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Looking Back to Look Forward‐Lessons from USAID in estments inLessons from USAID investments in reducing micronutrient deficiencies
Rolf Klemm, DrPH
A2Z Technical Director
Johns Hopkins School of Public Health
What has been the return on USAID’s Micronutrient investments?
Key FactorsKey Factors
• Bold Leadership (combined with)Bold Leadership (combined with)……
– Investments in 3D’s
•Discovery Development Deployment
–Credible inter‐disciplinary expert groupsCredible inter disciplinary expert groups
–Evidence summits
– “Luck”?
The Great Protein Fiasco, Lancet, 1974The Great Protein Fiasco, Lancet, 1974
Dogma Disputed
1974
Flooding inPetroleum Crisis Ethiopian Famine
Flooding in Bangladesh
First World Conference on Nutrition, Rome, 1974
“Today we must proclaim a bold objective—that jwithin a decade NO CHILD WILL GO TO BED HUNGRY, that no family will fear for its next day’s bread, and that no human being’s future and capacities will be stunted by malnutrition”
Henry Kissinger,World Food Conference, 1974
1st Success Factor1st Success Factor
Bold LeadershipBold Leadership……
Martin Forman, USAID James Grant, UNICEFAlfred Sommer, Johns HopkinsLeadership and Nutrition Ch i
Frances Davidson USAIDErnest Loevinsohn CIDA
ChampionsFrances Davidson, USAID
Duff Gillespie, USAID
Ernest Loevinsohn, CIDAEmorn Wasantwisut,Mahidol University
Melinda Gates Hillary Clinton
Howdy Boius,Harvest Plus
Meera Shekar,World Bank
Institutional ChampionsInstitutional Champions
…and many others
2nd Success Factor
Discovery Development
Investments in the 3D’sD l t
Why? Acceptable? How to delivery at l ?
Discovery Development Deployment
Where?Who?Wh l i
Affordable?Safe?Delivery
scale?*Assessments*Nat’l policyWhat solution—
dose, frequency?Delivery Mechanism?
Nat l policy*Logistics/Supplies*Mgmt*Capability*Communications*M i i*Monitoring*Evaluation
DiscoveryDiscovery…….
Vitamin A Reduces Preschool Child MortalityPreschool Child Mortality
~23% d ti~23% reduction
Therapeutic Effects of Zinc on Duration of Acute Diarrhea
*Bangladesh, 1999*India, 1988
*India, 2000*Brazil, 2000*India, 2001
I d i 1998Indonesia, 1998India, 1995
Bangladesh, 1997India 2001India, 2001
India, 2001
Nepal, 2001
Pooled
Bangladesh, 2001
1
*Difference in mean and 95% CIRelative Hazards and 95% CI
0.5 0.75 1.25
Development of SolutionsDevelopment of Solutions…….
Home‐based Fortification‐Micronutrient “Sprinkles”Micronutrient Sprinkles
Microencapsulated ferrous fumerate in powdered form are as effective as ferrous sulphate drops in treating
i i i f t 6 18anemia in infants 6‐18 mo.
Zlotkin, AJCN, 2001Zlotkin, J Nutr, 2003Zlotkin, J Nutr, 2003
Bio‐fortification
Tropical Maize varieties ith hi h l l f b t Orange‐fleshy sweetwith high levels of beta‐
carotene
Orange fleshy sweet potato
Sodium Iron EDTA
Deployment……
Deployment—Using global lessons to move local programs
YearUSAID‐supported
MN P j tFocus
$/yrMilli
move local programs
MN Projects Million
2005‐2011
"A2Z“(AED)
Sustaining VAS coverage, Food Fortification, Maternal Anemia, ~8
2011 (AED)Newborn VA
1998‐ “MOST”VAS Child Survival Weeks, VA in
PL480 oil Food‐based interventions ~102005 (ISTI)
PL480 oil, Food based interventions, MN indicators in DHS
10
1993‐ “OMNI ” VAS, wheat flour & sugar ~10
1998 (JSI) fortification, salt iodization, IFA 10
1989‐“VITAL”(ISTI)
Expand known methodologies to ?
1994(ISTI)
p gcombat VA deficiency
?
Example: VA SupplementationExample: VA Supplementation
Fortification PublicationsFortification Publications
Program Components for Successful Micronutrient Intervention Implementation
Assessment Inputs
Micronutrient Intervention Implementation
Policy Formation
Advocacy
ProcessPolicy Formation
Political SupportOutputs
LogisticsOutputs
Capacity Building Outcomes
CommunicationsProcess
MonitoringEffectiveness Evaluation
3rd S ccess Factor3rd Success Factor
Credible Inter-disciplinary Expert Groups
INACGIVACG
Interdisciplinary Expert Groups‐IVACG, INACG, MF
Innocenti Process, 2008Innocenti Process, 2008
Evidence‐based stock‐taking ofstock taking of performance and ff ti feffectiveness of micronutrient interventions at scalescale
4th Success Factor“Evidence Summits”Evidence Summits
IVACG, INACG & MF meetings
“Luck”?Luck ?
Vitamin A Supplementation
Iodine FortificationExcellent food vehicle
SimpleVisible
Simple technology Inexpensive
InexpensiveLife‐saving results
Visible results
LessonsLessons
• Bold Leadership & Powerful ChampionsBold Leadership & Powerful Champions
• Investment in the 3’DsE id i t h– Evidence is not enough.
• Credible cross‐disciplinary expert groups to accelerate the filling of the “Know‐Do” gap
• Evidence summits to rapidly promote & disseminate evidence‐based findings/practices
• “Luck”?
Remaining ChallengesRemaining Challenges
• Sustaining gains of previous investments• Sustaining gains of previous investments• Moving from Donorship to Ownership• Reducing anemia in women and children• Delivery at‐scale of efficacious interventions• Investment in how to move from “Farm‐to‐Fork” to enhance nutrient content & diversity of dietsenhance nutrient content & diversity of diets
• Maintaining visibility of MNs because preventing “non‐events” make it difficult sustain MN investments
• New discoveries for other MNs (e.g vitamin D) & enhanced discoveries of “old” MNs (e.g. long‐term effects))
Thank you!Thank you!
Fortification
Diet
SupplementsSupplementsDeficientPopulation