CDC-UNICEF: A SUCCESSFUL PARTNERSHIP IN NUTRITION · lipid-based nutrient supplements. Through its work with the Food Fortification Initiative and Iodine Global Network, the partnership

CDC-UNICEF: A SUCCESSFUL PARTNERSHIP IN NUTRITION

Documentation of the years 2001 - 2014


Documentation of the years 2001 - 2014

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Contents

Abbreviations ............................................................................................................................................................................... III

Executive summary ................................................................................................................................................................... IV

Introduction ....................................................................................................................................................................................1

Projects .............................................................................................................................................................................................2

Country-focused projects ....................................................................................................................................................2

Globally focused projects .....................................................................................................................................................3

Partnership achievements .......................................................................................................................................................4

Shaping the global nutrition agenda ..............................................................................................................................5

Program design and monitoring .......................................................................................................................................5

Assessing impact ..............................................................................................................................................................6

Delivery in challenging terrain ...................................................................................................................................6

Evaluating effectiveness .............................................................................................................................................7

Building capacity .......................................................................................................................................................................8

Strengthening laboratories .........................................................................................................................................8

Scaling up home fortification ....................................................................................................................................9

Generating and sharing knowledge ................................................................................................................................9

Lessons learned on partnership-building ...................................................................................................................... 10

The way forward .......................................................................................................................................................................... 11

Conclusion...................................................................................................................................................................................... 11

Annex 1: Country-focused activities ................................................................................................................................. 12

Annex 2: Globally focused activities ................................................................................................................................ 14

Annex 3: Key publications ..................................................................................................................................................... 16

References ..................................................................................................................................................................................... 17

III

Abbreviations

CDC Centers for Disease Control and Prevention

FFI Food Fortification Initiative

GAVA Global Alliance for Vitamin A

IMMPaCt International Micronutrient Malnutrition Prevention and Control Program

IYCN Infant and young child nutrition

LQAS Lot quality assurance sampling

MNP Micronutrient powder

UNICEF United Nations Children’s Fund

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Executive summary

In 2001, the Centers for Disease Control and Prevention’s International Micronutrient Malnutrition Prevention and Control Program (CDC/IMMPaCt) and UNICEF began a joint effort to combat micronutrient malnutrition by enabling national governments, food industry actors and civic organizations to design, implement, and monitor effective programs. The partnership worked on projects in over 25 countries focusing on four main strategies: (1) shaping the global nutrition agenda, (2) designing and monitoring programs, (3) building capacity and (4) generating and sharing knowledge. The partnership has helped shape the global nutrition agenda by taking an active role in global nutrition initiatives and producing guidance and technical resources that promote evidence-based micronutrient interventions. This has built momentum for a number of positive developments such as the scaling up of home fortification programs, which aim to improve the nutritional quality of diets through the addition of micronutrient powders or small quantity lipid-based nutrient supplements. Through its work with the Food Fortification Initiative and Iodine Global Network, the partnership has helped to mold the global micronutrient architecture. With the Global Alliance for Vitamin A, the partnership has helped reshape global Vitamin A efforts to fit a changing epidemiological environment.

At country and global levels, many programs benefitted, especially in terms of program design, from the partnership’s unique combination of robust scientific knowledge, research skills, technical expertise and on-the-ground programmatic experience. China, Democratic Republic of the Congo, Ethiopia, Guatemala, Kazakhstan, Kyrgyzstan, Malawi and Nepal are just a few of the countries in which the partnership was involved in planning and designing micronutrient projects , setting up monitoring systems and implementing assessments. Resources for improving program design and monitoring – such as a monitoring manual for Vitamin A supplementation programs and many tools for planning, costing, implementing and monitoring home fortification programs – have been developed and made available through the partnership.

The partnership is committed to building capacity globally to improve the quality of programs and services aiming to improve the nutritional well-being of the population. As part of that it has invested in improving the quality of data used to inform program design. Capacity building has been carried out in many different ways. For example, five regional home fortification workshops, attended by delegates from 66 countries, built capacity of staff from UNICEF and government and partner agencies and led to a significant expansion in home fortification programs globally. At the country level, the partnership has strengthened capacity to conduct surveys and other assessments, analyze data and use the results for decision-making. Laboratory resources and capacity have been strengthened in a number of countries.

One of the partnership’s fundamental strategies is generating and sharing knowledge. Evidence generated by this work has been shared widely in the form of reports and articles in peer-reviewed scientific journals. In addition to these traditional methods of dissemination, the partnership has developed webinars, toolkits, manuals and interactive websites, so that information can be shared more broadly and so that stakeholders working in nutrition globally can learn from subject matter experts and from each other. Information on home fortification has also been made accessible through the Global Assessments of Home Fortification [1] and the creation of the Nutridash platform in 2013, which collects, analyzes and reports global information on nutrition programs, including micronutrient powder programs.

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The partnership has shown that through synergizing efforts and maximizing complementary skills, far more was achieved together than would have been possible working independently. Additionally, the partnership has been able to catalyze critical support from other agencies and stakeholders, which has in turn led to creating/strengthening other collaborations, networks and initiatives. Looking to the future, the partnership is poised to continue its collaboration and bring further innovative and evidence-based nutrition programming.

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Introduction

Malnutrition contributes substantially to the global burden of disease, causing 3.1 million child deaths annually or 45% of all child deaths. Deficiencies in micronutrients (vitamins and minerals needed in small amounts but essential to health) can not only put children at increased risk of serious infectious diseases or even death, but also hinder their cognitive development [2].

Multiple agencies and movements have committed to combating this problem. In 2001, the Centers for Disease Control and Prevention’s (CDC’s) International Micronutrient Malnutrition Prevention and Control (IMMPaCt) program and UNICEF embarked on a cooperative effort to combat micronutrient malnutrition globally. The main focus of the work was to enable national governments, food industry actors and civic organizations to implement evidence-based strategies, monitor and evaluate micronutrient interventions and show program impact at the population level. This was done by funding, promoting and implementing micronutrient interventions including mass fortification of staple foods, home fortification and supplementation. Additionally, the partnership – blending CDC/IMMPaCt’s laboratory capacity and skills in assessment, monitoring, and evaluation with UNICEF’s strong country presence and experience in program implementation – has turned global guidance into concrete action on the ground.

Micronutrients are vitamins and minerals needed in miniscule amounts to enable the body to produce enzymes, hormones and other substances essential for growth and development. The consequences of micronutrient deficiencies, in particular iron, vitamin A, iodine, zinc and folate can be severe, including blindness, impaired cognitive development, an impaired immune system and death [3].

Mass food fortification

One of the main types of food fortification, which refers specifically to the deliberate addition of one or more vitamins and/or minerals to staple foods that are commonly consumed, such as flours, oils and condiments.

Home fortification

An approach which involves adding specialized ingredients such as multi-micronutrient powders, lipid-based nutrient supplements (LNS) and other nutritious foods to the local meals that people (often young children) eat every day.

Supplementation

Supplements intend to provide nutrients that may otherwise not be consumed in sufficient quantities. Important supplementation strategies include vitamin A supplementation to children 6-59 months of age and iron and folic acid supplementation during pregnancy.

Interventions to reduce micronutrient deficiencies

Four key strategies have guided this work: shaping the global nutrition agenda, program design and monitoring, building capacity, and generating and sharing knowledge. Each strategy has short- and medium-term outcomes that contribute to the partnership’s long-term goal of reducing micronutrient deficiencies in vulnerable populations.

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1. Shaping the global nutrition agenda: The partnership has built nutrition collaborations and networks worldwide and has actively participated in key global nutrition initiatives to influence the direction of micronutrient-focused strategies, using innovation and rigorous science.

2. Designing and monitoring programs: The partnership has developed and implemented micronutrient programs while establishing robust monitoring and evaluation systems, ensuring that program data are readily available and used in program management. As a result, replicable models for program implementation and assessment are now being implemented in several countries globally, with the potential for further expansion

3. Building capacity: The partnership has contributed to the development of knowledge and skills that have led to better implementation of nutrition interventions. Capacity-building activities have included the development of resources such as toolkits, manuals and webinars. Workshops and trainings have enabled delegates from countries implementing programs such as home fortification and mass fortification to receive hands-on training and learn from other participants.

4. Generating and sharing knowledge: Partnership activities at the country and global levels have produced new knowledge, presented existing information in a variety of formats, including peer- reviewed journals, and developed platforms for capturing and sharing information and experiences.

“The partnership has been part of an evolving process to improve programs. The focus has always been on meeting long term goals and objectives.”

— Project officer, micronutrients, UNICEF Headquarters

Projects

The partnership has brought technical, financial and organizational support to important micronutrient related projects. At the country level (Annex 1), UNICEF, with its strong country presence and direct contact with ministries of health, has been instrumental in identifying country needs for specific technical expertise. Activities with a global focus (Annex 2) have aimed to tackle broader needs, such as the development of guidance documents and strengthening of global partnerships. The direct in-country experiences have been crucial to inform and ground activities at the global level.

Country-focused projects

Over the past 15 years, the partnership has worked in over 25 countries, as shown on map 1. The partnership’s initial focus was on planning and implementing micronutrient interventions, such as home fortification and mass food fortification. To ensure that countries used evidence-based planning and demonstrated impact, the partnership also helped several countries conduct micronutrient surveys (see annex 1). In more recent years, the focus has shifted to the establishment of internal and external monitoring systems and the

Micronutrient Powders (MNPs)

Powdered preparation of micronutrients, which is mixed into food that is ready to eat in order to improve dietary quality.

Small Quantity Lipid Based Nutrient Supplements (SQ-LNS)

Paste preparation containing vitamins and minerals, energy, protein and essential fatty acids, which is mixed into food that is ready to eat in order to improve dietary quality.

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partnership’s work has contributed to the development of scalable and sustainable models that can be expanded globally. National-level technical staff (from ministries or other institutions) have benefited from training and other capacity-building activities related to the topics of monitoring and evaluation, data collection and analysis, and laboratory analysis of survey samples. The partnership has also supported the development of nutrition strategies and program activities and reports and publications have helped inform relevant nutrition legislation in a number of countries. Country projects also helped develop an evidence base that has been used to inform global guidance. The documentation of country experiences, drawing out lessons learned, and publishing of the results of program impact assessments in reports and scientific journal articles have contributed to the large body of evidence on public health practice that is now available on topics such as Vitamin A and MNPs.

Niger

Democratic Republic of Congo

Ethiopia

Nepal

Tanzania

Malawi

Romania

Ukraine

Georgia

Turkey

Turkmenistan

Kyrgyzstan

China

Bangladesh

Timor-Leste

Vietnam

Lao PDR

Philippines

Mongolia

Kazakhstan

Myanmar

Thailand

Papua New Guinea

Guatemala Guyana

Countries with projects that have been supported by the partnership

This map is stylized and not to scale. It does not reflect a position by UNICEF or CDC on the legal status of any country or territory or the delimitation of any frontiers.

Map 1: Countries with partnership-supported projects

Globally focused projects

“UNICEF and CDC bring particular strengths to our shared projects. Staff in UNICEF’s country offices with local contacts and expertise help shape the national work. UNICEF is often the main fortification advocate in countries, particularly in Eastern Europe. CDC’s rigor helps country leaders develop a plan to monitor their fortification programs for quality and impact. Working together with the Food Fortification Initiative’s expertise in grain fortification, this partnership has accomplished more than any of us could have even imagined separately.”

— Director, Food Fortification Initiative

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Compared to country-focused projects, the global projects focused on shaping the global nutrition agenda. For example, the partnership helped create and strengthen global micronutrient networks that align stakeholders around a common goal and allow for more coordinated and efficient approaches (see Box 1). Globally-focused projects, whether implemented by the partnership directly or as members of one of the global micronutrient networks, have relied on the strategies of program design and monitoring, capacity building and knowledge generation and sharing in order to achieve results in combatting micronutrient deficiencies. For example, from 2011 to 2014, the partnership, in collaboration with the Global Alliance for Vitamin A (GAVA), helped develop programmatic guidance for continued Vitamin A supplementation to complement the World Health Organization’s revised Vitamin A guidelines and helped develop monitoring manuals for Vitamin A programs.

Box 1: Networking and capacity strengthening

UNICEF and CDC/ IMMPaCt are founding members of the Food Fortification Initiative (FFI), born out of joint efforts by the two partners, with the intention of facilitating the creation of public–private-civic partnerships to eliminate micronutrient malnutrition. FFI helps country leaders plan, implement and monitor fortification programs. The partnership supported FFI in a variety of ways, including documentation of successful monitoring systems for flour fortification.

The partnership helped facilitate the unification of two iodine networks into a single Iodine Global Network, which blends clinical and programmatic capacities and has taken on the role of coordinating the work of public, private, scientific and civic organizations on eliminating iodine deficiency in a sustainable manner. The partnership provides strong support through its scientific expertise and experience in the field of iodine nutrition to the Network’s secretariat.

The partnership established the International Resource Laboratories for Iodine network to strengthen the capacity for laboratory analysis of iodine in urine and salt. Network laboratories serve as resources to national and regional laboratories. They train personnel, facilitate technology transfer to national laboratories and set up systems for information sharing with other regional networks.

As founding members of the Global Alliance for Vitamin A the partnership took a leading role in strengthening global commitment to different approaches aimed at reducing vitamin A deficiency. UNICEF and CDC/IMMPaCt have taken on a leadership role in the core working group which focuses on knowledge management around Vitamin A and provides guidance to countries implementing vitamin A deficiency control programs.

Partnership achievements

Innovative collaborations and interventions initiated by the partnership in its first 15 years have had a ripple effect and positive outcomes throughout the global nutrition arena. A few of these are highlighted below.

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Shaping the global nutrition agenda

“Both CDC and UNICEF Nutrition Section have played an important role in galvanizing technical consensus leading to normative guidance on the application of Multi-Nutrient Powders in Infant and Young Child Nutrition. Their collaboration with the global technical community through the Home Fortification Technical Advisory Group (HFTAG), and building of capacity for home fortification at the country level over the last decade have been key in improving infant and young child nutrition programming worldwide.”

— Senior Technical Advisor Policy and Programs, Global Alliance for Improved Nutrition (GAIN)

The partnership was instrumental in moving forward key global nutrition initiatives that influenced the direction of micronutrient-focused strategies. One of the most successful of these has been the promotion, expansion and scale-up of home fortification using MNP. Home fortification has been proven effective in decreasing anemia and iron deficiency in young children. The partnership organized five regional home fortification workshops to provide guidance on the design and implementation of home fortification interventions within the context of infant and young child nutrition (IYCN) and early child development programs [4]. The workshops – serving 66 countries in Asia, Latin America and the Caribbean, West and Central Africa, Southern and Eastern Africa, and the Middle East and Central Asia (see map 2) – addressed countries’ needs for support in designing, implementing and monitoring these programs [5]. They also aligned agency thinking, garnered support within governments and other organizations and catalyzed action. The workshops also served as a platform for exchange of the latest programmatic and scientific knowledge on home fortification programs. In 2013, 43 countries were implementing home fortification programs with MNP, reaching over 3 million children worldwide [6]. Although final data are not yet available for 2014, the number of children is expected to have increased substantially as many programs have been scaled up.

Program design and monitoring

“The partnership drew on the comparative advantages of two organizations in an effort to implement high quality nutrition programs worldwide.”

— Senior advisor, micronutrients, UNICEF headquarters

The partnership helped design programs and build up monitoring and evaluation systems in a variety of ways to meet different countries’ needs. Work has included development of internal and external monitoring systems, application of survey methods such as lot quality assurance sampling (LQAS),1 rigorous formative research and the design of programs and behavior change interventions.

1 LQAS, originally developed for industrial quality control, makes it possible to use small sample sizes when conducting surveys in small geographical or population-based areas (lots). A sample size is specified along with a maximum acceptable number of permissible defects in the sample. LQAS does not provide an estimate for the lot sampled; it only classifies it as acceptable or unacceptable.

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Assessing impact

One of the most challenging micronutrient deficiencies to address is iron deficiency due to its multifactorial nature. Although programmatic approaches exist to combating this debilitating deficiency, there are often serious implementation difficulties. Kyrgyzstan was one of the first countries to develop and implement a comprehensive monitoring and evaluation system to show the effect of the MNP Gulazyk (see Figure 1) in a program setting. The partnership led the design and setup of an internal and external monitoring system to assess the effect of Gulazyk and integrated the collection of data on the MNP program into existing systems. The Ministry of Health and other partners in Kyrgyzstan worked closely with CDC/IMMPaCt and UNICEF to learn how to use LQAS methods to measure coverage, adherence and acceptability of the intervention. Assessments of the Gulazyk pilot in 2008 and 2010 revealed a relative decline of 13% in anemia and 27% in iron deficiency anemia [7]. The program has been scaled up nationwide and has reached more than 205,000 children 6–23 months of age.

Delivery in challenging terrain

In Nepal, the partnership implemented a feasibility assessment to identify an appropriate delivery platform for the planned MNP intervention. Nepal’s geographically challenging terrain demanded an approach that would reach as many members of the target population as possible, and not just those with access to transportation. The study looked at a delivery model using female community-health volunteers who traveled to communities and a more traditional health-facility-based model, where users received MNP at health facilities. The community volunteer model

Mexico

Burkina Faso

Mauritania

Mali

Algeria

Niger

ChadSudan

Senegal

Sierra Leone

LiberiaGhana

Nigeria

RwandaUganda

Ethiopia

Yemen

India

Pakistan

Nepal

Somaliland

Somalia

Kenya

Tanzania

Malawi

Madagascar

Zimbawe

Mozambique

Burundi

Palestine

Iraq

Georgia

AzebaijanTurkmenistan

TajikistanKyrgyzstan

China

Sri Lanka

Bangladesh

Indonesia

Timor-Leste

Vietnam

Lao PDR

Philippines

Cambodia

MongoliaUzbekistan

Jordan

Cameroon

Zambia

Namibia

South Africa

Guatemala

El Salvador

Honduras

Nicaragua

Ecuador

Peru

Bolivia

Columbia

Brazil

Uruguay

Cuba

Haiti

Dominican Republic

GEOGRAPHIC REGIONS

Asia (2009)

Latin America and Caribbean (2010)

Sub-Saharian Africa (2012)

Sub-Saharian Africa (2011)

Middle East and Northern Africa and Commonwealth of Independent States (2013)

This map is stylized and not to scale. It does not reflect a position by UNICEF or CDC on the legal status of any country or territory or the delimitation of any frontiers.

Map 2: Countries participating in the home fortification workshops 2009–2013

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reached a higher proportion of mothers regardless of topography. An innovative program was adopted that used both approaches depending on a particular area’s need. That program is now being implemented in 15 districts with further expansion underway. The partnership’s unique mix of skills and expertise made it possible to utilize appropriate methods to be able to identify the most appropriate way to access the programs target population. UNICEF was able to provide the on the ground implementation expertise and IMMPaCT was able to support the program through designing and implementing an efficient and responsive monitoring system, that enabled the project staff to easily utilize the data and make program modifications as needed.

The partnership provided technical assistance for a national micronutrient survey and an impact evaluation in the program districts, which will provide needed information to both Nepal and the global community about the effects of integrated home fortification programs under programmatic conditions. Partnership support of this project has attracted the attention of other stakeholders and led to a coordinated effort lead by UNICEF to secure other sources of funding (the national government and the United States Agency for International Development) and eventual national procurement of the MNP.

The Nepal Ministry of Health and Population (MOHP) highly values the UNICEF/CDC partnership. The country has benefitted greatly from their partnership by improving programs and filling data gaps to support evidence-based decision making in Nepal. Since 2009, UNICEF and CDC have played an important role in supporting government to improve infant and young child nutrition, as well as designing a comprehensive National Micronutrient Survey.

— Chief, Nutrition Section, Ministry of Health and Population, Nepal

Evaluating effectiveness

The Democratic Republic of the Congo was the first country to implement a large-scale pilot program integrating infant and young child nutrition (IYCN) approaches and a small-quantity lipid-based nutrient supplement (SQ-LNS), locally known as Kulabora (see Figure 2), in a non-emergency programmatic setting using the existing health care infrastructure.

Figure 1: Gulazyk sachets, used in the Kyrgyzstan home fortification program

Figure 2: Kulabora strip, used in the Democratic Republic of the Congo’s integrated infant and young child nutrition/home fortification program. Kulabora was developed by Nutriset France.

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The partnership supported extensive formative work and development of the behavior change intervention strategy for Kulabora, as well as the design and implementation of the program and setup of the monitoring system. Baseline and end-line assessments evaluated the impact of the program and will help other programs make decisions on the use of SQ-LNS. Rigorous monitoring systems were developed to track program functioning and coverage on a routine basis and have enabled the program to make corrective actions quickly, which improved program quality. Kulabora is integrated into the existing IYCN program, which is also strengthened and enhanced through collaboration with other sectors including water and sanitation and infectious disease. The findings from this partnership-supported project have demonstrated that supplementation with a SQ-LNS can be successfully integrated into a multidimensional program in a complex, non-emergency field setting.

Building capacity

“Thanks to the collaboration between CDC and UNICEF, the workshops on home fortification provided up-to-date information of best practices, support, and networking for the participants from countries in the regions implementing or preparing to implement home fortification interventions in their country. CDC’s technical expertise combined with UNICEF’s global presence and ability to mobilize action at country-level are a very good combination. I have observed very positive and productive interactions between CDC and UNICEF, and the MNP Toolkit and workshops are examples of the concrete products of this collaboration.”

— Technical Advisor, Maternal Infant and Young Child Nutrition, Global Alliance for Improved Nutrition (GAIN)

The partnership’s capacity-building work has sought to expand the knowledge base for micronutrient programming as well as increase technical capacity and develop resources for improved implementation of micronutrient interventions.

Strengthening laboratories

The partnership provided extensive in-country support, guidance, quality assurance and training to laboratories to ensure quality biochemical assessments of micronutrient status. Laboratory specialists from numerous countries received training on high quality methods and support to develop standardized systems for analyzing specimens, maintaining quality control and ordering laboratory equipment and supplies for micronutrient assessments.

One important contribution of this effort has concerned the monitoring of iodine status. Iodine deficiency diseases are the main cause of brain damage and intellectual disabilities worldwide, threatening the health and capacity of more than a billion people [3]. But monitoring is challenging due to differences in measurement and analysis methods, qualifications of specialists, and laboratory capacity. The partnership has supported the establishment of reference labs such as the Regional Iodine Reference Laboratory in Kazakhstan. Such reference laboratories provide lower-income countries with access to a reliable laboratory in their region. The laboratories provide not only high-quality assessments of biological samples, but also training and other resources (see Box 2). Countries’ increased capacity to carry out laboratory measurements has enabled more efficient and reliable assessments of nutritional status, resulting in better data to support programs and advocate

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for policies. Furthermore, the transfer of technology for resource-appropriate methodologies strengthens the infrastructure of lower-income countries and makes them more autonomous.

Box 2: Ensuring high quality data

Supported both technically and financially by the partnership, the Regional Iodine Reference Laboratory was established in 2009 by the Kazakhstan Academy of Nutrition (KAN). Joint efforts led to an up-to-date, high-quality reference laboratory and resource center for iodine assessments, led by technical experts capable of managing reliable iodine measurements in salt and urine and coordinating

an external quality assurance service for 14 national iodine labs operating in the region. Through the technical support of a business model expert funded by the partnership, the Regional Iodine Laboratories Network were able to develop a sustainable business model, become a fee-for-service laboratory and obtain contracts from other countries in the region which will ensure future growth.

“The CDC/IMMPaCt laboratory support provided by the partnership has contributed to successfully carrying out high quality specimen collection in difficult field settings. People leave laboratory training with new skills and techniques as well as relationships with other trainees which helped build up a support network.”

— Nutritionist, CDC/IMMPaCt

Scaling up home fortification

As more countries began to implement home fortification interventions, the demand for support and guidance increased dramatically. In response, the partnership developed a series of resources in conjunction with the Home Fortification Technical Advisory Group, to provide valuable opportunities for knowledge exchange, resource identification and continued learning on the topic of MNPs.

The Home Fortification Network is a web-based community of practice where experts and practitioners can exchange knowledge and share lessons learned on different aspects of designing, implementing and monitoring a home fortification program.

An MNP toolkit contains a variety of checklists, templates and practical guides for planning, implementing and monitoring home fortification programs

A webinar series provides further information and support, increases knowledge and capacity to design and implement effective programs, and serves as a forum to share country experiences and lessons learned.

Generating and sharing knowledge

The partnership worked to ensure that knowledge generated by the projects it supports is documented and disseminated in diverse forms and more than 27 major reports and articles have been produced (Annex 3). Many more publications are anticipated, as several major country projects enter the completion phase. The partnership has also emphasized sharing of information through other less formal means of communication, including presentations and scientific posters.

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With the broad expansion of home fortification programs globally, an assessment of the current status of programmatic interventions was warranted. In 2011, the partnership led the design and implementation of a questionnaire-based Global Assessment of Home Fortification Interventions2 with a focus on both planned and currently implemented programs targeting young children, school-age children, pregnant and lactating women and households. This initial assessment identified 63 implemented home fortification interventions (16% of which were national level programs) in 36 countries and 28 planned interventions (in 21 countries)[1]. A second Global Assessment in 2013 used the web-based Nutrition Dashboard (NutriDash) for data collection and focused only on home fortification interventions using MNP. The partnership developed the NutriDash MNP module, which captured up-to-date information on the scale of MNP programs, the age groups targeted by the interventions, their integration with other programs, population reached, delivery methods and recommended consumption. Data collected from this moduleshowed that the number of countries implementing MNP interventions doubled between 2011 and 2013 [5].

Lessons learned on partnership-building

For a successful partnership a clear vision and identification of the complementarities between two agencies is necessary. You need to identify what you can achieve together for the good of the country.

— Chief, nutrition and food security, UNICEF Ethiopia

The CDC–UNICEF partnership experience has been rich in experiences. This productive collaboration between two major agencies with different strengths has yielded numerous lessons learned that can be beneficial as the collaboration continues and may provide insights on elements essential for other successful partnerships. Some of these are highlighted below.

The success of the partnership is grounded in a clear joint vision and the ability to identify agency strengths. In this partnership, each agency had something essential to offer. CDC/IMMPaCt brought a rigorous systematic approach to monitoring, selection of indicators, laboratory support and operational research methods. UNICEF brought nutrition programming expertise and on-the-ground presence as well as a natural entry point into countries. An acknowledgement of each agency’s strengths helped us to understand what can be achieved as partners.

Joint planning, follow-up and decision-making helped ensure project success. Detailed co-planning between UNICEF headquarters, UNICEF country offices and CDC/IMMPaCt assured unified thinking and decision-making. Yearly joint planning meetings and frequent communication between project partners for both country-level and global projects have assured that projects stay on track. A key to success has been addressing problems in a timely manner.

Multi-year collaboration enabled the partnership to mature and has allowed development of a medium- to long-term work plan that facilitates engagement of all stakeholders. It has also strengthened working relations; agency, country and political buy-in.

2 www.hftag.org/resource/global-assessment-of-home-fortification-interventions-2011-pdf

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Early recognition and identification of possible challenges facilitated working relationships. The partnership and its scope of work are highly complex. Language and cultural issues and diverse agency ways of working have sometimes been a challenge, resolved by ensuring that communication channels remain open and include relevant stakeholders.

Regular dissemination of partnership achievements through multiple communication channels inspired support and collaboration from other agencies. An example of this was the home fortification workshops, which started as a CDC/UNICEF initiative but resulted in being a multi-agency collaboration over multiple years and led to several key publications. Partnership achievements were regularly disseminated and communicated to external audiences through both scientific and lay mechanisms (such as reports, presentations, papers and round tables).

Close collaboration and interaction with local institutions is critical to program success and can build and strengthen local capacity. Throughout the course of the partnership team members spent a significant amount of time particularly in the early stages of a project, carefully cultivating and managing new relationships and establishing ways of working together. This was particularly important with in-country projects where capacity, skill sets, staff turnover and time availability sometimes presented challenges. Through close interaction and multi-year collaborations several institutions and local partners have been able to develop and strengthen skills that will improve nutrition programs globally.

The way forward

CDC and UNICEF expect to continue working together in the coming years. A new area for collaboration, as part of the partnership is maternal nutrition, in particular supplementation during pregnancy. The partnership will continue to employ the same four strategies: shaping the global nutrition agenda, program design and monitoring, building capacity, and generating and sharing knowledge. Specific countries to be supported will be determined based on country needs and interest through discussions with the UNICEF country offices.

Conclusion

The partnership has proven that it is possible to implement high-quality programs and address issues of micronutrient malnutrition with a multi-agency and multifaceted approach. A cornerstone of the partnership was to engage and promote communication with key stakeholders. The partnership also took an active role in promoting global nutrition initiatives and evidence-based micronutrient interventions while helping build up sound monitoring systems for these programs. In the 15 years of its existence, it has paved the way for a greater understanding of the importance of using data in decision-making, and has shown how combining UNICEF’s programmatic experience and country presence with CDC/IMMPaCt’s technical expertise and laboratory capacity can promote innovation and evidence-based programming in the field. Its work, both in individual countries and at the global level, will continue to make major contributions to the reduction of micronutrient deficiencies and the improvement of the lives of vulnerable populations around the globe.

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Annex 1: Country-focused activities

Country Activity Strategy 2: Program design and monitoring

Strategy 3: Building capacity

Strategy 4: Generating and sharing knowledge

East Asia and the Pacific

Lao People’s Democratic Republic

Training on survey methodologies (2004) XNational micronutrient survey (2006) X X X

Papua New Guinea Training on survey methodologies (2004) X XNational micronutrient survey (2005) X X X

China Strengthening of the national salt iodization monitoring system (2001)

X X

Technical support for the iron and folate and multiple micronutrient program (2004)

X

Monitoring and evaluation of flour fortification in Gansu Province (2007–2008)

X X

Ying Yang Bao home fortification project (2007–2010)

X X

Viet Nam Evaluation of the impact of a package of health services typically provided to newly married women, on maternal anemia (2008)

X X

Thailand Trainings on survey methodologies and technical support at Mahidol University (2005–2006)

X

Philippines Situational analysis of factors related to anemia; support for development of an integrated anemia control and prevention program (2007)

X X X

Timor-Leste Training on survey methodologies (2004) XMyanmar Training on survey methodologies (2004) XMongolia Training on survey methodologies (2004) X

Support for national micronutrient survey (2010)

X X X

South Asia

Bangladesh Technical support for work on nutritional risk factors and arsenicosis (2002)

X X

Nepal Implementation of home fortification/IYCN program and assessment of different delivery platforms (2009 -2015)

X X X

Central and Eastern Europe and the Commonwealth of Independent States

Kyrgyzstan Implementation of a home fortification program (Gulazyk) (2008-2014)

X X X

National survey to assess Gulazyk program impact (2010 and 2013)

X X X

Technical support to establish an external flour fortification monitoring system (2011)

X X

Kazakhstan Establishment of a regional reference laboratory for iodine nutrition (2010 - 2014)

X X

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Country Activity Strategy 2: Program design and monitoring



Romania Capacity strengthening for national milling associations in Central Asia and Eastern Europe (Kyrgyzstan, Kazakhstan and Tajikistan also participated) (2007–2008)

X

Turkey Technical support for flour fortification activities (2007)

X X

Ukraine Support of national policies for universal salt iodization (2007–2008)

X X

Turkmenistan Evaluation of the flour fortification program (2004)

X X

Georgia Assessment of the elimination of iodine deficiency in Georgia (2005–2006)

X X

West and Central Africa

Niger Assessment of the acceptability of different home fortification products (2007–2009)

X X

Democratic Republic of the Congo

Implementation of an integrated home fortification and IYCN program (2009–2015)

X X X

Eastern and Southern Africa

Ethiopia National micronutrient survey (2013-16) X X XUnited Republic of Tanzania

Technical support for the development of a stunting reduction program including implementation of home fortification (2013-14)

X X

Malawi National micronutrient surveys (2001, 2009, 2015)

X X X

Latin America and Caribbean

Guatemala Development and support of a national nutrition surveillance system (2014–2015)

X X X

Guyana Technical support for programmatic use of double fortified salt with iodine (2001–2002)

X

14


Annex 2: Globally focused activities

Strategy 1: Shaping the global nutrition agenda

Strategy 2: Program design and monitoring



Support for the Global Alliance on Vitamin A (2011-2015)

X X X X

Support for the Iodine Global Network (2001-2015) X X X XSupport for the Home Fortification Technical Advisory Group yrs

X X X X

Development of vitamin A monitoring manuals for district- and national-level programs yrs

X X

Collaborate on the development of a framework for shifting from supplementation to sustained elimination of vitamin A deficiency, in coordination with the Global Alliance for Vitamin A, (2011-2015)

X X X X

Hosting of an expert consultation to develop policy recommendations based on the systematic review on the use of multiple micronutrient supplements in pregnancy, 2007

X X

Support for the development of regional reference laboratories (2004-2014)

X

Nutrition situation assessment of nutrition programs and nutritional status and identification of information gaps in the Pacific region (2006-2007)

X

Assessment of IYCN practices in the Central and Eastern Europe/Commonwealth of Independent States region (2005-2007)

X

Workshop for Pacific island countries on removing nutritional barriers for optimal child survival and development and achievement of the Millennium Development Goals (2006-2007)

X X

Workshops on flour fortification in five countries in Central Asia (Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan) (2004)

X

Development of indicators for assessing flour fortification monitoring systems (2012-2014)

X

Development of three case studies on monitoring systems for flour fortification (Chile, Indonesia and South Africa) (2011- 2014)

X X

CDCynergy (communication strategy) workshops (2004)

X

Development of World Health Organization/UNICEF/World Food Programme guidelines on the use of vitamin and mineral preparations in emergencies (2008-2009)

X X X

Development of guidance based on recommendations of the expert consultation on the systematic review of the use of multiple micronutrient supplements in pregnancy and policy implications (2007-2008)

X X

Expert consultation for countries in East and Southern Africa to develop programmatic guidance on the use of iron supplementation in countries with malaria (2010)

X X

15


Strategy 1: Shaping the global nutrition agenda

Strategy 2: Program design and monitoring



Planning and implementation of a global assessment of home fortification programs (2011)

X X X

Development of NutriDash, a system designed to collect key information annually on MNP and other programs (2013-2014)

X X

Regional workshops on design, implementation and scale-up of home fortification programs in Asia (2009), Latin America (2010), West Africa (2011), East and Southern Africa (2012) and Central Asia and the Middle East (2013)

X X X

Development of a webinar series to provide an interactive platform to discuss issues related to home fortification (2013-2015)

X X

Development of a resource toolkit for MNP programs (2013-2014)

X

Support for technical staff in East Asia regional offices in overseeing projects including the acceleration of flour fortification in six Asian countries and the whole Pacific region (2006-2007)

X

Analysis of the feasibility of rice fortification in Asia (2008-2009)

X X

Development, as part of the Maternal and Young Child Nutrition Security in Asia initiative, of a logic model and framework for a regional approach to improving child nutrition (2012-2013)

X X

16


Annex 3: Key publications

Reports

Monitoring of Flour Fortification: Experiences from Chile (2014)Monitoring of Flour Fortification: Experiences from Indonesia (2014)Monitoring of Flour Fortification: Experiences from South Africa (2014)

NutriDash 2013 – Global Report on the Pilot Year (2014), UNICEFFormative Study for Development of a Lipid-Based Nutrient Supplement for a Fortification Program to Improve the Nutritional Status of Young Children in the Democratic Republic of Congo (2013)Global Assessment of Home Fortification Interventions, Final Report, 2011

Follow-up Survey of Nutritional Status in Children 6–24 Months of Age, Talas Oblast, Kyrgyz Republic, 2010Formative Data Collection for Development of a Market-Based Point-of-Use Fortification Program to Improve the Nutritional Status of Young Children in Niger (2010)

National Survey of the Nutritional Status of Children 6–59 Months of Age and Their Mothers, Kyrgyzstan, 2009

Nutritional Status in Children 6–24 Months of Age, Talas Oblast, Kyrgyz Republic, 2008National Micronutrient Survey, Laos, 2006National Micronutrient Survey, Papua New Guinea, 2005

National Survey of the Nutritional Status of Children 6–59 Months of Age, Women of Reproductive Age, Men 18 Years and over, Papua New Guinea, 2005Malawi National Micronutrient Survey 2009Malawi National Micronutrient Survey, 2001

Articles

Shinoda N, Sullivan KM, Tripp K, Erhardt JG, Haynes BMH, Temple VJ, Woodruff B (2013). Relationship between Markers of Inflammation and Anemia in Children of Papua New Guinea, Public Health Nutrition, vol. 16, no. 2, pp. 289–295.Serdula M, Lundeen E, Nichols E (2013). Effects of a Large Scale Micronutrient Powder and Young Child Feeding Education Program on the Micronutrient Status of Children 6–24 Months of Age in the Kyrgyz Republic, European Journal of Clinical Nutrition, vol. 67, pp. 703–707. doi: 10.1038/ejcn.2013.67Jefferds ME, Irizarry L, Timmer A, Tripp (2013). UNICEF-CDC 2011 Home Fortification Global Assessment: Current Status, New Directions, and Implications for Policy and Programmatic Guidance, K, Food & Nutrition Bulletin, vol. 34, no. 4, pp. 434–443.

De Pee S, Irizarry L, Kraemer K, Jefferds ME (2013). Micronutrient Powder Interventions – the basis for current programming guidance and needs for additional knowledge and experience. Sight and Life. 2013;51-56.Timmer A, Irizarry L, Tripp K, Flores-Ayala R, Jefferds ME. (2013).UNICEF and CDC Collaboration: Leveraging Regional Workshops to Support the Scaling-up of Home Fortification to Improve the Quality of Complementary Foods for Young Children 6–23 Months of Age, Sight and Life, pp. 42-50.Huo J, Sun J, Huang J, Li W, Wang L, Selenje L, Gleason G, Yu X (2011).The Effectiveness of Fortified Flour on Micro-nutrient Status in Rural Female Adults in China, Asia Pacific Journal of Clinical Nutrition, vol. 20, no. 1, pp. 118–124.Tripp K, Perrine CG, de Campos P, Knieriemen M, Hartz R, Ali F, Jefferds ME, Kupka R (2011) Formative Research for the Development of a Market-Based Home Fortification Programme for Young Children in Niger Maternal & Child Nutrition, vol. 7, suppl. 3, pp. 82–95.Suchdev P, Jashi M, Sekhniashvili Z, Woodruff BA , (2009).Progress toward Eliminating Iodine Deficiency in the Republic of Georgia, International Journal of Endocrinology and Metabolism, vol. 3, pp. 200–207.Sehnishvili Z, Sudchev P, Gerasimov G, (2007). Elimination of Iodine Deficiency in the Republic of Georgia, IDD [Iodine Deficiency Disorders] Newsletter, vol. 24, no. 2

17


References

[1] UNICEF-CDC. Global Assessment of Home Fortification Interventions, 2011. Geneva: Home Fortification Technical Advisory Group, 2013

[2] Black RE, Victora CG, Walker SD, Bhutta ZA, Christian P, de Onis M, Ezzati M, Grantham-McGregor S, Katz J, Martorell R, Uauy R and the Maternal and Child Nutrition Study Group. ‘Maternal and child undernutrition and overweight in low-income and middle-income countries’, The Lancet, vol. 382, no. 9890, 3 August 2013, pp. 427–451.

[3] Centers for Disease Control and Prevention. ‘IMMPaCt – International Micronutrient Malnutrition Prevention and Control Program, Micronutrient Facts’, <www.cdc.gov/immpact/micronutrients/>, 4 December 2014.

[4] UNICEF and CDC Collaboration: Leveraging Regional Workshops to Support the Scaling-up of Home Fortification to Improve the Quality of Complementary Foods for Young Children 6–23 Months of Age, Timmer A, Irizarry L, Tripp K, Flores-Ayala R, Jefferds ME, Sight and Life. September 2013, pp. 42-50.

[5] UNICEF. Nutridash 2013: Global Report on the Pilot Year. UNICEF, New York, 2014.

[6] Serdula MK, Lundeen E, Nichols EK, Imanalieva C, Minbaev M, Mamyrbaeva T, Timmer A, Aburto NJ and the Kyrgyz Republic Working Group (Samohleb G, Whitehead R Jr, Mandava U and Sullivan KM). ‘Effects of a large-scale micronutrient powder and young child feeding education program on the micronutrient status of children 6–24 months of age in the Kyrgyz Republic’, European Journal of Clinical Nutrition, vol. 67, no. 7, July 2013, 703–707.

[7] Home Fortification Technical Advisory Group. A Manual for Developing and Implementing Monitoring Systems for Home Fortification Interventions. Geneva: Home Fortification Technical Advisory Group, 2013, p.46.

United Nations Children’s Fund3 United Nations PlazaNew York, NY 10017, USAwww.unicef.org

Centers for Disease Control and Prevention1600 Clifton Road AtlantaGA 30329-4027 USA www.cdc.gov/

Documents

CDC-UNICEF: A SUCCESSFUL PARTNERSHIP IN NUTRITION · lipid-based nutrient supplements. Through its work with the Food Fortification Initiative and Iodine Global Network, the partnership