The Role of Donors in Catalyzing Scale-up of Multiple Micronutrient Supplements: A perspective from the Eleanor Crook Foundation

The Role of Donors in Catalyzing Scale-up of Multiple Micronutrient Supplements

A perspective from the Eleanor Crook Foundation

Nicki Connell

Eleanor Crook Foundation, San Marcos, TX, USA

Key messages

∙ Given the high potential of multiple micronutrient supplements (MMS) to improve maternal and child health, the Eleanor Crook Foundation (ECF) has pledged

US$1 million towards advocacy and implementation research activities to effectively implement and scale up

MMS programs among pregnant women. This pledge was announced through the Healthy Mothers, Healthy

Babies Accelerator as part of the Bill & Melinda Gates

Foundation’s 2019 Goalkeepers event. ∙ Three critical factors will determine the success of scaling MMS: a reliable supply of MMS, successful sustainable delivery platforms and demand generation among pregnant women in low- and middle-income country (LMIC) settings. Underpinning all of these factors is policy change at the global and national level, and prioritization of MMS by policymakers. ∙ ECF intends to strategically invest in three main areas to support MMS scaling: (1) research to improve the implementation of MMS delivery at scale in key East

African countries with significant governmental interest; (2) research focused on generating demand for MMS through creative solutions; and (3) country-level advocacy to ensure prioritization of MMS delivery in national guidelines as the antenatal standard of care.

Mainstreaming MMS into ECF’s long-range strategy

MMS for pregnant women, which contain 15 essential vitamins and minerals, have been shown to be safe and highly effective in reducing child mortality at 6 months of age by up to 29 percent, reducing low birth weight by up to 19 percent and reducing infants born small for gestational age by up to 8 percent, particularly for anemic mothers.1,2 In high-income countries, doctors have long recommended that mothers take MMS during pregnancy. In LMICs, however, where the prevalence of maternal anemia and risk of child mortality is high, the World Health Organization (WHO) recommends that pregnant women be given a supplement containing only two nutrients, iron and folic acid (IFA).3 This double standard for expectant mothers in high-income versus low- and middle-income countries has troubling ethical implications but has long been justified by the significant additional cost of producing MMS in place of IFA. While challenges with delivery and demand remain, most experts agree it is time for LMICs to start shifting from IFA to MMS.2,4

“Most experts agree it is time for low- and middle-income countries to start shifting from IFA to MMS”

Thanks to recent efforts by businessman-philanthropist Spencer Kirk of Kirk Humanitarian, working in collaboration with Vitamin Angels and Contract Pharmacal Corporation, MMS is now being produced at scale and at cost parity with IFA.5 However, a key challenge remains: adherence to IFA supplementation by pregnant women in LMICs is low.6 Without addressing how IFA is delivered, MMS is likely to suffer from low adherence as well. To tackle this low adherence, global nutrition donors and experts must engage with, and encourage creative thinking from, marketing professionals and those working in behavioral economics. Novel approaches, such as human-centered design focused on consumer insights, could help increase demand for, and adherence to, MMS.

As a US-based philanthropy working to scale up more cost-effective solutions to fight global malnutrition, ECF has committed a minimum of US$1 million in new funding for implementation research and advocacy through the Healthy Mothers, Healthy Babies Accelerator as part of the Bill & Melinda Gates Foundation Goalkeepers 2019.7 This investment will help LMICs generate the additional evidence and solutions they need to make the switch from IFA to MMS, and to deliver it at scale.

Based on the deeply held conviction that we can, and should, end global malnutrition, the Foundation makes catalytic invest-

arah Fretwell UG18 S / © Vitamin Angels

While challenges with delivery and demand remain, most experts agree it is time for LMICs to start shifting from IFA to MMS

ments in both on-the-ground research that shows how to end malnutrition and advocacy that can make the case for why. Over the past year, ECF has established its first long-range strategy, setting the Foundation’s direction, including its investment strategy, through to 2025. Within this strategy, the Foundation has committed to fund implementation research to identify efficient and effective approaches to scaling promising nutrition interventions, filling what has been identified as a neglected gap in the funding landscape between demonstrating the efficacy of new approaches or interventions and scaling of effective interventions.8

“ECF has committed to fund implementation research to identify efficient and effective approaches to scaling promising nutrition interventions”

In addition, the Foundation’s strategy is anchored in a commitment that all future ECF research investments will be made following two specific principles. First, funding will be directed towards promoting the adoption and implementation of evidence-based, cost-effective interventions that have a high likelihood of being scalable and sustainable. Second, ECF investments will capitalize on opportunities to bridge or connect larger initiatives, accelerate ongoing processes and partner with scale implementers. Through strategic analysis, it became apparent that a few key interventions not only had evidence behind their potential impact, but also had a great deal of momentum, facilitating an enabling environment for scaling. Given the high impact of intervening as early as possible (i.e., during pregnancy) on child outcomes, MMS was particularly primed for further investment at this critical time.

What does success look like?

Three key factors will determine the success of scaling MMS: a reliable supply of MMS, successful sustainable delivery platforms and generating demand for MMS among pregnant women living in LMIC settings. Underpinning all these factors is advocacy around policy change and prioritization of MMS by policymakers and budget holders. Given the work of Kirk Humanitarian and others in ensuring the supply of an affordable MMS product,5 ECF intends to invest to improve the efficiency and effectiveness of MMS delivery at scale in key East African countries where there is significant governmental interest in scaling up MMS. This may take the form of implementation research or pilot activities to identify and test delivery platforms and mechanisms. It will also involve country-level advocacy activities to ensure prioritization

of MMS delivery in national guidelines as the antenatal standard of care, and may include global-level advocacy with WHO and other key stakeholders to update the relevant global guidelines on the use of MMS. ECF will also invest to generate demand for MMS among pregnant women once a delivery system and supply is established. This will include identifying the enablers and barriers in the countries of focus in support of increased uptake of MMS, and also researching the most successful ways to increase demand for MMS among pregnant women, through a strong focus on consumer insights, social marketing and social behavior change communication.

“ECF intends to invest to improve the efficiency and effectiveness of MMS delivery at scale in key East African countries”

ECF is one of several donors who are prioritizing the scaleup of MMS as part of the Healthy Mothers, Healthy Babies Accelerator, for which the Micronutrient Forum is a tentpole holder, and which has leveraged nearly US$50 million in financial and in-kind contributions.7 This Accelerator will reach over 17.5 million pregnant women and their newborns over the next 3 years. This demonstrates a commitment by key stakeholders, including governments, to prioritize this urgently needed intervention to promote the health and wellbeing of both pregnant women and their newborns. Success will be measured by the level of MMS coverage and adherence achieved, and the impact, in terms of lives saved, of the effective use of MMS. Collectively, we have a singular opportunity to improve pregnancy outcomes now.

References

1 Bourassa MW, Osendarp SJM, Adu-Afarwuah S, Ahmed S, Ajello

C, Bergeron G, et al. Review of the evidence regarding the use of antenatal multiple micronutrient supplementation in low- and middle-income countries. Ann N Y Acad Sci. 2019;1444(1):6–21. 2 Black R, Dewey K. Benefits of supplementation with multiple micronutrients in pregnancy. Ann N Y Acad Sci. 2019;1444(1):3–5. 3 World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. Geneva: WHO; 2016. 4 Keats EC, Haider BA, Tam E, Bhutta ZA. Multiple‐micronutrient supplementation for women during pregnancy. Cochrane Database

Syst Rev. 2019;3:CD004905. 5 Kirk Humanitarian. Version current 31 October 2019. Internet: https://kirkhumanitarian.org/ (accessed 31 October 2019). 6 Garcia-Casal MN, Estevez D, De-Regil LM. Multiple micronutrient supplements in pregnancy: Implementation considerations for integration as part of quality services in routine antenatal care.

Objectives, results, and conclusions of the meeting. Matern Child Nutr. 2018;14 (Suppl 5):e12704. 7 Micronutrient Forum Goalkeepers Accelerator. Version current 31

October 2019. Internet: https://micronutrientforum.org/goalkeepers/ (accessed 31 October 2019). 8 Eleanor Crook Foundation. Grantee Guidance Series: Theory of

Sustainability and Theory of Scale. Washington DC. Internet: https://static1.squarespace.com/static/551db914e4b0998e40bbd10d/t/5bc518a971c10b9813d5c1e6/1539643577159/ecf-granteeguidance_Oct2018.pdf (accessed 31 October 2019).

Correspondence: Nicki Connell MBE, MSc, BSc, Technical Director, Eleanor Crook Foundation, 227 North Mitchell Street, San Marcos, TX 78666, USA Email: nicki@eleanorcrookfoundation.org