The presentation outlines a project proposal aimed at capacity building in health and nutrition for Timor-Leste, developed through extensive consultation with the Ministry of Health, development partners, NGOs, and civil society. The primary objective of the project is to enhance the nutritional status of women and children who are particularly vulnerable to malnutrition. The project proposal comprises four key areas that address the capacity gaps identified through stakeholder consultations and documented in published reports and strategies. By providing additional support and interventions, as well as strengthening existing structures, the proposed interventions would help to improve the nutrition status of children and women. The proposal further suggests that the capacity of Integrated Community Health Services (Sisca) could be enhanced to improve rural health services. Such improvements would help to address the existing disparities in health outcomes between rural and urban areas in Timor-Leste. Through the proposed interventions, the project aims to support the overall development of the health and nutrition sector in Timor-Leste. By addressing the identified capacity gaps, the project would help to build sustainable systems that can deliver effective health and nutrition services to the population. In conclusion, the presentation explains a comprehensive project proposal that aims to improve the nutritional status of vulnerable women and children in Timor-Leste. The proposal is based on extensive consultation with stakeholders and would address capacity gaps identified through published reports and strategies. Through this project, it would be possible to enhance rural health services by strengthening the capacity of Integrated Community Health Services (Sisca) and supporting existing structures. Ultimately, the proposed interventions would contribute to the development of sustainable health and nutrition systems in Timor-Leste.

1. Consultation Meeting on
Capacity Building in Nutrition
Programmes in Timor-Leste
Dr. Kazuko Yoshizawa
Consultant for WHO Timoer-Leste
Consultation Meeting
August 11th, 2016

2. Organizations Consulted
Embassy of Japan,, MoH: National
Directorate of Public Health,
Departments of Nutrition, Surveillance
and Epidemiology, Institute of National
Science, Dili Hospital, DHS, Comoro
CHC, DFAT, Centro CHC, UNICEF,
WFP, FAO, UNFPA, Ministry of
Agriculture, Dept. of Industry of MCIE,
SHARE, ALORA Foundation, JICA

3. The 2030 Sustainable Development Goals
(SDGs)
• In 2015 countries adopted the 2013 Sustainable Development Goals
(SDGs), a set of 17 goals to end poverty, protect the planet, and
ensure prosperity for all as part of a new sustainable development
agenda.
• Goal 2: End hunger, achieve food security and improved nutrition
and promote sustainable agriculture.
• The National Nutrition Strategy 2014 – 2019 aims to achieve the
following three outcomes:
1. Increased coverage of nutrition specific intervention
2. Increased coverage of nutrition sensitive intervention
3. Enabling national policies, programmes and coordination
mechanism

4. Human Development Index
•Timor-Leste ranks 133 out of 188
countries in the Human Development
Index (HDI), placing it in the medium
human development category.6 Between
2000 and 2013, the HDI increased by
33.4%.
(Explanatory note on the 2014 Human Development Report composite
indices, UNDP, July 2014)

5. • Under-5 child mortality remains high at
64/1000 live births.
• HMIS data for the year 2010 show that
leading causes of under-5 deaths include
pneumonia (15%), diarrhoea (5%) and
malaria (3%).
• The causes of approximately 76% of
under-5 deaths are unknown and are
classified as ‘others’.
• Wide variations in rates between rural
and urban areas and across income
quintiles.

6. Proportional mortality (distribution of total deaths,
all ages, both sexes)
WHO, Non-communicable Diseases Country Profiles, 2014

7. •An estimated 45 percent of deaths of
children under age 5 are linked to
malnutrition (Black et al. 2013).

8. Achieving nutrition’s full impact on health and
development outcomes requires a multi-sectoral
approach

9. SGDs and Sensitive Indicators
THE NEW CHALLENGE: END ALL FORMS OF MALNUTRITION BY 2030,
Global Nutrition Report 2016

10. Proposed Nutrition Programmes
1. Strengthening capacity in the management of severe acute
malnutrition in infants and children.
2. Update of evidence-based guideline on management of
severe acute malnutrition
3. Strengthening nutrition surveillance.
4. Capacity building on anthropometry for the WHO new
growth standards, and supplementary feeding programme
for moderate acute malnutrition.
5. Project implementation by use of multifactorial approaches
and strengthening of partnership. Community based
programmes of breast feeding and complementary feeding,
and nutrition education at school are emphasized.

11. 1. Strengthening capacity in the management
of severe acute malnutrition in infants and
children.
• Output: Institutional capacity of the Government ant national and
district levels, and community levels strengthened to implement
management of sever acute malnutrition.
• Indicator: Case fatality rate to less than 5％. Improved rate of
recovery of severely malnourished children.
• Means of Verification: Capacity development assessment, and annual
semiannual progress reports.
• Assumption/Threats: Assumption: The project proposal is prepared
with potential financial support from the Japanese Government.WHO
will continue to support MoH, and collaborate with partners.

12. 2. Update of evidence-based guideline on
management of severe acute malnutrition
• Output: Case fatality rates have decreased to below 5% in
treatment centres applying at the national government hospital.
Improvement of the case fatality rate at CHC.
• Indicator: Set-up of a working group to prepare updated
guideline. Number of WG meeting held. Final Draft Guideline
is in place. The working group will be led by Department of
Nutrition, MoH. Member of the WG will consist of MoH and
the partners.
• Means of Verification: Capacity Development Assessment and
Annual Progress Reports.
• Assumption/Threats: WHO will continue to support MoH, and
collaborate with partners.

13. 3. Strengthening nutrition surveillance.
• Output: Several nutrition indicators are included in the
currently existing communicable disease surveillance in
reporting system.
• Indicator: Number of workshop held. Number of health
workers attended. Department of Nutrition submits a minimum
set of nutrition data to Department of Surveillance and
Epidemiology on weekly basis, for the currently existing
communicable disease surveillance.
• Means of Verification: Capacity Development Assessment and
Annual Progress Reports
• Assumption: This project proposal is prepared with potential
financial support from the Japanese Government.

14. 4. Capacity building on anthropometry for the WHO
new growth standards, and SFP for MAM.
• Output: Anthropometric measurement is reliable to assess
growth of infants and children by use of the new WHO growth
standards. Estimation of no. of beneficiaries for SFP for
MAM is reliable.
• Indicator: Number of workshop held. Number of health
workers attended.
• Means of Verification: Capacity Development Assessment and
Annual Progress Reports.
• Assumption: The project proposal is prepared with potential
financial support from the Japanese Government. Monitoring
by MoH.

15. 5. Project implementation by use of
multifactorial approaches and
strengthening of partnership.
• Output: Nutrition programme implementation by use of
multisectoral approaches are strengthened.
• Indicator. Number of The National Council for Food Security,
Sovereignty and Nutrition in Timor-Leste (KONSSANTIL)
held. Number of students’ parents who attended nutrition
classes in Dili Municipality.
• Means of Verification: Progress report by line Ministries.
Report by UN partners. Report by NOG: SHARE. Report by
ALORA Foundation.
• Assumption/Threats: Monitoring by MoH

16. SAM Cases at Dili National Hospital
• Study Design: a prospective observational study
• Study Period: Mar. 2002 – Feb. 2004
• Findings:
- Children aged 2 mos – 12 yrs
- WH <-3SD and/or bilateral oedema 61% , and 53.7% were both wasted
and stunted
- Case Fatality Rate 12.9%
- WHO Guidelines were used.
- Of 205 children for whom information about timing of introduction of
complementary foods was available, 21 % had started before 4 months of
age, 56% before 6 months.

17. Distribution of weight-for-height Z score
(WHZ) scores among the study population
Ingrid K Bucens et al Survey of childhood malnutrition at Dili National Hospital,
East Timor. Journal of Paediatrics and Child Health 42 (2006) 28–32.

18. Paediatric Mortality and Morbidity at Dili
National Hospital
• Study Design: a retrospective study
• Study Period: 2008 – 2010
• Findings:
- Children n=5,909, 60% <2 yrs.
- Case Fatality Rate 5%
- WHO Guidelines were used.
-Nine percent of hospital infants aged 1-6 months of age
died and half of all deaths occurred within 2 days of
admission.

19. Data Collection: SAM Programme at CHC
•Data on children who were transferred from
CHS to National Hospital is missing.
•Information on children who visited CHC and
returned to community is missing.

20. Case Fatality Rate at Dili National
Hospital
2006 12.9 %
Ingrid K Bucens et al Survey of childhood malnutrition at Dili National
Hospital, East Timor. Journal of Paediatrics and Child Health 42 (2006)
28–32.
2013 6%
Bucens IK et al. J Paediatr Child Health. 2013 Dec;49(12):1004-9

21. Priority Area
• Delay of reporting
• Possible reason
• Filing and recording system is mission.
• Transportation is difficult,
• =>

22. Hierarchy of Evidence

23. Example of forest plots of the meta-
analysis Source: Haidich HB, Hippokratia.
2010 Dec; 14 (Suppl 1): 29–37

24. Weekly Data Collection thru Communicable
Disease Surveillance in Sudan

25. Nutrition Surveillance
Assessment
• Sustainable on-going data collection of nutritional status
nationwide is needed for the government to cope with early
warning system.
Commutable disease (CD) surveillance is being conducted by
Dept. of Surveillance and Epidemiology, MoH. No. of Case
are reported from 22 sentinel sites.
Suggested activity
• Inclusion of 3-4 nutrition indicators into currently existing
CD surveillance
• Workshop on nutrition indicators is need.

26. Guideline on Community Based
Management of SAM
• There are many nutrition programmes. Coordination among
partners is needed to avid overlapping.

27. Workshop SAM
• Workshop on strengthen of management of SAM
• Improving the Inpatient Management of Severe Acute
Malnutrition
• Background
Six health workers participated WHO training course on the
management of severe malnutrition in Bangladesh. These can
be trainer of training.
• It is intended for health personal working at central and
district level, including physicians, nurses and nutritionists.
• Case fatality rates have decreased to below 5% in treatment
centres applying an appropriate management scheme
recommended in WHO guidelines.
• This training course should be properly combined with a
community based approach.

28. Training Couse on SAM
OBJECTIVES
• Reduce case fatality rate to less than 5 % among
severely malnourished children
• Improve rate of recovery of severely malnourished
children
COURSE SCHEDULE
• A three-day orientation for instructors
• A six-day programme for participants (physicians,
nurses and other senior health workers)

29. COMPONENTS
Instructor guides
• Course director guide
• Facilitator guide
• Clinical instructor guide
Participant guide
• Seven modules
• Support materials
TARGET GROUPS
• Physicians , Nurses , Other senior health worker
FEEDING
• Preparing F-75 and F-100 feeding formulas
• Planning feeding for a 24-hour period
• Measuring and giving feeds to children
• Recording intake and output
• Planning feeding for a ward

30. • Strengthening capacity in the management of severe acute
malnutrition in infants and children. In this proposal capacity building
on clinical based management of clinical base therapeutic feeding
programme (TFP) nationwide. The capacity building target pediatricians,
midwives, dietitian, nurses and other health workers.
• Formulating evidence-informed guidelines, strengthening nutrition
surveillance. Currently existing CD surveillance will include several
nutrition indicators.
• Promoting child growth standards and complementary feeding.

31. Needs on Health Statistics
•% weight for Age <-2SD & <-3SD?
•% Height for Age <-2SD & <-3SD?
•% Wight for Height <-2SD & <-3SD?

32. How to conduct a workshop
Case Study in Sudan
Trainees 14 – 15, Course director 1, Co-director 1
Clinical instructors 4, Nutritionist 1
Four clinical instructors and a nutritionist worked and
they worked the Iraqi facilitators. The course director and
co-director are faculty of International University of
Africa and University of Khartoum.
• Five officers of State and Federal Ministry of Health of
Sudan also joined it as part of capacity building. It was
a good opportunity for both from Iraq and Sudan to
share information and issues on the management of
treatment of severe malnutrition.

33. • As for treatment of SAM in regard to transition phase feeding,
certainly further research is needed to identify risk factors
for refeeding syndrome, particularly among children treated
exclusively as outpatients for SAM, as well as comparative
trials of feeding regimens. Until such evidence is
accumulated, the best recommendation is for a gradual
increase in dietary energy as the child moves from
stabilization to rehabilitation.
• Systematic review of transition phase feeding of children
with severe acute malnutrition as inpatients Mark Manary1
Indi Trehan2 Ariana Weisz3 February 2012 1 Helene B.
Roberson et al.
• http://www.who.int/nutrition/publications/guidelines/updat
es_management_SAM_infantandchildren_review5.pdf?ua=1

34. • Strengthening of integrated disease surveillance and
implementing the provisions of the International Health
Regulations. 5.1 Strengthening risk reduction through
addressing the