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Overview of Micronutrient Powders Operations Pilot

Presentation overview • What are micronutrient powders (MNPs)? • What are the benefits of MNPs? • When/where and who should use them? • Safety of MNPs • Are MNPs relevant for Lao PDR context? • Overview of the operations pilot supported by MMG

What are micronutrient powders (MNPs)? • MNPs are sachets (like small packets of sugar) containing a blend of micronutrients (vitamins and minerals) in powder form, which are easily added to semi-solid foods prepared in the home. • Single serving sachets allow families to fortify a young child’s food at an appropriate and safe level with needed vitamins and minerals for healthy physical and cognitive development.

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

What are the benefits of MNPs? • MNPs reduce anemia in young children by as much as 45 per cent • More attractive than other interventions for anemia due to limited gastro-intestinal side effects and limited to zero effect on the taste and colour of the food to which they are added • Affordable cost of the product and intervention, the benefit:cost ratio for MNPs estimated at 37:1

Where/when are MNPs used? Where foods do not provide enough essential micronutrients: • Dietary diversity is low (due to limited availability or affordability); • Complementary foods prepared for small children have insufficient nutrient content and density; • The bioavailability of micronutrients is poor due to absorption inhibitors in the diet (fiber, phytate, tannin), which is especially the case in plant-source based meals

Who should use them? Target group at risk of having an inadequate intake of micronutrients: • children 6 to 23 months (priority!) • children 24 to 59 months of age • school-age children WHO recommends the home fortification of foods with MNPs for children 6 to 23 months of age to improve iron status and reduce anemia in populations where the prevalence of anemia in children under 2 or 5 years is 20% or higher 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

Are MNPs safe? •

MNPs are formulated to contain one recommended nutrient intake (RNI) per person per day, which is the amount that should normally come from the diet.

Even if taken in amounts of up to 4 sachets a day, intakes are safe according to international recommendations of overdosing – the single-dose packaging and bland taste of the micronutrient powder prevent this.

16 scientific studies evaluated the efficacy and effectiveness of micronutrient powders in thousands of children in Africa, Asia and the Americas >>> Overall, less than 1% of caregivers have reported an increase in vomiting, stomach upset, hard stools, dark stools or diarrhea (Source: HF-TAG, Guideline: Programmatic Guidance brief on use of micronutrient powders (MNP) for home fortification)

Are MNPs safe? •

MNP can be safely provided in addition to twice-yearly high-dose of vitamin A capsule, iodized salt and general food fortification

Children already consuming other products containing a similar or higher amount of micronutrients, should not be given MNPs, until the child is no longer consuming these products: – RUTF (ready-to-use therapeutic food) for treatment of SAM (severe acute malnutrition), – RUSF (ready-to-use supplementary food), – fortified blended foods such as WSB++ (wheat-soy blend) or CSB++ (corn-soy blend), also known as Super Cereal Plus, for treatment of MAM (moderate acute malnutrition), – small-quantity LNS (lipid-based nutrient supplement, <= 20 g/d, providing <=120 kcal/d)

Are MNPs relevant for Lao PDR context? Yes, due to very high prevalence of anemia in children under five and a very modest improvement in anemia over the past 10 years 0-59 mo 80 70 60 50 40 30 20 10 0


68 48.2

NHS 2000

6-12 mo

62.8 41



Nutrition Assessment 2010*

*Nutrition Assessment covered 9 provinces affected by 2008 floods and 2009 Ketsana typhoon **Nutrition tag-on survey to LSIS covered 4 provinces only (Attapeu, Saravane, Sekong and Luangnamtha); preliminary data

Are MNPs relevant for Lao PDR context? Yes, due to very poor complementary feeding practices among young children Age appropriate frequency of complementary feeding in Lao PDR (2011-2012) 60



50 40

43 33

Minimum acceptable diet of children under-5 in Lao PDR



50 40 30









Attapeu Country average

7.5 Saravane




Average (4 provinces)

Source: Nutrition tag-on survey to LSIS covered 4 provinces only (Attapeu, Saravane, Sekong and Luangnamtha); preliminary data

National Nutrition Strategy and Plan of Action (NNS/NPAN) includes MNPs as high impact intervention to address undernutrition • NNS/NPAN aims to achieve 80% national coverage with MNPs by 2015 • In 2009-2010, NIoPH operational research in Savannakhet demonstrated high efficacy of MNPs on anemia reduction among chidren • As of 2013, an effective delivery modality at scale has not been identified >> existing distribution models are not effective and anecdotal evidence suggests low acceptability and compliance • There is a need to develop an effective delivery model, while investing in further formative research to assess the issues of MNP acceptability, compliance and linkages to complementary feeding practices

Main objectives of the partnership MoH-UNICEF-PSI supported by MMG Contribute to reduction in micronutrient deficiencies in young children, including anemia, in Lao PDR Develop/test MNP distribution model in Lao context • At least two delivery channels are tested and evaluated individually and in combination for the distribution of micro-nutrient powders (MNPs): • (a) free distribution for 6-23 month old children through the health sector, and • (b) market based distribution to 6-59 month old children through private sector outlets (i.e. pharmacies, shops)

Reach children under five across three provinces • An estimated 180,000 children under 5, including 67,000 children under 2, are reached with MNPs in selected provinces and districts engaged in the development/testing of operational delivery models

Enhance global evidence base • Global evidence base on public and market-based distribution of MNPs is enriched by Lao PDR operations pilot

Duration: 2013-2015 Programmable amount: 1.2 mln

Geographic focus ●

● ●

Savannak het Saravan Attapeu

Rationale for province selection: 1. Very high prevalence of anemia 2. Extremely poor complementary feeding practices 3. Ability to build synergies with Infant and Young Child Feeding supported by EU-UNICEF Nutrition Security Initiative 4. Geographical clustering of the provinces easing access 5. Basic nutrition capacity established through previous efforts – emergency response and EU-UNICEF supported Nutrition Security Initiative 6. Savannakhet – one of the most developed and the most populous province in Lao PDR - provides good market conditions and sufficient population size for testing private sector approaches

A control province might be needed – TBD during the design stage

Intervention mix by provinces Intervention/ delivery modality for MNPs


Public sector distribution of MNPs



Private sector distribution of MNPs



Focused complementary feeding education



Other interventions (supplementary food)


Control province 1?

Control province 2? (WFP supported province?)



MNPs as an opportunity to improve complementary feeding practices



Lao PDR is one of the four countries globally, along with Mozambique, Madagascar and Somalia, involved in developing/testing of market based approaches for MNP distribution

Key evaluation criteria for MNP delivery models Delivery models

Public sector distribution Market based distribution Mixed model

Evaluation criteria Coverage Equity Acceptability Compliance Cost/ affordability

No intervention

Capacity for expansion

Operations pilot phases and timelines

Inception (JanJuly 2013)

Developing detailed design and monitoring & evaluation framework for public and private distribution models

Formative research and baseline establishment

Development of marketing and communication strategies, including branding

Preparatory/ production (JulyNovember 2013)

Procurement of Sprinkles and their distribution to service delivery points

Production and distribution of communication materials

Training/orientation of relevant staff in public and private sector

Implementation (November 2013November 2015)

Distribution of Sprinkles to children via public and private sectors in three provinces

Ongoing monitoring of implementation and adjustment as necessary

Reordering of supplies, reproducing of communication materials and refresher

Evaluation and preparing for scale-up (JanDec 2015)

Evaluation of the two models and developing recommendations for scale-up

Development and costing of scale-up plans

Resource mobilisation for Sprinkles scale-up

Development of training strategy

Partners and fund flows for MNP operations pilot 1.

Ministry of Health of Lao PDR: DHHP, NNC and NIoPH

2. 3.


University of British Columbia

2. 3.


Financial flows Technical exchanges

Population Services International


Oversee the design and operations of the pilot implementation and evaluation (through sub-TWG Nutrition?) Lead the development of public sector distribution Based on the results made the decision on MNP expansion Provide technical assistance for detailed operations pilot design, monitoring and evaluation framework Assist with the design/implementation of baseline study and evaluation design Assist MoH with development and implementation of training strategy for public sector distribution modality Provide technical support for branding and communication strategy development for the operations pilot Provide technical assistance for developing, implementing and monitoring of the market based distribution model

Supply flow Ministry of Health of Lao PDR

Public Distribution through bi-annual outreach Provincial Health Departments of Saravan and Attapeu

Market Based Distribution via pharmacies and shops Population Services International for Savannakhet and Saravane

Generation of programme income for re-ordering of supplies

Immediate next steps

May June

• Share the overview for MNPs operations pilot in sub-TWG Nutrition • Formative research on complementary feeding and MNPs • Brand development (package design) for public and market-based distribution

• Order MNPs with branded package design • Development of MNPs communication strategy • Design of operational delivery models • Design of monitoring plan/log-frame • Design of evaluation plan and baseline assessment

Mnp operations pilot overview 1