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Looking Back to Look Forward‐Lessons from USAID in estments inLessons from USAID investments in reducing micronutrient deficiencies

Rolf Klemm, DrPH

A2Z Technical Director

Johns Hopkins School of Public Health

What has been the return on USAID’s Micronutrient investments?

Key FactorsKey Factors

• Bold Leadership (combined with)Bold Leadership (combined with)……

– Investments in 3D’s

•Discovery       Development       Deployment

–Credible inter‐disciplinary expert groupsCredible inter disciplinary expert groups

–Evidence summits

– “Luck”?

The Great Protein Fiasco, Lancet, 1974The Great Protein Fiasco, Lancet, 1974

Dogma Disputed

1974

Flooding inPetroleum Crisis Ethiopian Famine

Flooding in Bangladesh

First World Conference on Nutrition, Rome, 1974

“Today we must proclaim a bold objective—that jwithin a decade NO CHILD WILL GO TO BED HUNGRY, that no family will fear for its next day’s bread, and that no human being’s future and capacities will be stunted by malnutrition”

Henry Kissinger,World Food Conference, 1974

1st Success Factor1st Success Factor

Bold LeadershipBold Leadership……

Martin Forman, USAID James Grant, UNICEFAlfred Sommer, Johns HopkinsLeadership and Nutrition Ch i

Frances Davidson USAIDErnest Loevinsohn CIDA

ChampionsFrances Davidson,  USAID

Duff Gillespie, USAID

Ernest Loevinsohn, CIDAEmorn Wasantwisut,Mahidol University

Melinda Gates Hillary Clinton

Howdy Boius,Harvest Plus

Meera Shekar,World Bank

Institutional ChampionsInstitutional Champions

…and many others

2nd Success Factor

Discovery Development

Investments in the 3D’sD l t

Why? Acceptable?  How to delivery at l ?

Discovery Development Deployment

Where?Who?Wh l i

Affordable?Safe?Delivery

scale?*Assessments*Nat’l policyWhat solution—

dose, frequency?Delivery Mechanism?

Nat l policy*Logistics/Supplies*Mgmt*Capability*Communications*M i i*Monitoring*Evaluation

DiscoveryDiscovery…….

Vitamin A Reduces Preschool Child MortalityPreschool Child Mortality 

~23% d ti~23% reduction 

Therapeutic Effects of Zinc on Duration of  Acute Diarrhea

*Bangladesh, 1999*India, 1988

*India, 2000*Brazil, 2000*India, 2001

I d i 1998Indonesia, 1998India, 1995

Bangladesh, 1997India 2001India, 2001

India, 2001

Nepal, 2001

Pooled 

Bangladesh, 2001

1

*Difference in mean and 95% CIRelative Hazards and 95% CI

0.5       0.75 1.25

Development of SolutionsDevelopment of Solutions…….

Home‐based Fortification‐Micronutrient “Sprinkles”Micronutrient  Sprinkles

Microencapsulated ferrous fumerate in powdered form are as effective as ferrous sulphate drops in treating 

i i i f t 6 18anemia in infants 6‐18 mo.

Zlotkin, AJCN, 2001Zlotkin, J Nutr, 2003Zlotkin, J Nutr, 2003

Bio‐fortification

Tropical Maize  varieties ith hi h l l f b t Orange‐fleshy sweetwith  high levels of beta‐

carotene

Orange fleshy sweet potato

Sodium Iron EDTA

Deployment……

Deployment—Using global lessons to move local programs

YearUSAID‐supported

MN P j tFocus

$/yrMilli

move local programs

MN Projects  Million

2005‐2011

"A2Z“(AED)

Sustaining VAS coverage, Food Fortification, Maternal Anemia, ~8

2011 (AED)Newborn VA

1998‐ “MOST”VAS Child Survival Weeks, VA in 

PL480 oil Food‐based interventions ~102005 (ISTI)

PL480 oil, Food based interventions, MN indicators in DHS

10

1993‐ “OMNI ” VAS, wheat flour & sugar ~10

1998 (JSI) fortification, salt iodization, IFA 10

1989‐“VITAL”(ISTI)

Expand known methodologies to ?

1994(ISTI)

p gcombat VA deficiency

?

Example: VA SupplementationExample: VA Supplementation

Fortification PublicationsFortification Publications

Program Components for Successful Micronutrient Intervention Implementation

Assessment Inputs

Micronutrient Intervention Implementation

Policy Formation

Advocacy

ProcessPolicy Formation

Political SupportOutputs

LogisticsOutputs

Capacity Building Outcomes

CommunicationsProcess 

MonitoringEffectiveness Evaluation

3rd S ccess Factor3rd Success Factor

Credible Inter-disciplinary Expert Groups

INACGIVACG

Interdisciplinary Expert Groups‐IVACG, INACG, MF

Innocenti Process, 2008Innocenti Process, 2008

Evidence‐based stock‐taking ofstock taking of performance and ff ti feffectiveness of micronutrient interventions at scalescale 

4th Success Factor“Evidence Summits”Evidence Summits

IVACG, INACG & MF meetings

“Luck”?Luck ?

Vitamin A Supplementation

Iodine FortificationExcellent food vehicle 

SimpleVisible

Simple technology Inexpensive

InexpensiveLife‐saving results

Visible results

LessonsLessons

• Bold Leadership & Powerful ChampionsBold Leadership & Powerful Champions

• Investment in the 3’DsE id i t h– Evidence is not enough.

• Credible cross‐disciplinary expert groups to accelerate the filling of the “Know‐Do” gap

• Evidence summits to rapidly promote & disseminate evidence‐based findings/practices

• “Luck”?

Remaining ChallengesRemaining Challenges

• Sustaining gains of previous investments• Sustaining gains of previous investments• Moving from Donorship to Ownership• Reducing anemia in women and children• Delivery at‐scale of efficacious interventions• Investment in how to move from “Farm‐to‐Fork” to enhance nutrient content & diversity of dietsenhance nutrient content & diversity of diets

• Maintaining visibility of MNs because preventing “non‐events” make it difficult sustain MN investments 

• New discoveries for other MNs (e.g vitamin D) & enhanced discoveries of “old” MNs (e.g. long‐term effects))

Thank you!Thank you!

Fortification

Diet

SupplementsSupplementsDeficientPopulation