utritional

1. E ducation N P rogram utritional A vitamin L for ife By: Juana P Bustamante, Vanessa Cirulli, Federico Giovannelli, Claudia Lasprilla

2. MDG 4:REDUCE CHILD MORTALITY INDICATORS Under five mortality rate Infant mortality rate Proportion of 1 year-old children immunised against measles Probability of dying between birth and exactly five years of age expressed per 1,000 live births. Probability of dying between birth and exactly one year of age expressed per 1,000 live births. TARGET Reduce by two thirds, between 1990 and 2015, the under-five mortality rate Measles vaccine is recommended to be given at 9 months, except in specified countries mostly found in the Pan American Health Organization (PAHO) region, where it is recommended to be given between 12 and 15 months.

3. NEPAL A little bit of…. GEOGRAPHY • A landlocked country, the size of Arkansas • Between India and the Tibetan Autonomous Region of China • In the North borders with the Mount Everest FIGURES by 2005 • 27.7 million people • Growth rate: 1.9 % • Birth rate: 30.5/1000 • Life expectancy at birth (years): 62.9 • Adult literacy rate (% of people ages 15 and over): 33% • Infant Mortality Rate: 56/1000 • Child Mortality Rate: 74/1000 • Immunised against measles: 85/1000 (2003/04)

4. ECONOMY Gross National Income ($): 8.1 billion GNI per capita ($): 290.0 External debt (% of GNI): 44.3 Investment (% of GDP): 30.3 Trade (% of GDP): 56.3 POVERTY Population below $1 a day: 24.1% Percentage share of income or consumption held by the poorest 20%: 6.0% Prevalence of child malnutrition (% of children under 5): 45.0% Population below minimum level of dietary energy consumption: 17.0% NEPAL

5. Vitamin A Supplementation to Reduce Child Mortality in Nepal Vitamin A deficiency: • Affects approximately 21% of the developing world’s preschool-aged children and leads to the deaths of over 800,000 women and children each year • It is responsible for 20–24 percent of global child mortality from measles, diarrhea, and malaria • Compromises the immune system

7. THE PROGRAM

8. Vitamin A Supplementation to Reduce Child Mortality in Nepal Program: • In 1993, the government of Nepal initiated the National Vitamin A Programme (NVAP) with the support of UNICEF, USAID, WHO and local researchers • Providing twice-yearly supplements of vitamin A capsules to children in priority districts • NTAG strategy for implementing the program that includes training, cultivation and maintenance of multi-sectoral support, logistic support, supervision, monitoring, and promotion • A large cadre of women who served as community-based volunteers was integral to the rapid expansion of the program to Nepal’s 75 districts • The volunteers also provide: • nutritional education to parents • distribute contraceptives and oral rehydration salts (the latter for treatment of diarrhea in children) • are a primary source of information about health and family planning

9. CONTRIBUTION OF MAJOR VAP PARTNERS, 1999-2004, Nepal

10. Vitamin A Supplementation to Reduce Child Mortality in Nepal Objectives: • Reduce child mortality and morbidity through prophylactic supplementation of children 6–60 months old with high-dose (200,000 IU) vitamin A capsules twice yearly in 32 priority districts. • Based upon the initial success of the program, the government of Nepal decided to extend vitamin A supplementation to all its 75 districts. • Treat xerophthalmia, severe malnutrition, prolonged diarrhea, and measles in all 75 districts. • Bring about behavior change to increase dietary intake of vitamin A and improve breast-feeding in the 32 priority districts.

11. INTAKE OF VITAMIN A-RICH FOOD AMONG PRESCHOOL CHILDREN, NEPAL

12. Vitamin A Supplementation to Reduce Child Mortality in Nepal Progress: • NVAP prevents blindness in approximately 2,000 children each year, and was found to reduce under-five mortality in Nepal by about half between 1995 and 2000 • It is estimated that approximately 80–90% of children are covered by the vitamin A program in districts where the program is active • Overcame the country’s economic and geographic hurdles by harnessing local capacity and relying on new channels of public health delivery—bridging the once insurmountable gap between where the formal health ended and the needs of the poor began Study: Assess the effect of Nepal’s vitamin A supplementation program on child mortality : • “The effect of 100% community-level vitamin A coverage since the child’s birth, relative to no coverage, is to reduce the odds of dying at age 12–59 months by slightly more than half (OR ¼ 0.47, P ¼ 0.03)” • Underlines the importance of female community health volunteers who distribute vitamin A capsules

13. % AND NUMBER OF CHILDREN REACHED WITH VITAMIN A CAPSULES: COVERAGE IN NEPAL 1993-2002

14. Vitamin A Supplementation to Reduce Child Mortality in Nepal Cost and Cost-Effectiveness: • The cost of delivering two rounds of vitamin A per year was approximately $1.25 per child covered. • With an estimated cost of $327 –$397 per death averted and $11-12 per disability-adjusted life year (DALY) gained, NVAP is considered highly cost-effective. • The NVAP also was estimated to produce cost savings for the Ministry of Health by averting severe episodes of diarrhea disease and measles.

15. COMPARISON OF THE COST-EFFECTIVENESS OF PRIMARY CARE INTERVENTIONS

16. WEAKNESSES STRENGHTS • Many languages • Country’s economic and • geographic hurdles • Health System: Frequent changes • in staff at all levels & absenteeism • Distrusted of the Health system • Limited National Resources • Devoted to Health services • development • Poor utilization rate of public • health facilities • Strengthening international partnerships, health workers and health volunteers • Community field intervention • Ownership at the grassroots • Low cost low intervention • technologies • Involves the goverment participation and committment to action • Multisectoral approach INTERNAL

17. THREATS OPPORTUNITIES • Supply of capsules • Shortage of personnel and geographical maldistribution • Lack of monitoring and supervision • Political uncertainty • Food Market problem • Early adopters will propagate the message to the rest of the population • Builds community capacity through the training • Community participation, women selected by mothers to deliver the services: Empowerment of women EXTERNAL

18. Gender • 49,000 public health agents, who were able to reach 3.7 million children with vitamin A capsules twice per year • Thefemale community health volunteers function to some extent as multipurpose health workers, in addition to their primary duty of distributing vitamin A capsules. • In a culture, where women are not often given prominence in society, this program had the added effect of challenging deeply rooted gender biases, giving women responsibilities valued by their families and communities.

19. Why we have chosen this particular project: Evidence of great progress between 1995 and 2000: under- five mortality reduction by about half Contradiction: reduction of the overall child mortality, while increasing newborn mortality Long history of Nepal’s health sector investments that involved communications, behaviour change and community approaches Strengthened experience with community organization, participation and health agents in child health activities Flows of substantial investments in child health by USAID, United Nations, UNICEF, WHO, bilaterals and private foundations Importance of “lessons” for other countries from high-impact intervention in Nepal

20. What would we change in the project? • Implementation of further strategies to improve the sustainability of the project, in order to maintain the achieved results constant overtime FOR EXAMPLE: Importance of providing right tools to agricultural sector in order to make Nepal self-sufficient and free from vitamin A capsules. Strengthening the program of nutritional education to make Nepal independent of supplementation • Transfer of “lessons” from more mature programs to currently under-invested components of child survival in Nepal FOR EXAMPLE: More attention for newborn mortality

21. Transferring the program in another environment: • The FCHVs network was critical in the success of the program, but its absence may not be an impediment to develop in another country • Many countries have networks of health promoters that might serve a similar function • The complete absence of such a network will caused that the start-up phase of a program will be more expensive and take considerably longer • Countries may wish to invest in developing similar training approach of NTAG • Effective donor coordination contributed to the scaling-up and sustainability of some intervention • Good monitoring, based on routine data and on specialized systems, built awareness and belief in program success and helped with advocacy

22. INTERCONNECTIONS TO THE OTHER MDGs

23. Acronyms • AusAID Australian international aid agency • CIDA Canadian International Development Agency • DALY Disability-Adjusted Life Year • FCHV Female Community Health Volunteer • IMR Infant Mortality Rate • NTAG National Technical Assistance Group • NVAP National Vitamin A Program • NWO Nepal Women’s Organization • UNICEF United Nations • USAID The United States Agency for International Development • U5MR Under 5 Infant Mortality Rate • VAC Vitamin A Capsule • WHO World Health Organization

24. Bibliography • Basic Support for Institutionalizing Child Survival Project (BASICS II) for the United States Agency for International Development. (2004). “Nepal Child Survival Case Study: Technical Report”. Arlington, Virginia. • “Child Mortality- Statistics” Unicef, (2007) http://childinfo.org/areas/childmortality/ • Goal 4 – Reduce child Mortality, UNDP Nepal. http://www.undp.org.np/publication/html/mdg2005/07_MDG_NPL_Goal4.pdf • “Nepal Demographic and Health Survey” (2001) www.measuredhs.com/pubs/pdf/FR132/00FrontMatter.pdf • Reduce Child Mortality, MDG monitor. http://www.mdgmonitor.org/story.cfm?goal=4 • “Reducing Child mortality with vitamine A in Nepal” Center for global development. http://www.cgdev.org/section/initiatives/_active/millionssaved/studies/case_04 • “Report of the Sub-Committee on Nutrition as its Twenty Session”, UN Standing Committee on Nutrition, United Nations (1998). • Shyam Thapa, Minja Kim Choe and Robert D. Retherfor . (2005). “Effects of vitamin A supplementation on child mortality: Evidence from Nepal’s 2001 Demographic and Health Survey” Tropical Medicine and International Health volume 10 no 8 pp 782–789 • “The Millennium Development Goals Report”, (2007) United Nation http://mdgs.un.org/unsd/mdg/Resources/Static/Data/Stat%20Annex.pdf; • UNDP (2006) “Millennium Development Goals for Nepal- Needs Assessment” Government of Nepal, http://www.undp.org.np/publication/html/mdg%5FNAN/ • UNICEF. (2003) “Getting to the Roots: Mobilizing Community Volunteers to Combat Vitamin A Deficiency Disorders in Nepal” Third Draft. http://www.mostproject.org/CHVs/gettingattherootscomplete.pdf • “World Development Indicators Database” World Bank, 2007 http://devdata.worldbank.org/external/CPProfile.asp?PTYPE=CP&CCODE=NPL • WHO (2007) Country Health Profile. http://www.searo.who.int/LinkFiles/Nepal_nepal.pdf • UNICEF Video http://www.unicef.org/infobycountry/nepal_33515.html Images: • Devecchi S., Viaggio in Nepal. Nautilaus http://www.nautilaus.com/devecchi/devecchi33.htm • Millennium Development Goals. Nepal country profile. http://devdata.worldbank.org/idg/IDGProfile.asp?CCODE=NPL&CNAME=Nepal&SelectedCountry=NPL; • UNICEF (2003) http://www.mostproject.org/CHVs/gettingattherootscomplete.pdf • UNICEF (2006) http://www.unicef.org/infobycountry/nepal_33515.html • UNICEF (2006) http://www.childinfo.org/areas/vitamina/priority.php