Consultant - Bottleneck Analysis to understand issues with policy implementation for maternal nutrition in South Africa (105 days)

Consultant Medical & Health Programme & Policy

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Background and challenges

Women’s nutrition is an important determinant of children’s nutrition, growth, health, and development outcomes especially during the 1,000-day window from conception to age 2, and beyond.

All forms of malnutrition in women, including underweight, anaemia and overweight, have serious consequences for women’s health and well-being. Women who are underweight or overweight before pregnancy face additional risk factors when they become pregnant, such as gestational diabetes, hypertension, pre-eclampsia and caesarean section, as well as poor pregnancy and breastfeeding outcomes. During pregnancy, gestational weight gain less than or greater than guideline recommendations increases the risk of adverse infant outcomes such as small-for-gestational-age or large-for-gestational age births and preterm births.

These factors put their children at risk of undernutrition in early childhood (including wasting, stunting and micronutrient deficiencies) with long-term negative consequences for school readiness, enrolment and learning performance. Maternal malnutrition is also linked to adverse outcomes for their children due to the intergenerational link of malnutrition, which accounts for 20% of childhood stunting globally.

In South Africa, 28% of pregnant women are anaemic , while among women of reproductive age (WRA) in 2017, 22% were vitamin A deficient and 20% iodine deficient. Meanwhile, 68% of WRA are overweight or obese. When it comes to children, despite a small decrease over the years, in 2015 about 1 in 7 children were born with low birthweight. Low birthweight is an important risk factor for stunting among children less than 2 years and puts children at higher risk of mortality. Stunting affects almost one in three children under five years in South Africa and has remained stubbornly high over time.

Malnutrition in women is largely the result of poor diets and poor care services and practices. In South Africa, mothers in low-income households often struggle to purchase adequate nutritious food. When it comes to services, the nutritional status of pregnant women is screened for, but the Guidelines for Maternity Care provide no recommendations on nutritional advice to be given according to weight status. Moreover, data on the micronutrient status of pregnant women is sparse.

To address maternal anemia, WHO recommends daily oral iron and folic acid (IFA) supplementation with 30 mg to 60 mg of elemental iron and 400 μg (0.4 mg) of folic acid for pregnant women. Folic acid supplementation (with or without iron) provided before conception and during the first trimester of pregnancy is also recommended for decreasing the risk of neural tube defects. South Africa has implemented this recommendation and the coverage was estimated to cover about 75-100% of districts in the country in 2018. To address maternal overweight and obesity, counselling about healthy eating and keeping physically active to pregnant women is recommended and has been implemented in South Africa.

Despite implementation of some antenatal nutrition services, South Africa is not on track to meet the World Health Assembly target to halve anaemia in women of reproductive age by 2025. Studies indicate no improvement in the prevalence of iron deficiency anaemia among pregnant women, despite the routine high-dose iron supplements that are provided. Moreover, antenatal nutrition interventions have tended to be fragmented and greater efforts are needed to ensure an integrated approach to maternal malnutrition.

A Regional Study on maternal nutrition conducted by UNICEF showed a number of bottlenecks related to implementing maternal nutrition interventions, including the daily IFA supplementation. Moderate bottlenecks were identified in the areas of leadership, management and coordination, budget and financing, information, essential commodities and supplies, service delivery and effective coverage. When it comes to counselling about healthy eating and keeping physically active, significant bottlenecks were identified when related to health workforce, social norms and social and cultural practices, and effective coverage.

Although some evidence is available on policy implementation and maternal nutritional status, the actual coverage, uptake and quality of antenatal nutrition services as well as the bottlenecks and their root causes are not fully understood. The considerable burden of childhood stunting and overweight and poor maternal nutrition in South Africa has far reaching consequences for maternal health, child survival, growth, and development. To address this and ultimately improve the health of children in South Africa, it is of high importance to improve the antenatal nutrition services quality, coverage and uptake.

The solution

The UNICEF Bottleneck Analysis (BNA) methodology is a participatory and consultative process undertaken with all stakeholders involved. This approach uses the Tahanashi model to critically examine the main determinants of effective health services coverage and can effectively be used to assess maternal nutrition services. The BNA approach adopts a problem-solving focus that can support analysis and taking timely corrective action in addition to informing scale-up strategies and programme designs.

The BNA can serve to monitor and assess programme coverage in a cost-effective and time-efficient manner. This approach is based on problem solving to support analysis and take timely corrective action. The aim of the BNA is to identify, target and monitor key bottlenecks and put programme reforms in action toward increase of antenatal nutrition programme quality, coverage and uptake.

The BNA process starts with inception workshops to define and contextualize the indicators used to perform the analysis, followed by collecting the necessary qualitative and quantitative information (from available database and structured questionnaires). A joint critical analysis is then performed to identify and articulate bottlenecks or barriers to access to antenatal nutrition services and effective coverage and quality, followed by a causal analysis of the root causes. The outcome of this process will lead to the joint definition and prioritization of evidence-based solutions to address the bottlenecks, which will lead to the development of actionable policy recommendations to outline and guide the implementation of the programme reforms and set targets.

The following areas related to antenatal nutrition services should be assessed for bottlenecks: 1. Enabling environment 2. Supply side 3. Demand side 4. Quality of care

The BNA approach is a means not only to improve the access and effective coverage of antenatal nutrition services including counselling on healthy eating and physical activity and daily iron and folic acid to pregnant women. It can also inform the necessary improvements in the current actions and maximize the chance to achieve more responsive programming and better results for children of South Africa.

SCOPE OF WORK:

Objectives:

The two main objectives of the consultancy are: 1) to understand the bottlenecks and their root causes related to policy implementation of antenatal nutrition services in South Africa. 2) to generate evidence-based, cost-effective policy solutions to improve quality, coverage, and uptake of antenatal nutrition services among this group.

Scope of work:

The service provider will contribute to the critical analysis of barriers and bottlenecks and the development of recommendations to improve the quality, coverage and uptake of antenatal nutrition services particularly in areas with high burden of maternal anaemia and maternal overweight and obesity. The consultancy will also support the National Department of Health in documenting lessons learned, good practices, case studies and experiences in implementing antenatal nutrition services across Provinces in South Africa. The work will focus on the following key enabling areas to unlock the policy and programmatic issues:

1. Analysis: Systematically address key context-specific drivers of maternal malnutrition at district level. Improved geospatial allocation of services for the prevention, early detection and treatment of maternal malnutrition by identifying specific ‘hot-spots’ in the country with persistently high levels of maternal anaemia and overweight or obesity. This will help prioritize services and resources where they can be most impactful, improve targeting over time and space, and allow for better allocation of resources for the prevention, early detection and treatment of maternal malnutrition. This will entail the analysis of the DHIS data and other existing reports, which could also include triangulation of data for decision-making purposes.

2. Prevention: Increase access to services for the prevention of maternal malnutrition, in particular IFA supplementation and nutrition counselling. There is a need to assess if the “hot-spot” areas for maternal malnutrition are of sufficient quality, have effective coverage and to make recommendations for scaling them up.

3. Early detection: Improve early detection of maternal malnutrition at community level. This will include exploring the sustainability and costs associated with the scaling-up of improved services for early detection.

4. Treatment: Optimize and simplify coverage and uptake to antenatal nutrition services through the expansion of modelling of simplified approaches.

5. Supply chain: increase availability and sustainability of supplies for the prevention and treatment of all forms of maternal malnutrition. A better understanding of the financial resource flow for the procurement of essential supplies and availability of those supplies at the district level.

6. Evidence generation: A targeted evidence generation agenda on the prevention, early detection and treatment of maternal malnutrition through documenting pathways towards reducing its incidence in a variety of vulnerable contexts, while generating new evidence to simplify and optimize protocols and programmes for the prevention and treatment of maternal malnutrition.

Tasks and deliverables

The service provider will report to the UNICEF nutrition team. The following tasks and deliverables are expected: 1. Design, conduct and facilitate a consultative inception workshop in four Provinces (a balanced combination of urban and rural areas) to define and contextualize the indicators and necessary tools to perform the analysis. 2. Conduct investigative visits to the four provinces to collect qualitative and quantitative information regarding bottlenecks for antenatal nutrition service quality, coverage and uptake, using agreed indicators and tools. 3. Conduct and facilitate Participatory Validation Workshops with relevant stakeholders to critically analyse gathered information to identify and analyse bottlenecks and barriers to quality, access and effective coverage and perform causality analysis of root causes. 4. Through a consultative process with UNICEF and other relevant stakeholders, develop a strategic action plan and prioritization of evidence based solutions to address bottlenecks and improve the implementation of antenatal nutrition services. 5. Develop case studies on the experience, good practices, lessons learned and challenges in delivering antenatal nutrition services. 6. Develop a comprehensive final report of the BNA including the situation analysis, key findings and policy recommendations to improve the quality, coverage and uptake of antenatal nutrition services in South Africa.

Work Assignment Overview

Tasks/Milestone:

Deliverables/Outputs:

Timeline

Estimate Budget

Design, organize and facilitate inception workshop on bottleneck analysis in four Provinces (a balanced combination of urban and rural areas, to be agreed upon).

Inception report, including the workplan for BNA, draft indicator list and tools and

documentation of the workshop

20 days

20%

Data collection of qualitative and quantitative information in the 4 Provinces using agreed indicators and tools for quality and effective coverage and uptake of antenatal nutrition services.

Report on qualitative and quantitative information collected.

4 case documentation on experiences, best-practices, lessons learned and challenges on providing quality antenatal nutrition services with effective coverage and uptake.

40 days

30%

Facilitation of analysis of Bottlenecks and development of strategic action plan through a Participatory Validation Workshops

Validation workshop

Documentation of BNA and Action Planning workshop

5 Case Studies documentation

Process documentation of the BNA exercise.

30 days

30%

Final Report of the Bottleneck Analysis including situation analysis, identified and prioritized evidence-based solutions and corrective actions at national, provincial and district levels.

BNA and Action Plan document

9 Case Studies and Process Documentation

1 Policy Brief

1 Peer reviewed article

15 days

20%

To qualify as an advocate for every child you will have…

• An advanced university degree (Master’s or higher) in Health, Nutrition, Medicine, Social Sciences or other relevant qualification
• At least 5 years of relevant professional work experience on health systems/health governance/bottleneck analysis/program evaluation/operations research from developing countries on nutrition.
• Practical experience in the management of nutrition programs supported by reports and documents
• Technical knowledge in the field of maternal nutrition is an advantage.
• Ability to work in consultative and coordinated manner and with demonstrated skills for building consensus between a wide group of experts supported by reports and documents.
• Previous with UN and other international development partners in Africa an asset
• Excellent written communication, presentation, and analytical skills.

For every Child, you demonstrate…

UNICEF's values of Care, Respect, Integrity, Trust, Accountability, and Sustainability (CRITAS).

To view our competency framework, please visit here.

UNICEF is here to serve the world’s most disadvantaged children and our global workforce must reflect the diversity of those children. The UNICEF family is committed to include everyone, irrespective of their race/ethnicity, age, disability, gender identity, sexual orientation, religion, nationality, socio-economic background, or any other personal characteristic.

UNICEF offers reasonable accommodation for consultants/individual contractors with disabilities. This may include, for example, accessible software, travel assistance for missions or personal attendants. We encourage you to disclose your disability during your application in case you need reasonable accommodation during the selection process and afterwards in your assignment.

UNICEF has a zero-tolerance policy on conduct that is incompatible with the aims and objectives of the United Nations and UNICEF, including sexual exploitation and abuse, sexual harassment, abuse of authority and discrimination. UNICEF also adheres to strict child safeguarding principles. All selected candidates will be expected to adhere to these standards and principles and will therefore undergo rigorous reference and background checks. Background checks will include the verification of academic credential(s) and employment history. Selected candidates may be required to provide additional information to conduct a background check.

Remarks:

Only shortlisted candidates will be contacted and advance to the next stage of the selection process.

Individuals engaged under a consultancy or individual contract will not be considered “staff members” under the Staff Regulations and Rules of the United Nations and UNICEF’s policies and procedures, and will not be entitled to benefits provided therein (such as leave entitlements and medical insurance coverage). Their conditions of service will be governed by their contract and the General Conditions of Contracts for the Services of Consultants and Individual Contractors. Consultants and individual contractors are responsible for determining their tax liabilities and for the payment of any taxes and/or duties, in accordance with local or other applicable laws.

The selected candidate is solely responsible to ensure that the visa (applicable) and health insurance required to perform the duties of the contract are valid for the entire period of the contract. Selected candidates are subject to confirmation of fully-vaccinated status against SARS-CoV-2 (Covid-19) with a World Health Organization (WHO)-endorsed vaccine, which must be met prior to taking up the assignment. It does not apply to consultants who will work remotely and are not expected to work on or visit UNICEF premises, programme delivery locations or directly interact with communities UNICEF works with, nor to travel to perform functions for UNICEF for the duration of their consultancy contracts.

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Added 1 year ago - Updated 1 year ago - Source: unicef.org