Home > Full Report and Chapter Summaries > 4. Investments in Human Capital

4. INVESTMENTS IN HUMAN CAPITAL

Delivering vitamins and minerals to large populations involves commitment, coordination and cooperation - all held together by strong and durable partnerships. Key partners in micronutrient interventions include national governments, donors, aid agencies, foundations, industry, community leaders, and the agricultural sector.

Vitamin A

Vitamin A supplementation is one of the most effective large-scale child survival interventions. Two annual high-dose supplements are all that is required to provide the recommended amount of vitamin A to a child.

In 2007, it was estimated that 62 % of children under the age of five in developing countries received two high-dose vitamin A supplements. However, around the world approximately 190 million children remain affected by vitamin A deficiency.

Priorities actions include the need to:

• Scale up the delivery of integrated package of health services, including twice yearly vitamin A supplementation for children aged between 6 months and five years, to achieve at least 80% coverage on a recurrent basis.
• Target the hard-to-reach through complementary strategies, such as special outreach programmes, to reach the final 20% who have not been reached through regular programmes.
• Improve programme sustainability by mobilizing resources in national budgets to cover costs pertaining to vitamin A supply and local distribution.
• Establish dedicated delivery strategies, monitoring of programmes, and tracking of progress.

Salt Iodization

Salt is consumed throughout the world in small, fairly consistent amounts on a daily basis. Because of this, it is an ideal vehicle for fortification with micronutrients. In most countries, potassium iodate is added to salt after it is refined and dried and before it is packed. Even very small-scale iodization at the village level is possible with tried and tested processes and in some countries, small processers are the ones producing the majority of the salt.

Between 1993 and 2007, the number of countries in which iodine deficiency disorders were a public health concern reduced by more than half - from 110 countries to 47. Despite this progress, many countries are lagging far behind. In 12 countries, less than 20% of the population is consuming adequately iodized salt.

Priorities actions include the need to:

• Enact mandatory legislation and ensure adequate resources are made available to enforce it.
• Build financial sustainability to transition from a donor-supported to a market-supported supply of iodate.
• Undertake strategic advocacy and communication efforts through media, health systems, and schools.
• Strengthen population-monitoring systems so that programme adjustments can be made as habits and diets change over time.
• Create incentives for processors to iodize their salt.

Flour Fortification

For more than 60 years, flour fortification has proven effective in the reduction of vitamin and mineral deficiencies. Flour fortification provides a platform to increase folic acid, iron, zinc, and other B vitamins in the diet of the population. In general, flour fortification is technically simple, requiring only minor modifications in most the modern flourmills.

Priorities actions include the need to:

• Set and monitor national standards for flour fortification and ensure standards are enforceable, so that all millers have equal financial obligations.
• Identify and train fortification champions from both the public and the private sectors to build on success to date and help rapidly expand fortification efforts.
• Launch communication and public education initiatives to create a market demand for products and support for government investment.

Multiple Micronutrients Solutions for Children

Home-based multiple micronutrient supplements developed to date have primarily taken the form of powders to be added to food just before it is eaten. They typically come in small packets, each with adequate powder for one serving. Current formulations for in-home use include a range of vitamins and minerals including iron, vitamin A, folic acid, zinc and sometimes vitamin C.

Thus far, large-scale distribution has been limited to a small number of countries. However, early results show great promise. In 2007, the government of Bolivia became the first to provide free public distribution of multiple micronutrient powders on a national scale and reached approximately 750,000 young children.

Priorities actions include the need to:

• Scale up availability of multiple micronutrient supplements for in-home use, such as Sprinkles, in non-malaria endemic regions.
• Direct research efforts to find safe and cost-effective ways to improve iron intake by young children in malarial areas.

 Supplements for Women of Child-bearing Age

Since micronutrient intake is critical from the point of conception, it is important to reach not just pregnant women with multiple micronutrient supplements, but all women of child-bearing age.

Iron and folic acid are the focus of most current supplementation programmes. This is due both to the particularly harmful effects of anaemia and folate deficiency for babies and mothers, and to increasing evidence of efficacy of these supplementation programmes. Many supplementation programmes are reaching women through antenatal clinics. Others are achieving success by means of community volunteers. In some countries, outreach is taking place through community organizations, as well as businesses that employ great numbers of women.

Priorities actions include the need to:

• Expand and scale-up iron and folic acid supplementation for all women of child-bearing age. 
• Bring increased focus on improving adherence rates, through community outreach, counselling, and related efforts.
• Explore the feasibility of providing women with multiple vitamin and mineral supplements. 

Zinc Supplementation for Diarrhoea Management

The use of zinc supplements, in addition to oral rehydration, is a relatively new and extremely powerful method for reducing diarrhoeal. By quickly rehydrating the child whose body rapidly loses dangerous amounts of fluid during a diarrhoeal episode, death from diarrhoea can be averted.

Priorities actions include the need to:

• Incorporate zinc supplementation into national diarrhoea management policy.
• Ensure zinc supply.
• Identify public and private delivery strategies.
• Create demand through social marketing campaigns.
• Provide adequate financing for start-up.

Food-based Approaches

Biofortification: Biofortification refers to the use of traditional crop breeding practices and/or modern biotechnology to produce micronutrient-dense staple crops. Orange-fleshed sweet potato is one of the crops receiving the attention of biofortification programmes, primarily in Africa and Asia. Priorities for action include the need to increase investments in biotechnology research to accelerate development and testing of biofortified crops and to ensure micronutrient content. Promoting awareness and adoption of new biofortified crops to farmers will also be important.

Behaviour-centred nutrition education: Nutrition education and the use of local foods to improve access to and consumption of micronutrients, was ranked highly by the Copenhagen Consensus. In remote, resource-poor environments where fortified products and access to health delivery systems is poor, sometimes it is the only option available to under-nourished and vitamin deficient populations.  Promotion of leafy green vegetables, and location- specific foods, such as baobab seeds, can be a useful resource where communities far from markets must rely on their own resources to enhance micronutrient consumption. Behaviour-centred programs that are informed by formative research on local foods, local feeding behaviours and practices, and barriers to optimal feeding/food choices can be both effective and sustainable.

Priorities for action include the need to conduct further research into best practices from community based programs in order to document successful nutrition education approaches and operational solutions that can be replicated and supported by existing local institutions. Further, micronutrient interventions should be integrated with related health, nutrition and food security programs. Finally, the provision of regionally based technical assistance to ensure quality progamme delivery will also be important.