CWS MNP PROGRAM

LESSONS OF A MICRONUTRIENT
POWDERS SUPPLEMENTATION
PROGRAM AND FORMATIVE STUDY
HOME FORTIFICATION WORKSHOP
JAKARTA 8 MAY 2014

Overview
Background
CWS Indonesia MNP Program
(implementation strategy and result)
CWS HKI UNICEF MNP Formative
Research in Timor Leste
Lesson Learnt

 Founded in 1946
Mission: end hunger, promote peace and justice
Supported by 37 member communions
Program areas: food, water, assisting refugees
and the vulnerable
Active in more than 30 countries
cwsglobal.org

Background
2003 CWS nutrition rehabilitation program
micronutrient supplementation, nutrition
promotion and education in Indonesia.
2003 2006 in collaboration with HKI brought
VitalitaTM, MNPs tailored to Indonesias context
2007 2008 CWS delivered MNPs to around
4,700 children in post-tsunami areas of Sumatra
2008-2009, CWS delivered VitalitaTM to around
5,300 children in three districts with support from
H.J. Heinz Foundation and Heinz ABC Indonesia.

Background
Initial results of earliest MNP work
positive impact on children nutritional
status
significant cuts in anemia (based on
hemoglobin measurement) in TTS and
Nias District.
Anemia cut by 15 percent in TTS, 11
percent in Nias

Background
2011: CWS proposed to H.J. Heinz
Foundation to continue supporting the
VitalitaTM Program as we have seen the
positive
Beside two previous areas TTS (East
Nusa Tenggara Province and Nias (North
Sumatera Province), CWS proposed new
intervention area in Central Sulawesi
Province

Background
Chronic malnutrition (36.1%) and acute
malnutrition (14.8%) amongst under-5
children in Central Sulawesi
(National Basic Health Research 2010)

Chronic malnutrition (29.5%) and acute

malnutrition (19%) in Poso District
(National Basic Health Research 2007)

CWS INDONESIA - VitalitaTM

PROGRAM

The goal
to improve nutritional
status of children
under-5 years of age
through sustainable
community marketbased micronutrient
powder supplements

PROGRAM IMPLEMENTATION
STRATEGY

VitalitaTM Implementation Strategy

Program duration: March 2011 June 2012
(it was planned for 3 years 2011 2014)
Target group: children 6 59 months
Target area:
30 villages, 5 sub-districts, TTS District,East
Nusa Tenggara
32 villages, 3 sub-districts, Poso District, Central
Sulawesi Province
12 villages, 3 sub-district, Nias, North Sumatera

VitalitaTM Implementation Strategy

Composition

Amount

Vitamin A

400 g RE

Vitamin C

30 mg

Vitamin D

5.0 g

Vitamin E

5 mg a-TE

Vitamin B1

0.5 mg

Vitamin B2

0.5 mg

Vitamin B6

0.5 mg

Vitamin B12

0.9 g

Folic Acid

150 g

Niacin

6 mg

Iron

10 mg

Zinc

4.1 mg

Copper

0.56 mg

Iodine

90 g

Maltodextrin*

5.0 mg

VitalitaTM Composition

Heinz ABC donated the products

VitalitaTM Implementation Strategy

VitalitaTM distribution and consumption:
Delivered through government health facilities
and community integrated health posts
(Posyandu)
Caregivers received 90 sachets of VitalitaTM in
6 months.
Caregivers were advised to add the VitalitaTM
to their childrens meal everyday or every
other day whichever is most convenient

VitalitaTM Implementation Strategy

Social marketing for
VitalitaTM and health
nutrition promotion
Development of IEC
materials (flipchart,
brochure, flashcard and
Q&A cards)
Nutrition information session
Cooking class

VitalitaTM Implementation Strategy

Social marketing for VitalitaTM and health
nutrition promotion
Development of IEC materials (flipchart,
brochure, flashcard and Q&A cards)
Nutrition information session
Cooking class

Trainings for staff/ cadres/ health workers/

womens groups
Nutrition trainings for cadres and health workers
Livelihood trainings for mothers

VitalitaTM Implementation Strategy

Other supporting activities:
Deworming medications were given to
children greater than 23 months of age
when they came to clinics.
Home visit and counseling

VitalitaTM Implementation Strategy

VitalitaTM M&E strategy
Baseline survey (10 16 October 2011)
Cross sectional study
Sample size: 300 HHs with U5 children
Location: 3 sub-districts of intervention areas

Program monitoring
Conducted by CWS staff, midwives and cadres
Home visit for 10% of the total children
Data on: #VitalitaTM distributed, consumed,
perceived changes, perceived challenges

VitalitaTM Implementation Strategy

VitalitaTM M&E strategy
Feasibility study for market-based VitalitaTM
to gather in-depth information on the local
government agencies, parents and other
stakeholders perceptions on VitalitaTM
To determine the capacity of a potential marketbased VitalitaTM program
February March 2012
Qualitative study
Poso District and TTS District

VitalitaTM Implementation Strategy

VitalitaTM M&E strategy
Feasibility study for market-based VitalitaTM
27 in-depth interviews with mothers (13 in Poso and 14
in TTS)
2 in-depth interviews with nutritionist in District Health
Office
5 in-depth interviews with midwives in Puskesmas
5 in-depth interviews with PKK in sub district office
6 in-depth interviews with cadres
6 FGDs with mothers, one FGD conducted in each subdistrict in Poso and TTS. In total there were 45 FGD
participants. 6-9 mothers were involved in each FGD.

Data on acceptability, willingness to purchase,

potential distribution channels and capacity

RESULTS AND DISCUSSION

Results and Discussion

Program results
By the end of June 2012, a total of 934,905 Vitalita
sachets had been distributed to a total of 11,954
children under the age of five.
300,180 Vitalita sachets had been distributed to 3,329
children in Poso
529,995 sachets had been distributed to 7,394 children in
TTS
104,730 sachets to 1,231 children in Nias

About 70-80% of Vitalita was consumed by the

children (Poso 70.9%, TTS 86%, and Nias 73%) by
the end of June 2012.
On average children consume Vitalita every other day,
therefore while the program finished in June 2012, the
remainder of Vitalita sachets is still being distributed,
and consumed by children.

Results and Discussion

Program results
79.8% of children (N=3198) consumed at
least 60 sachets of VitalitaTM in 6 months.
Mothers fed their children food mixed with
VitalitaTM daily (46.8%) or every other day
(53.2%) (N=3050).

Results and Discussion

Program results
To support the social marketing and the
health & nutrition promotion

250 flipcharts
12,300 promotional brochures
1,000 food and nutrition flash cards
750 Q & A cards

They were produced and distributed to

Posyandu, cadres, midwives, mothers and
other stakeholders to support the information,
education and communication activities
(IEC).

Results and Discussion

Program results
A series of health and nutrition trainings
focusing on IYCF, were conducted for 496
health workers and cadres in 3 locations.
Livelihood trainings were conducted for
544 mothers focusing on art and craft
using plastic materials, like used VitalitaTM
sachets .

Results and Discussion

Mothers Report on Child Feeding

Behavior During MNP Supplementation
70

66,3
60,1

60

50

Better appetite
40

37,9

Less prone to illness

35,2

Active, cheerful
30

26,9

Lost appetite

26

24,3

Susceptible to illness
20

Weak, sluggish
9,4

10
3,9

2,7
0,3

0,4

1,7

0,9

1st monitoring month

(N=2775)

2nd monitoring month

(N=2826)

3rd monitoring month

(N=2646)

Results and Discussion

Mothers Perceives Challenges in

Feeding Food Mixed with MNP
90,0

80,0

76,9

70,0

60,0

Changes in food color

50,0

45,3

Changes in food taste

40,1

39,8

Changes in food smell

40,0

33,2

Difficulty in feeding the food

30,0

Others
20,0

16,1
12,0
8,9

10,0

3,9

5,6

1,7

3,3

8,8
2,3

2,2

0,0

1st Monitoring Month

(N=2827)

2nd Monitoring Month

(N=2416)

3rd Monitoring Month

(N=1832)

Results and Discussion

VitalitaTM Market-based Feasibility Study

Acceptability
Most mothers were aware about the importance
giving vitamin to children for their.
The concept of adding MNPs to ready-to-eat
meal was new in Poso but acceptable.
VitalitaTM acceptance was good with special note:
Improve the product, so it wont change the food color
and taste.
VitalitaTM in syrup or chewable table is preferable as it
is considered easier to feed to children related to the
first point

Results and Discussion

VitalitaTM Market-based Feasibility Study

Willingness to purchase
Mothers willing to buy VitalitaTM with price
range of Rp500 1000 (equal to 5 10 US
cents)
Daily or weekly purchasing was preferable
due to economic ability

Results and Discussion

VitalitaTM Market-based Feasibility Study

Potential distribution channel and its capacity
Mothers considered VitalitaTM as medication, so
they prefer that it is distributed through
government health facilities/workers and cadres.
These people are considered as the trusted
source of health information and easy to be
accessed.
Health workers and cadres considered that they
need more trainings in small business
management before implementing market-based
VitalitaTM

CWS-HKI-UNICEF MNP Formative

Research in Timor Leste

Objective:

To explore contextual factors that could

influence acceptance, delivery, and use of
micronutrient powders (MNP) in Aileu
District, Timor-Leste.

Methodology
Study area: 3 villages, Laulara Sub-district, Aileu
District
A qualitative study:
4 FGDs with mothers of children 6 23 months
56 IDI and Key Informant Interview (KII)

Mothers (n=18)
Fathers (n=14)
Grandmothers (n=14)
Health workers (n=8)
Catholic Catechists (n=2)

A 14-days usability trial (a short-term feeding of MNP

to 45 children) followed by home visit, interview the
mothers, and key stakeholders (at the end of the
usability trial)

Methodology
Study timeframe: Dec 2010 September
2011
FGDs and IDI: 28 March 8 April 2011
to understand the sociocultural factors that influence
breastfeeding and complementary feeding practices
to explore caregivers knowledge and perceptions
regarding anemia, iron and vitamin A
to assess if caretakers knew about or had ever used
MNP, whether they would like to use the product,
to elicit their preferences for the name, packaging
design, promotional messages, and distribution
channels of MNP

Methodology
The usability trail: 26 April 13 May 2011
to assess product acceptance, potential
difficulties, perceived health benefits, and side
effects of MNP
To assess family and community members
responses on the MNP supplementation whether
it should be continue or not.

The study reviewed and approved by the

Cabinet of Health Research and
Development the ethical review board of
MOH TL.

Methodology
Usability trial
14 days of MNP supplementation
45 children
Inclusion criteria

children of 6 23 months of age

Not severely wasted based on MUAC 115 mm
Did not suffer from fever
Had slept under a bednet in the 24 hours before the
trial
Had participated in SISCa (Servisu Integrado Saude
Comunitaria) at least once in the 3 months prior to the
study

Daily consumption

Methodology
Usability trial
Each child was provided with 14 sachets of MNP and
an insecticide-treated bednet.
Daily consumption
Prior to the usability trial, mothers/caregivers were
informed about the MNP composition and benefits,
how to tear and mix the MNP to the food, and as well
as an on-site demonstration on how to mix and feed
MNP to their children.
Same information were also provided to community
health volunteers, government health workers,
Catholic catechists, and head of villages
Home visit on day 1-3, day 7-9 and , and day 14-17

Methodology
Study materials:

FGD guideline
IDI set of question
MNP information sheet written in Tetun and Mambae
A short video demonstrating how to mix MNP with
food
Different MNP sachets (MixMe, Babyfer(Ghana),
SuppleForte (Canada and Israel), Vitalita(Indonesia),
Chispitas (Bolivia), Sprinkles plus (Heinzin India), and
others used in China, Haiti, Mongolia,and Nepal.
A chart of seven colors (green, red, blue, yellow,
orange, purple, and brown) with different color
gradation
MNP MixMe (DSM): 15 vitamins and minerals

MNP PRODUCT USED IN THE STUDY

Various MNP Packaging

Color Set with Different Gradation

Results

Results

Results

Results

Results

Results

Results
Preferred distribution channel:
SISca and or government health facilities

Forty four out of the 45 mothers who participated

in the usability trial said they would continue giving
MNPs to their children.
More than half of the mothers (69%) were willing
to buy MNPs for their children. The preferred price
range for each sachet of MNPs by these mothers
was 0.5 to 5 US cent. The remaining mothers said
they will not buy MNPs and preferred them to be
free because they do not have the funds to do so.

LESSONS LEARNT AND NEXT

STEP

Lessons Learned
and Next Steps
STRENGTH
Using Posyandu or SISCa (Servisu Integrado
Saude Comunitaria) for the distribution point helps
in reaching the children and increases the
attendance of monthly growth monitoring
Engagement of government health workers and
cadres is crucial for product acceptability. It is also
important for institutionalizing the program.
Intensive nutrition education, home visit and
counseling is crucial to increase the acceptance
and compliance
Tailored product packaging and name will increase
the acceptance too

Lessons Learned
and Next Steps
CHALLENGES
Product supply chain
Financial challenge for free distribution however it
is also a challenge to create market-based MNP in a
very poor community.
Simple, practical, inexpensive but accurate
micronutrients measurement tools to assess the
micronutrient deficiencies and program impact
Reaching out remote areas
Food insecure areas
Changes in food color and taste, in particular when it
is mixed with smaller amount of food.

Lessons Learned
and Next Steps
OPPORTUNITIES
At some extent, mothers are aware the
importance of micronutrients supplementation
i.e vitamin A
The needs and markets are high
We have a scientific proven product for home
fortification MNP
We have the momentum for SUN

Lessons Learned
and Next Steps
What we can do?
NGOs
Support the government MNP Program by
Enhance social marketing to create demands and
product acceptance.
Support outreach to the remote areas
Support the promotion of proper MIYC feeding and
care

Work on economic empowerment, in particular

for women
Support government on nutrition-sensitive
actions, i.e. nutrition-sensitive agriculture

Lessons Learned
and Next Steps
What we can do?
Private sector
ensures product/supply chain
provide expertise in product marketing
build capacity for small business management
use company CSR to invest in nutrition-specific
and /or nutrition-sensitive actions

Special thanks to
the Heinz Foundation
for their support!