The Design, Monitoring and Evaluation of Operations Pilot on Multiple Micronutrient In-Home Fortification of Young Children in Lao PDR
UNICEF Lao PDR (2013 – present)
Although Lao PDR has made significant progress in the area of child and maternal mortality reduction, high undernutrition prevalence remains one of the biggest challenges for the country.
Preliminary data from the Lao Social Indicator Survey (LSIS) 2011-2012 suggests that undernutrition is improving, but that the current levels remain very high by regional standards and that the pace of change is slow (less than 1% point per year). The prevalence of undernutrition by age shows a particularly steep increase in malnutrition in the first two years of life. This indicates the special importance of maternal nutrition and of the first 1,000 days of life (from conception until two years of age)for prevention of ‘growth faltering’ and for improving child nutrition. In Lao PDR, the major immediate causes of malnutrition are low calorific intake and micronutrient deficiencies. These two problems are related to the low consumption of fats and oils which are essential for the absorption of key micronutrients.
Iron deficiency, the main cause of anaemia in infancy, childhood and pregnancy, is the most common nutritional disorder world-wide and particularly prevalent in the low and middle income countries. In these settings, iron deficiency co-exists with other conditions such as protein/energy malnutrition, vitamin A/folate/zinc deficiency and infection. The Lao PDR is no exception: the country registers high levels of anaemia among both children and women, along with other micronutrient deficiencies. According to the latest available data, 41% of children under-five years of age in Lao PDR suffer from iron deficiency anaemia (MICS 2006). This is comparable to the global prevalence of iron deficient anaemia among pre-school children in developing countries (47%) (WHO, 2008). Disaggregation of child anaemia prevalence in Lao PDR by social, economic and demographic variables shows higher prevalence in children living in rural areas without roads and in poor families. Younger children (6-11vmonths and 12-23 months) have particularly high levels of anaemia, 68% and 59%, respectively.
There is clear global evidence that major damage can result from undernutrition, especially during the first two years of life, and that this damage can be irreversible. Complementary feeding interventions are among the only nutritional interventions shown to have a direct and significant effect on reducing stunting. Nevertheless, available data suggest that only 55% of breastfed children in developing countries receive any complementary foods between the ages of six and nine months. Moreover, the quality and quantity of the foods and feeding practices are usually far from optimal. The situation is similar in Lao PDR where only 52% of children 6-8 months old receive any complementary food and 43% of children 6-23 month old are fed with aged-appropriate frequency. Proteins and fats are largely missing from the young children’s diet.
However, even when dietary diversification and modifications are made at household level, they may be insufficient to overcome early deficits in iron and other micronutrients.
UNICEF’s integrated approach to nutrition programming focuses on the critical “window of opportunity” for preventing undernutrition: from pregnancy to 24 months of age. It supports programming in two main areas: IYCF and the improvement of micronutrient status through home fortification programmes with emphasis on community based approaches and channels to implementation.
UNICEF in Lao PDR has been working with the Ministry of Health to support the development of comprehensive IYCF programme response including the development of the National IYCF Policy, a nation-wide communication plan on breastfeeding and complementary feeding, and a community-based programme promoting adequate IYCF/WASH practices. In addition, UNICEF has been promoting the introduction in Lao PDR of multiple micronutrient powders for young children (MNP or Sprinkles). Multiple micronutrient in-home fortification of young children is currently included in the Lao PDR nutrition policies as a high-impact intervention to address iron deficient anaemia, as well as other micronutrient deficiencies. The operational delivery model, however, was not defined and the resource implications of scaling-up this intervention using different delivery modalities were not assessed.
The home fortification with MNP for young children in Lao PDR will support the Department of Hygiene and Health Promotion (DHHP) and the National Nutrition Center (NNC) of the Ministry of Health of Lao PDR to design an operations pilot on multiple micronutrient in-home fortification of young children in order to test the feasibility, effectiveness and efficiency of public and private sector operational delivery models.
The research focuses on the development of:
- Detailed design for the MNP operations pilot
- Monitoring plan and monitoring system
- Evaluation plan, including baseline and end-line study design and tools
- Competency-based training package for health managers and providers on programme implementation and monitoring
The MNP introduction will be done through three steps: (1) conduct formative research on MNP acceptability and utilisation with a 14-day trial, (2) pilot the MNP intervention, and (3) scale up of the MNP intervention.
In order to support the operationalization of the national policies and to inform the MNP expansion plan, UNICEF aimed to support the Ministry of Health with the designing, testing and evaluation two delivery modalities – free distribution via public health sector and market-based distribution using social marketing approach.
The main idea behind this work was to test different delivery models to allow for identification of the most effective, feasible and sustainable option (or a combination of delivery methods) in the context of Lao PDR. The pilot has also explored how different MNP approaches work synergistically with other nutrition interventions and in particular complementary feeding promotion.
1 Ramakrishnan, Usha, et al., ‘Effects of Micronutrients on Growth of Children Under 5 Years of Age: Meta-analyses of single and multiple nutrient interventions’, The American Journal of Clinical Nutrition, vol. 89, no. 1, January 2009, pp. 191−203