UNICEF works in some of the world’s toughest places, to reach the world’s most disadvantaged children. To save their lives. To defend their rights. To help them fulfill their potential.

Across 190 countries and territories, we work for every child, everywhere, every day, to build a better world for everyone.

And we never give up.

TERMS OF REFERENCE 

Background and Justification

The maternal, infant and young child nutrition situation in a number of countries in the Eastern and Southern Africa region (ESAR) has been improving over time, but further progress is needed to address all forms of malnutrition—undernutrition, overweight/ obesity, micronutrient deficiencies—in order to achieve the global SDG nutrition and health targets. The quality of young child diets also remains very poor, with only one in ten children aged 6-23 months in ESAR receiving a minimum acceptable diet. In Sub-Saharan Africa, 66% of under 5 children are at risk of poor developmental outcomes – far too few children are thriving because of poor health, inadequate nutrition, exposure to stress, a lack of early stimulation, and limited opportunities for early learning. They are not thriving in the crucial first 1,000 days when the foundations for healthy, lifelong physical growth and mental development are laid.

Scaling up interventions to improve key direct determinants of malnutrition and poor child development outcomes-  with a focus on the “1000 days” period during pregnancy and the first two year’s of a child’s life – including maternal and infant and young child feeding (IYCF) practices and behaviors, responsive caregiving and stimulation, are essential to accelerate progress. The provision of skilled, quality infant and young child feeding counselling is critical to improving breastfeeding rates, the quality of complementary feeding practices and responsive caregiving/stimulation. The provision of counselling on breastfeeding to mothers and other family members by community health workers, peer-to-peer counsellors, nurses, midwives, lactation counsellors, or other health providers, can increase exclusive breastfeeding significantly. Full integration of these interventions into the health and community systems and ensuring quality of care in their provision is crucial for achieving progress on national and global nutrition targets.

The 2013 “WHO guidance on counselling for maternal and new-born health care: a handbook for building skills” lays out a framework for counselling for maternal and new-born health (see Figure 1). Several nutrition global guidelines define the expected maternal and IYCF counselling services and competencies of staff and they include the 2016 “WHO recommendations on antenatal care for a positive pregnancy experience” (WHO, 2016a), the 2018 “WHO guidelines on counselling of women to improve breastfeeding practices” (WHO, 2018), the 2020 “UNICEF programme guidance on improving young children’s diets during the complementary feeding period” (UNICEF, 2020). and the 2021 UNICEF-WHO  “Implementation guidance on counselling women to improve breastfeeding practices (UNICEF 2021). To further improve responsive caregiving and stimulation, UNICEF and WHO, with partners, developed and rolled-out Care for Child Development and Caring for the Caregiver interventions. The Care for Child Development (CCD) Intervention provides tools for counseling families on play and communication activities to stimulate the child’s learning and to strengthen caregiving skills and the interaction between caregivers and their children. The Caring for Caregiver (CFC) interventions is designed to promote caregiver’s mental health and emotional wellbeing, encouraging self-care, partner and family engagement, and problem-solving barriers to resources.

To ensure provision of quality IYCF counselling to mothers and caregivers, in 2010 UNICEF published an IYCF counseling package[1] targeting frontline health workers and community cadres to build their capacity on providing counselling to mothers and caregivers. In 2012 the second edition of the package integrated key content on early childhood development (ECD). The package is currently undergoing a further updating to enhance the ECD content further, add a more substantive reflection of overweight prevention and make various other updates. Some countries were early adopters of the first edition of this package and others the second edition, while some of the early adopters also added additional elements such as ECD later on. The extent to which the ECD elements are effectively integrated and well-implemented is not known.

Achieving universal access to quality counselling services requires more explicit attention to how health systems function. UNICEF acknowledges that a health-systems strengthening (HSS) focus is imperative in the post-2015 context, and even more so in the (post) COVID-19 context. UNICEF defines HSS as actions that establish sustained improvements in the provision, utilization, quality and efficiency of services delivered through the health system, and encourage the adoption of healthy behaviours and practices. These actions may also influence the health system context, including key performance drivers such as policies that impact on health in all sectors, governance, financing human resource capacity for implementation, supplies, service delivery models and platforms, and information systems. They also implicitly improve health and nutrition security by strengthening the system’s resilience and its preparedness to respond efficiently and effectively in the context of emergencies. The figure below displays how IYCF can be incorporated in the 6 health systems building blocks.

UNICEF’s HSS approach includes activities appropriate to the three major functional levels of health systems (community, sub-national and national) in different contexts, enabling the promotion of good health, delivery of essential interventions to all children and women, accountability, and achievement of equitable outcomes.

Despite the heavy investment by UNICEF country offices and other partners to train health workers and community cadres to deliver IYCF counselling, the service of IYCF/ECD counselling is not well integrated in the health system building blocks and is often not delivered as a routine essential service at scale in many countries in the region. It often still depends on external funding and is delivered in selected areas only, and sometimes only for the duration of a funding cycle. Despite existing evidence on the cost effectiveness of IYCF/ECD counselling, the service is not reflected in health policies, strategies and standards, has no budget allocation and minimal efforts have been done to integrate it in pre- and in-service trainings for health workers.  Furthermore, IYCF/ECD counselling is not included in the essential package for continuum of care and there is no standard definition, recording and reporting. Often countries report existence of an IYCF programme linking to the number of trainings conducted. There are also issues with the quality of services. Monitoring of delivery of IYCF/ECD counselling is weak and coverage of IYCF/ECD services is difficult to assess: in many countries, counseling and education or messaging are lumped together without the possibility to disaggregate or to discern whether a mother/caregiver has been counseled or reached with messages multiple times. No country is able to follow a single mother/child pair longitudinally to assess whether the minimum number of counseling contacts from pregnancy through to the second year have been received.

Against this background, the nutrition and ECD sections in UNICEF ESARO propose to issue a consultancy to understand how maternal nutrition and IYCF/ECD counselling, focusing on the 1000 days period,  is integrated in the building blocks of health systems in selected countries of the region and is being delivered at both health facility and community levels. A comprehensive understanding of the health system bottlenecks and enablers to fully integrate and deliver quality maternal nutrition and IYCF/ECD counselling services at facility and community level is essential in order to identify and prioritize context specific barriers and enabling factors to inform the design of evidence-based policies and programmes to deliver skilled counselling support and nutrition and ECD education that is fully integrated within all building blocks of the health system. The findings will help to guide countries to better integrate maternal nutrition/IYCF/ECD counseling in the building blocks of the health system and exploring possibilities of institutionalizing in other systems outside the health sector, e.g. ECD and child care centres that include children less than two years old.

Scope of work