Global Alliance for Improved Nutrition
Date/Timeframe and location
January 2016 to June 2017 – 3 Districts of Sofala Province, Mozambique
Main responsible entity
Mozambique is one of the poorest countries in the world where one third of the population is chronically food-insecure, and the average life expectancy is 50. Nearly 30% of the population has a staple-based diet with limited access to a diversity of foods that are able to provide a full range of nutrients, including micronutrients, needed for optimal health, and physical and mental development. The prevalence of vitamin A and iron deficiencies in children under five are also very high, at 69% and 74% respectively; 1 in every 2 children under five do not achieve their potential physical, cognitive or mental and development. Less than a third of children consume more than four food groups a day, with only 13% of children 6-23 months being fed according to Infant and Young Children Feeding (IYCF) practices.
Malnutrition, including micronutrient deficiencies is a major impediment to socioeconomic development that contributes to a vicious cycle of underdevelopment and has long-ranging effects on health, learning ability, and productivity. It also leads to high social and public costs, reduced work capacity in populations due to high rates of illness and disability, and tragic loss of human potential.
Key characteristics of the food system(s) considered
The Cost of the Diet Study conducted in different regions of Mozambique (WFP 2010) showed that 80% of the households could not cover the minimum cost of a (nutritious) diet. Providing nutrient rich complementary foods to children 6-23 months is challenging for low income households who do not have access to micronutrient rich food, both in terms of availability and affordability. The study also showed that by distributing free sachets of micronutrient powders, containing 15 essential vitamins and minerals to be mixed into the food of children 6-24 months, it would be possible to make the diet of the child more affordable (i.e. reduce the minimum cost of the diet of the child by 68%).
Given iron-deficiency anemia is a serious public health concern for children under 5 in Mozambique, the Ministry of Health (MISAU) decided to adopt home fortification with micronutrient powders as a preventative measure.
Projects in Mozambique that provide free distribution of MNPs are only available to around one sixth of the population, are hard to sustain in the long run, and the costs of extending schemes nationally exceeds available budgets. While MNPs are seen as an effective solution to improve micronutrient intake, distributing them for free through the health system alone is seen as a burden on the health providers in terms of managing storage and distribution of a product which is time consuming and costly.
Key characteristics of the investment made
The project set out to test a hybrid MNP distribution model with two elements – (a) using vouchers redeemed via commercial retail outlets to handle distribution and reduce pressure on the health system. This opens up the possibility of subsidized and targeted distribution; and (b) explore the development of building a market for commercial sales of MNPs. It was implemented the Sofala province includes the delivery of vouchers to caregivers of children 6-23 months through the public health system, both in health facilities (through either health facility staff or dedicated promoters) and communities (through community activists). Each voucher – which can either be a paper or an electronic (on-demand voucher requested through short messaging service (SMS)) – allows caregivers redeem 3 boxes of 20 MNP sachets at small retail outlets that sell fast moving goods, registered with PSI as “Troca Aki”. These outlets are registered through PSI’s electronic data platform managed called “Movercado” which provides real-time tracking data of which vouchers are redeemed by caregivers.
This mechanism was selected for this project such that the voucher system could alleviate pressure on the government supply chain system for health supplies and medicines delivered directly through MISAU health centers, and to promote the market-based channel and decrease the burden on the public sector, which does not have funds to provide MNPs for the entire country.
Key actors and stakeholders involved (including through south-south/triangular exchanges, if any)
GAIN was responsible for coordinating and overseeing the overall project design and implementation. GAIN partnered with Population Services International (PSI), Save the Children (SCI) and the District Health Authorities to conduct the implementation. GAIN also partnered with the MISAU and the Provincial Health Directorate of Sofala Province for strategic alignment and direction with national policies and priorities
Key changes (intended and unintended) as a result of the investment/s
The intended outcome of the project would be to improve the accessibility (availability and affordability) of MNPs for caregivers with children 6-23 months as well as their knowledge of optimal infant and young child feeding practices. The intention behind this would be improved message coverage of MNPs (caregivers who had heard of MNPs), improved contact coverage (caregivers who have tried feeding MNPs to their child) and improved effective use (continuous use of MNPs according to dosage recommendations) in order to have an impact on nutritional status.
Through the project 2,000,000 sachets of MNPs were distributed to caregivers in a period of 15 months in 3 districts. Preliminary results from an evaluation indicate that the majority of caregivers (>60%) have heard about the scheme, while 35% have used MNPs.
- The initial project design intended for MNPs to be sold using vouchers through the “troca aki” posts. However, due to a change in policy set by MISAU requiring MNPs to be distributed free to children 6-24 months the project model had to be adapted. Thus the project concentrated on testing distribution via non health service infrastructure
- MNPs are currently classified as a medicine in Mozambique, which meant it was not possible to conduct social marketing activities to create demand for the product, which was necessary for a new product category and behaviour.
- All interpersonal communication material and radio spots on the general product category of MNPs underwent thorough reviews and discussion by stakeholders, causing some delay in implementation.
- Access to MNPs for caregivers was dependent on the supply through Troca Akis, however many of them experienced stock outs due to slow demand providing a disincentive for Troca Aki owners to re-stock.
- Community reach of caregivers was dependent on the community volunteer cadre (activistas), however the dropout rate of activistas was higher than 50%, and during the rainy season, most active activistas would be working in their fields;
- Overall the movercado platform worked very well in terms of reporting number of doses of MNPs distributed. Unfortunately the Electronic voucher was used infrequently because most of the caregivers did not own mobile phone. This meant that the project had to rely mainly on paper vouchers which made the process for data collection more cumbersome and expensive;
- The low use of the electronic voucher also meant that the monitoring of paper voucher distribution to caregivers was dependent on registry books filled in by activistas and at the health centers. This led to many problems in terms of data quality and reporting
- Use of the commercial platform (channels) providing MNPs can increase the reach of the product, and provides an opportunity to cover costs for future sustainability, and encourages more continuous use from the perspective of the consumer
- Social marketing is crucial for new product category like MNPs to build the trust of the “consumer” and increase demand for the product. The use of mass media and social media can reinforce face-to face communication such as counselling at the health center and in the communities – this should be opted for in future programs;
- Relying on registry books managed by the National Health System to monitor any intervention program should be avoided as it is not reliable and there can be serious issues with data quality. Instead, using a platform such movercado to monitor any intervention program is extremely useful and efficient at generating real-time, accurate data
- To move towards the use of the Movercado type of system, and overcome the inefficiencies of using a paper voucher, more thought/analysis has to be given on how to rely on electronic vouchers to register any transactions;
- Community activists have the potential to reach many more beneficiaries and the issue of lack of motivation and high dropout rates could perhaps be overcome if a proportion of the margin generated from the sale of the product is reverted to them as an incentive to perform well as part of the program.
- The results are feeding directly into a policy review process of the national strategy on MNPs to make it more sustainable and MNPs more widely available, which is being led by the Minister of Health.
Mr. Hans Brand