Background and introduction

Reducing child mortality is a key Millennium Development Goal (MDG). But by 2003 evidence of slow progress towards this, and other health Goals, had already begun to emerge, and is now clearly evident[i][ii]. This prompted calls[iii] for renewed national and international efforts to be directed specifically towards child survival.

Malnutrition is a major factor underlying an estimated 54% of child deaths. The control of one aspect of malnutrition - Vitamin A Deficiency (VAD) - has long been recognized as one of the most cost-effective means of improving child survival. In order to fully protect children from VAD, it is critical to ensure that sufficient vitamin A is consumed to satisfy physiological requirements. The most direct way of doing this where VAD is endemic is through the twice yearly distribution of high dose Vitamin A Supplements to all children aged 6-59 months.

Vitamin A supplementation (VAS) has been associated with a reduction in all cause mortality of 23% among children aged 6–59 months in areas where vitamin A deficiency was a public health problem[iv], and is recognized as a key component of the ‘arsenal of effective interventions against childhood killers[v]’. From 1998, the World Health Organization (WHO), recognising an opportunity to start to make vitamin A supplementation widely available, recommended[vi] administering VAS during National Immunization Day campaigns aimed at eradicating polio became widespread, many countries included VAS with oral polio vaccine (OPV) distribution, enabling large numbers of children to receive at least one high-dose of VAS each year.

The percentage of children aged 6-59 months who receive at least one high dose of vitamin A each year, remains an important indicator of progress towards improved child nutrition and health. It is monitored and reported annually in UNICEF’s State of the World’s Children It has also been informally adopted as an additional ‘core intermediate indicator’ for monitoring progress towards MDG1 (eradicating extreme poverty and hunger) and as an additional optional indicator for monitoring progress towards MDG 4 (reducing child mortality).[vii] [viii]

It has long been recognized that linking with polio NIDs could only be a time-limited strategy for the large-scale delivery of vitamin A supplements. The WHO[ix] aimed to complete the eradication of polio by the end of 2005 although some residual activity will continue after that date, depending on progress. This means that other high coverage mechanisms for delivering vitamin A supplements have to be in place very soon to maintain and increase the protection of young children in high mortality countries. Some countries are already achieving high coverage every six months without the use of NIDs, by integrating VAS within the scope of regular primary health care activities such as child health days or weeks. National micronutrient day and other campaigns are still used successfully in some countries, although others have difficulty in mobilising the resources needed to stage regular national campaigns. Overall, several high burden countries have yet to put in place delivery strategies that will ensure the delivery of VAS to all eligible children twice a year.

Building on lessons learnt from their own programs plus others such as those funded by USAID, the Micronutrient Initiative (MI) and the United Nations Children’s Fund (UNICEF) set out to identify how progress towards sustained high coverage might best be accelerated. With support from CIDA - MI and UNICEF jointly launched a series of missions to over 20 countries between January and June 2004 to assess key bottlenecks to progress in achieving and sustaining high coverage with each required dose of vitamin A supplements (VAS)[1]. As part of the process, the aim was to assess the costs needed to remove the bottlenecks and so achieve very high (85%+ for each dose required), and ultimately to quantify the expected health outcomes.

This report summarises and analyses the findings of a series of assessments of VAS programs in 20 countries in Asia and Africa with high child mortality rates.

Asia and the Middle East	Sub-Saharan Africa
Afghanistan	Angola
Bangladesh	Burkina Faso
Cambodia	Democratic Republic of Congo
India	Ethiopia
Indonesia	Kenya
Iraq (via Jordan)	Mali
Pakistan	Malawi
Yemen	Mozambique
	Niger
	Nigeria
	Senegal
	Sudan

The assessments undertaken in the first two quarters of 2004 provide a detailed description of current programs to deliver vitamin A supplements (VAS) to preschool children and women in the post-partum period. The main result for each country was a report for policy-makers highlighting key opportunities and challenges, which led to recommendations for action.

This report aims to identify common lessons learned such as examples of best practices and bottlenecks encountered across all countries included in the assessment. It goes on to analyse and interpret these findings in the context of wider national and international efforts to redouble efforts to improve child health and survival and maternal health and to improve impact and equity in health service provision.

The report concludes with some recommendations of how the best practices observed in some of the countries might provide the framework for more systematic approach to providing VAS as part of national primary health care systems in countries where VAD is a public health problem and child mortality is high. These recommendations are elaborated upon in a list of the specific factors considered most critical to the successful integration of vitamin A supplementation into primary health care provision that are emerging in some countries. These ‘success factors’ are intended to help guide the implementation and tracking of progress towards high and sustained protection of children under-five from vitamin A deficiency and its impact on mortality and morbidity.

The audience for this report is mainly those who form and inform decisions about primary health care. The report does not aim to prescribe exactly what needs to be done. But it does aim to help decision-makers identify, appreciate the benefits of, and consider ways of using VAS as a cornerstone for a child survival strategy.

Assessments conducted jointly by the Micronutrient Initiative and UNICEF in early 2004 took stock of current VAD control programs and VAS activities in twenty countries in Africa and Asia. The assessments found several countries integrating VAS with (routine) immunization contacts at fixed sites and via outreach as their main non-NIDs strategy. Although this offers some scope to protect infants, coverage may not be optimal as the reach of immunization contacts is often limited and crucially, there is little or no provision to protect children aged 12 months and above as they are not targeted for immunization services. Unfortunately, few countries had begun to identify additional activities to address this older age group, or to find other ways of achieving and sustaining high rates of protection for all children under five. There are three major areas both at international and national level for improved programming in the future:

· Policy, program advocacy and coordination

· Capacity strengthening in training, supervision and monitoring and supply logistics management

· The move from measuring the percentage of children covered to the percentage of children protected

The assessments found a number of countries working to implement integrated packages of preventive health services for their populations, with many phasing out individual ‘vertical programs’ (including stand-alone VAS distribution). Fuller and wider integration of VAS with other essential health services such as immunizations, deworming, malaria prevention and antenatal checks offers a promising and pragmatic vision of the best way forward. The challenge will be to ensure adequate reach with packages of such services and to ensure that VAS provision remains sustainably and comprehensively integrated into protective child survival and health services in all countries.

Summary of findings and situation analysis

The findings of the 20 country assessments summarised here follow the main areas that were focused upon during the country reviews. These areas were selected based on earlier field experience and on factors identified elsewhere [IVACG (2003); Houston (2001); GAVI (2003) inter alia] as key to success. The assessments explored the strengths and weaknesses in each country concerning the:

national Primary Health Care (PHC) infrastructure
extent and nature of the demand from communities for PHC services generally and VAS in particular
national policies, strategies and plans for using VAS to address vitamin A deficiency and child mortality
effectiveness of leadership of both policies and programs
financial resources available
degree and effectiveness of coordination of efforts at national level and below
operational support available for delivery to all target groups
monitoring, reporting and other feedback mechanisms
supply chain and logistics employed

These areas are by no means mutually exclusive and impact on each other in various ways. The sections that follow summarise the most common findings in these areas, and highlight significant issues (in particular weaknesses that need to be addressed) and recurring themes.

Recommendations
Policy /planning /strategy: Child survival not yet a major focus or identified benefit within VAS policy. Mortality impact lost in focus on blindness.	o Support development and implementation of advocacy strategy and dissemination of materials
o Launch Damage Assessment Reports as major advocacy event
PHC infrastructure /capacity: Access to services limited, infrastructure destroyed by war Limited technical capacity at all levels.	o Develop planning guidelines for twice yearly VAS within routine services and EPI outreach
o Support planning for high VAS coverage in all districts
o Support implementation in all districts
Financial resources: Limited funding due to huge post war reconstruction needs. Funding relatively inadequate given degree of need	o Calculate shortfall in resource provision to achieve acceptable coverage through fixed posts and outreach o Advocate with Government for adequate funding for child survival activities including VAS to cover shortfall o Advocate with donors for continued support to maintain high coverage of key child survival activities including VAS o Advocacy with government and donors to cover gap in funding for integrating VAS into EPI routine and outreach
Leadership /attitudes:	o See Policy above
Co-ordination /all levels: Community structures weakened by war / conflict	o Develop and sign agreements with traditional structures, Faith Based Organisations, NGOs for social mobilization and other support activities in support of VAS (such as continued use of radio channels for information and mobilization; collaboration with CBOs involved in Luanda Urban Poverty Programme)
Beneficiary uptake: Consumer awareness and demand for VAS low; multiple misconceptions	o Identify and develop key messages and strategies for behaviour change
o Support implementation / dissemination of materials
Operational support: Health worker knowledge inadequate with lack of clear and accessible materials	o Develop and disseminate simple material for health workers, integrated into existing materials
o Develop / adapt guidelines for VAS planning, supervision and management through different strategies
o Training of managers / supervisors
Technical capacity limited with very poor operational support	o Recruit coordinators for priority provinces and provide support to them
	o Implement integration of VAS into supervisory systems
Monitoring /reporting: Monitoring system very weak, new system currently being developed	o Integrate data on VAS twice yearly into information and planning system
Supply chain management: Supply chain and logistic system generally very weak, shortage of capsules at delivery level	o Monitor and support VAC forecasting, stock management and supply systems as part of EPI o incorporate needs for various distribution channels into the system o provide technical assistance to staff as necessary
o Support wider initiatives to improve logistics system where appropriate (including examination of possible supply of 100 capsule bottles and ensure opaque containers for re-packing to preserve VA activity)

Burkina Faso – Summary of recommendations

Recommendations
Policy Lack of consistent policy guidelines; health worker uncertainty; clarity needed	o Elaborate a comprehensive set of policy guidelines on the use of vitamin A supplements in health and development programs and have it presented in different formats according to user and place of use. o Develop and implement an orientation plan to disseminate policy guidelines to Regional and District level health workers on the use of vitamin A supplements in line with the policy guidelines.
Leadership VAS not priority in health sector; lack of proactive national level leadership	o Conduct a national-level advocacy meeting with the participation of relevant programmes (EPI, IMCI, Safe Motherhood, Malaria), international agencies, and donor community with the objective to position VAD control in general and VAS in particular as a key intervention for the reduction of under-five mortality rates. o Conduct a series of regional-level advocacy meetings with the participation of regional and district health workers and NGOs with the objective to position VAD control in general and VAS in particular as a key intervention for the reduction of under-five mortality rates. o Ensure proper reference to VAS of women in the early post-partum (<2 months) in the final Policy and Strategy on Infant and Young Child Feeding.
Coordination Among Programs Lack coordination between overlapping MoH directorates and other partners	o Establish clearly defined coordination mechanisms among the various nutrition-relevant health programs and their supporting agencies. o Establish quarterly coordination meetings on nutrition action with partner organizations. o Reinstate NMD organization and coordination meetings, which involve not only partner organizations but also Health Districts and Medical Regions.
Training and Capacity Building	o Review and update nutrition training of the curriculum at the ENSP (probably requiring a local consultant). o Evaluate possibilities of using HIPC of other funding sources for the training of 10 future nutrition focal points at Regional level. o Finalize and reproduce HKI’s nutrition training manual o Develop and implement a training plan for all health workers who have not yet benefited from the nutrition training. o In partnership with NGOs, develop a community health strategy, which starts simple, but can grow according to capacity. o Develop and implement a training plan for community health agents.
Communication Lack of key messages and communication strategy	o Develop and implement a training/orientation plan for itinerant workers on the use of the image cards. o Establish an IEC Task Force to develop an appropriate communication strategy to raise awareness on vitamin A and demand for VAS among the general population. o Prepare a proposal for funding of the communication strategy.
Supply and Distribution	o Prepare an information circular for health workers and NGOs on the purpose, use and limitation of MI/UNICEF capsules. o Change the procedure of needs forecasting with more involvement from Health Districts and Medical Regions. o Review the order form by taking into account high levels of coverage (and losses), regular (preventive) service delivery, integrated management of childhood illnesses, and emergencies. o Assess the possibility of repackaging of capsules in smaller lots.
Monitoring and Information Management System Inconsistent registration and aggregation of VAS data	o Conceive of a simple and effective monitoring and information system (including the generation of feed-back). o Conduct a comprehensive review and revision of the monitoring and reporting tools for VAS towards simplification, standardization and the generation of useful information. o Ensure proper orientation of health workers in the use of the monitoring and reporting tools.
Financial Resources	o Recruit a consultant to assist the DN in effective mobilization of government development funds from budgetary assistance. o Develop a business plan outlining costs, sources and contributions, and gradual take over of financial responsibility by government. o Appoint of a VAS coordinator at the national level to assist with the overall coordination of the proposed activities

Recommendations

Problem Areas

Solution

Policy

Lack of consistent policy guidelines; health worker uncertainty; clarity needed

o Elaborate a comprehensive set of policy guidelines on the use of vitamin A supplements in health and development programs and have it presented in different formats according to user and place of use.

o Develop and implement an orientation plan to disseminate policy guidelines to Regional and District level health workers on the use of vitamin A supplements in line with the policy guidelines.

Leadership

VAS not priority in health sector; lack of proactive national level leadership

o Conduct a national-level advocacy meeting with the participation of relevant programmes (EPI, IMCI, Safe Motherhood, Malaria), international agencies, and donor community with the objective to position VAD control in general and VAS in particular as a key intervention for the reduction of under-five mortality rates.

o Conduct a series of regional-level advocacy meetings with the participation of regional and district health workers and NGOs with the objective to position VAD control in general and VAS in particular as a key intervention for the reduction of under-five mortality rates.

o Ensure proper reference to VAS of women in the early post-partum (<2 months) in the final Policy and Strategy on Infant and Young Child Feeding.

Coordination Among Programs

Lack coordination between overlapping MoH directorates and other partners

o Establish clearly defined coordination mechanisms among the various nutrition-relevant health programs and their supporting agencies.

o Establish quarterly coordination meetings on nutrition action with partner organizations.

o Reinstate NMD organization and coordination meetings, which involve not only partner organizations but also Health Districts and Medical Regions.

Training and Capacity Building

o Review and update nutrition training of the curriculum at the ENSP (probably requiring a local consultant).

o Evaluate possibilities of using HIPC of other funding sources for the training of 10 future nutrition focal points at Regional level.

o Finalize and reproduce HKI’s nutrition training manual

o Develop and implement a training plan for all health workers who have not yet benefited from the nutrition training.

o In partnership with NGOs, develop a community health strategy, which starts simple, but can grow according to capacity.

o Develop and implement a training plan for community health agents.

Communication

Lack of key messages and communication strategy

o Develop and implement a training/orientation plan for itinerant workers on the use of the image cards.

o Establish an IEC Task Force to develop an appropriate communication strategy to raise awareness on vitamin A and demand for VAS among the general population.

o Prepare a proposal for funding of the communication strategy.

Supply and Distribution

o Prepare an information circular for health workers and NGOs on the purpose, use and limitation of MI/UNICEF capsules.

o Change the procedure of needs forecasting with more involvement from Health Districts and Medical Regions.

o Review the order form by taking into account high levels of coverage (and losses), regular (preventive) service delivery, integrated management of childhood illnesses, and emergencies.

o Assess the possibility of repackaging of capsules in smaller lots.

Monitoring and Information Management System

Inconsistent registration and aggregation of VAS data

o Conceive of a simple and effective monitoring and information system (including the generation of feed-back).

o Conduct a comprehensive review and revision of the monitoring and reporting tools for VAS towards simplification, standardization and the generation of useful information.

o Ensure proper orientation of health workers in the use of the monitoring and reporting tools.

Financial Resources

o Recruit a consultant to assist the DN in effective mobilization of government development funds from budgetary assistance.

o Develop a business plan outlining costs, sources and contributions, and gradual take over of financial responsibility by government.

o Appoint of a VAS coordinator at the national level to assist with the overall coordination of the proposed activities

Recommendations
Policy /planning /strategy: Policy - Nutrition and VAS not seen as a priority at national level. All health services extremely under-funded and nutrition has no government funding at all.	Integrate VAS as far as possible with other child survival and maternal health/safe motherhood activities so that it is not a “stand alone” activity.
Identification of all programmes that VAS could be linked to.
Advocacy at national planning level about key role of regular VAS in child survival.
Advocacy to all international donors to integrate VA as part of their intervention packages
Strategy - Campaigns time consuming at national and provincial levels and possibility that there will be fatigue	Annual reviews of VAC distribution through routine health services in each province.
Provincial plans developed on strengthening routine delivery alongside campaigns
PHC infrastructure /capacity: Very poor access to fixed health services throughout country and poor quality of services that do exist.	Campaigns should continue for foreseeable future but review funding, planning and management of campaigns Revisit door-to-door strategy. Consider fixed-post outreach using relais communautaires. Improve visibility of community workers by providing printed T-shirt, caps, arm bands, etc. Review possibilities for extended outreach Increase post partum supplementation a. Devise strategy to access or include TBA in VAS b. Strengthening current strategy (every delivery contact assisted by trained personnel be used to ensure PP-VAS) c. Expand current strategy by using TBA’s, BCG/OPCV contacts and postnatal visits d. Supply all maternities in the country with stocks of VA capsules
Financial resources: see above
Leadership /attitudes: see above Limited understanding of VAS as a child survival activity at national level	Develop clear policy and advocacy messages for identified key policy audiences
	Conduct a national-level advocacy meeting with the participation of government, international agencies and donor community
	Advocacy meetings with policy makers to provide feedback and update on VAS activities
Co-ordination /all levels: Coordination among health programs for strengthened delivery systems	Appoint three technical coordinators and second them to the PRONANUT program to support implementation of action plan (to be based in Kinshasa, Goma and Lubumbashi)
Technical coordinators to identify all opportunities to deliver VA through health and non-health system
	Call and hold a coordination meeting with identified programs
	Draw joint/harmonised business plans
Operational support: Lack of technical skills mainly at provincial and district level for planning and implementation of VAS activities. Lack of capacity at all levels for planning, management and supervision	Liaise with EPI about on-going microplanning and identify opportunities for collaboration / sharing of data
Conflicting messages to health care workers and lack of training materials at provincial and district level	Expand training of provincial and district based health care workers Provision of materials, posters to health care workers with benefits of VA and strategies for supplementation
Supply chain management: Supply chain - VA supplement procurement and logistics	Flexible planning for procurement and logistics A 200,000 VA capsule with every BCG and Measles vaccine. Initiate stock management system in all health zones Keep separate stores for the East (Goma) and West of the DRC (Kinshasa)
Beneficiary uptake: Beneficiary awareness and demand creation limited	Development of clear messages and strategies that will address perceptions, motivations and practices regarding VA and VAS Development and implementation of a communications and social marketing strategy
Monitoring /reporting Monitoring system inadequate	Gather accurate baseline data for VAS coverage Conduct local census to determine denominator or use the information gathered by the EPI program Reconsider the need to conduct a micro planning exercise separate from the EPI sponsored one

Recommendations
Policy and strategy does not prioritize 2 annual doses to children under 5; leadership sceptical of effectiveness of VAS	Information materials and tailored advocacy strategy developed for all levels
Strategy implemented (champions, events, information)
PHC infrastructure and access very low; ambitious Health Extension Plan has political support but will take years to roll out	evaluate Enhanced Outreach Strategy (EOS) to guide further implementation / scale-up and links to HEP
progressive implementation VAS through EOS / EPI+ / HEP
Financial resources: Financing - insufficient funding with low public health expenditure
Leadership /attitudes:	See above
Co-ordination /all levels:	See above
Operational support: Operational support and supervision very weak	recruit regional coordinators for 6 key regions
develop / adapt guidelines and tools for VAS planning, supervision and management through different strategies
training of managers / supervisors
Health worker knowledge poor, significant misinformation	develop and disseminate materials on VAS; guidelines on safety
training of trainers including HEP trainers
Support to training of staff at woreda level
Beneficiary uptake: Utilization / demand for services extremely low especially children >1 yr.	adapt / design materials and strategies to reach communities and families including integration into other strategies
implement / disseminate IEC
Supply chain management: Supply chain not delivering capsules to facilities for routine services	propose and conduct evaluation of VAC procurement and distribution
develop guidelines and tools for forecasting and logistics management
implement and support logistics system
Monitoring /reporting: Information system does not include data for VAS	advocacy and support to ensure VAS included in routine system for recording and performance agreements

Recommendations
Policy /planning /strategy / Leadership - Lack of awareness at the highest levels of the MoH regarding VAS as a key child survival intervention that has the potential to impact achievement of MDGs	o Develop and reiterate clear policy and advocacy messages for identified key policy audiences
o Identify and support a champion for VAS with the ear of the MoH leadership
o Conduct national-level advocacy meetings with the participation of GOK, international agencies and donor community
PHC infrastructure /capacity:Lack of sufficient capacity with the government to support implementation of VAS intervention activities.	o Appoint technical coordinator and second to GOK and other partners to support implementation of action plan.
Financial resources:	See above
Leadership /attitudes:	See above
Co-ordination /all levels: Poor coordination at all levels	o Develop advocacy materials to different donors to promote importance of including VAS with routine health services, particularly EPI, reproduce and disseminate
o Ensure VAS plans are included in all appropriate health program strategies
o Identify key gaps not covered by this integrated approach to prioritize use of existing VAS resources
Beneficiary uptake: Current lack of demand for VAS or of positive messages from health workers	o Development of clear messages and strategies that will address perceptions, motivations and practices regarding VA and VAS
o Development and implementation of a communications and social marketing strategy
Operational support:	See above
Monitoring /reporting:- Lack of reliable data on coverage of VAC delivered through routine services due to weak and fragmented systems in place	o Establish more robust baseline coverage estimates of VAS using routine services. This may entail review of the DHS data (need to be stratified by Province), or an alternative rapid survey o Refine protocol for compilation of data on tally sheets and for more efficient flow of data o Extend protocols for tracking antigen supplies for VAS, considering the possibility of two distinct supply forecasts; one for 100,000 IU by EPI and one for 200,000 IU by community workers o Implement protocol for routine information collection o Identify alternative data collection mechanisms to gather data from child welfare cards to be able to establish coverage of children with 1 or 2 doses per year o Develop feedback from information systems to improve program performance of health workers
Supply chain management:- VA supplement procurement and logistics – unavailability of capsules and wastage	o Technical assistance to ensure better forecasting linked to planning for delivery, together with improved turnover and distribution
	o Development and implementation of a systematic plan for more efficient and timely distribution, reduced wastage and regular monitoring of its implementation
Post partum VAS	o Consider the use of “fast track” lanes to make it easy for mothers to come to a health facility if she is only to receive a dose of Vitamin A in the post-partum period, or for children only receiving VA
o Develop guidelines and disseminate information to promote the administration of post-partum VAS to post-partum women at all OPV-0 or BCG contacts up to 4 weeks
o Technical assistance provided to facilitate consensus on revising policy to extend post-partum interval to permit administration of VAS up to 8 weeks post partum

Mali – Summary of recommendations

Recommendations
Policy and Strategies Policy not spelled out in nutrition policy paper or separate policy paper.	Elaborate a comprehensive set of policy guidelines on the use of Vitamin A supplements in health and development programs and have it presented in different formats according to user and place of use. Develop and implement an orientation plan to disseminate policy guidelines to Regional and District level health workers on the use of vitamin A supplements according to the policy guidelines
Leadership and Commitment Lack of proactive national level leadership	Develop policy and advocacy information strategy for key policy and project management audiences using the recently published Damage Assessment Report to advocate for effective VAD control. Strengthen the leadership role of the Nutrition Division of the MoH (DN) in planning, coordination, advocacy and resource mobilization.
Coordination DN operates too often as a collection of vertical projects with little coordination	o Improve coordination between DN’s public nutrition projects. o Initiate and pursue coordination meetings between the two MoH Divisions with a mandate for nutrition action (eventually leading to coordinated work plans). o Seek regular coordination meetings with the various nutrition-relevant health programs (Expanded Program for Immunization, Safe Motherhood, Roll-Back Malaria, and Integrated Management of Childhood Illnesses) and their supporting agencies.
Training and Capacity Building Confusion around reaching post-partum women Nutrition Division constrained due to lack of transportation	o Organize a “brainstorming” session on VAS of women in the early post-partum (<40 days) to identify missed opportunities (e.g., BCG immunization contacts) and unused mechanisms (e.g., traditional birth attendants, SIAN). o Develop program support tools for VAS of post-partum women within 40 day of birth following the identification and selection of strategies. o Promote integrated strategies for VAD control, by integrating VAS of children aged 6-59 months and women in the early post-partum (<40 days) with ongoing efforts to enhance early initiation of breastfeeding, promote exclusive breastfeeding for the first six months, and, in the near future, the promotion of vitamin A-fortified foods. o Lobby for the purchase of adequate transportation means for the DN, possible from HIPC funds. o Involve local NGOs in the monitoring and supervision of VAS, and use HIPC funds for this if possible. o Review and update nutrition training of the curriculum at medical and nursing schools
Communication Lack of communications materials and key messages for mothers	Establish an IEC Task Force to develop an appropriate communication strategy to raise awareness on vitamin A and demand for VAS among the general population. Prepare a proposal for funding of the communication strategy.
Supply and Distribution District-generated estimates not incorporated into UNICEF’s central level ordering; chronic capsule shortages; need small lots of capsules	Jointly conduct the needs assessment and have capsules stored in the MoH’s warehouse, as agreed upon during a recent harmonization workshop. Review the order form by taking into account adjusted figures for target population (children and women), high levels of coverage, VAS campaigns, regular (preventive) service delivery, integrated management of childhood illnesses, and emergencies. Assess the possibility of repackaging of capsules in smaller lots.
Monitoring and Information Management System Inadequate registration and aggregation of VAS information; lack of subclinical data on VAD	Initiate a comprehensive review and revision of the monitoring and reporting tools for VAS towards simplification, standardization and the generation of useful information, while taking into account its use during SIAN. Sensitize potential donors and prepare a survey protocol and proposal for a national prevalence survey.
Financial Resources Reliance on external donors; need for a medium-term approach to funding	o Develop a business plan outlining costs, sources and contributions, and gradual take over of financial responsibility by government. o Recruit a consultant to assist the DN and DSSAN in effective mobilization of government development funds from budgetary assistance. o Appoint a VAS coordinator at the national level to assist with the overall coordination of the proposed activities

Recommendations

Problem Areas

Type of Solution

Policy and Strategies

Policy not spelled out in nutrition policy paper or separate policy paper.

Elaborate a comprehensive set of policy guidelines on the use of Vitamin A supplements in health and development programs and have it presented in different formats according to user and place of use.
Develop and implement an orientation plan to disseminate policy guidelines to Regional and District level health workers on the use of vitamin A supplements according to the policy guidelines

Leadership and Commitment

Lack of proactive national level leadership

Develop policy and advocacy information strategy for key policy and project management audiences using the recently published Damage Assessment Report to advocate for effective VAD control.
Strengthen the leadership role of the Nutrition Division of the MoH (DN) in planning, coordination, advocacy and resource mobilization.

Coordination

DN operates too often as a collection of vertical projects with little coordination

o Improve coordination between DN’s public nutrition projects.

o Initiate and pursue coordination meetings between the two MoH Divisions with a mandate for nutrition action (eventually leading to coordinated work plans).

o Seek regular coordination meetings with the various nutrition-relevant health programs (Expanded Program for Immunization, Safe Motherhood, Roll-Back Malaria, and Integrated Management of Childhood Illnesses) and their supporting agencies.

Training and Capacity Building

Confusion around reaching post-partum women

Nutrition Division constrained due to lack of transportation

o Organize a “brainstorming” session on VAS of women in the early post-partum (<40 days) to identify missed opportunities (e.g., BCG immunization contacts) and unused mechanisms (e.g., traditional birth attendants, SIAN).

o Develop program support tools for VAS of post-partum women within 40 day of birth following the identification and selection of strategies.

o Promote integrated strategies for VAD control, by integrating VAS of children aged 6-59 months and women in the early post-partum (<40 days) with ongoing efforts to enhance early initiation of breastfeeding, promote exclusive breastfeeding for the first six months, and, in the near future, the promotion of vitamin A-fortified foods.

o Lobby for the purchase of adequate transportation means for the DN, possible from HIPC funds.

o Involve local NGOs in the monitoring and supervision of VAS, and use HIPC funds for this if possible.

o Review and update nutrition training of the curriculum at medical and nursing schools

Communication

Lack of communications materials and key messages for mothers

Establish an IEC Task Force to develop an appropriate communication strategy to raise awareness on vitamin A and demand for VAS among the general population.
Prepare a proposal for funding of the communication strategy.

Supply and Distribution

District-generated estimates not incorporated into UNICEF’s central level ordering; chronic capsule shortages; need small lots of capsules

Jointly conduct the needs assessment and have capsules stored in the MoH’s warehouse, as agreed upon during a recent harmonization workshop.
Review the order form by taking into account adjusted figures for target population (children and women), high levels of coverage, VAS campaigns, regular (preventive) service delivery, integrated management of childhood illnesses, and emergencies.
Assess the possibility of repackaging of capsules in smaller lots.

Monitoring and Information Management System

Inadequate registration and aggregation of VAS information; lack of subclinical data on VAD

Initiate a comprehensive review and revision of the monitoring and reporting tools for VAS towards simplification, standardization and the generation of useful information, while taking into account its use during SIAN.
Sensitize potential donors and prepare a survey protocol and proposal for a national prevalence survey.

Financial Resources

Reliance on external donors; need for a medium-term approach to funding

o Develop a business plan outlining costs, sources and contributions, and gradual take over of financial responsibility by government.

o Recruit a consultant to assist the DN and DSSAN in effective mobilization of government development funds from budgetary assistance.

o Appoint a VAS coordinator at the national level to assist with the overall coordination of the proposed activities

Recommendations
Policy /planning /strategy: Leadership /attitudes: Policy – VAS seen as important for vision	Develop clear policy and advocacy messages for identified key policy audiences
Advocacy meetings at policy level
Development of clear appropriate materials for health care workers
Integration with other programmes – malaria, EPI, IMCI	Regular meetings with other health programmes
	Include VAS in business and operational plans
Limited access to routine health services – especially by children over the age of one	Use of existing mobile teams and outreach. Strengthen logistics and reliability
	Identify NGO’s at district level to strengthen delivery of VA
PHC infrastructure /capacity: Lack of human resources at all levels, number and skills	Technical coordinators in three provinces (to cover whole country)
Training of provincial nutrition focal points and district level staff
Strengthen monitoring and supervision of current activities
Financial resources:	See above
Co-ordination /all levels:	See above
Beneficiary uptake:	See below
Operational support:	See above
Monitoring – Health Information system – VA data not part of HIS	Improve feedback to districts.
Setting of targets – reward good performance
Improve supervision of data collection
Identification of especially poorly performing districts and concentrate on these
Improve / consolidate denominator data
Collection of data on coverage for children over and under one.
Supply chain management:
Post partum women supplementation – no national implementation	Support to roll-out programme – training of health care workers, beneficiary awareness and supervision

Niger – Summary of recommendations

Recommendations

Problem Areas

Solution

Policy

Clarity needed on target group, purpose, dosage, administration frequency, distribution mechanisms

o Elaborate a comprehensive set of policy guidelines on VAS and have it presented in different formats according to user and place of use.

o Develop and implement an orientation plan to periodically disseminate policy guidelines to Regional and District level health workers and NGOs.

Leadership

support for the nutrition service in the MoPH has been dwindling fast; Nutrition Unit (BN) downgraded

o Install a director for nutrition and have the BN offices equipped with communication means.

o Undertake some aggressive fund raising in order to get the vacant nutrition post at UNICEF funded.

o Solicit the PROFILES training with particular attention to the effective lobbying for VAS to be retained in the PDS 2005-2009.

Coordination Among Programs

Lack of systematic coordination ; no director at BN

o Re-activate regular coordination meetings among the nutrition sections of the BN.

o Re-activate regular coordination meetings between the technical units of the DSF.

o Re-activate BN’s participation in the regular coordination meetings for immunization.

o Establish regular (e.g., quarterly) coordination meetings on nutrition action with partner organizations.

Training and Capacity Building

o Review and update nutrition training of the curriculum at the ENSP (probably requiring a local consultant).

o Develop and implement a training plan for all health workers who have not yet benefited from the nutrition training, using the training module developed by HKI/MoPH.

Communication

Ineffective IEC materials; Lack of communication strategy

o Establish an IEC Task Force to develop an appropriate communication strategy to raise awareness on vitamin A and demand for VAS among the general population.

o Prepare a proposal for funding of the communication strategy.

Supply and Distribution

Inadequate storage for delicate products; Central-level commands do not always match the needs at District level

o Coordination on supply, storage and distribution of VACs with ONPPC.

o Adapt the procedure of needs forecasting with more involvement from Health Districts and Medical Regions.

o Review the order form by taking into account high levels of coverage (and losses), regular service delivery, curative use, and emergency stock.

Monitoring and Information Management System

No system in place that allows for VAS coverage reporting outside NIDs and NMDs

o Review and agree on immunization reporting forms regarding VAS.

o Conduct a comprehensive review of the VAS recording forms kept at family level, and the VAS registration tools kept at facility level.

o Ensure proper orientation of health workers in the use of the monitoring and reporting tools.

Financial Resources

VAS activities reliant on external funding

o Develop a business plan outlining costs, sources and contributions, and gradual take over of financial responsibility by government.

o Appoint a VAS coordinator at the national level to assist with the overall coordination of the proposed activities

Nigeria – Summary of recommendations

Recommendations
Problem areas	Type of Solution
Policy /planning /strategy: - Current National FNP does not recognize the role of VA supplementation for VAD control	TA to update of the National Food and Nutrition Policy to include VAS as one of the strategies to control VAD in children 6-59 months and post-partum women.
	Use/adapt the DAR as a key advocacy tool to accelerate VAS and seek appropriate opportunity for launch
Strategies – Current strategies are insufficient to ensure geographical reach and > 80% biannual dosing	Map out the current strategies and coverage currently achieved, identifying geographical areas not currently covered
	Expand geographical reach to areas currently unreached (esp. the 2^nd dose for the first 3 years; for both doses in 2008 and 2009), and develop more intense strategies for hard to reach groups
	The Federal Government of Nigeria finalises and put into legislation the document on Health Reform and Health Act, which includes strengthening the primary health care system.
PHC infrastructure /capacity: The Health System is decentralized but still weak. Capacity to deliver is limited because financial resources do not reach the lower levels. Current training curricula inadequate to create a new generation of VAS/VAS aware health professionals (physicians, nurses, and midwives)	Explore ways of involving the private practitioners in future VAS, while efforts are being made by the government to strengthen the health system through ward centers.
	Harmonize and disseminate appropriate training materials for VA supplementation
	Review curricula/training materials (pre-service and in-service) to send a clear message about the problem of MND, particularly VAD control, and the role of VAS for morbidity and mortality reduction
	Provide training of trainers
	Increase support at zonal level by appointing 6 zonal VAS coordinators (1 per zone)
Financial resources:	TA to develop business plan in coordination with all partners to clearly identify strategies in place, what needs to be achieved by when, how, and required resources
Leadership /attitudes: – No clear leadership for VAS in the country	Hold a retreat with partners to clarify the understanding of roles and accountabilities of each partner involved in VAS (i.e., policy development, M&E lies within the Nutrition Division at the FMOH whereas implementation lies within NPHCDA)
Co-ordination /all levels: – ineffective coordination among stakeholders at the central level	Maintain/appoint a VAS coordinator at the national level to support the implementation of the business plan and supervise the VAS coordinators at the zonal level (6)
Beneficiary uptake: – Lack of awareness at all levels and low demand for VAS outside of NIDs/SNIDs	TA to develop guidelines for the development of an advocacy and communication plan
	TA to develop and implement a sound advocacy and communication plan:
	Accelerate training of IMCI (which includes a VA component) in states that have not been trained yet
Monitoring /reporting; there is no monitoring system in place	Develop and validate unified health card that allows for adequate reporting on VAS activities for children up to 59 months
	TA to review existing reporting formats to develop a simple format allowing completeness of information
	TA to develop guidelines for the development of a M&E plan for VAS
	Generate awareness about the importance of adequate data collection systems for advocacy, planning & resource mobilization
Supply chain management: – inadequate supply; lack of consistency in the denominator used to estimate intended coverage	Allow for sufficient supply of VAC for routine VAS (including post-partum supplementation) and for potential emergency situations, including the right dosage mix of both 100,000 IU and 200,000 IU
	Revisit the planning procedures to piggy-pack VAS with BCG/OPV and measles vaccines
	Partners to agree on the approach for determination of the target population for VAS
	Establish a supply chain with state-of-the-art tools and procedures to allow timely availability of VACs.
Post-Partum women very low coverage because of lack of recognition of the importance of pp VAS	Use all delivery contacts (facility- or hh-based) assisted with trained health personnel (incl. TBAs) to ensure PP VAS.
	Promote using the immunization contacts for BCG and OPV0 for children for the mother to receive VAS at the same time if she has not received it at delivery
	Intensify community mobilization delivering messages that target post-partum mothers

Recommendations
Policy and strategies – need of an effective dissemination strategies and meaningful orientation; certain districts may not have the capacity to implement the new guidelines	Plan and organize regional level policy orientation for district health workers on the new national policy guidelines on VAS
Develop a plan of action to facilitate the implementation of the new guidelines, in particular in low coverage districts
Use/adapt the DAR as a key advocacy tool to accelerate VAS and seek appropriate opportunity for launch
PHC infrastructure and capacity – Some districts have very little or no support; content of nutrition and MND is insufficient in the curricula for health professionals	Review and increase content of nutrition, control of MND in particular, in the curricula for medical doctors, nurses and other health workers, and emphasize the role of VAS for morbidity and mortality reduction. In particular, ensure that all future (assistant) nurses receive up to date training on VAD and VAS
	Ensure regular (e.g. quarterly) supervision visits to selected districts
Financial resources – No business plan available	Develop a business plan outlining costs, sources and contributions, and gradual take over of financial responsibility by government
Policy level awareness and leadership – no proactive leadership, boosted by partners	Promote pro-active leadership in decision-making, coordination, lobbying and advocacy
	Develop clear policy and advocacy information messages for key policy and project management audiences
	Conduct a national-level advocacy meeting with the participation of relevant programs (EPI, Safe Motherhood, Malaria), international agencies, PRN, and donor community
	Conduct a series of regional-level advocacy meetings (9) with the participation of regional and district health workers and NGOs
Coordination – poor coordination within MOH between programs and directorates	Strengthen coordination between the 2 directorates at central level, and within the Nutrition Division
	Appoint an (inter-directorate) VAS coordinator
	Promote inter-agency coordination at district level to avoid duplication
	Ensure VAS plans are included in all appropriate health program strategies (EPI, malaria, Safe Motherhood, IMCI) at all levels (central, regional, district)
	Identify key gaps not covered by this integrated approach to prioritize use of existing VAS resources
Beneficiary uptake, awareness and demand creation - social mobilization for VA limited to NID/MNDs; poor awareness of the importance of VAS in case management of childhood illnesses & for PP women	Develop clear messages on the importance of VAS in case management of childhood illnesses, PP women, and emergency
	Disseminate more rapidly IEC materials currently available
	Develop a policy advocacy and program communication strategy to improve profile of VAS and create demand
Monitoring – No systematic approach to information gathering and reporting on VAS	Revise the health card and other recording/monitoring tools to allow for adequate reporting on VAS activities
	Review existing reporting formats to develop a simple format which (i) allows completeness of information (in terms of age groups and intervention areas) and (ii) can be integrated easily with the existing ones
	Plan and conduct a micronutrient survey on VAD and anemia linked to the upcoming DHS
	Develop guidelines for the development of a M&E plan for VAS
Supply & logistics – Lack of clarity about supply and distribution procedures; poor planning and need estimation	Develop clear guidelines about supply and distribution procedures
	Develop a plan for more efficient and timely distribution, and better need estimation

Recommendations
Policy: No unified strategy for vitamin A Supplementation	-Coordinate high level meetings to establish a unified policy for VAS to under five children and postpartum women and delivery strategies.
Strategy: After phase out of NIDs, new campaign type events need to be developed.	-Add vitamin A capsules to measles campaign -Use “Acceleration Events” such as World Breast feeding week and Child Health and possibly Vitamin A Days
PHC infrastructure /capacity: Lack of sufficient capacity with the government to support implementation of VAS intervention activities.	-Support government through hiring a coordinators to oversee 26 districts (10 coordinators) 10*50,000=500,000 -Total cost/year includes: vitamin A Acceleration days, Measles campaigns, support to post-partum women, campaigns , Khalawi schools
Infrastructure is weak and attendance to health centres is low. (coverage 40%-70% depending on area) for CU1Y and post-partum women	-Mobile teams and outreach activities to add a nutrition educator to reach children >1 and post-partum women; (2438 PHC in total in Sudan: required to have a trained nutritionist for each Health Centre to join mobile—need for an additional 1500 in total. Per year an additional 300 nutritionist; 50CAD/12month*300=180,000CAD/year. (Assumption: These will be an addition to the current available nutritionist)
	-Use of VMW to assist in the delivery and education of Vitamin A to children >1 and post-partum women. -1 VMW required per 2000 population –for population of Sudan(23,000,000), this would require an additional 11,500 in total; per year an additional 2300 VMW); 2300*10CAD=23,000;Total/year:
Financial resources:	See above
Leadership /attitudes:	See above
Co-ordination /all levels:	Technical coordinator (Dept of Nutrition or UNICEF)
Beneficiary uptake: Attendance to health centres is low	-Mobile teams and outreach activities to add a nutrition educator to reach children >1 and post-partum women; -Use of VMW to assist in the delivery and education of Vitamin A to children >1 and post-partum women.
Operational support: Guidelines are outdated and not well distributed	-Update guidelines and design a process whereby information is circulated throughout the health system; Enhance supervision, develop guidelines, print guidelines
Monitoring /reporting: No systematic process in place	-Implement a process for a unified recording and reporting system that is to be integrated into the existing Health Information System (HIS). Printing of uniform reporting schedules, child Growth Monitoring Cards,
Supply chain management:

Recommendations
Policy and Strategy: No unified strategy for vitamin A Supplementation	Coordinate high level meetings to establish a unified policy for VAS to under five children and postpartum women and delivery strategies.
Data on prevalence and magnitude of the problem of Vitamin A Deficiency is not available;	Support is required to ensure that a survey takes place to measure the extent of the problem of Vitamin A deficiency and the necessary support (equipment, technical etc) required to address this issue;
Leadership Resistance to Vitamin A supplementation by the scientific community due to misinformation and lack of updated evidence and research;	A meeting for the scientific community whereby results/experiences from different countries are exchanged is crucial to dispel resistance and suspicions about VAS;
Coordination Lack of coordination and communication amongst the key donors working in Vitamin A Supplementation;	A forum by which discussion and coordination of efforts for Vitamin A supplementation amongst the donor organizations is needed to streamline activities amongst themselves and to clearly identify the roles and responsibilities;
Communication Lack of a communication strategy that identifies the key areas that need to be addressed and the roles and responsibilities of the stakeholders;	e) Communication and advocacy activities for the beneficiaries and the health workers, guidelines, training materials etc. regard are needed urgently. It is recommended that efforts are put into a comprehensive Communications Strategy for Vitamin A Supplementation.

Bangladesh – Summary of recommendations

Recommendations
Problem areas	Type of Solution
Policy /planning /strategy	Hire extenders and develop special strategies to increase coverage in lower coverage pockets (immunization <60% coverage currently in those areas)
	Operational research to assess practice of therapeutic use of Vitamin A.
	Advocacy with GoB on importance of VAS during pregnancy. Development of policy and procedures for VAS during pregnancy.
Financial resources	Determination of availability of NNP/HNPSP (or other) funds for campaign logistics costs
Financial resources	Determination of availability of NNP/HNPSP funds for capsule supply (or identify alternative sources of funds)
Beneficiary uptake	Development of communications strategy for transition from NID-linked campaigns to all Vitamin A campaigns
Operational support	Development of post-partum supplementation with BRAC Shastya Shebika (country-wide coverage)
Monitoring /reporting	Development of monitoring protocol for 100,000 supplement supply
	Explore options for independent assessment of coverage
Supply chain management	Introduction of special container for 100,000 capsules.
Supply chain management	Introduction of twist-open capsules

Cambodia – Summary of recommendations

Recommendations
Policy and Strategy – · Outreach Guidelines have remained in draft for more than a year · The policy for post partum supplementation appears not to be as clearly articulated or known to health workers as the policy for young children. · In particular the revised outreach instruction to take some capsules out every month for PP women is not being well-implemented. · Many health workers do not know about the policy (which is to provide it every month, throughout the year) and/or do not remember to report doses provided.	o Expand and strengthen financial and technical support the delivery of VAS through basic health services delivery, using both outreach and fixed health centers, to cover the whole country o Finalize and disseminate document “Definition of Roles and Responsibilities for Distribution of Vitamin A and Mebendazole during Routine Outreach Sessions” o Develop detailed implementing guidelines for the planning, management & implementation of outreach activities o Ensure full dissemination of these guidelines and conduct integrated training for outreach, at least in relation to ‘system’ – reporting, mopping up etc.
Leadership and Coordination – · some confusion over who is responsible for vitamin A and mebendazole distribution within outreach and who is responsible for outreach (coordination between immunization program and nutrition program) · Technical and operational support to outreach, volunteer networks and specific sectoral activities e.g. vitamin A supplementation is not standardized and there is significant variation across the country. · Uneven distribution of support to districts. Within that support, some receive it for only for certain sectoral programmes rather than for outreach in general. · Often districts are ‘supported’ to do different things by different agencies, on occasion even in conflict to government guidelines.	o Assign an outreach focal point at each health centre through which all programmes support outreach activities. o Finalize and disseminate document “Definition of Roles and Responsibilities for Distribution of Vitamin A and Mebendazole during Routine Outreach Sessions” o Finalize and disseminate detailed implementing guidelines for the planning, management & implementation of outreach activities o conduct integrated training for outreach, at least in relation to ‘system’ – reporting, mopping up etc. Develop forum to hear feedback on how outreach is operating, what problems are experienced and what are lessons learned for strengthening outreach. This forum should facilitate taking successful initiatives to scale and incorporating them into future revisions of the outreach guidelines. E.g. Outreach operating working group o All health centres and districts get at least some basic financial support for outreach
Awareness and demand creation · low awareness about VAD and the importance of VAS among health workers and public.	o Strengthen health education component of outreach services so that people understand what benefits they are receiving and the importance of attending.
PHC infrastructure – capacity – There is very low use of health services and poor capacity and motivation of staff at lower levels. Outreach services and several sectoral activities, including vitamin A remain very dependent upon external support. national capacity to provide training, supervision and monitoring is low. While the policy for outreach and what activities should and shouldn’t be included are clear, there is less guidance on what needs to take place when planning for outreach, how supplies should be ordered and managed, how to record and report following outreach and how operational districts and Provincial Health Departments should provide support and monitoring of outreach activities. The operational efforts of many NGOs have focused on establishing pilots or small scale activities. While these have provided useful lessons and built capacity in the limited geographical areas in which these NGOs work, many areas remain without support and useful lessons have not always been taken to scale. Village Health Support Groups (VHSGs) appear to be a useful resource but are not operating in all villages and appear not to be receiving necessary support to make them fully functional or as effective as they might be.	o Improve compliance with existing guidelines and policies on volunteer groups to ensure a more standardized approach for establishing and supporting VHSGs o Strengthen VHSG and other volunteer networks to support outreach through training, increased supervision and strengthening linkages with the health centre o Train and support health centre staff to provide primary ‘mental’ & technical support to VHSG including guiding them on their roles and responsibilities o Develop procedures to work with VHSGs to help support monitoring, particularly in the compilation of standardized listings of target groups (< 1, 1-5, pregnant women) o Strengthen health education capacity of VHSGs to raise the profile of VHSGs in their community and their capacity to mobilize people to attend outreach. o Involve VHSGs in post activity assessments.
Monitoring · There are conflicting data on population size (different projections at different levels vs. community listings), that makes it difficult for forecasts of VA supplement needs as well as to estimate coverage · New population figures are not yet available at district or village level. Without these, it is not yet possible to apply the new multipliers for specific population groups to re-calculate denominators. · few health centres have listings at village level of key population groups which would help in identifying unreached children and women and improving coverage. · Multiple tally sheets exist for recording outreach activities. While these might generate coverage figures for certain sectoral programmes they do not assist health workers in ensuring that all their target population receive the complete package of services. Similarly they do not facilitate integration of services which are often all the responsibility of one person at health centre level. · It is not clear whether children who are reached with vitamin A outside of the designated vitamin A months, i.e. during the mopping up process, are recorded.	Strengthen and expand post activity assessments and GAVI data quality audits to include vitamin A Develop three standard registers to take to outreach that record services for target groups, rather than sectoral programmes. This will require good coordination between the different sectoral programmes. The registers should list all individuals in that village/outreach catchment area within each target group, have spaces to indicate they have received each service and a way that the number of people reached with each service at each service can be counted to assess coverage. Under 1 register: Ø Birth weight, EPI, maternal TT coverage, PP vitamin A, PP iron folate, vitamin A blue capsule(s), infant mortality 1-5 register: Ø Vitamin A red capsule, mebendazole, U5 mortality Pregnant women register: Ø ANC, iron folate, TT, maternal mortality Cross-check registers of HC with listings of VHSGs Explore the possibility of creating a system to link registers, listings & yellow card with a common ID number. Yellow card - include space for mebendazole and PP supplementation Consider how it would be possible to estimate the % of children (1-5 years) getting two doses VAC per year Integration of PP VAS into graphical presentations of EPI coverage to monitor cumulative coverage of PP VAC
Supply logistics · Government budget for procurement of drugs and vaccines, including vitamin A, is often not available until late in the year which delays submission of the order and necessitates purchasing 1.5 year’s supply at a time. · The National Nutrition Program has not in the past provided clear technical specifications for vitamin A capsules procurement (including color codes, shape, shelf life, etc.). · Health centres and operational districts do not always order their capsules on time to be shipped down in time for the distribution month.	o Technical support to review current VAC logistics management practices o Develop forms and guidelines to streamline and improve supply systems o Consider possibility of procuring ‘donated’ capsules from MI/CIDA from Kimia Farma
Post-partum VAS – very low coverage because of lack of recognition of the importance of pp VAS · Coverage of post-partum women with VA remains low (e.g. missed opportunities of linking PP supplementation with neonatal EPI contacts) · Missed opportunity for linking PP supplementation with neonatal EPI contacts (hep B at birth, BCG, OPV0)	o Give special emphasis to PP supplementation in all future trainings and supervision for VAS and outreach in general – reiterate that unlike supplementation of U5s, supplements for PP women are provided at every outreach o Explore the value and opportunities for linking PP supplementation BCG/Hep B birth dose or PP iron folate (if BCG or Hep B, coordinate with NIP so that PP VAS is included in their training and supervision)

Recommendations

Problem areas

Type of Solution

Policy and Strategy –

· Outreach Guidelines have remained in draft for more than a year

· The policy for post partum supplementation appears not to be as clearly articulated or known to health workers as the policy for young children.

· In particular the revised outreach instruction to take some capsules out every month for PP women is not being well-implemented.

· Many health workers do not know about the policy (which is to provide it every month, throughout the year) and/or do not remember to report doses provided.

o Expand and strengthen financial and technical support the delivery of VAS through basic health services delivery, using both outreach and fixed health centers, to cover the whole country

o Finalize and disseminate document “Definition of Roles and Responsibilities for Distribution of Vitamin A and Mebendazole during Routine Outreach Sessions”

o Develop detailed implementing guidelines for the planning, management & implementation of outreach activities

o Ensure full dissemination of these guidelines and conduct integrated training for outreach, at least in relation to ‘system’ – reporting, mopping up etc.

Leadership and Coordination –

· some confusion over who is responsible for vitamin A and mebendazole distribution within outreach and who is responsible for outreach (coordination between immunization program and nutrition program)

· Technical and operational support to outreach, volunteer networks and specific sectoral activities e.g. vitamin A supplementation is not standardized and there is significant variation across the country.

· Uneven distribution of support to districts. Within that support, some receive it for only for certain sectoral programmes rather than for outreach in general.

· Often districts are ‘supported’ to do different things by different agencies, on occasion even in conflict to government guidelines.

o Assign an outreach focal point at each health centre through which all programmes support outreach activities.

o Finalize and disseminate document “Definition of Roles and Responsibilities for Distribution of Vitamin A and Mebendazole during Routine Outreach Sessions”

o Finalize and disseminate detailed implementing guidelines for the planning, management & implementation of outreach activities

o conduct integrated training for outreach, at least in relation to ‘system’ – reporting, mopping up etc. Develop forum to hear feedback on how outreach is operating, what problems are experienced and what are lessons learned for strengthening outreach. This forum should facilitate taking successful initiatives to scale and incorporating them into future revisions of the outreach guidelines. E.g. Outreach operating working group

o All health centres and districts get at least some basic financial support for outreach

Awareness and demand creation

· low awareness about VAD and the importance of VAS among health workers and public.

o Strengthen health education component of outreach services so that people understand what benefits they are receiving and the importance of attending.

PHC infrastructure – capacity –

There is very low use of health services and poor capacity and motivation of staff at lower levels.
Outreach services and several sectoral activities, including vitamin A remain very dependent upon external support.

national capacity to provide training, supervision and monitoring is low.

While the policy for outreach and what activities should and shouldn’t be included are clear, there is less guidance on what needs to take place when planning for outreach, how supplies should be ordered and managed, how to record and report following outreach and how operational districts and Provincial Health Departments should provide support and monitoring of outreach activities.

The operational efforts of many NGOs have focused on establishing pilots or small scale activities. While these have provided useful lessons and built capacity in the limited geographical areas in which these NGOs work, many areas remain without support and useful lessons have not always been taken to scale.

Village Health Support Groups (VHSGs) appear to be a useful resource but are not operating in all villages and appear not to be receiving necessary support to make them fully functional or as effective as they might be.

o Improve compliance with existing guidelines and policies on volunteer groups to ensure a more standardized approach for establishing and supporting VHSGs

o Strengthen VHSG and other volunteer networks to support outreach through training, increased supervision and strengthening linkages with the health centre

o Train and support health centre staff to provide primary ‘mental’ & technical support to VHSG including guiding them on their roles and responsibilities

o Develop procedures to work with VHSGs to help support monitoring, particularly in the compilation of standardized listings of target groups (< 1, 1-5, pregnant women)

o Strengthen health education capacity of VHSGs to raise the profile of VHSGs in their community and their capacity to mobilize people to attend outreach.

o Involve VHSGs in post activity assessments.

Monitoring

· There are conflicting data on population size (different projections at different levels vs. community listings), that makes it difficult for forecasts of VA supplement needs as well as to estimate coverage

· New population figures are not yet available at district or village level. Without these, it is not yet possible to apply the new multipliers for specific population groups to re-calculate denominators.

· few health centres have listings at village level of key population groups which would help in identifying unreached children and women and improving coverage.

· Multiple tally sheets exist for recording outreach activities. While these might generate coverage figures for certain sectoral programmes they do not assist health workers in ensuring that all their target population receive the complete package of services. Similarly they do not facilitate integration of services which are often all the responsibility of one person at health centre level.

· It is not clear whether children who are reached with vitamin A outside of the designated vitamin A months, i.e. during the mopping up process, are recorded.

Strengthen and expand post activity assessments and GAVI data quality audits to include vitamin A
Develop three standard registers to take to outreach that record services for target groups, rather than sectoral programmes. This will require good coordination between the different sectoral programmes. The registers should list all individuals in that village/outreach catchment area within each target group, have spaces to indicate they have received each service and a way that the number of people reached with each service at each service can be counted to assess coverage.

Under 1 register:

Ø Birth weight, EPI, maternal TT coverage, PP vitamin A, PP iron folate, vitamin A blue capsule(s), infant mortality

1-5 register:

Ø Vitamin A red capsule, mebendazole, U5 mortality

Pregnant women register:

Ø ANC, iron folate, TT, maternal mortality

Cross-check registers of HC with listings of VHSGs
Explore the possibility of creating a system to link registers, listings & yellow card with a common ID number.
Yellow card - include space for mebendazole and PP supplementation
Consider how it would be possible to estimate the % of children (1-5 years) getting two doses VAC per year
Integration of PP VAS into graphical presentations of EPI coverage to monitor cumulative coverage of PP VAC

Supply logistics

· Government budget for procurement of drugs and vaccines, including vitamin A, is often not available until late in the year which delays submission of the order and necessitates purchasing 1.5 year’s supply at a time.

· The National Nutrition Program has not in the past provided clear technical specifications for vitamin A capsules procurement (including color codes, shape, shelf life, etc.).

· Health centres and operational districts do not always order their capsules on time to be shipped down in time for the distribution month.

o Technical support to review current VAC logistics management practices

o Develop forms and guidelines to streamline and improve supply systems

o Consider possibility of procuring ‘donated’ capsules from MI/CIDA from Kimia Farma

Post-partum VAS – very low coverage because of lack of recognition of the importance of pp VAS

· Coverage of post-partum women with VA remains low (e.g. missed opportunities of linking PP supplementation with neonatal EPI contacts)

· Missed opportunity for linking PP supplementation with neonatal EPI contacts (hep B at birth, BCG, OPV0)

o Give special emphasis to PP supplementation in all future trainings and supervision for VAS and outreach in general – reiterate that unlike supplementation of U5s, supplements for PP women are provided at every outreach

o Explore the value and opportunities for linking PP supplementation BCG/Hep B birth dose or PP iron folate (if BCG or Hep B, coordinate with NIP so that PP VAS is included in their training and supervision)

Indonesia – Summary of recommendations

Recommendations
Policy and Strategy – · Policies for post-partum supplementation have not been well disseminated and are not part of the Minimum Services Standard (MSS) · Obligatory Functions/Minimum Services Standard Package is in place to help guide priority setting (which includes preschool VAS) at district level, yet there is currently no legal basis for enforcement · Policies for posyandu revitalization remain unclear · Policies and guidelines for case management of infectious disease with VA are not being implemented · A secondary constraint, that affects policy, strategic planning and general management of the VAS programmes is the limted extent of donor funds available for improving the systems that support the VAC programme such as policy setting, guideline development, coordination with other programmes, formative research, reporting and monitoring. · Over-expectation that IEC and social mobilization is the main obstacle in reaching high coverage	o Develop advocacy plan and tools for policy implementation by district leaders on the importance of VA, including economic consequences of VAD
Leadership – · District leaders who set priorities for budget do not necessarily recognize VAS as an important intervention	o Hold provincial policy and advocacy meetings for district leaders on the importance of VAD
· Coordination – Inadequate coordination between Nutrition Directorate and other directorates within MOH for linkage of vitamin A with other MCH services. · VAS perceived purely as “nutrition” activity for which only nutrition staff are responsible; lack of coordination with other staff, e.g. immunization · Decentralization is a challenge	o Maintain/appoint a national VAS coordinator to strengthen coordination and supervision of acceleration activities within Indonesia:
Awareness and demand creation Health care worker awareness (cadres and bidans) · VA is considered to be important only for visual health, but is not commonly associated with child survival · Lack of awareness about the importance of providing PP women with VA · Perception that VA supplementation is a short-term intervention · Perception that there is no evidence of benefits of PP supplementation Public awareness and demand · VA is considered to be important only for visual health, but there is less understanding of its association with child survival and improved immune function to reduce susceptibility to illness, hence to child survival · Lack of awareness among PP women of the importance of VA	o Develop advocacy and policy tools for district leaders on the importance of VA, including economic consequences of VAD o Modify materials used for training of heath workers to emphasize role of VA in improving immune function and child heath, importance of PP, & treatment with vitamin A o Revise, print and disseminate IEC materials nationwide to give more emphasis to post-partum supplementation, case management of infectious diseases with VA, and role of VA in improving immune function and child health
PHC infrastructure – capacity – · There is inadequate supervision of posyandu activities at community level by puskesmas staff · There is low retention of cadre at posyandu, in part due to limited incentives and recognition · Bidans and other health staff are not well informed on VAS policies and their responsibilities for supporting VAS ·	o Modify materials used for training of heath workers to emphasize role of VA in improving immune function and child heath, importance of PP, & treatment with vitamin A o Training for revised guidelines on VAS to emphasize new systems and methodologies and PP supplementation, treatment and importance of VAS for child health (start in UNICEF focus districts and integrate with other trainings where possible.
Monitoring · There are conflicting data on population size (different projections at different levels vs. community listings), that makes it difficult for forecasts of VA supplement needs as well as to estimate coverage · There is no feedback provided from monitoring activities to improve program performance · There is limited understanding by those who are collecting and reporting data on how they can use information for understanding program strengths and weaknesses, and taking corrective actions · There is no linkage between data collected on coverage and inventories · There is variation in existing reporting systems and flow of data, which creates confusion and inefficiencies for monitoring · Although there is provision to record data on VA receipt on KMS card, it is not routinely done. · There is no concept built into reporting systems to measure the indicator of coverage of children (12 to 59 months of age) who received two doses per year · Perceived need to monitor and track changes in the prevalence of xerophthalmia which diverts resources/focus from other program activities	o Reconcile population figures used for forecasting and to estimate coverage figures o Develop guidelines for generation of community-population listings for local area monitoring o Support the development of tools and guidelines for reporting coverage, including feedback mechanisms that can be provided to heath care workers o Technical support for implementation of new reporting forms and monitoring mechanisms
Supply logistics – inadequate supply; lack of consistency in the denominator used to estimate intended coverage · At district-level, systems have yet to be fully developed for capsule forecasting, procurement and logistics management · There is insufficient clarity on who is responsible for funding of capsules leading to inefficiencies and mismatch of supply vs. need. · Current package size of UNICEF capsules (500 cap/bottle) is not very practical (too large) for distribution at community-level · In the context of decentralization, the system for forecasting and supply of CIDA-funded capsules is not functioning well · Decentralized procurement poses logistic difficulties for the producer Kimia Farma	o Technical support to review current VAC logistics & management practices o Develop forms and guidelines to streamline and improve supply systems o Consider possibility of procuring ‘donated’ capsules from MI/CIDA from Kimia Farma
Post-partum VAS – very low coverage because of lack of recognition of the importance of pp VAS · Coverage of post-partum women with VA remains low (e.g. missed opportunities of linking PP supplementation with neonatal EPI contacts) · Missed opportunity for linking PP supplementation with neonatal EPI contacts (hep B at birth, BCG, OPV0)	o Review findings from operational research on PP supplementation and develop specific guidelines on innovative delivery opportunities at community-level o Disseminate guidelines for Post-partum VA supplementation o Promote using the immunization contacts for BCG and OPV0 for children for the mother to receive VAS at the same time if she has not received it at delivery

Recommendations

Problem areas

Type of Solution

Policy and Strategy –

· Policies for post-partum supplementation have not been well disseminated and are not part of the Minimum Services Standard (MSS)

· Obligatory Functions/Minimum Services Standard Package is in place to help guide priority setting (which includes preschool VAS) at district level, yet there is currently no legal basis for enforcement

· Policies for posyandu revitalization remain unclear

· Policies and guidelines for case management of infectious disease with VA are not being implemented

· A secondary constraint, that affects policy, strategic planning and general management of the VAS programmes is the limted extent of donor funds available for improving the systems that support the VAC programme such as policy setting, guideline development, coordination with other programmes, formative research, reporting and monitoring.

· Over-expectation that IEC and social mobilization is the main obstacle in reaching high coverage

o Develop advocacy plan and tools for policy implementation by district leaders on the importance of VA, including economic consequences of VAD

Leadership –

· District leaders who set priorities for budget do not necessarily recognize VAS as an important intervention

o Hold provincial policy and advocacy meetings for district leaders on the importance of VAD

· Coordination – Inadequate coordination between Nutrition Directorate and other directorates within MOH for linkage of vitamin A with other MCH services.

· VAS perceived purely as “nutrition” activity for which only nutrition staff are responsible; lack of coordination with other staff, e.g. immunization

· Decentralization is a challenge

o Maintain/appoint a national VAS coordinator to strengthen coordination and supervision of acceleration activities within Indonesia:

Awareness and demand creation

Health care worker awareness (cadres and bidans)

· VA is considered to be important only for visual health, but is not commonly associated with child survival

· Lack of awareness about the importance of providing PP women with VA

· Perception that VA supplementation is a short-term intervention

· Perception that there is no evidence of benefits of PP supplementation

Public awareness and demand

· VA is considered to be important only for visual health, but there is less understanding of its association with child survival and improved immune function to reduce susceptibility to illness, hence to child survival

· Lack of awareness among PP women of the importance of VA

o Develop advocacy and policy tools for district leaders on the importance of VA, including economic consequences of VAD

o Modify materials used for training of heath workers to emphasize role of VA in improving immune function and child heath, importance of PP, & treatment with vitamin A

o Revise, print and disseminate IEC materials nationwide to give more emphasis to post-partum supplementation, case management of infectious diseases with VA, and role of VA in improving immune function and child health

PHC infrastructure – capacity –

· There is inadequate supervision of posyandu activities at community level by puskesmas staff

· There is low retention of cadre at posyandu, in part due to limited incentives and recognition

· Bidans and other health staff are not well informed on VAS policies and their responsibilities for supporting VAS

o Modify materials used for training of heath workers to emphasize role of VA in improving immune function and child heath, importance of PP, & treatment with vitamin A

o Training for revised guidelines on VAS to emphasize new systems and methodologies and PP supplementation, treatment and importance of VAS for child health (start in UNICEF focus districts and integrate with other trainings where possible.

Monitoring

· There is no feedback provided from monitoring activities to improve program performance

· There is limited understanding by those who are collecting and reporting data on how they can use information for understanding program strengths and weaknesses, and taking corrective actions

· There is no linkage between data collected on coverage and inventories

· There is variation in existing reporting systems and flow of data, which creates confusion and inefficiencies for monitoring

· Although there is provision to record data on VA receipt on KMS card, it is not routinely done.

· There is no concept built into reporting systems to measure the indicator of coverage of children (12 to 59 months of age) who received two doses per year

· Perceived need to monitor and track changes in the prevalence of xerophthalmia which diverts resources/focus from other program activities

o Reconcile population figures used for forecasting and to estimate coverage figures

o Develop guidelines for generation of community-population listings for local area monitoring

o Support the development of tools and guidelines for reporting coverage, including feedback mechanisms that can be provided to heath care workers

o Technical support for implementation of new reporting forms and monitoring mechanisms

Supply logistics – inadequate supply; lack of consistency in the denominator used to estimate intended coverage

· At district-level, systems have yet to be fully developed for capsule forecasting, procurement and logistics management

· There is insufficient clarity on who is responsible for funding of capsules leading to inefficiencies and mismatch of supply vs. need.

· Current package size of UNICEF capsules (500 cap/bottle) is not very practical (too large) for distribution at community-level

· In the context of decentralization, the system for forecasting and supply of CIDA-funded capsules is not functioning well

· Decentralized procurement poses logistic difficulties for the producer Kimia Farma

o Technical support to review current VAC logistics & management practices

o Develop forms and guidelines to streamline and improve supply systems

o Consider possibility of procuring ‘donated’ capsules from MI/CIDA from Kimia Farma

Post-partum VAS – very low coverage because of lack of recognition of the importance of pp VAS

· Coverage of post-partum women with VA remains low (e.g. missed opportunities of linking PP supplementation with neonatal EPI contacts)

· Missed opportunity for linking PP supplementation with neonatal EPI contacts (hep B at birth, BCG, OPV0)

o Review findings from operational research on PP supplementation and develop specific guidelines on innovative delivery opportunities at community-level

o Disseminate guidelines for Post-partum VA supplementation

o Promote using the immunization contacts for BCG and OPV0 for children for the mother to receive VAS at the same time if she has not received it at delivery

India – Summary of recommendations

Recommendations
Problem areas	Type of Solution
Policy /planning /strategy:	Ensure Vitamin A indicator is included in RCH 2
	Ensure that ICMR recommendations (health and nutrition months twice yearly) are disseminated to States and implemented
	Broaden partnership for delivery (in low performing States) – key interventions: form State task forces that include MI, CARE, WFP, others; hire extenders
	Develop special more intense strategies for hard to reach groups (more IEC, mobility for workers, intense micro-planning)
PHC infrastructure /capacity:	Improve micro-planning
Financial resources:
Leadership /attitudes:
Co-ordination /all levels:	Creation of a small task force at Central level (as recommended by the MoH) MI to be on this task force with UNICEF, WHO, gov’t and national institutes. Use this opportunity to develop capacity within MoH on Vitamin A issues.
	Form a Vitamin A network of champions and support them with an information repository (e.g. web site).
	State-level task forces (see 1b above
Beneficiary uptake:	Work with community organizations to generate sustained demand for Vitamin A (mainly IEC)
Operational support:	Strengthen Vitamin A section of training modules for workers and ensure workers are provided durable IEC tools to use at the community level
Monitoring /reporting;	Revise current reporting format to enable reporting of “% of children adequately protected”. Use new indicators.
	Child-centered monitoring and use of tally sheets
	Common register for anganwadi workers and auxiliary nurse midwives at the village level
Supply chain management:	Conduct supply system logistics review (hire an expert)
	UNICEF to continue to fill the gaps in supply at the State level (with MI support)
	Explore alternative dosing mechanism (e.g. capsules, dropper)
	Create rotating buffer stocks at State level
	Increase the quantity of Vitamin A provided through Kit A (by the Central government)

Recommendations
Policy /planning /strategy:	Support to VA supplementation through current NIDs.
Pilot “child health and nutrition months” in 25 districts, working through routine EPI (measles) and Lady Health Workers (10-59 months)
Pilot “special campaigns” in same 25 districts where there is poor coverage of vaccinators and/or LHWs
Scale up the above pilots to the whole country after NIDs end up in early 2006
PHC infrastructure /capacity:
Financial resources:
Leadership /attitudes: Prioritization and demand creation	Advocacy at all government levels
Training of workers (including developing durable tools that they can use at community level)
Co-ordination /all levels:
Beneficiary uptake: Prioritization and demand creation	Advocacy at community level
Operational support:
Monitoring /reporting;	Add Vitamin A to the registers.
Introduce new indicators (% of children adequately protected)
Training in how to use monitoring information to take action (e.g. preparing a Vitamin A defaulter list)
Support in using child-centered monitoring (forms, training, supervision)
Supply chain management:	UNICEF to continue to fill supply gap (equivalent of children ages 15-59 months)
Improve assessment of requirements (training and monitoring)
Create a buffer stock at provincial level (and ensure prompt delivery to district level)
Post-partum supplementation	Develop a strategy and guidelines
Create awareness among workers and beneficiaries
Develop supply chain
Develop monitoring protocol

Interpretation and conclusions

This section interprets the findings within the current operating context. It draws a series of overall conclusions from the main findings of the assessment reports in the twenty countries about the impact on the protection provided for children, and about how various aspects of good practice might best be combined and utilised more widely.

With this in mind, Appendix 1 goes on to outline a paradigm for regular health contacts to achieve high and sustained protection for all children against VAD. This package of preventive services for child health builds on the extensive experience developed in several countries which have implemented different variations of regular semi-annual, integrated, preventive health care programs[2]. This model is proposed as a framework within which the development of cost-effective (non-NIDs) strategies for VAS distribution might most appropriately accelerate coverage. A generic list of the critical factors that emerged from these country assessments as indicative of program success are proposed as potential measures of progress for such a strategy.

Main conclusions

The over-riding conclusions from the findings of the twenty country assessments are that:

Conclusion 1: The status quo is not a viable basis for achieving high coverage and more importantly, for achieving high and sustained protection from VAD for all children under 5

If things are left as they are, indications are that vitamin A supplementation could all too easily slip back to “pre-NIDs” coverage levels in many countries. Taken in combination, some of the most critical issues affecting VAS program performance – such as invisible leadership, poor co-ordination, weak management, sub-optimal client demand and over-reliance on a narrow external donor resource base - could all too easily result in VAS provision becoming an ‘optional extra’ within Primary Health Care provision. Given the very substantial impact of vitamin A on child mortality and the lack of realistic effective food-based interventions for improving the vitamin A status of young children, this is not an acceptable option.

Specifically:

Conclusion 2: The integration of VAS with routine immunization contacts at fixed sites and via outreach offers some scope to protect infants, but not to protect all children under 5.

EPI appears to be the most common delivery mechanism with which VAS continues to be linked in many countries. It offers some scope for the protection of children under 1 year, although in practice many opportunities are still being missed, particularly:

o BCG given to infants at up to 4 weeks is not being fully taken advantage of as an opportunity to provide a high-dose of VAS to post-partum mothers

o DPT3 contacts (14 week up to 6 months) are not being exploited as a contact to provide an initial dose of VAS to children under 6-month of age

o Measles is the main vaccine that is provided to children between 9-12 months of age and the contact is not being used as widely or effectively as possible

More importantly, linking VAS exclusively to immunizations is clearly inadequate as a sole strategy for VAS distribution, as it does not currently provide a vehicle to reach children over one year of age with VAS. In addition, providing VAS on a continuous basis as in the case of EPI may not to be the most effective distribution strategy. Several countries have chosen instead to implement regular events on a six monthly basis for the distribution of VAS. This makes more sense from a management and logistics perspective and also for social mobilization.

EPI must however continue to be a central, essential and integral part of any package of “regular or routine integrated child preventive health services’ that includes vitamin A. Management options that favour the use of monthly or quarterly EPI outreach would be particularly valuable for embedding (or reintroducing) the concept of regular intensified contact events as an integral part of routine health services.

Conclusion 3: VAS can be the cornerstone of a package of low –cost and high-impact preventive PHC services delivered at special events, twice a year

Many assessments noted widespread resistance to the prospect of using “campaigns” – especially stand-alone ones for VAS – as a viable long-term delivery strategy. However teams observed the positive impact on participation and coverage when VAS distribution took place twice yearly and was coupled with other preventive health services, notably de-worming. As care-givers see an immediate impact from de-worming children, the latter is popular. Many care-givers also see vitamin A in a positive light, and together these two interventions can and do offer a strong incentive for attendance of care-givers with children over a year old - for whom the ‘draw’ of immunizations is no longer relevant. The six-monthly frequency requirement for deworming tablets, vitamin A supplements and other preventive activities such as the treatment of (standard) bed-nets lends itself well to a regular, routine, cycle of twice-yearly intensified PHC efforts or Regular Events to Advance Child Health (REACH)

Many other preventive services could also be included within such a package, including breastfeeding promotion, growth promotion, complementary feeding (where micronutrient-rich home fortificants offer potential for added value); zinc supplementation and iodized salt promotion. See Appendix 1. In addition, there is scope in such a regular cycle of events to include the provision of essential maternal and newborn health services that could include ante-natal care (for example iron and folic acid supplements, Intermittent Preventive Treatment [IPT] of pregnant mothers for malaria. Such events also offer a platform for providing key treatment services such as oral rehydration therapy, anti-malarials, antibiotics, and treatment doses of vitamin A and zinc supplements where appropriate.

The choice of elements within such a package must be tailored to each country, based on the epidemiological profile of the population, incorporating interventions that are cost-effective and efficacious in impact terms on child survival and maternal health, manageable effectively within the capacity of both the outreach teams and the community resource people directed by the national PHC system. VAS can and must have a central place in such a package - which among other benefits, could also help bring nutrition back into the mainstream of Primary Health Care.

Conclusion 4: In populations where VAD is endemic among children under five, the rationale for VAD control needs to be clearly recognized in policy terms as essential to achieving reductions in mortality amongst pre-school age children

In order to ensure that the maximum benefits of VA in preventing mortality, it is well established that all children under-five need two doses of VAS annually. Any policy or strategy to distribute VAS must therefore provide for this as a minimum. Yet recognition of VAS as a high-priority child survival intervention has not been well established among policy makers. The issue lacks promotion and a champion at the national level in many countries, and VAS policies and strategies are often both inadequate and poorly communicated. Wherever this is the case, this gap must be addressed with compelling arguments as a pre-requisite to other actions in a country. The essential messages are as follows.

The reduction of child mortality is one of the Millennium Development Goals (MDGs) that most Governments have endorsed and accepted. Vitamin A Deficiency (VAD) control remains one of the most cost-effective means of improving child survival and vitamin A supplementation of under five children has been associated with a 23?% reduction in excess mortality among preschool children in populations where VAD is endemic.[3] In order to protect children fully from the adverse consequences of VAD, it is critical to ensure that adequate vitamin A is consumed. Figure 1 illustrates the different ways of fully protecting a child from the consequences of VAD.
Figure 1: Relationship between Vitamin A and Child Survival
	Although it is possible for children to have an adequate dietary intake of vitamin A (including fortified foods where available and accessible), the most feasible and effective way for many children in developing countries to satisfy their physiological requirement for vitamin A intake is through regular supplementation with high dose vitamin A capsules.

National ‘championship’ for VAS – based on a chorus of influential voices acting in unison rather than just one figurehead (although this can be useful) – is needed urgently to address this gap.

Such championship will require both depth - to reach down to decision-makers and their advisers at sub-national and local levels – and breadth to include advocates for and leaders of other essential child survival interventions. It will also need pro-active co-ordination and adequate resources to achieve the momentum and changes that are essential to further progress.

Conclusion 5: Policy leadership and strategic choices for VAS programs are compromised by inadequate coordination and communication at both international and national levels.

The quality and effectiveness of national VAS policies are not influenced only by local capacity, circumstances and knowledge. Priorities can be, and are, swayed by messages from leading technical authorities within the international community, especially when those messages are supported by funding. Yet these ‘international messages’ are not always consistent, clear and comprehensive as they need to be for national policy makers.

Coordination at the global level needs to be improved to provide clear strategic international recommendations and guidelines and to avoid conflicting advice on the prioritization of efforts and resources. Such efforts are of course constantly being made to improve coordination. But for example, valuable initiatives such as the vitamin A alliance could perhaps, be used more to achieve pro-active international collaboration between international actors, and IVACG could potentially play even more of a leadership role. WHO could usefully develop and disseminate an integrated policy response involving all programs contributing to child survival and to strengthened health systems.

At national level, inadequate coordination may be due to common factors such as gaps in local capacity, a lack of history of coordination, competition for resources and because - quite simply - doing it takes “too much” time, commitment and compromise. However, some of the weak coordination is undoubtedly being exacerbated by a lack of explicit collaboration between different international agencies and the various associated (vertical and other) programs they support.

Mixed and contradictory messages can compromise the quality of policy, undermine the influence of national championship, and interfere with the effectiveness of local co-ordination and communication throughout national PHC systems. This is particularly evident where clear and well-disseminated guidelines are lacking for health workers about the provision of VAS to different groups, and for various levels of manager for effective planning, supervision and monitoring of VAS programs. It is especially evident in the policy confusion surrounding supplementation for women post-partum, where a variety of mixed (positive and negative) messages are effectively undermining standing WHO guidelines.

A number of creative solutions to improve co-ordination are outlined below:

o creating an inter-sectoral working group that shares information and plans jointly for the effective and efficient provision of an essential package of PHC services that include VAS, supported inter alia by a national micronutrient working group. The group needs the mandate and authority to affect policy and implementation

o program leadership by a single entity, ownership by all involved and a common sense of strategy to achieve maximum buy-in and optimal coordination

o ensuring coordination at national policy level as well as coordination of implementation

o including the regular review of monitoring data by the coordinating working group as a way to assess and notify others of progress and success, as well as to identify problems

o a stronger engagement by international agencies in the important role of building capacity and support for coordination e.g. through technical assistance

o improved coordination beyond preventive measures – i.e. for example around the delivery of therapeutic vitamin A supplementation through IMCI and individual-oriented health services

Conclusion 6: There is little evidence of national budgeting for VAS programs intended to provide complete protection to all children under five with the requisite two annual doses.

Where there is not clear and urgent policy priority or leadership, it is not surprising to find that there is not a clear idea of the full costs of VAS programs. Most Government Primary Health Care budgets, as currently funded, are insufficient to either procure, and/or assure the delivery of two doses of VAS for all children aged between 0 and 5 years each year.

Vitamin A provision in most cases is appropriately linked with the provision of one or more essential services. This however also means that the costs of VAS provision cannot easily be identified separately. The total costs of VAS provision can end up fragmented across different programs, rather than costed out completely and then integrated into different program budgets. This fragmentation does little for efficient utilization of primary health care resources for two reasons.

o Firstly, national decision-makers have an incomplete picture of the resources that are available in total, and so have limited capacity to deploy resources to the areas of greatest need or low coverage as and when these are revealed by regular monitoring and feedback.

o Secondly, individual elements of the financial support that are used to support VAS programs tend to come with distinctive information requirements and may be restricted (by the donor) in terms of their application.

In the worst case scenario, this can lead to duplication of functions and effort in areas such as reporting and accountability, as well as diminishing local ownership of VAS provision overall. The impact on coverage alone of this fragmentation of resource management argues for stronger national program leadership and financial control. Developing a ‘business plan’ for an integrated package of services including VAS delivered through REACH seems to be a generic priority across several countries. This would ideally be a rolling, costed implementation plan for delivering an essential package of primary health care services to children that includes adequate resources for providing each child with Vitamin A supplementation every six months. It would need to be positioned clearly within the scope of a policy, resourcing and performance monitoring framework for essential child health services.

There may already be resources available in a country at least sufficient to enable some distribution of VAS (donated or purchased) during a range of health contacts – for example at fixed site facilities. But where ‘extension’ mechanisms such as ‘expanded outreach’ events, or ‘door-to-door’ delivery are needed to reach high levels of coverage, and especially if extension is implemented by separate (e.g. international) agencies, care is needed to ensure that national PHC system control and ownership are both strong and well supported.

There are all too often resourcing gaps in the spectrum of protection against VAD that needs to be provided (see Figure 1). For example more resources may be available for preventive provision to children in non-emergency contexts, and less provision for developing cost-effective food-based approaches or for supplements for women post-partum, for emergencies, of for treatment. Provision can be skewed (by funding) towards achieving higher short term ‘coverage’, with only minimal levels of effort going towards institutionalising ways of achieving high and sustained protection. Resource allocation and prioritization need to achieve a balance in the investments that are made.

Conclusion 7: An emphasis on (measuring %) “coverage” alone obscures the importance of assuring the provision of full and sustained protection for each child under 5 from VAD.

As part of the global drive towards achieving the Millennium Development Goals, and especially the “child survival” goal, many countries and international organizations focus attention on achieving high rates of VAS coverage as a proxy measure of progress. However the conversion of ‘coverage rates’ into meaningful estimates of reduction in disease burden and/or child mortality (the main Goal indicator) is difficult, for two main reasons.

First, one of the main problems in assessing coverage is due to differences between population denominators projected from census data, and from field-based enumeration of the clients eligible for, and who receive, PHC services. Common symptoms of this include: reported coverage rates for a given VAS dose that exceed 100%; various ‘official’ coverage rates reported by different sources for the same country; and so on.

Second, when using absolute coverage data, it is usually not possible to report on the percentage of individual children who are fully protected and receive two doses per year. It is however possible to assess this at the population level.

Third, except where there are reliable coverage rates that are close to 100% for each of two doses, there are likely to be children who are ‘missed’ altogether and do not receive even one dose. There is a risk that these children are the most marginalised and vulnerable, and thus more likely to die without VAS.

In some countries, current practice is usually to report coverage; but follow-up action to investigate and close gaps is not always taken. A few countries do have explicit ‘mopping up’ mechanisms that increase the coverage of people targeted by a given event. This ‘mopping-up’ often takes the form of follow-up in the home by community resource people, and requires listings to be compiled and maintained regularly of all the individuals who are eligible for services. It also requires a strong policy commitment to monitor the number of children fully protected from deficiency as opposed to coverage, and to provide safety nets.

One point that emerges from the assessments is that the wider adoption and use of client registers and monitoring could offer several potential benefits, such as the simplification and harmonisation of data collection and higher coverage. Taking the concept a step further, each register could record ALL the services for that target group; and there need not be different registers for different programs (as there often are currently). Such client-centred, rather than program-centred, monitoring could contribute significantly to integration of primary health care interventions, making PHC services more consumer friendly and increasing coverage. Such registers could also help guard against overdosing, and could make ‘mopping up’ of clients who do not attend services feasible. In this context, a gradual reduction in dependency on ‘mopping-up’ activities door-to-door for achieving complete protection schedules, could become an indicator of health seeking behaviour that could be monitored and acted upon.

Summary data could easily be developed from lists and aggregated to provide statistics that maintain the relationship between numerator and denominator as they are rolled-up. Client-centered monitoring could also show which clients have received all intended services, for example which children above five have received all ten doses of vitamin A since birth.

Placing responsibility for both initial data gathering and follow-up into the hands of the community resource people (who collaborate with health workers) could increase opportunities for improving equity in provision, for obtaining locally relevant and more accurate performance reports, and for enhanced program accountability. It does however imply that community registers need to be well-prepared and do include the ALL members of the target population and that policy makers at higher levels accept the community registers as true and accurate representations of local communities.

Conclusion 8: Significant gaps in coverage stem from gaps in capacity and training in key operational areas, including supervision and supply chain and logistics management.

Removing bottlenecks in policy, leadership and coordination will provide significant benefits to the operational management and delivery of PHC services and VAS programs in particular. Stronger government control and ownership of VAS programs is also more likely to include the procurement of VAS in their national budgets.

But many operational problems cannot be removed simply by resolving all or some of the leadership issues. There are several key areas for action that emerged in the overall area of operational management that could potentially lead to rapid improvements in program implementation, including:

1. As most countries have an emergency preparedness plan, forecasts for the VAS requirements that may be distributed as part of emergencies should be made consistent with general plans. Provision is made in the guidelines to countries that make supply requests via UNICEF for stock for emergencies, yet this stock was found to be absent in some countries.

2. The forecasting of VAS requirements at all the levels of PHC systems is challenging; and appropriate tools and training are often lacking. Ways of integrating supply forecasting into monitoring systems are needed so that the data are explicitly connected and more accurate. This is especially important where integrated delivery mechanisms are used: there are critical opportunities to link forecasting among many actors and services. Among all these actors, roles, responsibility and accountability for ensuring national supplies all need to be clear. In addition mechanisms and responsibility for improving the management of inventory at all levels (central, regional, district, and health post) need to be put in place where they are currently absent.

3. Individual bottles of 100,000 and 200,000 IU doses contain a number of VAS capsules that may be unmanageably large in some settings, and may need to be sub-divided to respond to local requirements. A smaller pack size for at least the 100,000 IU capsules and perhaps for the higher doses may be desirable, and early consideration of the costs and benefits is needed.

4. The decentralisation of management responsibilities within many health systems has created some unique challenges in terms of financial and operational management skills. Great value can be obtained from investing in good quality, systematic, and integrated training that builds local capacity that may deliver VAS and other primary health care interventions. The country assessments revealed instances of sound models - such as one that uses initial intensive training to get systems up and running, followed by refreshers and ‘maintenance’.

5. Investment in training can help develop the knowledge and skills of staff involved in the distribution of VAS at all levels. However separate training for each program (such as VAS) does not always need to be delivered separately. The competencies that are needed to manage VAS (and programs to which VAS distribution is linked) need to be identified locally. Training provision in areas such as forecasting, supervision and monitoring could benefit from the capacity, skills and materials already developed for EPI. And there is a specific need in the short term for the pro-active incorporation of materials on VAD and VAS into the pre-service and in-service training of all PHC workers, along with a general strengthening of knowledge of nutrition. There are opportunities in several settings to reduce redundant training activities that are carried out by different sectors and to manage and coordinate them more efficiently. Training for effective supervision of VAS activities is also critical. Proper supervision will in turn reinforce, and safeguard the investments made in training. A more positive, constructive and integrated approach to training and supervision could do much to empower and motivate staff and to solve problems.

6. In countries no longer using NIDs, people who were trained for different VAS-related activities when they were administered as part of NIDs can be an important resource in the transition to new approaches. These are potentially a pool of community resource people who could do much to strengthen the delivery of a package of integrated preventive health services for children led by national PHC systems based on their experience with the polio NIDs.

Appendix 1 Regular Events to Advance Child Health (REACH) with a package of integrated preventive child health services

The collective findings and conclusions from these twenty country assessments point towards a vision of a ‘new paradigm’ for delivering vitamin A supplements as the cornerstone of national efforts to improve child survival and health. This new paradigm is not a blueprint and will differ from one country to another, and even from one district to another. But all approaches would likely have a number of commonly identifiable characteristics:

o A strengthened national PHC system: with adequately and appropriately trained and supervised health staff

o A cycle of regular events or rounds that reach communities at least twice yearly

o An integrated package of preventive and/or treatment services defined by local circumstances and epidemiological which may include any combination of interventions in the following table:

Women	Children under five
Re-treatment of standard insecticide-treated nets every 6 months
USI promotion re utilisation of iodized salt especially among pre-pregnant and pregnant women
Mothers within 8 weeks of delivery: 200,000 IU Vitamin A (re: breast-fed infants 0-6 m) Breastfeeding promotion	Infants aged 6-12 m: 100,000 IU Vitamin A Children aged 12-59m: 200,000 IU Vitamin A, twice a year approximately 6 months apart
	De-worming (Mebendazole) every 6 months
Iron and folate supplements (especially for pregnant women)	Promotion of complementary feeding including nutrient-rich options such as sprinkles and home mixes
Ante-natal care: o Intermittent Preventive Treatment [IPT] for pregnant mothers especially malarial areas o Voluntary Counselling and Testing for HIV/AIDS as part of ANC + Nevirapine[4]	Immunizations: Polio; Diphtheria / Pertussis / Tetanus (DPT) 1,2 and 3 + booster at 5 years; Measles; BCG; HiB; Hep B; yellow fever etc
Nutrition counselling and education Etc	Growth monitoring / ‘road to health’ tracking
	Zinc supplementation

o Using and building on all PHC infrastructure to maximize twice yearly health contacts with locally appropriate combinations of fixed sites, outreach by PHC staff and other approaches such as contracting NGOs for outreach[x]. Fixed date campaign style approaches eg. child health days/weeks may work in some places, although it is expected that distance and other factors may prevent health staff from making the rounds of all the communities they need to serve within a given timeframe.

o Close collaboration with communities. As well as being embedded as normal ‘routine’ activities, REACH services will typically be delivered with the active participation of Community Resource People, supervised and supported by the national PHC system. Their roles would be integral and likely include: enumeration (maintaining community level client-centred monitoring lists); community mobilization through locally appropriate media to achieve optimal client participation and attendance; assistance with services provided to clients at outreach or similar events; follow-up to help identify and ‘mop-up’ missed clients - either door-to-door or at the next event if within three months; and occasional post-activity assessments to verify coverage.

o A clearly communicated national comprehensive VAD control policy and strategy[xi]: positioned in the context of child survival and poverty alleviation that states the importance of reducing vitamin A deficiency for child health and survival, articulates clearly the impact of VAD on child mortality and specifies (at least) the role of VAS for prevention and treatment for children under five and food-based approaches.

o Recurrent financial provision in national / regional / district PHC budgets: to protect the nation’s children from VAD through various means including the twice-yearly provision of preventive vitamin A supplements to all children from birth (via their mothers post partum) up to the age of five years, and the use of the appropriate doses of Vitamin A for the treatment of specified childhood diseases. In all cases policy will be updated to reflect current WHO guidelines (see Annex). Any complementary national policies will contain consistent statements and explicit references to this policy.

o Client-centered monitoring, based on comprehensive registers of all eligible clients and of their attendance at REACH that are maintained by Community Resource People, will help to maximise the numbers of eligible children and mothers who receive all elements of the essential package, and help to ‘mop up’ those who miss events. Summary totals from these registers, together with stock-out, event and/or household survey data will help generate more reliable assessments of coverage, protection, equity and impact for all elements of the package (including – for VAS - the % of all eligible children receiving (a) two doses (b) 1 dose; (c) no doses per year; and the % fully protected by 10 doses/5 years). This approach will ensure greater equity and impact as all children under-five can be identified and protected.

o Equity-focus: emphasis on ensuring that the poorest and most vulnerable groups in society are reached

o Clear and simple supply and inventory management procedures will be needed for all the commodities that are required for REACH, linked to their utilization and shelf life, and to field-based estimates of eligible populations. They will need to include clear guidelines to all levels on forecasting, ordering and management of supplies. They will be also need to be (increasingly) procured through national PHC systems.

o Regular systematic supervision and comprehensive training for staff and managers will support the sustained implementation of REACH.

Appendix 2 Critical Success Factors (CSFs)

As efforts are made to build a REACH approach to deliver an integrated package of services, benchmarks are needed to help assess program inputs and performance. Several ‘critical success factors’ are suggested to help guide the assessment of program implementation, grouped by area:

Policy

o A comprehensive national VAD control policy and strategy clearly positioned in the context of child survival and poverty alleviation

Finance

o Implementation plan and recurrent resource allocation for an essential package

o Government plan to increase Government ownership and control over funds for VAD control

Ownership, leadership and advocacy

o (A) champion(s) is/are in place at the national level with adequate influence to accord VAD control priority as a public health intervention and an integral component of a child survival and health strategy

o Evidence of national ownership of comprehensive VAD control

o Clear assignment of roles and accountability to assure and effect coordination

o Protection against VAD for children under five is seen at all levels as a key component of national child survival and poverty alleviation

Coordination

o A formal body coordinates VAS policy and implementation as part of an essential package

o Coordination takes place actively at all key management levels

Primary Health Care Intra-structure

o Acknowledgement and active engagement of community resource people to help ensure adequate and effective outreach to communities

o Delivery of a (defined) essential package of services, that delivers at least VA semi-annually to at least 85% of children under five (including mop-up) and integrates VAS (and nutrition outreach) with key PHC activities

Awareness on the part of clients

o Clients gain an understanding from IEC of the importance of VAD for child survival and health promotion (as well as eye benefits) sufficient to motivate them to seek VAS at health contact events for all target age groups of children in their care

Operational Support

o Consistent, comprehensive, training and IEC with standardized messages about VA

o Tiered training protocols (intensive at the outset followed by refreshers, and periodic ‘maintenance’ training) covering: importance; what to do; how to report; how to validate; etc

o A clearly communicated paradigm of supervision as supportive and problem-solving, of a respectful PHC provider-client relationship and of an ethical PHC environment

Monitoring

o Child-centered monitoring focused on assessing full protection against VAD among children under 5 years of age, e.g. receipt of 10 doses of VAS

o Use of data to address gaps and low coverage areas and to target intensive follow-up action

Supply and logistics

o data on utilization and inventory stocks are used to drive forecasting and supply estimates

o adequate supplies reach health facilities for treatment, maternity contacts, and emergencies as well as adequate supplies of preventive doses for all children aged 6-59 months

[2] Key examples include the Child Health Weeks advocated, supported and documented by USAID – see for example BASICS II/MOST/USAID (2001) and Tanzania’s Day of the African Child and National AIDS Day events)

[3] Beaton GH, Martorell R, L'Abbé, et al. Effectiveness of vitamin A supplementation in the control of young child morbidity and mortality in developing countries. United Nations, ACC/SCN State-of-the-Art Series, Nutrition Policy Discussion Paper No. 13, 1993.

[4] linked with Voluntary Counselling & Testing for HIV/AIDS offered in private in antenatal check-up tent

Recommendations
Problem areas	Type of Solution
1) Coordination	Hire a national coordinator to undertake tasks such as: policy formulation; oversee pilot scale test for VAS in post-partum women; coordinate tasks for the integration of VAS into routine EPI; support working group under the leadership of the Nutrition Institute
2) 2) No alternatives being sought as substitutes for NID with regard to VAS for preschool children	Advocacy for integrating VAS into routine EPI, CBHC and non-NID campaigns through advocacy meetings and activities, materials, participation of high-level policy makers to advocacy and scientific events such as IVACG meetings, study tours, etc.
3) Limited coverage and comprehensiveness of routine EPI for optimal VAS for preschool children	Feasibility testing and operational research of complementary strategies (outreach, Community Based Health Care [CBHC], NGO-linked interventions)
4) Policy and technical guidelines and protocols for VAS have not been adopted	Provision of technical documentation and assistance
5) Extremely low coverage of VAS for postpartum mothers	Support trials for VAS to postpartum women in maternity and EOU at the provincial and district level. Support policy for community based midwifery services Provide technical and management support to VAS based at MOH and/or UNICEF for two years

Please contact Alison Greig, agreig@micronutrient.org for more information.

Conclusion 1: The status quo is not a viable basis for achieving high coverage and more importantly, for achieving high and sustained protection from VAD for all children under 5

Conclusion 2: The integration of VAS with routine immunization contacts at fixed sites and via outreach offers some scope to protect infants, but not to protect all children under 5.

Conclusion 3: VAS can be the cornerstone of a package of low –cost and high-impact preventive PHC services delivered at special events, twice a year

Conclusion 4: In populations where VAD is endemic among children under five, the rationale for VAD control needs to be clearly recognized in policy terms as essential to achieving reductions in mortality amongst pre-school age children

Conclusion 5: Policy leadership and strategic choices for VAS programs are compromised by inadequate coordination and communication at both international and national levels.

Conclusion 6: There is little evidence of national budgeting for VAS programs intended to provide complete protection to all children under five with the requisite two annual doses.

Conclusion 7: An emphasis on (measuring %) “coverage” alone obscures the importance of assuring the provision of full and sustained protection for each child under 5 from VAD.

Conclusion 8: Significant gaps in coverage stem from gaps in capacity and training in key operational areas, including supervision and supply chain and logistics management.

Appendix 1

Finance

Ownership, leadership and advocacy

Coordination

Primary Health Care Intra-structure

Awareness on the part of clients

Operational Support

Monitoring

Supply and logistics

Bibliography