Kathy Spahn, CEO Helen Keller International

1. How to effectively scale up interventions and actions that address malnutrition, including among children Kathy Spahn, CEO Helen Keller International

2. 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.”

3. 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

4. Relationship between nutrition and child survival Deaths associated with under-nutrition 60% Sources: EIP/WHO. Caulfield LE, Black RE.Year 2000

5. 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

6. Trends in stunting (low height for age) in children < 5 yrs, by region and year 4th Report on World Nutrition Situation, ACC/SCN

7. 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

8. 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

9. 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

10. 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

11. Our challenge is the effective at-scale delivery and utilization of these solutions to the populations most in need

12. Three examples from HKI of taking vitamin A interventions to scale • West Africa: Multi-partner private-public sector regional initiative in 8 countries to fortify cooking oil with vitamin A • 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

13. HKI serves as a ‘catalyst’ to initiate sustainable large scale programs with broad networks of development partners

14. Financial Partners Ministry of Industry Food industries Ministry of Agriculture Ministry of Health HKI as CATALYST UN Family Other NGOs Consumers Associations Academia

15. 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

16. 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

17. 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

18. 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

19. 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.

20. 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)

21. 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

22. 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.

23. 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

24. 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

25. Observations from these three case studies…

26. 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

27. 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

28. Elements of Successful Scale Up: • 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

29. Common challenges: • 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’

30. Common misperceptions: • 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

31. 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

32. Remember that partners are important and that “alone we can do so little; together we can do so much.” - Helen Keller