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					        MOTHER AND CHILD HEALTH:

   A REVIEW OF THE DEVELOPMENT PROJECT
“NUTRITIONAL SUPPORT TO VULNERABLE GROUPS
   IN THE FIVE EASTERN PROVINCES” IN CUBA


            27 January – 4 February 2007


                 Nina Kolbjornsen
                   Edith Heines




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The Mission
The Mission took place from 27 January until 4 February 2007. Members of the
mission were Edith Heines (Gender, Mother and Child Health Service, PDPG, Rome)
and Nina Kolbjornsen (Nutrition Service, PDPN, Rome).
The objective of the mission to Cuba was to collect information and learn from the
development project (DEV 10032.0) “Nutritional Support to Vulnerable Groups in the
Five Eastern Provinces”.

Four days were spent in Havana in meetings with WFP project staff, relevant
Government staff and the Women’s Federation. Centres close the Havana were
visited. One day was spent in Holguin province in the east of the country. Meetings
with relevant Government staff were held and WFP-supported centres were visited.
The schedule of the mission is attached in Annex 1.

The Mission would like to thank the WFP Havana office for their help and assistance
in planning and conduction the Mission. We would especially like to thank Ivette
Suarez and Gabriela Hernandez.

Background
Cuba is an archipelago of islands located in the Caribbean Sea, with a population of
some 11 million people and a GNP of some 33 billion US$. Ranking 52nd on the
human development index with a life expectancy at birth of 78 year and a under 5
mortality rate, per 1000, of 6, Cuba is one of the better off countries in Latin America.
The Cuban Government adheres to socialist principles in organizing its largely state-
controlled planned economy. Most of the means of production are owned and run by
the government and most of the labor force is employed by the state. Recent years
have seen a trend towards more private sector employment. By the year 2000, public
sector employment was 77.5% and the private sector at 22.5%, compared to the 1981
ratio of 91.8% to 8.2%. Cuba's major exports are sugar, nickel, tobacco, fish, medical
products, citrus, coffee and skilled labor; imports include food, fuel, clothing, and
machinery.

Despite high achievements in human development such as free health care, free
education for all, and a social welfare system, Cuba still faces challenges in meeting
its development goals due to trade restrictions, the need for higher rates of foreign
investment, and a limited domestic economy. Cuba experienced a period of austerity
and hardship in the early 1990s when the Soviet Bloc was dismantled, resulting in a
35-percent loss in the Cuban gross domestic product. To address the crisis, the Cuban
economy was restructured and gradually opened to the international market economy
through new foreign joint ventures in tourism, mining, and oil and gas production.

As a result of the 1989 fall of the socialist countries, and due to the tightening of the
US blockade, an economic depression led Cuba to a true crisis notably affecting the
food and nutrition sector. On the one hand, there was a decrease of food availability,
which resulted in the lowest statistics regarding the food energy supply (i.e. 1863
Kcal per capita), according to the National Statistics Office. On the other hand, there
was a qualitative change of the Cuban diet. While carbohydrate consumption
increased protein and fat decreased considerably. As of the beginning of the years




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1992-95, a gradual recovery of the food situation has been observed which reached
the 2,610 kcal mark, according to FAO statistics1 in the year 1999-2000.

Concerning food and nutritional habits, national surveys which have assessed the risk
factors for the Cuban population between the years 1995 and 2001 show the
following: little variety of foodstuffs, excessive sugar consumption (with values of
over 15% of the total energy intake), low consumption of whole cereals, fish,
vegetables and fruits, inadequate balance of energy in the meals. These eating habits
put a lot of Cubans at risk for chronic and generative diseases.

In 1999/2000, the WFP together with Cuba’s Institute for Physical Planning
conducted a VAM (Vulnerability Assessment and Mapping)2 study, which identified
the five eastern provinces (Holguín, Las Tunas, Granma, Santiago de Cuba and
Guantánamo) as the most food insecure and prone to natural disasters.

Children between 6 and 24 months old are highly affected with anaemia (48-68 %),
but the most affected sub-group are infants of 6 to 12 months with a prevalence of 34
to 78 %. In comparison, primary school children between 6 and 12 years of age show
lower anaemia levels, i.e. between 19 and 27 %.

Anaemia prevalence in different age groups in the eastern provinces (INHA 2005)

    Provinces                         6-24 months (%)         6-12 months (%)            6-12 years (%)
    Las Tunas                               48.5                    34.0                      21.4
    Granma                                  58.8                    65.2                      18.8
    Santiago de Cuba                        68.2                    78.3                      27.4
    Holguín                                 55.6                    69.2                      14.3
    Guantánamo                              64.4                    68.1                      19.2

Between 25 and 35 percent of women of reproductive age are anaemic, while 23.2
percent (ranging from 20 to 25 percent) of pregnant women have anaemia. Anaemia
in pregnant women reduced from 57 percent in 1992, to 28 percent in 2002, to its
current 23 percent.

In 1995, the process of distributing iodized salt began as part of the UNICEF - Cuba
Programme of Cooperation. In 2002, 100 percent of the salt produced for human
consumption was iodized. In 2005, Cuba was declared an iodine deficiency disorder-
free country.

Public distribution system
In Cuba, basic food items are provided to the general population at subsidized prices
through a public distribution system. Each household has a booklet specifying the
ration per food commodity. Distributions are carried out on a monthly basis, except
for bread which can be purchased daily and milk which is distributed three times a
week.

1
  The state of Food Insecurity in the World 2003 (www.fao.org/docrep); See also Perfiles de nutrición de
los países de la FAO para Cuba; y Hernandes. M. Jiménes. S.; Placencia. D.; Diaz. J. Situación de la
Alimentación y Nutrición en Cuba. Havana. 2004
2
         IFP-WFP. Vulnerability Map of Cuba. Havanna, 2001


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In addition to the basic food, special food commodities for vulnerable groups
(pregnant and lactating women, young children, elderly, disabled and chronically ill)
are provided.

The Government supplies all education and health institutions with food and other
commodities.

Public health sector
Cuba has a unique Public Health System which is free of charge for the whole
population. Primary health care consists of a network of professionals and
technicians, working closely with the family doctors. Family doctors are based at
municipality level in both urban and rural areas. Medical attention is also available in
schools, day-care centres and in large enterprises. There are policlinics in each
municipality. Hospitals are available at provincial level.

The Government has a comprehensive strategy with the objective to reduce
infant/child and maternal mortality, anaemia in children <5 and PLW, and low birth
weight. Activities include:
 Establishment of Maternity Homes for high risk pregnant women
 Screening of anaemia among children under 5 and PLW
 Establishment of a food and nutrition surveillance system (see below for details)
 Promotion of exclusive breastfeeding
 National iodine salt fortification programme
 Fortified milk for <1 year olds
 Fortification of all wheat flour
 “Prenatal”, i.e. a supplement of iron, folic acid, vitamin A and C for pregnant
    women (free of cost)
 “Muffer”, i.e. a supplement of iron and folic acid for women of reproductive age
    (started January 2007 – at a highly subsidized price)
 “Forferr”, i.e. a supplement of iron and folic acid for children 6 – 60 months (at a
    highly subsidized price)
 Fortified fruit compote (iron and vitamin C) for children 6 – 36 months (at a
    highly subsidized price)
 Nutrition education on the importance of a balanced diet during and after
    pregnancy and a healthy family diet
 Provision of IEC materials on the education messages provided and guidelines on
    nutrition education methodology for institutions
 Training and refresher training for health staff
 Collaboration with the Women’s Federation of Cuba to increase the coverage and
    outreach of the education component

Almost all deliveries of babies take place in a hospital.

Food and Nutrition Surveillance Systems
The Food and Nutritional Surveillance System (SISVAN) was established in 1977
and consists of the following, implemented in the different health institutions:




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1. In educational institutions: food consumption.
   Kcal in relation to RDA: intake below 90% is inappropriate and below 70% is
   critical.
2. Health institutions: food availability (delivery of food at warehouses, frequency of
   food consumption) and quality (cut-off for energy, protein and fat is 90% of the
   RDA); nutritional status (cut-off for W/H is below 10 percentile and for BMI
   below 18.5).
3. Mother and child health nutritional status:
   For women: W/H at beginning of pregnancy (cut-off below 19.8), weight gain at
   end of pregnancy (cut-off is below 8 kg), anaemia during first and third trimester
   of pregnancy (Hb less than 110 g/l).
   For children under 5: W/H (under 3rd percentile is malnourished, between 3rd and
   10th percentile is slender)

The information obtained in the polyclinics, schools and health institutions are sent to
the municipal and provincial monitoring units. This flow of information ends up in the
Nutrition and Food Hygiene Institute, INHA, for final use and interpretation.

WFP’s development project (10032.0) “Nutritional Support to
Vulnerable Groups in the Five Eastern Provinces”
As mentioned above, the Government has a comprehensive strategy to address
maternal and child mortality, and anaemia. WFP’s assistance should be seen as part of
this overall strategy.

Long-term objective:
   To contribute to the improvement of the nutritional situation of vulnerable
   groups, pre-primary and primary school children in the five most vulnerable
   provinces of Cuba.

Short-term objectives:
    To contribute to the improvement of the nutritional status and the reduction of
        anaemia in expectant and nursing mothers and children under the age of two in
        the targeted areas.
    To help people to relieve the short-term hunger and increase the learning
        capacity of students of pre-primary and primary levels.
    To contribute to the promotion of nutrition, health and sanitary education in
        health centres and schools.

Targeting
Following the 1999/2000 VAM study, it was decided that WFP would provide
assistance in the five eastern provinces.

Beneficiaries and food rations:
Because of the political system in Cuba, there is a blanket food distribution for each
targeted beneficiary group.

The beneficiary groups and food rations are summarized in the table below.




                                                                                         5
                                     Daily food ration (gram)        Distribution
Beneficiary group
                                       (planned for 2007)            mechanism
Pregnant and lactating           -   Vegetable oil 20 gram           PDS
women

Children 6 -59 months            -   CSB 18 gram                     PDS


Patients in health institutes:   -   Vegetable oil 20 gram           On-site
mother homes, homes for          -   Milk powder 20 gram
elderly and disabled
Students in full-time            -   Milk powder 32 gram             On-site
boarding schools (primary)       -   Fortified biscuits 30 gram
                                 -   Vegetable oil 20 gram
Students in part-time            -   Milk powder 25 gram             On-site
boarding schools (primary)       -   Lactosoy 25 gram (WFP
                                     provides 9 of 21 days –
                                     local product)
                                 -   Fortified biscuits 30 gram
                                 -   Vegetable oil 10 gram
Students in regular primary      -   Lactosoy 25 gram                On-site
schools                          -   Fortified biscuits 30 gram

Children 1-5 years in day-       -   Vegetable oil 10 gram           On-site
care centers


Distribution system
The Ministry of Domestic Trade (MINCIN) is responsible for receiving the food
commodities in the port of Santiago de Cuba, and transporting it to the provinces. In
coordination with the education and health sectors, MINCIN is responsible for: i) the
delivery of commodities in warehouse of the recipient health and education
institutions; and ii) the distribution of food rations through its regular outlets to the
beneficiaries who are not in health institutions.

MINAL, through its local factories, is responsible for processing the necessary
fortified products. The cost of these products is less than similar imported
commodities, since the Government of Cuba covers the cost of production.

Monitoring
The Government ensures data collection at municipal, provincial, and central levels.
Since the health, education, domestic trade and food industry sectors have established
procedures for the handling and control of food resources, these same procedures and
instruments are utilized.

WFP monitors warehouses, beneficiary numbers, food and non-food deliveries to
partner institutions.



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In each of the five province assisted, WFP has a sub-office shared with other UN
representatives such as UNDP, UNICEF and WHO, with one staff member who acts
as the food monitor. He/she monitors the food distribution and assistance provided at
the institutions.

At provincial level, a monthly meeting is held with the Provincial Project Committee
to discuss the implementation of the project. Specific problems are discussed and
actions proposed.

Outcome indicators
 Percentage of food norms of beneficiaries satisfied by the complete ration they
   receive.
 Percentage of food norms satisfied by the complementary ration distributed by
   WFP.
 Percentage of pregnant mothers living in homes consuming a diet that contains
   less than 70 percent of the recommended allowance of proteins and fats.
 Percentage of maternity homes where hygienic practices are applied in the
   preparation of food.
 Index of body mass (weight/height) of beneficiaries at the beginning, middle and
   end of the project.
 Index of low weight at birth and weight gain in pregnant mothers, measured
   through control points.
 Percentage of pregnant mothers and mothers who have been nursing up to six
   months with anaemia.
 Percentage of children under the age of two with anaemia.

Data for the nutrition indicators are obtained through the nutrition surveillance system
mentioned above.

Nutrition education
WFP, in collaboration with the INHA, developed a capacity manual on food, nutrition
and hygiene education. A poster and leaflet on healthy diets for the population over
the age of two was produced. The manual was distributed to all health and educational
institutions.

Findings and recommendations
Strength of the MCH project
 The set-up of the MCH project is very comprehensive. It covers aspects of health,
    nutrition, prevention and education.
 The strategy used is multisectorial and covers all relevant factors: i.e.
    supplementation, fortification, food diversification and a surveillance system.
 Collaboration with the Women’s Federation of Cuba and other local groups
    increases the coverage and outreach at community level.
 In the areas visited, the implementation of the activities was sound, with monthly
    meetings of all parties involved.
 Human capacity is available with well trained and highly educated staff that are
    committed to their work.
 Overall, the project has good coverage and outreach, with institutions at
    Provincial and Municipality level.



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   Data on Low Birth Weight and mortality are available nation-wide and are very
    good MCH indicators. It would be useful if these data, at provincial and
    municipality level, could be reported on.
   Fortified CSB is a good vehicle for iron (to address iron-deficiency anaemia). A
    bigger ration (currently 18 gram) could be considered to provide more
    micronutrients. CSB is also a good food to encourage good feeding practices for
    complementary feeding.

Challenges of the MCH project
 Implementation: The system in place is comprehensive, but only functions as it is
   intended if all people involved understand it fully and work well. It needs to be
   ensured that people remain motivated.
 Supply: The set-up will yield results if all necessary supplies (supplements, food,
   etc.) are available everywhere and at all times.
 Coverage of health institutes/centres: The need still exceeds the availability in
   many places.
 Coordination and consistency of education messages between all parties (e.g.
   Government, UNICEF, WFP) needs to be ensured.
 Refresher training at all levels is a constant requirement (e.g. change from 4 to 6
   months exclusive breastfeeding has not trickled down to most staff at
   (sub)provincial level.).
 Warehouse management needs to be ensured to reduce food losses to <1%.
 Fortification levels of CSB need to be optimal. Specific problems to be identified
   and addressed (e.g. supply, training level, accurateness of staff etc.).
 Due to heavy reliance on Government systems, monitoring of the project is rather
   weak. Monitoring capacity of WFP is very limited, with only one food monitor
   per province. WFP is planning to strengthen their M&E system for the new
   development project due to start in 2008.
 Good results on mortality and LBW have been achieved, whereas anaemia –
   especially in children – remains a problem. Over the next period, anaemia in
   young children requires special attention. The critical age group is 6 months and
   above.
 Education on health and nutrition is an important part of the MCH project.
   Anecdotal evidence of the success is available. A comprehensive evaluation
   looking at knowledge and practices at household level would measure actual
   impact and could serve to further improve this component.
   Before starting any new activities on education, a Knowledge Attitude Practices
   (KAP) study should be carried out to establish a baseline. The impact/success can
   than be measured with a follow-up KAP study.
 Messages on a diversified diet, i.e. including vegetables, fruit and meat, are
   provided to the whole population and through different channels. In discussions
   with people, it was regularly mentioned that access to these food items is an issue
   due to relatively high cost. This has to be taken into account when addressing this.
 Although information on nutrition and health, focusing especially on food and
   eating habits, of young children is available at present, it does not stand out.
   Information materials (e.g. handouts, posters) in non-technical, easy to understand
   language should be developed and made available for the whole population (i.e.
   not only in health institutions)



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Suggestions for future collaboration between the Government of Cuba and WFP
WFP is an agency that provides all its assistance through food aid. Therefore, an
analysis is required to show that this type of aid is required because to lack of access
to food. Data at provincial level will be needed to describe the situation and needs.

Most health and nutrition indicators are at the level of a developed country and do not
justify a WFP intervention. Therefore, the focus should be on what is currently an
issue in the country, i.e. anaemia in young children.

Any WFP programme will have to be integrated into the overall strategy to address
health and nutrition of the target group. WFP assistance should be one aspect of a
package of services provided by different partners, e.g. to address anaemia in young
children.

Concrete activities to be considered:
(i) Support to local production of CSB. This could include:
- technical assistance
- vitamin/mineral premix
- assistance in quality control (production process, end product, fortification levels)

(ii) IEC materials and training (TOT) on CSB and complementary feeding practices

(iii) Continued training/capacity building in warehouse management to reduce food
losses.

(iv) Priority target groups:
- Pregnant and lactating women
- Children 6 – 59 months of age. If there are resource constraints, it could be
considered to cover children from 1 year onwards only, since the children < 1 year
received fortified milk from the Government.

These groups should receive food through the Public Distribution System in order to
reach those that are not in institutions.

(v) Food commodities:
- CSB is recommended for the 6-59 months children.
- From the nutrition point of view, CSB would be a good food commodity for PLW.
However, the Government voiced their concern that it might not be accepted by this
target group because if differs from the local eating habits.
- If other food commodities should be considered, substantial data to support the need
(lack of availability and access), including cost-effectiveness must be available to
support this.




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ACRONYMS USED IN THE DOCUMENT

BMI      Body Mass index
CNPES    Centro Nacional para la Promocion de la Educacion de la Salud
         (Nacional Centre for the Promotion of Health Education)
CSB      Corn Soya Blend
FMC      Federacion de Mujeres Cubanas (Women’s Federeation of Cuba)
INHA     Instituto de Nutrition e Higiene de los Alimentos (Institute of Nutrition
         and Food Hygiene)
KAP      Knowledge Attitude and Practice
MCH      Mother and Child Health
MINAL    Ministerio de la Industria Alimenticia (Ministry of Food Industry)
MINED    Ministerio de Educacion (Ministry of Education)
MINCIN   Ministerio de Comercio Interior (Ministry of Domestic Trade)
MINSAP   Ministerio de Salud Publica (Ministry of Public Health)
MINVEC   Ministerio de Inversion Extranjera y de Colaboración (Ministry of
         External affaire and Collaboration)
MOH      Ministry of Health
PDS      Public Distribution System
PLW      Pregnant and Lactating Women
SISVAN   Food and Nutritional Surveillance System
W/H      Weight for height




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Annex 1
               Schedule: Mother and Child Health Field Mission to Cuba
                            27 January – 4 February 2007

Sunday, 28 January 2007
                             Arrival in Havana
Monday, 29 January 2007
9 - 10 am                    Briefing at WFP Country Office
10 – 11 am                   Meeting with Ministerio de Inversion Extranjera y de Colaboración
                             (Ministry of External affaire and Collaboration) (MINVEC)
11.30 am – 12.30 pm          Working sessions with institutes of Ministerio de Salud Publica
                             (MINSAP – Ministry of Public Health):
                             - Directorate of the MCH programme
                             - Institute of Nutrition and Food Hygiene (INHA)
                             - National Centre for the Promotion of Health Education (CNPES)
12.30 – 1.50 pm              Lunch
2 – 5 pm                     Continuation of the working sessions with institutes of MINSAP

Tuesday, 30 January 2007
9 – 11.30 am                 Meeting with the Directorate of the Ministry of Education (MINED)
                             and visit a Day-Care Centre
11.30 – 12.30 am             Meeting with the Directorate of the Federacion de Mujeres Cubanas
                             (FMC – Women’s Federation of Cuba)
2 - 4 pm                     Discussion with WFP staff
6 pm                         Departure for Holguin province

Wednesday, 31 January 2007
8.45 am                      Courtesy visit to provincial MINVEC office
9 am                         Meetings with the Provincial Project Committee and the Ministry of
                             Public Health (MINSAP)
10 am                        Visit a home for the prevention of low birth weight
10.45 am                     Visit a Maternity Home
11.30 am                     Visit a family doctor
12.15 am                     Visit a centre for the promotion and education of the family
1 pm                         Lunch
2.30 pm                      Visit a semi-boarding school
3.30 pm                      Visit a day-care centre
10 pm                        Departure for Havana

Thursday, 1 February 2007
1- 5 pm                      Visit health institutions in Havana municipality

Friday, 2 February 2007
9 – 12 am                    Debriefing at WFP Country Office
1.30 – 3 pm                  Debriefing at the Ministry of Public Health

Sat. & Sun, 3-4 February
2007
                             Report writing and departure
                             Depart for airport



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