USAID/South Africas portfolio of nutrition projects and activities is intended to improve the nutritional status of vulnerable groups throughout South Africa using nutrition assessment, counseling, and support (NACS) as a standard of care approach. Primary target groups include:

Children less than 2 years old

HIV-positive pregnant and lactating women in prevention of mother-to-child transmission of HIV (PMTCT) programs

Orphans and vulnerable children (OVC) more than 2 years old with evidence of growth faltering

People living with HIV (PLHIV) in care and treatment programs

The Capable Partners (CAP) Capacity Building Project (NACS) now known as NACSCAP uses three key strategiesadvocacy, capacity strengthening, and provision of essential nutrition suppliesto contribute to reduced malnutrition and to create an integrated and self-sustaining community health, nutrition, and HIV care system for target populations.

NACSCAP is intended to strengthen the capacity of the South African Government (SAG) to deliver a comprehensive set of nutrition interventions. It will support the countrys primary health care (PHC) reengineering by building the capacity of cadres working on PHC teams to deliver elements of the NACS approach through relevant training. It builds on and expands FHI 360s CAP South Africa Program, which integrates PMTCT, maternal health, and infant and young child feeding (IYCF) into existing health facility and community services. Adding NACS as a major thrust under NACSCAP will ensure integration of nutrition interventions into existing service provision at facility and community levels.

The goal of NACSCAP is to strengthen the SAGs capacity to deliver a comprehensive set of nutrition interventions to improve health outcomes of people living with and affected by HIV and TB as well as OVC. The objectives of which are 1) To assist the NDOH to improve a multi-sectorial approach to reducing malnutrition among PLHIV, people with TB, and OVC in selected health districts 2) To build the capacity of health facility and community health workers as well as NGOs and CBOs to successfully deliver nutrition assessment, counseling, and support (NACS) for target populations 3) To assist target districts to improve the availability of essential supplies and equipment to effectively deliver NACS services.

Experience has shown that advocacy for the importance of integrating nutrition into care and treatment is needed throughout the entire system from the community to national level. The project will work to establish a multi-sectorial nutrition working group, improve coordination of nutrition programming and services, and mainstream NACS guidelines into relevant policies. In this regard conducting decision makers one day courses will be critical in support of the initiative so that management can fully support and include NACS supervisory lists into their regular supervisors check lists. Advocacy meetings will include integration of NACS into existing strategies such as Integration of Management of Illnesses in Children (IMIC), and Management of Severe Malnutrition (SAM).

Key success of CAP SA was the focus on district-level support through on-site mentoring and coaching using a curriculum that includes NACS in an eight-step process in the context of PHC re-engineering. NACSCAP will use lessons learned and will build on their experience, relationships, and structures. FHI 360 understood fully that training alone does not translate into appropriate implementation of services and identified the following best practices: In collaboration with provincial DOH and PEPFAR partners identification of selected( primary and secondary) sites, where intensive implementation will be demonstrated has been initiated, this will include:

Training of health facility staff and community health workers followed by joint learning and planning in during on-site mentoring and coaching led to mobilizing the community in health promotion activities. This led to improved access to health services and strengthened links between the health structure and the surrounding community services

Training of health workers in basic understanding of M&E concepts, processes, and application led to identification of gaps in the health system and provided opportunities to improve program performance.

Mapping of HIV, PMTCT, nutrition and related services and resources led to establishing linkages and improved follow-up of clients in the community.

Well-coordinated, structured, and representational clinic committees assisted in providing essential community health services and increased coverage.

FHI 360 will provide technical assistance to the treatment care and support partners to develop action plans and build their capacity to integrate NACS into their existing services. CAP is contributing to developing National NACS curriculum, (training manual) for health workers, community health workers and decision makers.

**Not Provided**

CAP SA is a specialized partner providing technical assistance to train and build capacity of health care workers and community caregivers to integrate PMTCT, maternal healthand nutrition and Infant and Young Child Feeding into health facilities and community services in all nine provinces. The conceptual framework builds on the successful implementation of the CAP SA integrated PMTCT program. The Nutrition Assessment Counselling Support Capacity Project ( NACSCAP) will work at all levels of the health system within SAGs PHC reengineering focusing on target sites at the health facility and community levels. Selection of sites is being done in consultationwith SAG Provincial, District DOH as well as xomprehensive HIV services PEPFAR Partners. FHI 360 CAP program developed, tested, refined and effectively used in South Africa a model of capacity strengthening that adheres to the WHO building blocks for health-systems strengthening and fully integrates PMTCT, maternal health and nutrition and IYCF of HIV service delivery at health care facilities and community service delivery points.

The model is in line with all relevant DOH policies, guidelines, declarations and strategies such as NSP 2012 2016, Maternal Neonatal Health and Nutrition, and Tshwane Declaration 2011(promotion of exclusive breastfeeding for all mothers). The declaration also requires that all health facilities that are providing prenatal and maternity services must be awarded the BFHI status by 2015, the national regulation to regulate marketing and promotion of breastmilk substitutes has been legislated in SA, therefore there is need to create awareness on the regulation, implementation and monitoring. BFHI is also quality assurance strategy to improve service delivery.

In collaboration with national and provincial DOH, FHI360 is the Agency that trains health workers in the integrated program. In preparation to be an assessor participants must have an in depth knowledge on maternal child health and nutrition related issues, including HIV and AIDS. To attain this knowledge and skills health workers must be trained in the 10 day integrated PMTCT, maternal health /nutrition and infant and young child feeding and skills developed. The BFHI assessors undergo an intensive 5 day training based on the WHO/UNICEF BFHI assessors course, followed by practicum to ensure that they are skilled. The Step Ten of the BFHI is strengthening the community component; FHI 360 trains and builds the capacity of Community Health Workers in selected sites to strengthen linkages and referrals from health facility to community support including NGOs using Social Behavior Change Communication (SBCC) approaches. In addition CAP trains and builds capacity of clinic committees in defining their roles and responsibilities and provides necessary support and follow up on PMTCT maternal health and infant and young child interventions.

Training in international Code on Marketing Breastmilk Substitutes and its subsequent relevant World Health Assembly Resolutions (in South Africa referred to as Regulation). Training includes creating awareness, implementation and monitoring.

Childhood under nutrition is an underlying cause of 35 per cent of deaths among children under 5 in the developing world. According to the 2008 Lancet Series on Maternal and Child Under nutrition, severe acute malnutrition (SAM) is one of the most important contributing causes of childhood mortality. Breastfeeding has shown to be one of the effective strategies to reduce child mortality. In South Africa Underweight prevalence among young children (12-71 months), suggesting both acute and chronic malnutrition was at 11.1 per cent in 1999 compare to 12.8 in 2005. The 2005 National Food Consumption Survey (NFCS) shows that 18% of children are stunted compared to the 21.6% in the 1999 survey. About 9.3% of children are underweight which reflects a decrease from 11% in children aged 1-3 years

Paediatric HIV Technical working group led by National DOH Child Directorate developed a paediatric frame work based on the following: NACSCAP is a member of this working group focussing on nutrition.

1. Preventive strategies to prevent primary HIV infection in children and adolescents

2. Treatment access for all HIV positive children and adolescents including early infant diagnosis

3. Nutritional care for infants, children and adolescents infected with HIV or TB

4. Care and psychosocial support for children infected and affected by HIV and AIDS

NACSCAP will support SAG and PEPFAR partners to build the capacity in the implementation of safe infant feeding practices. In terms of the Tshwane Declaration, South Africa promotes exclusive breastfeeding for six months for all mothers. This applies also to those living with HIV and AIDS as a strategy to reduce mother-to-child transmission (MTCT), with antiretroviral prophylaxis for children whose mothers are not on HAART. Older children and adolescents should be assured of healthy diets. Moderately and severely malnourished children should be appropriately managed.

NACSCAP will continue providing technical assistance and building capacity on this area and will continue to build capacity of health professionals and community health workers in effective counselling and support for infant feeding. The community and family support is critical in the promotion of optimal infant feeding, therefore conducting community dialogue to engage them for the support using social behavior change communication approaches. CAP will be guided by suggested areas of implementation e.g. program and clinical management, training and mentorship, partner coordination and support for counselling.