the National Nutrition Development Policy (PNDN); and joining the Scaling Up Nutrition (SUN) Movement in 2011.

Building on this momentum at national level, the Ministry of Social, Childhood and Family Affairs (MASEF; French acronym for Ministère des Affaires Sociales de l’Enfance et de la Famille) set up a National Nutrition Programme (NNP) (20132016) to tackle the causes of malnutrition and to promote good nutrition and eating habits at the household level. The main objective of the plan was to improve the nutritional status of infants and children aged 0-59 months in ten of the country’s 15 regions. The old NNP has been replaced by a new one (2016-2025) which is more multi-sector in its focus, while retaining important nutritionspecific actions.

For several years MASEF, with support from the World Bank, has been running sector nutrition activities that focus on behavioural change communication (BCC). These activities aim to prevent malnutrition by educating mothers and raising awareness of the problems linked to malnutrition, although the level of coverage of multi-sector activities remains limited.

A new country approach to communicating behaviour change

Mauritania has long undertaken awareness-raising activity to encourage people to adopt preventative health behaviours, but the approach has varied over time. The current NNP strategy is built on the following three key elements:

• A Community Nutrition Centre (CNC);

• A female Community Nutrition Officer (CNO) who runs the CNC; and

• A Mother Representative. This officer is appointed by the community in line with criteria such as being able to read and write, being motivated to do the job and being able to speak to an audience. The officer must be accepted and chosen by consensus by the women in the village or neighbourhood, of which they must be a permanent resident.

CNOs have a number of tasks, such as organising child weighing days to monitor growth and systematic screening of children in the village or neighbourhood at least once a month by taking mid upper arm circumference (MUAC) measurements. They are responsible for referring malnourished children for treatment and counselling and for monitoring progress. Treatment using the community management of acute malnutrition (CMAM) model is offered in most of the health centres; geographic coverage of interventions for treatment of severe acute malnutrition (SAM) is estimated at 88 per cent (2012) (GNR 2017).

The officers dispense iron supplementation to pregnant and lactating women, ensure that all children in the village receive vitamin A supplements during MoH campaigns and give children deworming tablets. They also organise education sessions on nutrition-related topics.

The CNO is supported by the Mother Representative. In fact, the women in the village all take turns in the role for one month, ensuring that they remain connected to the CNC and feel directly involved in its activities. The small financial ‘reward’ they receive at the end of the month is given as an alternative to giving food rations, as without it there is a risk that the women would have no motivation to attend the centre.

A programme supervisor who monitors the activities of the CNOs and presents a CNO activity report containing figures at the end of each month. The programme received funding from the World Bank to include a communication component on changing nutritional behaviour and it has funded income- generating activities to support the economic activity of women who are generally the head of their household in villages and in outlying neighbourhoods.

In the next phase of the NNP the CNCs could have a role to play as gateways to building local multi-sector platforms.

Aligning actions around a Common Results Framework (CRF)

The new NNP has been organised around a Strategic Multi- sector Nutrition Plan (2016- 2025) that is awaiting political validation. As a reference document for nutrition-related interventions, it does not contain an action plan but forms a policy framework for all actors involved. A planning workshop for implementation is scheduled to operationalise the Plan, prioritising actions that contribute to nutrition and evaluating actors’ implementing capacity.

According to the SUN Movement guidance, the specific interventions in the CRF will be operationalised through scaling up plans that are being produced on treating acute malnutrition, promoting good feeding practices for infants and young children, and combating the lack of micronutrients. Other priorities include:

• Ensuring the support of financial partners by reviewing the NNP in line with the resultsbased CRF approach and by developing a monitoring system to document impact indicators; and

• Improving budgeting and funding based on a cost estimate, development of a financing plan and a resource mobilisation plan.

Reference

GNR 2017. Global Nutrition Report (2017) Nutrition Country Profiles: Mauritania. Bristol, UK: Development Initiatives.