Ms Zamazulu Mtshali

Department of Health- KZN

World Nutrition Congress 2016

Introducing micronutrient powders (MNP) into the Public

Health System: A case study of KwaZulu - Natal,

South Africa

KZN SCENARIO• KZN has the second largest population in the country of 10 694 400 million

• Unemployment rate at 33% compared 29.8% nationally. (Census 2011)

• KZN bears a disproportionately high burden of poverty with 63% to 82% of households living on less than R800 per month (District Health Barometer 2015)

• Proportion of households with no access to piped water 14.1% . Second highest in the country

• HIV incidence 39,4%, More than 1 million people on ART Antenatal Seroprevalence Survey 2013

• an estimated infant mortality rate (IMR) of 25.4/1000 and a child mortality rate (U5MR) of 35/1000 (2nd Triennial Report of the Committee on Morbidity and Mortality in Children under 5

Years (CoMMiC-2014 Report),

• The Province has an exclusive breastfeeding rate of 45.1% (KIBS baseline 2014)

compared to 34.3% at 14 weeks as per the Impact Assessment of the 2011

• Malnutrition remains one of the leading comorbidities for children under the age of 5 years 34%4

BACKGROUND• Optimum nutrition during the first 1000 days is critical for

child survival.

• Poor nutrition during this period is linked to poor childhealth outcomes.

• Vulnerability to micronutrient malnutrition due to rapid

growth and development 1.

• (NFCS- FB) 2005 demonstrated that South Africanchildren intakes of micronutrients were below two-thirdsof the RDAs.

1Guideline: Use of multiple micronutrient powders for home fortification of foods consumed by infants and children 6–23 months of age. WHO (2011)

2.Labadarios D, et al (2005). National Food Consumption Survey-Fortification Baseline (NFCS-FB). South Africa

BACKGROUNDContributing factors to a poor micronutrient intake andstunting in children in South Africa

(a) early introduction of solid foods,

(b) low rates of exclusive breastfeeding,

(c) lack of dietary diversity

(d) complementary foods based on maize, but low in animal

foods, vegetables and fruits3,4 .

• 3HF-TAG (2013). A manual for developing and implementing monitoring systems for home fortification interventions. Report of the home fortification technical advisory group (HF-

Key proven interventions for the prevention and treatment of stunting and other forms of undernutrition

• Nutrition interventions that have been cited to contribute to

optimum growth includes:

Improvement of exclusive breastfeeding and adequate timely

complementary feeding has been found to play a crucial role throughout

the life cycle.

• Micronutrient supplementation has been cited as one of the

interventions that has an impact on the nutritional status even at community level.

Key proven interventions for the prevention and treatment of stunting and

other forms of undernutrition

• The MNPs were introduced as part of the IYCFstrategy because the intention is improvenutrient intake from complementary foods.

• MNPs given in a package of child care i.e.strengthening assessment, screening,counselling and support for the targetedgroup

• Strengthening education to mothers/caregivers on IYCF including communicatingcomplementary feeding messages

• Training on Standard operatingprocedures was done targetingall relevant stakeholders

• Implementation and reportingtools were developed

• Complementary feeding training was conducted

Pilot: 169 Poorest Wards in KZN88 878 children 6-24mths

4 856 984 sachets

Implementation of the Pilot: December 2014- October 2015

– 10 Districts

– clinics and households by health

care workers and community

caregivers respectively.

Objectives of the Evaluation

Implementation 1 April 2016

3 Districts

5 688 000 sachets

From 18 Hospitals to

272 clinics

31 600 Children 6-

24mths

R5m Prov budget

allocation

• To assess the acceptability ofthe MNPs to mothers,caregivers and health careworkers

• To assess the feasibility of theintroduction of MNP into thecurrent public health system inKwa-Zulu Natal, South Africa toinform provincial policy.

METHODOLOGY• A cross sectional descriptive survey was conducted

• Fifty-percent (n=5) of the piloted districts were targeted forparticipation.

• Pre-tested semi-structured questionnaires wereadministered to health care workers through interviews

• Fifty (n=50) interviews were held with health care workers

• 18 CCG group interviews (n=125) were held with CCCGs

• 18 Focus group discussions were held with (n=66) mothersand caregivers

• Data was analyzed using a specifically designed MS Excelspreadsheet.

RESULTSAcceptability:

• 63 out of 68 (93%) of the health care workersindicated that the micronutrient powders wereimportant to improve the health of the child.

• Overall, mothers/caregivers accepted the interventionwell and were enthusiastic about the positive effectsexperienced by their children on use of the MNP

RESULTSFeasibility:

• 60 out of 64 (94%) health care workers interviewed,indicated that the MNP intervention fitted in well &easily with other nutrition and child health interventions

• Over 70% health care workers experienced no problemswith regards to delivery, storage, distribution, stockcontrol & reporting

• Responses from <30% of the health care workersindicated that communication on delivery, distribution,and storage space could be improved.

RESULTSTraining

• Just over half (56%) of the health care workersinterviewed revealed satisfaction with the training andsupport provided prior to the implementation of theMNP pilot intervention whilst (51%) indicated thatthey made reference to the standard operatingprocedure

RESULTS

• 18% (n=8) health careworkers recalled havingdiscussed appropriatefeeding of the child withthe mothers/caregivers.

• The feeding advice onlyfocused on adding theMNP to porridge

RESULTS

What mothers have said“It increased her appetite because she

never used to like porridge but now she eats it and her skin rash has cleared.”

I have seen a difference like I said before…my baby's weight picked up fast.”

“It will give our children extra vitamins that will help them to grow. I am already seeing the results. My child is eating and growing

well.’’

’If a child has poor appetite the powder helps to open up the

appetite

“I was not sure what was it for and “why it was given to my child but I did not have ask the nurse. They gave me

sufficient information and I understood very well.”

“We'd buy it because with it our children are

growing well on it”

CONCLUSION

• The findings in this evaluation compares with literature interms of acceptability among mothers/caregivers andrecognition of the benefits to the child5.

• Overall micronutrient powders were accepted by thehealth care workers and by the mothers/caregivers.

• However, logistical arrangements require attention forfuture implementation.

Jefferds MED, Ogange L, Owuor M, Cruz K, Person B, Obure A, Parminder S, Suchdev PS, Ruth LJ (2010). Formative research exploring acceptability, utilization, and promotion in order todevelop a micronutrient powder (Sprinkles) intervention among Luo families in western Kenya.

Food and Nutrition Bulletin 31(2): supplement.

CONCLUSION• In order to address challenges and concerns that emanated from

the evaluation process,

• the KZN Province have subsequently decided to implement theMNP intervention at scale in 3 Districts to ensure proper alignmentto current health systems, as per one of the key recommendationsfrom the evaluation report.