The global micronutrient goals : lessons learned, analysis and the way forward (1990-2005)

Micronutrient malnutrition, deficiencies of vitamins and minerals, affects one in three children in the world today, more than 2 000 million people, resulting in an enormous public health impact on the numbers of premature deaths in women and children particularly. These deficiencies, and their interaction with other health and care modalities, cause widespread morbidity, reduced intellectual potential, and an overall negative impact on national development and economic growth. To address this, global goals were established for the elimination or significant reduction of the prevalence of these deficiencies. The three micronutrient deficiencies of current greatest public health significance are iron, vitamin A and iodine, although zinc is receiving increasing attention, as is folate, vitamin B12 and other micronutrients in emergency situations. The thesis emphasized vitamin A as an example, while recognizing that different approaches to prevention and control will also be needed to adequately address other micronutrients. One aim of the thesis was to identify constraints and facilitating factors contributing to the success, or otherwise, towards achieving the first set of international micronutrient goals by the stated date of the end of the previous decade (2000). The programmes and policy decisions used in addressing micronutrient malnutrition were described and critically examined. This analysis was then used to examine this current decade (2000-2010) and the new decade goals of the UN Special Session of the General Assembly on Children. Since then the Millennium Development Declaration and Goals have to a large extent become the overarching global framework of goals, with the earlier goals being the basis for work planning and implementation. The hypothesis that the first set of international micronutrient goals was not reached globally because identifiable steps and pre-conditions were not met was addressed through access to a variety of sources, including a literature review through Medline and the search machines used by the Library systems of UNICEF, Columbia University and the University of Tasmania, with follow-up of likely articles or documents found from these identified articles. These were supplemented by national and United Nations system reports (especially WHO and UNICEF but also UNDP, World Bank and WFP), and the author’s current daily work activities contributed significantly to the final product. Based on this approach, identification of trends, commonalities, and differences, were part of the analysis, taking into account cultural, socio-economic, resources and epidemiological variety of the many countries involved. This analysis led to a suggested re-interpretation of why micronutrients have over the last decade and a half become so prominent in international public health priorities; to a compilation and analysis of constraints and facilitating factors. There is no doubt there has been enormous progress, particularly over the last two decades. Both constraints and facilitating factors were summarized, using the UNICEF Nutrition framework under four broad areas: basic or global (mega-) factors; underlying or national (macro-) factors; underlying or sub national (meso-) factors; and, proximal or immediate community and household factors (micro-), and by matrices. In essence the main factors included: (i) demonstrated commitment by government and a relevant policy in place; (ii) a knowledge of the magnitude of the problem; (iii) an awareness of the public health and social consequences by all levels; (iv) an intersectoral approach; (v) an awareness of the direct link to poverty, socio-economic and politico-social issues, and hence the need to address these specifically, as part of micronutrient deficiencies prevention and control programmes; (vi) initial presence of external funding; and, (vii) a ‘champion’ both internationally and nationally. National and local factors also played different roles in different settings. Firstly, micronutrient interventions were often not integrated at the community and district level e.g. vitamin A capsules and immunization were very infrequently integrated, except for the relatively short-lived National Polio Immunization Days, including having separate reporting systems and being implemented by different sections of the Health Ministry. Secondly, the micronutrient programmes, including universal salt iodization (USI), were often seen as externally driven e.g. by donors, or in the case of USI as a ‘UNICEF Programme’. As part of this, the goals were sometimes seen as an external, international goal, not necessarily as relevant to the perceived or documented needs of the country, despite virtually all countries having signed off on them. Thirdly, clearly ineffectual programmes continued to be promoted e.g. iron/folic acid supplementation. Fourthly, inadequate health and other systems with poor infrastructure and inadequate staffing have made delivery of many health interventions, including micronutrient supplementation, difficult. Finally, in the face of continuing and often increasing social disparities and other inequities, for most poor populations, diets are unlikely to improve sufficiently, and in the short run at least, neither will delivery systems.