Planning and Budgeting for Nutrition Programs in Tanzania: Lessons Learned From the National Vitamin A Supplementation Program.

BACKGROUND: Micronutrient deficiency in Tanzania is a significant public health problem, with vitamin A deficiency (VAD) affecting 34% of children aged 6 to 59 months. Since 2007, development partners have worked closely to advocate for the inclusion of twice-yearly vitamin A supplementation and deworming (VASD) activities with budgets at the subnational level, where funding and implementation occur. As part of the advocacy work, a VASD planning and budgeting tool (PBT) was developed and is used by district officials to justify allocation of funds. Helen Keller International (HKI) and the Tanzania Food and Nutrition Centre (TFNC) conduct reviews of VASD funds and health budgets annually in all districts to monitor the impact of advocacy efforts. This paper presents the findings of the fiscal year (FY) 2010 district budget annual review. The review was intended to answer the following questions regarding district-level funding: (1) how many funds were allocated to nutrition-specific activities in FY 2010? (2) how many funds were allocated specifically to twice-yearly VASD activities in FY 2010? and (3) how have VASD funding allocations changed over time? METHODS: Budgets from all 133 districts in Tanzania were accessed, reviewed and documented to identify line item funds allocated for VASD and other nutrition activities in FY 2010. Retrospective data from prior annual reviews for VASD were used to track trends in funding. The data were collected using specific data forms and then transcribed into an excel spreadsheet for analysis. RESULTS: The total funds allocated in Tanzania's districts in FY 2010 amounted to US$1.4 million of which 92% were for VASD. Allocations for VASD increased from US$0.387 million to US$1.3 million between FY 2005 and FY 2010. Twelve different nutrition activities were identified in budgets across the 133 districts. Despite the increased trend, the percentage of districts allocating sufficient funds to implement VAS (as defined by cost per child) was just 21%. DISCUSSION: District-driven VAS funding in Tanzania continues to be allocated by districts consistently, although adequacy of funding is a concern. However, regular administrative data point to fairly high and consistent coverage rates for VAS across the country (over 80% over the last 10 years). Although this analysis may have omitted some nutrition-specific funding not identified in district budget data, it represents a reliable reflection of the nutrition funding landscape in FY 2010. For this year, total district nutrition allocations add up to only 2% of the amount needed to implement nutrition services at scale according to Tanzania's National Nutrition Strategy Implementation Plan. CONCLUSION: VASD advocacy and planning support at the district level has succeeded in ensuring district allocations for the program. To promote sustainable implementation of other nutrition interventions in Tanzania, more funds must be allocated and guidance must be accompanied by tools that enable planning and budgeting at the district level.

Integrating Vitamin A Supplementation at 6 months into the Expanded Program of Immunization in Sierra Leone.

Since 2004, twice-yearly mass vitamin A supplementation (VAS) has equitably reached over 85% of children 6-59 months old in Sierra Leone. However infants who turn 6 months after the event may wait until they are 11 months old to receive their first dose. The effectiveness of integrating VAS at 6 months into the Expanded Program of Immunization (EPI) in a revised child health card was studied. Health facilities matched according to staff cadre and work load were assigned to provide either a 'mini package' of VAS and infant and young child feeding (IYCF), a 'full package' of VAS, IYCF and family planning (FP), or 'child health card' only. 400 neonates were enrolled into each group, caregivers given the new child health card and followed until they were 12 months old. More infants in the full: 74.5% and mini: 71.7% group received VAS between 6 and 7 months of age compared with the new CH card only group: 60.2% (p = 0.002, p < 0.001 respectively). FP commodities were provided to 44.5% of caregivers in the full compared with <2.5% in the mini and new child health card only groups (p < 0.0001). Integration of VAS within the EPI schedule achieved >60% coverage for infants between 6 and 7 months of age. Provision of FP and/or IYCF further improved coverage. Funding was provided by the Canadian Department of Foreign Affairs, Trade and Development who had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

Coverage of vitamin A supplementation and deworming during Malezi Bora in Kenya.

Twice-yearly child health weeks are an effective way of reaching children with essential child survival services in developing countries. In Kenya, child health weeks, or Malezi Bora, were restructured in 2007 from an outreach-based delivery structure to a health facility-based delivery structure to reduce delivery costs and increase sustainability of the events. Administrative data from 2007 to 2011 have demonstrated a decrease in coverage of Malezi Bora services to targeted children. A post-event coverage (PEC) survey was conducted after the May 2012 Malezi Bora to validate coverage of vitamin A supplementation (VAS) and deworming and to inform program strategy. Nine hundred caregivers with children aged 6-59months were interviewed using a randomized, 30×30 cluster design. For each cluster, one facility-based health worker and one community-based health worker were also interviewed. Coverage of VAS was 31.0% among children aged 6-59months and coverage of deworming was 19.6% among children aged 12-59months. Coverage of VAS was significantly higher for children aged 6-11months (45.7%, n=116) than for children aged 12-59months (28.8%, n=772) (p<0.01). Eighty-five percent (51/60) of health workers reported that Malezi Bora was implemented in their area while 23.6% of primary caregivers reported that Malezi Bora occurred in their area. The results of this PEC survey indicate that the existing Malezi Bora programmatic structure needs to be reviewed and reformed to meet WHO guidelines of 80% coverage with VAS.

High and equitable mass vitamin A supplementation coverage in Sierra Leone: a post-event coverage survey.

BACKGROUND: In Sierra Leone, children ages 6-59 months receive twice-yearly vitamin A supplementation (VAS) through Maternal and Child Health Week (MCHW) events. VAS coverage in 2011 was calculated using government tally sheets of vitamin A capsule distribution and outdated population projections from the 2004 census. We conducted a national post-event coverage (PEC) survey to validate coverage and inform strategies to reach universal coverage of VAS in Sierra Leone. METHODOLOGY: Immediately following the November 2011 MCHW event, we conducted a national PEC survey by interviewing caregivers with children ages 6-59 months using a randomized 30X30 cluster design (N = 900). We also interviewed one health worker and one community health worker in each cluster to determine their knowledge about VAS (N = 60). RESULTS: VAS coverage was 91.8% among children ages 6-59 months, which was lower than the 105.1% reported through tally sheets. Coverage was high and equitable among all districts and between age groups (98.5% for infants ages 6-11 months and 90.5% for children ages 12-59 months). Major reasons for not receiving VAS were that the child was out of the area (42.4%), the household was not visited by community health workers (28.0%), and the caretaker was not aware of the event (11.9%). CONCLUSION: Twice-yearly delivery of VAS through MCHW events achieved consistently high and equitable coverage in Sierra Leone. Universal coverage may be achieved through continued focus on communication and targeted outreach to hard-to-reach areas during the MCHWs.

Lifestyle approaches and dietary strategies to lower LDL-cholesterol and triglycerides and raise HDL-cholesterol.

This article discusses specific dietary factors as well as dietary patterns that affect the major coronary heart disease (CHD) lipid risk factors (ie, LDL-C, HDL-C, and TG). Based on a very large evidence base, it is clear that diet and lifestyle practices can markedly affect these major CHD lipid risk factors, and consequently decrease CHD risk substantively.