Version 2 REACH - UNSCN...REACH_Acting at Scale_Guide_Micronutrients_v2.ppt 3 Preliminary Key messages Micronutrient deficiencies are widespread, with severe effects • 44M DALYs

REACHEnding Child Hunger and Undernutrition

Version 2

Acting at Scale: Intervention GuideMicronutrient Supplementation and Fortification

February 2009

1REACH_Acting at Scale_Guide_Micronutrients_v2.ppt

Preliminary

Context

The following document is part of the REACH Acting at Scale set of materials• The documents' aim is to provide highly condensed information and lessons learned for scaling up REACH-promoted

interventions to support field practitioners and other interested parties• They are intended to become a living set of materials, updated periodically by the REACH Global Interagency Team• These materials are a first step towards a larger REACH Knowledge Sharing service, which will be developed over time

The full set of Acting at Scale materials includes• An Intervention Summary

– An overview document containing key facts for all of the 11 promoted interventions• Intervention Guides for each of the interventions1

– Containing rationale, lessons learned, costs and further resource lists• Implementation Case Studies for each of the interventions1

– Initial set of details and lessons learned from programs implemented at scale• Resource Lists

– Lists of key documents, organizations and programs at scale– Included at the back of each Intervention Guide and in Excel spreadsheets available from the REACH Global

Interagency Team

These materials represent a preliminary version, to be validated and refined via additional consultations• Prepared in Summer 2008 by the REACH Global Interagency Team, based on inputs from 56 practitioners and experts, as

well as extensive desk research• A revised Version 2 of these documents will be released in late 2008 or early 2009, incorporating feedback from initial

recipients

If you have questions or feedback on these materials, please• Contact your local REACH facilitator in Lao or Mauritania, or• Contact the REACH Interagency Team Coordinator, Denise Costa-Coitinho, at [email protected]

1. Breastfeeding and complementary feeding have been combined into a single document due to strong linkage in delivery


Preliminary

Key messages

Why implement

How to implement at scale

• Define strategy• Design• Implement• Monitor, evaluate and refine

What it costs

Where to go for further information

• Key reference materials• Organizations• Experts (under construction)

• Scaled-up programs

Appendix: experts consulted

Table of contents


Preliminary

Key messages

Micronutrient deficiencies are widespread, with severe effects

• 44M DALYs and 1.1M deaths of children under five are associated with micronutrient deficiencies• Undernutrition leads to severe health issues, e.g. blindness, anemia and cognitive developmental impairment as well as death• Heavily affects women and children <5, e.g. one quarter of world's women and children are affected by anemia

Fortification is a cost-effective way to address widespread micronutrient deficiencies among the general population

• Requires a national alliance with strong commitment from both public and private sectors• Besides coverage, technical feasibility, cost and suitability as a public health measure, the industry's preparedness and

willingness should be considered in the choice of vehicle• Social marketing of fortified food products via public and private marketing is important to foster adoption of fortified products• Requires strong quality assurance to succeed; including both industry quality control and government oversight and

enforcement• Fortification may not satisfy needs of most vulnerable populations, including the rural poor lacking access to markets for

processed foods (even if more cost-effective), or <2s who may not consume sufficient quantities of the products

Micronutrient supplementation is a costlier, but more targeted approach to serve specific populations, e.g. <5s and P&Lwomen

• A variety of delivery models are used, ranging from a carefully controlled, semiannual mass campaigns providing vitamin Adrops to social marketing campaigns for zinc supplements to treat diarrhea

• Strong logic exists for integrating supplement delivery into other interventions, e.g. Immunizations– Determine suitability based on frequency, sophistication of treatment and the target group

• Multimicronutrient Management Nutrition Products (MMNPs), may be appropriate for children <5, given their cost-effectivenessand ease of use (e.g. MixMe™, Sprinkles™)

• Awareness building and behavior change is important where supplements are administered in the home


Preliminary

Why implement


Preliminary

Iodine

deficiency

Iodine

deficiencyIron

deficiency

Iron

deficiencyVitamin A

deficiency

Vitamin A

deficiencyZinc

deficiency

Zinc

deficiency

Vitamin and mineral deficiencies cause a variety of diseases

and account for about 10% of the DALYs in children under 5

TotalTotal

1,146421453

668

Deaths ofchildren <5 in K

443216

23

DALYs ofchildren <5 in M

10.2%5.3% 3.8% 0.5% 0.6%

Share ofDALYsattributedto children<5

• Cognitive impairment• Stillbirth,

spontaneous abortion,congenitalabnormalities

• Cretinism

• Anaemia• Maternal death• Impaired physical and

cognitivedevelopment

• Reduced workproductivity in adults

• Visual impairmentand blindness

• Higher risk of severeillness (diarrhoealdiseases andmeasles)

• Night blindness formother and child

• Reduced immunestatus in neonatesand children

• Additional zinc canreduce incidence ofdiarrhea andpneumonia inchildren

Source: "Addressing Micronutrient Deficiencies: Alternative Interventions and Technologies" Unnevehr et. al., 2007.; "Maternal and child undernutrition: global and regional exposures and healthconsequences." Black et. al., 2008.


Preliminary

Two strategies to address micronutrient deficiencies

SupplementationSupplementation FortificationFortification

Definition

Benefits

Drawbacks

• Add micronutrients via tablets, syrups orhousehold-level fortification products

• Typical delivery channels: mass campaigns, thepublic health care services, other social services

• Add micronutrients to food at point of production• Delivery via regular food supply chain

Micronutrients

most typically

used

• Vitamin A• Zinc• Iron (mostly also including folic acid)

• Vitamin A• Iodine• Iron

In the long-term diet diversification should be promoted to

increase micronutrient intake through the regular diet

• Highly cost-effective per person• Enables at-scale coverage• Very sustainable as local capacity is built• Limited behavior change required

• Enables targeting of specific population groups• Consumption of micronutrients is diet-

independent

• May not reach most vulnerable populations– Rural, low-income people may not

purchase/consume fortified products– Children <2 tend not to consume commonly

fortified products• Costly for more specific fortification in small

scale/local level

• Requires regular, sustained delivery• More costly per person than fortification• Requires investment in awareness building and

acceptance to modify behavior

• B Vitamins• K Vitamins• Other


Preliminary

How to implement at scale


Preliminary

Key lessons learned about implementing

micronutrient supplementation programs at scale

• Foster political commitment for the supplementation program to signal the importance to health and otherworkers across sectors as well as beneficiaries

• Consider whether multimicronutrients can be distributed, given generally higher cost-effectiveneess andimpact on nutritional status

• Integrate delivery into existing public health or mass campaigns to increase cost-effectiveness and scale– e.g. vitamin A supplementation is often linked with immunization

• Leverage private and other sector capabilities to ensure program sustainability– e.g. SUZY in Bangladesh contracted a private manufacturer to produce zinc which is distributed through

private sector distribution facilities

• Design and employ simple education materials to encourage proper use of supplements and multi-micronutrients

– e.g. simple counseling cards teach mothers how and when to administer supplements– e.g. calendars to remind of frequency of administration

• Invest in strong planning and management of distribution and logistics to ensure sufficient and on-timesupply of supplements

• Use simple M&E systems with reporting forms to report overall number of supplements distributed andcoverage of beneficiaries

– e.g. to track/register vitamin A supplement recipients to avoid administration to pregnant women oroverdose to children

Source: tbd ; expert interviews; literature review; REACH analysis

Definestrategy

Design

Implement

Monitor,evaluate,

refine

Supplementation


Preliminary

Delivery strategy selection depends on the local setting and

concentration of target population

1. e.g. due to low purchasing power or due to dominance of subsistence farmingSource: Expert interviews; REACH analysis

Define strategy

Delivery strategyDelivery strategy

Supplementation

(single and multi-

micronutrients)

When to useWhen to use

• To target micronutrientdeficiencies of particularpopulations, e.g., P&Lwomen or children < 5

• To target families in ruralareas with limited access tofortified foods1

Fortification

• Private sector is capable andwilling to participate

• Strong policymaking andenforcement is available

• Advocacy to improvecapacity and policies

This is not an either/or decision – Countries should usually employ both strategiessimultaneously for a given micronutrient to reach all target group needs and broad coverage

Targeting needsTargeting needs Local capacityLocal capacity OtherOther

• High-quality fortification canbe assured

• Food vehicles are widelyconsumed

• Fortification enforcement orproduction quality isinsufficient

• High rates of deficiencies ofparticular micronutrient

• Deficiencies occur only inselect geographic areas

• Fragmented productionindustry makes fortificationcooperation and compliancedifficult (resource intensive)

• To target the wholepopulation


Preliminary

Delivery strategy also depends on micronutrient

and target beneficiaries

Define strategy

If fortification does not reach the target beneficiaries,

supplementation is always strongly recommended

Target beneficiariesTarget beneficiaries Vitamin AVitamin A IronIron ZincZinc IodineIodine

Supp.1Supp.1 Fort.Fort. Supp.1Supp.1 Fort.Fort. Supp.1,2Supp.1,2Fort.Fort. Supp.1Supp.1 Fort.Fort.

Children < 2

Children 2 – 5

P&L women

1. Provision through either single or multi-micronutrient supplementation 2. For diarrhea treatment 3. Iron supplementation is needed for under twos in addition to iron fortification as they usually donot consume enough of the fortified food; Usually also includes folic acid 4. If diarrhea is present 5. Not recommended for pregnant women at all 6. Recommended daily allowanceSource: Expert interviews; "Reaching optimal iodine nutrition in P&L women and young children." WHO/UNICEF, 2007.; REACH analysis

RecommendedStrongly recommended Not necessary if fortification is done

3 4

4

4

30% 30% 30% 100%Typical fortificationlevel in % of RNI6

Not necessary but in isolated cases

5


Preliminary

Multi-micronutrient powders are often used instead of

individual supplement tablets

Source: Homepage of the Sprinkles Global Health Initiative; Expert interviews

Define strategy

Multi-micronutrients overviewMulti-micronutrients overview

Delivered via supplements

• e.g. MMNP’s added to food or as multimicronutrienttablets or syrups

• Delivers essential micronutrients regardless ofamount or quality of available food

Provides suite of all essential vitamins and minerals

in low doses (in most cases)

Originally designed for emergency settings

• But broader applicability given light weight,balanced formulation

Relatively easy distribution requirements

• Lightweight, easy to store, and heat stable

Easy to use by beneficiaries

• No literacy or special handling required

Offer several advantages over single-

micronutrient options

Offer several advantages over single-

micronutrient options

• Micronutrients may be better absorbed if deliveredtogether

• Low risk of overdose– Infant would have to consume

~ 20 sachets to reach toxicity levels

• Easy for young children to use if MMNPs are used– No tablets to swallow– Tasteless, with no affect on food– Fun packaging

• Good economics– Cost per sachet of Sprinkles™ of 1.5-3.5 US

cent


Preliminary

Sprinkles™ are a common multi-micronutrient provided to

vulnerable populations

Product

features

• Sachets containing powdered blend of micronutrients to sprinkle onto any semi-solid foodsprepared at home

• Available as two standard formulations: (and can be customized per situation)– Nutritional Anemia Formulation: vitamin A & C, iron, zinc, folic acid– Multi-Micronutrient Formulation: vitamins A, C, D, E, B1, B2, B6, B12, iron, zinc, iodine,

folic acid, niacin, copper• Recommendation that 60 single-dose sachets are consumed over 60 - 120 days per year

(from 6 months onwards once complementary food is given)

Target

beneficiaries

• Designed for children 6–24 months of age (can be customized), who– Have trouble swallowing tablets– Do not consume enough food to benefit from fortification

• Often used by rest of population, e.g. adolescents, P&L women

Source: Homepage of the Sprinkles™ Global Health Initiative; Expert interviews

Costs• Cost per sachet ranges from $ .015 - .035

– Varies according to scale and local production costs– Annual cost / child / year = approx. $ 6.30 USD

Risks

• MMNPs with iron should be withheld from severely malnourished children during the first 7 daysof treatment

• In malaria-endemic regions, MMNPs should be combined with malaria prevention or treatmentprograms

• Drawback of sharing with others and compliance

Key

organizations

• UN agencies: UNICEF and WFP (especially during emergencies)• NGOs: HKI, World Vision, Micronutrient Initiative• Sprinkles™ Global Health Initiative (SGHI) provides program support

Define strategy


Preliminary

Children < 5 &

New mothers1

Children < 5 &

New mothers1Children < 5 &

P&L women

Children < 5 &

P&L women

Supplementation delivery channels depend on target group,

delivery frequency, doses and training requirements

Design

Frequency

Vitamin AVitamin A Iron3Iron3

Children < 5Children < 5Children 7-24 months

& P&L women

Children 7-24 months

& P&L womenChildren < 5 &

P&L women

Children < 5 &

P&L women

ZincZinc IodineIodine

Multimicro-

nutrients

Multimicro-

nutrientsSingle micronutrient supplementsSingle micronutrient supplements

• Children <5– Every 4-6 months

• New mothers– Immediately after

delivery

• Daily/weekly• To children not in

malaria-endemicregions

• If diarrhea is present • Single annual dosefor children2

• One dose duringpregnancy

• Once yearly provision of60 sachets to be usedover 120 days (not bestin some situations)

Training

requirements

• Only to be given byhealth and otherworkers to ensureproper registrationand avoid overdose

• Can be given bymother at home


• Proper registrationmust be ensured

• Dosage varies bytarget group


High Low Low LowHigh

1. Never to be given to pregnant women 2. In special circumstances only; Alternatively daily doses can be used 3. Usually including folic acid supplementSource: "Vitamin A supplementation. A decade of progress.", UNICEF, 2007; "Guidelines for the use of iron supplements to prevent and treat iron deficiency anaemia.", INACG, 1997; "Reachingoptimal iodine nutrition in P&L women and young children." WHO/UNICEF, 2007.; REACH analysis

Public

health

Mass

campaign

UN

facilities

Private

sector

Ch

an

nels

Frequently used Seldom used


Preliminary

Micronutrient supplementation delivery channels

1.Integrated Management of Childhood Illness (IMCI)Source: Expert interviews; REACH analysis

Public health system

Existing mass campaign

UN facilities• e.g. along with supplementary

or therapeutic feeding

Private sector• e.g. zinc marketed as diarrhea

treatment or marketedmultimicronutrients

• Low incremental delivery cost• Sustainable as capacity is built• Product/cost

• Low incremental delivery cost• Often high coverage / uptake

• Low incremental delivery cost• Reaches same set of target

beneficiaries as current UNprograms

• Sustainable once marketdemand and new supply arelinked

• Leverages distribution andmarketing strengths of privatesector

• If capacity is weak, providemanagement or technicaltraining/support

• If coverage is low, supplementwith other channels

• Need to ensure technical andprogrammatic fit

• Food distribution is well suitedfor distribution of multi-micronutrient sachets

• Critical to understand andframe partnership aroundprivate sector partnerobjectives and incentives

Typical delivery channelsTypical delivery channels StrengthsStrengths Lessons learnedLessons learnedHow-toHow-to

• Encourage MoH to includesupplements as part of currentservices, e.g. IMCI1

• Depending on supplement addtraining to existing staff

• Advocacy

• Encourage UN/MoH to includesupplements in campaigns

• If needed, add training toexisting staff

• Encourage UN to includesupplements

• Provide varying degrees oftraining to existing staff

• Identify potential partners• Approach private sector

partners and highlight theirbenefits from their involvement

• Products commercialavailability by private sector

Design


Preliminary

Vitamin A supplements largely delivered via mass campaignsOften yield higher coverage than fixed-site channels

Note: Data is derived from all vitamin A distributions registered in the UNICEF vitamin A supplementation database that were carried out in 2004 (for frequency of delivery channel data) and from1999-.2004 (for coverage data) respectively.1. Integration with deworming and bed-net distribution increases demand for services 2. Polio campaigns increasingly phased-out due to successfulSource: "Vitamin A supplementation. A decade of progress.", UNICEF, 2007; REACH analysis

Frequency of delivery channel usageFrequency of delivery channel usage Typical coverage ratesTypical coverage rates

Child health days123%

26%

5%

15%

14%

17%

100% N/A

34%

58%

70%

71%

81%

82%

Polio immunizationdays2

Measles supplemen-tary immunization

Micronutrient event

Fixed site andoutreach

Fixed site

Public

health/

UN

facilities

Mass

campaign

% of times used for vitamin A capsule distribution Mean one-dose vitamin A coverage achieved in %

Total

Design


Preliminary

Vitamin A supplementation programs are often linked with

other interventions

Note: Analysis for frequency of linkage is based on vitamin A supplementation programs in 14 countries contained in the UNICEF vitamin A supplementation database.Source: "Vitamin A supplementation. A decade of progress.", UNICEF, 2007; REACH analysis

InterventionIntervention

Immunization

Bed nets

Growth monitoring

Iron supplementation

Infant & young child feedingpromotion

Tetanus vaccination

Frequency of

linkage

Frequency of

linkage

But joint implementation requires an ability

to deliver joint programming

But joint implementation requires an ability

to deliver joint programming

Requires consistent messaging to facilitate joint

advocacy to government

Requires joint planning and execution

• Staff training

• Joint M&E

Requires aligned logistics and distribution

capacity

• On-time delivery of all required materials

• Synchronized purchasing

Requires donor/funding alignment

• Same funding period

• Same disbursement patterns

When implemented well, linked interventions lead to

significantly reduced delivery costs

Frequent

Seldom

Design


Preliminary

Private sector also used as delivery channel to broaden

coverage for particular micronutrients

Private healthcare providers

Prescribe and/or sell supplements

Potentially important where private care is

commonly used by target audience, e.g. in

Bangladesh 90-95% of the health care market

is controlled by private providers

• Have strong influence on patient

Build awareness via associations or directly,

e.g. SUZY leveraged the Bangladesh Pediatric

Association

• Benefits of supplementation• Available tools• Appropriate use of tools

Understand and try to address the low profit

margins generated by supplements

SUZY project in Bangladesh:

Distribution and prescription of zinc tablets

by private providers

Groceries/ pharmacies

Expand supplements distribution and sales

into rural areas

Often have best distribution networks in low-

income settings

Often have frequent daily contact with target

populations

Partner in awareness campaigns

• Program generates awareness• Store supplies new demand

"Sell" partnership by appealing to often co-

existing motives

• New revenue stream for store• Reputational benefits of social responsibility

activity

Sprinkles™ project in Bolivia:

Distribution through commercial

channels on national scale

Role

Rationale

How to engage

Examples

Source: Expert interviews; REACH analysis

Design


Preliminary

Supplements often require basic education on usageExamples of behavior change tools

Helps pregnant women rememberto take a daily iron pill

Educates pregnant women onhow and when to take iron pills

Advises the pregnant womenabout the symptoms of anemiaand steps to procuresupplements

Source: "Guidelines for the Use of Iron Supplements to Prevent and Treat Iron Deficiency Anemia." International Nutritional Anemia Consultative Group, 1998.

Implement

Calendar

from Malawi

Calendar

from MalawiCounseling card

from Indonesia

Counseling card

from IndonesiaInformation card

from Indonesia

Information card

from Indonesia


Preliminary

Key lessons learned about implementing

micronutrient fortification programs at scale

Source: Expert interviews; literature review; REACH analysis

• Create strong, coordinated national alliances to foster broad buy-in for fortification projects– e.g. HKI helped initiating the national alliances in West Africa as a central coordinator organizing

workshops, holding up communication and seconding staff for advocacy• Legal code• Promote private sector cooperation by articulating the sustainable business case for fortification

– Producers may not participate if clear business case is not made– May include providing subsidies to lowest-income consumers to reach scale

• Add multiple fortificants to vehicles if technically feasible to improve cost-effectiveness and health impact• Consider industry's capacity, as well as technical and consumption criteria, to select vehicle

– e.g., in HKI's Fortify West Africa program, vegetable oil was selected in part due to the high level oforganization and motivation vegetable oil industry

• Aim for integrated public and private sector marketing to maximize beneficiaries' awareness of fortificationbenefits

– e.g., in the HKI's Fortify West Africa program, the public sector program created a marketing logo foradoption by several companies across different countries and for different food vehicles

• Employ both preventive production quality management systems and ex-post, government qualityoversight and enforcement controls to ensure quality of food productions and fortification

– e.g., in the HKI fortification project in West Africa, the private sector integrated fortification qualitymanagement effectively into its regular quality systems, complemented by government productsampling

• Engage national or international associations to strengthen quality assurance oversight

• Invest in M&E to document successes of fortification to encourage ongoing investment and consumption• Involve government legislative body

Fortification

Definestrategy

Design

Implement

Monitor,evaluate,

refine


Preliminary

An effectively coordinated national alliance is key to

fortification success

HKI initiated partnership and facilitated partner activities

for the Fortify West Africa program

HKI initiated partnership and facilitated partner activities

for the Fortify West Africa program Keys to effective coordinationKeys to effective coordination

Effective coordination mechanisms

• One central coordinator• Steering committees for project

supervisory• Seconded staff for advocacy,

especially to governments• Technical workshops• Improvement of coordination

between different governing bodies

Effective coordination principles

• Frequent and transparentcommunication to create trust

• Understanding for different paceand cultures of differentorganizations

• Continuous monitoring of activitiesand progress

8 national governments

• Pass legislation• Sponsor public

marketing campaigns

Donors

• Provide funding• Oversee progress• Support advocacy

Local private sector

• Fortify oil• Perform quality

assurance• Market products

International private sector

• Provide premixes• Provide technical

assistance

International organizations

• Recommend legislation• Coordinate governments

Source: Project documents from HKI West Africa; Expert interviews

Define strategy

Implementing partner / NGO

• Initiated program• Facilitates partnership• Provides technical

expertise

Steering committeesWorking groups


Preliminary

Private sector is critical partner in fortificationCritical to identify and address business interests to forge effective partnership

Private sector plays critical

role in fortification

Private sector plays critical

role in fortificationCritical to understand

industry's

Critical to understand

industry'sFortification programs

must address these

Fortification programs

must address these

Typical local producer concerns

• Unclear business case thatfortification will increasedemand/share

• Perceived erosion of profitsthrough fortification

• Additional complexity inbusiness operations

• Perception of being tasked withpublic health measure thatshould be rather done by thegovernment

Governments or program

implementers need to work with

companies or associations to build

case for investment/compliance

• Provide free or subsidizedfortification equipment andpremixes

• Waive import duties and taxes onpremixes and equipment

• Make business case thatfortification will increase demand ifsupported through social marketing

• Make business case that mandatoryfortification will create a protectivemechanism against cheap,unfortified imports


Local food processors

• Process and package foodproducts

• Participate in fortificationprocess

• Implement fortification

– Purchase premixes

– Produce fortified food

– Maintain equipment

• Market food

– Incorporate key nutritionmessages into marketing

– Use logos

• Distribute fortified foods

International nutrient producers

• R&D new technologies

• Produce and sell premixes

• Provide technical and analyticsupport

Define strategy


Preliminary

Critical to select appropriate delivery vehicleExample: HKI's Fortify West Africa's fortification vehicle selection criteria

Design

Vehicle selection criteriaVehicle selection criteria

Coverage

Technical feasibility

Central processing

Cost

Industry

preparedness and

willingness

Suitability as public

health measure

• Minimum 60–70% of population shouldregularly consume vehicle1

• No change of organoleptic and functionalproperties of food

• Limited fragmentation of large-scalemanufacturers, otherwise equipment cost toohigh and control difficult (in some smallproducers will be more effective and costly)

• Cost of fortification equipment and premixes

• Industry associations available to work with• Sufficient technical expertise• Sufficiently high professional standards• Sufficiently strong social commitment• Monitoing and Evaluation

• Should not counteract other nutritionstrategies or interventions

1

2

3

4

5

6

1. It also has to be assured that the resulting total consumption of the added micronutrient through the regular diet and the fortified food is within the tolerable upper intake levels to assure safetySource: HKI project documents; Expert interviews; REACH analysis

Example: HKI Fortify West Africa selected

cooking oil to deliver vitamin A

• High coverage: ~ 90% of children 6-59months in urban Senegal consumed in last24 hours

• Technically feasible: oil fortification withvitamin A is technically easy

• Centrally processed: 14 cookingmanufacturers in the 8 UEMOA countries

• Cost: relatively inexpensive process

• Industry preparedness and willingness

– Active industry association AIFO-UEMOA

– High industry interest in fortification dueto economic and social motives

• Suitability: does not interfere with otherpublic health measures


Preliminary

Certain fortification vehicles are more appropriate for each

micronutrient

VehiclesVehicles

Water

Milk

Cooking oil

Fish/soya sauce

Salt

Sugar

Wheat flour

Maize flour

Rice

Fortified blended food

X

X

X

X

X

X2

X1

X4

X

X2

X

X2

Vitamin AVitamin A IronIron ZincZinc IodineIodine

X6

4

X3

X

X

X

X

Sta

ple

sC

on

dim

en

tsL

iqu

ids

1. Fish sauce succesfully used in Vietnam and soya sauce successfully used in China 2. Fortification of food that is used for food aid, no national fortification 3. Only included in fortified blended foodsourced from the USA 4. Salt that is fortified with iron and iodine is called "Double Fortified Salt" 5. Not enough flour is consumed at typical fortification levels 6. Not cost-effective in comparison tosalt iodizationSource: "Guidelines on food fortification with micronutrients." WHO/FAO, 2006., expert interviews; REACH analysis

X Most commonly used vehicles

X

X

Fo

od

aid

X Sometimes used as a vehicle

Design

RecommendationRecommendation

Not recommended as it detractsfrom breastfeeding messages

Additional supplementationneeded as <2s do not consumeenough5

Fortificants commonly usedFortificants commonly used


Preliminary

Multiple fortificants should be added to vehicles if technically

feasible

Vehicles suitable for multiple fortificationVehicles suitable for multiple fortification AdvantagesAdvantages

Higher effectiveness

• Presence of other micronutrients improve absorptionrates, e.g. of iron

• Body receives balanced and full portfolio of essentialvitamins and minerals

Higher cost-effectiveness

Easy to implement

• Just one industry has to be coordinated andcontrolled instead of multiple industries if severalvehicles are used

Wheat flour

Maize flour

Rice

Salt

Vit-

amin A

Vit-

amin A IronIron ZincZinc IodineIodine

Design

But interactions between micronutrients and changes of organoleptic andfunctional properties of food have to be taken into account

1. Fortification of flour and rice with vitamin A is more costly than oil fortificationSource: Expert interviews

1

1

1


Preliminary

Fortification success depends on effective product marketingBoth public and private sector roles

Public sector invests in building

social awareness

Public sector invests in building

social awareness

Develop fortification logos

• For use by all producers• Can be used for several fortified foods

– e.g. HKI Fortify West Africa used a singlelogo for fortified cooking oil and wheat flourin West Africa

Develop and implement public marketing

campaigns advertising the benefits of fortified

products

• e.g. media advertisement• e.g. local celebrities

Encourage NGOs and local community

development partners to include fortification

information into their social marketing

Private sector reinforces

key health messages

Private sector reinforces

key health messages

Use fortification logos on products

Integrate key fortification messages into

regular product marketing

• Through all marketing channels

Develop specific fortification marketing

campaigns

Include fortification activities into PR and

CSR work

Implement


Consumer


Preliminary

Fortification requires strong quality assuranceBoth producers and governments play a role

Implement

Activities

Manufacturer's

"upstream" quality assurance

Manufacturer's

"upstream" quality assurance

• Producers integrate fortification into regular

quality management system

– Develop fortification manuals– Train of staff– Employ in-process sampling

• Industry associations audit production

processes

– To ensure compliance with industry andfortification standards

• Monitor and Evaluation

Government's

"downstream" oversight

Government's

"downstream" oversight

• Government regulatory authorities check

quality of fortified foods

– Sample products in factory– Sample products "off the shelf"

• Government regulatory authorities audit

quality management systems of private sector

Both mechanisms need to be established

for programs to succeed

Require-

ments

• Capable and motivated private sector

• Effective self-control/regulation mechanisms

through industry associations

• Strong legislative and regulatory system

• Technical and management capacity at

government level



Preliminary

What it costs


Preliminary

Supplementation cost per beneficiary varies widely

depending on the micronutrient and the program

Supplementation

Source: "Repositioning nutrition as central to development." World Bank, 2006.; "Copenhagen Consensus 2008 Challenge Paper: Hunger and malnutrition." Horton et. al., 2008.; "What would it costper child to meet the needs of some 300 million hungry children?" WFP, 2004.; "World Hunger Series 2007. Hunger and Health." WFP, 2007.; "What works? A review of efficacy and effectiveness ofnutrition interventions." Allen et al, 2001.

0.67

3.17

0.50

2.80

0.470.47

2.75

3.17

5.305.30

1.50

2.45

1.25

0.50

1.70

0.550.25

1.001.010.90

0

1

2

3

4

5

6

World Bank

(Caulfield)

World Bank

(Fiedler)

Copen-

hagen

Consensus

WFP World

Hunger

Series

World Bank

(Caulfield)

World Bank

(Fiedler)

WFP 2004 Copen-

hagen

Consensus

WFP World

Hunger

Series (10-

day

treatment)

World Bank

- Iodized oil

injection

(Caulfield)

WFP 2004 Allen 2001

Cost range (US$/person/year)


Cost ranges in the literature


Preliminary

Fortification cost per beneficiary varies tremendously

depending on the micronutrient and the program/source

0.20

0.98

0.17 0.150.10

1.00

0.12 0.10 0.06 0.05

0.50

0.050.10

0.05 0.09 0.100.09 0.02

0.69

0

1

2

World Bank

(Caulfield)

World Bank

(Fiedler)

Copen-

hagen

Consensus

WFP World

Hunger

Series

World Bank

(Caulfield)

World Bank

- Sugar

(Fiedler)

WFP 2004 WFP World

Hunger

Series

World Bank

(Caulfield)

World Bank

(Horton)

Copen-

hagen

Consensus

WFP 2004

Cost (US$/person/year)


Source: "Repositioning nutrition as central to development." World Bank, 2006.; "Copenhagen Consensus 2008 Challenge Paper: Hunger and malnutrition." Horton et. al., 2008.; "What would it costper child to meet the needs of some 300 million hungry children?" WFP, 2004.; "World Hunger Series 2007. Hunger and Health." WFP, 2007.; "What works? A review of efficacy and effectiveness ofnutrition interventions." Allen et al, 2001.

Cost ranges in the literature

Fortification


Preliminary

Premix costs comprise ~80 to 90% of total fortification costsBut costs can be passed to the consumers via slight price increase

Fortification

1. Data from HKI fortification project in West AfricaSource: Expert interviews

Main cost itemsMain cost items

Premixes

DescriptionDescription

• Fortificant premixes, typically sourced from international suppliers• Available at different concentration levels, affecting price and handling

Typical payerTypical payer

• 1-2% mark-up usuallypassed onto consumer

• Often absorbed bypremix suppliers ordonor in first year

Fortification

equipment

• System costs vary based on specific production process and configuration– e.g. in West Africa a system to add fortificants during existing production

process costs about $25-50k whereas a batch system that addsfortificants post-production costs about $50-100k

• Can be manufactured locally if local suppliers are available– Often much cheaper, no import duties occur

• Industry• Sometimes funders

cover costs for 1styear of operations

• Sometimes premixsuppliers provideequipment or fund for1st year

Public marketing• Costs for public marketing of fortification

– TV, radio, posters, logo development• Donor or government

Partnership

building and

legislation

• Staff and consultant costs to perform– Government advocacy– Technical consultations– Demand/consumption studies– Stakeholder workshops

• Donor or government


Preliminary

Where to go for further information


Preliminary

Key reference materials: Micronutrients – general

• "Fortification handbook."Micronutrient Initiative, 2004

• "Preventing micronutrient malnutrition:A guide to food-based approaches -A manual for policy makers andprogramme planners." FAO, 1997.(only weblink available)

• "Guidelines on food fortification withmicronutrients." WHO/FAO, 2006

• "Vitamin and mineral requirements inhuman nutrition." WHO/FAO, 2004

• "Preventing and controllingmicronutrient deficiencies inpopulations affected by anemergency." WHO/WFP/UNICEF,2007

• "Composition of a multi-micronutrientsupplement to be used in pilotprogrammes among pregnant womenin developing countries. Report of anUNICEF/WHO/UNU workshop."UNICEF/WHO/UNU, 1999

• N/A

Normative guidance Operational guidance Training materials


Preliminary

Key reference materials: Micronutrients – vitamin A

• "Vitamin A supplements: a guide totheir use in the treatment andprevention of vitamin A deficiencyand xerophthalmia." WHO, 1997

• "Indicators for assessing vitamin Adeficiency and their application inmonitoring and evaluatingintervention programmes." WHO,1996

• "Vitamin A deficiency and itsconsequences: a field guide to theirdetection and control." WHO, 1995

• "Safe vitamin A dosage duringpregnancy and lactation." WHO,1998.

• "Vitamin A training activities forcommunity health and development ."HKI, 1993. (not yet available)



Preliminary

Key reference materials: Micronutrients – iron

• "Iron deficiency anaemia: assessment,prevention and control - A guide forprogramme managers." WHO, 2001

• "Preventing and controlling irondeficiency anaemia through primaryhealth care - A guide for healthadministrators & program managers."WHO, 1989

• "The guidebook nutritional anemia."Sight & Life, 2007

• "Anemia prevention and control: Whatworks.” USAID/WB/UNICEF/WHO/FAO/MI, 2003

• "Anemia detection in health services:Guidelines for program managers."PATH/OMNI, 1996

• "Guidelines for the control of irondeficiency in countries of the easternMediterranean." WHO, 1995

• "Guidelines for the use of ironsupplements to prevent and treat irondeficiency anemia." WHO, 1998

• "Focusing on anaemia - towards anintegrated approach for effectiveanaemia control." WHO/UNICEF,2004

• "Iron supplementation of youngchildren in regions where malariatransmission is intense."WHO/UNICEF

• N/A



Preliminary

Key reference materials: Micronutrients – zinc

• "Diarrhoea treatment guidelinesincluding new recommendations forthe use of ORS and zincsupplementation for clinic-basedhealthcare workers."USAID/UNICEF/WHO, 2005

• "Conclusions of the jointWHO/UNICEF/IAEA/IZINCGinteragency meeting on zinc statusindicators." de Benoist et. al., 2007

• N/A



Preliminary

Key reference materials: Micronutrients – iodine

• "Assessment of iodine deficiencydisorders and monitoring theirelimination - A guide for programmemanagers." WHO, 2007

• "Guidelines for a national programmefor the control of iodine deficiencydisorders in the easternMediterranean region." WHO, 1988

• "Salt iodization for the elimination ofiodine deficiency." ICCIDD, 1995.

• "Monitoring universal salt iodizationprograms." PAMM/MI, 1995

• "Universal salt iodization. SCN News35." SCN, 2007

• "The safe use of iodized oil duringpregnancy." WHO, 1996

• "Recommended iodine levels in saltand guidelines for monitoring theiradequacy and effectiveness." WHO,1996

• "Reaching optimal iodine nutrition inP&L women and young children."WHO/UNICEF, 2007

• N/A



Preliminary

Organizations: Micronutrients (I)

Food and Agriculture

Organization of the United

Nations (FAO)

• www.fao.org

UNICEF

• www.unicef.org

World Health Organization

(WHO)

• www.who.org

• United Nations food andagriculture program

• United Nations Children'sFund

• United Nations HealthOrganization

• Provides assistance andsupport to governments indeveloping the food,agriculture, and nutritioncomponents of theirmicronutrient strategies

• Provides financial andtechnical support fordeveloping country activitiesaimed at controllingmicronutrient deficienciesthrough supplementation,fortification and dietarymodification

• Maintains global micronutrientdata bank, providesinternational technicalguidelines and providestechnical assistance tomicronutrient programsthrough national ministries ofhealth

OrganizationOrganization DescriptionDescription Key activitiesKey activities

Multilateral


Preliminary

Organizations: Micronutrients (II)

World Bank

• www.worldbank.org

UN Standing Committee on

Nutrition

• www.unsystem.org/scn

World Food Programme

• www.wfp.org

• International development bank

• UN committee to promotecooperation among UNagencies and partnerorganizations to endmalnutrition

• UN Nations food emergencyprogram

• Provides loans formicronutrient programs indeveloping countries, withspecial interest infortification programs

• Serves as a focal point forharmonizing anddisseminating informationon micronutrient policiesand activities in the UNsystem

• Uses Mixme in some of itssupplementary feedingprograms


Multilateral

(cont'd)


Preliminary

Organizations: Micronutrients (III)

Canadian International

Development Agency (CIDA)

• w3.acdi-cida.gc.ca

US Agency for International

Development (USAID)

Office of Health and Nutrition

Bureau of Global Programs

Field Support and Research

• www.info.usaid.gov

ICCIDD (International council

for control of iodine deficiency

disorders)

• www.iccidd.org

• Canadian development aidagency

• US development aid agency• (A2Z project through AED)

• Multidisciplinary globalnetwork consisting of over600 specialists (scientists,public health workers,development managers,technologists, communicators,economists, salt producers,other industry experts)

• Supports micronutrientactivities in Africa, LatinAmerica, and Asia

• Provides technical supportand assists agencies toimplement and evaluateprograms and policies toprevent micronutrientdeficiencies throughsupplementation, fortificationand dietary modification;

• Funds projects

• Advocacy• Support of country programs• Provision of data on iodine

deficiency• Publication of a newsletter• Provision of technical

resources


Bilateral

NGO


Preliminary

Organizations: Micronutrients (IV)

Helen Keller International

(HKI)

• www.hki.org

International Vitamin A

Consultative Group (IVACG)

• http://ivacg.ilsi.org/

Iodine Network

• www.iodinenetwork.net

• Global NGO focusing on thetwo major areas of eye healthand nutrition

• Established by USAID toprovide support and guidanceto eliminate vitamin A deficiency

• Alliance of severalorganizations (e.g., WHO,GAIN, MI) to eliminate iodinedeficiency

• Provides technicalassistance on a wide rangeof components ofmicronutrient deficiencycontrol programs, includingadvocacy, assessment,training, social marketingand operational research

• Sponsoring of expertmeetings, developing ofguidelines, and knowledgeexchange

• Supports national efforts toeliminate iodine deficiencyin a sustainable manner bypromoting collaborationamong public, private,scientific and civicorganizations


NGO (cont'd)


Preliminary

Organizations: Micronutrients (V)

GAIN

• www.gainhealth.org

International Zinc Nutrition

Consulting Group (IZINCG)

• www.izincg.org

Micronutrient Initiative

• www.micronutrient.org

• Funding• Provides technical assistance

on the design, implementationand evaluation of nutritionprograms and food fortificationin particular

• Communications and advocacy• Strong focus on performance

measurement and monitoring

• Advocacy• Education/training• Technical assistance• Development and evaluation of

zinc programs• Dissemination of technical

information

• Basic research• Setting up local fortification• Developing & implementing

national programs• Serves over 75 countries

• Swiss foundation aimed atreducing malnutrition throughthe use of food fortificationand other strategies in closecooperation with the privatesector

• International NGO to promoteand assist efforts to reducezinc deficiency

• Canada- based internationalNGO dedicated to eliminatingvitamin and mineraldeficiencies worldwide


NGO (cont'd)


Preliminary

Organizations: Micronutrients (VI)

Iron Deficiency Project

Advisory Service (IDPAS)

• www.idpas.org

Micronutrient Forum

• www.micronutrientforum.org

Sprinkles Global Health

Initiative

• sghi.org

Flour Fortification Initiative

• www.sph.emory.edu/wheatflour

• Project of the InternationalNutrition Foundation and UNUniversity with primary supportfrom Micronutrient Initiativededicated to improve ironnutrition

• Successor organization ofIVACG and INACG funded byUSAID that focuses particularlyon vitamin A, iron, folate, iodine,and zinc

• Initiative comprising a group ofresearchers, academics andpublic health professionalsbased at the Hospital for SickChildren in Toronto, Canada

• Network of private, public andcivic organizations workingtogether to make micronutrientfortification of flour standardpractice

• Provides technical information• Responds queries from

researchers & projects toimprove intervention delivery

• Organizes int. meetings onmicronutrient science

• Organizes global meetings andfacilitates knowledge exchangeon policy-relevant sciencearound micronutrients

• Research & program design• Advocacy & partnership

development & communication• Sprinkles™ production, procure-

ment & technology transfer

• Enables interaction andpartnership between publicsector & flour industry

• Informs and encourages flourindustry to do fortification


NGO (cont'd)


Preliminary

Scaled-up programs: Micronutrients

1. Initial case study provided

• Wheat flour fortification became mandatory in Indonesia in 1998• Fortified with iron, zinc, thiamin, riboflavin, and folate

GovernmentWheat flour fortification,Indonesia

• Vitamin A program reached 6.6M beneficiariesGovernmentNational iron and vitamin Asupplementation programs,Brazil

• National level "Micronutrient Days" enabled coverage of 3.8Mchildren (> 95% of target children) and > 1.3M women

Ministry of health, UNICEFVietnam vitamin Asupplementation campaign

• Mandatory fortification• Prevalence of iron deficiency (ID) dropped from 37% in 1992 to 16%

in 1994 only 1 y after the iron fortification program was started

GovernmentVenezuela, iron fortification offlours

• Nationwide coverage as food fortification law passed in 2000• Increase in haemoglobin observed

GovernmentPhilippines, iron fortification ofrice

• Program accounts for more than 50% of all vitamin A in theGuatemalan diet

• Its success drove its expansion to Honduras and Nicaragua

GovernmentGuatemala, sugar fortificationwith vitamin A

HKI, local governments, industry association AIFO-UEMOA

Government

ICDDR, B, government and private sector partners

Implementing partners

• Fortification of vegetable oil with vitamin A• Multi-country project in Benin, Burkina Faso, Côte d'Ivoire, Guinea

Bissau, Mali, Niger, Senegal, Togo

Fortify West Africa in 8 countriesof Monetary & Economic Unionof West Africa1

• Reached 94% population coverage since 1991 launch• Prevalence of goiter fell from 20% in 1995 to <9% within 2 years

China, salt iodization

• Zinc tablets produced by private manufacturer and distributedthrough private sector channels

• 90% of urban and 50% of rural mothers became aware that zincshould be used as diarrhea treatment

Bangladesh Scaling Up ZincTreatment for Young Children(SUZY)1

Other informationName/country


Preliminary

Appendix: experts consulted


Preliminary

Experts consulted during preparation of this document

Micronutrients, implementationWFP, Chief Nutrition, MCH & HIV/AIDSTina Van Den Briel

FortificationHKI Senegal, Regional food fortification coordinatorMawuli Sablah

Supplementation and fortificationMicronutrient Initiative, Regional Director AsiaLuc Laviolette

ICDDR,B Bangladesh, SUZY project

UNICEF, Special Advisor to the Executive Director on Ending Child Hungerand Undernutrition Initiative

HKI Senegal, Vice President and Regional Director for Africa

Organization and title

Zinc supplementation

Micronutrients in general

Vitamin.A/Iron fortification

Area of expertise

Charles Larson

Ian Darnton-Hill

Shawn K. Baker

Name

Documents

Version 2 REACH - UNSCN...REACH_Acting at Scale_Guide_Micronutrients_v2.ppt 3 Preliminary Key messages Micronutrient deficiencies are widespread, with severe effects • 44M DALYs