1. AIMING FOR PROGRAM EXCELLENCE — HOME FORTIFICATION WEBINAR SERIES
Hello everyone and thank you very much for joining us today for the launch of the home fortification webinar series. My name is Jonathan Siekmann and I serve as the Secretariat of the Home Fortification Technical Advisory Group.
Moderated by Jonathan Siekmann, PhD
Technical Advisor, GAIN
Secretariat, Home Fortification Technical Advisory Group (HF-TAG)

2. Home Fortification Webinar Series
What: A series webinars organized by UNICEF, CDC, and HF-TAG to address the increasing demand for technical support and to continuously address knowledge capacity gaps in home fortification
Objectives:
Increase knowledge and capacity to design and implement effective home fortification programs.
Share country experiences and lessons learned with developing, implementing, and scaling up home fortification programs
Target audience:
The main audience for the webinars will be program implementers who are either planning or implementing home fortification programs.
Where: The HF-TAG site
Frequency: Bi-monthly
Today’s launch session is the first of a series of webinars organized jointly by UNICEF, the US Centers for Disease Control and Prevention, and the Home Fortification Technical Advisory Group. These webinars aim to address the increasing demand for technical support and to continuously address knowledge gaps in home fortification by increasing knowledge and capacity to design and implement effective home fortification programs and by sharing country experience and lessons learned.
The primary target audience for the webinars are program implementers who are planning or are presently implementing home fortification activities.
The webinars can be accessed through the HF-TAG website and the URL is listed on this slide. We plan to have these webinars every two months so please check the website for information on upcoming webinars.

3. Today’s webinar Global evidence and policies for home fortification
WHO guideline and HF-TAG complement each other in support to countries
Monitoring to improve program effectiveness
Speakers
Dr. Werner Schultink (UNICEF) 10 min
Dr. Martin Bloem (WFP) min
Dr. Juan Pablo Peña-Rosas (WHO) 10 min
Dr. Laurence Grummer-Strawn (CDC) 10 min
Today’s launch will highlight the global evidence and policies for home fortification and the the implementation of home fortification globally. Today’s webinar will also describe the existing WHO home fortification guideline and emphasize the complementary relationship with WHO policies and the HF-TAG in supporting countries to translate and adapt the WHO guideline in national settings. Finally, it will emphasize the importance of program monitoring to improve program implementation and effectiveness.
We are grateful to our speakers, listed here, for presenting at this launch webinar, and we look forward to your questions after all speakers have delivered their presentations. Please type your questions in the message box and we will consider them for the discussion period at the end.
I would now like to introduce our first speaker. Dr. Werner Schultink is Associate Director in the Programme Division of UNICEF in New York and Chief of Nutrition. In this position he provides guidance on UNICEF global nutrition policy and programming, and represents the organization on nutrition issues. Dr. Schultink, we welcome your presentation now.
[before second speaker]
Martin Bloem: I would now like to introduce our second speaker. Dr. Martin W. Bloem is Senior Nutrition Advisor and UNAIDS Global Coordinator at the United Nations World Food Programme, in Rome, Italy. He also participates in task forces convened by many organizations, including international non-governmental organizations. Dr. Bloem, we welcome your presentation now.
[before 3rd speaker]
Juan Pablo Peña-Rosas: Dr. Juan Pablo Peña-Rosas coordinates the Evidence and Programme Guidance, Department of Nutrition for Health and Development at the World Health Organization (WHO) in Geneva, Switzerland. He oversees the development of WHO evidence-informed guidelines for nutrition interventions, including home fortification. Dr. Peña-Rosas, we welcome your presentation now.
[before 4th speaker]
Laurence Grummer-Strawn: Dr. Laurence Grummer-Strawn is chief of the Nutrition Branch at the U.S. Centers for Disease Control and Prevention (CDC). He provides guidance on nutrition policy and programming both in the US and internationally and is a member of the Executive Committee of the HF-TAG.

4. Home Fortification Webinar Series Launch
Werner Schultink,
Chief, Nutrition Section, UNICEF
Headquarters, New York

5. Session Outline Overview of global nutrition situation UNICEF’s work
Home fortification technical resources to address increasing demand

6. The global picture: stunting prevalence
Recent estimates show that 162 million children are stunted (80% of these children live in just 14 countries). These 162 million children with stunted growth have compromised cognitive development and physical capabilities, making yet another generation less productive than they would otherwise be. It is not sufficient to only look at national average figures. Wide disparities within countries, and across income quintiles. And also highest in rural than in urban area in general
UNICEF Improving Child Nutrition Report 2013

7. The global picture: severe acute malnutrition
There are 17 million children are severely malnourished globally
UNICEF Improving Child Nutrition Report 2013

8. The global picture: “Hidden Hunger”
Iron
Folic acid
Iodine
Vitamin A
Zinc
The global picture: “Hidden Hunger”
Vitamin and mineral deficiencies account for over 50 million disability-adjusted life years (DALYs) lost globally (Murray et al, 2013)
Global estimates of anemia prevalence are 42% in pregnant women and 47% pre-school age children. (WHO, 2009)
Severe anemia kills more than 50,000 women a year during childbirth. (Micronutrient Initiative, 2014)
18 million babies are born mentally impaired due to iodine deficiency each year. (Micronutrient Initiative, 2014)
Deficiencies of vitamin A and zinc account for nearly 300,000 child deaths annually (Black et al., 2013)

9. Growing momentum to scale up nutrition
Scaling Up Nutrition (SUN) movement
Interest in nutrition increased dramatically
Investing in nutrition key development priority
Partnerships are more operational, enhanced complementarity
54 countries have committed to SUN
Scaling Up Nutrition (SUN)
Support to nationally driven action to scale up of nutrition interventions
Home fortification programs are important in the context of the SUN Initiative
Interest in nutrition increased dramatically
Stunting newly positioned
More evidence for action
Investing in nutrition key development priority
Nutrition high on agenda G8, UN, many governments
UN zero hunger challenge

10. UNICEF’s programmatic work in nutrition
UNICEF’s commitment to nutrition
Markedly improve nutrition for all children and women by creating an enabling environment that results in evidence-based, sustainable, multisectoral nutrition actions delivered at scale
Protect, promote and support appropriate feeding & adequate food
Reduce micronutrient deficiencies
Prevent and treat SAM
Improve nutritional care for those with infectious disease
Increase synergies with health, WASH, ECD and social protection
Promote strengthened linkages with agriculture
Promote linkages with health & education to prevent childhood obesity
programme actions
UNICEF
Adolescent girls
Women of RA
Children under 2 years
Children aged 2−5 years
Pregnant & lactating women
most disadvantaged)
(focusing on the
populations
Target
UNICEF’s programmatic direction in nutrition is guided by the Health and Nutrition Strategy 2006–2015
Nutrition is a new outcome area in UNICEF Strategic Plan,
-recognition of the global importance of addressing malnutrition
-momentum to leverage political support and funding for nutrition
UNICEF is supporting the scale up of priority nutrition interventions and home fortification using MNPs is one of the key intervention.
Home fortification, is a relatively new intervention with promising prospects in reducing micronutrient deficiencies among vulnerable groups. Therefore, implementation of home fortification interventions at scale and reaching the most vulnerable is critical.
Nutrition-specific interventions
Nutrition-sensitive approaches
Maternal nutrition (prevention of low birth weight)
Infant & young child feeding
Prevention and treatment of severe acute malnutrition
Micronutrient fortification and supplementation
Nutrition support for those with infectious diseases
Health, WASH, early childhood development, social protection, education, agriculture, poverty reduction

11. UNICEF’s operational approaches to improving nutrition programming for mothers and children
UNICEF’s commitment to nutrition
Markedly improve nutrition for all children and women by creating an enabling environment that results in evidence-based, sustainable, multisectoral nutrition actions delivered at scale
programme actions
UNICEF
Protect, promote and support appropriate feeding & adequate food
Reduce micronutrient deficiencies
Prevent and treat SAM
Improve nutritional care for those with infectious disease
Increase synergies with health, WASH, ECD and social protection
Promote strengthened linkages with agriculture
Promote linkages with health & education to prevent childhood obesity
Operational approach 1:
Perform a rights-based, equity-focused situation analysis for nutrition and its determinants to inform policy development and programme design.
Operational approach 2:
Build commitment, strengthen leadership and strengthen governance for improved nutrition.
Operational approach 3:
Support the scale-up of evidence-based, sustainable nutrition-specific interventions and nutrition-sensitive programming.
Operational approach 4:
Develop human, institutional and organizational capacity to implement contextually relevant nutrition programmes.
Operational approach 5:
Foster a community-centred approach that empowers communities with the knowledge and tools to address their own nutrition issues.
Operational approach 6:
Strengthen systems to ensure effective monitoring, evaluation and knowledge management for policy and programming for nutrition.
Notes: Green arrows illustrate that the operational approaches are interrelated.

12. Work in Home Fortification using MNPs
Partnership
Global/national policies and guidelines
Capacity: Workshops reaching 66 countries on design, implementation, scale up and monitoring of HF programs
Information: 2011 global assessment of HF. UNICEF to make it annual through NutriDash from 2013
Implementation of home fortification programs
Partnership: Partnership is key to UNICEF’s work. UNICEF has worked with partners ( CDC, WFP, WHO, GAIN and other HF-TAG partners) to shape strategic direction for home fortification programmes and enhance harmonization and coordination. At national and sub-national levels, working with partners to scale up implementation and strengthen monitoring systems.
Global policies/ guidelines - UNICEF provides support to development to policies/ technical guidelines to guide implementation that have been developed both at national and global level.
Capacity: Between 2009 and 2013, UNICEF and CDC and other HFTAG partners implemented home fortification workshops reaching stakeholders in 66 countries on design, implementation, scale up and monitoring of HF programs
Information: UNICEF and CDC commissioned the first global HF assessment in A follow-up assessment on HF using MNPs was made in 2013 through NutriDash and UNICEF will collect information on annual basis
Implementation of home fortification - UNICEF is supporting scale of home fortification programs using MNPs in over 40 countries .

13. Impressive scale-up 2011* 2013**
36 MNP interventions implemented in 22 countries
Planned interventions in 20 countries
4 countries were implementing at national scale
62 MNP interventions implemented in 42 countries
MNP interventions are planned in 19 countries
13 countries implementing at national scale
2011 – Home Fortification Global Assessment
UNICEF NutriDash
MNP interventions assessed are are supported by multiple partners
* Home Fortification Global Assessment 2011
**UNICEF NutriDash, 2014

14. With rapid scale up Increased technical needs
Variation in challenges depending on the level of implementation
Great opportunity for inter-country and inter-agency learning
Rapid scale up is impressive, but comes with challenges and opportunity. High technical needs like in monitoring and supply issue, countries are at different levels of implementation as observed from the questions from the field and through community of practice discussion.

15. Aiming for Program Excellence
Community of practice online opportunity for inter- country learning
MNP toolkit ( upcoming) consolidation various tools, best practices and examples on implantation of home fortification
Series of Home Fortification Webinars
Technical Resources to address the growing capacity needs
As a relatively new program, there is a tremendous need for technical support - countries need to learn fast and address bottlenecks to scaling up home fortification interventions. With relatively low costs, real time discussions and learning are required between countries and agencies to bottlenecks and scale up implementation.
Community of practice is an online opportunity for inter- country learning on home fortification created through UNICEF/PSI partnership. This has provided an exchange of information and learning between countries and agencies. People from 124 countries are using the community of practice!
MNP Toolkit consolidation various tools, best practices and examples can help countries implement their home fortification more effectively. This is being developed by UNICEF and CDC in partnership with HFTAG partners
Finally, series of home fortification webinars that are we are launching today

16. Timely opportunity to build capacity
Home fortification webinars are great and timely opportunity to enhance capacity of program implementers for program improvement
Webinars and resources are open to all program implementers
Today, as UNICEF, CDC, WFP, WHO and HF-TAG we are launching a series of webinars to address home fortification program challenges and build capacity to design, implement, monitor and scale-up effective home fortification programs and to share country experiences and lessons learned. The webinar sessions will be tailored to the real issues affecting implementation.
Webinars will be conducted every 2 months on different topics with speakers drawn from countries, regions and global level.

17. HF-TAG Home Fortification Webinar: Session One
Martin Bloem
Senior Nutrition Advisor, Nutrition Advisory Office
World Food Programme #

18. Key messages
Home fortification (HF) is a key and promising intervention to address micronutrient deficiencies and to improve quality of food for young children
Home fortification is a priority nutrition intervention for WFP
WFP is working with HF-TAG partners to enhance capacity and provide harmonized guidance on why and how to implement HF
Home fortification webinars are an important opportunity to enhance understanding and capacity of program implementers for design and implementation of infant and young child feeding (IYCF) programs that have an HF component

19. Home fortification (HF) is a promising intervention
Rationale for home fortification
Young children require a large range of nutrients in order to grow, develop and remain healthy
Even when affordability and availability do not constrain food access, it is difficult to meet the recommended intakes of some nutrients, – e.g. iron and zinc, particularly for children 6-23 mo
Objectives of home fortification programs
Increase micronutrient (MN) intake and improve IYCF practices
Improve MN status
Improve child health, appetite and growth, and reduce morbidity and mortality

20. HF-TAG brief & WHO MNP guideline
WHO guideline based on review of studies that provided MNP
Studies primarily focused on anemia and iron deficiency and used limited set of MN
Hence: WHO guideline: Minimum 3 micronutrients and at least 60 sachets/6 mo
Note that this is a guideline for decision making, not a fixed prescription
HF-TAG programmatic guidance brief further expands WHO guideline
Improve micronutrient intake in order to meet the recommended nutrient intake(FAO/WHO RNI) for more micronutrients, in addition to those relevant for anemia
Considering programming circumstances and experience
Integrate with wider infant and young child nutrition & ‘1000 days’ programming

21. HF is a priority intervention for WFP’s work
WFP’s work in home fortification
WFP is committed to preventing undernutrition and meeting nutrient requirements during the critical first 1,000 days
MNPs play a critical role in combatting micronutrient deficiencies through fortifying meals of vulnerable populations, in particular young children
WFP and UNICEF are the main procurers of MNPs, and WFP is the only organization that utilizes MNPs in school feeding
WFP uses MNPs in 19 countries in nutrition programming
In 2013, WFP reached over a half a million beneficiaries under 5 in 7 countries
Through school feeding programmes, WFP reached almost 900 thousand school children aged 6-15 in 12 countries

22. HF-TAG: Better results through partnership
WFP is working together with HF–TAG partners to enhance capacity for home fortification
HF-TAG: Better results through partnership
WFP is a committed partner of HF-TAG, with the aim of providing harmonized guidance on why and how to implement HF
HF-TAG works closely with private sector partners, including manufacturers of MNP
WFP also works with HFTAG partners through the Scaling Up Nutrition (SUN) Movement and the SUN Business Network

23. Webinars are a high potential opportunity to enhance capacity for program improvement
Webinars and resources are open to everyone, and particularly aimed at program implementers
Webinars will cover design and planning of home fortification programs, including:
For whom?
What formulation?
How much and for how long?
What frequency for distribution and use?
Cost?
How quickly can a program start?
What distribution channels to use?
What to monitor and evaluate?

24. Dr Juan Pablo Peña-Rosas
Point-of-use fortification of foods with multiple micronutrient powders: WHO recommendations
Dr Juan Pablo Peña-Rosas
Coordinator, Evidence and Programme Guidance
Department of Nutrition for Health and Development

25. WHO core functions
providing leadership on matters critical to health and engaging in partnerships where joint action is needed;
shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge;
setting norms and standards and promoting and monitoring their implementation;
articulating ethical and evidence-based policy options;
providing technical support, catalysing change, and building sustainable institutional capacity; and
monitoring the health situation and assessing health trends.
These core functions are set out in the Twelfth General Programme of Work, entitled "Not merely the absence of disease", it covers the 6-year period from 2014 to 2019

26. Vitamin and mineral malnutrition
It is estimated that 42.6% of children 6-59 months of age are anaemia (2011), which represented million children worldwide, with SEARO and WPRO having the absolute highest numbers of children affected.
Children's haemoglobin status might have deteriorated in some southern countries in Africa.
It is estimated that about half of the anaemia is due to iron deficiency although the relative contribution varies.
Iron deficiency is thought to be the most common cause of anaemia globally, although other conditions, such as folate, vitamin B12 and vitamin A deficiencies, chronic inflammation, parasitic infections, and inherited disorders can all cause anaemia.
Data on the prevalence of other vitamin and mineral deficiencies is scarce.

27. WHO evidence-informed guideline development process
New WHO guideline development process
2nd edition of WHO Handbook for guideline development released in December 2014
Provides guidance on the development of documents or publications containing WHO recommendations
Sets out procedures to follow

28. WHO evidence-informed guideline development process

29. WHO evidence-informed guidelines
WHO. Guideline: Use of multiple micronutrient powders for home fortification of foods consumed by infants and children 6–23 months of age. Geneva, World Health Organization, 2011.

30. The evidence
De-Regil LM, Suchdev PS, Vist GE, Walleser S, Peña-Rosas JP. Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age. Cochrane Database of Systematic Reviews 2011, Issue 9. Art. No.: CD DOI: / CD pub2.

31. WHO recommendations
Home fortification of foods with multiple micronutrient powders is recommended to improve iron status and reduce anaemia among infants and children 6–23 months of age (strong recommendation)

32. WHO recommendations
In malaria-endemic areas, the provision of iron should be implemented in conjunction with measures to prevent, diagnose and treat malaria.
Programmes should be preceded by an evaluation of the nutritional status among children and existing measures to control anaemia and vitamin A deficiency
Behaviour change communication strategy that promotes: awareness and correct use of the powders along with information on recommended breastfeeding practices; commencement of complementary foods at 6 months of age; preparation of complementary foods at age-appropriate frequency, amounts, consistency and variety

33. WHO recommendations
Hand washing with soap and hygienic preparation of food; prompt attention to fever in malaria settings; and measures to manage diarrhoea.
The selection of the most appropriate delivery platform should be context-specific, with the aim of reaching the least favoured populations and ensuring an adequate and continued supply of the powders.

34. Adoption and adaptation
WHO offers several tools to help countries adopt and adapt the global guidelines into their national and subnational contexts.
To ensure that WHO global guidelines and other evidence-informed recommendations for micronutrient interventions are better implemented in low and middle-income countries, the Department of Nutrition for Health and Development works with the WHO Evidence-Informed Policy Network (EVIPNet) programme.
EVIPNet promotes partnerships at country level between policy-makers, researchers, and civil society to facilitate policy development and implementation through use of the best available evidence.

36. Home-Fortification Technical Advisory Group (HFTAG)
The Home Fortification Technical Advisory Group (HF-TAG) is a community of stakeholders involved in home fortification comprised of members from the public, private, academic and non-governmental organization sector.
Its vision is a world without malnourished children.
WHO has observer status in this group.

37. HFTAG resources for implementation

38. Updating WHO recommendations
To include recommendations to the preschool and school-age children informing by the growing body of evidence.
Confirm results from previous 2011 recommendations with updated evidence from Cochrane reviews.
Identify research gaps, particularly in the area of implementation research.
Highlight the need to address the social determinants of health in the implementation of these interventions.

39. Acknowledgements
The Evidence and Programme Guidance Unit receives financial resources from several external sources for biennium
Ongoing support – longer term agreements
Bill & Melinda Gates Foundation ( )
US Centers for Disease Control and Prevention (CDC) ( )
IMMPaCt Programme
National Center on Birth Defects and Developmental Disabilities
The Micronutrient Initiative ( )
Harvest Plus (2014)
Donors do not fund specific guidelines and do not participate in any decision related to the guideline development process including the composition of policy questions, membership of the guideline groups, the conduct and interpretation of systematic reviews, or the formulation of recommendations.

40. Monitoring Home Fortification Programs Laurence Grummer-Strawn, PhD Chief, Nutrition Branch Division of Nutrition, Physical Activity, and Obesity U.S. Centers for Disease Control and Prevention
Hello. I’m happy to able to join you today to launch this series of webinars on home fortification. You’ve heard from our previous speakers about the importance of home fortification programs, evidence for their effectiveness, and a little about how these programs can best be structured.
I would like to talk a little about monitoring today. Without sufficient energy and time put into developing quality monitoring systems the effectiveness of programs is in jeopardy. These days many people know what monitoring means and that it is important, but there is not necessarily the skill set or capacity within countries to set up monitoring systems. Up until recently there has been a lack of tools and resources available to help people to develop and strengthen systems.
Today I intend to briefly consider the importance of monitoring and to discuss some of the ways in which CDC and other colleagues and agencies represented today have been working on developing key tools and resources to help improve monitoring systems.
In subsequent webinars in this series there will be more opportunities for a detailed focus on monitoring and discussions with presenters with substantial monitoring experience

41. Principles of monitoring
Monitoring improves program effectiveness
Helps achieve good coverage and adherence to the intervention
Programmes must be well designed, implemented and monitored in order to achieve and sustain impact
Different data collection systems needed for different purposes
Monitoring changes and adapt over time
Capacity in country can impact the quality of monitoring systems
So why is monitoring so important ?
We need to monitor programs in order to improve their effectiveness over time. For home fortification, if we are to achieve expected coverage rates and ensure that families adhere to recommended feeding practices, we need to monitor what happens over time. Changes to the program implementation can improve or worsen the program performance, and monitoring is essential to track what actual effects are.
Without monitoring there are many questions unanswered, which makes it difficult to know why the program is functioning the way we hope it is, if the results that we expect are being achieved. Careful monitoring can help us identify if there are problems with the program, what kinds of problems and what we can do to fix these problems.
Often multiple data collection systems need to be put in place to monitor a range of program indicators. Some indicators maybe collected through routine systems, such as the HMIS (health management information system) and others might be collected on a less routine basis, through systems like LQAS.
It is important to recognize that monitoring is not a static process and changes over time. At the onset of a program monitoring may be intense to quickly identify problems and to resolve them fast. In the middle and latter stages of a mature program monitoring systems may shift and indicators may be modified.
Finally it is important to note that the capacity in country will impact the kinds of monitoring needed and what systems are possible.

42. Monitoring Manual Multi agency and institutional involvement
Monitoring frameworks
Practical tools –such as worksheets
Case studies
There are variety of monitoring frameworks and tools available to assist program implementers
In April A Manual for Developing and Implementing Monitoring Systems for Home Fortification Interventions was disseminated
CDC led the development of the manual and was supported by a variety of other agencies and institutions including GAIN, WFP, UNICEF, HKI, UC DAVIS, WFP, MI. SGHI and Sight and Life
The manual describes monitoring concepts and frameworks, and includes monitoring tools and worksheets.
The manual can either be read in sequence or a more experienced user might use it as a reference

43. The manual goes through the various steps of developing a monitoring system from:
describing the steps of developing and implementing a monitoring system for home fortification interventions, including:
identifying and engaging stakeholders;
developing a programme description including logic model and logical framework;
Designing the monitoring system, including the indicators and core components of the entire monitoring plan;
Putting the system into place and maintaining it over time;
Utilizing the system to shape conclusions about how the program development can be improved;
and disseminating results to key decision makers
Whether you are experienced in developing monitoring systems or relatively inexperienced, the manual has information to meet your needs. There is also a fictional case study that is used throughout the monitoring manual to illustrate these steps

44. Will be available late 2014 at:
HF-TAG MNP Toolkit
In additional to the manual, a toolkit with a focus on MNPs will be available in late The toolkit will cover all aspects of MNP programming but there will be a module specifically on monitoring
The kinds of tools you will find in this module include:
Monitoring checklists
Lists of monitoring indicators
Data collection templates
Example monitoring reports
Monitoring protocol templates
Guidance on pros and cons of different kinds of monitoring approaches
Generic logic models and log frames
All of these tools will be available on the new HF-TAG website shortly under the tab “Toolkit” circled in yellow here
The home fortification manual that I have just briefly mentioned can also be found on this site
Will be available late 2014 at:

45. Webinar series Future sessions will include monitoring topics
Potential topics might include:
Log frames and logic models – how to develop these tools for your program
How to select monitoring indicators
Developing a monitoring protocol
Pros and cons of different approaches to monitoring
Future sessions in this webinar series will aim to support monitoring capacity. The webinars will be on specific topics, covering overarching themes around monitoring. Potential topics might include:
Log frames and logic models – how to develop these tools for your program
How to select monitoring indicators
Developing a monitoring protocol
Pros and cons of different approaches to monitoring
Specific requests will also be considered through questions posed on the HF-TAG community of practice, through audience feedback on the webinars, etc…. The aim of the webinars is to provide concrete guidance and assistance on topics most needed.

46. Thank you
Source – GAIN Global Alliance for Nutrition