USAID/Zambia: Integrated Nutrition Investment Framework--Overview

USAID/ZAMBIA: INTEGRATED 

NUTRITION INVESTMENT 

FRAMEWORK 

OVERVIEW 

MARCH 2011 

This publication was produced for review by the United States Agency for International Development. 

It was prepared by Dorothy Nthani, Jim Levinson, Kayoya Masuhwa, and Mellen Tanamaly through the 

Global Health Technical Assistance Project.

USAID/ZAMBIA: INTEGRATED 

NUTRITION INVESTMENT 

FRAMEWORK 

OVERVIEW 

DISCLAIMER 

The authors‘ views expressed in this publication do not necessarily reflect the views of the 

United States Agency for International Development or the United States Government.

This document (Report No. 11-01-395-2) is available in printed or online versions. Online 

documents can be located in the GH Tech website library at resources.ghtechproject.net 

Documents are also made available through the Development Experience Clearing House 

(www.dec.org). Additional information can be obtained from: 

The Global Health Technical Assistance Project 

1250 Eye St., NW, Suite 1100 

Washington, DC 20005 

Tel: (202) 521-1900 

Fax: (202) 521-1901 

info@ghtechproject.com 

This document was submitted by The QED Group, LLC, with CAMRIS International and Social 

& Scientific Systems, Inc., to the United States Agency for International Development under 

USAID Contract No. GHS-I-00-05-00005-00.

CONTENTS 

ACRONYMS ........................................................................................................... iii 

1. EXECUTIVE SUMMARY .................................................................................. 1 

2. INTRODUCTION ............................................................................................. 3 

2.1. Purpose ................................................................................................................................. 3 

2.2. Methodology ....................................................................................................................... 3 

3. SITUATIONAL ANALYSIS ............................................................................. 5 

3.1. Overall Status and Progress in Nutrition—Including Feasibility of Achieving 

Targets Including Those in the Relevant Millennium Development 

Goals (MDG) ...................................................................................................................... 5 

3.2. Sector-specific Status Pertinent to Nutrition, Progress and Gaps, Including 

Efforts of the GRZ, the USG and other donors ....................................................... 14 

3.3. Issues of Particular Concern .......................................................................................... 28 

4. RE-POSITIONING NUTRITION AND FOOD SECURITY ....................... 33 

4.1. Suggested Approaches for Nutrition and Health Service Delivery ...................... 33 

4.2. Suggested Approaches for Household Food and Nutrition Security 

Interventions ..................................................................................................................... 34 

4.3. Suggested R&D Approaches for Urban Nutrition Challenges ............................... 36 

5. SUGGESTED APPROACHES TO INSTITUTION BUILDING, SYSTEMS 

STRENGTHENING, CAPACITY BUILDING AND ADVOCACY ............ 39 

5.1. Community Health Workers Nutrition Training and Roll-Out ............................ 39 

5.2. Support the Start-up and Development of the New BSc in Human Nutrition at 

University of Zambia, Faculty of Agriculture ............................................................. 39 

5.3. Reinforce and Strengthen the Nutrition Diploma Program at the Natural 

Resources Development College (NRDC) ................................................................ 40 

5.4. Support and Upgrade MACO Extension Agents to Assist Farmers Achieve 

Food and Nutrition Security ......................................................................................... 40 

5.5. Nutrition Advocacy ......................................................................................................... 41 

ANNEXES 

ANNEX A. SCOPE OF WORK ........................................................................... 43 

ANNEX B. PERSONS CONTACTED ................................................................ 57 

ANNEX C. ZAMBIA NUTRITION FRAMEWORK .......................................... 59 

ANNEX D. STUNTING IN ZAMBIA: CAUSES, CONSTRAINTS AND 

PROPOSED STRATEGIES AND INTERVENTIONS .................. 65 

USAID/ZAMBIA: INTEGRATED NUTRITION INVESTMENT FRAMEWORK OVERVIEW 

i

TABLES 

Table 1. Rates of Stunting, Wasting and Underweight Among Children 

Under Age 5; Low Body Mass Index Among Women of 

Reproductive Age; and Infant and Young Child Feeding 

Practices by Province (ZDHS 2007) ..................................................... 6 

Table 2. Nutrition Indicators for Children Under 5 Years of Age in 

Zambia 2002–2007 ................................................................................. 12 

Table 3. Millennium Development Goals in Zambia: Targets and 

Indicators ................................................................................................ 13 

Table 4. Land and Population Distribution Across Farm Household Types .. 15 

Table 5. Essential Nutrition Actions ................................................................... 24 

Table 6. Number of Nutritionists in Possession Various Certificates ............. 31 

FIGURES 

Figure 1: Causes of Stunting .................................................................................. 7 

ii 

USAID/ZAMBIA: INTEGRATED NUTRITION INVESTMENT FRAMEWORK OVERVIEW

ACRONYMS 

AIDS 

ANC 

AO 

ART 

BCC 

BMI 

CAADP 

CARMMA 

CBGMP 

CHAZ 

CHV 

CHW 

COMACO 

CSO 

DFID 

ENA 

FP 

FTF 

FSP 

GHI 

GINA 

GMP 

GRZ 

HAART 

HEPS 

HFP 

HIV 

HMIS 

IEC 

IYCF 

IYCN 

MACO 

MCC 

MCDSS 

MDG 

MOE 

MOH 

NASF 

NDP 

Acquired immune deficiency syndrome 

Antenatal care 

Assistance objective 

Antiretroviral therapy 

Behavior change communication 

Body mass index 

Comprehensive Africa Agriculture Development Program 

Campaign for Accelerated Reduction of Maternal Mortality 

Community-based growth monitoring and promotion 

Churches Health Association of Zambia 

Community health volunteer 

Community health worker 

Community markets for conservation 

Central Statistical Office 

Department for International Development 

Essential Nutrition Actions 

Family planning 

Feed the Future 

Food Security Pack 

Global Health Initiative 

Gender-informed nutrition agriculture 

Growth monitoring and promotion 

Government of the Republic of Zambia 

Highly active antiretroviral therapy 

High energy protein supplement 

Homestead food production 

Human immunodeficiency virus 

Health management information system 

Information education communication 

Infant and young child feeding 

Infant and young child nutrition 

Ministry of Agriculture and Cooperatives 

Millennium Challenge Corporation 

Ministry of Community Development and Social Security 

Millennium Development Goal 

Ministry of Education 

Ministry of Health 

National AIDS Strategic Framework 

National Development Plan 

USAID/ZAMBIA: INTEGRATED NUTRITION INVESTMENT FRAMEWORK OVERVIEW 

iii

NFNC 

NGO 

NHSP 

NRDC 

OVC 

PEPFAR 

PMTCT 

PLHIV 

R&D 

RTEF 

RUTF 

SADC 

SNDP 

STI 

UNICEF 

USAID 

USG 

VCT 

WASH 

National Food and Nutrition Commission 

Non-governmental organization 

National Health Strategic Plan 

Natural Resources Development College 

Orphans and vulnerable children 

President‘s Emergency Plan for AIDS Relief 

Prevention of mother-to-child transmission of HIV 

People living with HIV 

Research and development 

Ready-to-eat food 

Ready-to-use therapeutic food 

Southern Africa Development Community 

Sixth National Development Plan 

Sexually transmitted infections 

United Nations Children‘s Fund 

United States Agency for International Development 

United States Government 

Voluntary counseling and testing 

Water, sanitation, and hygiene 

iv 

USAID/ZAMBIA: INTEGRATED NUTRITION INVESTMENT FRAMEWORK OVERVIEW

1. EXECUTIVE SUMMARY 

While the Government of the Republic of Zambia (GRZ) and its partners have achieved some 

success in addressing malnutrition in the country, the principal problems of protein-energy 

malnutrition and iron-deficiency anemia have yet to be systematically addressed. The successes 

are clear: Twice annual Child Health Weeks, organized by the Ministry of Health (MOH), 

provide 80% of children under age 5 with semi-annual Vitamin A supplements and de-worming 

medication; most imported salt is now iodized; and sugar for domestic consumption is fortified 

with Vitamin A. Yet the country continues to suffer from some of the most serious young child 

nutritional stunting in the world, at 45%. Further, malnutrition is an underlying cause in a 

conservative estimate of 35% of under-5 child deaths, resulting in an estimated 10% loss in 

lifetime earnings and a minimum of 2–3% loss in gross domestic product. 1 Thus, the case for 

improved nutrition is unquestioned. In the presence of pervasive rural poverty, addressing 

malnutrition will require not only the provision of effective nutrition and health services, both at 

community and facility level, but also a serious effort to address problems of household food 

insecurity by increasing the resilience of small-holder farming households. 

Nutritional stunting among children aged 0–24 months is the primary malnutrition issue. The 

determinants of stunting are sufficiently cross-sectoral that stunting levels could well serve as an 

indicator of overall development. And the effectiveness of robust nutrition and food security 

interventions to reduce stunting may be constrained by an unsafe water supply or inadequate 

female education. It should also be noted that it will be difficult to reduce stunting significantly 

without increased attention to maternal malnutrition and low birthweight issues, which 

currently receive minimal attention at the community level. 

Household food insecurity is the most important determinant of malnutrition in Zambia. Unlike 

many Latin American countries, where young child and maternal malnutrition have been 

reduced significantly through behavioral change communications (BCC) alone, household food 

insecurity in Zambia is too serious to permit many needed changes in food consumption-related 

behaviors without first increasing household access to food. 

Food insecurity; under-nutrition; poor educational performance; infant, child and maternal 

mortality; high mortality from infectious diseases; low labor productivity and low life expectancy 

are all interconnected and preventable. 

Accordingly, this strategy suggests a two-pronged approach by (1) giving equal attention to 

improved nutrition services at the community and facility levels, with a strengthened cadre of 

community health workers (CHW) and improved package of behavioral change communication 

materials available through the Infant and Young Child Feeding (IYCF) initiative and the MOH; 

and (2) a cost-effective agricultural production package designed to increase the resilience of 

targeted small-holder households. The program will intensify both approaches in targeted areas 

where they are best implemented together. And particular attention is given to the need for a 

coordinated nutrition-related BCC strategy that involves mutually reinforced messages provided 

by (1) CHWs, health volunteers and facility staff, (2) MACO extension agents and (3) 

community radio. 

1 The Lancet‘s Series on Maternal and Child Undernutrition, January 2008. 

USAID/ZAMBIA: INTEGRATED NUTRITION INVESTMENT FRAMEWORK OVERVIEW 1

The strategy also: 

Seeks to address malnutrition-associated diarrheal infection through the integration of 

water, sanitation, and hygiene (WASH) initiatives into health and HIV programming— 

designed to protect vulnerable mothers, children and the HIV+ population. 

Suggests research and development (R&D) on urban gardening and possible local production 

and commercialization of complementary and related foods in urban areas. 

Identifies in-school and out-of-school youth as potentially important targets for integrated 

efforts at pregnancy and HIV prevention; gender equity counseling; skill training and 

nutrition (reducing anemia in pregnancy through adolescent iron-folate supplementation). 

The program also suggests capacity building and institutional strengthening in the areas of CHW 

training and roll-out, where particular opportunities exist for donor collaboration to strengthen 

efforts by the MOH and the National Food and Nutrition Commission (NFNC); in strengthening 

agricultural extension staff in the Ministry of Agriculture and Cooperatives (MACO) and 

extending their mandate to include the provision of key nutrition messages; in upgrading 

professional nutrition training at the University of Zambia and at the Natural Resources 

Development College (NRDC); and in facilitating a much-needed and well-championed nutrition 

advocacy initiative. 

2 USAID/ZAMBIA: INTEGRATED NUTRITION INVESTMENT FRAMEWORK OVERVIEW

2. INTRODUCTION 

2.1. PURPOSE 

USAID/Zambia hired a team of consultants to develop an integrated nutrition framework in 

order to provide a clear roadmap for short- and long-term investments (including potential new 

procurement needs), to demonstrate a commitment to a Zambia-led process and plan, and to 

work collaboratively with other partners and stakeholders. 

―Based on a comprehensive and integrated strategic approach that addresses the multiple 

dimensions and causes of Undernutrition, this framework must aim to improve the nutritional 

status of Zambians, targeting women and children under age 2. It must also link the 

contributions of USAID/Zambia‘s economic growth, education, health, HIV/AIDS, and 

humanitarian assistance programs. Additionally, this framework must incorporate the principles 

and leverage the resources of the Food for Peace (FFP) program, Global Hunger and Food 

Security Initiative (GHFSI), Global Health Initiative (GHI), and President‘s Emergency Plan for 

AIDS Relief (PEPFAR).‖ 

2.2. METHODOLOGY 

The consultant team reviewed background documents provided by USAID/Zambia, interviewed 

key informants in Zambia and Washington, D.C., and met with USAID/Zambia leadership and 

technical teams on several occasions (See Annex C). The team held a planning meeting on 

October 22–23 and worked collectively and individually in Lusaka through November 14, 2010. 

They then conducted site visits to health facilities and agricultural programs in other provinces. 

The team held a preliminary debriefing with key USAID/Zambia and other U.S. Government 

(USG) staff and then debriefed the USAID/Zambia Mission Director, Deputy Mission Director 

and Health, Economic Growth and HIV technical staff on their final day in country. 



3. SITUATIONAL ANALYSIS 

This situational analysis focuses on women of reproductive age and children under age 2 as they 

are at high risk for malnutrition and suffer its most serious consequences. In Zambia, the rural 

poor, mainly farmers with small agricultural holdings, comprise the majority of the food and 

nutrition insecure. However, many poor urban households also struggle to satisfy their dietary 

needs. In addition, people living with HIV (PLHIV), orphans and vulnerable children (OVC) and 

out-of-school adolescents present nutritional challenges that are discussed below. 

3.1. OVERALL STATUS AND PROGRESS IN NUTRITION— 

INCLUDING FEASIBILITY OF ACHIEVING TARGETS INCLUDING 

THOSE IN THE RELEVANT MILLENNIUM DEVELOPMENT GOALS 

(MDG) 

The population of Zambia is estimated at 12.5 million with an average population growth rate of 

2.4%. The burden of disease in Zambia is serious and communicable diseases such as HIV/AIDS, 

tuberculosis and malaria are highly prevalent. Maternal and child health indicators reveal that 

while some progress has been made in recent years, much remains to be done to improve the 

quality of life for Zambian families. Poor nutrition status among children is both the result of the 

high infectious disease burden and a contributor to the unacceptable high rates of maternal and 

child mortality. Without adequate nutrition in the first two years of life, a child‘s physical and 

mental development is compromised irreversibly. 

Primary Target Groups and Status 

Children Under Age 2 

Stunting remains the most common nutritional disorder that affects children in Zambia. Fortyfive 

percent of children under age 5 are stunted/chronically malnourished (the sub-Saharan 

Africa average is 42%) and 21% are severely stunted. 2 Stunting prevalence rates have decreased 

since 2001–2002 when 53% of children under age 5 were stunted; but there has been no period 

of significant progress since the years preceding 1992 when stunting prevalence was reduced to 

46%. 3 In Zambia, low height/age peaks at 18–23 months when 58.9% of children are below -2SD 

(moderately or severely stunted). Stunting is inversely related to household wealth, although 

stunting is high in all wealth quintiles (48 and 33.2% in the lowest and highest quintiles 

respectively). The 2009 National Nutrition Surveillance System (NNSS) Report, issued by the 

National Food and Nutriton Commission (NFNC), found overall under age 5 stunting 

prevalence in Zambia to be 49.7%. 4 In particular, Mwinilunga, Mansa, Mbala, Chinsali, Lundazi, 

Chipata, Mumbwa, Chongwe, Chingola and Kalomo Districts recorded stunting in children 

under 5 years well above 50%. Although the NNSS uses a different sampling method than the 

ZDHS, these recent findings are cause for serious concern. 

Male children (48%) are more likely to be stunted than female children (42%), while more rural 

children are stunted (48%) than urban children (39%). Provincial variation in nutritional status of 

children is substantial, with stunting prevalence highest in Luapula province (56%) and lowest in 

Western and Southern provinces (36% each). 

2 While the child nutrition target of this strategic framework is children under age 2, most data collected 

in the country to date, including ZDHS data reports on children under age 5. 

3 DHS, 1992. 

4 National Nutrition Surveillance System Report: Key Indicators by District, 2009. National Food and 

Nutrition Commission. 


The prevalence of wasting (low weight for height) among children under age 5 has remained relatively constant at approximately 5% 

over the past three ZHDS surveys (1992, 1996, and 2001–02). However, the results of the 2007 ZDHS show notable improvement in 

nutritional status of children as measured by weight-for-age: from 23% underweight in 2001–2002 to 14.6% in 2007. 5 

Stunting is also inversely related to a mother‘s education. DHS data indicate that children born to mothers with no education are more 

likely to be stunted (44.6%) compared to those children born to mothers with a secondary education (38.6%). 6 

Table 1. Rates of Stunting, Wasting and Underweight Among Children Under Age 5; Low Body Mass Index Among 

Women of Reproductive Age; and Infant and Young Child Feeding Practices by Province (ZDHS 2007) 

Province 

Children

Infant and young child feeding practices are an important determinant of nutritional status. 

Among the most important are early initiation and exclusive breastfeeding until age 6 months, 

followed by the addition of appropriate complementary foods alongside breast milk from age 6 

months to at least 24 months. In Zambia, nearly all infants are breastfed, but the median 

duration of exclusive breastfeeding at the national level is only 3 months, and only slightly more 

than half (56.5%) of newborns are breastfed within one hour of birth. The lowest median 

duration of exclusive breastfeeding is found in Eastern, Luapula, Northern, and Northwestern 

provinces—areas where child malnutrition levels also are highest. 

Most stunting occurs during the first two years of life, at which time children have a particularly 

high demand for nutrients, but face serious limitations in the quality and quantity of their diets 

usually beginning at the age of 4 to 6 months. Inadequate complementary feeding is common in 

Zambia, with low nutrient density foods being the norm and with little consumption of animal 

protein by children in low-income households. Using dietary diversity as a measure, the 2007 

DHS survey found that only 25% of children aged 6–23 months receive a minimally acceptable 

diet. 7 

Infectious diseases—particularly diarrhea, malaria and respiratory illness—are also critically 

important determinants of stunting and common in the 6–23 month age group. Indeed, suboptimal 

feeding practices and a high prevalence of illness and infection make children more 

vulnerable to growth faltering and malnutrition in the first two years of life than at any other 

time in the life cycle. 

The 2007 ZDHS indicates that 41% of households have access to improved sources of water 

and that 25% of households have no toilet facilities. 

Figure 1: Causes of Stunting 

7 Zambia DHS 2007, page 172. 


Reproductive Age Women 

A woman‘s nutritional status is an important factor for her own quality of life as well as for the 

health of her children. In Zambia, an estimated 10% of women of reproductive age have a low 

Body Mass Index (BMI)—below 18.5—while an estimated 11% of infants are born with low 

birthweights. 8 A BMI under 18.5 usually implies particularly low caloric intake and/or particularly 

high caloric expenditure (arduous labor), and often also suggests that the woman was 

malnourished as a young child. 

The nutritional status of a woman before and during pregnancy is important for a healthy 

pregnancy outcome. Low maternal BMI is associated with intrauterine growth restriction. 

Birthweight, or ―perceived size at birth‖ relative to other newborns, is an important predictor 

of the subsequent growth of children—as well as of their likelihood of survival. Children 

reported to be of average size or larger at birth are less likely to be stunted than children 

reported to be small or very small at birth. (DHS data indicates that 44% of recently born 

children in Zambia who were reported to be average or larger at birth became stunted 

compared with 63% of children who were reported to be very small at birth.) Stunting also is 

slightly higher among children born less than 24 months apart than among first-born children or 

those with a longer birth interval. 

The IYCN Program notes the following with respect to women‘s nutrition status in Zambia: 

―Undernutrition is highest in adolescent girls compared to all other age groups of women, 

reflective in part of their lack of decision-making power. This high prevalence of women‘s 

malnutrition is related to a number of factors, particularly poverty, women‘s high burden of 

productive and reproductive tasks and lack of decision-making power and access to resources. 9 

A Ngoni and Chewa saying from the Eastern Province of Zambia states that ―A man should 

always be well fed.‖ This emphasizes that it‘s a woman‘s responsibility to ensure that the best 

and most nutritious food available is given to the men in the family, especially her husband. 

Similar information was found in a qualitative study in Luapula province, where women reported 

that they must ensure that men receive sufficient food, even if the woman is pregnant. 10 This 

results in inequitable food distribution within the household to the disadvantage of women. It 

should also be noted that if a woman fails to cook to the satisfaction of her husband and his 

family, he may divorce her, resulting in social and economic isolation for the woman. 11 

During pregnancy, women need to reduce their workload to ensure they maintain their health 

and that of the fetus, particularly to reduce the risk of low birthweight. However, this is virtually 

impossible, given women‘s many obligations in agricultural work and household chores, such as 

hauling water and firewood and caring for young children. Women in Zambia generally work 

twice as long as men: 12–13 hours each day, compared to 6–7 hours by men. 12 The study in 

Luapula noted above found that while women may know they should avoid working in the fields, 

carrying heavy loads and walking long distances when pregnant, they feel obligated to do so 

because of social pressure and lack of assistance from their husbands and other family 

8 Low birth weight (LBW) is defined by WHO as 3.0 kg than for infants between 2.5 and 3.0 kg. The percentage of infants born < 3.0 in Zambia, as in 

most developing countries, is likely to be more than double the official low birth weight percentage. 

9 Milimo et al, 2004, pp. ix-x. 

10 Goetz, G. 2000. Improving Household Food Security and Nutrition in the Luapula Valley, Zambia, 

Knowledge, Attitudes, Perceptions and Practices (KAPP), A Study on Nutrition of Children under Five 

Years and Pregnant and Lactating Women, Nutrition Program Service (ESNP), Food and Nutrition 

Division, FAO, December 2000, p. 39. 

11 Milimo, Munachonga, Mushota, Nyangu and Pnga, 2004, p. 13. 

12 Milimo, et al. 2004, p. ix. 


members. 13 Some women emphasized the need to sensitize men to the need to help women in 

their work, especially when pregnant or lactating, but noted that men may fear others will laugh 

at them if they do. In addition, women‘s time constraints point to the need for time- and laborsaving 

technologies. Added to these burdens is the HIV crisis because (1) a higher proportion of 

women, compared to men, are infected because they lack control over their own sexuality and 

their bodies, and (2) healthy women must care for those who are sick in addition to their other 

daily tasks. Tuberculosis, which often occurs in connection with HIV infection in Zambia, is also 

a growing, serious health problem.‖ 14 

Micronutrient Status Among Young Children and Reproductive Age Women 

Data on micronutrient status in Zambia is less readily available, 15 but existing evidence indicates 

that micronutrient deficiencies continue to be prevalent, perhaps most importantly iron 

deficiency anemia. 

Anemia prevalence is 53% among children aged 6–59 months (2003) and 46.9% among pregnant 

women (1999); as many as 50% of women attending antennal clinics are affected. At least 50% of 

anemia is caused by inadequate iron intake; the major cause is low consumption of animal 

source foods, particularly in low-income households. 

Vitamin A deficiency has traditionally been a public health problem in Zambia due to inadequate 

dietary intake. A 1997 national survey showed a prevalence of Vitamin A deficiency of 65.7% and 

21.5% in women and children respectively. However, no surveys have been conducted since the 

MOH began distributing Vitamin A supplements during the twice-annual Child Health Weeks 

and since sugar fortification was introduced. 

Although no studies have been conducted on zinc deficiency in Zambia, there is evidence 

internationally of an association between the levels of absorbable zinc in the food supply (usually 

from animal sources) and the prevalence of stunting. Zinc is an essential nutrient for normal 

growth in children and vital for the immune system; even mild deficiency may increase the risk 

of infection. In Zambia, zinc deficiency may be an important contributing factor to stunting given 

evidence of low animal-source food consumption especially for young children, reliance on 

maize and other staples from which zinc is poorly absorbed, and frequent infections such as 

pneumonia and diarrhea, which cause significant zinc losses. 

Iodine deficiency disorder (IDD), once a common problem in Zambia with goiter prevalence at 

32% in 1993, has been greatly reduced as a result of imported salt that is now iodized. A 2002 

survey showed that the overall median urine iodine concentration had increased to 245 µg /l—a 

five-fold increase from 49µg/l in 1993. Only 4% of the population was considered to be at risk of 

mild to severe IDD in 2002. 16 However, routine monitoring of iodized salt consumption is 

needed. 

Other micronutrients of concern in maternal and child health include calcium, folic acid, and 

vitamin B12, nutrients that also will be assessed in the upcoming micronutrient survey. 

Food Insecure Households 

Food insecurity is the major underlying cause of malnutrition in Zambia. Only 36% of 

households in Zambia have been found to have ―enough food to eat,‖ while 19% of households 

13 Ibid, p. 39. 

14 IYCN report. 

15 Recognizing the shortcomings indicated here, UNICEF is planning both a national food consumption 

survey and a micronutrient survey. 

16 NFNC 2003, Iodine Deficiency Disorders (IDD) Impact Survey, Lusaka, Zambia. 


―seldom‖ or ―never‖ have enough to eat, categorized in Zambia as ―chronically food insecure.‖ 17 

This is consistent with data indicating that 64% of Zambians live below the international poverty 

line (Sub-Saharan average is 53%) and that 36.5% live in ―extreme poverty.‖ 18 

Food security exists when all people, at all times, have physical and economic access to sufficient 

safe and nutritious food to meet their dietary needs and food preferences for a healthy and 

active life. Some contributing factors to food insecurity in Zambia include seasonal fluctuations 

that limit access to sufficient food; an inadequate quantity of food to meet the energy needs of 

growing children and adolescents, pregnant and lactating women and working adults; limited 

dietary diversity to provide essential micro- and macro-nutrients needed for good health; and 

limited distribution of food stocks within the country to enable those who must purchase food 

to do so. 

Nearly half of the country‘s rural population (45%) consume less than 1,750 calories per day 

(food balance sheet calculation),19 20 and these families spend nearly 80% of their incomes 

on food. 

While extreme poverty is more common in rural areas of Zambia, evidence indicates that the 

poor in urban and semi-urban areas also face challenges obtaining sufficient food. An urban food 

consumption study conducted in 2007 found that the Total Food Security Index (more 

accurately a self-assessed food insecurity index) for those households in the lowest expenditure 

category was about double that of urban dwellers as a whole:21 in Lusaka 14.5 vs. 7.7; in Kitwe 

16.2 vs. 8.6; and in Kasama 9.9 vs. 6.6.22 

The same survey revealed that food budget shares among relatively poor households in the four 

sampled urban areas (Lusaka, Kitwe, Mansa, and Kasama) remain very high at 60–73%. Fixed 

expenditures for rent, utilities, transportation and other essentials leave little cushion for the 

very poor to avoid episodes of hunger. 23 At the same time, many urban dwellers live in crowded 

conditions in which poor access to safe water and adequate sanitation 24 significantly increase the 

risk of infection. 

In 2008 rising food and fuel prices and the subsequent global recession led to a sharp increase in 

child malnutrition rates, especially in urban areas. 25 Programs in urban areas that serve families 

with malnourished children, such as the urban food voucher program (SPLASH card) and 

therapeutic feeding programs for the acutely malnourished have high caseloads and increasing 

demand. 

17 National Food and Nutrition Commission. 2008. 

18 Rural poverty has declined from 92% in 1993 to 76.8% in 2006, but remains 

high relative to other sub-Saharan African countries. 

19 

FAO 2009. Retreived from http//www.fao.org/economic/ess;food-security-statistics/en/. (December 17, 

2010). 

20 This figure is based on standards for human energy requirements released by FAO, WHO and UNU in 

2004 and on standards for Body Mass Index (BMI) released by WHO in 2006. The minimum dietary 

energy requirement for Zambia, calculated for Zambia for the 2004–06 period is 1,750 kcal/person/day. 

21 CSO/MACO/FSRP Urban Consumption Survey, 2007-2008. 

22 

The higher the index number, the greater the number of times that the household experienced one or 

more forms of food insecurity. 

23 According to the MSU Study on Urban Consumption, (CSO/MACO/FSRP Urban Consumption Survey, 

2007-2008), the percentages of total expenditure spent on housing, transport and communication, 

household furniture and appliances, as expected, are higher in Lusaka and Kitwe—larger and more highly 

urbanized—while the share of expenditures on gas, charcoal, firewood, paraffin, candles and batteries is 

higher in smaller towns and among lower income groups in all urban areas. 

24 Zambia DHS, 2007. 

25 National Food and Nutrition Commission, 2008. 


People Living with HIV/AIDS and Orphans and Other Vulnerable Children 

Zambia has the third highest level of risk for HIV worldwide.26 The country‘s generalized HIV 

epidemic is fueled by structural factors, gender and social norms, unequal distribution of wealth, 

and unemployment. However, HIV prevalence in adults gradually decreased from 16% in 

2001/2002 to 14.3% in 2007.27 More than 900,000 Zambians live with HIV and more than 

280,000 receive antiretroviral therapy (ART), allowing them to live longer and healthier lives.28 

More females (16.1%) than males (12.3%) are HIV positive because of biological, economic and 

social factors. Urban areas have a higher prevalence (20%) than rural areas (10%).29 An 

estimated 16.4% of pregnant women are HIV positive,30 and an estimated 10% of HIV 

transmission in Zambia is the result of mother to child transmission during pregnancy, birth or 

breastfeeding.31 Half of the approximately 1.3 million orphans in Zambia are estimated to have 

lost one or both parents to AIDS.32 HIV and AIDS have had a negative impact on health 

indicators including those related to nutrition. Life expectancy at birth dropped from 52 years in 

the 1980s to 37 years in 2000, but has since risen to 48.33 HIV and AIDS increase disease 

burden and thereby increase pressure on the health care system. 

According to Lusaka‘s University Teaching Hospital, in 2007 between 40 and 50% of 

malnourished children admitted to the hospital were HIV positive, 60% of the beds in adult 

medical wards were occupied by HIV-positive individuals, and about three-quarters of those 

patients had BMIs so low as to be categorized as ―emaciated.‖ Given Zambia‘s level of 

malnutrition, the number of malnourished HIV-positive people needing food and nutrition 

support is high. 

High mortality is reported among HIV-positive patients in treatment facilities. A 2004–2005 

study among clients starting ART found that patients with BMIs less than 16 were 2.4 times 

more likely to die during the first few months of starting therapy than those with higher BMIs.34 

Patients with hemoglobin levels lower than 8 g/dL were 3.6 times more likely to die during the 

first 90 days than those with higher levels.35 The University Teaching Hospital Malnutrition 

Rehabilitation Unit reported average mortality among severely malnourished children admitted 

to the unit as 40%, compared with an overall rate of 55% among HIV-positive children.36 

Feasibility of Achieving Targets Including Those in the Relevant Millennium 

Development Goals 

Malnutrition is a major challenge in meeting targets 1, 4 and 5 of the Millennium Development 

Goals (MDGs). In fact, MDG 1 is to eradicate extreme hunger and poverty—recognizing that 

policies, programs and processes to improve nutrition outcomes play a critical role in the 

country‘s development. 

26 Measurements were calculated by Maplecroft, a global risk advisory firm. Mozambique and Uganda have 

been ranked first and second. Retrieved from http://www.maplecroft.com/about/news/hiv-aids-index.html 

(December 17, 2010). 

27 Central Statistics Office, 2009. 

28 

MOH and National AIDS Council, 2010. 

29 Central Statistics Office, 2009 

30 MoH, 2010 

31 MoH and National AIDS Council, 2010. 

32 UNAIDS, 2009 

33 Central Statistics Office, 2009. 

34 Stringer et al., 2006 

35 Ibid. 

36 Mwambazi and Irena (2010) cited in NFNC 2010. 


According to World Health Organization (WHO) standards, nutrition indicators in Zambia 

remain unacceptably high, with a negative impact on maternal and child health. Child 

malnutrition is decreasing, but still contributes to 42% of all under-5 deaths in Zambia, 37 a figure 

slightly higher than the international estimate of 35%. 38 Undernutrition is a major cause of 

under-5 and maternal mortality. Table 2 summarizes the nutritional status of children under 5. 

Table 2. Nutrition Indicators for Children Under 5 Years of Age in Zambia 

2002–2007 

Indicator 2001–2002 (ZDHS) 2007 (ZDHS) 

Stunting (chronic malnutrition—low 

ht/age) 53% 45% 

Wasting (acute malnutrition—low 

wt/ht) 6% 5% 

Underweight (low wt/age) 23% 15% 

Vitamin A deficiency 39 68% 54% 

Vitamin A supplementation 37% 80% 

Anemia among children ages 6–59 

months 65% (1998) 53% (2003) 

Maternal underweight (BMI

While these gains are impressive, the mortality rates are still high by regional and global 

standards and do not at all guarantee meeting the health-related MDGs by 2015.Table 3 

presents Zambia‘s position vis-a-vis achieving the MDGs by 2015. 

Table 3. Millennium Development Goals in Zambia: Targets and Indicators 

MDG Goal Number Indicator Target 2015 2002 (ZDHS) 2007 (ZDHS) 

Goal 1: Eradicate 

extreme hunger and 

poverty 

Prevalence of 

underweight 

children under 

age 5 

11% 23% 15% 

Proportion of 

population below 

minimum level of 

dietary energy 

consumption 

29% 

58% 

(1991 FAO) 

51% 

(2006 FAO) 

Goal 4: Reduce child 

mortality 

Goal 5: Reduce 

maternal mortality 

Goal 7: Water and 

sanitation 

Infant mortality rate 

(per 1,000 live 

births) 

Under-5 mortality 

rate (per 1,000 live 

births) 

Maternal mortality 

ratio (deaths per 

100,000 live births) 

The proportion of 

the population 

without sustainable 

access to safe 

drinking water and 

basic sanitation 

30 95 70 

63 168 119 

162 729 591 

Households with 

access to potable 

water – 58% 

Complementary strategies and smart integration will be required to achieve MDGs 1, 4 and 5. 

The USG has initiated new strategies and approaches designed to assist countries to improve 

health and reduce poverty: Feed the Future (FTF) and Global Health Initiative (GHI), which 

intersect in their focus on nutrition. FTF and GHI guidance for developing country programs 

include robust nutrition components, acknowledging that improved nutrition is both a necessary 

objective of foreign assistance programs and a fundamental building block of development. 


3.2. SECTOR-SPECIFIC STATUS PERTINENT TO NUTRITION, 

PROGRESS AND GAPS, INCLUDING EFFORTS OF THE GRZ, 

THE USG AND OTHER DONORS 

Government of the Republic of Zambia Policies Pertinent to Nutrition 

To meet its policy objective of reducing poverty and improving income distribution, Zambia has 

adopted the development objective of accelerating pro-poor economic growth through 

macroeconomic stability, structural reform, and investment in human development. Specific 

2030 targets are (a) reduce poverty from 68% (2007 LCMS) to 20% of the population living 

below the poverty datum line, defined by the World Bank as USD $1 per day; and (b) improve 

income distribution to a Gini coefficient of less than 40 from the current (2004) level 

of 53. 

The Sixth National Development Plan also includes the following objective: to achieve a ―well 

nourished and healthy population by 2030.‖ 

―With 45% of children under age five stunted and 21% severely stunted, it is clear that Zambia‘s 

recent economic growth has not solved the country‘s food security problems. The country 

needs an approach to food security that addresses the underlying causes of undernutrition 

affecting food availability, access, and utilization.‖ 41 

3.2.1. Agriculture 

Given the vital relationship of household food security to nutrition and that the majority of rural 

households are engaged in agriculture, efforts to improve the resilience of small-holder farm 

families are critical to improved nutrition. This section (1) describes the agricultural sector and 

its imbalance toward maize production; (2) emphasizes the connection between agriculture and 

nutrition, and the importance of addressing agricultural production diversity and, in turn, dietary 

diversity; and (3) provides necessary background for the framework‘s recommended support of 

the ―Food and Nutrition Security Pack.‖ 

3.2.1.1. Agriculture in Zambia 

Agricultural crops fall into four groups: (1) cereal crops: maize, sorghum and millet, plus ―other 

cereals‖ including rice, wheat, and barley; (2) root crops, including cassava, Irish potatoes and 

sweet potatoes; (3) other food crops: pulses and oil crops, groundnuts, vegetables and fruits; 

and (4) higher-value export-oriented crops: cotton, sugar and tobacco, plus ―other export 

crops‖ including sunflower seeds and paprika. The livestock sub-sectors are cattle, poultry, and 

―other livestock‖ including sheep, goats and pigs. An additional sub-sector is fisheries. 

Rural agricultural production is disaggregated across Zambia‘s four main agro-ecological regions. 

To capture the importance and unique circumstances of urban agriculture, agricultural 

production is disaggregated across main metropolitan centers and other urban areas as well.42 

Crop production is further disaggregated across small- medium- and large-scale producers 

According to the Living Conditions Monitoring Survey (LCMS) 2004, almost one 

third of rural farm households grow only maize. Far fewer households produce only 

root crops. See Table 4 below for this data by household type, size of area 

cultivated and yield. 

41 Zambia FTF Implementation Plan. 

42 Metropolitan centers are restricted to urban areas in the following districts: Kabwe in Central province; 

Chingola, Chililabombwe, Kitwe, Kalulushi, Lufwanyama, Mufulira, and Ndola in Copperbelt province; 

Lusaka in Lusaka province; and Livingstone in Southern province. 


Small-scale farmers in Zambia are defined as those harvesting less than 5 hectares of land. Average smallholder plots measure 1.21 hectares, while 

the average plot for medium-scale farmers is between 5 and 10 hectares. Although the roughly 40,000 medium-scale rural farmers captured in the 

2004 LCMS 43 amount to only 3.5% of farm households in Zambia, they account for a quarter of rural agricultural land and more than a third of rural 

land allocated to higher-value export-oriented crops. Medium-scale farmers also have high maize yields due, at least in part, to their greater 

adoption of hybrid seeds. 

As is the case globally, farmers respond to changes in production technology, commodity demand and prices by reallocating their land across different 

crops in order to maximize incomes. These representative farmers also reallocate labor and capital between farm and non-farm activities—including 

livestock and fishing, wage employment on larger-scale farms, and migration to non-agriculture work in more urbanized sectors. 

Table 4. Land and Population Distribution Across Farm Household Types 

National Urban Rural 

Farm 

Farm 

High 

value 

Maize 

only 

Maize 

and 

other 

foods 

Maize 

and 

roots 

only 

Maize, 

roots 

and 

other 

foods 

Roots 

only 

Roots 

and 

other 

foods 

Nonfarm 

Nonfarm 

Smallscale 

(5- 

Table 4. Land and Population Distribution Across Farm Household Types 

National Urban Rural 

Farm 

Farm 

High 

value 

Maize 

only 

Maize 

and 

other 

foods 

Maize 

and 

roots 

only 

Maize, 

roots 

and 

other 

foods 

Roots 

only 

Roots 

and 

other 

foods 

Nonfarm 

Nonfarm 

Smallscale 

(5- 

3.2.1.2. Agriculture and Nutrition 

Internationally, agricultural projects are often justified on the premise that the food produced 

will provide some combination of improved household food security and improved nutrition. 

Rarely, however, do agricultural projects measure these effects. Even in retrospect, it is not 

always clear what type of impact (positive or negative) a given project has had on the food 

security and nutrition levels of food insecure households and undernourished 

individuals/malnourished households. 

Of these two outcomes, improved food security and nutrition, it is food security—the access to 

adequate food—that is more likely to be affected by an agricultural intervention. Nutrition 

effects (normally measured by anthropometric measurements of young children and sometimes 

by dietary intake) are further removed from agricultural interventions. In most, but not all cases, 

improved nutrition depends on accessible food and: 

The distribution of that food within the family. 

Positive care and feeding practices. 

Control of infectious disease. 

Positive and significant nutrition impacts are most likely to occur from agricultural interventions 

when (1) household members regularly consume the food commodity being produced; 44 (2) the 

intervention includes explicit nutrition counseling; (3) the intervention includes home gardens or 

small livestock, and/or (4) the project introduces micronutrient-rich plant varieties. 

A good example of an agriculture program that focuses on nutrition is the Homestead Food 

Production (HFP) program developed by Helen Keller International in Bangladesh and now 

operating in several countries of Asia and Sub-Saharan Africa. Homestead Food Production 

promotes an integrated package of home gardening, small livestock production and nutrition 

counseling. The aim is to increase household production, availability and consumption of 

nutrient-dense foods and improve the health and nutritional status of women and children. 

Evaluative evidence indicates that HFP in Bangladesh has achieved improved food security for 

nearly 5 million vulnerable people in diverse agro-ecological zones. This has been accomplished 

through increased production and consumption of micronutrient-rich foods; increased income 

from gardens and expenditures on micronutrient-rich foods; women‘s empowerment; enhanced 

partner capacity; and community development.45 

The Gender Informed Nutrition and Agriculture (GINA) Program, funded by 

USAID/Washington and implemented by the Food and Nutrition Department of Makerere 

University in Uganda, is another example of an integrated nutrition counseling and agricultural 

development initiative coupled with improved hygiene and food safety that has improved the 

growth of young children as measured by reductions in underweight within a relatively short 

time.46 

This report recommends a strategy that utilizes these very principles to strengthen and build 

upon an existing cost-effective, but underfunded, government agriculture and food security 

project to address both food and nutrition insecurity. This program, which currently focuses on 

44 A World Bank report on the subject concludes ―household production for the household‘s own 

consumption is the most fundamental and direct pathway by which increased production translates into 

greater food availability and food security.‖ ―From Agriculture to Nutrition: Pathways, Synergies and 

Outcomes.‖ The World Bank Agriculture And Rural Development Department (2007). 

45 IFPRI. Millions Fed: Proven Successes in Agricultural Development. Retrieved from www.ifpri.org/millionsfed. 

(November 22, 2010). 

46 GINA Project Evaluation, 2008. 


―vulnerable but viable‖ rural agricultural households, could accomplish important nutrition 

results by (1) intensifying extension efforts relating to a broader range of crops; (2) providing 

extension education on home garden production of vegetables and fruits and on drying and 

preserving these foods; and (3) offering nutrition-related counseling that complements 

information provided through health services and community radio. 

Government of the Republic of Zambia Actions 

The SNDP seeks to create an environment conducive to promoting private sector-led 

agricultural development. 

Key policy developments will include the review and revision of the National Agriculture Policy 

(NAP) 2004–2015 to align it to changes in the sector and the development of the livestock and 

fisheries policies. 

In addition, the GRZ will put in place the Agricultural Marketing Act that will regulate market 

players in the sector. The Agricultural Credit Act is being revised to allow for using a 

warehousing receipt system as collateral in obtaining loans. 

At the start of the SNDP period, detailed bankable investment programs will be formulated in 

line with the Zambia Comprehensive Africa Agriculture Development Program (CAADP) 

framework. The sector will also ensure that all policies, programs, projects and activities are 

engendered during the SNDP. 

Additionally: 

The Ministry of Agriculture and Cooperatives facilitated the establishment of statutory 

boards to assist in its regulatory role. These include the Food Reserve Agency (FRA), the 

Tobacco Board of Zambia, and the Coffee Board of Zambia. 

In recent years, MACO partnered with stakeholders to set up trusts as innovative tools for 

service delivery. These include the Golden Valley Agricultural Research Trust (GART), 

Cotton Development Trust (CDT), Livestock Development Trust (LDT), In-service Training 

Trust (ISTT) and Zambia Export Growers Trust (ZEGA Trust). 

To promote dialogue among sector stakeholders, MACO facilitated the formation of the 

Agricultural Consultative Forum (ACF). 

The Department of Agriculture, Advisory Services has a Food and Nutrition Section. 

Other Donors 

Food and Agriculture Organization. 

Norwegian Embassy (conservation agriculture). 

International Fund for Agricultural Development. 

Japan International Cooperation Agency (irrigation). 

3.2.1.3. USAID Activities and Partners in Agriculture-related Projects 

USAID Funded Projects: 

Production, Finance and Improved Technologies Project (PROFIT); CLUSA. 

Market Access, Trade and Enabling Policies Project (MATEP); DAI. 

Food Security Research Project (FSRP); Michigan State University. 

Land O‘Lakes. 


USAID Funding to Zambian Institutions: 

Zambia Agribusiness Technical Assistance Center (ZATAC); Copperbelt Economic 

Diversification Project 

Zambia Agricultural Commodity Agency (ZACA) 

The Agricultural Consultative Forum (ACF) 

Other USG programs 

Peace Corps: 

Agriculture Volunteers work with small farm operators to increase food production while 

promoting environmental conservation practices. They introduce farmers to techniques that 

prevent soil erosion, reduce the use of harmful pesticides and replenish the soil. They work 

alongside farmers on integrated projects that often combine vegetable gardening, livestock 

management, agro-forestry and freshwater fisheries. 

3.2.2. Education 

There is irrefutable evidence of the negative impact of malnutrition on children‘s cognitive 

development and, in turn, active learning capacity. Additionally, hungry children have difficulty 

concentrating and learning. 

A World Bank study indicates the effects of stunting on IQ and, in turn, on wages: 

Between 5–11 points loss in Intelligent Quotients (IQ) has been associated with 

stunting. With a prevalence of 46%, Zambia is losing human capital by about 10% IQ 

point losses in almost half of its under-five children. If the impact on IQ point losses 

is added up from other nutrition problems including inadequate breastfeeding and 

iron deficiency then another 10% of IQ points may be lost. Studies have also shown 

that the impact of linear growth retardation (stunting) continues in adulthood with 

1% of reduced adult height being associated with a 2.2% loss in adult wages. 

The report also indicates that widespread malnutrition can reduce national GDP by as much 

as 4%. 47 

The GRZ presently spends 18% of its national budget on the education sector. In order to 

maximize its investments, the above estimates suggest that a reduction in nutritional stunting is 

critical. Zambian student performance, measured by regional standardized tests, is presently 

among the lowest in the southern Africa region. Malawi, with a national under-five stunting 

prevalence of 53% (the highest in the region), is the lowest in student performance. Clearly, 

optimal growth and development of infants and young children are fundamental for success in 

school and as productive members of society. 

In Zambia, net primary school enrollment has increased from 80% in 1990 to 97% in 2006 as a 

result of GRZ and donor efforts. During the same period, Zambia achieved an increase of 19 

percentage points in primary school completion rates from 64 to 83%. The net female 

secondary school attendance ratio for the 2004–2006 period, however, remains low at 36% 

compared to 38% for males. 48 

Girls‘ education is important because of the relationship between mothers‘ education level and 

malnutrition prevalence. Studies conducted in multiple countries reveal that the literacy, formal 

schooling and completion of primary education by a mother decrease the risk for stunting in her 

47 World Bank/Zambia. Technical Note on Nutrition (unpublished). 2010. 

48 Central Statistics Office. Living Condition Monitoring Survey (LCMS), 2009. 


children. And while studies show that paternal education is a significant determinant of the risk 

of stunting in children, results suggest that the influence of a mother‘s education is at least three 

times larger than that of a father—even when controlling for household economic resources 

and parental health. 

The MOE has embarked on a school health and nutrition (SHN) program in selected schools, 

particularly targeting OVCs. Children receive both iron tablets and a high-energy protein 

supplement (HEPS) in the form of porridge and they are de-wormed. 

This strategic framework identifies a primary gap in outreach and service for out-of-school 

youth, given the high dropout rates for girls in the fourth and fifth grades. 

USAID investments in nutrition-related education programs at present include: 

School health and nutrition (limited). 

School health days. 

Construction of water points at schools with community access. 

Construction of school latrines. 

Student-led ―total sanitation‖ undertakings. 

Scholarship assistance to OVCs. 

Re-entry policy of some school dropouts. 

Attention to gender equity. 

Additionally, a USAID-assisted program builds on the initial success of a national radio education 

program called ―Learning at Taonga Market.‖ This interactive instruction program, produced by 

the Zambian Ministry of Education, covers the primary school curriculum in an engaging and 

enjoyable way. 

Government of the Republic of Zambia 

Ministry of Education National School Health and Nutrition Policy (2006) 

Other Donors 

Irish Aid and the Netherlands government contribute to aspects of school health and nutrition. 

3.2.3. Health and HIV/AIDS 

Health and Nutrition 

Undernutrition is a major cause of both under-5 and maternal mortality. Globally, an estimated 

35% of under-5 mortality and 25% of maternal mortality are attributed to undernutrition. 

Zambia‘s infant mortality rate is 70 per 1,000 live births with neonatal mortality comprising 49% 

of infant mortality; its under-5 mortality is 119 per 1000 live births. Immediate and exclusive 

breastfeeding could reduce neonatal mortality by an estimated 20%. 49 

Previous reductions in infant and child mortality are mainly attributed to child survival services 

provided through the biannual Child Health Weeks. Services include childhood immunization 

and Vitamin A supplementation. 

Infant and young child feeding (IYCF) practices are far from optimal in Zambia. Yet, 

breastfeeding is a universal practice at 98%, with 93% of these infants breastfed within the first 

49 Maternal and Child Undernutrition Series. The Lancet, Vol. 371 February 2, 2008. 


day of birth according to the ZDHS 2007. This is an improvement from the ZDHS 2001–2 that 

showed that 51% of babies were breastfed, 90% within the first day of birth. Despite high 

prevalence of breastfeeding, the majority of infants are not fed according to recommendations, 

resulting in low rates of exclusive breastfeeding and increased rates of morbidity and mortality. 

Both early initiation rates (57%) and exclusive breastfeeding (61%) are low (CSO 2007). In 2009, 

61% of infants 5 months of age and below were found to be exclusively breastfed. 

Poor Infant and Young Child Feeding Practices Contribute to Child 

Malnutrition 

Although the percent of babies aged 6 months or less who are exclusively breastfed increased 

from 40% to 61% in the same time period mentioned above, the median duration of exclusive 

breastfeeding remains low at 3.1 months nationally—ranging from 1.6 months to 4.4 months. 

The main obstacles to exclusive breastfeeding are a general lack of knowledge; inappropriate 

advice by health personnel; lack of skilled support for breastfeeding mothers; harmful lactation 

management practices; lack of confidence on the part of mothers; commercial promotion of 

breast milk substitutes; and cultural beliefs and practices. These include not believing that a 

mother can provide adequate breast milk to sustain a baby for six months; not knowing that 

additional foods or fluids during this period can be harmful; not feeding colostrum to newborns; 

providing pre-lacteal feeds; and having inappropriate expectations of infant behavior. 

Mothers living in urban are especially pressured to find alternative means for feeding their 

infants because of their work schedules. Another obstacle is the high prevalence of HIV and 

concerns about mother to child transmission via breastfeeding. 

According to the ZDHS, the lowest median duration of exclusive breastfeeding is found in 

Eastern, Luapula, Northern and Northwestern provinces—also areas where levels of 

malnutrition are very high. The Infant and Young Child Nutrition (IYCN) Project describes the 

situation as follows: 

At the national level, the median age of predominant breastfeeding where children are either 

exclusively breastfed or in addition to breast milk just given plain water and/or other non-milk 

liquids (mixed feeding), is also low at 3.8 months. Hence, many children are being fed solid foods 

too early, displacing nutrient- and energy-rich breast milk and potentially exposing infants to 

pathogens that can result in diarrhea, one of the top five causes of death among children in 

Zambia. 50 A 2005 qualitative study in Southern Province found that barriers to exclusive 

breastfeeding included the perception of insufficient breast milk; fear of dying or becoming too 

sick to breastfeed; the conventional practice of mixed feeding; the perception of ―bad milk‖ (e.g. 

because the mother is ill or infected with HIV or becomes pregnant); and lack of knowledge, 

especially among fathers and grandmothers who often have negative attitudes toward exclusive 

breastfeeding and have considerable authority over mothers, children and infant feeding 

decisions. 

Inadequate Attention to Maternal Malnutrition 

Maternal health and nutrition has not received a great deal of attention in the past. The maternal 

mortality ratio is 591 per 100,000 live births in Zambia. Post-partum hemorrhage is one of the 

major causes of mortality and high rates of anemia contribute to this risk. In addition, the total 

fertility rate is 6.2. While there has been an increase in the contraceptive prevalence rate from 

23 to 33% during the same period as above, there remains an estimated unmet need for family 

planning of 27% (ZDHS 2007). The low use of contraceptives and resulting short birth intervals 

50 GRZ, Ministry of Health, National Health Strategic Plan 2006-2010, December 2005, p. 30. 


do not allow a mother to regain her strength and recoup her nutrient stores or to adequately 

attend to her current child before the next birth. 

A qualitative study conducted in 2009 found that existing health and nutrition activities largely 

focus on health outcomes of children rather than both children and pregnant and lactating 

women. Nutrition counseling that women presently receive is likely to take place during 

antenatal care (ANC) visits, but such counseling provided by CHVs and clinicians also would be 

highly valuable. 51 

An estimated 28%—35% in rural areas—of girls aged 15 to 19 are pregnant or have given birth. 

Pregnancy places additional nutritional stress on young girls who are still growing and 

significantly increases the risk of maternal mortality and low birthweight. 

Inadequate Hygiene and Sanitation 

The country‘s huge disease burden is in part attributed to poor environmental health and 

sanitation conditions, a major source of public health problems and epidemics. ―Over 80% of the 

health conditions presented at health institutions are water and food borne diseases such as 

cholera, dysentery and typhoid.‖ 52 

Partly because of these water and sanitation conditions, diarrhea incidence (measured at 

facilities) has showed a slight decrease from 2006 to 2008—from 43 to 40 per 1000 

admissions. 53 Poor access to safe water and sanitation also contributes to other infectious 

diseases including cholera. See Section 3.2.4. 

Shortcomings in Health Facilities 

The main providers of health care services in Zambia are public health facilities under MOH, the 

Ministry of Defense, the Ministry of Home Affairs, Mine hospitals and clinics, mission hospitals 

and clinics that are coordinated by the Churches Health Association of Zambia (CHAZ), private 

hospitals and clinics, nongovernmental organizations (NGOs), and traditional healers. For 

historical reasons, each of these categories of health care providers is concentrated in particular 

areas of urban and rural Zambia. 

The smallest facilities are Health Posts (195 established by the GRZ), which cater to populations 

of 500 households (3,500 people) in rural areas, populations of 1,000 households (7,000 people) 

in urban areas, or are established within a 5-kilometer radius of sparsely populated areas. The 

next level are Health Centers, also available in rural and urban areas. Urban Health Centers 

(192 established by the GRZ and 416 total) serve a catchment population of 30,000 to 50,000 

people while Rural Health Centers (910 GRZ and 1032 total) serve a catchment area with a 29- 

kilometer radius or a population of 10,000. 

First Level Referral Hospitals are found in most of the 73 districts. General or second level 

hospitals (21) are located at the provincial level and provide services in internal medicine, 

general surgery, pediatrics, obstetrics and gynecology, dental, psychiatry and intensive care. 

These hospitals are also intended to act as referral centers for the first-level institutions, 

including the provision of technical backup and training functions. The last referral level is the 

Central Hospitals (five in the country). These have sub-specializations in internal medicine, 

surgery, pediatrics, obstetrics, gynecology, intensive care, psychiatry, training and research, and 

also act as referral centers for second-level hospitals. Hospitals are the focus for nutrition 

51 Qualitative Assessment of Maternal Nutrition Practices in Zambia, NFNC and IYCN, 2010. 

52 NHSP 2011-2015, MOH, p. 27. 

53 Ibid p. 29. 


ehabilitation units for extremely malnourished children referred from primary health care units 

or by community workers. 

Health infrastructure is inadequate in both rural and urban areas. In rural areas, 46% of families 

live outside a radius of 5 kilometers from a health facility (compared to 1% in urban areas), 

making it difficult to access needed services. While the distribution of health facilities in urban 

areas is better, long waiting times indicate the need to increase the number of facilities or 

expand existing ones. 

Shortages of Human Resources 

Zambia faces a serious challenge in terms of human resources for health. This critical shortage is 

a major obstacle to providing improved health care service delivery; to achieving the MDGs 

related to child health and maternal health; and to combating priority diseases such as malaria, 

TB and HIV/AIDS. The shortage is due to inadequate production, recruitment and retention of 

core health workers—especially doctors and nurses—the result, in turn, of economic and fiscal 

limitations. 

Fewer than 50% of frontline health workers (nurses, midwives, clinical officers and 

Environmental Health Technicians (EHT)) are available relative to their need in the provision of 

primary health care services. These workers are concentrated in urban areas, leaving rural areas 

particularly vulnerable. The country‘s high attrition rate is itself a serious threat and 

compounded by the HIV/AIDS epidemic. With only 11,708 clinical health workers, Zambia is 

19,606 clinical health workers short of the WHO recommendation. In terms of nutrition staff 

deployed in the country, there has been increase from 65 staff in 2005 to 112 in 2009, with 87 

located in the MOH. Although this is an impressive increase, staffing remains 44% below the 

WHO recommended number of 200, which has been endorsed by the government. 54 

The Community Health Worker Strategy 

To address these shortages, several NGOs trained informal workers as community health 

volunteers (CHVs) to handle disease-specific issues. However, these volunteers had no formal 

training and insufficient supervision. In response, the Government introduced the National 

Community Health Worker (CHW) Strategy in order to maximize effectiveness and standardize 

the training and compensation of this informal health care sector. The CHW Strategy (August 

2010) states that the primary functions of CHWs ―are to engage in promotive and preventive 

health activities that are initiated and accepted by the local community.‖ The approved Scope of 

Work for these workers includes ―promotive activities and health promotion activities such as 

IEC and health advocacy within the community, reproductive and maternal/child health 

programs such as immunizations, growth monitoring, family planning, nutrition, antenatal and 

postnatal care, and school health programs such as health promotion, screening, nutrition, and 

mass drug administration.‖ Prevention of malnutrition is an important part of CHWs 

responsibility. But while the Community Health Workers Curriculum Draft 1 (June 2010) sets 

out a yearlong training program that covers child and in-school nutrition, maternal nutrition and 

nutrition topics such as stunting and micronutrients are not included. 

MNCH Interventions 

Despite the gains in reducing the maternal mortality ratio, the coverage of Maternal, Newborn, 

and Child Health (MNCH) interventions is still low. The coverage of key maternal and child 

survival interventions along the continuum of care has varied from a high of 94% (first ANC 

visit) to a low of 39% (postnatal visit within two days). While more than 80% of facilities provide 

54 ECSA report. 2007. 


egular outreach ANC sessions and family planning (FP) services, only 46.5% of deliveries are 

assisted by nurses/midwives or physicians. 55 

The quality of nutrition services at ANC and well-child clinics is generally inadequate. Some 

elements of the Essential Nutrition Actions (ENA) are being implemented, such as distribution 

of iron supplements to pregnant women (See Table 5). However, other aspects are neglected— 

such as effective counseling for women‘s nutrition, the importance of taking iron/folic acid 

supplements, and optimal infant feeding practices. And while children‘s growth is monitored, no 

feedback and advice tailored to the particular needs of the child is given to the parent or 

caregiver. 

Table 5. Essential Nutrition Actions 

1. Optimal breastfeeding 

2. Appropriate complementary feeding 

3. Feeding of the sick child 

4. Women‘s nutrition 

5. Control of Vitamin A deficiency 

6. Control of anemia 

7. Control of iodine deficiency disorders 

Throughout the country, CHVs hold growth monitoring sessions, but the quality of monitoring 

and promotion is limited. Nevertheless, mothers often attend with their young children and 

guard their child health cards that contain the growth chart and weight notations. 56 Building on 

this well-accepted practice, CHVs can bring attention to children whose growth is beginning to 

falter or who have suddenly lost weight and then offer appropriate counseling and follow up. 

Government of the Republic of Zambia Strategies 

The National Health Strategic Plan (NHSP) is closely linked to the Sixth National Development 

Plan 2011–15 (NDP). The NDP chapter on health presents a summary of the health sector 

strategy; the NHSP presents an expanded version of that chapter including more detailed 

analysis of the existing situation, sector priorities, proposed strategies and expected outputs. It 

constitutes an important tool for implementing the NDP. 

The Overall Goal of the ―National Health Strategic Plan 2011-2015: Towards Attainment of 

Health Related Millennium Development Goals‖57 is ―to improve health services in order to 

attain significant reductions in morbidity and mortality.‖ The ―implementation of the 

comprehensive roadmap and plan for Maternal, Newborn and Child Health Services at District 

level is part of the Basic Health Care Package to be implemented under the Plan.‖ One 

intervention included in the Plan is the ―promotion of maternal and child of nutrition programs;‖ 

a second is to ―strengthen health promotion programs for maternal child health.‖ Within these 

services, evidence-based nutrition interventions can be implemented. Other portions of the 

NHSP that will impact nutrition include newborn care, family planning, malaria control and IMCI. 

55 NHSP 2011-2015, p. 27. 

56 It would be useful to have plastic covers for these child health cards, which are often torn along 

the folds. 

57 NHSP 2011-2015, MOH, February 3, 2010. 


CARMMA (Campaign for Accelerated Reduction of Maternal Mortality) is an international 

effort inaugurated at the African Union meeting in Addis Ababa in May 2009 and launched by 

Zambia Ministry of Health (MOH) in June 2010 under the theme ―No Woman Should Die 

While Giving Life.‖ 

Other Donors 

World Bank: A World Bank grant supports the concept of results- or performance-based 

financing of health care. The principles and processes to be implemented are based on 

experiences from other countries and from experiments in the Katete district. A pilot project is 

planned for nine districts, followed by an impact evaluation to determine how the continued 

development should be designed. The concept requires stronger linking of planning processes 

and programs using strategic plans. Targets and incentives will be reviewed to ensure the link 

between operational plan content and strategic plan priorities. The project includes a review of 

supervisory and oversight systems and a strengthened linkage between performance assessment 

and information systems, including management planning, performance programming and 

financial reporting. Other experiments with performance-based financing will be implemented in 

Lusaka and two districts under CHAZ support. The aim is to have one concept for 

performance-based financing for the entire sector during the NHSP plan period. 

JICA: Supported by JICA, the MOH is implementing a health capital investment support project, 

piloted in three provinces to address management of physical capital assets and the development 

of standards and guidelines for maintenance of physical infrastructure. 

UNICEF is supporting the National Food and Nutrition Commission in its development of a 

national nutrition strategy. 

DFID is supporting an institutional capacity assessment of NFNC and has been the primary 

donor supporting the new Community Health Worker Strategy. 

Irish Aid is planning an expanded nutrition program. 

HIV/AIDS and Nutrition 

Due to the emergence and introduction of potent ART in the Zambian health care system, adult 

HIV/AIDS has been transformed from an acute, emergency life-threatening illness to an endemic, 

manageable chronic disease. But this impressive transformation is under threat from a health 

system—at facility and community level—that is lagging behind the rapid scale-up of ART. Unless 

this gap is dealt with quickly and efficiently, these shortfalls in service delivery could have a 

serious negative effect on ART outcomes. 

The National Policy on HIV/AIDS is guiding national efforts to mitigate the epidemic‘s impact. 

Government mitigation interventions and approaches are channelled through a national strategic 

framework on prevention, treatment, care and support services carried out by government 

ministries, the private sector, religious groups and civil society. Nutrition is an important 

component in the treatment and care of people living with HIV. For many, the disease causes or 

worsens malnutrition through a combination of reduced food intake, nutrient malabsorption and 

increased energy needs. Malnutrition in turn can worsen the disease by impairing immune 

function, increasing vulnerability to infections, and in some cases reducing the effectiveness of 

treatment. Nutrition assessment, education, counseling, and provision of specialized food 

products to PLHIV help to prevent and manage malnutrition, promote effective treatment and 

manage symptoms. 

Nutrition guidelines are in place for use by health care managers, health service providers and 

nutritionists who implement nutrition and HIV/AIDS interventions. Policymakers and training 

institutions can also use these guidelines to standardize the management of HIV-related 


malnutrition. At the same time, it is recognized that integration of nutrition care and support in 

the health delivery system as a whole continues to be weak. 

Prevention of mother-to-child transmission (PMTCT) has proved to be an effective strategy in 

virtually eliminating pediatric HIV/AIDS and promoting provision of comprehensive and quality 

PMTCT services to all females of reproductive age. It is a priority for the NASF. 

In developing the PMTCT, linkages between PMTCT and the scaling-up of ART are being 

developed. Prevention of Mother to Child Transmission will further be integrated into other 

appropriate clinical-based services including maternal, newborn and child health clinics, HIV 

treatment centers, voluntary counseling and testing (VCT) centers, sexually transmitted 

infections (STI) clinics, and other sexual and reproductive health care and family planning service 

centers. The PMTCT integration with other services strategy will ensure increased availability of 

a comprehensive package of essential services for quality maternal, newborn and child health 

care that will include routine quality antenatal care for women regardless of HIV status. The 

capacity to provide HIV counseling and testing to pregnant women attending ANC will be 

strengthened. Ministry of Health will strengthen collaboration with traditional birth attendants 

to increase its access to females who give birth at home. 

In terms of care and support, HIV positive women will be placed on Highly Active Antiretroviral 

Therapy (HAART) as early as 14 weeks of gestation (second trimester) and will be able to 

continue for the duration of breastfeeding until a week after cessation. Infants will be eligible for 

both the Cotrimoxazole prophylaxis and ART once they are diagnosed. During the period of 

the NASF (2011-15), the PMTCT protocol will be periodically revised to ensure its alignment 

with WHO guidelines. Counseling for HIV positive mothers concerning breastfeeding their 

infants is a critical need to ensure the lowest risk of infection for newborns with and without 

HIV, and to prevent other infections and malnutrition that may occur if mixed feeding or other 

types of feeding are provided in lieu of exclusive breastfeeding. 

Under the NASF‘s Treatment, Care and Support objectives, nutritional information and services 

will be provided for ―adults and children on ART who are malnourished.‖ However, nutritional 

assessment and counseling is needed for all PLHIV who need to maximize nutrition status to 

achieve the best possible health status. 

Orphans and other vulnerable children are a priority group for the GRZ, NGOs and donors. 

Half of the estimated 1.3 million orphans in Zambia have lost one or both parents to AIDS. 58 

Strategies to address their needs must be multi-pronged to address the multiple challenges 

experienced by this group, including food and nutrition insecurity. The NASF focuses on OVC 

needs that include protecting their human rights; ensuring access to adequate food, shelter, basic 

education and health care services; and providing an environment conducive to the elimination 

of gender-based violence. 

A national framework for the protection, care and support of OVC includes the following 

strategies: 

Support the implementation of the National Plan of Action for Children, in particular 

interventions for OVC. 

Provide education, psychosocial and material support, nutrition, shelter and caregivers for 

in- and out-of-school female and male OVC. 

Build capacity of community care providers. 

Strengthen integration of OVC and home-based care services. 

58 UNAIDS, 2009. 


Promote and support community-based care of OVCs and families looking after them. 

Sensitize and support community leaders to promote post-basic education for girls. 

A key strategy is to ensure female and male OVC access to complete a program of basic 

education (first through ninth grades) in line with MOE policy. In order to attain the Millennium 

Development Goals (MDGs) and Education For All goals, Zambia is committed to making such 

basic education compulsory, free and available to all. 59 Female students are encouraged to 

pursue higher education (high school and tertiary) through a quota system that allocates 30% of 

placement to girls (Education and Skills Chapter, SNDP) to combat gender biases in higher 

education 60 . 

Government of the Republic of Zambia Inputs 

National AIDS Strategic Framework (2011-2015). 

New Comprehensive HIV Prevention Strategy (2010). 

The National Policy on HIV/AIDS guides national efforts to mitigate the epidemic‘s impact. 

Materials produced by the MOH include the National Operational Strategy for Infant and Young 

Child Feeding (IYCF) and recommendations for IYCF within the context of HIV. Also included 

are nutrition guidelines for people living with HIV/AIDS. 

Nutrition Guidelines for Care and Support of People Living with HIV/AIDS 

Recommendations for Infant and Young Child Feeding (IYCF) in the Context of HIV 

for Zambia 

U.S. Government Inputs 

The USG initiated a process to develop a Partnership Framework that defines a five-year 

horizon for cooperation between the U.S. and Zambia in order to combat HIV and AIDS. The 

years covered are 2010 to 2015, with implementation starting in the last two quarters of 2010. 

The draft guidance note for the development of a strategic framework emphasizes that (1) the 

strategic framework should be fully supportive and aligned with the national strategic 

frameworks, and (2) it is preferable to use existing coordination mechanisms such as Global 

Fund Coordinating mechanisms or structures for the International Health Partnership and 

related initiatives. 

Centers for Disease Control and Prevention (CDC) has also been providing important 

nutrition-related assistance to PEPFAR in program monitoring, impact evaluation research and 

analysis, and operations research. Additionally, CDC plays a role in implementing priority 

program areas relating to prevention, laboratory testing and training. 

Other Donors 

UNAIDS has similarly provided nutrition support to address HIV-affected populations. 

3.2.4. Water and Sanitation 

The 2007 ZDHS indicates that only 41% of households in Zambia have access to improved 

sources of water, with urban households much more likely to have access than rural households 

59 MOE, Chapter in the Sixth National Development Plan. 

60 Girls are more vulnerable to discontinuing formal educational programs than boys as a result of early 

marriage and/or pregnancy; lack of support (financial, material, and psychosocial) to continue; and fear of 

sexual abuse by male students, teachers or school administrators. Girls continue to drop out of school 

beyond fourth grade. Ministry of Education. Educational Statistical Bulletin Enrolment in all Schools by Gender 

and Year, 2006. 


(83% compared with 19%). More than half of Zambian households (56%) draw water from 

unprotected sources. Most households (65%) do not treat their water. An estimated 25% of 

households in Zambia have no toilet facilities, which is more common in rural areas (37%) than 

in urban areas (2%). Almost four in 10 households (39%) in Zambia use pit latrines that are open 

or have no slab (27% in urban areas and 45% in rural areas). Flush toilets are mainly found in 

urban areas and used by 26% of households, compared with 1% in rural areas. 

U.S. Government Inputs 

Millennium Challenge Corporation (MCC): Lusaka Water Supply, Sanitation and Drainage 

Project. 

The objective of this proposed project is to increase incomes through improved health and 

employability of project beneficiaries through the provision of clean and safe water supply and 

adequate sanitation and drainage in targeted areas. Millennium Challenge Corporation intends to 

fund (1) feasibility studies, (2) an environmental and social assessment, and (3) a monitoring and 

evaluation scoping and baseline study. 

3.2.5. Humanitarian Assistance 

Food for Peace resources, which have been an important tool for assisting vulnerable 

households and high-risk groups, will no longer be provided by the U.S. Government (USG) in 

Zambia beginning in 2011. 

The U.S. Food for Peace Program in collaboration with C-FAARM will be ending in FY 2012. C- 

FAARM activities (in six districts of two provinces) have focused on sustainable diversification 

(including dairy cooperatives), increased agricultural livelihoods and improved nutrition and 

health status among the most vulnerable. In sum, Title II programs have provided emergency 

relief, reduced vulnerability to shocks and natural disasters, and focused on food availability 

(including conservation farming), access to food and utilization. 

Other food-related safety net programs include the following: 

1. World Food Program: Supported a food voucher program (ZMK 100,000 per month) for 

undernourished children and their families in urban areas of Kafue, Livingstone, Lusaka, 

Mongu and Ndola (for an 8-month period) using an electronic ―SPLASH card.‖ 

2. Food Security Pack: Funded by GRZ through MCDSS for vulnerable but viable families—and 

the program to which primary recommendations of this strategic framework relate. 

Norwegian Aid may assist in making the program more effective and efficient and introduce 

a ―SMART card‖ to track input deliveries and recoveries. 

3. Social Cash Transfer: DFID supports universal child grants of K55,000/month in 15 districts. 

Targeted households continue to receive these grants as long as they have a child under 

age 5. 

3.3. ISSUES OF PARTICULAR CONCERN 

3.3.1. Nutrition and Food Consumption Issues in Zambia 

Food Consumption Levels 

Food consumption patterns in Zambia are generally poor, exhibited in low daily meal frequency 

and dietary diversity. The best available direct measure of food insecurity is an estimate of daily 

energy intake. Inadequate caloric intake manifests itself in high rates of stunting for children and 

low BMI for adults. Daily caloric intake (an average for individuals of all age groups) has been 

estimated by FAO food balance sheets to range from 1,185 in Luapula province and 2,103 in 


Lusaka compared with an estimated average daily requirement of 1,750 calories per person in 

Zambia. 61 

Total household expenditure, often a proxy for household food consumption, is higher among 

lower income households. Expenditures (imputed for households growing food) on cereals are 

highest, ranging from 24 to 28% of total expenditures, followed by meat and eggs, ranging from 

13 to 17%. Expenditures on vegetables rank third, ranging from 11 to 15% of total expenditures. 

(Rape, tomato, onion and local leaves are the most consumed vegetables.) Expenditures on 

legumes, sugar, oils and processed foods are higher among less poor households. 

The FAO food balance sheet calculation also indicates that, on average, only 2% of calories 

consumed by Zambians are from pulses, vegetables and nuts. Dietary diversity is particularly 

limited among women and young children in rural areas, the poorest households, and women 

with little or no education. 62 

According to an IYCN- NFNC study, 63 improvements in the diets of pregnant and lactating 

women are constrained by lack of finances; the nature of subsistence agriculture; limitations in 

seasonal availability of diverse food commodities; a perceived responsibility to meet the food 

needs of men first; and other competing priorities for scarce time and resources. ―Clinicians, 

CHVs, and community members all noted the importance of economic constraints in nutritional 

practices. Community members commonly said that a lack of adequate financial resources is a 

barrier to healthy nutritional behaviors, and women said they primarily do not eat healthy foods 

during pregnancy or breastfeeding because they do not have enough money to purchase 

nutrient-rich foods. Decisions about food purchasing and preparation are based largely on 

economic considerations. In most cases, community members said that men supply money to 

purchase foods, while women select and purchase specific foods. Financial problems are usually 

due to the unemployment or under-employment of men. Some families have found strategies to 

overcome this barrier by seeking out cheap but nutrient-rich food. Health providers see family 

planning as a key area for improvement that would enable families to have positive nutrition 

behaviors with limited finances.‖ 

3.3.2. Socio-cultural Norms Related to Food and Nutrition 

Cultural norms are major determinants of what is eaten, especially among low-income 

populations, and thus have important influence on food and nutrition. Some harmful practices, 

enumerated in the IYCN-NFNC qualitative analysis, include the following on deleterious food 

consumption practices during pregnancy: 

Women who are not pregnant do not have to avoid any specific foods and can eat 

what they wish. However, several respondents noted that women are not supposed 

to eat the back of a chicken (which contains a little flesh) or its gizzard, as these are 

parts reserved for men as a sign of respect. Non-pregnant women should also avoid 

beer and smoking. One woman younger than 30 years from Chalata and a man from 

Chawama said that groundnuts cause women to have extra vaginal discharge. During 

pregnancy, women said they avoided consuming certain foods because of the food‘s 

effects on their bodies and on their fetuses. Kapenta and kasepa (small fish), oily 

61 The FAO food balance sheet reflects calories and protein averages per capita food availability calculated 

by dividing total food production by population figures. Accordingly, results do not reflect inequitable 

access to the food, storage and cooking losses or intra-household maldistribution. 

62 FAO 2009. Retrieved from www.fao.org/economic/ess;food-security-statistics/en/. (December 17, 

2010). 

63 Qualitative Assessment of Maternal Nutrition Practices in Zambia, NFNC, MOH and IYCN. March 

2010. 


food, and cold food all caused nausea, vomiting, and heartburn. Women based their 

aversions to certain foods on both biomedical and local knowledge of how the 

foods might negatively impact the development of the fetus. Both female and male 

respondents described alcohol, tobacco, and soil as substances that interfered with 

healthy child development. Specifically, they said alcohol affected children‘s brains 

and smoking harmed children‘s lungs and brains. The respondents did not describe 

any specific physical effects of eating soil. 

Women also mentioned: 

Chilies (considered to cause red eyes or burnt skin). 

Lemons (considered to lead to underweight babies). 

Sugar cane (considered to cause ―lines in the stomach‖ of a child and dry skin). 

Food cooked with soda, which is not ―vitamin-rich.‖ 

Fried maize (considered to cause delayed physical development in female children). 

Bubble-fish (may cause miscarriage or a baby ―born with a big head‖). 

Pork (can affect a child mentally). 

Women also avoided chicken and eggs. Explained one respondent: ‗It is said that if a 

woman eats eggs, her children will be born without hair. It is also said that if a 

woman eats certain parts of the chicken, such as the back part, she will not be able 

to have children.‘ Women‘s aversion to the back and gizzard of a chicken is likely 

due in part to local tradition, which dictates reserving these parts of the chicken for 

special consumption by men. However, it was not clear whether the tradition was 

regularly practiced. One female respondent older than 30 years from Chalata said: 

‗There was a long time ago when women could only eat a few parts of a chicken like 

the feet. This does not happen nowadays. Things are changing now because women 

are being taught about their rights, and our husbands are also changing because now 

they see how women were being taken advantage of.‘ An older male respondent 

from Chalata said, ‗A long time ago there were traditional restrictions on what food 

a woman could eat, but these no longer apply.‘ 

When women are breastfeeding they should avoid alcohol, said both female and 

male respondents. They said alcohol hurts a mother‘s milk production and her 

ability to care for her children, increases her metabolism, and hurts child 

development. One female younger than 30 years from Chalata said that alcohol 

does not necessarily affect a child‘s health but does affect the mother‘s care-giving 

abilities. ‗I think drinking is discouraged, because if you get drunk how will look after 

your child?‘ she said. Other foods that respondents cited as interfering with milk 

production include lemons, chilies, sweet potato leaves, okra, and foods with soda. 

Respondents said mutton, pork, and fish (all rich sources of protein and 

micronutrients!) cause a rash in both the mother and the child. 

The Infant and Young Child Nutrition Project, in conjunction with NFNC and other partners, 

has developed an IYCF Community Pack of best practice messages and materials to address 

harmful cultural norms—especially those harmful to breastfeeding and to infant and young child 

feeding, including food taboos during pregnancy and lactation. 

UNICEF has contracted with an external consultant to help with further development of the 

package, which is undergoing pretesting prior to finalization. 


3.3.3. Human Resource Capacities 

While efforts have been made to provide a strong and sustainable framework for nutrition 

programming, little has been achieved to ensure that professional capacity is developed to 

address nutrition both at policy and program levels. In general, nutritionists in Zambia are ill 

equipped to deal with policy and programming activities within the public and private sector; and 

the ability to attract material, technical and financial support for programs is inadequate. 

Currently, the Natural Resources Development College (NRDC) only offers a three-year 

program in human nutrition (diploma level). This level of education is not sufficient to address 

intricate nutritional issues and challenges that require specialized understanding in the design, 

formulation, promotion and support of appropriate public health messages for desirable 

nutrition. Addressing nutrition problems is complex, requiring technical competence across 

sectors particularly at prevention and curative levels. 

Further, those with a diploma in nutrition work as technicians under the supervision of more 

senior officials who rarely understand nutrition issues themselves. As a result, programs are 

poorly planned and implemented—yielding poor performance at high cost. 

Lack of capacity has been compounded not only by lack of higher learning, but also by 

inadequate numbers to carry out the major tasks required. Despite the additional 65 graduates 

in the last two years, the number required by the public and private sector is far from optimal. 

There is inadequate staffing at all levels (See Table 6). 

Table 6. Number of Nutritionists in Possession Various Certificates 64 

Male Female Total 

Diploma 34 70 169 

Bachelor‘s degree 15 8 23 

Masters 8 12 20 

Doctoral degree 1 2 3 

Source: ECSA, 2007. A Report on data collection for the development of the database 

for nutrition professionals in the East, Central and Southern Africa (ECSA) Health 

Community, Arusha, Tanzania. 

With more human resource capacity, nutritionists could effectively promote appropriate public 

health interventions to reduce stunting. The role of nutritionists in national development calls 

for effective coordination across actors in various sectors as well as the encouragement of 

complementary strategies and common indicators including stunting. 

64 It might be useful to consider a study that would estimate the optimal number of nutrition staff at each 

degree level needed in the country. This would require a ministry by ministry analysis as well as 

systematic identification of projected NGO needs. At present MACO requires 73 nutritionists at district 

level, 9 at provincial level and three at national level. Of these 85 professionals needed, MACO, at present 

has 23 diploma holders and one MSc. graduate. In the MOH, almost all nutrition staff presently filling 87 

positions are diploma holders, although the Ministry has expressed a need for 12 BSc. graduates (9 at 

provincial level, 3 at national level). The Ministry of Education and MCDSS each need one degree holding 

nutritionist, but, thus far, have been unable to fill these positions. Many nutrition diploma holders are 

employed in NGOs in Zambia, but the optimal number (likely to increase as USAID and other donors 

scale up their programs) is unclear. 


Agriculture extension personnel are deployed throughout the country and their role includes 

food-related assistance to farmers. The extension service helps farmers select crops, improve 

food storage, and process and preserve foods among other tasks. Some of the extension agents 

have good practical knowledge, especially in food processing and preservation, but no formal 

training exists for this work. Extension agents work with women‘s groups and farmer groups 

through which new and improved technologies and approaches can be introduced. In the 

context of CAADP and the SNDP, there is justification to train and support agriculture field 

agents in providing information on improving not only food production, but food and nutrition 

security as well. Their role in increasing animal source foods for household consumption is also 

important; this may require collaboration with the Ministry of Livestock and Fisheries. In this 

regard, capacity for veterinary technician services is also vital to support small and large 

livestock production. 


4. RE-POSITIONING NUTRITION AND FOOD SECURITY 

Zambia needs an approach to food security that addresses the underlying causes of 

undernutrition alongside the problems of food availability, access and utilization. 

The USAID Nutrition Operational Guidance for Missions stated in Feb 2010: ―A comprehensive 

strategy must address all variables of food security: availability, access, and 

utilization/consumption. While increased production of food can lead to increased income, 

increased purchasing of food, and reduced food prices, productivity alone does not lead to longterm 

improvements in nutrition, especially among the most vulnerable.‖ 

Undernutrition, poor educational performance, food insecurity, high mortality from infectious 

diseases, low labor productivity, unacceptable life expectancy and infant, child and maternal 

mortality are all interconnected and preventable. Accordingly, the thrust of recommendations in 

this strategic framework is multi-sectoral in nature with a primary focus on reducing stunting in 

children under age 2. 

4.1. SUGGESTED APPROACHES FOR NUTRITION AND HEALTH 

SERVICE DELIVERY 

There is a strong evidence base for cost-effective nutrition interventions. The most costeffective 

interventions are currently being implemented at some level by the health sector in 

Zambia. These include the promotion of breastfeeding and improved complementary feeding; 

supplementation/fortification of key micronutrients for mothers and children; hygiene 

interventions; de-worming; insecticide treated bed nets; and treatment of severe acute 

malnutrition. 

However, coverage is generally inadequate, with the exception of twice annual distribution of 

Vitamin A supplements to children, the iodization of imported salt and the fortification of sugar. 

And other factors, such as poor water and sanitation and limited female education, are likely 

limiting their impact. 

This strategy recommends that primary health care facilities incorporate the ENAs into their 

services in order to shift the focus from cure to prevention. This will strengthen communityand 

facility-based health and nutrition programs and give priority to the most vulnerable period 

of birth to 24 months and pregnant and lactating women. 

The newly developed IYCF community counselling package—consisting of a trainer‘s guide, 

participant handouts and counselling cards—should be introduced both to health providers who 

provide counselling for mothers as well as incorporated into the new CHW based health 

program in Zambia. 

Two primary strategies are being recommended to improve nutrition status through the health 

system: 

1. Community-based nutrition service delivery activities: 

– Upgrade and train CHWs. 

– Inclusion of BCC-oriented IYCF Community Pack. 

– Increase attention to pregnant women. 

– Promote and support of the same food-based initiatives (promoted in Section 5 below), 

including home gardens to improve household food consumption, and to provide an 

income-generating activity and healthy nutritional practice for women. 


2. Facility-based nutrition service delivery activities: 

– Ensure that ENAs are implemented in all health facilities. 

– Promote maternal nutrition, including, where possible, clinic-based women‘s nutrition 

and breastfeeding groups as a source of social support for community women. (Incomegeneration 

and skill-building activities also can be carried out through such groups.) 

– Integrate HIV/AIDS nutrition services with routine MCH care, including breastfeeding 

counselling for HIV+ mothers and nutrition counselling as part of routine treatment, of 

care services and of Baby Friendly Hospital initiatives. 

4.2. SUGGESTED APPROACHES FOR HOUSEHOLD FOOD AND 

NUTRITION SECURITY INTERVENTIONS 

The FTF initiative is based on twin goals of increasing agricultural growth and improving 

nutritional status, especially for women and children. The USAID/Zambia FTF and GHI-led 

nutrition framework will support a set of interventions under each of these pillars to increase 

agricultural productivity and competitiveness of smallholders; to improve the functioning of 

markets and trade efficiencies; and to protect the nutritional wellbeing of the most vulnerable. 

Experience demonstrates that, as important as increased agricultural production and incomes 

are, they are not in themselves sufficient to improve nutrition status of the population. The 

CAADP and FTF include improved food and nutrition security among their objectives. In 

addition to reducing poverty overall, MDG 1 aims to halve the proportion of people suffering 

from hunger as measured by prevalence of underweight children under age 5 and the 

proportion of the population below a minimum level of dietary energy consumption. 

In addition, FTF is targeting nutrition improvements in women who are often malnourished and 

whose children are affected by their lack of access to sufficient nourishing foods. 

Achieving crop diversification has been difficult in Zambia because of uncertainties in 

marketability for these crops—in contrast to maize where the market is usually stable. In some 

cases, however, production of specific non-maize crops is encouraged by ―outgrower schemes.‖ 

These are partnerships with commercial farms or agribusiness entities that encourage mediumscale 

farmers to produce commodities to be marketed by these firms. The essence of the 

agreement is that the firm provides the farmer with necessary technical advice and inputs 

needed to produce the agreed upon commodity and then sells it. The arrangement provides 

financial support and an assured market outlet for the farmer and reduces fears of defaulting. 

This investment plan proposes a principle food and nutrition security strategy that focuses on 

the expansion, strengthening and monitoring of the government‘s Food Security Pack; on the 

strengthening of MACO extension staff; and on the continued support of NGOs earlier involved 

in such activities through the U.S. Title 2 program. 

This approach seeks to address the ―resiliency‖ objective of FTF and focuses on small farm 

households where improved nutrition is constrained by serious household food insecurity and 

where dietary diversity is particularly limited for women and young children. 65 In households 

where both food intake and income levels are so low, there is little likelihood that they will be 

65 FAOSTAT 2008. 


able to take full advantage of even high-quality health services and behavioral change 

communications. 66 

The approach suggested here seeks to significantly reduce household food insecurity through 

support of agricultural intervention that focuses on (1) income generation for particularly 

vulnerable low income households, but with the potential (minimally adequate land and labor) 

for agricultural viability; (2) increased productivity and crop diversity on the small farms of these 

households (average size is 2 hectares) designed both to increase small farmer incomes and the 

quantity and quality of small farmer household diets; and (3) increased attention to home-based 

food processing, small animal production (provision of two pre-vaccinated free range hens or 

one female goat) and home gardens, all primarily involving women for better translation of 

income improvement into food consumption, nutrition and health seeking behaviors, while 

directly producing food for home consumption. 

The vehicle recommended to accomplish these tasks is the Food Security Pack (FSP), a welldesigned 

and potentially highly cost-effective package of inputs. It was originally developed and 

implemented by the Program Against Malnutrition (PAM) in 2000, and is now operated by the 

Ministry of Community Development and Social Services (MCDSS) in collaboration with the 

Ministry of Agriculture and Cooperatives (MACO) and the Ministry of Finance and National 

Planning (MOFNP). The FSP presently targets ―vulnerable but viable‖ farmers—estimated to be 

primarily in the poorest rural deciles excluding the very lowest)—with a package of inputs 

including seed (cereals, pulses, cassava and sweet potato) and fertilizer, and training in 

conservation farming and food processing for a two-year period. Beneficiaries, in turn, are 

required to pay back, in the form of grain, 10 to 20% of the value of the provided inputs, which 

is, in turn, provided to neediest households by local food security committees. 

The program reaches roughly 200,000 households, or a quarter of the estimated 800,000 

households who are in need of such assistance and would be eligible. 

Recent data indicates that 60% of targeted beneficiaries are women, with 28% of beneficiary 

households female headed. 67 

The FSP appears capable of ―graduating‖ as many as 50% of its beneficiaries. ―Graduation‖ is 

defined as the ability to purchase adequate inputs after two years in the program. 68 There is 

even some limited evidence that FSP participation has a direct effect in reducing young child 

undernutrition. 

But the program faces two major constraints. The first is resource limitations. The annual 

government budget for the program is ZMK 10 billion (USD $2 million.) 69 Instead of 

concentrating on a limited number of priority provinces and districts, the government decided 

on political grounds to thinly spread this limited resource across the provinces, thus eliminating 

the program‘s potential for major effectiveness. At present, a farmer with two hectares of land 

receives inputs only sufficient to cover one quarter of 1 hectare. As a result, only an estimated 

10% of households have been ―graduating.‖ Importantly, budgetary limitations also seriously 

constrain MACO extension staff with primary implementation responsibility. 

66 

Zambia‘s Gini Coefficient, estimated at between 49.8 and 52.6 indicates that its income distribution is 

among the most unequal in sub-Saharan Africa. U.N. Gini Coefficient Fact Sheet. Retrieved from 

http://www.scribd.com/doc/328232/United-Nations-Gini-Coefficient. (October 30, 2010). 

67 Program Against Malnutrition, Annual Report to MCDSS. February 2010. 

68 Graduates then move into the much larger Subsidized Inputs Program in which seeds and fertilizer are 

made available at 50% of their market value. 

69 In 2009, the program received, as a one year only supplement, an additional 14 billion kwacha from the 

African Development Bank, in response to the economic recession. For the year 2011, the government 

has increased the budget for the Food Security Pack by 50%. 


The second constraint is the limited capacity of the MCDSS at present to aggressively 

implement a program of this magnitude and importance. 

This strategy accordingly suggests support of the government‘s FSP, but, ideally, with additional 

inputs to transform it into a Food and Nutrition Security Pack. These additional (and 

interrelated) inputs could include the following: 

Diversification of agricultural products: food legumes, groundnuts, oilseeds, vegetables, fruit, 

cereals, tubers, small livestock and fish. 

Seedlings for fruit trees (adequate to permit three trees per household). 

Microcredit, particularly for FSP-graduating families, for the purchase of equipment for 

community-level drying and processing of cassava, fruits and vegetables (e.g. cassava flour, 

chili sauce and dried vegetables) for home consumption throughout the year and for sale. 70 

Intensified home garden vegetable production with water harvesting utilized to permit 

garden irrigation. 

Food-related nutrition BCC messages will be offered in the community-based nutrition and 

health services discussed above and will be aired by radio. 

This strategy recognizes that MACO provides these extension services to the small farmer 

households, but that the agents are seriously constrained by inadequate transport and logistical 

support. Thus, efforts would be made to address these constraints and expand the agents‘ skills 

to include the abovementioned activities through training. (See Section 5.4.) 

With such assistance, MACO extension agents would be able to provide efficient and effective 

crops extension and technical services; to assist farmers in increasing agricultural production and 

productivity and to diversify crop production and utilization. MACO extension agents also can 

promote and strengthen farmer groups and farmer field schools as targets for technology 

transfer through the formation of on-farm demonstrations of proven technologies giving priority 

to crops that will enhance food and nutritional security (groundnuts, vegetables, fruits, pulses 

and oilseeds) and incomes. Promoting and strengthening women farmer groups in simple food 

processing and utilization of technologies that ensure food sufficiency in lean periods will also be 

a means toward that end. 

The Extension Service—and its food and nutrition unit—will need a more substantial budgetary 

allocation to cover (1) the logistical and transportation costs required for on-farm assistance to 

FSP households, and (2) the training discussed in Section 5.4. 

Related, the strategy recommends continued support of NGOs that were earlier supporting 

similar initiatives, sometimes with U.S.-provided food commodities. 

4.3. SUGGESTED R&D APPROACHES FOR URBAN NUTRITION 

CHALLENGES 

Two R&D activities are proposed to assist urban dwellers: 

70 More highly organized, commercial food processing by low income women is, at present, particularly 

difficult given the tying of credit for such purposes to the need for adequate collateral. 


4.3.1. Research and Development Efforts to Test Urban Gardening Options 

in Different Settings. 

Malnutrition in urban areas is concentrated in a boom of unplanned settlements, where the 

populations continue to grow. Poor peri-urban households have little land on which to practice 

agriculture, eat better, earn income and improve the environment. Urban agriculture can be 

practiced on vacant land within communities, with town planners and councils negotiating land 

rights. The team had the opportunity to witness such successfully negotiated land rights in the 

Copperbelt. The same might be possible in other urban areas, particularly those that are close 

to rivers and streams. 

The informal food sector is the first source of employment for unskilled individuals who often 

inhabit these urban slums. Opportunities abound for horticulture and small livestock production, 

employing a value chain approach that includes promotion of product utilization, processing, 

marketing and distribution. Families can grow food to reduce their food budgets and provide job 

opportunities, especially for youths. 

Concerted planning of urban gardens can also contribute to environmental management through 

the greening of these communities. The gardens can help to prevent erosion and thus limit the 

impact of floods, often a problem in these areas. They also provide for the recycling of organic 

waste and waste-water. However, urban agriculture requires strong organization of community 

units that ensures its members have bargaining power for appropriate support and better access 

to resources including clean water, inputs, services, and markets that include quality control at 

various points in the value chain. 

To start, strategic marketing alliances could be formed with hospitals, schools, hotels and 

restaurants, thus guaranteeing sustainability. As organized groups, they can have more influence 

on policymaking and design—and more equipped to participate in public debates. As groups, 

they will also have more power to negotiate for training, technical and financial support. Urban 

agriculture stands to make cities more inclusive, productive and sustainable, but requires 

producers to be more organized to maximize their contribution to food and nutrition security, 

income and environmental management. 

A significant proportion of urban households grow either field or horticultural crops (41% in 

Lusaka, 79% in Kitwe and 92–93% in Kasama and Mansa). Most households have gardens rather 

than fields. Policies that support the urban production of cassava and to promote the availability 

of cassava products in public markets could also contribute to improved urban food security. 71 

Although urban agriculture has been remarkably successful in many international settings (See 

Box), careful analysis is needed to determine its potential as a large-scale intervention in the 

Zambian context, and to identify the specific constraints that would need to be addressed. 

71 Staple Food Consumption Patterns in Urban Zambia: Results from the 2007/2008 Urban Consumption 

Survey by Nicole M. Mason and T.S. Jayne FSRP Working Paper No. 42. Retrieved from 

http://www.aec.msu.edu/fs2/zambia/wp42.pdf. (November 19, 2010). 


SCOPE AND EFFECTIVENESS OF 

URBAN AGRICULTURE INTERNATIONALLY 

Analysis of urban agriculture programs in 31 countries has identified some impressive successes. a b 

Among the more important findings: 

Urban agriculture, involving an estimated 800 million persons worldwide and producing an 

estimated 15% of the world‘s food production, is practiced over smaller and more 

dispersed areas than rural agriculture, uses land and water more sparingly and efficiently, 

integrates systems more effectively, and produces much higher yields and more specialty 

crops. 

More than 40 farming systems have been identified, ranging from horticulture to 

aquaculture, kitchen gardens to market gardens, and including livestock as varied as cattle, 

chickens, snails, and silkworms. 

Most urban farmers are low-income men and women who grow food largely for their own 

consumption on small plots that they do not own, and with little if any support or 

protection. The food grown constitutes much if not most of the food consumed by these 

households. 

The disproportionate production of vegetables and other nutritious foods on these plots 

has had positive effects on the growth of children in these households. 

Savings from the producers‘ consumption of their own produce represent up to several 

months of annual income. 

In Africa, both Cote d‘Ivoire and Tanzania presently subsidize urban agriculture; Guinea Bissau is 

now allocating open spaces to communal agriculture through purpose-specific leaseholds and 

providing credit and technical assistance to urban farmers; and cities in Zimbabwe and Tanzania are 

using multi-stakeholder consultations to resolve conflicts regarding urban agricultural issues. 

a Smit, J. Urban agriculture, progress and prospect:197–205. International Development 

Research Centre, Otawa, ON, Canada, Cities Feeding People Report 18; 1996. 

b Smit, J. Rata, A. Bernstein, J. Urban agriculture: an opportunity for environmentally sustainable 

development in Sub-Saharan Africa. Environmental Sustainable Division, African Technical 

Department, World Bank, Washington DC, USA. Post-UNCED Series, Building Blocks for Africa 

2025, Paper No. 1. 

4.3.2. Examination of In-country Private Sector Initiatives to Produce and 

Commercialize Complementary Foods and Related Products. 

At present, there are several uncoordinated initiatives that seek to make commercialized 

complementary foods or related products available on the market for purchase, primarily in 

urban areas. 

An IYCN-developed, commercially produced food supplement designed to be mixed with 

cereal-based porridges currently consumed in most households. 

Products developed by COMACO including Yummy Soy, a commercially available sequel to 

its previously publicly-distributed HEPS products; 

Ready-to-Use Therapeutic Food (RUTF), presently patented and imported for use in health 

facilities for severe acute malnutrition cases, but potentially valuable also as commercialized 

products. 

The Mission may wish to explore means of facilitating R&D efforts on such products, exploring 

social marketing options for them, and possibly seeking ways to better integrate these efforts. 


5. SUGGESTED APPROACHES TO INSTITUTION 

BUILDING, SYSTEMS STRENGTHENING, CAPACITY 

BUILDING AND ADVOCACY 

5.1. COMMUNITY HEALTH WORKERS NUTRITION TRAINING AND 

ROLL-OUT 

As indicated above, the proposed training and deployment of CHWs is an opportunity to 

strengthen the focus on preventative health care and ensure a robust nutrition component in 

the training, as well as community-based growth monitoring and promotion (GMP). A 

cooperative donor effort (USAID, DFID, UNICEF and the World Bank) in concert with the 

MOH and NFNC may lead to better-trained CHWs and, in turn, more effective GMP and 

nutrition services at the community level. It is recommended that the IYCF counseling package 

be incorporated into the CHW training curriculum. This can be negotiated with the MOH, 

which partnered in the development of the materials. 

The IYCF community-counseling package is comprehensive, comprising the trainer‘s guide, 

participant handouts and counseling cards. Messages include the importance of breastfeeding for 

the infant and young child, the mother, the family, the community and nation at large. Further, it 

provides recommended breastfeeding practices and possible counseling discussion points, 

including the schedule for visits from pregnancy to 6 months after birth. The package also 

provides information on anatomy of the human breast including good and poor latch-on of the 

baby for nursing. It also addresses common situations that can affect breastfeeding and common 

breastfeeding difficulties. 

The package further includes recommended complementary feeding practices, using different 

types of locally available foods, and possible counseling discussion points. In addition, it provides 

tips for active or responsive feeding for young children including jobs aid for IYCF assessment of 

the mother/child pair. 

Information to support the counselor‘s role includes skills on listening and learning, as well as 

for building confidence and giving support. Further, the package discusses features of an IYCF 

Support Group, actions to break the undernutrition cycle, and an IYCF Follow-up Plan 

Checklist. 

5.2. SUPPORT THE START-UP AND DEVELOPMENT OF THE NEW 

BSC IN HUMAN NUTRITION AT UNIVERSITY OF ZAMBIA, 

FACULTY OF AGRICULTURE 

In order to create and offer a BSc in Human Nutrition, the Faculty of Agriculture will need a 

myriad of additional academic, technical and support staff. This includes 14 academic staff (at 

professional, senior lecturers I, II and III); six laboratory staff (one chief technician, one senior 

technician, two laboratory assistants); and two secretarial staff (one stenographer and one 

typist). Students currently pursuing a diploma in food and nutrition—a three-year program— 

take one nutrition course during their second year; this new program will require four nutrition 

courses during this time. The availability of courses should not be an issue, as they exist in other 

departments. During the first two or three years of launching the program, the university must 

engage in rigorous staff development for nutrition-specific courses so that they are available by 

students‘ fourth year. 


In this regard, the department needs to quickly devise a staff development plan. One 

intermediate solution is to hire nutritionists (national and international) who can help start the 

program; another is to employ visiting lecturers from other universities under staff exchange 

programs. Partnerships with other universities should be developed for faculty development and 

research linkages. Together with faculty development, the program requires additional 

classrooms and laboratories, equipment, and learning and teaching materials. The department 

must also reach out to the local and international community in order to establish itself in the 

relevant research, public service and consultancy sectors. Collaboration with partners—the 

private and public sector, the health industry, and NGOs—are essential for student training and 

internships. 

5.3. REINFORCE AND STRENGTHEN THE NUTRITION DIPLOMA 

PROGRAM AT THE NATURAL RESOURCES DEVELOPMENT 

COLLEGE (NRDC) 

This diploma-level nutrition program at NRDC is currently training nutritionists in ministries of 

agriculture, health, and community development, and NGOs in the country. As such, it is an 

invaluable national resource. It has a need for equipment, library resources, nutritional 

assessment laboratory and information technology. 

5.4. SUPPORT AND UPGRADE MACO EXTENSION AGENTS TO 

ASSIST FARMERS ACHIEVE FOOD AND NUTRITION SECURITY 

As discussed above, the nationwide network of MACO extension agents is vital to the effective 

implementation of the of the FSP program and to improving the nutritional wellbeing of food 

insecure households generally. With additional training and a budgetary allocation to address 

transport and logistical constraints, extension agents can advise farmers on growing diverse 

crops and introduce new and improved technologies for food storage, food processing and 

preservation. Training is needed in the following areas: 

Production of non-maize crops. 

Assistance to households in small livestock. 

Extension assistance in home garden production. 

Home-based food drying and preservation. 

Microcredit training to assist graduating households. 

Household food and nutrition counseling. Agriculture field workers have the capacity to 

become a partner in the three-part mutually reinforcing set of food and nutrition-related 

BCC messages; the other partners are health staff (at facilities and communities) and 

community radio (See Box.) 


COMMUNITY RADIO IN AFRICA 

Over the last decade, there has been an explosion in the number of radio stations 

across Africa—particularly community and commercial FM stations. New techniques 

such as phone-in shows, live community forum, and radio diaries are transforming 

radio into an interactive medium for rural farm families. 

The African Farm Radio Research Initiative (AFRRI) was launched in 2007 by the 

Gates Foundation to assess the effectiveness of farm radio in improving the food 

security of rural farm households in Africa. 

AFRRI also is developing, testing and evaluating a Participatory Radio Campaign 

(PRC). Working with five partner radio stations in each of five African countries— 

Tanzania, Uganda, Mali, Ghana and Malawi—AFRRI is producing, broadcasting and 

evaluating PRCs related to disease-resistant cassava, improved composting 

techniques, improved chicken management, soil and water conservation and other 

topics. 

Following the PRC, findings indicate a clear increase in the percentage of farmers now 

practicing, or planning to introduce, the improved practices as compared to control 

populations. In the case of improved composting methods in Mali, the PRC was 

responsible for a 400% increase in improved practice. a 

a http://www.farmradio.org/english/partners/afrri/casestudy-report.pdf 

5.5. NUTRITION ADVOCACY 

Addressing malnutrition is not yet a national priority in Zambia. All too often, maize security 

equals food and nutrition security in the minds of senior decisionmakers. There is little concern 

with dietary diversity (increasing effective demand for pulses, legumes, fruits and vegetables) or 

with young child and maternal malnutrition. What‘s needed is a championed, well-focused 

nutrition advocacy campaign, using an array of media outlets, which seeks to convince both the 

public and senior government officials of the importance of improved nutrition and the actions 

required to address the problem. Such advocacy campaigns have been carried out in the 

Philippines, Brazil, South Korea and other countries. 

Important in such advocacy is the presentation of a sequence that compels change. For example: 

well-paying employment requires good school performance, which, in turn, requires cognitive 

ability, which, in turn, requires good maternal and child nutrition in order to avoid intra-uterine 

growth retardation and young child stunting. 

A second compelling sequence can indicate that intra-uterine growth retardation and young 

child stunting may lead to chronic diseases as an adult (high blood pressure, diabetes, greater 

risk of heart attacks and strokes, and even overweight and obesity). 

A third thrust can address the rapid increase of overweight and obesity in urban areas, their 

disease consequences, and the steps necessary to combat and prevent these conditions. All 

three of these thrusts will be facilitated by the national food consumption survey being planned 

by UNICEF. 


Such advocacy campaigns benefit enormously when endorsed by a local champion. First Lady 

Michelle Obama serves as that champion in the U.S. In Zambia, this person might be the 

country‘s first president, Kenneth Kaunda. Since retiring, he has supported various charitable 

organizations including the Centre for Traditional Medicines and Drugs Research, has shown 

considerable zeal in the battle against HIV/AIDS, and is known for his personal attention to 

healthy food consumption and nutrition. 


ANNEX A. SCOPE OF WORK 

GLOBAL HEALTH TECHNICAL ASSISTANCE PROJECT DEVELOPMENT 

OF USAID/ZAMBIA’S INTEGRATED NUTRITION INVESTMENT 

FRAMEWORK 

(Final/Revised: 09-28-10) 

OVERVIEW AND PURPOSE 

This scope of work calls for the development of an integrated nutrition framework that 

provides a clear roadmap for short- and long-term investments (including potential new 

procurement needs); demonstrates a commitment to a Zambia-led process and plan; and works 

collaboratively with other partners/stakeholders. Based on a comprehensive and integrated 

strategic approach that addresses the multiple dimensions and causes of undernutrition, this 

framework must aim to improve the nutritional status of Zambians, targeting women and 

children under age 2. It must also link the contributions of USAID/Zambia‘s economic growth, 

education, health, HIV/AIDS, and humanitarian assistance programs. Additionally, this framework 

must incorporate the principles and leverage the resources of the Food for Peace (FFP) 

program, Feed the Future Initiative (FTF), Global Health Initiative (GHI), and President‘s 

Emergency Plan for AIDS Relief (PEPFAR). 

To develop this framework, USAID/Zambia will hire a team of consultants for up to four weeks 

to assess the following issues in addressing undernutrition: 

Nutrition and food consumption issues in Zambia, including the production and use of 

specialized food products (therapeutic, supplementary, or complementary foods). 

Socio-cultural norms related to food and nutrition. 

Link between agricultural production and nutrition. 

Current policy environment. 

Current programs and resources. 

U.S. Government (USG) management structure and capacity, including the comparative 

advantage of the USG. 

Human resource capacities. 

Involvement of country-level stakeholders, including other donors and the private sector. 

Optional delivery mechanisms for nutrition services and products. 

The assessment will begin on/around October 19, 2010, and include meetings with the Mission 

as well as visits to project/activity sites. The team must submit a draft of the integrated nutrition 

investment framework before their departure from Zambia. 


BACKGROUND 

Multi-disciplinary programming that strategically involves economic growth, education, health, 

HIV/AIDS, and humanitarian assistance can effectively improve nutrition. The FTF and L‘Aquila 72 

principles of a comprehensive response around food security support such an approach. 

USAID/Zambia developed a FTF implementation plan (IP) based on these principles; drafted a 

diplomatic strategy that discusses political engagement with the Zambian government (GRZ) and 

other stakeholders; and attended regional meetings in Nairobi on the FTF. The Feed the Future 

Guide furnishes further guidance concerning the dominant role of nutrition in the FTF. 

Globally, the FTF aims to reach 8.5 million children with an appropriate package of evidencebased 

nutrition interventions that reduce child mortality, improve nutrition outcomes, and 

protect human capital. The package includes interventions in the development window of 

opportunity (-9 to 24 months, including maternal nutrition, promotion of exclusive 

breastfeeding, infant and young child feeding practices, etc.); diet quality and diversification (food 

fortification, consumption of nutrient rich foods); community management of acute malnutrition; 

and targeted micronutrient supplementation. 

USAID/Zambia‘s IP outlines interventions designed to address the systemic constraints to 

agricultural productivity and access to more lucrative markets. Overcoming the multiple 

constraints will lead to greater household income security. However, translating income security 

into food security, in terms of improved maternal and child nutrition, requires a concerted and 

coordinated cross-sectoral effort. Centering on women and children, this effort in Zambia will 

contribute to the global goal/target established by the FTF and GHI for the sustainable reduction 

of child malnutrition by 30%, while recognizing the impacts of HIV and the resources available 

through PEPFAR. To meet this target, the USAID/Zambia-supported effort will foster nontraditional 

alliances between the GRZ, other cooperating partners, civil society, and the private 

sector across the economic growth, education, health, HIV/AIDS, and humanitarian assistance 

sectors. 

In September 2009, Acting Director of U.S. Foreign Assistance, Richard Greene, approved the 

creation of the Nutrition Program Element under the Health Program Area in the Investing in 

People Objective. The creation of this element responds to the heightened importance of 

nutrition in reducing maternal and child mortality and achieving food security. A separate 

nutrition element facilitates integration of programming and tracking of nutrition funding for 

both the FTF and GHI. Zambia will receive USD $3 million in Global Health and Child Survival 

(GHCS) funds in FY 2010 for nutrition activities, which will complement the USD $21.0 million 

in Development Assistance (DA) funds for agriculture-led economic growth and USD $12 

million in FFP funds, along with substantial resources through PEPFAR. USAID/Zambia will use 

these funds to plan and implement a comprehensive nutrition and agriculture-focused food 

security program. 

72 

The Joint Statement on Global Food Security (―L‘Aquila Food Security Initiative‖) is endorsed by the G8 

and by Algeria, Angola, Australia, Brazil, Denmark, Egypt, Ethiopia, India, Indonesia, Libya (Presidency of 

the African Union), Mexico, The Netherlands, Nigeria, People‘s Republic of China, Republic of Korea, 

Senegal, Spain, South Africa, Turkey, Commission of the African Union, FAO, IEA, IFAD, ILO, IMF, 

OECD, The Secretary General‘s UN High Level Task Force on the Global Food Security Crisis, WFP, The 

World Bank, WTO who attended the food security session at the G8 Summit in L‘Aquila on 10 July 2009 

and by the Alliance for a Green Revolution in Africa (AGRA), Biodiversity/Consultative Group on 

International Agricultural Research (CGIAR), Global Donor Platform for Rural Development , Global 

Forum on Agricultural Research (GFAR). 


Contributing to the aims and results of the FTF and GHI, USAID/Zambia plans to implement 

nutrition activities through the following current and/or future bilateral programs in the health 

and HIV/AIDS sectors: 

Community-based Prevention Initiative for Orphans and Vulnerable Children (COPI-OVC, prime 

partner: World Vision Zambia) will integrate efforts to prevent undernutrition and deliver 

nutrition services among OVC. 

Infant and Young Child Nutrition (IYCN, prime partner: PATH) aims to improve the nutritional 

status of mothers, infants and young children, targeting those infected with or affected by 

HIV. The IYCN activities promote interventions in five areas: breastfeeding, complementary 

feeding practices, infant feeding during illness, infant feeding and HIV, and maternal nutrition. 

Partnership for Integrated Social Marketing (PRISM, prime partner: Population Services 

International) works with the private sector to support the manufacturing and distribution of 

point-of-use water treatment solution and zinc to prevent diarrheal diseases among 

children. 

Zambia Behavioral and Social Change Communication Program (ZBSCCP, prime partner: 

Chemonics) will work with the Ministry of Health (MOH) at the central level to develop 

campaigns and health promotion materials that focus on key nutrition practices. These 

practices will promote maternal nutrition, exclusive and continued breastfeeding, and 

appropriate infant and young child feeding. 

Zambia Integrated Systems Strengthening Program (ZISSP, prime partner: Abt Associates) will 

work with the MOH at the central, provincial, and district levels to support the delivery of 

nutrition services through community-based and sustainable facility platforms. These 

services include implementation of the integrated management of childhood illness 

protocols, supplementation with micronutrients, and community management of acute 

malnutrition. 

Zambia Nutrition Services, Support, and Therapy Program (prime partner: TBD) will work with 

the agricultural and health sectors to strengthen institutions, policies, and practices that 

support sustained, Zambian-led improvements in nutrition. Activities include the 

development of clinical/community modules to prevent malnutrition among adults and 

children enrolled in HIV/AIDS programs, as well as orphans and vulnerable children (OVC). 

Another set of modules aims to improve economic development/value chain opportunities 

on the production of fortified foods and specialized food products. 

Zambia Prevention, Care, and Treatment Partnership II (ZPCT, prime partner: Family Health 

International) works with the MOH at the central, provincial, and district levels to promote 

consumption of specialized food products among people living with HIV/AIDS (PLHIV). 

Zambia Prevention Initiative (prime partner: AED) will complement and reinforce the clinical 

(ZISSP and ZPCT II) and communication (PRISM and ZBSCCP) efforts to promote nutrition 

interventions among PLHIV through community-based activities. 

In February 2010, the Bureau for Global Health issued the Nutrition Operational Guidance for 

Missions (See Annex D). This guidance presents a multi-dimensional model, rationale, and 

strategic approach to address undernutrition and identifies Missions, including USAID/Zambia, 

to develop integrated nutrition investment frameworks. 

During March 2010, USAID/Zambia hosted a team of consultants from the Food and Nutrition 

Technical Assistance Project II (FANTA II), with support from the FFP program based at 

USAID/Washington, to develop the Food Security Country Framework (FSCF). USAID/Zambia‘s 

FSCF, part of the 2011 Multi-Year Assistance Program development process, will outline 

interventions in humanitarian assistance, but aim to integrate FFP resources fully into the 

Mission‘s objectives for food security and nutrition through the FTF and GHI. For example, 


these interventions include the three core services of the food-assisted approach to prevent 

undernutrition among women and children under age 2: 

Conditional food ration for the individual woman or child and for the household. 

Preventive and curative health and nutrition services for women and children. 

Behavioral and social change communication. 

STATEMENT OF WORK 

Objective 

As their primary objective, the team must draft an integrated nutrition investment framework 

for Zambia, building on efforts by the Mission to develop similar planning documents for the 

FFP, FTF, GHI, and PEPFAR. In response to the Nutrition Operational Guidance for Missions, 

this framework must provide a clear roadmap for short- and long-term investments (including 

potential new procurement needs); demonstrate a commitment to a Zambia-led process and 

plan; and map collaborative relationships with other partners/stakeholders (See Annex D). 

Based on a comprehensive and integrated strategic approach that addresses the multiple 

dimensions and causes of undernutrition, this framework must aim to improve the nutritional 

status of Zambians and link the contributions of USAID/Zambia‘s economic growth, education, 

health, HIV/AIDS, and humanitarian assistance programs. Additionally, this framework must 

explain how proposed investments will increase gender equity and sustain nutritional 

improvements. 

PERFORMANCE PERIOD 

To begin around mid-October and continue through the end of December 2010. 

FUNDING SOURCE 

USAID/Zambia 

Oversight 

In USAID/Zambia, the team must seek guidance from the leaders and relevant staff of the 

economic growth, education, health, HIV/AIDS, and humanitarian assistance teams, which will 

provide information and technical advice. The Population, Health, and Nutrition (PHN) Office 

Director will provide overall direction for the team as identified in Section 5. 

Analytic Tasks and Illustrative Key Questions 

To develop this framework, the team must examine the following issues in addressing 

undernutrition (illustrative): 

Nutrition and food consumption issues in Zambia, including the production and use of 

specialized food products (therapeutic, supplementary, or complementary foods). 

Socio-cultural norms related to food and nutrition and gender. 

Link between agricultural production and nutrition. 

Current policy environment. 

Current programs and resources. 

U.S. Government (USG) management structure and capacity, including the comparative 

advantage of the USG. 

Human resource capacities; 

Involvement of country-level stakeholders, including other donors and the private sector. 


Optional delivery mechanisms for nutrition services and products. 

The Nutrition Operational Guidance for Missions offers a set of specific questions for each issue 

(See Annex D). Additionally, the Feed the Future Guide highlights the issues on the linkages 

between agriculture and nutrition interventions. 

The team must also address the questions included at the end of this section. Refinement of 

these questions and development of additional questions will occur in the beginning of the 

assessment, in consultation with the economic growth, education, health, HIV/AIDS, and 

humanitarian assistance teams. 

What linkages should USAID/Zambia establish between the programs that it supports to 

generate the greatest impact of DA, FFP, and GHCS (including HIV/AIDS) funding? 

In regards to nutrition interventions: 

– Identify the most effective individual prevention, population-based nutrition service 

delivery, and enabling environment/capacity development activities that will sustainably 

reduce malnutrition by 30%, focusing on children under age 2. To what extent do 

current projects supported by USAID/Zambia and other country-level stakeholders 

include these activities? In particular, characterize how these activities should link with 

FFP-supported programs to strengthen the connection between emergency relief and 

longer-term development. 

– Describe how these activities fit within the scopes of current and future projects. If they 

do not, then propose appropriate changes to the strategic direction of current projects 

and/or design of future projects. Recommend how technical teams should invest the 

anticipated funding to support these activities. 

– Discuss how these activities relate to nutrition programs supported or implemented by 

other country-level stakeholders. 

– Discuss and make recommendations on how nutrition assistance programs may be 

sustained. 

In regards to targeting for nutrition interventions: 

– Based on existing data, does Zambia have geographic areas with high concentrations of 

people in need of assistance? Alternatively, do Zambians who need assistance work and 

live throughout the general population? If insufficient data exist, then propose a design of 

a situational analysis that will inform decisions related to the delivery of targeted 

assistance. 

– Describe the options of identifying and targeting individuals in need of assistance 

(including PLHIV and OVC). Present the benefits, costs, and feasibility for each option. 

– Propose general identification procedures/tools that maximize screening accuracy. 

Methodology 

The assessment will follow a non-quantitative methodology through a desk review of relevant 

data sources and documents, interviews with key informants, and visits to field sites. 

Document Review 

Prior to arriving in country and conducting fieldwork, the team will review various project 

documents and reports. The USAID/Zambia team will provide the relevant documents for 

review as soon as possible. 

The team must review relevant data sources and documents, including the following: 

Nutrition Operational Guidance for Missions. 


Feed the Future Guide. 

Zambia Demographic and Health Surveys. 

UNICEF Multiple Indicator Cluster Surveys. 

Other international and national data sources on maternal and child health and nutrition, 

agriculture, income, and livelihoods. 

Previous nutrition and food security assessments. 

USAID/Zambia Country Strategic Plan 2004–2010 and Strategy Statement 2006. 

GRZ Fifth National Development Plan. 

FTF IP. 

Relevant narratives from the Operational Plan, HIV/AIDS Country Operational Plan, and 

Malaria Operational Plan. 

GRZ National Health Strategic Plan 2006 – 2010. 

GRZ National AIDS Strategic Framework 2006 – 2010. 

Zambia National Agriculture Policy. 

Comprehensive Africa Agriculture Development Program Country Compact. 

Relevant national nutrition and food policies and guidelines. 

Results and evaluation reports from past projects/activities; 

Relevant program documents from current projects/activities. 

Existing FFP program proposals. 

Strategies and reports produced by other cooperating partners, including the World Bank 

and World Food Program in Zambia. 

Relevant published and grey literature for Zambia. 

These will be provided by the mission well in advance of team arrival in country. 

Consultations in Washington, DC 

Prior to arrival in country, the international consultants will visit Washington, DC and meet with 

key informants, USAID staff and other appropriate stakeholders. 

Washington, DC 

FANTA II. 

USAID/Washington, Bureau for Africa. 

USAID/Washington, Bureau for Democracy, Conflict, and Humanitarian Assistance. 

USAID/Washington, Bureau for Economic Growth, Agriculture, and Trade. 

USAID/Washington, Bureau for Global Health (Malia Boggs). 

Team Planning Meeting 

A two-day planning meeting (TPM) will be held during the team‘s first two days in-country. This 

time will be used to clarify team roles and responsibilities—including specific availability and 

tasks/duties to be assigned for part-time team members as well as USAID team members that 

may have limited availability; deliverables; approach; and refinement of agenda. In the TPM the 

team will: 

Share background, experience, and expectations for the assignment. 


Discuss and finalize roles and responsibilities for team members including writing 

assignments. 

Formulate a common understanding of the assignment, clarifying team members‘ roles and 

responsibilities, level of effort and availability. 

Agree on the objectives and desired outcomes of the assignment. 

Establish a team atmosphere, share individual working styles, and agree on procedures for 

resolving differences of opinion. 

Develop a work plan, timeline and strategy for achieving deliverables. 

In-Briefing and Out-Briefing 

Refer to Expected Deliverables for details. 

Site Visits and Key Informant Interview 

The team will visit field sites in Zambia. The selection of these sites should prioritize locations 

that highlight the following: 

Nutritional status of potential target populations. 

Enabling environment and institutional capacity, including the coverage and quality of 

implementing nutrition-related policies and guidelines. 

Individual and population-based service delivery platforms to expand nutrition interventions. 

The team must conduct interviews with key informants in Washington and Zambia. A 

preliminary list is included below: 

Zambia 

U.S Government agencies: USAID/Zambia, U.S. Centers for Disease Control and 

Prevention, U.S. Department of State, U.S. Peace Corps. 

USAID/Zambia-supported implementing partners across all sectors. 

Other cooperating partners, including the UK Department for International Development. 

United Nations and other multilateral agencies: World Bank, World Food Program. 

GRZ: Ministry of Agriculture and Cooperatives, Ministry of Livestock and Fisheries, MOH, 

National HIV/AIDS/STI/TB Council, National Food and Nutrition Commission. 

Civil society organizations. 

Private sector firms. 

Team Composition and Size 

The team will consist of four members, two international hires and two locally-engaged 

consultants: 

Team Leader (International). 

Technical Specialist (Nutrition – International). 

Technical Specialist (Institutional and Stakeholder Analyses – Zambian. 

Technical Specialist (Agriculture and Private Sector Development – Zambian). 

Team Leader 

Responsibilities: Reporting to the USAID/Zambia PHN Office Director, the Team Leader will 

coordinate and participate in the conduct of the assessment and preparation of the deliverables. 

With familiarity of USAID programs and operations at the Mission level, he/she will focus on 


examining the USG management structure and capacity to oversee the proposed investments in 

the framework. For the deliverables, the Team Leader will provide continuity in the content and 

style of presentations and reports. He/she will assume responsibility for the overall quality of 

work and manage the tasks, calendar, and schedule for the team. 

Experience/skills: The Team Leader must have at least 10 years of experience working with 

USAID and/or USAID-supported implementing partners in the PHN sector, with some 

experience in Southern Africa. He/she must understand USAID‘s policies and principles in 

program design and management. The Team Leader must think creatively and flexibly, with 

strong communication (especially writing) and interpersonal skills. 

Technical Specialist (Nutrition) 

Responsibilities: Reporting to the Team Leader, this Technical Specialist will participate in the 

conduct of the assessment and preparation of the deliverables. He/she will focus on examining 

the nutrition and food consumption issues, including the production and use of specialized food 

products (therapeutic, supplementary, or complementary foods). Additionally, the Technical 

Specialist will assess the effectiveness of existing nutrition and related WASH interventions and 

recommend changes, new interventions, cross-sectoral linkages, and targeting approaches. 

Experience/skills: This Technical Specialist must have at least five years of experience in the 

prevention of undernutrition and/or delivery of nutrition services in a developing country 

context, preferably in Southern Africa. He/she must have exposure to USAID‘s PHN programs 

and demonstrate familiarity with the technical approaches of these programs to improve 

nutritional status. The Technical Specialist must have strong communication (especially writing) 

skills. 

Technical Specialist (Institutional and Stakeholder Analyses) 


conduct of the assessment and preparation of the deliverables. He/she will focus on examining 

the current policy environment, existing programs and resources, human resource capacities, 

and stakeholder involvement to address nutrition in Zambia. 

Experience/skills: This Technical Specialist must have at least ten years of experience in health 

and/or another development sector in Zambia. With such experience, he/she must demonstrate 

substantial knowledge of the roles and resources of the GRZ, bilateral and multilateral agencies, 

civil society, private sector, and other country-level stakeholders to address food security and 

nutrition in Zambia. The Technical Specialist must have strong communication (especially 

writing) skills. 

The Director and staff of the PHN Office as well as the leaders and staff of the economic 

growth, education, HIV/AIDS, and humanitarian assistance teams will work closely with the team 

throughout the course of the assignment. 

Technical Specialist (Agriculture and Private Sector Development) 


assessment and preparation of the deliverables. He/she will focus on the current opportunities 

to leverage the increasing productivity and profitability of smallholder agriculture production to 

improve the nutritional status of women and children. The specialist will address farming 

systems in the Zambian context and inform the team regarding how crop diversity and market 

opportunities could improve dietary diversity and significantly reduce undernutrition. 

Experience/skills: He/she will have an in-depth understanding of the Zambian culture as it relates 

to farming practices and the incentives that govern decisions related to the risks of investments 

in farming systems upgrades. The Technical Specialist will have at least ten years experience in 


the Zambian agriculture sector, with a demonstrated and in-depth understanding of the lead 

GRZ Ministries that guide the development of the sector. The Technical Specialist will 

demonstrate his/her understanding of policy and technical issues that impact the performance of 

Zambian agriculture and how to effectively work within the limits of the Zambian context to 

influence on-farm responses to reduce undernutrition. 

Procurement Sensitivity 

The product of this exercise may be used to inform future procurement efforts related to 

nutrition in Zambia. All personnel involved will be required to sign confidentiality agreements 

governing use of the information generated as part of this assignment. 

Illustrative Calendar 

The team should expect to participate in tasks according to the following proposed schedule: 

Week 1 (Washington): Meetings with USAID/Washington and FANTA II and desk review of 

documents. 

Week 2: Meetings with USAID/Zambia, finish desk review of documents, and begin meetings 

with country-level stakeholders. 

Week 3: Finish meetings with country-level stakeholders and begin visits to field sites. 

Week 4: Finish visits to field sites and draft and present the integrated nutrition investment 

framework. 

Logistics 

Arrangements 

USAID/Zambia will coordinate with other USG agencies, implementing partners, and other 

country-level stakeholders to arrange courtesy calls, substantive meetings, field site visits, and incountry 

travel, including transportation and accommodation. 

GH Tech will be responsible for the following: 

Arranging travel in the U.S. and from the U.S. to overseas assignment location (country 

clearance, visa, plane tickets, hotel reservations and meeting space, communications costs 

for consultants, processing travel advance and expenses). Consultants are responsible for 

arranging in-country travel while overseas and ground transportation in the U.S. GH Tech 

will need to approve in-country travel quotes prior to purchase (for consultant 

reimbursement). 

Facilitating contact with USAID staff. 

Instruction and/or assistance with formatting charts, graphs, tables, and PowerPoint slides. 

The team should expect to bring their own laptops. 

Workweek 

USAID/Zambia authorizes a six-day work week when the team is working in country. 

Estimated Level of Effort (LOE) 

Activity 

Days 

Background Reading— All members 3 

Travel to Washington (Team Leader) 1 

Consultations in Washington via meetings and interviews (Team Leader) 3 


Activity 

Days 

RT International Travel (Team Leader—4; Technical Specialist/Nutrition – 3) 4/3 

Assessment Planning (setting up meetings/field visits) – Technical Specialist/Nutrition 4 

Team Planning Meeting (TPM)— all team members 2 

Conduct of assessments in Zambia (includes site visits and key informant 

interviews)—Team Leader and 3 Technical Specialists 

Preparation of deliverables—Team Leader + 3 Technical Specialists (Discussion, 

analysis of data, framework/report drafting) 

13 

4 

In Briefing and Out-Briefing (Preparation and Presentation) (x4 persons) 2 

Revisions of Deliverables (Team Leader—5 + team members–3) 5/3 

Total LOE—Team Leader 37 

Total LOE—Technical Specialist (Nutrition) 34 

Total LOE—Technical Specialist (Institutional and Stakeholder Analyses) 24 

Total LOE—Technical Specialist (Agriculture and Private Sector 

Development) 

24 

Relationships and Responsibilities 

Prior to in-country work: 

Consultant Conflict of Interest. To avoid conflicts of interest (COI) or the appearance of a 

COI, review previous employers listed on the CVs for proposed consultants and provide 

additional information regarding any potential COI. 

Background Documents: Identify and prioritize background materials for consultants and 

provide them to GH Tech as early as possible prior to team work. 

Key Informant and Site Visit Preparations: Provide a list of key informants, site visit 

locations, and suggested length of field visits for use in planning for in-country travel and 

accurate estimation of country travel line items costs (i.e. number of in-country travel days 

required to reach each destination, and number of days allocated for interviews at each 

site). 

Lodging and Travel: Provide information as early as possible on allowable lodging and per 

diem rates for stakeholders that will travel/participate in activities with the evaluation 

team. Also, provide guidance on recommended secure hotels, and identify a person in the 

Mission to assist with logistics. 

During in-country work: 

USAID/Zambia will undertake the following while the team is in country: 

Mission Point of Contact: Ensure constant availability of the Mission Point of Contact 

person(s) to provide technical leadership and direction for the consultant team‘s work. 

Meeting Space. Provide guidance on the team‘s selection of a meeting space for interviews 

and/or focus group discussions (i.e. USAID space if available or other known office/hotel 

meeting space). 


Meeting Arrangements and Field Visits. While consultants typically will arrange meetings for 

contacts outside the Mission, support the consultants in coordinating meetings with 

stakeholders and provide USAID transportation for field visits. 

Formal and Official Meetings. Arrange key appointments with national and local government 

officials and accompany the team on these introductory interviews (especially important in 

high-level meetings). 

Other Meetings. If appropriate, assist in identifying and helping to set up meetings with local 

professionals relevant to the assignment. 

Facilitate Contacts with Partners. Introduce the team to project partners, local government 

officials and other stakeholders, and where applicable and appropriate, prepare and send out 

an introduction letter for team‘s arrival and/or anticipated meetings. 

Following in-country work: 

USAID/Zambia will undertake the following once the in-country work is completed: 

Timely reviews: Provide timely review of draft/final draft reports and approval of the 

deliverables. 

EXPECTED DELIVERABLES 

The team must produce the following deliverables: 

A written methodology/work plan: This design/operational work plan will be prepared during 

the TPM and submitted to the Mission for review and approval before fieldwork and key 

informant interviews begin. 

A draft report outline: This will be prepared during the TPM. 

In-briefing presentation: This presentation must summarize the preliminary findings and 

conclusions, based on the desk review of relevant data sources and documents and 

interviews with Washington-based key informants. The team should anticipate that the inbriefing 

will last for approximately one hour, with the majority of time spent on identifying 

information gaps to fill through key informant interviews and field visits in Zambia. 

Out-briefing presentation: This presentation must propose highlights from the integrated 

nutrition investment framework, drafted in response to the illustrative key questions in 

section 3.3 and based on all information gathering activities. The team should anticipate that 

the out-briefing will last for approximately two hours, with the majority of time spent on 

questions and discussion. 

Draft Integrated Nutrition Investment Framework (report): As described in section 3.1 and 

summarized in the out-briefing presentation, this framework must describe the strategic 

thrusts and program priorities in economic growth, education, health, HIV/AIDS, and 

humanitarian assistance (See SOW Annex 1 for the proposed outline). The Team Leader 

must submit the draft of this framework before his/her departure from Zambia. USAID will 

provide comments on the draft framework within 10 working days of receipt of the report. 

The draft framework/report will be used internal to the mission and labeled 

―For Internal USAID Distribution Only.‖ 

Final Integrated Nutrition Investment Framework (Report): The final report will be due within 

approximately seven working days after the team receives comments from USAID/Zambia. 

USAID/Zambia requests both an electronic version of the field report (Microsoft word) as 

well as two hard copies of the report. The final framework/report will be used 

internal to the mission and labeled ―For Internal USAID Distribution Only.‖ 


After the final (but unedited) draft report has been reviewed by USAID, GH Tech will have the 

documents professionally edited and formatted and will provide the final report to 

USAID/Zambia for internal distribution (two hard copies and a CD Rom). It will take 

approximately 30 business days for GH Tech to have the report edited, formatted, and printed. 

RELATIONSHIPS AND RESPONSIBILITIES 

Primary USAID/Zambia point of contact for this assignment will be: 

William Kanweka 

Senior Health Advisor 

PHN Office, USAID/Zambia 

Email; wkanweka@usaid.gov 

Telephone: 260-211-254303 ext 179 

Mobile: 260-978-771499 

MISSION CONTACT PEOPLE: 

AO/0ffice Contact Position Email address 

Front Office Ryan Washburn A/Deputy Mission 

Director 

Population Health and 

Nutrition (AO7) 

HIV Mutlisectoral 

Response (AO9) 

HIV Mutlisectoral 

Response (AO9 

rwashburn@usaid.gov 

Randy Kolstad Director rkolstad@usaid.gov 

Rene Burger Team Leader rberger@usaid.gov 

Abeje Zegeye 

HIV/AIDS Food and 

Nutrition Advisor 

azegeye@usaid.gov 

Program (PRM) Michael McCord Program Officer mmccord@usaid.gov 

Economic Growth 

(AO5) 


(AO5) 


(AO5) 

Andrew Levin 

Kristy Cook 

Agric. Development 

Officer 

Senior Agric. 

Economist 

alevin@usaid.gov 

kcook@usaid.gov 

Ballard Zulu Deputy Team Leader bazulu@usaid.gov 

Education (AO6) Wick Powers Education Officer rpowers@usaid.gov 

Education (A06) Cornelius Chipoma Education Specialist cchipoma@usaid.gov 

COST ESTIMATE—ATTACHED 


ANNEX 1: ILLUSTRATIVE OUTLINE FOR THE INTEGRATED 

NUTRITION INVESTMENT FRAMEWORK 

I. Executive Summary 

II. 

III. 

IV. 

Introduction 

– Purpose 

– Methodology 

Situational Analysis 

– Overall status and progress, including feasibility of achieving targets in the relevant 

Millennium Development Goals. 

– Sector-specific status and progress, including efforts of the GRZ, USG, and other 

donors. 

– Economic growth 

– Education 

– Health and HIV/AIDS 

– Humanitarian Assistance 

Re-positioning Nutrition and Food Security 

– Working definitions of key concepts: integration, linkages, sustainability, ownership, 

capacity development, and gender equity. 

– Contribution to the global results of the FTF and GHI. 

– Contribution to USAID/Zambia‘s Assistance Objectives. 

V. Guidelines on Cross-sectoral Integration and Linkages 

VI. 

Guidelines on Nutrition Interventions 

– Individual prevention activities. 

– Population-based nutrition service delivery activities. 

– Enabling environment and capacity development. 

VII. Guidelines on Targeted Assistance 

– Need for targeted assistance and/or further situational analysis. 

– Types, benefits, costs, and feasibility of targeting options. 

– Promising practices in targeted assistance. 

VIII. References 



ANNEX B. PERSONS CONTACTED 

U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT 

Malia Boggs, Technical Advisor, Nutrition Division 

James Hazen, Technical Advisor, Nutrition Division (Note: He will be out of the country 

during informant interviews, but has offered to communicate with the team by email if needed.) 

Roy Miller, Washington Bureau for Africa, Sustainable Development 

IYCN ZAMBIA 

Kali Erickson 

PATH 

Denise Lionetti, Project Director, Infant and Young Child Nutrition 

Altrena Mukuria, Country Program Specialist 

Tom Schaetzel 

THE WORLD BANK 

Richard Seifman 

Jessica Tilahun, Research and Program Coordinator, Monitoring and Evaluation Specialist 

FANTA-2 

Monica Woldt, MCHN Advisor 


KEY INFORMANT INTERVIEW SCHEDULE 

1.395 Zambia Integrated Nutrition Framework Development 

Time Contact Affiliation 

8:30 

9:30– 

11:00 

Richard 

Seifman 

World Bank 

Interview 

Location 

Monday, October 18 

Starbucks near 

World Bank- call 

when you arrive 

at World Bank 

Notes 

Prefers to meet outside the 

Bank to avoid security process. 

Erika Lutz GH Tech GH Tech GH Tech Orientation Meeting 

12:30 

3:00 

4:30 

10:00 

Roy Miller 

USAID/W 

Bureau for 

Africa/ SD 

Malia Boggs USAID/ W/ 

GH/ HIDN/ 

NUT 

Jessica 

Tilahun 

Denise 

Lionetti, 

Tom 

Schaetzel, 

Altrena 

Mukuria 

Global Food 

and Nutrition, 

Inc. 

PATH/ IYCN 

RRB 3.7.1 

RRB 3.7.1 

TBD 

PATH/ IYCN 

12:00 Kali Erickson IYCN Zambia GH Tech 

3:30 

Monica 

Woldt 

FANTA -2 

AED 

Call Roy or Kaitlyn Patierno 

for escort 

Tuesday, October 19 

2:35 PM— Flight departs Washington Dulles 

Wednesday, October 20 


ANNEX C. ZAMBIA NUTRITION FRAMEWORK 

Target 

groups 

Women of 

Reproductive 

Age (WRA ) 

At risk Subgroups 

Food 

insecure 

households 

Nutrition 

Problems 

Iron def. 

anemia 

High likelihood 

of other 

micronutrient 

deficiencies 

Immediate 

and 

Underlying 

Determinants 

Insufficient iron 

in diet 

Lack of dietary 

diversity 

Low intake of 

animal source 

foods (protein, 

zinc, iron 

calcium, B12) 

Interventions Indicators GRZ Programs 

Essential Nutrition 

Actions 

Increase quality 

and quantity of 

diet through food 

and nutrition security 

pack and other 

agriculture actions 

Lighten women‘s 

labor burdens 

through access to 

technology for food 

production, 

harvesting, 

processing and 

preservation 

Women‘s 

Dietary 

Diversity as a 

measure of 

micronutrient 

adequacy 

BMI 

—National 

Agriculture Policy 

—National Food 

and Nutrition 

Policy and 

Implementation 

Plan 

◦National Nutrition 

Strategy in process 

—New 

Community Health 

Worker Strategy 

—Essential 

Nutrition Package 

of Care in the 

Health Sector 

Partner 

support 

ZISSP : 

strengthening 

health and 

nutrition 

services at 

health facilities 

and community 

level 

BCC 

WVI 

Gaps 

No systematic 

way of 

working with 

women‘s 

groups or 

providing 

micro-credit 

Nutrition care 

and support in 

health care 

systems 

inadequate 

(poor M & E) 

Promotion of 

adequate birth 

spacing 

Pregnant 

Women 

Underweight 

women 

Pregnant 

adolescents 

Food 

insecure 

households 

(BMI < 18.5) 

Maternal 

mortality ratio 

(MMR) 591 

Anemia 

Same as above 

Antenatal care, 

micronutrient 

supplementation and 

other preventive and 

curative health and 

nutrition services 

Women‘s 

Dietary 

Diversity as a 

measure of 

micronutrient 

adequacy 

BMI 

Weight gain 

MCH 

Iron/folate 

supplementation 

CARMMA 

Use of BMI 

for targeting 


Target 

groups 



Problems 

Immediate 

and 

Underlying 

Determinants 


Birthweights 

Partner 

support 

Gaps 

Day time rest 

Adequacy of 

food intake 

Lactating 

women 

Newborns 

Food 

insecure 

households 

Low 

birthweight 

Target 

groups 



Problems 

Immediate 

and 

Underlying 

Determinants 


Partner 

support 

Gaps 

starting at 6 

months 

Children of 

HIV+ 

mothers 

death at this 

age, especially 

if undernourished 

of dietary 

diversity 

Behavior change 

services targeted to 

caregivers/families/ 

communities for 

adequate 

complementary 

feeding practices 

consuming at 

least 3 foods 

at last meals 

Child feeding 

adequacy 

score 

Adolescent 

girls 

In-school 

girls, plus 

out-of-school 

girls from 

food insecure 

households 

Iron deficiency 

anemia 

Lack of dietary 

diversity 

Increase 

nutritional 

requirement 



adolescent girls and 

their families to 

assure adequate 

micronutrient intake, 

plus counseling on 

reproductive health, 

women‘s rights and 

infant requirements 

BMI 

SHN for ―in 

school‖ 

adolescents in 

selected schools 

Education for all 

policy 

No program 

at present for 

out of school 

adolescent 

girls who are 

most 

vulnerable 

Rural poor 

farming 

households 

Food 

insecure 

households 

HIV affected 

households 

High stunting 

among 

children 

resulting 

from 

combination 

of inadequate 

food intake, 

inadequate 

dietary 

diversity and 

infection, 

resulting in 

part from 

hygiene and 

Lack of land 

and/or 

agricultural 

inputs 

Lack of 

adequate 

formal 

education 

Household 

food insecurity, 

inadequate 

caring 

practices, 

inadequate 

Food and nutrition 

security pack 

Upgraded CHW 

training program 

with intensified 

counseling 

responsibilities 

Incorporation of 

WASH activities in 

health sector 

services 

Number of 

meals per 

day 

water 

quality 

testing 

Behavior 

change 

adoption 

Resilience 

% reduction 

CAADP 

Compact 

MACO including 

FRA 

GART 

CDT 

ZEGA 

ACF 

GRZ/MCDSS 

FAO 

Norwegian 

Embassy 

JICA 

USAID - 

PROFIT 

MATEP 

FSRP 

Land ‗O‘Lakes 

ZATAC 

ZACA 

ACF 

Micro-credit 

schemes 


Target 

groups 


Urban poor Children 

who are not 

breastfed 

Children not 

fed 

complement 

ary foods 

starting at 6 

months 

Children of 

HIV+ 

mothers 


Problems 

sanitation 

problems 

low BMI for 

women 

High risk of 

infections and 

wasting 

High 

mortality 

Immediate 

and 

Underlying 

Determinants 

health facilities, 

poor hygiene 

and sanitation 

Food insecurity 

(poor quality 

and quantity) 

Unsafe water 

sources 

Lack of user 

fees for health 

facility 

attendance 

Lack of 

adequate 

education for 

mothers 

lack of 

information 

systems 


Urban agriculture 

Cash transfer 

improved water 

supplies 


education and 

health promotion 

income generating 

activities 

micro-credit 

schemes 

in diarrhea 

prevalence 

Number and 

types of 

communicati 

on materials 

available 

Number of 

meals per 

day 

water 

quality 

testing 

Behavior 

change 

adoption 

Resilience 

% reduction 

in diarrhea 

prevalence 

number and 

types of 

communicati 

on materials 

available 

DFID-supported 

Social Cash 

Transfer program 

Partner 

support 

C-FAARM 

WFP – 

SPLASH card 

Gaps 

Land for 

urban 

agriculture – 

to be 

negotiated 

with local 

councils 

Farming 

groups or 

associations 


Target 

groups 



Problems 

Immediate 

and 

Underlying 

Determinants 


Partner 

support 

Gaps 

HIVaffected 

households 

Children 

who are not 

breastfed 

Children not 

fed 

complement 

ary foods 

starting at 6 

months 

Stunting, 

underweight, 

wasting 

Micronutrien 

t deficiencies 

Food insecurity 

Dietary 

monotony 

lack of 

agricultural 

labor 



caregivers/families/ 

communities for 

adequate 

complementary 

feeding practices 

food 

security 

BMI for 

affected 

women and 

men 

Stunting for 

children 

NAC, NFNC, 

MOH 

UNAIDS 

CDC, USAID 

Children of 

HIV+ 

mothers 

HIV+ adults 

with severe 

and 

moderate 

acute 

malnutrition 

diversity and 

frequency of 

infant and 

child feeding 

consistence 

of 

complement 

ary feeds 



ANNEX D. STUNTING IN ZAMBIA: CAUSES, CONSTRAINTS AND PROPOSED STRATEGIES 

AND INTERVENTIONS 

Household Food Insecurity 

Inadequate Health Facilities, Water and 

Sanitation 

Inadequate Caring Practices 

Causes 

Continual or episodic lack of 

sufficient food in the household to 

meet dietary needs of family 

members, especially those with 

high nutrient needs: children 

under 2 years and pregnant and 

lactating women, and adolescent 

girls 

Frequent illnesses, including chronic 

high incidence of gastro-intestinal 

infections in children (diarrhea, 

parasites, etc.) caused by lack of 

sanitation in household 

Women and men lack 

understanding of importance of 

nutrition and optimal infant and 

young child feeding practices 

(adequate caloric and nutrient 

density and frequency of 

feeding, etc.) 

Multiple micronutrient deficiencies 

Constraints 

Low productivity and production 

of staple crops, other crop types, 

fruits and vegetables 

Seasonal shortages 

In some areas and seasons 

monotonous diets based on low 

value carbohydrates (nshima, 

cassava, etc.) 

Lack of sufficient income to 

purchase needed food 

Women‘s decision making limited 

concerning agricultural and other 

household resources 

Micronutrient rich foods are not 

appreciated and grown in sufficient 

quantities and variety 

Water sources often far in rural areas 

& may be poor quality, so water for 

hygienic practices is constrained 

(limited water quantities encourage 

recycling and therefore contamination) 

Inadequate sanitation facilities in rural 

and poor urban areas 

Health facilities are often far away and 

transport is expensive or non-existent 

resulting in visits for health care only 

for acute illness 

Poor attitude of health workers 

Mothers have limited time for child 

care due to high work loads in food 

production, processing and 

preparation 

Nutrition information and 

education not reaching rural 

families 

Illiteracy among women* 

Limited time for practicing 

recommended child feeding 

behaviors 

Materials and capacity for 

nutrition messages inadequate 

for reaching target groups 




Sanitation 


High cost of foods especially 

animal source foods 

Limited utilization of wild 

biodiversity 

Inadequate knowledge of 

recommended feeding practices and 

care for sick children 

Inadequate knowledge and practice of 

good hygiene 

Strategies 

Work with agricultural agents and 

programs to improve quality and 

quantity of diet through increasing 

production of diverse crops and 

availability of nutritious food 

Increase extension and veterinary 

services to farmers to promote 

more large and small livestock and 

fisheries and consumption by 

family members of dairy and other 

animal products 

Use rural radio to disseminate 

messages about nutrient dense 

food commodities and dietary 

diversity 


sanitation and hygiene messages 

Increase knowledge and skills of 

community health workers to convey 

disease prevention, sanitation and 

hygiene messages 

Increase investments in safe water 

provision and improved sanitation 

facilities 

Strengthen application of 


(ENA) within the health system 

Support community health 

workers to expand community 

nutrition programs, including 

growth monitoring and 

promotion 

Develop and diffuse labor 

saving technologies for food 

processing and preparation 


messages to parents on infant 

and young child nutrition as 

well as the importance of good 

nutrition for pregnant and 

lactating women 




Sanitation 


Strategies 

Work with agricultural agents and 

programs to improve quality and 

quantity of diet through increasing 

production of diverse crops and 

availability of nutritious food 

Increase extension and veterinary 

services to farmers to promote 

more large and small livestock and 

fisheries and consumption by 

family members of dairy and other 

animal products 


messages about nutrient dense 

food commodities & dietary 

diversity 


sanitation & hygiene messages 

Increase knowledge and skills of 

community health workers to convey 

disease prevention, sanitation and 

hygiene messages 

Increase investments in safe water 

provision and improved sanitation 

facilities 

Strengthen application of 


(ENA) within the health system 

Support community health 

workers to expand community 

nutrition programs, including 

growth monitoring and 

promotion 

Develop and diffuse labor 

saving technologies for food 

processing and preparation 


messages to parents on infant 

& young child nutrition as well 

as the importance of good 

nutrition for pregnant & 

lactating women 

*Education and wealth are both inversely related to stunting levels. Stunting decreases with increasing levels of mother‘s education. For 

example, ZDHS 2007 data show that children born to mothers with primary level education are more likely to be stunted (49%) than 

children born to mothers with more than secondary education (21%). 



For more information, please visit: 

http://resources.ghtechproject.net

Global Health Technical Assistance Project 

1250 Eye St., NW, Suite 1100 

Washington, DC 20005 

Tel: (202) 521-1900 

Fax: (202) 521-1901 

www.ghtechproject.com

USAID/Zambia: Integrated Nutrition Investment Framework--Overview

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