AIMING FOR PROGRAM EXCELLENCE — HOME FORTIFICATION WEBINAR

SERIES

Moderated by Jonathan Siekmann, PhD

Technical Advisor, GAINSecretariat, 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 programsTarget 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

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The global picture: stunting prevalence

UNICEF Improving Child Nutrition Report 2013

The global picture: severe acute malnutrition

UNICEF Improving Child Nutrition Report 2013

8

• Vitamin and mineral deficiencies account for over 50 million disability-adjusted 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 annually (Black et al., 2013)

The global picture: “Hidden Hunger” Iron Folic acid

Iodine

Vitamin A Zinc

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

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

Adolescent girlsWomen of RA Pregnant & lactating women

Maternal nutrition (prevention of low birth weight)Infant & young child feeding

Prevention and treatment of severe acute malnutritionMicronutrient fortification and supplementation

Nutrition support for those with infectious diseases

Health, WASH, early childhood development, social protection, education, agriculture, poverty reduction

Targ

etpo

pula

tions

(foc

usin

g on

the

mos

t dis

adva

ntag

ed)

Nutrition-specific interventions Nutrition-sensitive approaches

Children under 2 yearsChildren aged 2−5 years

UN

ICEF

prog

ram

me

actio

ns Reduce micronutrient

deficiencies

Prevent and treat SAM

Improve nutritional

care for those with

infectious disease

Protect, promote and

support appropriate feeding &

adequate food

Increase synergies with health, WASH, ECD and social

protection

Promote strengthened linkages with

agriculture

Promote linkages with health & education to

prevent childhood obesity

UN

ICEF

’s co

mm

itmen

t to

nutr

ition

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

Operational approach 6:

Strengthen systems to

ensure effective

monitoring, evaluation

and knowledge

management for policy and programming for nutrition.

Operational approach 5:

Foster a community-

centred approach that

empowers communities

with the knowledge and tools to

address their own nutrition

issues.

Operational approach 4:

Develop human,

institutional and

organizational capacity to implement

contextually relevant nutrition

programmes.

Operational approach 3:

Support the scale-up of evidence-

based, sustainable nutrition-specific

interventions and nutrition-

sensitive programming.

Operational approach 2:

Build commitment,

strengthen leadership

and strengthen governance for improved

nutrition.

Operational approach 1:

Perform a rights-based,

equity-focused situation

analysis for nutrition and

its determinants

to inform policy

development and

programme design.

Reduce micronutrient

deficiencies

Prevent and treat SAM

Protect, promote and

support appropriate feeding &

adequate food

Increase synergies with health, WASH, ECD and social

protection

Promote strengthened linkages with

agriculture

Promote linkages with health & education to

prevent childhood obesity

Improve nutritional

care for those with

infectious disease

UN

ICEF

’s

com

mit

men

t to

nu

trit

ion

UN

ICEF

pro

gra

mm

eacti

on

s

Notes: Green arrows illustrate that the operational approaches are interrelated.

UNICEF’s operational approaches to improving nutrition programming for mothers and children

12

• Partnership

• 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

Work in Home Fortification using

MNPs

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Impressive scale-up 2011*

36 MNP interventions implemented in 22 countries

Planned interventions in 20 countries

4 countries were implementing at national scale

2013** 62 MNP interventions

implemented in 42 countries

MNP interventions are planned in 19 countries

13 countries implementing at national scale

**UNICEF NutriDash, 2014 * Home Fortification Global Assessment 2011

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

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– 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

Technical Resources to address the

growing capacity needs

Aiming for Program Excellence

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• 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

Timely opportunity to build capacity

HF-TAG Home Fortification Webinar:

Session One

Martin Bloem Senior Nutrition Advisor, Nutrition Advisory OfficeWorld 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

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-TAG brief & WHO MNP guideline

HF is a priority intervention for WFP’s work

• 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’s work in home fortificationWFP’s work in home fortification

• 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

• 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

HF-TAG: Better results through partnershipHF-TAG: Better results through partnership

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-RosasCoordinator, 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. 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.

WHO evidence-informed guidelines

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.

The evidence

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 evidence-

informed 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 policy-makers, 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 ObesityU.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

Will be available late 2014 at:www.hftag.org

HF-TAG MNP Toolkit

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