. 2019 Feb 12;15(Suppl 1):e12721. doi: 10.1111/mcn.12721

Table 4.

Identified challenges and recommendations for strengthening integration of micronutrient interventions in primary healthcare services

Micronutrient interventions	Challenges	Recommendations	Justification
Vitamin A supplementation	• Low demand for VAS through routine child health services • Missed opportunities for VAS in outreach immunization services • Top‐bottom supply chain leading to localized stock‐outs • Vertical reporting of VAS that is not inclusive of all delivery platforms • Lack of up to date nationally representative vitamin A deficiency prevalence data	• Operationalize the communication plan to strengthen routine vitamin A and deworming services to generate demand • Improve community involvement to map populations with unequal access to health facilities and adequately plan vitamin A supplements to serve that population, as part of RED/REC, to improve coverage • Improve forecasting and programme monitoring through the use of sub‐national coefficients and microplanning to better estimate the target population • Improve supply chain management to enable facility health workers and CHWs to request the amount of vitamin A capsules needed to serve the population in their catchment areas, rather than being passive receivers • Roll out the use of the new child health monitoring tools to eliminate vertical reporting of VAS and improve completeness • Pursue inclusion of CHW VAS data in the national DHIS2 platform • Assess the current prevalence of VAS to make informed decision‐making • Make opportunist use of future immunization campaigns as catch‐up/acceleration of routine supplementation of vitamin A based on the last dose received as registered on the child heath card instead of mass supplementation	These actions will address the factors known to limit VAS coverage in integrated routine child health services, as part of the operationalization of the guide to strengthen routine vitamin A supplementation and deworming. Since the last nationally representative vitamin A deficiency survey was conducted in 2002, the MOH should plan to conduct another prevalence study within the next decade to make an informed decision on the continuation of routine vitamin A supplementation, in the context of mandatory industrial food fortification of sugar and oil with vitamin A since 2016 (Government of the Republic of Mozambique, 2016), and the increased availability and acceptance of OFSP and other products made with OFSP.a
Point‐of‐use fortification with MNP	• Low interest in continued and improved implementation of point‐of‐use fortification with MNP as a strategy to reduce iron‐deficiency anaemia in children • Lack of focus on the integration of MNP and malaria control measures • Lack of regular assessment of the formulation of MNP used	• Finalize and approve the MNP strategy taking into account lessons learned from the implementation to date (to be inserted as a priority in the MOH nutrition socio‐economic plan for 2019) • Revitalize the MOH MNP task force to address the core issues affecting the feasibility and sustainability of MNPs in the country, particularly regarding procurement and supply chain, legal framework around marketing of MNP, SBCC strategy on MNP, and integration with malaria control strategies. • Regularly assess the formulation of MNP used to permit adjustment in relation to other interventions implemented in the country, to prevent the risk of inadequate and high intakes of specific micronutrients, for example, vitamin A, given mandatory fortification of sugar and oil with vitamin A since October 2016	There are unaddressed issues pertaining to MNP procurement and supply chain, the legal framework around marketing of MNP, the need for an SBCC strategy on MNP, the integration of MNP promotion, and malaria control strategies WHO recommends regular assessment of the risk of high intakes of vitamin A considering complementary vitamin A deficiency reduction interventions implemented in the national context (WHO, 2016).
Dietary diversity promotion	• Lack of coordinated and harmonized cross‐sectoral efforts. • No information sharing among governmental sectors and/or partners implementing food‐based approaches to reduce micronutrient deficiencies, for example, agriculture with biofortification,b industry and commerce with industrial food fortification,c and health with supplementation and point‐of‐use fortification	• Develop a comprehensive national strategy on food‐based strategies to reduce malnutrition in Mozambique, for improved coordination and harmony of cross‐sectoral efforts	Food‐based approaches have the ability to produce the most sustainable improvements in micronutrient status, yet they have been implemented in silos, with no information sharing among governmental sectors and/or partners. Coordinated and harmonized cross‐sectoral efforts are required for sustainable improvements in micronutrient status

Micronutrient interventions

Challenges

Recommendations

Justification

Vitamin A supplementation

• Low demand for VAS through routine child health services

• Missed opportunities for VAS in outreach immunization services

• Top‐bottom supply chain leading to localized stock‐outs

• Vertical reporting of VAS that is not inclusive of all delivery platforms

• Lack of up to date nationally representative vitamin A deficiency prevalence data

• Operationalize the communication plan to strengthen routine vitamin A and deworming services to generate demand

• Improve community involvement to map populations with unequal access to health facilities and adequately plan vitamin A supplements to serve that population, as part of RED/REC, to improve coverage

• Improve forecasting and programme monitoring through the use of sub‐national coefficients and microplanning to better estimate the target population

• Improve supply chain management to enable facility health workers and CHWs to request the amount of vitamin A capsules needed to serve the population in their catchment areas, rather than being passive receivers

• Roll out the use of the new child health monitoring tools to eliminate vertical reporting of VAS and improve completeness

• Pursue inclusion of CHW VAS data in the national DHIS2 platform

• Assess the current prevalence of VAS to make informed decision‐making

• Make opportunist use of future immunization campaigns as catch‐up/acceleration of routine supplementation of vitamin A based on the last dose received as registered on the child heath card instead of mass supplementation

These actions will address the factors known to limit VAS coverage in integrated routine child health services, as part of the operationalization of the guide to strengthen routine vitamin A supplementation and deworming.

Since the last nationally representative vitamin A deficiency survey was conducted in 2002, the MOH should plan to conduct another prevalence study within the next decade to make an informed decision on the continuation of routine vitamin A supplementation, in the context of mandatory industrial food fortification of sugar and oil with vitamin A since 2016 (Government of the Republic of Mozambique, 2016), and the increased availability and acceptance of OFSP and other products made with OFSP.a

Point‐of‐use fortification with MNP

• Low interest in continued and improved implementation of point‐of‐use fortification with MNP as a strategy to reduce iron‐deficiency anaemia in children

• Lack of focus on the integration of MNP and malaria control measures

• Lack of regular assessment of the formulation of MNP used

• Finalize and approve the MNP strategy taking into account lessons learned from the implementation to date (to be inserted as a priority in the MOH nutrition socio‐economic plan for 2019)

• Revitalize the MOH MNP task force to address the core issues affecting the feasibility and sustainability of MNPs in the country, particularly regarding procurement and supply chain, legal framework around marketing of MNP, SBCC strategy on MNP, and integration with malaria control strategies.

• Regularly assess the formulation of MNP used to permit adjustment in relation to other interventions implemented in the country, to prevent the risk of inadequate and high intakes of specific micronutrients, for example, vitamin A, given mandatory fortification of sugar and oil with vitamin A since October 2016

There are unaddressed issues pertaining to MNP procurement and supply chain, the legal framework around marketing of MNP, the need for an SBCC strategy on MNP, the integration of MNP promotion, and malaria control strategies

WHO recommends regular assessment of the risk of high intakes of vitamin A considering complementary vitamin A deficiency reduction interventions implemented in the national context (WHO, 2016).

Dietary diversity promotion

• Lack of coordinated and harmonized cross‐sectoral efforts.

• No information sharing among governmental sectors and/or partners implementing food‐based approaches to reduce micronutrient deficiencies, for example, agriculture with biofortification,b industry and commerce with industrial food fortification,c and health with supplementation and point‐of‐use fortification

• Develop a comprehensive national strategy on food‐based strategies to reduce malnutrition in Mozambique, for improved coordination and harmony of cross‐sectoral efforts

Food‐based approaches have the ability to produce the most sustainable improvements in micronutrient status, yet they have been implemented in silos, with no information sharing among governmental sectors and/or partners. Coordinated and harmonized cross‐sectoral efforts are required for sustainable improvements in micronutrient status

Note. CHWs: community health workers; DHIS2: District Health Information System; MNP: micronutrient powder; MOH: Ministry of Health; OFSP: orange‐fleshed sweet potato; RED/REC: reaching every district/reaching every child; VAS: vitamin A supplementation; WHO: World Health Organization.

In 2015 alone, OFSP accounted for a third (32%) of the sweet potato production in Mozambique (Source: Ministry of Agriculture and Food Security, 2016).

OFSP is highly acceptable to Mozambicans, and trials of OFSP production and consumption have been shown to dramatically increase vitamin A intake (from 2‐ to 8.3‐fold) and reduce vitamin A deficiency among intervention children (Source: Jenkins, Byker Shanks, & Houghtaling, 2015).

Since October 2016, it is mandatory that the following foods are fortified: wheat flour fortified with iron, demerged maize fortified with iron, edible vegetable oils fortified with vitamin A, and sugar fortified with vitamin A. Fortification of salt with iodine has been mandatory since the year 2000 (Source: Government of the Republic of Mozambique, 2016).