AIMING FOR PROGRAM EXCELLENCE
— HOME FORTIFICATION WEBINAR
SERIES
Moderated by Jonathan Siekmann, PhD
Technical Advisor, GAIN
Secretariat, Home Fortification Technical Advisory Group (HF-TAG)
Home Fortification Webinar Series
What: A series webinars organized by UNICEF, CDC, and HF-TAG to
address the increasing demand for technical support and to
continuously address knowledge capacity gaps in home fortification
Objectives:
• Increase knowledge and capacity to design and implement
effective home fortification programs.
• Share country experiences and lessons learned with developing,
implementing, and scaling up home fortification programs
Target audience:
• The main audience for the webinars will be program implementers
who are either planning or implementing home fortification
programs.
Where: The HF-TAG site http://www.hftag.org/webinars/
Frequency: Bi-monthly
Today’s webinar
• Global evidence and policies for home fortification
• WHO guideline and HF-TAG complement each other
in support to countries
• Monitoring to improve program effectiveness
• Speakers
– Dr. Werner Schultink (UNICEF)
10 min
– Dr. Martin Bloem (WFP)
10 min
– Dr. Juan Pablo Peña-Rosas (WHO)
10 min
– Dr. Laurence Grummer-Strawn (CDC) 10 min
Home Fortification Webinar
Series Launch
Werner Schultink,
Chief, Nutrition Section, UNICEF
Headquarters, New York
Session Outline
• Overview of global nutrition situation
• UNICEF’s work
• Home fortification technical resources to address
increasing demand
The global picture: stunting prevalence
UNICEF Improving Child Nutrition Report 2013
6
The global picture: severe acute malnutrition
UNICEF Improving Child Nutrition Report 2013
Iron
The global picture: “Hidden Hunger”
Folic acid
Iodine
Vitamin A
Zinc
• Vitamin and mineral deficiencies account for over 50 million disabilityadjusted life years (DALYs) lost globally (Murray et al, 2013)
• Global estimates of anemia prevalence are 42% in pregnant women and
47% pre-school age children. (WHO, 2009)
• Severe anemia kills more than 50,000 women a year during childbirth.
(Micronutrient Initiative, 2014)
• 18 million babies are born mentally impaired due to iodine deficiency
each year. (Micronutrient Initiative, 2014)
• Deficiencies of vitamin A and zinc account for nearly 300,000 child deaths
8
annually (Black et al., 2013)
Growing momentum to scale up nutrition
• Scaling Up Nutrition
(SUN) movement
• Interest in nutrition
increased dramatically
• Investing in nutrition
key development
priority
• Partnerships are more
operational, enhanced
complementarity
54 countries have committed to
SUN
Target
populations
(focusing on the
most disadvantaged)
UNICEF
programme
actions
UNICEF’s
commitment to
nutrition
UNICEF’s programmatic work in nutrition
Markedly improve nutrition for all children and women by creating an enabling environment that
results in evidence-based, sustainable, multisectoral nutrition actions delivered at scale
Protect,
promote and
support
appropriate
feeding &
adequate food
Reduce
micronutrient
deficiencies
Improve
nutritional
care for those
with
infectious
disease
Prevent and
treat SAM
Adolescent girls
Women of RA
Increase
synergies
with health,
WASH, ECD
and social
protection
Children under 2 years
Children aged 2−5 years
Nutrition-specific interventions
Maternal nutrition (prevention of low birth weight)
Infant & young child feeding
Prevention and treatment of severe acute malnutrition
Micronutrient fortification and supplementation
Nutrition support for those with infectious diseases
Promote
strengthened
linkages with
agriculture
Promote linkages
with health &
education to
prevent
childhood
obesity
Pregnant & lactating women
Nutrition-sensitive approaches
Health, WASH, early childhood development, social protection,
education, agriculture, poverty reduction
UNICEF’s
commitment to
nutrition
UNICEF
programme
actions
UNICEF’s operational approaches to improving
nutrition programming for mothers and children
Markedly improve nutrition for all children and women by creating an enabling environment
that results in evidence-based, sustainable, multisectoral nutrition actions delivered at scale
Protect,
promote and
support
appropriate
feeding &
adequate food
Reduce
micronutrient
deficiencies
Prevent and
treat SAM
Improve
nutritional
care for those
with
infectious
disease
Increase
synergies
with health,
WASH, ECD
and social
protection
Promote
strengthened
linkages with
agriculture
Promote linkages
with health &
education to
prevent
childhood
obesity
Operational
approach 1:
Operational
approach 2:
Operational
approach 3:
Operational
approach 4:
Operational
approach 5:
Operational
approach 6:
Perform a
rights-based,
equity-focused
situation
analysis for
nutrition and its
determinants to
inform policy
development
and programme
design.
Build
commitment,
strengthen
leadership and
strengthen
governance for
improved
nutrition.
Support the
scale-up of
evidencebased,
sustainable
nutritionspecific
interventions
and nutritionsensitive
programming.
Develop
human,
institutional and
organizational
capacity to
implement
contextually
relevant
nutrition
programmes.
Foster a
communitycentred
approach that
empowers
communities
with the
knowledge and
tools to address
their own
nutrition issues.
Strengthen
systems to
ensure effective
monitoring,
evaluation and
knowledge
management
for policy and
programming
for nutrition.
Notes: Green arrows illustrate that the operational approaches are interrelated.
• Partnership
Work in Home
Fortification using
MNPs
• Global/national policies and guidelines
• Capacity: Workshops reaching 66
countries on design, implementation,
scale up and monitoring of HF programs
• Information: 2011 global assessment of
HF. UNICEF to make it annual through
NutriDash from 2013
• Implementation of home fortification
programs
12
Impressive scale-up
2011*
2013**
36 MNP interventions
implemented in 22
countries
62 MNP interventions
implemented in 42
countries
Planned interventions
in 20 countries
MNP interventions are
planned in 19 countries
4 countries were
implementing at
national scale
13 countries
implementing at
national scale
* Home Fortification Global Assessment 2011
**UNICEF NutriDash, 2014
13
With rapid scale up
• Increased technical needs
• Variation in challenges depending on the level of
implementation
• Great opportunity for inter-country and inter-agency
learning
Aiming for Program Excellence
Technical
Resources to
address the
growing
capacity needs
– Community of practice online
opportunity for inter- country learning
http://network.hftag.org/categories
– MNP toolkit ( upcoming) consolidation
various tools, best practices and
examples on implantation of home
fortification
– Series of Home Fortification Webinars
15
Timely opportunity to build capacity
• Home fortification webinars are great and
timely opportunity to enhance capacity of
program implementers for program
improvement
• Webinars and resources are open to all
program implementers
16
HF-TAG Home
Fortification Webinar:
Session One
Martin Bloem
Senior Nutrition Advisor,
Nutrition Advisory Office
World Food Programme
Key messages
• Home fortification (HF) is a key and promising intervention to address
micronutrient deficiencies and to improve quality of food for young
children
• Home fortification is a priority nutrition intervention for WFP
• WFP is working with HF-TAG partners to enhance capacity and provide
harmonized guidance on why and how to implement HF
• Home fortification webinars are an important opportunity to enhance
understanding and capacity of program implementers for design and
implementation of infant and young child feeding (IYCF) programs that
have an HF component
Home fortification (HF) is a promising intervention
Rationale for home fortification
• Young children require a large range of
nutrients in order to grow, develop and remain
healthy
• Even when affordability and availability do not
constrain food access, it is difficult to meet the
recommended intakes of some nutrients, – e.g.
iron and zinc, particularly for children 6-23 mo
Objectives of home fortification programs
• Increase micronutrient (MN) intake and
improve IYCF practices
• Improve MN status
• Improve child health, appetite and growth,
and reduce morbidity and mortality
HF-TAG brief & WHO MNP guideline
WHO guideline based on review of studies that provided MNP
• Studies primarily focused on anemia and iron deficiency and
used limited set of MN
• Hence: WHO guideline: Minimum 3 micronutrients and at
least 60 sachets/6 mo
• Note that this is a guideline for decision making, not a fixed
prescription
HF-TAG programmatic guidance brief further expands WHO
guideline
• Improve micronutrient intake in order to meet the
recommended nutrient intake(FAO/WHO RNI) for more
micronutrients, in addition to those relevant for anemia
• Considering programming circumstances and experience
• Integrate with wider infant and young child nutrition &
‘1000 days’ programming
HF is a priority intervention for WFP’s work
WFP’s work in home fortification
• WFP is committed to preventing undernutrition and
meeting nutrient requirements during the critical
first 1,000 days
• MNPs play a critical role in combatting
micronutrient deficiencies through fortifying meals
of vulnerable populations, in particular young
children
• WFP and UNICEF are the main procurers of MNPs,
and WFP is the only organization that utilizes MNPs
in school feeding
• WFP uses MNPs in 19 countries in nutrition programming
• In 2013, WFP reached over a half a million beneficiaries under 5 in 7 countries
• Through school feeding programmes, WFP reached almost 900 thousand
school children aged 6-15 in 12 countries
WFP is working together with HF–TAG partners to
enhance capacity for home fortification
HF-TAG: Better results through partnership
• WFP is a committed partner of HF-TAG,
with the aim of providing harmonized
guidance on why and how to implement
HF
• HF-TAG works closely with private sector
partners, including manufacturers of MNP
• WFP also works with HFTAG partners
through the Scaling Up Nutrition (SUN)
Movement and the SUN Business Network
Webinars are a high potential opportunity to enhance
capacity for program improvement
Webinars and resources are open to everyone, and
particularly aimed at program implementers
Webinars will cover design and planning of home
fortification programs, including:
•
•
•
•
•
•
•
•
For whom?
What formulation?
How much and for how long?
What frequency for distribution and use?
Cost?
How quickly can a program start?
What distribution channels to use?
What to monitor and evaluate?
Point-of-use fortification of foods with multiple
micronutrient powders: WHO recommendations
Dr Juan Pablo Peña-Rosas
Coordinator, Evidence and Programme Guidance
Department of Nutrition for Health and Development
WHO core functions
•
providing leadership on matters critical to health and engaging in partnerships
where joint action is needed;
•
shaping the research agenda and stimulating the generation, translation and
dissemination of valuable knowledge;
•
setting norms and standards and promoting and monitoring their implementation;
•
articulating ethical and evidence-based policy options;
•
providing technical support, catalysing change, and building sustainable
institutional capacity; and
•
monitoring the health situation and assessing health trends.
These core functions are set out in the Twelfth General Programme of Work, entitled "Not merely the
absence of disease", it covers the 6-year period from 2014 to 2019
Vitamin and mineral malnutrition
• It is estimated that 42.6% of children 6-59 months of age are
anaemia (2011), which represented 273.2 million children
worldwide, with SEARO and WPRO having the absolute highest
numbers of children affected.
• Children's haemoglobin status might have deteriorated in some
southern countries in Africa.
• It is estimated that about half of the anaemia is due to iron
deficiency although the relative contribution varies.
• Iron deficiency is thought to be the most common cause of anaemia
globally, although other conditions, such as folate, vitamin B12 and
vitamin A deficiencies, chronic inflammation, parasitic infections,
and inherited disorders can all cause anaemia.
• Data on the prevalence of other vitamin and mineral deficiencies is
scarce.
WHO evidence-informed
guideline development
process
• New WHO guideline
development process
• 2nd edition of WHO
Handbook for guideline
development released in
December 2014
– Provides guidance on the
development of documents
or publications containing
WHO recommendations
– Sets out procedures to
follow
WHO evidence-informed
guideline development
process
WHO evidence-informed guidelines
WHO. Guideline: Use of multiple
micronutrient powders for home
fortification of foods consumed by
infants and children 6–23 months of age.
Geneva, World Health Organization,
2011.
The evidence
De-Regil LM, Suchdev PS, Vist GE, Walleser S, Peña-Rosas JP.
Home fortification of foods with multiple micronutrient powders for
health and nutrition in children under two years of age. Cochrane
Database of Systematic Reviews 2011, Issue 9. Art. No.: CD008959.
DOI: 10.1002/14651858.CD008959.pub2.
WHO recommendations
• Home fortification of foods with multiple micronutrient powders is
recommended to improve iron status and reduce anaemia among
infants and children 6–23 months of age (strong recommendation)
WHO recommendations
• In malaria-endemic areas, the provision of iron should be
implemented in conjunction with measures to prevent, diagnose
and treat malaria.
• Programmes should be preceded by an evaluation of the nutritional
status among children and existing measures to control anaemia
and vitamin A deficiency
• Behaviour change communication strategy that promotes:
awareness and correct use of the powders along with information
on recommended breastfeeding practices; commencement of
complementary foods at 6 months of age; preparation of
complementary foods at age-appropriate frequency, amounts,
consistency and variety
WHO recommendations
• Hand washing with soap and hygienic preparation of food; prompt
attention to fever in malaria settings; and measures to manage
diarrhoea.
• The selection of the most appropriate delivery platform should be
context-specific, with the aim of reaching the least favoured
populations and ensuring an adequate and continued supply of the
powders.
Adoption and adaptation
• WHO offers several tools to help countries adopt and adapt the
global guidelines into their national and subnational contexts.
• To ensure that WHO global guidelines and other evidenceinformed recommendations for micronutrient interventions are
better implemented in low and middle-income countries, the
Department of Nutrition for Health and Development works with
the WHO Evidence-Informed Policy Network (EVIPNet)
programme.
• EVIPNet promotes partnerships at country level between policymakers, researchers, and civil society to facilitate policy
development and implementation through use of the best
available evidence.
Home-Fortification Technical
Advisory Group (HFTAG)
• The Home Fortification Technical Advisory Group (HF-TAG) is a
community of stakeholders involved in home fortification
comprised of members from the public, private, academic and
non-governmental organization sector.
• Its vision is a world without malnourished children.
• WHO has observer status in this group.
HFTAG resources for implementation
Updating WHO recommendations
• To include recommendations to the preschool and school-age
children informing by the growing body of evidence.
• Confirm results from previous 2011 recommendations with updated
evidence from Cochrane reviews.
• Identify research gaps, particularly in the area of implementation
research.
• Highlight the need to address the social determinants of health in
the implementation of these interventions.
Acknowledgements
• The Evidence and Programme Guidance Unit receives
financial resources from several external sources for
biennium 2014-2015
– Ongoing support – longer term agreements
• Bill & Melinda Gates Foundation (2013-2016)
• US Centers for Disease Control and Prevention (CDC) (2009-2014)
– IMMPaCt Programme
– National Center on Birth Defects and Developmental Disabilities
• The Micronutrient Initiative (2014-2017)
• Harvest Plus (2014)
• Donors do not fund specific guidelines and do not participate
in any decision related to the guideline development process
including the composition of policy questions, membership of
the guideline groups, the conduct and interpretation of
systematic reviews, or the formulation of recommendations.
Monitoring Home Fortification
Programs
Laurence Grummer-Strawn, PhD
Chief, Nutrition Branch
Division of Nutrition, Physical Activity, and Obesity
U.S. Centers for Disease Control and Prevention
Principles of monitoring
• Monitoring improves program effectiveness
– Helps achieve good coverage and adherence to the
intervention
– Programmes must be well designed, implemented and
monitored in order to achieve and sustain impact
• Different data collection systems needed for different
purposes
• Monitoring changes and adapt over time
• Capacity in country can impact the quality of monitoring
systems
Monitoring Manual
Multi agency and
institutional involvement
Monitoring frameworks
Practical tools –such as
worksheets
Case studies
HF-TAG MNP Toolkit
Will be available late 2014 at:
www.hftag.org
Webinar series
Future sessions will include monitoring topics
Potential topics might include:
• Log frames and logic models – how to develop
these tools for your program
• How to select monitoring indicators
• Developing a monitoring protocol
• Pros and cons of different approaches to
monitoring
Thank you
Source – GAIN Global Alliance for Nutrition