4, I~ ~ ~ ~~~~ , . 7If~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~' ar,4 Mineral techi;i"0lg a1og. * >t~~~~~~~~~~~. 0-v 0 I ly~~~~~~~~i:' D E V E L O P M E N T I N P R A C T I C E Enriching Lives Enriching Lves Overcoming Vitamin and Mineral Malnutrition in Developing Countries T HE W OR L D B AN K WASHINGTON, D.C. C 1994 The International Bank for Rcconstruction and Development TI -Hr WORLD BANK All rights reserved Manufactured in the United States of America Frst printing November 1994 The Development in Practice series publishes reviews of the World Bank's activities in different regions and sectors. It lays particular emphasis on the progress thzt is being made and on the policies and practices that hold the most promise of success in the effort to reduce poverty in the developing world. The findings, interpretations, and conclusions expressed in this study are entirely those of the authors and should not be attributed in any manner to the World Bank, to its affiliated organizations, or to members of its Board of Executive Directors or the countries they represent. Library of Congress Catalngmng-in-Publication Data Enriching lives: overcoming vitamin and mineral malnutrition in developing countries. p. cm. - (Development in practice) Includes bibliographical references. ISBN 0-8213-2987-1 1. Malnutrition-Developing countries. 2. Avitamninosis- Developing countries. 3. Minerals in human nutrition-Developing countries. 1. Intemational Bank for Reconstruction and Development H. Series: Dcvelopment in practice (Washington, D.C.) RA645.N87E57 1994 363.8-dc2O 94-27022 CIP Contents FOREWORD ix A C K N O W L E D G M E N T S xi AB BR E VI ATIO NS AND ACR O NYMS xii Executive Summary I The Need for a Comprehensive Approach 2 Three Types of Approaches 2 Social Mobilization 3 Pharmaceutical Supplementation 3 Effective Regulation and Incentives for the Private Food Industry 4 Developing Nutritional Awarc:ness and Habits 4 The Need for External Start-up Support 5 1 The Challenge of Dietary Deficiencies of Vitamins and Minerals 6 The Strategic Importance of Vitamin A, Iodine, and Iron 6 The Scope of Micronutrient Malnutrition 8 Beyond the Reach of Economic Development 9 Good Health Care Systems: Necessary but Not Sufficient 10 The Need for Special Programs 10 v vI E N R I C H I N G L I V E S 2 The Low Costs of Overcoming Vitamin and Mineral Deficiencies 14 Program Designs 16 Public and Private Financing 18 A Social, Not a Technical, Challenge 19 3 The Delivery of Supplements 20 Training and Support of Health Care Workers 20 Minimizing Supply Problems 21 Suppleinentation Programs 22 Targeting Special Groups and Using Existing Outreach Programs 22 4 Successful Fortification 27 Problems with Voluntary Fortification 27 The Importance of Consumer Participation and Education 29 Universal and Mandatory Fortification 31 5 Dietary Change through Education and Policy 33 Educating Consumers 33 The Influence of Agricultural Policies 34 Policy Support for Subsistence Horticulture 35 Preserving Foraged Foods 36 6 Characteristics of Successful Micronutrient Programs 37 Situation Analysis 37 Setting Priorities 38 Short-term Supplementation Goals as Part of a Long-term Dietary Improvement Strategy 39 The Importance of Feedback to Program Evolution 39 Sustainability 40 Habit Formation and Consumer Demand 42 7 Achieving Success within This Decade 44 Raising Awareness 46 C O N T E N T S vil Institutional Development 46 The World Bank's Role 47 Biochemical and Social Research 50 Summary 50 NOTES 53 A P P E N D I X A Prevalence Data 57 A P P E N D I X B Methods and Assumptions for Cost-Effectiveness Calculations 61 Criteria of Effectiveness 61 Cost-Benefit Analysis 61 Costs and Benefits 62 B I B L I O G R A P H Y 69 Boxes 1.1 When to Consider Using an Iron Program 12 3.1 Lessons Learned from Supplementation Programs 23 3.2 Supplementation through the Expanded Program on Immunization 24 4.1 How Fortification Won the West 27 4,2 Lessons of Experience from Fortification Programs 30 4.3 India Fortifies Salt through Transport Controls 31 5.1 Steps toward RaisingMicronutrientLevels in the Food Supply 34 6.1 Appropriate Monitoring 41 6.2 Appropriate 1echnology 42 Figures 1.1 Changes in Availability of Vitamin A, Iron, and Food Energy, by FAO Region from 1960165 to 1986/88 11 5.1 World Per Capita Availability of Legumes 35 vill E N R I C H I N G L I V E S Text Tables 1.1 Population at Risk of and Affected by Micronutrient Malnutrition, by wliO region, 1991 7 2.1 Costs of Micronutrient Control Programs 15 2.2 Returns on Nutrition Investments 16 4.1 Foods Successful'y Used for Fortification. 28 7.1 Decision Matrix and Program Options for Iron, Iodine, and Vitamin A Deficiencies 45 7.2 Incorporating Micronutrients into Selected World. Bank Operations 48 Appendix Tables A. I Micronutrient MaIlntrition as a Public Health Problem 57 A.2 Status of Country Programs 57 A.$ Developing Countries with Micronutrient Deficiency Disorders 58 B.l Assumptions in Calculating Costs per Disability-Adjusted Life-Year, Death Averted, and Income Enhancement 63 B.2 Nutrition Program Costs for Population of 10,000 65 B.3 Assumptions in Calculating Costs and Effectiveness of Iron Interventions 66 A.4 Costs andEffectiveness of Iodine Interventions 67 B.5 Costs and Effectiveness of Vitamin A Intervention 68 Foreword T WO years ago, when I was asked to become the Vice President for Human Resources Development and Operations Policy at the World Bank, few people were familiar with the tern; "micronutrients." Since then, mnany have learned that vitamin and mineral deficiencies impose high economic costs on virtually every developing country, but that micronutrient programs are among the most cost-effective of all health programs-with high returns in terms of human resources. World Development Repon 1993 highlighted both needs and opponuni- ties This follow-up book provides the underpinnings- -convincing detailed arguments for addressing micronutrient malnutrition and practical advice based on lessens learned from program experience. The messages are clear educate consumers so that they fully appreciate and understand the importance of micronutrients in the food they eat; encourage fortification of foodstuffs using a combination of market incentives and regulatory enfnrcement; and, when that still is not enough to meet a population's need, distribute micronutrient capsules and other supplements using all putblic and private channels avail- able- Public financing may be needed in the shr.rt run to launch such an effort and for those groups u3nable to pay, but over the long run consumers should pay for the necessary vitamins and minerals (les. than US$1 per person per year). Today World Bank-assisted. projects in thirty countries have mnicronutri- ent components. That is not enough. We propose to encourage coEt-effective micronutrient components in every appropriate World Bank project where micronutrient malnutrition exists and is not being addressed by other means. This effort will require greater client ownership and stronger partnerships with nongovernmental organizations, prh. ate industry, and bilateral and inter- I x x E N R I C H G N G L I V E S national agencies. Toward that same goal, we will continue to sponsor-along with the Canadian International Development Agency, the International Development Research Centre, the U:.ited Nations International Children's Educational Fund, and the United Nations Development Programme-the Micronutrient Initiative, which the World Bank helped create, as a catalyst of greater action in the affected countries, among donors, and by the food industry. Armeane M. Choksi Vice President Human Resource Development and Operations Policy The World Bank Acknowledgments T HIS paper was prepared by Judith McGuire, PIUN (Task Manager), and Rae Galloway (Consultant) from materials prepared by Howard Bouis, John Dunn, Rudolfo Florendino, Wilma Freire, Philip Gowers, Ted Greiner, the International Council for the Control of Iodinie Deficiency Disorders, Festo Kavishe, Benny Kodiat, The Manoff Group, Charlotte Neumann, Antonio Pardo, Mario Rivadeneira, Robert Tilden, M. G. Venkatesh Mannar, and Ray Yip. Gregg Forte was the editor. The team would like to thank the Internal Advisory Committee (Alan Berg, Alain Colliou, Joy De Beyer, Oscar EcheverTi, James Greene, Salim Habayeb, and Anthony Measham) and the External Reviewers (David Alnwick, Kenneth Bailey, Martin Bloem, Graeme Clugston, Frances Davidson, Ted Greiner, Peter Greaves, Steven Hansch, Basil Hetzel, E. J. R. Heyward, Abraham Horwitz, Rolf Klemm, Sonya Rabanek, Richard Seifman, Nevin Scrimshaw, Barbara Underwood, M. G. Venkatesh Mannar, Femando Viteri, and Richard Young) for their insightful comments. x I Abbreviations and Acronyms COIAR Consultative Group on International Agricultural Research DALY Disability-adjusted life-year EPI Expanded Program on Immunization FAO Food and Agriculture Organization of the United Nations GDP Gross domestic product ICCIDD International Council for the Control of Iodine Deficiency Disorders ICDS Integrated Child Development Program IDD Iodine deficiency disorders INACG Intemational Nutritional Anemia Consultative Group IVACG Intemational Vitamin A Consultative Group NGO Nongovemmental organization SCN SubCommittee on Nutrition of the UN Administrative Coordinating Committee UNICEF United Nations International Children's Educational Fund USAID United States Agency for International Development WHO World Health Organization xiI Executive Summary T HE control of vitamin and mineral deficiencies is one of the most extraordinary development-related scientific advances of recent years. Probably no other technology available today offers as large an opportunity to improve lives and accelerate development at such low cost and in such a short time. Dietary deficiencies of vitamins and minerals-life-sustaining nutrients needed only in small quantities (hence, "mnicronutrients")-cause learning dis- abilities, mental retardation, poor health, low work capacity, blindness, and premature death. The result is a devastating public health problem: about 1 billion people, almost all in developing countries, are suffering the effects of these dietary deficienc.es, and another billion are at risk of falling prey to them. To grasp the enormous implications at the county level, consider a country of 50 million people with the levels of mnicronutrient deficiencies that exist today in South Asia. Such a country would suffer the following losses each year because of these deficiencies: a 20,000 deaths * 11,000 children born cretins or blinded as preschoolers * 13 nullion person-years of work lost due to lethargy or more severe disability * 360,000 student-years wasted (3 percent of total student body). In terms of losses by type of dcficiency, more than 13 million people suffer night blindness or total blindness for the lack of vitamin A. In areas without adequate iodine in thc diet, five to ten offspring of every 1,000 pregnant women are dead upon birth- or soon thereafter due to iodine deficiency. Severe iron deficiency causes as many as one in five maternal deaths, as well as the death of about 30 percent of children who enter the hospital with it and do not get a blood transfusion (those who do get the transfusion are exposed to other risks). I 2 EN RICH ING LI V ES The World Bank's World Development Report 1993 found micronutrient programs to be among the most cost-effective of all health interventions. Most micronutrient programs cost less than $50 per disability-adjusted life-year (DALY) gained. Deficiencies of just vitamin A, iodine, and iron-the focus of this book-could waste as much as 5 percent of gross domestic product, but ad- dressing them comprehensively and sustainably would cost less than 0.3 per- cent of gross domestic product (GDP). The 1990 Summit for Children endorsed three micronutrient goals for the end of the decade: the virtual elimination of iodine and vitamin A deficier.cies and the reduction of iron deficiency anemia in women by one-third. The goals were reaffirmed in 1991 at the Ending Hidden Hunger confcrence and in 1992 at the International Conference on Nutridon. The goals are achievable only if political will, state-of-the-art technology, and private, public, and international resources are marshaled for the effort. The Need for a Comprehensive Approach The alleviation of poverty and the strengthening of national health care systems alone cannot solve the problem of micronutrient deficiencies. Because the rmicronutrient content of foods is a hidden property, consumers do not auto- matically demand micronutrient-rich foods with increased income. Thus, food and agriculture policies need to watch over not only the ouantity but the nutr- tional quality of the food supply and promote the production, marketing, and consumption of micronutrient-rich foods. Likewise, safety net progams, in- cluding refugee feeding, must respond to the total nutritional needs of target groups and not just to their calorie and protein needs. An overall improvement in health system management will go a long way toward improving mnicronutrient malnutrition as long as programs train and monitor medical personnel for the prevention and management of raicronutri- ent deficiencies, reach groups not currently using the health care system, and, through teaching and persuasion, transform consumers into a constituency for healthful diet Three Types of Approaches Even with the most nutritionally enlightened economic development plan, de- veloping countries must stll take direct aim at micronutrient malnutrition through consumer education, aggressive distribution of pharmaceutical supplements, and the fortification of commnon foodstuffs or water. Fortunately, all of these options are inexpensive and cost-effective. The particular mix of interventions chosen depends on country conditions. But the EX EC UT IV E SUM MARY 3 key constraints to achieving the summit goals are a lack of awareness and commitment of policymakers and consumers, a weak capacity to deliversupple- ments and education, and a lack of enforcement of industry compliance witi fortification laws. Social Mobilization Policymakers must be motivated to take action against micronutrient malnutri- tion. They need persuasive information on the economic and social costs of micronutrient malnutrition and on the political salience and cost-effectiveness of micronutrient programs. Then, during implementation, good management information systems and public education programs designed into the overall initiative can make the public aware of the improvements resulting from the micronutrient programs and draw the connection to the responsible program managers and policymakers. That connection provides public support and re- ward for the initiative of the political leaders. Beyond the immediate political feedback they provide, programs to edu- cate, persuade, and change the behavior of consumers are essential to the long- run elimination of micronutrient deficiencies. Subconscious consumer demand for micronutrients needs to be made conscious and directed to appropriate foods and pharmaceuticals. This demand will serv', as a 'pulr' factor to bring the target groups to distribution points for sur-y;iements, to overcome resis- tance, and, if necessary, to induce consuni"s to pay a little more for a better (that is, a fortified, altlough unfamiliar) diet Social marketing of micronutri- ents and micronutrient-rich foods is necessary in virtually all developing coun- tries, even where health service delivery is good and the food industry is well developed. Pharmaceutical Supplementation Two key problems in pharmaceutical supplementation have been poor oover- age of at-risk groups and inadequate supply management. To overcome the coverage problem, the delivery of supplements must break out of a single- cIiiiic-based track and employ every possible avenue of convenience and op- portunity, including school visits, workplace programs, and nutritional safety net programs. The goals of supply management are to procure effective supplements that look appealing, have helpful packaging and labeling, come in the right doses, and are affordable; to store and transport them for maximal quality and preser- vation; and to deliver them to well-selected distribution points in adequate numbers of doses at an appropriate frequency. Achieving these goals requires 4 E N R I C I I N G L I V E S committed program leaders, motivated and well-trained workers, good moni- toring and surveillance, and a demanding public. The private pharmaceuticals market may have an important role to play in developing new products and delivering supplements in a cost-effective manner at the community level. Effective Regulation and Incentives for the Private Food Industry The food industry responds to both positive and negative policy signals. Broad legislation, followed by technical regulations, should require micronutrient fortification of basic foodstuffs and support a fair and honest regulatory system that monitors compliance and punishes the noncompliant This legislation should be joined by financial and political inducements to industry. Some of the incentives used in effective fortification programs have been tax relief, import licenses, loans for equipment, subsidies on fortificants, and positive press coverage. A third component of any successful food control system is consumer awareness and pressure for industry compliance. Consumers can be mobilized through social marketing and consumer organizations to demand effective for- tification. Without confidence in both the industry and the regulatory appara- tus, enlightened consumers wi'll not be willing to buy new products. Developing Nutritional Awareness and Habits Political sustainability comes from monitoring and communications as well as satisfaction of consumer demands. One of the greatest advantages of micro- nutrient programs is that, because results are unambiguously attributable to specific interventions, policymakers can take credit for imnprovements. Operational sustainability depends upon good management, continual over- sight, the retraining of personnel, and the supervision of delivery systems (par- ticularly the health system and food industry). Behavioral sustainability will come only after consumers form good nutr- tion habits, whether that means eating carrots, taking a daily iron pill, or buying a fortified food. Economic sustainability is a function of national and household ability to pay. Micronutrients are so inexpensive that, regardless of the form, they should ultimately be affordable by the intended beneficiaries. For equity reasons or in the short term, some form of targeted subsidy may be necessary to reach the poorest and to form habits among the desired beneficiaries. In the long run, however, financial sustainability will depend upon consumers' willingness to EX EC UTI V E SU MMARY 5 pay for the nutrients. It is the government's responsibility to choose the most cost-effective means of delivering micronutrients to the population. The Need for External Start-up Support Micronutrient interventions are among the most cost-effective investnents in the health sector. Because fortification of water and foods is also extremely cost-effective, nontraditional sector involvement is desirable as well. Donors have a key role to play in assisting with program design and financing. Ad- dressing inicronutrient deficiencies globally will require an estimated $1 bil- lion per year-about $1 per affected person (all dollar amounts are U.S. dol- lars). That figure is equivalent to the economic costs of endemic deficiencies of vitamin A, iodine, and iron in a single country of 50 million people. Most of these costs will ultimately be borne by consumers when purchasing food with higher nutrtional quality. In the short run, however, donors and govemments may have to assume a major financial burden for project preparation, start-up costs, and recurrent costs in the early years. The economic and social payoffs from micronutrient programs reach as high as 84 times the program costs. Few other development programs offer such high social and economic payoffs. CHAPTER ONE The Challenge of Dietary Deficiencies of Vitamins and Minerals THE life and vitality of human beings depend crucially on certain vitamins and minerals that help deteriine the efficient functioning of the brain, the immune system, reproduction, and energy metabolism. The body needs only small amounts of these nutrients-micrograms or milligrams per day (hence the term micronutrients)-but it cannot manufacture them. They must be part of the diet or taken as supplements. Deficiencies of even the small amounts required cause learning disabilities, impair work capacity, and bring on illness and death. Micronutrient malnutrition is most devastating for pre- school children and pregnant women, but it is debilitating for all ages. And it is debilitating for the national economy as well. The Strategic Importance of Vitamin A, Iodine, and Iron Virtually every developing country has a deficiency in vitamin A, iodine, or iron that is large enough to constitute a public health problem; many develop- ing countries have multiple deficiencies.1 More than 2 billion people world- wide are at risk from deficiencies of these nutrients, and more an 1 billion are actually ill or disabled by them; almost all are in the developing world (Table 1.1). Unfortunately, the rise in caloric intake that accompanies economic devel- opment and higher income does not solve the problem of micronutrient mal- 6 THE CHALLENGE OF DIETARY DEFICIENCIES 7 Table 1.1 Population at Risk of and Affected by Micronutrient Malnutrition, by WHO Region, 1991 (rnilhonsy Iodine defiricicy Vitamin A disorders deficiency Affected Affected Iron-deficient Region At risk (goiter) At risk (xerophthalmia)b or anemic Africa 150 39 18 13 206 Americas 55 30 2 0.1 94 South and Southeast Asia 280 100 138 10.0 616 Europe 82 14 - - 27 Eastem Mediterranean 33 12 13 1.0 149 Westem Pacific and China 405 30 19 IA 1,058 Total 1,005 225 190 13.8 2,150 - Not availablc. a See Appendix A for furthr details b. Xerphtbalrda (drying of die cye) is a geneval tnu for all eye signs of severe vitnain A deficiency including bindness. Sr Appcndix A for furtherdeils. Source: WHO 1992. nutrtion-these nutrients are not present in all foods (some are present in very few), and people do not have a natural hunger for them. On the other hand, there are well-established, low-cost means of prevention and treatnent for deficiencies of vitamin A, iodine, and iron in developing countries. The effectiveness of these measures can be clearly measured, and they are the focus of this book. The dietary sources of the three mnicronutrients and the consequences of their deficiencies vary: * Vitamin A is found in fm-K:As and vegetables, liver, and breastmilk. Humans need less than one-thousandth of one gram of it per day, but more than 13 million people suffer night blindness or permanent blindness for lack of it. In areas of endemic deficiency, more than one of every 10,000 children under the age of six is blind. Six of every ten preschool children with severe vitamin A deficiency die. * Iodine has been depleted from the soil in many parts of the world. In those areas, five to ten offspring of every 1,000 pregnant women who do not eat seafood or otherwise get iodine (such as through iodine-fortified salt) are dead upon birth or soon thereafter (Clugston, Dulberg, Pandav, and Tilden 1987); 8 E N R I C Pe I N G L I V E S many of those who survive are cretins-mentally retarded, spastic, and with low life expectancy. Many others are deaf, mute, or mildly to moderately retarded. Iodine deficiency in adults reduces work potential (Hetzel 1989). More than 200 niillion people worldwide lack adequate iodine in their diet. * Iron is found in red meat and breasnuilk. It also :xists in grains, legumes, and vegetables but in a form less easily absorbed unless taken at the same time withT meat or foods rich in vitamin C. Thus diets of grains, legumes, and vegetables in developing countries are often deficient in absorbable iron (DeMaeyer 1989). About 1 billion people suffer clinical anenia. Severe ane- mia causes as many as one in five maternal deaths. Children born of anemic mothers are often stunted and sickly. Severe anemia kills about 30 percent of children who enter the hospital with it and do not get an immediate transfusion of blood; those who do get the transfusion are exposed to other risks (Lakritz, Campbell, and Ruebush II 1992). A less-severe deficiency of iron in the pre- school years, even if corrected, permanently reduces the manual dexterity of children, limits their attention span, and shortens theirmemory capacity (Seshadri and Gopaldas 1989; Lozoff, Jimenez, and Wolf 1991). As with iodine, a defi- ciency of iron in adults reduces work capacity: in anemic people, a 10 percent increase in hemoglobin (the iron-ontaining component of blood essential to transport oxygen) of a moderately anemic person raises work output 10 to 20 percent (Levin 1986). The Scope of Micronutrient Manutrition To grasp the costs of nutrient deficiencies, consider a country of 50 million with the level of micronutrient deficiencies that exists today in South Asia. Such a country would suffer the following losses each year, due entirely to inadequate vitamin A, iron, and iodine: * 20,000 deaths i 11,000 children born cretins or blinded as preschoolers 13 million person-years of work lost due to leth ormore severe disability n 360,000 student-years wasted. The monetary cost associated with the personal and social tragedy of these human losses depends on the wage rate and the imputed economic value of a human life. Assuming a conservative estimate of $750 in wages per person- year of work and $1,000 per life lost, the monetary cost of the 1.3 million person-years of work would reach almost $1 billion per year, about $20 per capita. The 20,000 excess deaths per year and the future social burden and THE CHALLENGE OF DIETARY DEFICIENCIES 9 wage losses imposed by the lost schooling and physical handicaps of the chil- dren add even more to the loss. To give only one example of the possible return on investment from a program of correction, and to anticipate the discussion in Chapter 2, fortifying the food and water supply with vitamin A, iodine, and iron for all in this country of 50 million would cost about $25 million per year, or $0.50 per capita (versus $20 per capita in the above estimate of annual malnutrition costs); such fortifi- cation could virtually eliminate the lost work capacity, blindness, cretinism, and death caused by deficiencies of the targeted micronutrients. The $25 mil- lion investment would thus yield a fortyfold annual return on investment even without: counting the future costs. Even with only a 50 percent coverage of the neediest people in the country, the returns from micronutrient programs vastly outweigh the costs. Put another way, assuming a per capita GDP of $350 ($17.5 billion for the whole country), the current-year losses from inicronutrient mal- nutrition ($1 billion) amount to more than 5 percent of GDP, whereas the $25 million program of fortification costs less than 0.15 percent of GDP (see Appen- dix B for further discussion). Beyond the Reach of Economic Development Poor people are more likely than others to suffer from miicronutrient malnutri- tion; but micronutrient intake does not necessarily improve in step with in- come, because the micronutrient content of fbods is a hidden quality to the uninformed consumer. People know when they are hungry and when they have had enough to eat They have no natural hunger, however, for vitamin A, iodine, iron, or other micronutrients; they generally do not know that they need them; and they do not know what foods provide them. The signs that someone hasn't eaten enough of a particular vitamin or mineral are subtle and delayed, and they may not seen severe or diet-related to the victim. Even cretinism and blindness are more likely to be attributed to divine retribution than they are to diet Some micronutnents are heavily concentrated in a few foods, so just by eating more or having a more varied diet will not necessarily increase the intake of those micronutrients unless consumer demand has been directed to the right foods. For example, in the absence of fortification, iodine intake can be con- stant regardless of income because its concentration in food is a function of its concentration in the soil. Only wealthy consumers in iodine-deficient regions may get adequate amounts of iodine because they can afford to buy seafood, food from abroad, and iodized salt. The intake of vitamin C (which helps in iron absorption) and vitamin A changes only erratically with income. Because these vitamins are concentrated 10 E N R I C H I N G L I V E S in perishable fruits and dark green, leafy vegetables, their consumption largely depends on agricultural seasons. In rural areas, wild foods contribute a consid- erable amount of vitamin A to the diet. As income rises, however, the consump- tion of vitamin A often decreases because traditional foods, including breastnilk, are disdained. With their access to cultivated fruits and dairy products and the refrigeration to keep them, the highest income groups are able to raise the level of vitanins C and A in their diet. In principle, both the quantity and quality of iron in the diet is related to income.2 Yet in Asia and Latin America, iron availability in the past twenty to thirty years has declined, perhaps because of a decline of legumes in the diet, while income and caloric intake have generally risen (Figure 1.1). In Africa, income and the supply of food have stagnated, and the supplies of both vitamin A and iron have declined, perhaps because of less reliable supplies of red palm oil (rich in vitamin A) and a dietary shift from grains to tubers. The consump- tion of vitamin A has risen in Asia largely because of greater supplies of red palm oil, and in Latin America and the NearEast because the more diverse diet that has been acquired with higher income has included more vegetables and dairy foods. Good Health Care Systems: Necessary but Not Sufficient Vitamin and mineral deficiencies loom as a public health problem in all devel- oping countries. They require preventive measures that go well beyond the function of health care delivery. Of course, good health care systems, important in their own right, can contribute a great deal to the nutritional condition of the population. Hookworm disease, for example, a cause of anemia, should be treated with antihookworm medicine and iron supplements. Vitamin and min- eral supplementation is an important part of the care of pregnant women and young children, and it is also vital in the treatment of numerous diseases, including measles, chronic diarrhea, lower respiratory infection, and malaria. Because breastmailk is rich in high-quality vitamnin A and iron, breastfeeding promotion should be central to any health care system as well. The Need for Special Programs The last few decades in the developing world have shown that serious vitamin and mineral deficiencies are not uniformly corrected by rising income, at least over any acceptable time frame. Although health care programs provide a necessary point of intervention, they cannot completely correct the causes of deficiencies. THE CHALLENGE OF DIETARY DEFICIENCIES 11 Figure 1.1 Changes in Availability of Vitamin A, Iron, and Food Energy by FAO Region from 1960165 to 1986/88 Africa Vicamin A (Re mcng/cputtday) 1v.n (mgkaputlday) Viunin A Kcal Iron Kcal '100o0S 3.fl0W 30 3.000 950- Vitamin A 25M 24 Iron 2,500 92 - Io 985O -- . 20 . -- 750 - 2.000 5Kel2,000 825- goo 300 - 10 1.500 60 3 _ _ _ _ _ _ _ _ _ _ _ _ _ _ t96163 19671 I9"4I 1966-3 196143 196i9-71 197941 1986. Asia (FarEast) Ut:unin A Ical Lran Ical 613 } 19 600 -3.00(1i 3,000 550 Vhtamin A 500 / 2 SW 14 Ir on 2,500 500 .2.5w~~~~~~~~~~~~~~~~~~~.0 450 350 - _ = > / , _ 12 12,000 l941-63 196-71 197t1 1936-U 1961.63 1969-TI 1979-91 19 Latin AmerDca VicruninA Kcal Irn Kcal 800 3.00 24 3,000 750 Iron 70D 2,750 14 . _ 2.750 62D ---0--------- 650 Kcal, 600 VkarninA 2,500 13 - cal 2500 550 500 2,250 12 . 2,250 196143 1969-71 1974t 19364- 196f4J 1969-71 197I4 1986- N'ear East Viarnin A Kcal Iron Kcal 22 900 -3.500 20 3.500 750 13.000minA 800 /,_ - 1900 Iro - -o , 3.0 700 is 650 ICcal 1 . Ka .0 625 00 Ke. 2-00 550 500 * *ODO200 16 2.OOD 1961-6 299-71 297941 4936 196143 1969-71 197941 194543 - Per capita requireents for vimamin Aor iron. ____ Kiloc2lories (food eneW). Source: FAO 1992 database (AGROSTAT7C. Fod Man= Sheets. FAO. Rome). 12 E N R I C H I N G L I VE S BOX 1.1 WHEN TO CONSIDER USING U designing horticultural projects. AN IRON PROGRAM Encourage the production and con- sumption of micronutient-rich foods. Iron deficiency is the most preva- * designingsocialforestryprojects. lent nutritional deficiency, and cre- Plant and animal sources of iron and ative means of delivering iron to vitamins A orC are abundant in multi- high-risk groups need to be devised. use forests. An iron program (supplementation as fortification) should be consid- * implementing livestock programs. ered when ... Usetheprogramsto encourage house- hold corsumption of meat or animal * r yt group of adolescent girls is by-products (especially of small stock) together in school or special classes. to make a major coninbution to the daily Give them iron to build up their stores intake of highly absorbed iron. and compensate for menstrual blood losses. * improving pharmaceutical supply programs oressentialdrugprogram& * any group of women is together Iron folate tablets are part of virtually (such as in a meeting at their farm evrbaidugpoamythyae co-op or well-baby clinic, in a health everybalic drungproeram yetdueysare eductonsesson,liteacydass or almost always neglected by drug-sys- education session, Irteracy class, or tenmngr.Imrvmnsi ta- loan solidarity group). Most women tem managers Improvements in tab are anemic. They may not be willing let color, coating, packaging, and dis- to take iron during pregnancy so take tribution will make majorcontributions advantage of all opportunities to give to improving compliance. them iron. . designing any maternal-child * designing food aid programs that health (McH) program. Iron deficiency use processed food. Flour, oil, condi- is so prevalent in women and chil- ments, and milk can be fortified with dren that an MCH program that does iron as well as iodine and vitamins. not give high visibility to anemia con- trol is seriously deficient. * developing weaning foods. Pro- cessed or fermented foods and ger- u manychildrengettransfusionsfor minatedflourscan be fortified with iron severe anemia. Their need for addi- orcan enhance iron absorption. Micro- tional iron, and perhaps for treatment nutrient-rich foods can be added to of iron-depleting disease such as homemade porridges. hookworm, is self-evident. THE COALLENGE OF DIETARY DEFICIENClES 13 Successful national strategies address micronutrient malnutrition as a dis- tinct problem and attack it through as many venues as possible: nutrition pro- grams with specific micronutrient components, direct delivery of supplements to target populations, clinic-based programs to prevent and treat deficiencies during regularly scheduled visits, school interventions, agricultural policies with a nutritional focus, and food fortification (see Box 1.1 for an example of opportunities with a special emphasis on iron). Underlying these diverse efforts and essential to them is a simultaneous campaign to inform people about micro- nutrients and to guide consumers to incorporate them in their diet. Only such a campaign, using print media, advertising, counseling, and other means, can create conscious demand for nutritious food, which constitutes the fundamental resolution of the problem. While the national strategy proceeds with the alleviation of poverty and the development of the health care system, specific micronutrient programs must be promoted. When the promotional efforts achieve a critical mass of agree- ment among political leaders and the public, an action program can begin on four planes at once, each with a progressively longer-term goal: (1) highly targeted, rapid interventions through the delivery of vitamin and mineral pills and other pharmaceuticals; (2) longer-term interventions through fortification of selected foods, if feasible; (3) consumer education programs to modify diets by building awareness of micronutnients; and (4) coordinated agricultural pro- grarns to increase the supply of micronutrient-rich food. It is fortunate that the costs of these strategies are among the lowest of all health-related programs. CHAPTER TWO The Low Costs of Overcoming Vitamin and Mineral Deficiencies W ITHIN an overall campaign of advocacy and education to cre- ate political support and popular demand for action on micronutrients, the three major ways of delivering micronutrients are: 1. Supplementation of the diet with pharmaceutical nutrients in capsule, tablet, injectable, or liquid 2. ForrlfIcation of food with nutrients 3. Dietary change by expanding the demand for, and supply of, nutrient- rich foods. When considered separately or in any combination, these three modes involve low costs and high returns. The direct costs of delivering nutrients as supplements or in food are remarkably low. In Indonesia and the Philippines, it cost an estimated $0.25 per person (1984 dollars) to deliver vitamin A in capsules; in India in 1M7, $0.05 per person to fortify salt with iodine; in Guatemala in 1980, $0.12 per person to fortify sugar with iron (Table 2.1). Costs in terms of life-years free of illness (disability-adjusted life-year gained, or DALY) is a measure for comparing health interventions. Some of the lowest-cost interventions have per DALY cost ranges that vary from $2 to $10 (for tetanus immunization), to $15 to $75 (for fertility control) (Jamison 1993). 14 THE LOW COSTS 15 Table 2.1 Costs of Micronutrient Control Programs Eitimiwed cost Estimated cost perperson per year in US$Iperson of proteclion Micronwrrent Country/year (1994) (1994$) Iodine Oil injection Peru 1978 2.75 0.55 Oil injection Zaire 1977 0.80 0.17 Oil injection Indonesia 1986 1.25 0.25 Water fortification Italy 1986 0.05 0.05 Salt fortification India 1987 0.02-0.05 0.02-0.05 Vitamin A Sugar fortification Guatemala 1976 0.17 0.17 Capsule Haiti 1978 0.27-0.41 0.55-0.81 Capsule Indonesia/Philippines 1975 0.25 0.50 Iron Salt fortification India 1980 0.12 0.12 Sugar fortification Guatemala 1980 0.12 0.12 Sugar fortification 1980 1.00 1.00 Tablets 1980 3.17-5.30 3.17-5.30 Source: Lz%in. Pollift. Galloway, ad McGuirc 1993. In these terms, micronutrient programs are extremely attractive: $4 per DALY for iron fortification, .58 for iodine fortification, and $29 for vitamin A fortifica- tion (Table 2.2). The most expensive strategy, supplementing the iodine intake of everyone under age o0, comes to $37 per DALY. The costs of dietary change are less well documented than those of fortifi- cation and supplementation. On-! effective program in Nepal combined educat- ing mothers in vitamin A nutrition with literacy based on a vitamin A-oriented curriculum; it cost $2 per person (the nutrition education alone cost about $1.25). Nutrition education about vitamin A prevented 1,085 deaths ($238 per death prevented) and 2,340 cases of xerophthalmia ($110 per case prevented) while nutrition education along with maternal literacy prevented 1,600 deaths ($252 per death prevented) and 3,510 cases of xerophthalmia ($115 per case prevented) (TMlden and others 1994). A project in Bangladesh to educate con- sumers about vitamin A and to stimulate production of foods containing it cost about $0.11 per person per year (not counting the SS per person per year in vitamin A foods the family would need to consume). 16 E N R I C H1 I N G L I V E S These costs for dietary change seem much higher than those shown abovc for fortification and supplementation. But dietary change programs may be more sustainable at the family and community level when the sources of micronutrients are locally avaiiable-established behavior pat- terns don't depend on the regular resupply of promotional messages or of pharmaceuticals for effectiveness. Dietary change can also generate wider payoffs: a study of the Nepal program showed that greater maternal lit- eracy and awareness of vitamin A generated other benefits in the area of child growth and the mother's use of health care (Tilden and others 1994). The greatest cost in these dietary change programs was that of the pro- moted foods, which were purchased by the family and often substituted for other foods in the family food basket. Program Designs With their finite budgets, developing countries must choose whether to aim their programs at specific subsets of the population (the poorest, pregnant women and preschool children, the already ill) or at the whole population. Table 2.2 Returns on Nutrition Investnents Discounted value (S) Cost per Cost per of producrivity disability- life saved gained per program adjusted life Deficiencylremedy (5J () year gained Iron deficiency Supplementation, of pregnant women only 800 25 13 Fortification 2,000 84 4 Iodine deficiency Supplementation (repm-aged women only) 1,250 14 19 Supplementation (all pcople under 60) 4,650 6 37 Fortification 1,000 28 8 Vitamin A deficiency Supplementation (under 5 only) 325 22 9 Fortification 1,000 7 29 Nutrition education' 238 La. n.a. Nutrition education and maternal literacy" 252 rLa. n.a. na. Not applicabic. a Tilden and oais 1994. Source: Levin. PallitL Galloway. and McGuirm 1993. SeC Appendix B. T H E L O W C O S T s 17 whether to develop nutritional self-sufficiency through dietary change or to focus on the rapid supply of nutrients through fortification and supplementa- tion. The appropriate choices are not fixed for all places and times. Examples of the trade-offs involved in various choices come from the Philippines and Indonesia. In the Philippines, investigators concluded that the ratio of costs to benefits was always lower for supplementation than for fortification or education (Popkin, Solon, Fernandez, and Latham 1980). In Indonesia investigators found that, at low annual micronutrient budget levels (less than $0.42 per person), dietary modification would be most cost- effective; at moderate levels ($0.43 to $0.87 per person), capsules would be preferred; and at higher levels, fortification was most cost-effeclive (Gross and rilden 1988). Supplementation and education, which require personal contact, can be relatively costly when targeted at those living in physically remote and cultur- ally isolaed regions. Theoretically, education generates new cultural norms for diet in these populations through their (presumably low-intensity) contact with the rest of the society. If this trasmission happens at all, however, it does so only after a long and sustained period of change. Because the success of fortification depends on the development of a prod- uct acceptable to the consumer and on the government's ability to enforce standards, its launch must be preceded by careful research, education, training, and institution building if it is not to risk failure. The scale of a fortification program is determined (1) by the foods to be fortified, and (2) by the proportion of the supply of those foods that is actually fortified. If a large part of the population is not at risk for a particular nutrient, one might want to select a food consumed by the needy and only by them. But if the cost of fortification is low-and in most cases it is-the extension to the non-needy may be adminis- tratively more practical and still economical. Consider the case of salt, which is consumed by practically everyone. In almost every country in the world, adding iodine to refined salt would cost less than $0.10 per person per year. If the entire supply of salt were fortified and only half the population were at risk from iodine deficiency, the cost per needy person would double, but the amount would still bejust $0.20 per person. Successful fortification of a staple food may be one of the most equitable health interventions available-especially if the slight cost of the additional nutrients is absorbed by the government-because it reaches everyone, includ- ing the poor, pregnant women, and young children, populations that social services can never cover completely. Only the adequate enforcement of fortifi- cation standards (and a palatable product) will guarantee that the intended scale is actually achieved. 18 EN RICH ING LI V ES Public and Private Financing Who should pay for micronutrient programs? Over the long run, programs that deliver micronutrients to those who can afford adequate caloric intake should be self-financing: widhproperinfornation, these consumers will havethe knowl- edge and the access to the foodstuffs and supplements necessaiy to avoid nutritional deficiency without subsidy. And those who cannot afford adequate food should be receiving the needed nutrients from nutritional safety net pro- grams, which are already being subsidized. Hence, ideally, no mnicronutrient program as such would be needed in the long term beyond efforts to sustain the population's knowledge regarding micronutrients. In the short term, the lackofconsumerawareness and the heavy social costs of malnutrition amply justify public intervention and subsidy to get countries with deficiencies on a nutritionally self-sufficient path. The specific strategy and financing plan for each country will be based on local diets, the structure of the food and drug industries, the coverage of public services, the sophistication of communications systems, and fiscal realities. Generally, assistance in the form of foreign exchange, price stabilization, and subsidies wl-l be critical aspects of initial micronutrient programs. Donor organizations and donor countries have a role in supplying the for- eign exchange needed to support fortification and supplementation: for supple- mentation, pharmaceuticals will likely come from abmrad; for fortification, the nutrients, the equipment to process the food, and the chemicals and laboratory equipment required for monitoring will also be largely of foreign origin! The synthetir nutrients used for fortification and supplementation are inex- pensive, but td, insecure food supply in many households and the substantial markup on the nutrients by commercial manufacturers can create the near-term need for subsidies and price controls. For example, vitamin A and iodine cap- sules cost under $050 per person per year as delivered; if they are sold through private retai outlets, however, some social marketing, surveillance, and price controls may be necessary to assure that the consumer is not being overcharged. Such markups can likewise lead to higher prices for fortified foods and the consequent shunning of them by consumers if the price is not subsidized. As all of the supplies of that food become fortified and awareness generates a prefer- ence for it, the need for price support dwindles. The remainder of the costs-largely recurring costs of supplies, delivery, and monitoring-should be assumed partially by consumers and partially by the government. In most cases, for example, the consumer bears virtually all the costs of iodizing of salt, while the costs of regulatory enforcement are appropriately covered by the government. Although iodizing refined salt re- THE LOW COSTS 19 quires little additional cost (in the United States, iodized salt carries the same price as uniodized salt), iodizing crude salt requires more processing, extra drying, and new waterproof packaging, all contributing to higher cost to the consumer. Iodizing crude salt, then, presents another case for near-term subsi- dies, to be gradually phased out as the salt industy modermizes. A Social, Not a Technical, Chaflenge The tools to corect niicronutrient malnutrition are well understood and techni- cally easy to apply-supplementation, fortification, and dietary change through education and food diversification. The costs are low and the payoffs large. But designing a program on the basis of cost-effective technology does not deter- mine the success of the program. A review of micronutrient prgrams around the world points to the creation of demand as the indispensable factor for success. Creating demand is a matter of modifying behaviors by easing resis- tance to dietary change-through education, demonstration, and advocacy- and by providing motivations to seek such change. Leaders must be motivated to support nutrition programs; beyond them, health care workers, teachers, the business community, mothers, and consumers at large must demand the supple- ments, nutrient-rich foods, and fortified foods that deliver good nutrition. Such popular demand, which creates political support, is essendal to the sustainability of micronutrient programs. Therefore a consumer perspective should be included in all elements of micronutrientprograms, including supple- mentation, fortification, agricultural initiatives, and communications. As de- mand is generated, supply must also be guaranteed through improved program managemenL CHAPTER THREE The Delivery of Supplements P HARMACEUTICAL supplementation can appear to be an easy solution to the micronutrient problem. In fact, supplementation is as complex as any other approach, if not more so: it requires a good logistical system capable of delivering high-quality pharmaceuticals when and where they are needed and a good social marketing program to sensitize and inform the popu- lation about micronutrients. But these elements only prepare the ground, so to speak, and set the stage for the effective delivery of micronutrients. The acual uptake of supplements by the targeted populations requires trained, motivated health care workers who can communicate effectively with consumers to over- come their fears, misinformation, and ignorance. Traminng and Support of Health Care Workers Taking pills and getting injections may require deep changes in behavior and belief. The neediest populations often see the nutritional quality of their diet as irrelevant to fatigue or other forms of ill health. Fears also play a part for example, a common fear among women is that an iron pill or iodized oil injection is a contraceptive. For pregnant women, taking iron means maintain- ing a new daily behavior that (1) may not be pleasant given the fishy aftertaste of iron and the constipation it may induce, and (2) may seem pointless after the women experience rapid relief from symptoms (even if the underlying anemia 20 T HE DE L I V ER Y OF SUP P LEM E NTS 21 lingers on). Thus, for targeted populations-and for mothers in particular, who must obtain supplements frequeatly, sometimes daily-merely showing up for the injection or actually taking the pill or giving it to a child often implies a great accomplishment: perceiving the three-way connection between health, the ongoing need for nutrients, and the supplement. In supplementation, therefore, much rides on the abilities and commitment of health providers. They must know enough and be sensitive enough to explain the nature and importance n£T the capsules, pills, or injectables; to determine which family members need them and in what dosage and fre- quency-, to tell when and where to get them; and to both warn and reassure the consumer about the supplement's possible side effects. In addition, the delivery of pharmaceuticas often requires health care workers to make strategic choices that must be informed by their knowledge of the particular attitudes and life situations of the targeted population. A campaign of supplementation can be far more effective when it includes con- sumers in the planning phase o learn the attitudes and perceptions of the targeted populations. Minimizing Supply Problems An effective social marketing campaign, combined with the effective counsel- ing of consume;s by health care workers, has a two-way benefit It helps in- crease the acceptability and penetration of the supplementation campaign, and it helps create a public demand for, and expectation of, good nutrition. The acceptance of supplementation is a necessary but insufficient condition for a long-term program; unless consumers demand supplementation out of a sense of enddlement, health providers are more likely to forget to distribute the nutri- ents, thc supplies are more likely to be given to the non-needy or deteriorate in warehouses, and the program is much more likely to fail, initial successes notwitsanding. Indeed, many supply problems, which the SCN5 has found to be more important than client noncompliance as a cause of iron program failures, are rooted in a lack of worker training and client education. One East African country, for example, almost dropped vitamin A from its list of essential drugs because health workers didn't know when to prescribe it and the community didn't demand it. Administrators saw the product accu- mulate in storage and thought it wasn't needed; training and community education remedied the problem. Training also permits workers to antici- pate and accommodate increased demand for supplements from newly informed consumers and to direct scarce supplies of supplements to the neediest. 22 EN RICH ING LI V ES Supplementation Programs To boost coverage levels rapidly, one Southeast Asian country in 1980 intm- duced a vertical (that is, single-focus) program (alongside its existing health care program) to deliver vitamin A supplements in schools, community cen- ters, and other locales of convenience and opportunity. After two years, cover- age had increased from 6 to 77 percent (West and Sommer 1987), a high rate, although the populations missed by the program were probably the neediest Today, however, coverage has fallen below 50 percent because momentum could not be sustained. If coverage dwindles in a high-intensity, initially suc- cessful program like this onie, then normal programs are not likely to sustain themselves. In a South Asian country, a "universal" program of vitamin A supplemen- tation, which uses existing health care providers, reaches only about 36 percent of the population (probably the least vulnerable portion) largely because the public health care system has poor coverage. Furthermore, coverage has fallen over time, perhaps because of worker apathy or because the intmended beneficia- ries do not perceive the need for vitamin A or the threat of blindness from vitamin A deficiency- If the intended beneficiaries were actively seeking the supplements, coverage would not be so low or decline over time, yet rarely do supplementation programs include any social marketing. In general, social marketing to raise demand and Iend theprogram urgency, more aggressive targeting of populations, increased outreach, and improved quality of services are needed to raise and sustain the coverage of suppl':menta- don programs (see Box 3.1). Targeting Special Groups and Using Existing Outreach Programs Targeting is a critical issue in the design of a micronutient supplementation progran because the deficiencies may affect specific subgroups in the popula- tion. Even in countries considered to have endemic vitamin A deficiency (Bangladesh, India, Indonesia), the prevalence of signs of moderate deficiency (nightblindnaess) rarely exceeds 5 percent in young children (in Bangladesh 2.6 percent of preschoolers were night-blind in 1991). With iodine deficiency, an incidence of visible goiter in 20 percent or more of the population is a sign of a serious public health problem. Iron deficiency commonly affects 30 percent of the general popalation and as much as 75 percent of pregnant women. Target- ing is econoniically desirable if it can be done at low cost In the case of iron, the deficiency may be so prevalent that presumptive treatment of all pregnant or reproductive-aged women may be more cost-effective than a program of T HE DE LI V ER Y OF SU P P L E M E N T S a BOX 3.1 LESSONS LEARNED FROM * Make sure health care providers SUPPLEMENTATION PROGRAMS know exactly what to do and why- train and supervise for performance. * Educate community leaders to win * Schedule regudarweeks or months them as allies. forsupplementsto ease management and marketing problems. a Rank target groups and try to reach highest priority groups first. s Distribute supplementation re- cords to beneficiaries and check * Induce families to come to clinics supplementation status whenever a by marketing the supplement as target-group member appears at a health-promoting rather than as a pre- clinic. vention for blindness or cretinism- these diseases are sufficiently rare * Counsel household decision- that people will think they won't be makers about giving micronutrient- affected. rich foods to young children and preg- nant and lactating women. This in- * Extend the program beyond the cludes breastfeeding promotion. clinics-the Expanded Program on Immunization can be useful. * Integrate pharmaceutical supple- mentation with the development of * Deliversuppies on time and in the longer-term solutions. tight amounts. screening plus therapeutic treaunent. In general the options for targeting are as follows: 1. Universal targeting, or nontargeting (targeting vitamin A to all pre- school children; targeting iron folate tablets to ail pregnant women; targeting iodized oil to all women of reproductive age; or all schoolchildren). In practice, universal targeting means reaching the most willing and accessible population. 2. Medical targeting. This includes targeting vitamin A to children with xerophthalmia, chronic diarrhea, severe acute respiratory infections, growth failure, tuberculosis, or measles; and targeting iron to premature and l0w- birthweight babies. 3. Geographic or seasonal targeting. Iodized oil is usually targeted to high-altitude areas and places beyond the reach of commercial salt mar- kets. Vitamin A supplements may be required only during the dry season or in semiarid areas. Iron may be targeted to malarious or hookworm- infected regions. 24 E N R I C H I N G L I V E S 4. Targeting using biochenical tests. This is generally inefficient and uneconomical except where prevalence of deficiency is very low or danger of toxic overdose very high. Medical targeting of vitamin A works well because ill children are likely to be brought to a health center, which facilitates distribution. Determining the coverage of such programs is difficult, however, because the total population of sick children is variable and unknown. Outreach is also difficult in this situation because health workers are unlikely to know when a child falls ill. Nonetheless, medical targeting can be an economical means of getting vitamin A to a sub- population of children who need it badly. If universal distribution is the mode of choice, the Expanded Program on Immunization (EPI) can help deliver supplements to remote areas (see Box 3.2). Many countries with the EPi immunize 80 percent or more of the En target group of 6- to 14-week-old children. Using the EP! village visits and programs to deliver micronutrient supplements to all children, as well as to adults, would yield a major advance in coverage of micronutrient supplements. EP! campaigns as currently configured are better suited to oral iodine (which needs only one annual dose) than to vitaniin A (which needs to be given every four to six months) because national campaign days usually run for two days BOX 3.2 SUPPLEMENTATION which limit access to iodized salt, also THROUGH THE EXPANDED PROGRAM make laboratory-based surveillance of ON IMMUNIZArION treatment progress impossible. Cov- erage and impactfigures are not avail- ltwill take a long tirm :xizedsaltto able, butthrough limited epidemiologi- addressiodine defic -icyintheremote cal assessments of goiter and cretin- districts of Nepal, so the country has lsm and through other indicators such set up a free-standing program to sup- as the disappearance of stocks, the ply iodized oil to those regions through program is seen as a success. the infrastructure of the Expanded Pr- The director of the program credits gram on Immunization (EPI). the success to many of the same fac- The goal is universal coverage in a tors associated with the succes of phased succession of districts, with EPI and malaria control, namely, repeated administration of injected clearly delineated objectives and tar- iodized oil after three to five years. gets, "clarity of purpose," a core group Workers focus community participa- of supervisory and managerial level tion on mobilizing interest in iodine workers with experience in surveys deficiency and the uptake of iodized and program management under di- oll. The poor infrastructure and re- ficultconditions, and a campaign men- moteness of the mountainous areas, tality (Acharya 1991). TH E DELI v ER Y oF SUP P LEM ENT S 25 four to six weeks apart. With some expansion of responsibilities and target groups, however, EPI workers could be used to deliver vitamin A every four to six months or during specific months. In countries with highly seasonal defi- ciencies (Nepal is an example), a single dose, properly timed, could be ad- equate. But in many countries, vitamin A deficiency is a year-round problem. Iron tonic could be delivered rough EPI to children above 6 months of age but it has not yet been tried. Where vitamin A and iodine deficiencies are geographically, ethnically, or socioeconomically concentrated, targeted rater than national programs may be preferable (although emerging evidence on the effects of subclinical defi- ciencies suggests that broader rather than narrow targeting may be warranted). High-risk areas are tairly easy to delineate on the basis of low iodine content in soils and water or of goiter incidence in school children. These high-risk areas often coincide with high altitude or flood plains because the iodine has been leached away over millennia Vitamin A clusters less well geographically than iodine, although it is likely to occur in arid areas. Although the risk of vitamin A deficiency may correlate with season or with rainfall levels, this indicator is not specific enough for general application. Epidemiological or dietary data on vitamin A deficiency is likely to be needed. India seeks delivery of vitamin A to young children thrugh a two-track approach involving both the health system and the Integrated Child Develop- ment Services (JCDS) program. The health system, trough the national immu- nization program, gives vitamin A supplements to children under 1 year of age. Older preschool children receive vitanin A supplementation twice yearly from health workers, of whom there are about one for every three villages. In addi- tion, through about 250,000 workers based in about half of India's villages, ICDS administers vitamin A-on demand where supplies are stable and other- wise twice yearly-to children under 6 years of age. Midwives and, increas- ingly, icus workers are also being enlisted to provide megadoses of vitamin A to women immediately after childbirth, thereby reaching not only the women but, through their breast milk, the babies. Other potential avenues of increased coverage could be school personnel, agricultural extension agents, religious leaders, and private pharmacists. In a Muslim country, for instance, iodine capsules could be distributed annually at local mosques on Eid, the celebration ending Ramadan. Supplements could also be supplied through retail stores (ftee, at-cost, or in exchange for a coupon from the health center) where public drug management is not adequate. (The approach has had some success in contraceptive social marketing.) In one African countiy, the private pharmacies are used to deliver iron tablets prescribed at the health clinic. In light of the popularity of pseudo- nutrients-ineffective, falsely advertised, and potentially dangerous concoc- 26 EN RICH ING LI V ES tions often sought out even in traditional cultures to cure disease-and of vitamin supplements of dubious value (especially injections of vitamin B com- plex), health workers must carefully inform consumers about the kind of supple- ment to take, the dosage, who is to take it and when, and the dangers of overdosing. In general, the production, advertising, and packaging of privately marketed micronutrient supplements needs tight regulation coupled with con- sumer education to prevent fraud and assure quality control. Biomedical screening can also guide targeting. The medical preference is to screen clients before prescribing therapeutic treatment. In large-scale national micionutrient programs, however, the cost of screening can exceed the cost of treatment. Where the prevalence of a deficiency is high enough to be a public health problem by World Health Organization (WHO) criteria, then presumptive treatment may be preferred. This is particularly true of iron supplementation for pregnant women. Toxicity becomes a potential problem with supplements when the population becomes more sufficient in the nutrient. In that case, commu- nity screening may be adequate-a subsample of people are selected, and if the prevalence of the deficiency is high, all target-age individuals receive supplements. CHAPTER FOUR Successful Fortification AS wit supplementation, fortification has the appeal of a panacea: if the right food is selected, high coverage of the population is assured. Indeed, fortification-the addition of specific vitamins and minerals to foods and wa- ter-has eradicated most vitamin and mineral deficiencies in the industrial countries (see Box 4.1). Unfortunately, an ideal fbod vehicle for fortification is not available in every situation. Nonetheless many foods have successfully been fortified in a number of countries (Table 4.1). and with dietary habits changing rapidly and food industries becoming more sophisticated, fortifica- tion is likely to be feasible in the near future in most countries. BOX 4.1 HOW FORTIFICATION WON forificatiom Fortficaton of margarne THE WEST with vitamin D is thought to have elimi- nated rckets from Britain and North- em Europe in the early part of this cen- Dietary diversification and poverty al- tury. Fortification of refined flour w-ih leviation have eradicated many historic iron in the Unied States and Sweden nutritional deficiencies-pellagra, is credited with the dramatic reduction scurvy, rickets, and beriberi among of anemia. The introduction of iodized them--but byfarthe most directpolicy salt in Swizerland in 1929 spelled the intervention in the West has been food end of cretnism in that country. 27 28 E N R I C H I N G L I V E S Table 4.1 Foods Successfully Used for FArtircation Micronuiri en Vehicle Iodine Salt B read Water Iron Whcat flour and bakery products Commeal Rice Salt Sugar Condiments Milk Infant cereals Processed foods Vitamin A Sugar Cooldng fat Margaiine Vegetable ails MSG Tca Source: Venkaiesh Man= 1993. Problems with Voluntary Fortification Over the long term, micronutrient deficiencies car be largely corrected through fortification at a cost per capita that is affordable by most of the intended beneficiaries. But fortification generally is not carried out voluntarily by the private food processing sector. Voluntary fortification has worked well in the United States for salt and flour and in the Netherlands for bread, because fortification is high on the list of consumer food preferences in these countries. In most developing countries, however, consumer demand is lacking, and voluntary fortification is unlikely to work because those companies that act first to foriify take more risks than those that act later or never act at all. For example, the costs of product development, market research, and advertising will be borne by the first company to fortify its product. Initially, either the price of the pioneering product will be higher than that of its competitors, at the cost of market share, or the profits of the pioneering company will be cut. On the one hand, competitors thatadd fortification laterwill get afree ride from the S U C C E S S F U L F O R T I F I C A T I O N 29 pioneering company, which may not be able to recoup profits or market share, as the case may be. On the other hand, successful marketing could reap profits for the first company to introduce fortified food. Consumer demand for nutritious food-natural or fortified-is the key to the long-term success of all micronutrient programs, including fortification. Because such awareness and demand does not exist to a sufficient degree in most developing countries, the government may need to take the lead and require fortification of strategic products. The two most important determi- nants of early success in fortification programs are the selection of the right rbods to fortify and the level of industry compliance with fortification rules. Whether the food chosen is the "right" one is largely a matter of consumer acceptance. In the past, fortification advocates have sought a single food for fortification, but under some conditions it may be more effective to select several food vehicles in order to reach segments of the population that have different diets (see Box 4.2). In general, fortification is considered a universal program, but targeted fortification may sometimes be appropriate. In Guatemala, the school-feeding program uses a biscuit fortified with a number of vitamins and minerals. The biscuits are baked by local bakeries and the vitamin-mineral premix is distrib- uted to them by the government. Undoubtedly the children in schools are a self- selected, relatively privileged group but they are easy to reach, and they profit educationally from the added nutrition. In South Africa, the Asian community was found to be the i)nly subpopulation that was deficient in iron, so cuny powder was fortified with iron. In Chile and the United States, infant foods are fortified with iron because that is one of the most vulnerable groups. One could also target foods consumed primarily by the poor or distributed in welfare programs. The Importance of Consumer Participation and Education Fortified foods must be eytensively tested in the development phase to ensure the feasibility of manufacture and their acceptability to the consumer. Such testing, covering availability, price, taste, appearance, and similarity to the unfortified product, is critical to ensure that the fortified food will not meet significant consumer resistance. If fortified products are even slightly off coG;, for example, they may be unacceptable to consumers. Fortification programs must include an educational component to motivate the consumer to purchase what otherwise might seem to be an unknown prod- uct that might be in direct competition with the old. Although technical manipulations are supposed to minimize the detectable difference between fortified and unfortified foods, consumers may consider the fortificant to be 30 E N R I C H I N G L I V E S BOX 4.2 LESSONS OF EXPERIENCE and inexpensive, or research must de- FROM FORTIFICATION PROGRAMS vetop such methods. 4. The fortification sites must be * Consumer education-about the easily monitored. nature of vitamin and mineral deficien- cies, their cost, and the benefits of u The law must require that all sup- fortified food-is essential. plies of the staple, domestic and im- ported, be fortified. * Intake of the nutrient must be well below estimated requirements. * Duties and fees on imported fortificants should be waived. * The food to be fortified must be chosen carefully: * The staff for monitoring compli- ance with fortification must be large 1. It must be a staple of the target enough for the task, well trained, and population to assure uptake of the motivated to do an honest and thor- fortificant (and to ensure that demand ough job. will not fall under the price increases required to pay for fortification). a Producers must receive incentives such as technical assistance, subsi- 2. It must retain its desirability dization forsmall producers, and jour- (color, flavor, texture, cooking prop- nalistic coverage of good performers, erties) after fortification. as weil as face sanctions such as swift but not overly punitive punishment of 3. Feasibility studies must show offenders and journalistic exposes of that its fortification will be fairly easy noncompliant companies. unnatural or "chemical"-witness the resistance to fluoridation of water in the United States. When fortified foods cost more than the unfortified, consumer demand needs to be oriented toward the fortified product Well-tested marketing tech- niques can be used to get consumers to try a new product The results of consumer tests must be given continually to public and private decisionmakers so they are informed when their support is needed. A way around some of these difficulties-but not around the fundamental need to gain the general support of consumers-is to require fortification of all stocks of a elected foodstuff, especially if it is a staple. In the case of salt, for example, all salt for human and animal consumption should be iodized to prevent any "leakage" of unfortified stocks into the food system. SU CC ES S F U L F OR T IF ICA TION 31 Universal and Mandatory Fortification Health minislers in many countries are not able or willing to control and moti- vate private industry. In such cases, a specified set of responsibilities and actions regarding fortification should be passed on to the ministry of industry? The preferred regulatory option requires fortification and yet also gives indus- BOX 4.3 INDIA FORTIFIES SALT ton, full train allotments only if the salt THROUGH TRANSPORT CONTROLS iS iodized. The Salt Department in the Ministry of Industry monitors the iodization of salt and certifies the salt Salt iocrization is well on its way to for shipment This system also allows becoming universal in India, largely India to avoid the common problem of because of govemment controls on inducing small producers to comply; rail transport. In 1984 the Indian Par- such producers generally sell to salt liament required the universal traderswho havethecapacityandthe iodization of salt, giving to states the equipment to iodize theirsalt. By con- responsibility of enforcement. All trolling the transport of salt, the gov- states (except the foursouthem states emment can thus effectively demand and Maharashtra, which have no iodization. widespread iodine deficiency) subse- Not all is solved, however. Today, quently banned the importation, pro- 3 million tons of salt are iodized out of duction, and trade in uniodized salt total salt consumption of 4. million The fines, however, are not punitive tons. One of the problems is that the enough to induce compliance. The lumpy brown 'rock' salt preferred in public subsidization of potassiurn io- some parts of the country is only date between 1987 and 1992 was an coated with iodine. The consumer effective incentive to industry to iodate washes off the iodine when he or she their salt, but the subsidy ceased in washes the salt (which is customary 1992 because of budgetary pressure. for the brown salt). Consumer educa- Salt producers comply because of tion is needed eiher to channel de- the control afforded by the geography mand toward the whiter iodized salt of salt markets. Salt is produced in (where the iodine is integrated into western and southern India and must the structure of the salt) orto discour- travel by rail to the consumer markets age the washing of the salt In addi- elsewhere in the country. Rail car al- tion, a bureaucratic problem is the lotments are scarce and sold only by Salt Commissioner's lack of fiscal the full trainload. They are worth a authority overthe health inspectors, greatdeal to traders. The government which causes needless delays and permits salt producers to use 2,000- inefficiencies. 32 E N R I C H I N G L I V E S try persuasive incentives to adopt the regulations. Such incentives can include low-interest loans to purchase new fortification equipment, reduced tariffs and duties on fortificants, technical assistance, import subsidies, and special certifi- cation or labeling provisions. In India, producers of iodized salt get preferential rail car allotments (see Box 4.3) to move salt from production centers to mar- kets across the country. Government enterprises that control most of the market for a specific food can adopt fortification and thereby push prvate-sector com- panies to do the same (if consumer reaction is correctly gauged and accuunted for).8 One approach to mandatory fortification is to have a national bureau of standards or the ministry of industry and trade establish a standard of identity" for the product that specifies the level of fortification in establishing licensing regulations. Another way is to establish regulations for fortifying specific foods through the food control laws. Legislation, which could take several years to be approved, should not establish technical details but should instead empower the appropriate ministry or departnent (usually health, or agriculture, or industry) to regulate fortification of appropriate foods at levels that will ensure effective- ness and at the same time be safe. Using these powers, the ministry can then issue directives or regulations fixing standards and specification for enforce- menL Choice between a fortified and unfortified product may need to be elimni- nated for both producers and consumers. Experience has shown that the most successful fortification programs have been mandatory.9 Attempts to require fortification only in certain regions has not workled. Some countries, for example, have attempted to iodize salt only in The regions where endemic iodine deficiency exists. Because markets in most food products do not follow political boundaries or coincide with epidemio- logical patterns, this differential application of mandatory fortification is not effective. It burdens regional producers unfairly and provides further opportu- nities for profiteering.10 Ensuring industry compliance with fortification programs requires an un- derstanding of how private industry functions for a specific food in a specific country. This will determine both the incentives and the legal sanctions needed, price and cost factors, technical assistance and capital requirements, and public- private responsibilities. C H A PT E R FIVE DietaU Change through Education and Policy C ONSUMERS can improve the nutritional quality of their diets if they are guided by well-designed communications and have ready access to niicronutrient-rich foods that are affordable and acceptable. Educating Consumers Consumers must believe that the desired change in their dietary behavior will bring tangible benefits. Vitamin A progams in four Asian countries could not persuade mothers to give green, leafy vegetables to their young children to avoid blindness, a malady too rare to compel achange in behavior. The promo- tion of good health, however, and the elevation of vitamin A foods from being merely "useful" to "essential," produced substantial results. The nutrition message is most effective when it reaches consumers through many channels, including the mass media Teinforced by personal contacts at locations such as schools, the workplace, and health clinics. Some programs have used a great variety of vehicles to carry the desired message: plastic produce bags, stickers, mobile drama groups, singers, comic books, recipe contests, and quiz shows. Spokespeople in advertising campaigns should be both attractive and credible; physicians and entertainers who can believably deliver a health message can be effective in such a role. 33 34 E N R I C H I N G L I V E S These educatonal efforts should stimulate the demand for more nutritious food in the diet, and they can also stimulate needed support for programs to expand the supply of such food (see Box 5.1). The Influence of Agricultural Policies Regarding cultivated foods, agricultural policies can send some powerful signals to farmers to encourage (or discourage) certain crops.1' Agriculture research BOX5.1 STEPSTOWARD RAISING adequatefordifferentagesofchildren MICRONUTRIENT LEVELS IN ThE FOOD and women. SUPPLY * Identify agriculture extension * Survey the food system. A sur- workers, successful local gardeners, vey should reveal what foods contrib- and other people in the commnunity ute to the year-round supply of micro- who can give technical assistance In nutrients and are being consumed by gardening or gathering wild foods. the target groups, whether gardening Training these people to improve lior- andtor gathering foods is a tradition, ticultural techniques would help im- what foods are sold, and whether the prove chances of success. additional income is used to buy other * Study local markets to determine foods high in the micronutrients. whether home production of certain * Determine the demand for gar- foods might disrupt marketing and den foods and gathered foods rela- later discourage produciffon- There is tive to their suppl. Learn whether much controversy about sefling pro- women have time for additional food duce from gardens because the in- production or collecting or whether come often does not benefit vulner- othergroups, like men ard the elderly, able groups, hence the need for a could be targeted to help increase the strong nucrition education and social family's supply of micronutrient-rich marketing program so that families foods. If traditional beliefs about cer- reserve at least part of the food they tain foods cannot be changed, look grow for themselves or so that the in- for alternative sources of the desired come generated from garderns is used micronutrient that do not violate tradi- to buy other micmnutrient-rich foods. tions and taboos. * Include beneficiaries in the plan- * Assess the nutrition status of tar- ning, implementation, monitoring, and get groups and develop a monitoring evaluation of theprogram- Local lead- system to show nutritional impact of ers should assume responsibility for gardening interventions. Set precise identifying demand for the program targets for consumption levels of and the types of interventions most micronutrient-rich foods that are useful to beneficiaries. ED U CAT IO N AND P U LI CY 3S and extension can make particular crops more profitable or feasible to culti- vate. Recent evidence suggests that selective breeding, seed treatment, and mineral fertilization can improve the micronutrient content of grains. In Thai-k land, agriculture extension agents distributed ivy gourd plants-which had> been identified as a key vitamin A food-and advised farmers on its culti- vation. When the so-called 'disease-resistant" crop developed insect and mold problems, scientists in collaboration with traditional experts solved the problem. Policies usually favor only those horticultural products and field and tree crops that sell well in export markets or otherwise have good effects on em- ployment and income. But these foods may offer little to improve local nutri- tion. For example, in many countries, narrow policies to promote either food grains or export crops have reduced substantially the production of legumes, generally a good source of both protein and iron (Figure 5.1). Policy Support for Subsistence Horticulture An important new area for agricultural policy is the encouragement of subsis- tence horticulture. For policymakers and extension agents, food grown for Figure 5.1 World per CapitaAvailabilityorLegumes Kilogram per year per person 10 9 7 6 - Years Source: FAO 1992 daabase (AGROSh1WPC. Food Balce Sbeets. FAO, Roar). 36 E N R I C H I N G L I V E S home consumption does not have the status of marketed crops. Further reduc- ing the status of home gardens is the fact that they are usually considered to be the women's domain and that they are cultivated in more traditional ways. Home gardens can, however, be both a major household food resource and a source of income, and much more could be done to elevate their status and productivity. The Asian Vegetable Research and Development Center, in Taiwan (affiliated with the Consultative Group on International Agricultural Research. CGLAR) has developed several garden designs that serve nutritional purposes as well as generate income. Horticultural products generally require copious amounts of water and are highly perishable. Public policy can greatly assist in the expansion by support- ing the improvement of water systems, helping create more mark-eting outlets, improving roads and storage facilities to reduce farm-to-market spoilage, and advancing preservation techniques. Proper food preservation is particularly important for vitamin A. which is often highly seasonal in its availability. Preserving Foraged Foods With foraged crops. the key policy issues relate more to land use and preserva- tion of natural resources than to active cultivation. Forest land, meadows, wet- lands, fallow land, and even weeds in cultivated fields have traditionally sup- plied much of the varietv (and micronutrients) in people's diets. Many of these foods are unavailable in markets. The destruction of forests can seriously limit the access of people living nearby to meat, edible leaves, and fruit From both an environmental and nutritional standpoint, preserving these lands in the wild state or encouraging nearby communities to husband them wisely is highly desirable.'3 In general, food policies can support a diversified food base if they give due weight to dietary quality; push the development of varied sources of nutritious food, including home gardens; protect foraging areas; and actively work against negative trends in the quality of the food supply. C H APTER S I X Characteristics of Successful Micronutrient Programs .ACTION in every country must start with a situation analysis to determine the nature and magnitude of the problem and the adequacy of current policies and programs. Many countries have performed these analyses as Children's Summitaction plans throughuNiCEF or in preparation for the annual International Conference on Nutrition. The initial analysis stage is crucial to establishing local "ownership7' of the program-a commitment to it on the part of experts and leaders. In Tanzania, for instance, national ownership resulted from a deliberate effort to have national professionals do their own problem assessment. Generamly such assessments are made on the basis of outdated, unrepresentative, and inadequate data, but the quality of the data matters less than the motivation it generates. External consultants may be needed, but local control of the program is desirable for its long-range vitality. Situation Analysis Situation analysis must often be based on best guesses from scanty data. Rather than wait for nationally representative epidemiological data to justify action, the project should use "good enough" evidence initially; it should be prepared to adapt to new findings, and it should include information systems that will improve future assessments. 37 38 E N R I C H I N G L I V E S The "situation" in a situation analysis is more than an estimate of the prevalence of malnutrition. It also includes important dietary and behav- ioral factors as well as relevant interactions of deficiencies and disease (for instance, the coexistence of malaria and hookworm) that contribute to micronutrient malnutrition. The analysis should assess the coverage, qual- ity, and cost of current efforts to remedy the problem, and it should also evaluate resources that could be marshaled in the future, including key food industries and markets. The initial program design, as well as the initial analysis, must allow for modification; a detailed blueprint for short-term and long-term phases of a program is bound to run afoul of reality. Experience suggests that flexible program design complemented by interim evaluation, appropriate infornation systems, and consultation with intended beneficiaries helps generate effective and sustainable programs. Equally cIear is the fact that programs require na- tional political support and long-term commitment. Under most circumstances, extemal technical and financial assistance is needed as well. In Thailand, the general direction of the program was established at the outset-addressing vitamin A deficiency through dietary means-butthe strat- egy was developed as the program evolved and intended beneficiaries partici- pated in iL In this iterative fashion, the beneficiaries and program staff identi- fied the key food for promotion, the means of promoting it, the most persuasive messages, and ways of increasing the availability of vitamin A foods. This last issue led them into agricultural promotion and extension. One characteristic of all successful country cases is the use of pilot projects and feasibility studies to try out delivery systems, communications concepts, or alternative souirces of micronutrients. This experimentation, when combined with national advocacy and leadership, has led to revisions in program design that were not anticipated initially (for example, the use of agricultural exten- sion). Informnation systems have facilitated further improvements as programs have been implemented. Setting Priorities After completion of the situation analysis comes the need to set priorities among nutrients and intervention options. In Tanzania, for example, program leaders decided that iodine was the simplest, and therefore the first, deficiency to attack, doing so with both supplementation via iodized oil capsules and iodine-fortified salt. Once the control of iodine deficiencies was well estab- lished, the government traded on the goodwill generated by that effort and moved on to tackle vitamin A deficiency, this time through supplementation via capsules plus promotion of the production and consumption of fruits and SUCCESSFUL MICRONUTRIENT PROGRAMS 39 vegetables rich in vitamin A. Tanzania addressed the correction of iron defi- ciency last, and that component is the least advanced. In contrast, one East Asian country tackled vitamin A deficiency first be- cause advocacy by scientists and nongovernmental organizations (NGOs), plus dramatic results from a pilot project that used supplements, made it a "high profile" problem with political support for a resolution. Unfortunately, supplementation with vitamin A capsules has been this country's mnajor micronutrient strategy for almost twenty years. It has not developed longer-term vitamin A strategies, such as nutrition education and the promotion of home gardens, with anything but a minor emphasis, nor has it moved on to raise awareness and develop solutions to iodine and iron deficiencies.'4 Short-term Supplementation Goals as Part of a Long-term Dietary Improvement Strategy Micronutrient programs require a long-term vision right from the start, even if it initially concentrates on supplementation. A long-term vision means legiti- mizing food sources of micronutrients in advocacy and educational materials, developi ng plans for fortification to be phased in over time (if appropriate), and simultaneously promoting consumption of micronutrient-rich foods. Overreliance on vitamin A capsules in one South Asian country caused consumers as well as health care workers to view supplementation as the only legitimate micronutrition strategy; phasing in dietary solutions is :ow proving very difficult In an East African country, by contrast, because supplementation is seen as therapeutic-vitamin A capsules for sick children and iron tablets for pregnant women-food sources are seen as the essential preventive strategy. The Importance of Feedback to Program Evolution Feedback from a program durinc its implementation is cridcal to its flexibility and its ability to evolve. The information systems should be as simple as possible. Programs that use nationally representative data to log progress and calcu- late social costs of deficiencies should use them sparingly because they con- sume time, resources, and personnel. ThewHO classification of deficient coun- tries provides an adequate basis for taking action. Where national surveys are not available, other sources of information should be exploited. Rapid assess- ment techniques or collection of relevant information in the process of program design and implementation can accomplisth both the statistical and program- matic tasks. 40 E N R I C H I N G L I V E S Program designers should choose deficiency indicators with regard to the practical realities of data collection and with due respect to people's fears and time constraints." Proxy measures of deficiencies (interviews about night blind- ness or breathlessness from exertion) and data from neighboring countries can be used. Perhaps more important than assessment of the micronutrient status of a population is monitoring the progress of program implementation. In fortifi- cation programs this means sampling the fortified food at the food plant and at the retail level. Some countries also test salt supplies in transit at pt 'ice check- points. Others test the food at the household level. With the new geru:ration of inexpensive, pocket-sized assessment kits, a food inspector or even a con- cerned consumer can check food for iodine and iron. Monitoring supplementation programs involves tracking flows of supple- ments from the central warehouse to the periphery and ultimately to the con- sumer. Uptake rates are a good indicator for iodine and vitamin A coverage, but monitoring the distribution of iron requires some indicator of compliance- women's reports or disappearance of the tablets. Focus groups can also help overcome compliance problems.'6 Monitoring dietary change programs requires discussions with intended beneficiaries on eating and feeding behaviors. It might also be possible to monitor price, availability, or sales volume of specific foods. (See Box 6.1.) Sustainability Political commitment is a key to getting funding for new programs and to keep getting them funded. Yet political support alone is unlikely to sustain a pro- gram long enough to outlive the micronutrient problem, and popular support must be generated. A politically powerful aspect of micronutrient programs is that people often feel better fast and the incidence of terrible disabilities is quickly reduced. Because these outcomes can be attributed unambiguously to the micronutrient programs themselves, the political leadership can take the credit for improved well-being. In Tanzania, for exarnple, the renewed sense of vigor after iodine supplementation, especially when communicated directly to the nation's president, was effective feedback in support of the program. Thus, advocacy is best when grounded on both the impact of deficiencies and the effectiveness of interventions. Low cost and high cost-effectiveness also enhance sustainability. If a gov- ernment cannot afford to carry on a prograrn after donors withdraw, it isn't viable. Cost and cost-effectiveness should be priority considerations in setting national strategies. One aspect of economic sustainability relates to the foreign exchange costs of an intervention. To the extent that interventions rely on imported materials (rspccially supplements and fortificants), a program may be SUCCESSFUL MICRONUTRIENT PROGRAMS 41 BOX 6.1 APPROPRIATE MONITORING yellow and is not packaged, students can easily point to their family's salt. In Ecuador, limited resources did not * If more than half of families use permit sampling or laboratory analy- iodized salt, the community was con- sis of the entire population for uptake sidered low risk of iodine through salt. Instead, social and epidemiological research enabled . If half or less of the families use the program to undertake low cost, iodized salt, a medical team carries probabilistic monitoring in high risk out a thyroid assessment and obtains communities. urine samples from at least thirty chil- dren for iodine analysis. A concentra- * In large communities (more than tion of iodine above a specified level 120 children in school), because more classifies the community as medium than 80 percent of families use iodized risk a concentration below that level salt, only smaller communities are defines high risk. monitored. . All high-risk individuals under the * In smaller villages, teachers ask age of 45 are injected with iodized students what kind of salt they use at oil. home (iodine deficiency is concen- trated in families that do not use io- * One hundred sentinel posts were dized salt). Iodized salt is very white established for ongoing surveillance and comes in small plastic packages; using goiter assessment and urnary because uniodized salt is grainy and iodine. unsustainaVhle during periods of economic crisis when foreign exchange is scarce. Dietary change becomes a more appealing approach under these condi- tions, particularly where the exchange rate is overvalued. Technical sustainability is also important. Not only must an intervention be technically efficient to be cost-effective, it also must be appropriate for the institutional capacity of the implementing agency. Moreover, the technology must be adaptable to changing environments (both institutional and epidemio- logical). Water fortification with iodine, for example, may start as a basic, household-level technology-adding drops of tincture of iodine to the family water pot. As hand pumps become available, the technology may need to change to community-level fortification by putting iodine-impregnated mod- ules in pumps (see Box 6.2). In several more years, the technology may need to change again as centralized water systems are installed, facilitating water iodization at the water treatment plant. Or perhaps salt iodization would replace 42 E N R I C H I N G L I V E S BOX 6.2 APPROPRIATE TECHNOLOGY one year. The cylinder needs to be changed annually. In Mall, a one- year test reduced moderate to se- Well water and pump water can now vere iodine deficiency (as measured be easily fortified with iodine for a by urinary iodine) from 94 to 40 per- year at a time with a plastic cylinder cent at an estimated cast of $0.10 developed by Rhone Poulenc Foun- per person per year. The beauty of dation. The cylinder, which contains this approach to fortification is that an iodine-infused polymer, is in- it requires no regulatory apparatus serted directly into the water and for setup or enforcement. It does, slowly releases iodine sufficient to however, require annual water pump meet the needs of 1,500 people for maintenance. water iodization altogether at this point. To be able to adapt technology as it goes, a program requires good monitoring, high technical capacity among its staff, and the use of up-to-date information and technology- Human resource development is intimately related to sustainability. If health workers are sensitized to the effects ofn micronutrient deficiencies, then preven- tion will be on a priority list in spite of economic conditions. Institutions and individuals within those institutions need the skills, organizational structures, resources, and reward structures to provide high-quality services. Therefore building institutional capacity-which often requires a long-term commitment- is critical to sustainability. Habit Formation and Consumer Demand One underappreciated aspect of sustainability is that once a behavior becomes a habit it is more sustainable. These behaviors include industrial practices, medical routines, provider-client communications, and dietary habits. Inte- grated programs that generate good medical practices regarding micronutrients are more efficient than vertical programs, which require a single action isolated from specialized workers. Tanzania purpcsely chose to integrate supplementa- tion into theprimary health system because it was concemed about sustainability; as a result, the impact was perhaps less rapid and dramatic, but is likely to last longer than a campaign-type programn. Any behavior needs reinforcement to be perpetuated, but social reinforce- ment ultimately can replace public health messages. Making conscious the subliminal desires for the benefits of micronutrients and directing demand to SUCCESSFUL MICRONUTRIENT PROGRAMS 43 appropriate supplements, fortified foods, and natural foods are essential in all micronutrient programs. That demand, in tum, should generate sustainability. If the target beneficiaries think they are e ititled to a supplement or a fortified or natural food, then their demands are likely to create pclitical currency and sustain the program. CHAPTER SEVEN Success within This Decade IN September 1990 the World Summit for Children endorsed some challenging goals for micronutrients for the year 2000: virtual elimination of vitamin A and iodine deficiencies and a reduction by one-third of iron defi- ciency anemia in women.17 Achieving these goals will require the combined efforts of governments, international organizations, NGOs, and private indus- try. Consumer education, improvement of supplement delivery infrastructure, and strengthening regulatory systems are the key activities in overcoming mi- eronutrient malnutrition. Complementing these three approaches are programs to increase the supply of mnicronutrient-rich unprocessed foods. Therefore, work over the remainder of this decade should focus on the following key issues: 1. Raising awareness of leaders of the need to take action against micronu- trient malnutrition for economic, political, and humanitarian reasons. 2. Raising consumer demand for micronutrients from pharmaceutical supplements, fortified food, and unprocessed micronutrient-rich food, using policy advocacy, social marketing, and commercial advertising. 3. Improving the effectiveness and coverage of pharmaceutical delivery systems using new outreach mechanisms, better logistics, and improved client counseling. 4. Maximizing industry compliance with fortification mandates through incentives to private industry and through building objective, competent, and respected regulatory enforcement institutions. 44 SU CC ES S WI T HI N T HIS DEC AD E 45 5. Designing and managing sustainable programs that are decentralized, enhance institutional capacity and human resources, and monitor performance through management information. Programs should consider both pharnaccutical supplements and food as sources of micronutrients, but all programs should include nutrition social marketing techniques. Table 7.1 shows a decision matrix for undertaking dif- ferent kinds of micronutrient programs. Table 7.1 Decision Matrix and Program Options ror Iron, Iodine, and Vitamin A Delciencdes Deficiences Sqpplementwuon Fonification Dicuy Change Vitamin A Likely to be needed Not likely to be needed Likely to be needed in short term where except for refugees, or in most deficient prevalence is high. except where climate countries. Start simul- Medical targeting and and/or dietary traditions tancousl, awith supple- delivery through EPI exclude major vitamin mentation. Support if desirable. A food sources from necessary, with agri- the diet. May be desir- cultural extension and able where the ideal inputs. food vehicle exiss Iodine Likely to be needed in Likely to be needed in Unlikely to be of use the short term wher- all deficient countries. except over the very ever cretinism exists. May not be inunediate long term (until the In the long term, it solution where the salt diet derives from dis- may be required in industry is dispersed tant, iodine-replete isolated geogaphical and artisanaL soils, and from certain areas where the salt seafoods). industry is traditiona! and commercial markets are poorly developed. Iron Likely to be needed in Ukely to be needed Most promising where the short and long in most countries, meat is consumed term for pregnant Research and develop- widely and where iron women and possibly ment probably needed. cooking pots used. y2ung children. Weaning foods need Agricultural extension iron fortification. to promote livestock production, legumes, and vitamin C foods needed. 46 EN RICH ING LI VE S Raising Awareness Despite three major international policy meetings at which micronutrients were high on the agenda, policymakers in many countries still need to be convinced of the imperative to attack micronutrient malnutrition. Moving leaders to action requires their learning and understanding the costs of micronutrient malnutrition and the cost-benefit ratio of interventions. Many of the lessons described in this book can be used to reassure policymakers that interventions are feasible, affordable, and effective. UNICEF has financed the production of several effective videos on micronutrient malnutrition; the U.S. Agency for Intetnational Development (USAID) has developed a computer model to show graphically what micronutrient malnutrition means to a country; and various drug manufacturers and NGOS have developed persuasive print materials and presentations on micronutrients. These materials, along with personal appeals from agency representatives and advocates, must be shown and given to top political leaders, professional arganizations, NGOs, and grass roots organizations. Moreover, the message that micronutrient malnutrition is a serious health problem that can be ad- dressed by specific behaviors must be reinforced in the population at large by health workers, educators, and agricultural extensionists. Understanding the potential gains from action and experiencing the de- mand from the public is enough to galvanize the political establishment to action in some countries. The feedback of results to the public and the leader- ship validates and sustains the resulting programs Institutional Development The ideal delivery infastructure for pharmaceutical supplements is the public health system, but the health systems in many countries-perhaps most-Ado not have good coverage of geographic regions and socioeconomnic groups at great- est risk Cmcluding women). In that event, the health system must be strength- ened while other avenues for education and distribution are brought into play alongside it. Other delivery vehicles could be vertical EPI programs, cbildcare programs, schools, agricultural extensionists, social welfare workers, religious organizations, political organizations, and the commercial phamaceuticals markets. Public mobilization and education is needed for all of the mechanisms to be effective and efficient. Fortification for public health purposes should be mandatory and territory- wide, and accompanied by a reguatory apparatus capable of detecting and enforcing compliance with regulations. Technical training and support are im- portant to the functioning of a regulatory system, but more important than SU CC ES S WITH IN T HIS DE CADE 47 anything else is professional integrity. Integrity is essentially a matter of indi- vidual values, but, to cultivate and protect those values, a regulatory institution must engender pride and professionalism in its staff. Adequate pay, respect, personal security, and rewards for cxemplary performance can reinforce the professional integrity and esprit de corps of regulatory institutions. "Whistle blowing" (reporting misdeeds of colleagues) is an important check on dishon- esty. If neither the food industry nor the consumer believes in the regulatory system, it is useless. lt is not necessary to build a complete food control authority in order to monitor compliance with fortification. Where some appropriate administrative unit already exists (generally in the ministry of health or industry or in the bureau of standards), specialized tasks and equipment can be given to it. Other- wise, a new mechanism, such as an independent private laboratory, can be charged with certifying compliance. In the past, many donor micronutrient programs have been directed from outside the target country and focused on supply, generally of pharmaceutical supplements. Donors must now concentrate on raising political commitment and finding locally appropriate solutions to micronutrient malnutrition. Each developing country has prepared a national nutrition assessment for the International Conference on Nutrition, and many are preparing action plans. The first priority 'or donors is to support the further refinement of these na- tional strategies and to support local feasibility studies, training, and technical assistance to help turn those concepts into national programs. Second, new resources have to be mobilized from governments and donors. At present donors spend barely $50 million per year worldwide on micronutri- ents (primarily UNICEF and USAID donations of vitamin A and iodine capsules). The worldwide goal for micronutrient sufficiency will never be achieved at that level of spending. The recurrent costs alone to address all deficiencies in the most cost-effective fashion in all deficient countries are estimated to be $1 billion per year. Clearly, consumers will pay some of these costs, but the residual costs plus starn-up costs far exceed the current government and donor expenditures. New donors, as well as NGOs and industry, must be mobilized and greater weight placed on feasibility studies, training, monitoring, and micronutrient socia' marketing. The World Bank's Role Until recently, the World Bank has not been a major donor in micronutrients. Recent investments in salt iodization, basic health packages tat include micro- nutrient supplements, and nutritional social marketing, however, have estab- lished a niche for the Bank, particularly in attracting political support, effecting Table 7.2 Incorporating Micronutrients into Selected World Bank Operations Sector analysis Factors Ethat affect MH Factors affected by AfN malnurrition malnutrition Policy levers Investment apportunilies Poverty and Analyze how lack of purchas- Estimate handicaps and lost Improve qualitative con- Introduce or improve safe- food security Ing power limits access to a work productivity due to SIN sumption effects of wage ty nets for the poor that varied diet. deficiencies. and cmployment policies, address qualitative as well tax and welfare policies, and as quantitative nutritional consumer food price policies; needs; microcredit schemes micro-credit access. plus consumer education. Health Estimate the contributions of Estimate excess morbidity Improve health policy so it Improve health system sector parasites, high fertility, inade- and mortality due to vitamin includes norms, training, delivery of supplcments; quate breast feeding, diarrhea, A deficiency and blindness, monitoring, and trcatmcnt of cnforce fortification; moni- and measles to deficiencies in anemia, and IDD. nutrient deficiencics; rational tor MN status; finance some or all MN dcficicncics, drug use to include MN sup- nutrition cducation and plemcnts; and drug suppiy deworming. management reforms to in- clude MN supplements. Education Examine educational ineffi- Broaden criteria for school- Include modules in educa- sector ciencies caused by anemia, readiness of students to in- tion projects to treat school vitamin A blindness, and IDD- clude nutritional status; train children (deworming, MIN Induced mental retardation teachers about MN malnutri- supplements, school feed- and deaf.mutism, (ion; allocate adequate re- ing); make capital invest- sourCLs to schoo1 nutrition. ments In school kitchens; TA and extension for school gardens. Food and Examine production, market- Estimate adverse effects of Anticipate consequences of Invest in consumer educa- agriculture ing, and trade policies for MN deficiency on agricul- food, trade, and financial poli- tion; technical assistance; sector effects on quality (nutrients) tural productivity. cies on MN and, if necessary, capital investments; agri- as well as quantity (calories) reform to improve impact. cultural research and ex- of food consumed. tension focused on MN. Industry Detertnine the effects of the Estimate lost productivity Develop and enforce regula- Support public marketing food industry on nutritional due to anemia and IDD; tions that promote nutrition campaigns for "good" quality of diet. Analyze the estimate workforcc dis- and provide level playing foods; public capital Invest- incentives and disincentives abled by MN deficiencies. field (content, labeling); ccrti- ment and equipment (espe- for producing nutritious fication of quality. Remove cially for quality control food (including fortified trade barriers and regulatory and fortification). food). barriers to food industry development. Infrastruc- Assess whether water can be Determine role of contami- Facilitate fortification of well Make capital investments ture (water, used to deliver MN at house- nated water in MN depletion. water or public water supplies, in water fortification; food roads) hold, village, or municipal market infrastructure. level; market access. MN Micronurient. IDD Iodine deficiency disorders. TA Technical assistance, &_ 50 E N R I C H I N G L I V E S cross-seotoral policy reforms, and building bridges between public and private sectors to bring about fortification. Taking advantage ofthis momentum, future solutions to micronutrient malnutrition should be considered an integral part of the World Bank country assistance strategy, including sector work, policy dialogue, and the investment program (illustrated in 'able 7.2). Even in non- social sectors-like industry and infrastructure-highly cost-effective interven- tions have been implemented on a large scale. Every appropriate World Bank project should include a micronutrient intervention where micronutrient mal- nutrition exists (Appendix Table A.3) and the project provides a framework for it when the problem is not being addressed adequately by other actions. The Bank complements quite well the other major donors in this area. Using its financial resources as well as its traditional strengths of economic analysis and management, the Bank can play a key role in supporting the appropriate roles for private food industry, public institutions, and the consumers. Because it is not a technical institution, the Bank coordinates closely with other donors, private industry, the academic community, and local experts to assure high- quality design and implementation. The Bank was a founding member of the Micronutrient Initiative, a multidonor mechanism to support feasibility studies, country assessments, and global communications to accelerate the resolution of micronutrient malnutrition. Biochemical and Social Research Aside from general feasibility studies to adapt technology to the specific needs of a country and the social marketing research that must inform a sustainable icronutrient program, more basic research is needed on certain key issues. The medical community needs a better understanding of dosages and nutri- ent/limmunization interactions in children under 6 months of age. In addition, research and development work should focus on diagnostic tools for vitamin A deficiency that are rapid, acceptable to the client, and appropriate to field conditions; cheap, simple, semiauantitative assessment techniques for verifica- tion of iron and vitamin A levels in fortified foods; and long-lasting iron supple- ments with no side effects. Operations research, preferable on actual programs, could yield better in- formation on the costs, cost-effectiveness, and social and economic benefits of micronutrient interventions, particularly of nutrition education. Summary Vitamin and mineral deficiencies deprive 1 billion people worldwide of their intellect, strength, and vitality. For less than 0.3 percent of their GDP, nutrient- SU CC ES S WITH IN T HIS D EC AD E 51 deficient countries could rid themselves of these entirely preventable diseases, which now cost them more than 5 percent of their GDP in lost lives, disability, and productivity. No country with micronutrient malnutrition can afford not to take action. This book has reviewed the lessons of experience in implementing micronutrient programs. If political will, adequate technical and financial sup- port, and these lessons are applied, micronutrient malnutrition can be reduced significantly throughout the world within this generation. Notes 1. Some othernutrients, including zinc. certain B vitamins, and calcium, are prob- ably deficient in many developing countries, but the tools for detecting the problem are inadequate. 2. Rising income first allows greater consumption of staple grains and legumes, which contain low-quality (not readily absorbed) iron. A furdter rise in income permits the substitution of meat (where religion does not forbid it), which has higher-quality iron, and hence the absorption of iron in the diet increases. Even if intake from grain souroes decreases among the wealthy, the meat raises the intake of net usable iron (Behrman and Deolalikar 1987; Bouis 1992; Kennedy and Payongayong 1991; Meesook and Chernichovsky 1984). 3. Otherinterventions with costs ranging between these two include case manage- ment of acute respiratory infection, diarrheal control via breastfeeding promotion and improved weaning, polio immunization, helminth (hookworm) control, immunizations for measles. and fertility control. 4. Even if some supplies are available locally. international competitive procure- ment yields the best price and quality. UNICEF. for example, buys potassium iodate (for salt iodation) for less than $10 per kilogram compared with prices of $20 to $30 per kilogram. 5. The SCN is the Sub-Committee on Nutrition of the UN Administative Coordi- nating Comrnittee, which convened a meeting on iron deficiency in Dublin during June 1990 6. Excessive intakes of vitamin A, iodine, and iron can have severe side effects but rarely have these been frequent enough to cause concem. A surprising fact is that the megadose capsules are not the most toxic but rather the iron tablets, which can be deadly when consumed in large quantities by young children. 7. In Bangladesh, the Small and Cottage Industries Corporation, which licenses and regulates salt producers and refiners, is charged with the responsibility for imple- menting the iodization program and monitoring it at the production level. Retail and 53 54 EN RICH ING LI V ES consumer level monitoring will have to be the responsib;ty.y of the ministry of health through the provincial or district health network. 8. This strategy has been effective in Bolivia through a state-run salt marketing company (Emeosal). Voluntary regulation was not effective in Kenya, however, where legal loopholes left almost half of the salt unfortified. Only after enactment of manda- tory fortification was a credible portion of the salt iodized. 9. One might arguc in favor of consumer choice as an absolute right, but that argument would seem to oppose health and safety regulations of all sors, In this case, society as a whole benefits from fortification, the benefits exceed the costs mnanyfold, and directing consumer choice to the socially preferred good (the fortified product) would be more expensive and take far longer than limiting consumer choice. Finally, consumer (citizen) support is ultimately necessary if the fortification program as a whole (including enforcement) is to work and if the larger micronutrient program, of which it is a part, is to work. 10. Algeria had hoped for years that regional iodization of salt would suffice. But because the regions not covered probably also had low iodine levels, universal fortifica- tion would have been more practical and economical than the regional approach. In 1991 Algeria acknowledged its failure, and the legislature passed a Iaw requiring nation- wide iodization. Now Algeria is considered to be a model for salt iodization. I 1. Food sources of vitamin C (which enhances iron absorption) and A and, to some extent, iron, are inexpensive, culturally acceptable, and widely available- The trouble is that they are not given to the most vulnerable individuals, household storage is difficult, or they are unavailable seasonally. The most important dietary sr-rces of these nutriens are dark green leafy vegetables, yellow and orange fruits and vcgetables, legumes, and red meaL Some of these foods are culiivated and others are foraged. Among the cultivated foods are tree crops (fruits, red oil palm, and edible leaf trees), legumes, Field crops (horticultural crops. leaves of tubers, and yellow-fleshed tubers), and small livestock. The foraged foods such as wild fruits and berries small animals, and green leaves, tend to be trapped or picked in uncultivated land and forests. 1 2. Haiti and Senegal have developed dried mango as a local industry for women and as an economical way to preserve a highly seasonal food that is rich in vitamin A. 13. When women in Nepal were encouraged to manage their own forests, they were able to protect wild foods they depended on (FAo 1990). 14. The fortification of MSG with vitamin A was launched with the hope that it would be a significant program, but technical difficulties and political resistance have prevented national implementation. The key strategy of the government regarding io- dine has been to iodize all salt, but compliance is still low; recent indications are that salt iodization wiU soon be a major effort Iodized oil injections, seen as a short-term cross- sectoral program for high-risk areas, have had high but decreasing coverage since they were initiated in 1974. The govemment has dealt with iron deficiency least effectively, and the government strategy relies virtually exclusively on getting pregnant women to take iron pills. 15. Taking blood, for instance, should be avoided if possible. If blood is taken at all. it should be analyzed for all three micronutrient deficiencies at once. If successful, a N o r E S 55 new technology for assessing the threc defrciencics from spots of blood on illter paper will bc a major brcakthrough. 16. One creativc monitoring system was used in Guatemala forsugar fortification with vitamin A. Bccause vitamin A status is best mcasured by liver storcs of the nutricnt, human liver samples wetc taken from a cross-section of cadavers in the country and showed quite well the coverage of the fortification progmm. The process was less expcnsivc than a survey but required access to a truly representative sample of cadavers. 17. These goals were subsequently reaffirmed at the "Ending Hidden Hunger' policy confcrcnce in October 1991 and at the Intcrnational Confrernce on Nutrition in Dccember 1992. Appendix A. Prevalence Data Table A.1 Micronutrient Malnutrition as a Public Health Problem (number of countries, latest data) ViUanin A lodine and Vitamin A and Iron No micro- and iron iron iodine and iron deficien- nutrient Countries with deficiencies deficiencies deficiencies cies deficiencies More than 20 percent undernutrition 9 8 22 9 1 Less than 20 percent undernurrition 2 13 2 28 3 No data on under- nutrition 0 6 5 8 4 Source: ICaDD I990; WHO 1988: ACCISC 1992. Se Table A. Table £2 Status of Country Programs (number of oDmpebcnsive national micronutrient prorans and number of countrics with pmblams) Region ~~~~iodine Vitamint A Iran Africa 0141 0/43 0/45 Americas 8/19 4/17 6/32 Southeast Asia 0/10 0/8 0/11 Europe 10/30 - - Eastern Medtenranean 0/10 - - West Pacific 3/21 0/9 5/23 - Not availabie Source: WHo 1992 Table ? 57 59 E N R I C H I N G L I V E S Table A3 Developing Countries with Micronutrient Deficiency Disorders Mficroinstrirenr deficiencies Vitamin A, Vitanin AJ' ludirie irom, and Area and ir n1 and iron iodine iron onlid Africa Countrics with Burundi CAR Benin Guinca-Bissau > 20 percent Mauritania Comoros Burkina Faso Libcria childrcn Niger Congo Ethiopia Mauritius underweighte Rwanda Madagascar Ghana Somalia Uganda Scnegal Kcnya (S. Africa) Sierra Leone Malawi Togo Mali Mozambiquc Nigcria Sudan Tanzania Zambia C-untries with Botswana Cape Vcrdc < 20 percent Cameroon Gabon children CBte d'lvoire Gambia undcrwcighte Lcsotho Sao TomU Zaire Principe Zimbabwe Scychelics Swaziland Countrics with Guinea Angola Djibouti unknown percent Namibia Chad Eq. Guinea of childrcn underweighte Asia Countries with PNG Malaysia Bangl:desh Maldives > 20 perccnt Thailand India children Indonesia underweighi Lao P.D.R. Myanmar Nepal Sri Lanka Viet Nam A P P E N nlI x E S 59 Table A.3 (continued) Micranuirieni deficiencies Vitamin A, Vitamin As Iodinec iron, and Area and iron" and iron iodine Iron onl1Y Asia (continued) Countries with Kiribati Philippines Fiji < 20 percent F. Polynesia children (Korea, underweight' Republic) Singapore Solomon Isi. Vanuatu W. Samoa Countries with China Bhutan (Korea D.) unknown percent Kampuchea Mongolia of children underweightE Middle East Countries with Iran Pakistan Yemen > 20 perccnt children underweighte Countries with Tunisia Egypt < 20 percent Jordan children Kuwait underweighte Lebanon Libya (Palest. Ref.) Countries with Algeria Afghanistan Omin unknown percent Iraq (Qatar) of children (S. Arabia) underweighte Syria Turkey (U.A.E.) (Table continues on thefollowing page-) so E N R I C H I N G L I V E S Table A3 (continued) Micronutrient deficiencies Vitamin A. Vitamin Al Iodinec' iron, and Area and ironi' and iron iodine Iron onit Latin Amnerica Countries with Haiti Gualcmala Guyana > 20 percent Honduras children underweighte Countrics with Brazil Bolivia Salvador Antigua < 20 percent Ecuador Barbados childrcn Mexico (Chile) underwcighr Paraguay Colombia Peru Costa Rica Domirnica Dom. Rep. Panama SL Lucia St. Vincent Trinidad/ Tobago (Uruguay) Countries with Venezuela Argentina unknown percent Cuba of children underweight a. WHO 1988. b. All developing countrics. c. ICCIDD 1990; Hetzel 1988. d. In countries with parentheses there is somc evidence that iron dcficiency is not a public health problef. c. Calloway 1991. Underweight is defined as less than 2 standard deviations below the mean of the rzfaence 'tandard weight-for-age. Appendix B. Methods and Assti nptions for Cost- Effectiveness Calculations This Appendix is excerpted from Levin, Pollitt, Galloway, and McGuire 1993; the tables have been renumbered. Criteria of Effectiveness Some interventions will have a high success rate in obtaining repletion, such as injected or oral iodinated oil or oral capsules of vitamnin A. Once ingested or injected, these interventions are almost invariably associated with iodine or vitamin A repletion. In contrast, medicinal supplementation with iron or di- etary fortification does not always ensure repletion. Because the capacity of the body to store iron is limited, iron supplementation requires that the participant take iron daily. When administered in schools or workplaces, this compliance can be readily maintained. When it is necessary to depend on households continually to take iron supplements, it is not realistic to expect a high level of compliance. Thus the cost of delivering the iron to households is not equivalent to the cost of obtaining iron repletion. Indeed, obtaining compliance may re- qruire continuing reinforcement through monitoring and persuasion by village health teamis and other educational efforts. The segme is true with fortification. Not only is it necessary for all persons at risk .o consume adequate amounts of the fortified food, but the food must have sufficient amounts of the micronutrient at the time of consumption. There may be a compliance problem when unfortified, local products compete with the nationally or regionally distributed fortified ones. In Ecuador it was necessary to mount a social marketing campaign to increase use of a fortified product such as iodinated salt because alternative salt sources were available at the local level (Manoff 1937). In tropical areas the hygroscopic nature of salt that is used for iodine fortification means that unless contained in watertight packaging until consumption, at least some of the iodine will be lost Iodinated salt in jute bags showed a loss of three-quarters of its iodine in nine months ([Venkatesh] Mannar 1987). The type of packaging, the time it takes to get to consumers, and the use of open or closed containers by shops and consumers will determine potency. In very humid climates with highly undependable transportation and long periods before sale or consumption in open containers, the salt may lose virtually all its iodine.... 61 62 E N R I C H I N G L I V E S Cost-Benefit Analysis .... Although it would be desirable to have a standard cost-benefit methodol- ogy with precise rules for calculation for every situation, this is not the present case.... [Aljthough the conceptual methods for identifying and measuring benefits are well established (Creese and Henderson 1980; Mills 1985), the application of these methods depends crucially on a variety of judgments on both the measurement of benefits and their values. Some of the best work on cost-benefit analysis in the health sector is found in the area of immunization (Creese and Henderson 1980; Creese 1983), and many of the methods used there can be applied to micronutrients. The basic method of estimating benefits is to identify the positive effects of micronutrient interventions on such areas as morbidity, work output, and edu- cational benefits for children. The benefits of reduced morbidity are generally considered to be the savings in health care and the value of lost productivity; the benefits of work output can be measured with respect to additional days of productive work (in the labor market or household) vomd the additional produc- tivity per day-, and educational benefits include the value of additional student achievement and the reduction in the cost of special educational services or grade repetition. Some of these benefits also have implications for costs. For example, if iron-replete workers are able to put out more work effort to increase productivity, they will also need additional food to compensate for the higher expenditure of energy (Levin 1985, 1986). .IEJ]ach of the micronutrient interventions has an effect on health, produc- tivity, and other aspects of behavior. In theory, it is only necessarv to tran,Sate the effects into benefits and to place monetary values on them to compare them with toe costs of an intervention. Unfortunately, the lack of field trials that incorporate data collection in the various benefit domains limits the application of cost-benefit analysis to this area. Nevertheless, there exist studies for each of the three micronutrients that are both informative and suggest high returns.... Costs and Benefits The tables in this appendix show the costs and benefits of various interventions. A P P E N D I X E S 63 Table B.1 Asswnptions in Calculating Costs per Disability-Adjusted Lire-Year, Death Averted and Income Enhancement Parameter Value Program effectiveness (percent) 75' Unemployment (percent) 25b Life expectancy (years) 70 Discount rate (percent) 3 Annual wage rate (U.S. dollars) 500 Population (number) 100,000 Age distribution (number) 0-1 year 3.900 1-2 years 3,250 2-3 years 2,340 3-4 years 1,950 4.5 years 1,560 5-9 years 12,000 10-14 years 9,000 15-59 years 57,000O 60 years and older 7,000 Malnutrition rates (number and percent) PEM Children younger than 5 3,900 (30) Adults stunted from childhood malnutrition 17,000 (30) Iron Anemic children under 15 18,000 (50) Anemic adult men 7,250 (25) Anemic pregnant women 2,520 (63) Total population anemic 49,000 Iodine Population deficient 24,000 (24) Cretinism So (Q.4)d Vitamin A Deficient children under 6 1,950 (15) Severely deficient children under 6 40 (.27) Severely deficient children under 6 dying 20 (.16) Partially blind children under 6 81 (0.060) Totally blind children under 6 41 (0.028) (Tabfe continues an t1efoUowingpage.) 64 E N R I C H I N G L I V E S Table B.1 (continued) Pararnecer Vatue Annual deathsfrom malnutrition (number) PEu-related causes in children under 5 160 Severe anemia in women at childbirth 10 Stillbirths rclated to iodine deficiency 10 Neonatal deaths related to iodine deficiency 10 Children under 5 with vitamin A deficiency 40 Degree of disability (percent) Undernutrition 10 Iron deficiency 20 Iodine deficiency 5 Cretinism 50 Partial blindness 25 Total blindness 50 a. Includes covcrge as wdl as efficacy. b. Adults ages 15-59. c. Includes 25,000 womcn of reproductive age, of whom 4.000 arn pregmuitL & One child is bom with crtnism each year. e He:alth and productivity disabitity. Source: Based on author's assumpnions. A P P E N D I X E S 65 Table B2 Nutrition Program Costs for Population or 10,000 Annual per Annual program Intervention Target group capita cost (USS) cost (USS) Food supplements Pregnant women 46.0 620,540 Children 0-3 years Nutuition education Pregnant women 2.0 26,980 Food subsidy Bottom quintile 30.0 600,000 Integrated nutrition PHC Pregnant women 25.0 337,250 School feeding Children 5-9 years 12.0 144,000 Iron Supplemente Pregnant women 2.0 8.000 Fortification Entire population 0.2 20,000 Iodine Supplernetn, selective Women 0.5 12,500 Supplement, total Entire 0-5 23,250 Fortification Entire population 0.1 10,000 Vitamin A Supplement Children 0-5 years 0.5 6,500 Fortification Entire population 0.2 20,000 Nose: Based on assumptions in Tablc B.t. a. Assumes six prenat visits plus 200 iron tabets. Source: Ho 1985; Levin 1985; Kennedy and Aldamun 1987. 66 E N R I C H I N G L I V E S Table B3 Assumptions in Calculating Costs and Effectiveness oF Iron Interventions Iron supplemenration Parameter of pregnant women Iron fortifcaiuian Target group Pregnant women All people Number 4,000 100,000 Avcnge rate (percent)a 63 50 Per capita cost (US$)b 2 0.20 Program cffectiveness (pcrcent) 75 75 Deaths avcrted 10 10 Immediate productivity gains (percent) 20 20 Program duration (days) ZCO Year rund Program costs (US$) 8,000 20.000 Discounted wage gains (US$) 221,280c 1,682,720d DALY gained 624C 4,520f Wage gains divided by prograrn cost 27.7 84.1 Cost per DALY (US$) 12.8 4.40 Cost per death averted (US) 800 2,000 Note, Based on assumptions in Table B.t. a. Rate of anemia f5r iron supplemennation of pregnmt women; mte of iron deficiency for iron fortification. b. Perprcunancy fcriron supplemnation;per paticipant foriron fordfidon. c. Calculated as the product of the number of anemic participants dtms disabilit times wages times effectivenss times employfnent, plus the product of number of deaths times wage times employment dmies produictive ife expccmyc ([0.631 x 3,9901 x 2 x 500 x 0.75 x 0.75) + (10 O x5 0.75 x 213) = 141,400 + 79,880 =221280. d. Calculated as the product of the number of adult participants times the rate of anemi times disability times effectiveness times employment times wage, plus the product of the number of deaths times wage times cmployment timcs productive life expectancy: (56.990 x 025 x 0.2 x 0.75 x 500) 4 (10 x 5001 0.75 x 213) = 1.602,840 + 79,880 = 1.682720. c Calculated as the product of the number of dcaths times life expectancy. plus the product of disability times number of malnourished participants times effeciveness: (10 x 24.7) + (0.2 x 0.63 x 3,99 x 0.75) = 247 + 377 = 624. f. Calculated as the product of noumber of adult participants times the rate of anemia times disability times effectiveness, plus the product of the munber of deaths times lifc cxpecancy. (56.990 x 05 x 0.2 x 0.75) + (10 x24.7) =4Z10 + 250 = 4.520. Sou'rcc Based or author's assumptions. A P P E N D I X E S 67 Table BA Costs and Effectiveness of Iodine Intervent;ons Iodine supplement: lodine supplement: lodization of salt Parameter targeted coverage mass coverage or water Target group Reproductive- Everyone under Everyone age women age 60 Number 25,000 93,000 100,000 Average rate of iodine deficiency (percent) 24 24 24 Per capita cost (US$)' 0.50 0.50 0.10 Program effectiveness (percent) 75b 75 75 Deaths averted 10f 10 10 Productivity loss (percent) Normal population 5 5 5 Cretins 50 50 50 Program duration Year round Year round Year round Program costs (US$) 12,500 46,500 100,000 Discounted wage gains (US$) 172,000d 280,00 280,000' DALY gained 660f 1,270 1,335h Wage gains divided by program cost (US$) 13.8 6.0 28 Cost per DALY (US$) 18.9 37 7.5 Cost per death averted (USS) 1,250 4,650 1,000 Note: Based on assumptions in TabL: B.I. a Perparticipantpcrar. b. Prevents both neona death and cretinismL c. Neonatal d. Calculated as the product of ibe number of prticipants times the rate of deficiency dmes disability dimes wage times effectiveness tiunes employment raie, plus Rlumber who died times productive life expectancy times employment dines wage for ten credns. plus the product of frquency times productive life expctancy times employment te mwages oer fren cats (25.000 x 0.24 x 0.5 x S00 s 0.75 x 0.75) + (I0 x 0 x 15.5765 x 0.75 x 500) + (O x 15.5765 x 0.75 x S00) = 84380 + 29,210+585410 = 172O410. e. Calculatedas in not d: C57,000x 0.24x 0.5 x500 x 0.7S x0.75)+(10 x05 x 15.5765 x 0.75 x 500) + (lOx 155765x C.75 x 5O) = 192.380 +29210+58.410= 280,00Q f. Clculated astbeprductof the numbr of pricipants times the nue of deficiency times disabiliy rries effectiveness, plus the product of disability times life expectancy for ten cetins plus the life expecancy for ten deaths: (25.00 0 x 24 x 0.05 x 075) + (10 x 0.5 x 29) + 10 x 29 = 225 + 145 + 290 = 660. g CalculAredzasinnotcS(93.OOOxO24xO.OSx0.75)+(IOxO5x29)+10x29=837+145+290= I'M. h. Calultod as in note f (99,9 0.24 x 0.05 x 0.7s ) + (10 x oLs x 29) + 10 x 29 = 900 + 145 + 290 1,335. Sourec Based on author's assumptions. 68 E N R I C H I N G L I V E S Table B. Costs and Effectiveness of Vitamin A Intervention Vitamin A Vitamin A Parameter supplementation' forlijication Target group Children under 5 Entire population Number 13,000 100,000 Average rate of vitamin A deficiency (percent)b 15 15 Per capita cost (USS)c 0.50 0.20 Program effectiveness (percent) 75 75 Deaths avcrted (number) 20 20 Blindness averted (number) Total 4 4 Partial 8 8 Productivity loss (percent) Totally blind 50 50 Partaly blind 25 25 Program duration Year round Year round Program costs (US$) 6,500 20,000 Discounted wage gains (US$) 140,188d 140,188d DALY gained 696' 696c Wage gain divided by progmm cost 21.6 7.0 Cost per DALY (USS) 9.3 29 Cost per death averted (US$) 325 1,000 Nore: Based on assunptions in Table B.l. a. Seniannual mass dosev :. In children under 5 years. c. PerprticipanL & Does not include losses due to excess child rmorbidity. Calculated as the product of the number of deaths avened times the productive life expectancy times employrnent times wagM plus the product of the numberof total blindness averted times productive lfe expectancy times disability times cmployment times wage, plus the product of the number of partial blindness averted times productive life expectancy Dmes disability dums employmt times wage: (20x 15.5765 x 0.75 x500)+ (4x 155765 t0.5 x 0.75 x500) 1 ( x 15.5765 x 0.25 x 75 x 500) = 11 6.824+ 11.682 + 11,682 = 140,l88. c. Calculated as deaths avcrted times discounted remaining life expectancy plts total blindness times disability times discounted rcmainring life expectancy plus partial blindness times disability dtmes discounted rmaining lifec xpectancy: (20x 2 9) + (4 x QS x 29) + ( x O.25 x 29) = 696. Source. Based on author's assumptions. Bibliography The word "processed" describes infonnally reproduced works that mray not be com- monly available through libraries. 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