Part one
THE IMPLEMENTATION OF THE NNS FOR 2001 - 2010
I. ACHIEVEMENTSAs a follow-up to the National Plan of Action for Nutrition 1995-2000, The National Nutrition Strategy for 2001-2010, ratified by the Prime Minister on February 22nd 2001 in Decision 21/2001/QĐ-TTg, was the official document guiding nutrition policy for the Government. It was the foundation to direct all nutrition interventions between 2001- 2010 supported by Government investment, to promote social mobilisation, as well as to guide activities supported by international organisations. Ten years following implementation, with comprehensive approaches and multi-sector cooperation and guidance from the Party and the Government at different levels, the nutrition status of the general population, and particularly that of mothers and children under 5 has significantly improved, and awareness of nutrition issues has increased among Vietnamese people.1. Achievements in communication, advocacy, and nutrition knowledge and practicesIn the decade following initial implementation, advocacy and communication inter- ventions have been diversified and varied in terms of both content and apprearance in order to improve awareness of proper nutrition and affect behavior change, particulary among target groups, remote/isolated areas, and ethnic minorities. It appears to have had significant influence on the awareness of different target groups in the community.The awareness of the importance of nutrition amongst Party and Government authori- ties at all levels has also remarkably improved. Reduction of malnutrition has become a socioeconomic development indicator both nationally and locally. Reduction of child mal- nutrition has significant implications for future generations and contributes to annual GDP growth through a healthier working population.The proportion of mothers with good nutrition knowlewdge and practices while caring for a child experiencing illness increased from 44.5% in 2005 to 67% in 2009. The propor- tion of adolescent females receiving education on proper nutrition and maternal health increased to 28% in 2005 and 44% in 2010, meeting the defined NNS objectives.2. Promulgation of nutrition supportive policiesOver the past 10 years, many documents and policies issued by the Party, the Govern- ment and the Ministry of Health to create the legislative framework and orientation for nutrition control, contributing to the achievement of the defined objectives. Reduction of undernutrition has become one of a few health indicators to be included amongst documents reviewed by the National Congress of the Vietnam Communist Party. This indicator has also been evaluated and monitored annually by the National Assembly.The Vietnam Strategy on social and economic development for 2001 - 2010 includes many important documents supporting nutrition, promulgated by the Government to enable implementation of the NNS. These documents include: The Strategy on protection and care for people’s health ratified by Decision 35/2001/QD-TTg dated Mar 19, 2001; National Strategy on Reproductive Health Care; Vietnam Population Strategy; Decree 163/2005/ND- CP dated Dec 12, 2005 on the production and supply of iodized salts; Decision of the Prime Minister No 149/2007/QD-TTg dated September 10, 2007 to ratify the National Strategy on Food Hygiene and Safety period 2006-2010; Decree 21/2006/ND-CP dated Feb 27, 2006 of the Government on the production and marketing of breastmilk substitutes; Decision63/NQ-CP dated Dec 23, 2009 on national food security; Decree 48/ND-CP dated Sep 23,2009 on the mechanism and policy to reduce post-harvest loss of agricultural and aquacul- tural products; Food safety Law; Decision 239/QD-TTg of the Prime Minister dated Feb 9,2010 to ratify the pre-school compulsory education for 5-year-old children for the period of 2010-2015.3. Increased investment in nutritionIn recent years, the Party and Government of Vietnam have invested in the control of undernutrition, particularly targeting pre-school children. Since 2000, programs addressing control of child undernutrition have been included amongst National Target Projects on social diseases and dangerous endemics, with an average funding of 100 billion VND per year. As a result of advocacy and communication, local governments at all levels, with support from international organisations, have contributed dozens of billions of VND, in addition to national funding, to support activities to control prevalence of child undernutri- tion annually.In addition to investment from the government, nutrition policies and support from international organisations, and governmental and non-governmental organisations, such as UNICEF, WHO, FAO, ADB, the Government of Netherlands, Japan, Australia, have provided increased attention and support for the achievement of the NNS objectives. This support has helped to strengthen nutrition interventions, increasing the effectiveness of implementation of the NNS nationally.4. Reinforced multi-sector cooperation guidance from the central to local levelsMulti-sector cooperation is a key component of effectively implementing nutrition activities and programs. The Government Decision 21//2001/TTg dated February 22nd,2001, assigned the Ministry of Health responsibility for developing, providing guidance, coordinating and evaluating the implementation of the NNS, working in collaboration with other ministries, sectors and organisations, as well as with international organisations. The Steering Committee of the NNS has focused on planning, multi-sector and inter-sector approaches, and resource mobilisation for the implementation of the NNS. Amongst other ministries and sectors at central level, there have been focal units to cooperate with the Ministry of Health to achieve the objectives of the NNS; actively developing action plans to jointly implement the NNS. Many other sectors and agencies have integrated nutrition interventions in their functional activities, such as the Ministry of Education and Training (kindergarten, primary School), the Ministry of Labor, Invalids and Social Affairs, the Ministry of Agriculture and Rural Development, the Vietnam Women’s Union, the Farmer’s Association, the Youth Union, and the Vietnam Labor Union.Following ratification of the NNS, provinces established Steering Committees (Chaired by Vice President of the Provincial People’s Committee with the Provincial Health Service as the standing body and the Provincial Preventive Health Center as the focal point) to develop action plans to implement the NNS, particularly incorporating the indicator of reduction of child undernutrition in the annual socioeconomic development plan for each locality.Many provinces/cities have further strengthened multi-sector cooperation, signing agreements to confirm the multi-sector commitments and ensuring necessary monitoring and supervision for the effective implementation of those commitments.5. Reinforced and extended implementation network for the NNSThe network for implementation of activities within the NNS framework has also been reinforced. There is now a department of nutrition and food hygine and safety in each of the 63 Provincial Preventive Health Centers. The Reproductive Health network has nutrition coordinators in provincial, district and commune levels. There are over 100,000 nutrition coordinators and collaborators which cover all hamlets nation-wide. In addition, the nutri- tion network incorporated staff from central to local levels of the Ministry of Education and Training, Agriculture and Rural Development, the Farmer’s Association, the Women’s Union, and others, who have expanded their participation in implementing the NNS. Build- ing and developing the nutrition network are key tasks needed to accomplish the goals of the NNS.Furthermore, advanced training for nutrition specialists has been reinforced. Nutrition departments in medical and non-medical schools have been set up and operate training programs in the field of nutrition. In order to develop a stronger nutrition network from central to local levels, the National Institute of Nutrition has also cooperated with univer- sities to train dietetic technicians, and nutritionists with bachelors, masters and PhD degrees in community nutrition. Currently, a program for a bachelor’s degree in nutrition is being developed, with a goal to provide more trained staff to local nutrition programs. Within the framework of the NNS, many technical training courses have been held for multi-sector staff working in nutrition, contributing more effective implementation of nutrition programs.6. Significant improvement of maternal and child nutritionDuring the period from 2001 to 2010, the nutritional status of Vietnamese people in general remarkably improved, as well as that of mothers and children.Prevalence of underweight (weight for age) in children under 5 has been signicantly reduced, with a national average of 1.5% annually, from 31.9% in 2001 to 25.2% in 2005 and 17.5% in 2010 (beyond the NNS objective). The progress in reduction of malnutrition of Vietnam has been acknowledged and highly appreciated by international organisations.Stunting rate (low height for age) in children under 5 nationally has also been signifi- cantly reduced from 43.3% in 2000 to 29.3% in 2010; however, Vietnam remains among the 36 countries with the highest stunting rates in the world1.The prevalence of overweight and obesity in children under 5 nationwide is 4.8% (5.7% in urban and 4.2% in rural), lower than that of the defined objective of the NNS (less than 5%).The rate of low birth weight (infants born less than 2500g) is one of major indicators included in the NNS, which the WHO defines as a key nutrition and health indicator. Based on reports from the Nutrition Surveillance system of the NIN in 2009, this rate was estimated at 12.5%.Chronic Energy Deficiency (CED) in women is correlated to significant problems in maternal health and nutrition care and is linked to IUGR. Nationally, the prevalence of CED in women of reproductive age has been decreasing at an average near 1% annually, from2000-2009. Nutrition surveys conducted by the GSO in 2005 and 2009 revealed the CEDrate in reproductive-aged women (defined as BMI less than 18.5) decreased from 28.5% in2000 to 21.9 % in 2005 and 19.6% in 2009. On average, between 2000 and 2009, the rate of reduction was 0.98% per year, nearly meeting the NNS defined objective of 1%.7. Reduction of Vitamin A and Iodine deficiency and nutritional anaemia in pregnant womenMicronutrient deficiency control is one of key interventions needed to improve nutrition and health status for women and children, particularly in its role in the reduction in the prevalence of stunting. In the past 10 years, over 85% of children between 6-36 months old and over 60% of mothers within one month of delivery have received vitamin A supplementation each year. In addition, vulnerable children including those with pneumonia, measles, or prolonged diarrhoea,are also provided high dose vitamin A supplements. This program of supplementation has been reported to be safe, and has enabled Vietnam to sustainably reduce clinical vitamin A deficiency since 2001.Since 2005, Vietnam has nearly eliminated iodine deficiency in pregnant women and children. At present, the NNS objective to reduce goiter prevalence in children 8-12 years old has been achieved, however, sustainability of maintaining mean urinary iodine level and iodized salt coverage have not yet met the standard set forth by the NNS. In recent years, qualified iodized salt coverage was reduced from 91.9% in 2005 to 69.5% in 2009.Iron deficiency anaemia amongst pregnant women in target areas has been reduced in recent years, with just18.9% prevalence in 2009, meeting the NNS objective. However, since target areas represent only a fraction of the country due to limitations in external funding for iron and folate supplements, prevalence remains very high at 36.5% nationally.In addition to direct supplementation of vitamin A, iron, and folate, food fortification methods have been also applied including iodine fortification of salt and iron fortification of fish sauce.8. Strengthened food hygiene and food safety controlsIn the past decade, numerous regulations have been established regarding the manage- ment of food hygiene and safety. The National Plan of Action for Food hygiene and safety in 2010 and the National Program for Food hygiene and safety 2006 - 2010 were ratified by the Prime Minister, attempting to move Vietnam in line with regional and international standards, in order to meet the needs for development and integration. Additional legislation regarding food safety was approved in the National Assembly in June 2010, providing an important legal framework to improve the effectiveness of food safety and protect the overall health of the population.Quality control, inspection, and laboratory systems have been reinforced in the food safety sector. The National Institute for Food hygiene and Safety was established in 2009 as a division of the Ministry of Health. Food laboratories in national and regional research institutes have also been established or upgraded, and food safety management systems in local areas have been strengthened. In order to further promote awareness, the Food Administration has regularly organized “Food Safety Month” from April 15th to May 15th, nationally.The comprehensive movements in organisation, management and implementation from central to local levels have enabled good progress in food hygiene and safety control. In2009, public food poisoning cases reported decreased by 53.5% compared to cases in 1999, and in the same decade, there was a 31.2% decrease in the total number of individuals who experienced food poisoning, and a 51.4% reduction in deaths related to food poinsoning.9. International CooperationFollowing the orientation, objectives and approaches of the NNS, many bilateral and multilateral international cooperation projects have been implemented in different areas of the country, including projects funded by UNICEF that have provided vitamin A capsules for children, support breastfeeding promotion, goiter control, and nutrition advocacy and nutrition monitoring and evaluation. In addition, numerous projects funded by organisaions and governments have helped further NNS objectives, including: the project for “Local Capacity Building for Effective and Sustainable Implementation of Community-based Nu- trition Activities for Women and Children in Ten Disadvantaged Provinces in Vietnam” funded by the government of the Netherlands in 2005-2008, the project for “Fortified FishSauce” funded by GAIN through the World Bank from 2005-2008, the project for “Com- plementary food for vulnerable children 6-24 months old in poor areas”, and the project for “Child nutrition improvement through Vitamin A supplementation for children 6-60 months old combined with deworming for children 24-60 months old in 18 disadvantaged provinces of Vietnam” both funded by Japan Fund for Poverty Reduction through the ADB. These projects have contributed remarkly to the improvement of the nutritional status of Vietnamese people.II. CHALLENGES1. In the past 10 years, the Party and the Government have increased attention and investment in nutrition programs/activities. However, due to limited budget, sufficient resources to reach the defined NNS objectives have not yet been realised. Many provinces have not yet provided necessary support, including funding to meet nutrition objectives. In addition, international funding for nutrition in Vietnam has been decreas- ing since 2005.2. The network for implementing nutrition activities has not been stable and synchronised.There is a high rate of turnover amongst nutrition staff, as well as a general shortage of qualified nutrition staff working in community, school and hospital settings. Further- more, many new staff have not received formal nutrition training to provide high quality services. Despite measures aimed to increase awareness, attention to nutrition issues amongst local authorities and awareness of community nutrition issues remain limited.3. Improper nutrition knowledge and practices are still common amongst mothers and family members, especially those living in rural and remote/isolated areas and ethnic groups.4. In many sites, ensuring food hygiene and safety has not been well implemented, thus affecting the nutrition status of local people.5. There is a disparity in prevalence of undernutrition among regions (including under- weight and stunting). Child underutrition prevalence is very high in Northern Midland and Mountain areas, Central Highlands and North Central and Central Coastal areas compared to the national average and other regions, requiring focused interventions.6. A number of objectives have not been achieved as expected:• Prevalence of stunting (height for age) in children under 5 remained high at 29.3% in2010. In 2010, 28 provinces reported prevalence of stunting greater than national average, amongst those provinces, 12 reported having rates over 35%, which is classi- fied as a high level by WHO.• The prevalence of iron deficiency anaemia in pregnant women is high at 36.5%nationally.• Exclusive breastfeeding rate remains low with 29.3% at 4 months and 19.6% at 6 months, although 93% of children receive some breast milk.• The coverage of qualified iodized salt has not been sustained following cessation of the project in 2005.III. SUCCESSES AND FAILURES1. Causes for achievement of NNS objectivesa) Leadership and guidance of authorities of all levelsThe Party, National Assembly, government, relevant ministries and sectors have enacted numerous guidelines and instructions to implement the NNS and nutrition-related issues. In the 35th session of the UN Standing Committee for Nutrition, held on March 2008 in Hanoi, the Governement of Vietnam committeed to continue to address issue of malnutrition, with a goal to reduce underweight to less than 20% by 2010, and less than15% by 2015.Reduction of undernutrition has become a national indicator in the Resolution of the National Party Cogress and annual resolutions of National Assembly and People’s Council at all levels.Central and local government is increasing investment in nutrition related issues every year. At the central level, funding has increased from 30 billion VND in 2001 to 122 billion VND in 2010. Local funding has also increased, from 8 VND billion in 2001 to 20 billion VND in 2010.b) Active involvement of relevant sectors and mass organisations at all levelsDuring implementation of NNS, many relevant ministries, sectors and mass organisa- tions have developed formats and models directed to target groups and specific tasks, with increased involvement of the population as a result. In addition, some sectors have advised the governement regarding the promulgation of nutrition supporting policies and even developed their own action plans for implementation of the NNS. Most of the localities have good multisectoral cooperation for NNS implementation.c) Policy to implement comprehensive nutrition activities from central to local levelsThe Ministry of Health, through their role as the chairing body, and National Institute of Nutrition as the focal point for nutrition activities, have developed proper intervention approaches, an effective implementation mechanism, and close monitoring and supervision.Nutrition activities have been conducted widely and comprehensively from the central to community levels nation-wide through designated nutrition coordinators and collabora- tors who have mobilised relevant sectors, mass organisations and communities.Awareness of proper nutrition and malnutrition control amongst government officials and local communities has been raised as a result of nutrition activities.d) Socioeconomic development and growth in science and technology create a favourable enviromentIn the last 10 years, the economy has grown rapidly. The proportion of poor households has been continuously and sustainably reduced . Education, information, and communica- tion systems have developed rapidly. International integration has increased in scope and depth. These achievements have contributed to the improved quality of life and enabled increased access to information and knowledge on health and nutrition topics.e) Effective support from international organisations, governmental organisations, and mobilisation of external and internal NGOsInternational organisations, government organisations and NGOs have provided generous technical and financial support for the implementation of many activities within the NNS, including research, staff training, education, communication, and intervention projects. Resources have been enhanced through domestic and international cooperation. Social mobilisation, especially in the child malnutrition control program, has achieved a high level of efficacy.2. Potential causes for failure to reach NNS objectivesa) In some localities, Party, government, and community authorities have not given adequate attention to nutrition issues, or not recognised their importanceIn some areas, steering committees for NNS implementation and malnutrition control programs have been established, following the instructions of the central government, but they have failed to thoroughly execute the objectives. In addition, nutrition indicators have not been integrated in local annual resolutions and socioeconomic plans. The implementa- tion, monitoring, evaluation and review have been done mostly by the health sector instead. As a result, knowledge and awareness of proper health and nutrition practices are still lim- ited amongst some segments of the population.b) Resource investment has not met actual needsResources invested to address nutrition issues have not yet met the actual needs for comprehensive and synchronised implementation of the NNS nationally. The nutrition network, particularly in the field of dietetics, remains weak due to the inadequate number of trained staff.The majority of the budget has been allocated for activities to control child malnutrition, focusing on reduction of underweight. Other important nutrition issues such as stunting and micronutrient deficiencies have not yet received due attention. The mobilisation of local resources for NNS implementation has been constrained. Many localities remain passive, depending mostly on funding allocated by the central government. Funding from international sources has not been coordinated and managed effectively, following the national priorities.c) Management and operation constraintsNutrition related policies have not been synchronised, for example, although the health sector promotes exclusive breastfeeding for 6 months, the labor laws provide only 4 months of maternity leave. Policies and decisions often overlap between different governing bodies, such as food hygiene and safety, production and marketing of nutrition products for infants. The nutrition network has been insufficient and unstable to accomplish the NNS objectives.The process of planning, determining objectives and budget allocation have not adequately considered local needs and situations. In addition, some evaluation indicators have not been closely monitored.The role of the health sector has also been lacking in coordination and technical guidance in some localities. Many programs and projects related to nutrition amongst other sectors have not properly focused on technical requirements or the sustainability of interventions.Multi-sector cooperation for certain activities has not been strong enough, and remains in theory more than in practice. Budget allocation for nutrition activites in other sectors remains limited. In general, there is a lack of united coordination in the framework to achieve the NNS objectives.IV. LESSONS LEARNT1. Strong committement of Party and governement authorities at all levels is an essential and prerequisite factor to ensure the success of nutrition activities. Objectives of malnutrition control should be incorporated into the resolution of the Party’s Congress and annual resolutions of the National Assembly and local People’s Councils.2. Malnutriton is not only caused by hunger but also by ignorance, therefore education and communication to raise awareness of proper nutrition and affect behaviour change are key interventions that should be maintained.3. Nutrition activities require more creative approaches based on an analysis of each localities’ needs. Local initiatives, proposals and models should be developed, collected, and reviewed in order to provide effective guidance and orientation for implementation.4. The successes in reduction of child malnutrition in many cities and provinces have provided an example of the important role played by multisector cooperation and mass organisations at different levels.5. Monitoring and evaluation of nutrition data and food intake should be systematically performed, focusing on vulnerable regions and populations. At the same time, new research should be proposed and conducted in order to identify and assess emerging nutrition problems, thus developing recommendations in a timely to rapidly respond with appropriate interventions.6. International cooperation should be strengthened, with mobilisation of additional resources in order to increase funding for nutrition programs and projects.Link download:
Full text: Decision Ratification of the National Nutrition Strategy for 2011 – 2020, With a Vision toward 2030.
Full text: National Nutrition Strategy for 2011-2020, with a vision toward 2030
Full text: Summary of Main findings of General nutrition survey and NNS, 2011-2020