Module 6: Intervention Strategies

Nutrition is widely-recognized as a high priority in global health and has become the focus of various intervention strategies. Of the world’s undernourished children, 80% live in twenty countries, concentrated among the regions of sub-Saharan Africa and Southeast Asia.(1) India provides an extreme example, with approximately 61 million children suffering from stunted growth. India alone represents 34% of the world’s stunted children.(2) Although national action is required to reverse these trends, most affected countries face limited resources, substandard knowledge, and lack of political commitment. Instead, many affected countries rely on international aid to address the issue of malnutrition.(3) 

Although there is no simple way to eliminate maternal and child undernutrition, it is clear that in order to make an impact there needs to be strong political commitment and leadership, as well as international collaboration. Public-private partnerships have vast potential to make interventions in nutrition successful.

The International Nutrition System

Despite great progress by international agencies to reduce undernutrition in the past decade, prevalence rates remain high in some countries. One reason for this trend is that there is no harmonized, comprehensive effort to address undernutrition among the international aid community and affected countries.(4) Morris, et al., claims that the international nutrition network of donor organizations, academia, private sector, and public support is “fragmented and dysfunctional,” and that agencies need better coordination in their efforts to reduce child and maternal undernutrition.(5) For instance, cooperation between international organizations and national governments can improve the direction of policy and implementation of aid practices.      

Since investing in nutrition is regarded as one of the most cost-effective development interventions, a large portion of international aid is directed towards micronutrient interventions or other nutrition strategies.(6) However, it has been acknowledged that funding provided by international donors has been poorly targeted and has not made sufficient change.(7) Research is necessary to monitor and evaluate nutrition intervention progress and effectiveness as they are applied to different cultures. Consideration of nutrition in its social and cultural context must be achieved locally, and funding and resources should be targeted at interventions that have been proven to work by evidence-based studies.  

The Public Sector

Nutrition should be a priority at the national level because it is a crucial aspect of human and economic development.(8) Evidence has shown that investing in nutrition will improve health and economic prosperity.(9) The major barriers to improving public sector nutrition include limited budgets, ineffective leadership, inadequate communication and information exchange, poor access to vulnerable groups, irregular supply of resources (i.e. supplement tablets), and distribution bottlenecks. Political commitment is necessary to make change, but nutrition often competes with other national issues such as HIV/AIDS, armed conflict, or natural disasters.(10) In a study that investigated how governments prioritize nutrition, 13 out of 15 of the most affected countries reported that nutrition was of low priority relative to areas such as HIV/AIDS, malaria, tuberculosis, or child immunizations.(11)

As a solution, partnerships between public and private sectors (also known as public-private partnerships) offer the inclusion of private organizations to address issues of funding, efficiency, and leadership while public involvement can scale-up interventions at a broader level. Together, the strengths of each sector can help establish nutrition interventions and improve nutrition policy.(12) It is important to recognize that nutrition is not only a health sector issue. Policymakers and key stakeholders can implement or advocate for economic and social policies that address food prices, low income and unemployment rates, international food trade, and agriculture, all of which can help improve a nation’s nutritional status.(13) 

Case Study: Reducing Children’s Vitamin A Deficiency in Nepal

In a country where approximately 28% of the population was impoverished and faced food insecurity, vitamin A deficiency comprised a major public health threat in Nepal in the 1990s.(14) Specifically, over 3% of preschool-aged children suffered from xerophthalmia, or deficiency associated with blindness and mortality risk, and many more experienced other resulting health complications. In response to the high prevalence of vitamin A deficiency in the population, the government of Nepal initiated the National Vitamin A Program (NVAP) in 1993. The NVAP has shown to be a very successful micronutrient intervention project and provides an example of an effective public-private partnership. One of the project’s main strengths has been its ability to build local capacity and reach rural villages.

During the 1990s, the public sector in Nepal faced hardships and was inadequately prepared for the scale of a national program. As a result, other international and domestic sectors took on a larger role. Financial and technical resources for the project originated from USAID and UNICEF, with other important roles provided by local researchers and NGOs. An NGO specifically designed for the NVAP called the Technical Advisory Group (TAG), was established to train personnel, develop administration, and monitor the program.

The World Bank endorses supplementation interventions as the most cost-effective strategy to reduce national vitamin A deficiency. Research conducted in Nepal in the late 1980s demonstrated that under-five mortality rates could drop by 25-30% upon administration of vitamin A capsules twice a year.(15) Although education strategies to promote nutrition and inform mothers about vitamin A deficiency and the associated health risks have been shown to be effective in Nepal, food behavior is slow to change.(16) Education is a necessary long-term strategy, but supplementation provides an immediate solution. The NVAP used both strategies, focusing primarily on supplementation. 

The aims of the National Vitamin A Program were to provide high-dose vitamin A capsules twice a year to children living in priority areas; treat xerophthalmia, diarrheal diseases, measles, and other infections; encourage dietary uptake of vitamin A-rich foods; and promote optimal breastfeeding practices among mothers. Vitamin A distribution was conducted through a large-scale mass distribution campaign. 

A major asset to the intervention was the attainment of reliable and efficient human resources at a low cost. The NVAP utilized an existing network of female community health volunteers (FCHVs) to distribute capsules and disseminate information among rural parents.(17) Nepal’s Ministry of Health had a history of engaging FCHVs to educate mothers and communities on primary healthcare and to encourage the use of healthcare services in rural villages. To attract participation among women in the community, FCHVs were given preference when hiring for other paid governmental positions, opportunities to speak at community meetings, and priority in lines for social services. The basis of success for these motivational strategies was that they helped empower the FCHVs and gave them newfound respect in their communities. One female community health volunteer expressed, “the [vitamin A] program has made us more active, [where] we undergo training every six months and people come to visit so often for advice.”(18)  

In 1993, Nepal recruited 36,000 FCHVs, who helped spread public health messages to rural communities and played an integral role in distributing vitamin A capsules. They recorded every child that was given a supplement and made strong efforts to trace children who missed treatment. Utilizing an existing network of communication and advocacy, the FCHVs helped bridge the gap between health providers and the local community. These women created awareness about vitamin A deficiency, encouraged dietary vitamin A intake, and promoted demand for vitamin A capsules for rural villages. Promoting community ownership greatly helped to improve the success of the campaign. 

The NVAP was originally designed with a four-year expansion plan. Research identified 32 out of 75 districts in the country as priority areas, but the NVAP began with only eight. Each year, the project scaled-up to include more districts, and by the end of 1997, all 32 priority areas had engaged FCHVs to address vitamin A deficiencies in the area.(19) This expansion plan allowed the government time and resources to organize, build local capacity, and adjust strategies according to lessons learned. By 2003, the program had expanded nationwide, making use of National Immunization Days to distribute vitamin A capsules.(20) 

At US$1.25 per child, the NVAP has saved an estimated $327 per “averted death” in addition to $1.6 million in Nepal’s cost of annual health services. The TAG has consistently reported coverage of vitamin A capsules of up to 90% for children under five.(21) Nepal’s Micronutrient Status Survey was used to monitor national malnutrition. Coverage rates were higher in rural areas compared to urban areas, and unlike many other health services, the most vulnerable children from households of low socioeconomic status were most likely to be reached.(22) The factor believed to be responsible for such high coverage rates among villages and vulnerable groups is the program of female community health volunteers. 

The NVAP helps prevent about 2,000 cases of childhood blindness in Nepal each year, and has helped reduce the child mortality rate by over 50% between 1995 and 2005, saving over 4,000 child lives per year.(23) The success of the program can be attributed to its organization, attention to quality research, and use of valuable resources. It is regarded among the global health community as a model program because of the development of mutually beneficial public-private partnerships and local capacity-building.(24) The program applied research at the local level to provide valuable insight on the use of female community health volunteers to distribute capsules. Such innovative strategy is what helps health interventions succeed, and the development of the NVAP can provide an example for other countries to create their own vitamin A supplementation interventions.

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Footnotes

(1) Bryce, J., Coitinho, D., Darnton-Hill, I. Pelletier, D., & Pinstrup-Andersen, P. (2008). Maternal and child undernutrition: effective action at the national level. The Lancet, 371: 510-526. 

(2) Black, R.E., Allen, L.H., Bhutta, Z.A, Caulfield, L.E., de Onis, M., Ezzati, M. et al. (2008). Maternal and child undernutrition: global and regional exposures and health consequences. The Lancet, 371: 243-260.

(3) Morris, S.S., Cogil, B., & Uauy, R. (2008). Effective international action against undernutrition: why has it proven so difficult and what can be done to accelerate progress? The Lancet, 371:608-621.  

(4) Ibid.

(5) Ibid.  

(6) Ibid.

(7) Ibid.  

(8) Bryce, J., Coitinho, D., Darnton-Hill, I. Pelletier, D., & Pinstrup-Andersen, P. (2008). Maternal and child undernutrition: effective action at the national level. The Lancet, 371: 510-526. 

(9) Black, R.E., Allen, L.H., Bhutta, Z.A, Caulfield, L.E., de Onis, M., Ezzati, M. et al. (2008). Maternal and child undernutrition: global and regional exposures and health consequences. The Lancet, 371: 243-260.

(10) Bryce, J., Coitinho, D., Darnton-Hill, I. Pelletier, D., & Pinstrup-Andersen, P. (2008). Maternal and child undernutrition: effective action at the national level. The Lancet, 371: 510-526. 

(11) Ibid.

(12) Ibid.

(13) Ibid. 

(14) Center for Global Advancement. Case 4: Reducing child mortality with vitamin A in Nepal. Accessed 18 October 2011.

(15) Fieldler, J.L. (2000). The Nepal National Vitamin A Program: prototype to emulate or donor enclave? Health Policy and Planning, 15(2): 145-156. 

(16) Pant, C.R., Pokharel, G.P., Curtale, F., Pokhrel, R.P., Grosse, R.N., Lepkowski, J. et al. (1996). Impact of nutrition education and mega-dose vitamin A supplementation on the health of children in Nepal. Bulletin of the World Health Organization, 74(5): 533-545.

(17) Fieldler, J.L. (2000). The Nepal National Vitamin A Program: prototype to emulate or donor enclave? Health Policy and Planning, 15(2): 145-156. 

(18) Center for Global Advancement. Case 4: Reducing child mortality with vitamin A in Nepal. Accessed 18 October 2011.

(19) Ibid.

(20) Gorstein, J., Shreshtra, R.K., Pandey, S., Adhikari, R.K., & Pradhan, A. (2003). Current status of vitamin A deficiency and the National Vitamin A Control Program in Nepal: results of the 1998 national micronutrient status survey. Asia Pacific Journal of Clinical Nutrition, 12(1): 96-103.

(21) Ibid.

(22) Ibid.  

(23) Thapa, S., Choe, M.K., & Retherford, R.D. (2005). Effects of vitamin A supplementation on child mortality: evidence from Nepal’s 2001 demographic and health survey, Tropical Medicine and International Health, 10(8): 782-789.

(24) Fieldler, J.L. (2000). The Nepal National Vitamin A Program: prototype to emulate or donor enclave? Health Policy and Planning, 15(2): 145-156.