Kathy Spahn, CEOHelen Keller International

How to effectively scale up interventions and actions that address malnutrition, including

among children

HKI’s Mission…

“to save the sight and lives of the most

vulnerable and disadvantaged. We

combat the causes and consequences of blindness

and malnutrition by establishing programs

based on evidence and research in vision, health

and nutrition.”

Child Mortality and Under-nutrition

•Every year, close to 10 million children in developing regions of the world die before the age of 5 (Lancet 2003)

•Many of these child deaths could be avoided if the interventions we already know work could be delivered to and utilized by families of all the children in need

•Under-nutrition contributes to 6 million of these child deaths each year either directly or indirectly; that is 1 child every 6 seconds

Diarrhoea12%

Other29%

Pneumonia20%

Malaria8%

Measles5%HIV/AIDS

4%

Perinatal22%

Deaths associated with under-

nutrition

60%

Relationship between nutrition and child survival

Sources:EIP/WHO. Caulfield LE, Black RE.Year 2000

Global Under-nutrition

Close to 1/3 of under-five children in Asia and Africa show a measurable deficit in height

as a result of the under-nutrition associated with a chronically inadequate diet combined

with frequent illness

While in Asia the trend over time indicates improvement, in Africa there is no such

indication

Trends in stunting (low height for age) in children < 5 yrs, by region and year

0

25

50

75

1980 1990 1995 2000

% s

tunt

ed

SS Africa Asia South America

4th Report on World Nutrition Situation, ACC/SCN

In addition to these growth deficits, there are also widespread vitamin

and mineral deficiencies (VMD)

Invisible to see but VMD have devastating consequences for child

survival and development

…includes deficiencies in vitamin A, iron, zinc, iodine

My focus today: Vitamin A Deficiency

An estimated 127 million preschool aged children are vitamin A deficient and thus

are at increased risk of death, mainly from diarrhea, measles and malaria

Strong evidence to show link between vitamin A deficiency and mortality

…. in areas where Vitamin A Deficiency is prevalent, improving vitamin A status can

reduce mortality in children 6-59 months by 23-34%

Source: various citations

We know the solutions to combat VAD in children. :

1. Fortify staple foods with vitamin A – cooking oil, wheat flour, soy sauce, fish sauce, bouillon, etc.

2. Provide at-risk children 6-59 months with high dosage vitamin A supplements every 6 months

3. Encourage production and consumption of a diversified diet rich in vitamin A and/or its precursors

Our challenge is the effective at-scale delivery and utilization of these

solutions to the populations most in need

Three examples from HKI of taking vitamin A interventions to scale

1. West Africa: Multi-partner private-public sector regional initiative in 8 countries to fortify cooking oil with vitamin A

2. Niger: Multi-partner program through health sector to achieve and maintain high national twice yearly coverage of vitamin A supplementation for children 6-59 months

3. Asia: Multi-partner program in four countries utilizing NGOs in agricultural sector to scale-up production and consumption of micronutrient-rich foods

Partners, partners, partners

HKI serves as a ‘catalyst’ to initiate sustainable large scale programs with

broad networks of development partners

Ministry of Health

Ministry of

Industry

UN Family

Consumers Association

s Academia

Financial Partners

Other NGOs

Food industrie

s

Ministry of

Agriculture

Case Study 1: ‘Broad scale’ fortification of cooking oil with vitamin A in West Africa region

Goal: reduce maternal and child morbidity and mortality by reaching 70% of population in the eight UEMOA (Monetary & Economic Union of West Africa) countries with fortified cooking oil by 2010

Private-public partnership working through professional association of cooking oil producers (AIFO) to secure their commitment to fortify all cooking oil products with vitamin A

Progress: rolling out according to plan. Will also be used as platform to launch new initiative to fortify wheat flour with iron

Initial Steps: Burkina Faso, Côte d’Ivoire, Guinea, Mali, Niger

• Population-based identification of food vehicles

• Industry assessments

• Assess legal framework

• Fortification started in: – Côte d’Ivoire (cooking oil, flour), Guinea (flour), Mali (cooking

oil)

• Based on national experiences – Assembly of Health Ministers of West African Health Organization (WAHO) adopted resolution in favor of mandatory fortification

• Regional Private Sector/Public Sector Dialogue called for acceleration of mandatory fortification

Some facilitating factors for scaling up….

•‘On the ground’ presence at country and regional levels

•Existing strong technical professional association of cooking oil industries

•Common monetary zone

•Premium placed on regular open and frequent communication

•Staying “on message” tenaciously

•Political will at regional level

Obstacles….

•More partners, more complexity…

•Lack of effective regulatory framework and quality control for fortification

•Develop regional norms for mandatory fortification

•Strengthen industries’ quality assurance capacity

•Identify and strengthen reference laboratories

•Prolonged negotiations with donors for initial funding

•Funding gaps

Case Study 2: Niger & Vitamin A Supplementation

Goal: As part of Niger’s child survival objectives, deliver twice yearly supplementation of vitamin A at a coverage of 80% or greater of children 6-59 months

Partnered with the MOH and UNICEF to spearhead the initiation and institutionalization of twice yearly supplementation

Identified existing platform of National Immunization Days and integrated vitamin A supplements in 1997. Also developed Africa’s first ever National Micronutrient Day in 1999.

Progress: Since 1999, combination of NIDs & NMDs has ensured >80% of children 6-59 months receive vitamin A supplementation twice a year. Niger has provided model for other countries in the region to follow.

Some facilitating factors for scaling up….Data existed that showed VAD was a serious public health problem in Niger

Evidenced based advocacy translated into powerful key message: “VAD control can avert over 25,000 child deaths in Niger per year”

Stayed ‘on message’

Reducing child mortality was a priority development objective of the government and donor partners

Strategic partnership with key stakeholders in the MoH and development partners

Maximized existing delivery mechanism (NIDs)

Obstacles….

Lack of funding: program highly dependent on external resources

Key agency field office not on-board with vitamin A supplementation

Conflicts between different MoH programs (EPI, Roll-back Malaria, nutrition….)

Skepticism about ability to reach high coverage in such a vast country

Case Study 3: Scaling up Homestead Food Production in four Asian countries

Goal: Improve nutritional status of vulnerable members of low income households through increased small scale production and consumption of micronutrient rich crops and small animals

HKI worked through broad networks of local NGOs (> 250) in these four countries as well as local government offices in health and agriculture to deliver the program

Progress: Current household coverage in Bangladesh is 850,000, Nepal is 25,000, Cambodia is 30,000 and scale-up currently underway in Philippines. Various studies of impact on food consumption, micronutrient status and income show positive results.

Some facilitating factors for scaling up….HFPP model tested, piloted and fine-tuned before scale up in each country

Used network of local NGOs to fast-track program and reach more areas of country

On-going monitoring system developed with NGOs and communities to allow for problems to be identified and adjusted immediately

Participatory decision making and cost sharing encouraged NGO ownership

Obstacles….Donors want ‘quick’ impact results. Not necessarily produced by HFPP which takes time

Challenge to coordinate the many different NGOs and partners

NGOs involved from Day One so all on ‘same page’

Strong overall management support from HKI

Flexible project model easily adapted to each NGO

More work is still needed to further study impact

Impact data essential to prove concept, strengthen advocacy and influence policy

Shortage of funding to continue and expand

Observations from these three case studies…

Elements of Successful Scale Up:

Political factors….

•Political will of government exists

•Agreed upon objectives by all partners (same goal)

•Adequate funding exists now and in the future

•Supportive policies and guidelines in place

•Adequate time-frame exists

Elements of Successful Scale Up:

Organizational factors…

•Leadership is vital

•Ownership is vital

•Get all partners on same page on Day One to create a shared vision to ‘go to scale’

•Networks of partners allow farther reach, quicker roll-out and greater leveraging of resources

•Invest time up front to define partnership; clarify roles and responsibilities

•Ensure harmonization and that all partners are “singing the same song to the same tune”

•Be opportunistic. Utilize existing structures and programs to the extent possible.

•All partners’ M/E targets have outcome indicators

•Create a “BUZZ” around the topic

•Be willing to make course corrections

•Keep the focus

Elements of Successful Scale Up:

•Lack of financing

•Donors wanting short-term results

•Involving lots of partners also adds complexity and may lead to competition if resources are scarce

•Changing development trends may lead to change of focus and abandonment of key programs for the ‘flavor of the day’

Common challenges:

• Once results have been achieved we can move onto something else.

Not the case. Support is often needed at critical points in time to maintain sustainability. For example,

• Ensure adequate funding each successive year

• Continuous oversight of quality control, e.g., in food fortification efforts, there may be slippage to cut costs by using inferior micronutrient pre-mixes

Common misperceptions:

• You have achieved success if you have gotten ‘interventions’ (e.g. the supply) out there.

Not the case. Target groups need to be using those interventions as they were originally planned (e.g. the demand).

• Ensure new practices are continuing

• Maintain social marketing to encourage target population to continue to purchase and utilize product

Common misperceptions:

Remember that partners are important and that “alone we can do

so little; together we can do so much.” - Helen Keller