Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

A State of Play Report

Multiple Micronutrient
Supplements in
Humanitarian Emergencies
March 2024

1

Authors
Philip James, Kate Sadler and Amir Samnani(Emergency Nutrition Network, Kidlington, UK)
and Emily Mates (UNICEF, New York, USA).

Acknowledgements
Many people have generously given their time andresources to help shape this State of Play report.
Philip James, Kate Sadler and Amir Samnani fromENN led the research and write-up of the report,with close collaboration and additional oversightfrom Emily Mates at UNICEF. The overall research,
including the case studies and MMS survey, wasfunded with the generous support of UNICEF andthe Department of Foreign Affairs, Ireland. We
are also grateful to the Eleanor Crook Foundation(ECF) for giving funding for further key informant
interviews, which provided additional informationon the barriers and opportunities summarisedin the concluding chapter, as well as on thinking
around the definition of humanitarian contexts.
For the Somalia case study, we thank Eric Alain
Ategbo, Biram Ndiaye, Pradiumna Dahal, Madina Ali
Abdirahman, Zephenia Gomora, Dr Abdirizak Osman
Hussein, and Dayib Said Ismail from UNICEF Somalia.
We also thank: Farhan Mohamed Mohamud at
the Ministry of Health and Human Services (MoH),
Fadumo Osman Nur (Fatima) at Concern Worldwide,
Mohamed Moallim at Banadir Primary Health Care
Consortium (BPHCC), Khadar Ahmed at the African
Network for the Prevention and Protection Against
Child Abuse and Neglect (ANPPCAN SL) and Adan
Mahdi at Save the Children.
For the Pakistan case study we thank Dr Khawaja
Masuood and Dr Abdul Baseer Khan Achakzai(Ministry of National Health Services, Regulation& Coordination, Government of Pakistan),
Anteneh Girma Minas (UNICEF country office),
Dr Naureen Arshad (UNICEF country office), Dr
Shehla Tabassum (UNICEF, Sindh), Asim Shahzad
Quresh (Nutrition International), Dr Irshad Danish(Nutrition International), Shahid Fazal (Nutrition
International), Dr Sajid Shafique (People Primary
Health Initiative), Dr Yozan Shahid (Save The
Children), Dr Shah Miran (Medical Emergency
Resilience Foundation (MERF)), Muhammad Ali(MERF), Dr Fatima Amin (Action Against Hunger),
Abdullah Waqar (Remington Pharmaceutical),Ayesha Hammad (Remington Pharmaceutical),and Dr Farhana Shahid (independent consultant
on multiple micronutrient supplements).

Additional key informants from a range ofcountries generously gave their time to speak to us
about micronutrient supplementation for womenand adolescent girls in humanitarian contexts:
Anjuman Tahmina Ferdous, Martin Nankap, EdmondRoboye, Tesfaye Chuko, Olivia Agutu, Laura Kiige,
Onjanarindra Razafimalaza, Fatoumata Lankoande,
Nemat Hajeebhoy, Yadika Charles, Olayinka
Chuku, Hanifa Namusoke, Abner Elkan Daniel, Dr
Ahmadwali Aminee, Rebecca Nerima, Kamanda
Bishimini Augustin and Mulamba Dièse.
This report benefitted enormously from detailed
reviews. We thank Yashodhara Rana (ECF), Chelsea
Cole (ECF), Martin Mwangi (Healthy Mothers
Healthy Babies Consortium), Filomena Gomes(Healthy Mothers Healthy Babies Consortium),
Tanya Khara (ENN) and Vilma Tyler (UNICEF) for
their helpful reviews and suggestions. We also
thank Kelsey Grey who helped conduct several of
the key informant interviews.
The ideas, opinions and comments includedin this report are entirely the responsibility ofthe document’s authors and do not necessarily
represent or reflect the policies of the donors, orthe views of the key informants or reviewers.

Recommended citation
Philip James, Kate Sadler, Amir Samnani and Emily
Mates (2024). Multiple Micronutrient Supplements
in Humanitarian Emergencies: A State of Play
Report. Emergency Nutrition Network (ENN):
Kidlington, Oxford, UK. March 2024. https://doi.
org/10.6084/m9.figshare.25135160
Designed by Terry Nightingale:www.tnightdesign.com
Copyeditor: MyBluePencil

Photo credit: Cover: © WFP/Josh Estey

Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Contents
Executive summary

3

Introduction

3

Methods

4

Background4	Survey results: use of MMS in humanitarian
emergencies

4

Summary of key findings

5

Conclusions

7

Section 3: Case study summaries

26

Somalia

26

Pakistan

27

Section 4: Summary of key findings29	Building block 1: Leadership andgovernance

29

Building block 2: Service delivery

30

Building block 3: Health system financing

32

Building block 4: Health workforce

33

Acronyms

8

Introduction and scope

9

Methods

12

Building block 5: Supplies and technology

33

MMS survey

12

Building block 6: Information systems

34

Case studies

14

Additional key informant interviews

14

Section 1: Background

15

MMS

15

Current policy and guidance for MMS

17

	Women’s nutrition in humanitarian
emergencies

17

Definition of humanitarian emergencies

19

The humanitarian system

20	The number of women and adolescent
girls reached by MMS in humanitarian
emergencies

21

Section 2: Mapping MMS acrosshumanitarian emergencies

22Survey response profile

22

Survey findings

23

Section 5: Summary and conclusions

35

	The overlap between humanitarian anddevelopment programming for MMS

35

Conclusions

40

References

41

Annex 1: Collation of selected MMS resources

44

Annex 2: Key informant interview guides

49

Annex 3: Terminology referring tohumanitarian emergencies

50

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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024
Photo credit: © WFP/Eulalia Berlanga

Executive summary
Introduction
In recent years there has been significant
global momentum on progressing women’s
and adolescent girls’ nutrition. Daily multiple
micronutrient supplements (MMS), received
through antenatal care (ANC) platforms, havereceived particular attention. The growing evidencebase describing the effectiveness of MMS forbirth and maternal outcomes, together with anincreasing volume of documented learning about
operational aspects from several implementation
research pilots, and a strongly supportive advocacy
agenda, means that our understanding of thepotential impacts of MMS when taken to scale is
rapidly improving.



Women and girls are disproportionately affectedby conflict and disasters due to their increased
nutritional needs and vulnerabilities. However,there is limited consolidated information on theextent to which women and adolescent girls
receive MMS in humanitarian emergencies. Where
MMS programming exists in these contexts, details
on implementation and barriers to successful
scale-up are often lacking. This report aims to fillsome of these important knowledge gaps, while
recognising that this is simply a starting point for
ongoing knowledge sharing and informed action.

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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Methods
Information for this report was sourced from asurvey, two in-depth country case studies, andadditional key informant interviews.
•	An online survey was conducted in countries
experiencing humanitarian emergencies in June
2023, addressing MMS provision, barriers andopportunities.
•	Pakistan and Somalia were chosen as casestudies from contrasting regional contexts. In thereport we summarise the main findings fromthese case studies but we direct readers to theaccompanying individual case study reports that
contain full details (Somalia and Pakistan).
•	To broaden insights into MMS programming,
additional key informant interviews wereconducted, including with stakeholders
providing iron-folic acid (IFA) but not MMS.
These interviews covered diverse humanitariancontexts, including refugee responses, conflicts,
economic crises, and natural disasters.

BackgroundMMS
MMS are formulated to contribute towards
the Recommended Dietary Allowance of 15
micronutrients for pregnant women. The formula
recommended for use, and which therefore forms
much of the evidence base, is the United Nations
International Multiple Micronutrient Antenatal
Preparation (UNIMMAP). When compared to IFA,MMS reduces low birthweight by 15%, stillbirth by
9%, preterm birth by 4%, and small-for-gestationalage deliveries by 7%. Compared to iron withor without folic acid MMS has similar benefits
for preventing maternal anaemia. The 2023
Copenhagen Consensus Report underscores theconsiderable economic advantages of replacing IFA
with MMS, estimating a return on investment of
USD 37 for every USD 1 spent.

Current policy and guidance for MMS
In 2007, the World Health Organization (WHO),
the World Food Programme (WFP) and theUnited Nations Children’s Fund (UNICEF) issued
a joint statement on preventing and controlling
micronutrient deficiencies in populations affectedby an emergency, including recommendations
on the use of daily MMS for pregnant andbreastfeeding women. Since the 2007 jointstatement, the recommendations have been
implemented to varying degrees around the world.

Survey results: use of MMS in
humanitarian emergencies
An online survey was sent to respondents from46 eligible countries1 in June 2023. A total of 131
individual responses were recorded, from 39
different countries. Most of the responses camefrom individuals working for non-governmentalorganisations (NGOs) (63%), followed by individuals
in UNICEF country offices (24%), governments(5%) and others (8%). Respondents from 28
countries stated they distributed MMS to women inhumanitarian programmes. Of the 11 countries thatindicated there was no MMS provision, respondents
from seven countries reported plans to implement
MMS programming in the next year.
In most countries (27 out of 28), all respondents
stated that under humanitarian programmes MMS
was given to pregnant women. Twenty of thesecountries also had respondents who said that MMS
was given to breastfeeding women, with a minority
giving MMS to non-pregnant women (six countries)
and non-pregnant adolescent girls (nine countries).
Financing of MMS programming was the mostcommonly reported barrier across countries, by alarge margin, followed by three similarly ranked
barriers: inadequate country policy/protocols,
inadequate supply chain, and inadequateawareness of benefits of MMS by healthcare
workers and target populations.

1	Eligibility was defined as countries having released a UNICEF
Humanitarian Action for Children Appeal in 2022/3, and/or being
listed as a Level 2 (L2) or Level 3 (L3) emergency, and/or having anactive cluster established under the Global Nutrition Cluster (GNC)
in 2022/3, as at June 2023.

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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Summary of key findings
The key findings from the survey, case studies andadditional key informant interviews are compiled
and summarised here by WHO health systembuilding block. While all of the barriers identified
here were described by key informants in thecontext of humanitarian emergencies, they are notnecessarily exclusive to these settings but rather
reflect recurring themes found across the spectrumof humanitarian and development contexts.

Building block 1
Leadership and governance
MMS programming is increasingly recognisedby governments as important for addressing
micronutrient deficiencies among women.
Support from non-government actors such as
United Nations agencies, NGOs, researchersand donors with expertise in nutrition andmicronutrient supplementation is often key
to assisting governments to integrate MMS
programming into national nutrition policy andstrategy in many countries. In countries where
national policies and strategies do not yet mention
MMS there can be a barrier to the development ofcorresponding implementation guidance.
Some stakeholders view global guidance on MMS
as confusing: some guidelines recommend using
MMS only in ANC within the context of rigorous
research, while other recommendations endorse
its use in emergency settings alongside IFA. A lackof clarity in global guidance may contributeto the slow integration of MMS programming
into national policy. Concerns about oversupplementation or micronutrient toxicity wasreported to be a potential barrier to including MMS
in national policy by a few key informants working
in refugee settings where other fortified food was
also made available. However, the majority of key
informants stressed that these concerns are lessrelevant in humanitarian emergencies.
UNIMMAP MMS has been on the WHO global
Essential Medicines List (EML) since 2022, which isreported to facilitate procurement, particularly ininternational humanitarian responses. MMS is also
beginning to be integrated into national EMLs –although in many countries this is still in process.
There is broad understanding that this will support
the scale-up of MMS through leveraging domestic
resources for its purchase, by mobilising further
political commitment for its integration into ANC
services, and potentially reducing breaks in MMS
supply chains.


Building block 2
Service delivery
Micronutrient supplementation is almost always
integrated into health service provision, mainly
in ANC. This is the case both in international
humanitarian response and domestic crisis
management. Many countries have a mixture ofboth IFA and MMS programming, most often withnational IFA programmes and smaller-scale MMS
programming at subnational level, and not yet
integrated into routine government programming.
Somalia and the Democratic Republic of Congo(DRC) are an exception: in these countries, MMS
is part of the national programme. In all surveyedcountries, MMS is currently provided to recipientsfor free during humanitarian responses, and ismainly distributed to pregnant women monthly as
part of ANC.
Key barriers to scaling MMS programmingin humanitarian emergencies and achieving
adequate coverage of the population include
limited awareness among healthcare workers andtarget populations, restricted access to healthservices, poor ANC service quality, and supply
chain breaks. Key informants made a few anecdotal
comments relating to fears/misconceptions among
pregnant women about having larger babies due tothe additional micronutrients given. Some confusion
also exists at the service delivery level regarding thedifferent uses of MMS and IFA for anaemia prevention
and treatment, linked to the lack of clear guidanceand challenges with health worker capacity.
Key informants described the fact that once
reached through outreach and mobilisation,
women are eager to participate in, andunderstand the value of, ANC services. Indeed,
the inclusion of MMS in ANC packages reportedly
encourages women to attend health facilities,
anecdotally because women prefer MMS over
IFA due to fewer reported side effects. Thereare examples, particularly from Somalia andMadagascar, of leveraging existing community
health worker infrastructure to improve
mobilisation and outreach for ANC.

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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Building block 3
Health system financing

Building block 4
Health workforce

Currently, MMS programming during humanitarian
emergencies heavily relies on donors, often throughnon-governmental agencies like UNICEF, Vitamin
Angels Alliance and other NGOs, or philanthropies
such as Kirk Humanitarian. However, initiatives suchas UNICEF’s Child Nutrition Fund (CNF) also aim tomobilise domestic funds for nutrition commodities,
including MMS provision, in 23 countries affectedby a high prevalence of child wasting. While the
CNF does not have a specific funding initiativetied to humanitarian emergencies, governmentsthat receive matching funds from the CNF could
leverage these resources in crisis-affected areas of
their countries.

MMS is mainly delivered through ANC services,
often by government health staff and occasionallyby NGOs/United Nations agencies in locations
with reduced government health service capacity.
Health staff knowledge on MMS benefits anddelivery protocols within ANC relies heavily on
limited in-service training and support from NGO/
United Nations agency-funded programmes. The
absence of national protocols and guidance for
MMS in humanitarian programmes sometimes
creates confusion around delivery protocols.

Key informants noted that the cost of purchasing
MMS is considerably higher than that related to
IFA. The factors underlying this vary by country,
but commonly include the additional cost of
MMS, which contains 15 different micronutrients(versus only two in IFA), the need to import MMS(versus IFA, which is often locally produced) and,in some countries, an importation tax on MMS.
Implementation research in countries like Pakistan
and Nigeria is exploring the feasibility and costadvantages of locally producing MMS.
Some key informants from the case studies
described how meeting financial requirementsfor programming MMS within humanitarian
emergencies is challenging, explaining that there
were other critical nutrition programmes, suchas those treating child wasting, also remaining
underfunded. Sustainable funding opportunities
for MMS programming within ANC is therefore
an urgent priority, recognising that this willneed to part of a wider discussion on how toprioritise which interventions to fund in complex
situations with constrained resources. However,opportunities are emerging in this area: key
informants described the growing attention being
given to the prevention of child undernutrition inhumanitarian contexts by some researchers, donors
and practitioners. Correspondingly, there is growing
momentum and evidence generation on the role ofimproved maternal nutrition to reduce the risks ofwasting and stunting in early childhood by reducing
the prevalence of poor birth outcomes, such as low
birth weight. Scaled-up MMS provision could play avital role in prevention efforts, potentially improving
funding for the product as well as improving thequality and reach of delivery platforms.


Health staff capacity challenges are common,
including limited staff availability and their existing
workload. Community health outreach staff, who
are crucial for mobilisation and for improving MMS
coverage, often face heavy workloads, making
integration of MMS programming into existing
work difficult, especially when remuneration isinadequate.
Enhanced in-service training, implementation
guidance, and updated job descriptions canhelp to strengthen MMS programming, inaddition to incorporating associated nutrition
education and counselling within ANC. The
increased focus on preventing child undernutritionin humanitarian settings, and the role maternal
nutrition plays in this, offers potential opportunities
to scale up support for MMS delivery through bothfacility-based and community-based workforces,
improving ANC service provision more broadly.

Building block 5
Supplies and technology
Currently, MMS used in humanitarian programmes
is imported from overseas, sourced largely through
UNICEF or Kirk Humanitarian supplies and procured
directly in-country by UNICEF Country Offices
or NGOs such as Vitamin Angels Alliance. MMS
tablets are mostly supplied in bottles of 100 or 180
tablets. Many countries adopt a protocol according
to which the whole bottle is given at once, so thatthe desiccant inside the bottle continues to keep
the tablets dry and to reduce the risk of tablets
becoming discoloured over time. However, somekey informants described how in order to aligndistribution with eight ANC contacts (i.e., monthly
visits during pregnancy), sometimes the tabletsfrom the bottles are decanted into smaller packages
at facilities, adding to health staff workload.
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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Blister packs of 30 tablets are available but canbe cost-prohibitive. While the in-country supply
chain works well in some cases, such as Somalia
and Sri Lanka, in other cases demand outpaces
supply or supplies take time to reach programme
locations. Breaks in MMS supply have occurred inseveral countries; these were linked to global market
availability, restricted funding, and challenges with
reporting and estimating need at health service
level. Considerable work is being undertaken by
UNICEF Supply Division and key partners, including
Kirk Humanitarian and the Bill & Melinda Gates
Foundation, to develop a more reliable global supplyof MMS. Key actions needed include investment
to strengthen and support a network of regional
producers, the adoption of a global set ofcommon product standards, and encouraging
more procurement commitments throughmechanisms such as the Child Nutrition Fund.
Developing local or regional MMS production insome countries could shorten the supply chain.
Establishing a buffer stock of MMS at the facility/
pharmacy level could also address unforeseen
increases in demand and reporting issues within
national supply chains. Finally, the inclusion of MMS
on national EMLs could facilitate procurementand distribution in line with national protocols,
especially in crises that are managed domesticallyfollowing national protocols.

Building block 6
Information systems
Monitoring of the coverage of MMS programmingis only just beginning to be integrated into
national health information systems in a few
humanitarian contexts, such as in Somalia.
In most places, where it exists, programmemonitoring and evaluation for MMS programming
relies on programme data collection and reporting,usually put in place by UNICEF, and this can beparallel to government systems. In some cases,
MMS and IFA are combined into one indicator.
Since in several countries MMS is not yet written
into national protocols, national-level surveys collectself-reported adherence data on iron-containing
tablets/syrups for pregnant women but do not yet
collect data on MMS availability and adherence.
There is also a lack of data on the explanatory
factors underpinning adherence to IFA or MMS.
All of this means that there are large gaps indata, and therefore in our knowledge of theavailability of, and adherence to, MMS.
Given Humanitarian Response Plans (HRPs) rely
first and foremost on an estimation of the numberof people in need of a service or intervention, thesedata gaps could be a barrier to ensuring MMS
programming is built into HRPs, fundraised for,and delivered.
The integration of MMS monitoring into DHIS2
in all countries where it is programmed, as wellas into relevant national surveys, is important
to strengthen our understanding of coverage of
MMS programming. This is already beginning tohappen in some places, e.g., Somalia and Pakistan,and these early experiences will contribute learningfor other countries.

Conclusions
The information compiled for this report highlights
a significant and growing interest in MMS
programming in humanitarian emergencies, yetcurrently MMS programming is not being deliveredat scale in these contexts. The opportunity of MMS,a much-improved product in terms of effectivenessfor improving nutrition, is seen by many as awelcome opportunity to improve maternal healthand pregnancy outcomes, including throughthe opportunity to revitalise quality ANC services
more generally. However, replacing IFA with MMS
cannot happen successfully without investment inovercoming many of the barriers discussed above.
While humanitarian emergencies undeniably
present additional, complex barriers to MMS
programming coverage, what is needed to address
them in these contexts remains fundamentallythe same as what is needed across all settings:
namely, it entails using the lens of health systems
strengthening to make MMS programming aseffective as possible within quality ANC services.
The opportunities this will bring are essential for theoverall health and well-being of pregnant womenand adolescent girls, and will help ensure we fulfil
our obligations to fully support their human right toadequate nutrition.

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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Acronyms
ANC

Antenatal care

CHW

Community health worker

DALY

Disability-adjusted life year

DHS

Demographic and Health Survey

ECF

Eleanor Crook Foundation

EML

Essential Medicines List

ENN

Emergency Nutrition Network

GNC

Global Nutrition Cluster

GWG

Gestational weight gain

HAC

Humanitarian Action for Children

HMHB

Healthy Mothers Healthy Babies Consortium

HRP

Humanitarian Response Plan

IASC

Inter-Agency Standing Committee

IFA

Iron-folic acid

MMS

Multiple micronutrient supplements

MoNHSR&C

Ministry of National Health Services, Regulations, and CoordinationNGO

Non-governmental organisation

SMART

Standardised Monitoring and Assessment of Relief and Transitions

UNFPA

United Nations Population Fund

UNHCR

United Nations High Commissioner for Refugees

UNICEF

United Nations Children’s Fund

UNIMMAP

United Nations International Multiple Micronutrient Antenatal Preparation

WFP

World Food Programme

WHO

World Health Organization

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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Photo credit: © WFP/Arete/Saiyna Bashir

Introduction and scope
In recent years there has been significant global
momentum on progressing women’s andadolescent girls’ nutrition, led by governments,
United Nations agencies, non-governmentalorganisations (NGOs), research institutions,the private sector and donors. Daily multiple
micronutrient supplements (MMS), received
through antenatal care (ANC) platforms, havereceived particular attention. The growing evidencebase describing the effectiveness of MMS forbirth and maternal outcomes, together with anincreasing volume of documented learning about
operational aspects from several implementation
research pilots, and a strongly supportive advocacy
agenda, means that our understanding of thepotential impacts of MMS when taken to scale is
rapidly improving.
However, despite the joint United Nations
statement published in 2007, which provided
recommendations on the use of MMS inemergencies (1), there is limited consolidated
information on the extent to which women andadolescent girls receive MMS in humanitarian
emergencies. Where MMS programming exists
in these contexts, details on implementation andbarriers to successful scale-up are often lacking.
This report aims to fill some of these important
knowledge gaps, while recognising that this issimply a starting point for ongoing knowledge
sharing and informed action.

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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

In Box 1 we provide a summary of the body ofwork the Emergency Nutrition Network (ENN)
has done leading up to this report. At the global
level, partners have been supporting several
governments to spearhead implementation
research on MMS and to program MMS in
humanitarian emergencies, as illustrated later
within this report. The United Nations Children’s
Fund (UNICEF) has also been advancing the casefor MMS distribution as part of strengthened,
quality ANC service provision, with some of the key
documentation summarised in Box 2. There has
been sustained research and advocacy on MMS
by a large number of research, operational anddonor institutions, such as the Healthy Mothers
Healthy Babies Consortium (HMHB), the MMS
Technical Advisory Group (MMS-TAG), Nutritional
International, the Sight and Life Foundation, theEleanor Crook Foundation (ECF), the Bill & Melinda
Gates Foundation, and many others. In Annex 1 we
provide a summary of selected resources on MMS
from a range of sources: here readers can findbackground documentation and tools that havebeen developed to support MMS scale-up.
In this State of Play report, we address gaps in our
knowledge of the use of MMS in humanitarian
emergencies through four main sections:•	In Section 1 we provide a brief backgroundto MMS, summarising the key evidence andpolicies, we define how we describe humanitarian
emergencies, and we summarise thehumanitarian system for nutrition programming.
•	In Section 2 we present the results of a survey toprovide a snapshot of where MMS is being usedin humanitarian emergencies and by whom.
•	In Section 3 we provide a short summary of
two case studies on MMS in humanitarian
emergencies: one from Somalia and one from
Pakistan.
•	In Section 4 we pull together the key themes
regarding barriers to, and opportunities for, theuse of MMS in humanitarian emergencies. These
themes are drawn from the findings of the survey,
both of the case studies and several additional key
informant interviews that were conducted, from a
range of contexts (see methods below).
Throughout the report we use the World HealthOrganization (WHO) definition of adolescenceas extending from the onset of puberty up until
adulthood, approximately corresponding to the 10–
19 years age bracket. Many source documents write
about ‘women aged 15–49 years’, and therefore
risk erroneously excluding adolescent girls and/or misclassifying them as women. Where possible,
we make this distinction. We provide definitionsof terms describing humanitarian emergencies in
Section 1, below.

Box 1: ENN’s work on women’s and girls’ nutrition
In 2012, ENN published a technical background paper summarising the existing evidence on maternal
nutrition interventions and identifying knowledge gaps relating to addressing maternal undernutritionin emergencies (2).
Given that substantial gaps remained in our understanding of the state of maternal nutrition globally,
and given the implications of poor nutritional status for adolescent girls and women, as well as theirinfants, ENN updated and expanded this technical paper in 2021 to summarise evidence, policy andpractice relating to all areas of women’s nutrition in a technical briefing paper on women’s nutrition (3).
In researching the 2021 paper, it became clear that there was a particular dearth of evidence and sharedlearning coming from humanitarian contexts. In 2022, ENN therefore summarised progress in a Stateof Play report, specifically focusing on humanitarian contexts (4). Information was gathered throughliterature reviews, policy document searches, and key informant interviews. The report presented thebackground to humanitarian response architecture, the importance of women’s and girls’ nutritionin humanitarian contexts, the state of women’s and girls’ nutrition in humanitarian contexts, thecurrent policy environment, existing scientific evidence on what works, combined with examples fromprogramme experiences, and a summary of the current gaps and recommendations. Readers are
therefore referred to this 2022 report for more detailed background information on the wider context
within which micronutrient supplementation sits.
10Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Box 1: ENN’s work on women’s and girls’ nutrition continued
The 2022 State of Play report was complemented by an in-depth case study on programming
for women’s and girls’ nutrition, including MMS programming, in Madagascar (5). The case study
summarised policies and programmes to support women’s and adolescent girls’ nutrition as partof the recent national humanitarian response in the country. It identified implementation gaps andchallenges, and recommended actions to strengthen advocacy, policies and programmes. It also
provided detailed information about the ongoing MMS pilot project in-country, much of the learningfrom which has been expanded on in this current report.
The 2022 State of Play report and the Madagascar case study were used as background documents fora 2022 roundtable discussion on MMS use in humanitarian contexts, co-hosted by ENN, UNICEF and
HMHB. The key findings and recommendations from this roundtable were summarised in an article in
the latest Sight and Life Foundation Special Report on MMS (6).

Box 2: Recent work from UNICEF on maternal nutrition
Over the past few years, UNICEF has been developing and documenting the evidence base for women’s
nutrition. The main vehicle for generating evidence through implementation research has been via the‘Introducing Antenatal Multiple Micronutrient Supplementation in Prioritized Countries (In Asia andAfrica)’, also known as the IMPROVING project, implemented since 2018 and reaching completion in
March 2024. With funding from the Bill & Melinda Gates Foundation, the project has been collecting
evidence on the enabling environment, delivery systems (including issues related to demand anddata systems), supply systems and experiences in identifying and addressing barriers to uptake andutilisation of maternal nutrition services. Final project documentation is underway, which will outline
key lessons learned from the operational implementation of MMS provision to pregnant women livingin Tanzania, Burkina Faso, Bangladesh and Madagascar.
Following the recommendations of UNICEF’s ‘Undernourished and Overlooked’ flagship report (seebelow), UNICEF has developed an ‘Improving Maternal Nutrition Acceleration Plan', to be launched in
March 2024. This Acceleration Plan intends to help governments and partners fast-track the delivery ofa package of essential services during pregnancy to prevent malnutrition and anaemia and includes
the provision of MMS. The Plan targets 16 million women across 16 low- and middle-income countries
over the next two years and has been estimated to cost US $20 per woman.
UNICEF has also been producing global publications on the importance of women’s nutrition moregenerally as well as scaling up MMS programming more specifically. In chronological order, recent
publications include:• Maternal nutrition integrating MMS in UNICEF’s Nutrition Strategy 2020-2030• Maternal nutrition included in UNICEF’s Core Commitments for Children, October 2020.
• Programme Guidance on Maternal Nutrition, January 2022.
• Maternal Nutrition Counselling Brief, January 2022.
• MMS Advocacy brief, January 2022.
•	
Undernourished and Overlooked: A Global Nutrition Crisis in Adolescent Girls and Women, Flagship
Report, March 2023.
UNICEF has also contributed to a series of journal articles, included in the resource compilation in Annex 1.

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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Photo credit: © WFP/Martin Karimi

Methods
Information for this State of Play report was sourced
from a survey, two in-depth country case studies
and additional key informant interviews.

MMS survey
Given the complexities of varying definitions ofhumanitarian contexts (see Section 1 below), a
simple way of categorising countries experiencing
humanitarian emergencies was adopted for the
purposes of targeting the survey. Countries (orsub-regions within countries) falling into thefollowing categories were defined as experiencing ahumanitarian emergency:•	having released a UNICEF Humanitarian Action
for Children (HAC) Appeal in 2022/3;2•	and/or being listed as a Level 2 (L2) or Level 3 (L3)emergency;3•	and/or having an active cluster established under
the Global Nutrition Cluster (GNC) in 2022/3.4
A list of countries fulfilling the above criteria wascompiled in June 2023.

2	Current HAC Appeals can be viewed here: https://www.unicef.org/
appeals3	Information on current and past L2 and L3 countries is provided on
an updated, public webpage: https://www.corecommitments.unicef.
org/level-3-and-level-2-emergencies
4	The GNC update on where there are active clusters can be viewed
here: https://www.nutritioncluster.net/where-we-work12Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

The survey was programmed in SurveyMonkey®.
It asked respondents about the organisation they
worked for, their country of work, and whether
MMS was provided for women and/or adolescent
girls in a humanitarian emergency. If the answer
was yes, respondents were then asked about who
received the MMS and who distributed the MMS,
information on localities and targets, the MMS
supplier, where MMS was procured from, barriers
to programming MMS at scale, and whether
MMS was on the national Essential Medicines
List (EML). If the respondent answered that there
was no MMS programming, they were directed
to a set of questions on whether iron-folic acid
(IFA) was used. These IFA questions were thesame in structure as those asked for MMS, witha set of additional questions on whether the
respondent was aware of the joint United Nations
2007 statement on controlling micronutrient
deficiencies in emergencies (1), whether they hadplans to implement MMS programming in thefollowing year, and the top issues that needed to beaddressed or changed in order to switch from IFA
to MMS programming in the future.
The survey was distributed to all countries defined
as experiencing a humanitarian emergency using
the above categorisation. The survey was initiallydistributed by UNICEF New York headquarters
to regional and relevant country offices. UNICEF
country office leads were asked to pass the survey
on to implementing partners in the country. In
parallel, other agencies helped to share the survey
with their partners working in relevant countries,
such as the United Nations Relief and Works
Agency for Palestine Refugees in the Near East
(UNRWA), Action Against Hunger, Médecins Sans
Frontières, Kirk Humanitarian and Vitamin Angels.
Responses were anonymous, but respondents
were optionally asked to provide their contact
details if they consented to being contacted forfurther information, which provided a pool of key
informants for some supplementary interviews(see below). Due to the differing numbers of
respondents per country, questions on the top
three barriers/opportunities were summarisedby country rather than by individual.

Survey limitations
The selection of countries to target for the survey(based on the criteria described above) was
necessarily imperfect, in order to enable a broad
enough yet rapid response. The definition did
not cater for countries that were not on the list
but that may have had geographical pockets ofhumanitarian emergency, or countries that wereentirely managing humanitarian emergencies
through domestic management. The sample was
self-selected, and responses were therefore notnecessarily representative of what was happening
overall at the country level. The survey results
should therefore be viewed as a snapshot of what
was happening in a complex, rapidly evolving field.
The survey was programmed so that respondents
had sets of questions filtered to MMS programmingor to IFA programming, but they did not havethe option to respond to both sets of questions.
Where countries had more than one respondent,
responses sometimes differed, or even conflicted.
This meant some questions were more appropriate
for being picked up by later key informant
interviews, rather than illustrated as over-simplified
survey responses. We have therefore chosen toreport a selection of the most informative survey
questions in our survey results section, focusing
on a sub-selection of questions related to MMS
programming. The remaining MMS-related
questions were used, together with the responses
on IFA programming, to further guide the casestudy and key informant interview guides, and tohelp shape key themes that are summarised in
Section 4 of this report.
We might have been able to obtain moreengagement if we had also supplied the survey
in French and Arabic, instead of just in English
and Spanish.

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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Case studies
Pakistan and Somalia were selected as examples of
two contrasting country contexts to illustrate key
themes in depth. UNICEF headquarters introduced
the ENN researcher team to the in-country UNICEF
offices, who in turn then helped with the selectionof key informants from relevant contacts fromgovernments, other United Nations agencies,
NGOs, and the private sector. An interview guide
was developed (Annex 2) and was used to guideconversations in both countries. Interviews lasted
45–60 minutes. All interviews with key informantsfrom Somalia were conducted remotely online(from June to August 2023), whereas the majority ofinterviews in Pakistan were conducted in person inIslamabad and Karachi, with a few supplementaryinterviews conducted online (in August 2023).
Key findings on barriers and opportunities weresummarised by WHO health system building
blocks. All key respondents provided oral consent
for the interviews to be recorded for the purposesof note-taking. Key respondents reviewed the final
draft of the case studies to check for accuracy andto provide their final consent for their inclusion
by name in the acknowledgements. We presenta short summary of each case study in this report
and we refer readers to the accompanying separatecase study reports for full details (Somalia andPakistan).

Key informants who provided information about
current IFA programming and barriers to MMS
scale-up represented work in Bangladesh,
Cameroon, Chad, Ethiopia, Kenya, Madagascar,
Nigeria and Sri Lanka. Key informants providing
information about MMS programming represented
work in Afghanistan, Uganda and the Democratic
Republic of Congo (DRC). However, the majorityof the country experiences that were described
actually used a combination of IFA and MMS at
different scales and stages of transition. Interviews
covered programmatic aspects, barriers toswitching from IFA to MMS, barriers to scale-up of
MMS, and recommendations on what would beneeded to improve MMS delivery. See Annex 2 forinterview guides. Consent processes were the sameas described above for the case studies.

Additional key informant
interviews
To gain additional understanding on MMS
programming from a wider range of humanitariancontexts, and to cover countries that were not yet
using MMS, additional key informant interviews
were conducted. A selection of key informants
were approached from among those who
had given consent to be contacted for further
information during the MMS survey. The aim wasto ensure we captured perspectives from key
informants amongst country-level stakeholders inprogrammes that a) provided IFA but not MMS in
humanitarian emergencies, and b) provided MMS.
A range of humanitarian contexts was covered,including those characterised by refugee responses,
conflict, economic crisis, and natural disasters.



Photo credit: ©
 UNICEF Somalia

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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024
Photo credit: © WFP/Arete/Saiyna Bashir

Section 1: BackgroundMMS
MMS is formulated to provide a combination of
essential vitamins and minerals that are neededfor overall health and well-being. The specificformulation can vary depending on the target
population, the purpose of the supplement,
and the prevailing nutritional deficiencies ina particular region.

The formula recommended for use in pregnancy,
and which therefore forms much of the evidencebase relevant to this report, is the United Nations
International Multiple Micronutrient Antenatal
Preparation (UNIMMAP) (Table 1). UNIMMAP MMS isformulated to contribute towards the Recommended
Dietary Allowance of 15 micronutrients in pregnant
women.

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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Table 1: UNIMMAP formulation of MMS
Micronutrient

Dose per tablet

Iron

30 mg

Zinc

15 mg

Copper2 mg

Selenium

65 µg

Iodine150 µgVitamin A

800 µg retinol
equivalent (RE)Vitamin B1

1.4 mgVitamin B2

1.4 mgVitamin B3

18 mg

Vitamin B6

1.9 mgVitamin B9 (folic acid)

400 µgVitamin B12

2.6 µgVitamin C

70 mg

Vitamin D

200 IU

Vitamin E

10 mg

The MMS Technical Advisory Group (MMS-TAG) is
an interdisciplinary group of experts in nutrition,maternal health, and public health, founded in2018 to interpret emerging evidence on MMS andto provide high-fidelity guidance and support
to stakeholders, including national actors. It has
recently published a summary of the existing
evidence base on MMS, demonstrating the impact
MMS has on maternal and infant outcomes. Readers
are referred to this summary of the evidence by
the MMS-TAG, which is both comprehensive andaccessible (8). When compared to the use of IFA,MMS reduces low birthweight by 15%, stillbirth by
9%, preterm birth by 4%, and small-for-gestationalage deliveries by 7% (9). MMS, as compared to ironwith or without folic acid, has similar benefits inregard to preventing maternal anaemia (10).

Sub-analysis has shown additional benefits of MMS for
anaemic or underweight women5 (11). Furthermore,
MMS has been shown to improve gestational weightgain6 (12), and adolescent pregnant women also
benefit substantially from MMS (13).
The 2023 Copenhagen Consensus Reportunderscores the considerable economic advantagesof replacing IFA with MMS, estimating an overall
annual benefit exceeding USD 3.1 billion and a
return on investment of USD 37 for every USD 1
spent (14). Additionally, recent studies have predicted
the potential cost-effectiveness of MMS were it
to be introduced at scale. For example, a teamfrom the University of Washington developed amicrosimulation model to investigate what theeffect of various antenatal interventions would be on
disability-adjusted life years (DALYs) and incremental
costs. In the model looking at the effect of 90%
coverage of MMS in ANC it was estimated thatmortality and morbidity would be improved amongst
children aged under two years, at an incremental
cost of USD 52 per DALY saved for Pakistan, USD
70 for India and USD 253 for Tanzania (15). Nutrition
International has also developed several resourceson the cost-effectiveness of MMS, including aninteractive tool that can help decision-makers see
a tailored scenario of the impact of switching from
IFA to MMS (see Annex 1 for more resources).

2023 Copenhagen Consensus“The
Report underscores the considerable
economic advantages of replacing
IFA with MMS, estimating an overall
annual benefit exceeding USD 3.1
billion and a return on investment
of USD 37 for every USD 1 spent.

”5	For women with anaemia (haemoglobin <110g/L), receiving MMS
was associated with reductions in low birthweight by 19%, versus 9%
for non-anaemic women. Small-for-gestational-age was reduced
by 8% and six-month infant mortality by 29% in anaemic women,
versus no effect for both outcomes in non-anaemic women. For
underweight women with body mass index <18.5 kg/m2, thosereceiving MMS had preterm birth reduced by 16%, versus 6% forwomen who were not underweight.
6	Women receiving MMS in the intervention arm had a greater
percentage adequacy of gestational weight gain (GWG) [weighted
mean difference (WMD): 0.86%], a higher GWG at delivery (WMD:
209 g), and a 2.9% reduced risk of severely inadequate GWG
compared to those in the control arm.



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Current policy and guidance
for MMS

Women’s nutrition inhumanitarian emergencies

In 2007, WHO, the World Food Programme (WFP),and UNICEF issued a joint statement on preventing
and controlling micronutrient deficiencies in
populations affected by an emergency, including
recommendations on the use of MMS for pregnant
and breastfeeding women (1). The statement says:

The Global Humanitarian Overview in 2023
estimated that 339 million people were in needof humanitarian assistance (18). Women and girls
are disproportionately affected by conflict anddisasters due to their increased nutritional needs
and vulnerabilities (Box 3). In 2023, the United
Nations Population Fund (UNFPA) appealed foran estimated USD 1.2 billion to provide life-saving
health and protection services to over 66 million
women, girls and young people in 65 countries(19). In June 2023, the United Nations HighCommissioner for Refugees (UNHCR) reported thatas at the end of 2022 there were an estimated 108.4
million people in the world who had been forcibly
displaced from their homes because of conflictand persecution, including 35.3 million refugees
and 62.5 million internally displaced people, around
26% of whom were women aged 18–59 years and
20% of whom were girls aged 0–17 years (20). The
scale and scope of humanitarian crises is increasing
worldwide, characterised by complex crises,
protracted crises, sudden-onset disasters, and slowonset disasters. For example, the number of acutely
malnourished pregnant and breastfeeding womenrose by 25% from 2020 to 2022, from 5.5 million
in 2020 to 6.9 million in 2022, across 12 countries
heavily affected by current food and nutrition
crises (21). Many countries move in and out of crises
periodically, and current humanitarian crises are
longer, more intense, and more disruptive than everbefore. Box 3 provides a summary of some of theways in which the vulnerability of women and girls
are heightened during humanitarian crises.

•	“Pregnant and lactating women should begiven this supplement [MMS] providing one
Recommended Nutrient Intake of micronutrients
daily, whether they receive fortified rations or not.”•	“MMS should be given until the emergency is over
and access to nutrient rich foods is restored.”Since the 2007 joint statement, therecommendations have been implemented tovarying degrees around the world, but data on
what micronutrient supplementation womenare receiving in humanitarian emergencies islacking. Note that in the context of routine ANC
care, WHO (2016) recommendations for a positive
pregnancy experience detail the provision of IFA
supplementation for all pregnant women in varying
therapeutic and preventive doses, dependingon whether anaemia has been diagnosed or not(16). A 2020 update to this guidance recommends
MMS only in the context of rigorous research (17).
Recently, MMS has been added to the WHO EML
as an antenatal supplement for pregnant women.
Readers are referred to ENN’s 2022 State of Play for
a comprehensive summary of all policies related tomicronutrient supplementation for adolescent girls
and women (4).

the 2007 joint United“SinceNations statement, theThe essential right for women to access anutritionally adequate diet is addressed in several
human rights instruments, as summarised in
UNICEF’s 2023 “Undernourished and Overlooked”
report and further expanded in Box 4.

recommendations have been
implemented to varying
degrees around the world, butdata on what micronutrient
supplementation women arereceiving in humanitarian
emergencies is lacking.

”



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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Box 3: Women’s and adolescent girls’ increased vulnerabilities during humanitarian emergencies.
Summarised from Lelijveld et al. (2022) (4).

Increased nutritional requirements and reduced intakes
Humanitarian crises, such as climate events, may impact women’s allocation of labour and/or intensify
workloads, increasing daily energy and nutrient requirements and the risk of maternal undernutrition
and micronutrient deficiencies. This, in turn, increases the risk of adverse infant outcomes for pregnant
and breastfeeding women and girls, as well as disrupting infant and young child feeding practices andchildcare. The risk of diarrhoeal and infectious disease increases during humanitarian crises, which often
results from mass migration and overcrowding, economic and environmental degradation, increased
poverty, limited access to safe water, poor sanitation and waste management, the absence of shelter,and poor access to healthcare (22). This can lead to the malabsorption or loss of nutrients, increasing
requirements for micronutrients and causing, or exacerbating, micronutrient deficiencies. Women andadolescent girls are often the ones who are most likely to restrict their food intake in favour of otherfamily members during times of short supply, either voluntarily or due to ongoing social and genderinequalities (22).

Increased risks for women and adolescent girls
Gender-based violence often increases during humanitarian crises as women’s status in society makes
them more vulnerable to exploitation, violence and abuse (23). Forced transactional sex and earlymarriage may also be more likely, resulting in more adolescent pregnancies and associated risks formaternal (and infant) nutrition and health. Some evidence indicates that women may be at greaterrisk of mental health problems, such as anxiety and depressive disorders and post-traumatic stressdisorders, during crisis situations (24).

Disruption of services and support
Access to routine health services (e.g., reproductive health services, ANC and obstetric care, andprevention of mother-to-child transmission of HIV services) is often disrupted during humanitariancrises. Reduced access may increase the risk of unwanted pregnancies, HIV transmission, reduced
access to interventions such as prenatal micronutrient supplementation, and pregnancy and delivery
complications for mother and baby. This may be particularly problematic in settings where reproductive
and maternal health services are already sub-optimal. Women’s health and nutrition is also affected by
reduced access to safe water and sanitation, which is commonly seen in emergency situations, alongwith poor-quality housing (25).

For the purposes of this report, we propose
an operational definition of a humanitarian
emergency as:

event or series of events“An
that represents a criticalthreat to the health, safety,
security or well-being of acommunity or other large
group of people, usually
over a wide area.

”



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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Box 4: The human right to adequate food and nutrition
The right to adequate food and nutrition is addressed in various international human rights
instruments. These instruments collectively contribute to the recognition and protection of the rightto adequate food and nutrition at the international level. Countries that are parties to these treaties are
expected to take measures to respect, protect and fulfil these rights. Some of the key instruments anddocuments include the following:
Universal Declaration of Human Rights (1948): encompasses the right to a standard of living that is
adequate for health and well-being, which includes access to food, and mentions the entitlement tospecial care and assistance for mothers and children (26).
International Covenant on Economic, Social and Cultural Rights (ICESCR, 1966): explicitly recognises
the right to an adequate standard of living, including adequate food, clothing and housing (27).
International Covenant on Civil and Political Rights (ICCPR, 1966): contributes to the right toadequate food by emphasising certain aspects of non-discrimination and the inherent right to life (28).
Universal Declaration on the Eradication of Hunger and Malnutrition (1974): describes the right ofevery individual to be free from hunger and malnutrition in order to develop and maintain full physicaland mental health (29).
Convention on the Elimination of all Forms of Discrimination Against Women (1979): emphasises
women’s right to access adequate healthcare services and highlights the importance of ensuring
women’s right to adequate nutrition during pregnancy and breastfeeding (30).
Declaration on the Right to Development (1986): recognises the right to development as an
economic, social, cultural and political process, with a focus on the realisation of the right to food. It
describes how women should have an active role in the development process (31).
Convention on the Rights of the Child (1989): addresses the right of the child to the highest attainable
standard of health, including the right to adequate nutritious foods and clean drinking water, as well as
appropriate prenatal and postnatal healthcare for mothers (32).
Voluntary Guidelines to Support the Progressive Realization of the Right to Adequate Food in theContext of National Food Security (2005): provide a framework for governments to implement theright to adequate food, with Guideline 10 focusing on nutrition (33).

Definition of humanitarian
emergencies
Various terms are used to describe different typesof emergencies and humanitarian contexts.
These terms frequently overlap and are usedinterchangeably. Some of the most common
terms are set out in Annex 3. For the purposes ofthis report, we propose an operational definitionof a humanitarian emergency as “an event orseries of events that represents a critical threat
to the health, safety, security or well-being of acommunity or other large group of people, usually
over a wide area”.7

This definition was chosen as it acknowledges thathumanitarian emergencies may be caused bymultiple concurrent events, it does not impose atime restriction on the resolution of the emergency,
and it encompasses the health and well-beingof communities. Using this definition, therecommendations from the 2007 United Nations
joint statement on the use of MMS in emergencies
would remain applicable (see Box 5).

7	This term is used by sources including WHO, UNFPA, and the
Humanitarian Coalition. See Annex 3 for more details andreferences.

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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Box 5: Can the United Nations jointstatement from 2007 apply to all
humanitarian contexts?
The United Nations joint statement (2007)
describes emergencies as transient situations
that may be resolved within a defined
timeframe before populations return to being
able to access nutrient-rich diets: “MMS should
be given until the emergency is over and accessto nutrient rich foods is restored” (1). However,
it is known that many populations may face
years of food insecurity due to protracted
conflicts, natural disasters (increasingly linked
to climate change) or a combination of these
events. Unless access to an adequate diet isachieved, the requirements for micronutrient
supplementation will likely remain. Evenin non-emergency settings, obtaining therecommended dietary intake of micronutrientsfrom food sources within an affordable diet isextremely difficult for pregnant women (34).
Where possible, context-specific analyses of
the nutritional status of pregnant women andadolescent girls is, of course, the preferred way
to determine what nutrition programming
requirements are. The guiding principles inregard to which interventions to prioritise
should consider the baseline nutritional
status, the vulnerabilities of women and girls
in humanitarian emergencies (Box 3) and thehuman right to adequate nutrition (Box 4).

The humanitarian system
While MMS provision is a suggested practicewithin humanitarian emergencies (Box 5), not
all humanitarian emergencies are covered bythe ‘humanitarian system’ nor by ‘international
humanitarian action’. It is important to note,
therefore, that there is no single system or platform
to leverage that will reach all those in need inhumanitarian emergencies. The ALNAP network
have some useful definitions, taken from their“State of the Humanitarian System” report (35):•	“Humanitarian action is the principled provisionof assistance and protection in order to save
lives, prevent and reduce suffering and preserve
people’s dignity in crises arising from armed
conflict, hazards and other causes.”•	“Humanitarian action is international whenthese activities involve resources (financial,technical or in-kind) provided by sources in
one country to respond to a crisis in another.
International humanitarian action excludes
responses that are fully resourced within the
country experiencing the crisis, which fall within
the domain of domestic crisis management.”
It can therefore be helpful to think about responses
to humanitarian emergencies in two maincategories:
1.	international humanitarian action (led by thenutrition cluster);
2.	domestic crisis management (government-led).
From the outset it must be noted that thehumanitarian system is complex and the above twocategories are not mutually exclusive. For example,
in many countries, government representatives arecentral to the coordination of the nutrition cluster,and in other countries United Nations agencies
may offer specific technical support within agovernment-led domestic crisis management
approach. However, given the fact that thetwo broad categories have different funding
mechanisms, and often different operational
approaches, it can be helpful to bear these broad
distinctions in mind when thinking about MMS
scale-up.

International humanitarian action
International humanitarian action is undertaken
or supported when local and national resources
are, on their own, insufficient to meet the needsof a population in crisis. Since 2005, the global
and country-level responses to humanitariancrises have been coordinated through the InterAgency Standing Committee- (IASC-) endorsed
global cluster and country-level cluster systems.
The cluster system supports country coordination
mechanisms in strategic decision-making,planning and strategy development, capacity
strengthening, advocacy, monitoring and reporting,and contingency planning/preparedness. Each of
the main sectors has a designated Global Cluster
Lead Agency that is responsible for ensuring
response capacity is in place for its sector andthat humanitarian activities are implemented incoordination with partners and following agreed
standards and guidelines. Women’s and girls’
nutrition predominantly sits within the Nutrition
Cluster, which is led by UNICEF.
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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

The decision to activate a cluster is only taken
when there are response and coordination gaps
due to a deteriorating humanitarian situationthat exceeds the national government’s existing
capacity.8 Furthermore, clusters are not permanent
coordination mechanisms; thus, at the end ofa crisis phase, the aim is to either resume or reestablish national coordination systems. Cluster
activities are informed by HRPs that outline theshared vision of how to respond to the needsof the population in crisis and are based on a
Humanitarian Needs Overview or other joint needs
assessment and analysis processes. HRPs aredeveloped by humanitarian country teams, which
include the coordinators of each cluster.
Funding, including funding for women’s nutrition,
comes through several mechanisms, many ofwhich are tracked through a financial tracking
service hosted by the United Nations Office for
the Coordination of Humanitarian Affairs. Cluster
partners commit resources to carry out specificactivities identified in the cluster response plansthat are based on the country HRP.
UNICEF also releases annual HAC appeals. These
detail the needs of children and women inhumanitarian emergencies. Current commitments
under HAC appeals relevant to maternal
micronutrient supplementation state that
“Pregnant women and breastfeeding mothers– with special attention to pregnant adolescent
girls and other nutritionally at-risk mothers –have access to a package of interventions that
includes at a minimum: iron and folic acid/multiple
micronutrient supplementation”. Hence, countries
may procure either IFA or MMS, depending on thepractice of the nutrition cluster in-country.
Readers are referred to Lelijveld et al. (2022) for moredetails on the international humanitarian system (4).

on actual MMS adherence“Datain humanitarian emergencies
is, at best, limited, and, at worst,
completely lacking.

”Domestic crisis management“Focusing on the international humanitariansystem to understand how people survive andrecover from a crisis is akin to viewing a large
landscape through a pin-sized hole.”(ALNAP, 2022) (35)
In many countries that are experiencing
humanitarian emergencies, the proportion offinancial resources from non-grant government
revenue and remittances can dwarf the amountreceived from international humanitarianassistance. Domestic crisis management refers
to situations where the government leads all
aspects related to the planning, financing andimplementation of humanitarian responses. The
responses will follow national development plans,
policies and protocols. Most external funding forgovernments comes from bilateral donors throughdevelopment aid (this also includes the World
Bank). Note that several countries show signs ofexerting increasing control over how humanitarian
responses are delivered, and by which agencies.
“In some contexts, governments feel in directcompetition with an international system that
actively disregards them.”(ALNAP, 2022) (35)

The number of women andadolescent girls reached by MMS
in humanitarian emergencies
There is currently no publicly available data on
MMS delivery in humanitarian emergencies. MMS
delivery is not captured routinely in Demographicand Health Surveys (DHSs) or in monitoring
platforms such as DHIS-2, nor is it routinely
captured in GNC annual reports. In 2022, it isestimated that Kirk Humanitarian donated 2.9
million bottles of MMS and WFP donated 100,000
bottles of MMS (6). However, it is not known how
many bottles from this amount reached areas
experiencing humanitarian emergencies, nor
the actual receipt of MMS bottles at healthcare
facilities or distribution to pregnant adolescent girls
and women. Data on actual MMS adherence inhumanitarian emergencies is, at best, limited, and,at worst, completely lacking.

8	The decision to activate a cluster is taken by the IASC-appointed
Emergency Relief Coordinator, collaborating with the relevant
Humanitarian Coordinator in-country.



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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Photo credit: © WFP/Geneva Costopulos

Section 2: Mapping MMS
across humanitarian
emergencies
Survey response profile
The survey was sent to respondents from 46 eligible
countries. A total of 131 individual responses wererecorded, from 39 (85%) of the 46 countries. Figure 1
provides an overview of responses, although they
were not equally distributed across countries. There
were a particularly high number of responses from
Uganda and Somalia.



The majority of the 131 responses came fromindividuals working for NGOs (63%), followed
by individuals in UNICEF country offices (24%),
governments (5%) and others (8%).

22Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Figure 1: Number of respondents per country

21

20

20

15

10

9
7

1

1

1

2

1

1

1

2 2

3

3 3
1

1

1

1

1

1

1

5

5

4

Nepal

2

3

Nicaragua

3

6
4

Mali

5

MexicoMyanmarNumber of respondents

25

3
1

1

1

1

2

3

2

Country

UgandaVenezuela
Yemen
ZambiaZimbabwe

Sudan
Syria

Niger

Nigeria
PakistanState of Palestine
Sierra Leone
SomaliaSouth Sudan
Sri Lanka

Kenya

LebanonMadagascar
Malawi

Haiti

Honduras
JordanDRC
Guatemala

Chad
Chile

BelizeBhutanBolivia
BurundiBurkina Faso
Cameroon

Afganistan
Bangladesh

0Survey findings
Table 2 shows that of the 39 countries that
responded, respondents from 28 countries
reported that they distributed MMS to womenin humanitarian programmes and 11 stated they
did not yet provide MMS. Of the 11 countries thatindicated there was no MMS provision, respondents
from seven countries reported plans to implement
MMS programming in the next year, respondents
from two countries (Chile and Sudan) were notsure of future plans for MMS distribution, and a
respondent from one country (Mali) reported
plans for future implementation research. Finally,a respondent from one country (Zambia) reported
no plans for future distribution.

Photo credit: ©
 WFP/Arete/Saiyna Bashir

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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Table 2: MMS provision
Countries

Are MMS provided for women/adolescent
girls in humanitarian emergencies?

Do you have plans to implement MMS
programming in the next year?*Afghanistan●●

Bangladesh●●

Belize●●Bhutan●●Bolivia●●

Burundi●●Burkina Faso●●

Cameroon

●

●

Chad

●

●

Chile

●

●

DRC

●

●

Guatemala

●

●

Haiti

●

●

Honduras●●

Jordan

●

●

Kenya

●

●

Lebanon●●Madagascar●●

Malawi

●

●

Mali

●

●

Mexico●●Myanmar

●

●

Nepal

●

●

Nicaragua

●

●

Niger

●

●

Nigeria●●

Pakistan●●State of Palestine●●

Sierra Leone●●

Somalia●●South Sudan●●

Sri Lanka

●

●

Sudan

●

●

Syria

●

●

Uganda●●Venezuela

●

●

Yemen

●

●

Zambia●●Zimbabwe●●

Legend:  ● Yes  ● No  ● Pilot or implementation research   ● Not sure   ● Not applicable*Responses exclusive to respondents stating that their agency was not currently providing MMS to women/adolescent girls.

24Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Who receives the MMS?

MMS on the EML

In most countries (27 out of 28), all respondents
stated that MMS in humanitarian programmes wasgiven to pregnant women. Twenty of these countries
also had respondents that said MMS was given tobreastfeeding women. A much smaller proportionof respondents suggested that they additionallygave MMS to non-pregnant women (six countries:
Guatemala, Malawi, Mexico, State of Palestine,
Somalia and Uganda) and adolescent girls (ninecountries: Lebanon, Malawi, Mexico, Pakistan, Stateof Palestine, Somalia, Syria, Uganda and Yemen).

Regarding the question of whether MMS appears
in the national EML, survey data recorded Yes (n=19 countries), No (n=14 countries), In process (n=5countries), Don’t know (n=1 country). However,when cross-checking with country’s published
EMLs, there were cases in which MMS did notappear on the list even where survey respondents
stated “yes”. This may be due to some confusion
around the process of at what stage products are
confirmed to be on the EML.

Barriers to programming MMS in
humanitarian emergenciesof MMS programming“Financing
was the most commonly

Figure 2 describes the barriers to MMS
programming at scale. Respondents were asked
to state the top three barriers to programming
MMS at scale in their country and the figure shows
the number of countries in which at least one
respondent ranked the stated barrier in their top
three. Financing of MMS programming was themost commonly stated barrier across countries,
by a large margin, followed by three similarlyranked barriers: inadequate country policy/
protocols, inadequate supply chain, and inadequateawareness among healthcare workers and target
populations of the benefits of MMS. Monitoringand evaluation of MMS was ranked least commonly
as a barrier to scale-up across countries.

stated barrier across countries,
followed by inadequate country
policy/protocols, inadequate
supply chain, and inadequateawareness among healthcare
workers and target populationsof the benefits of MMS.

”

Figure 2: Top three barriers to programming MMS at scale in humanitarian emergencies
Top three barriers: Inadequate
Funding

24

Country policy/protocol

15

Barriers

Supply chain for MMS

14

Awareness on the benefits of MMS

13

Coordination

6

Programme guidance5

Monitoring and evaluation of MMS programmes

4

Other (please specify)

3

0

5

10

15

20

25

30

Countries

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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Photo credit: © WFP/Arete/Saiyna Bashir

Section 3: Case study
summaries
Here we provide summaries of the two case studies.
We refer readers to the accompanying, separate casestudy reports for full details (Somalia and Pakistan).

Somalia
Somalia has been in a state of protracted crisis formany years, characterised by a complex politicalenvironment, extreme poverty, food insecurity,
conflict and instability. In recent years, Somalia
has faced devastating drought emergencies,
mainly as a result of reduced rainfall in mostparts of the country. In some areas, escalated
insecurity in recent years has resulted in new waves
of displacements. Alongside drier than normal
conditions that reduce milk availability below
normal levels, as well as the recent food price rises,
the deteriorating security situation has aggravatedthe already-poor nutrition situation.



MMS programming has been included as part of
ANC services in Somalia since the launch of the2014 National Micronutrient Deficiency Control
Strategy. MMS programming has also been
included in the national Maternal, Infant, YoungChild & Adolescent Nutrition (MIYCAN) strategy.
Somalia has 74 districts in total, of which 69 arelabelled “accessible” and the national MIYCAN
programme is active in all 69 accessible districts.
While geographic coverage of MMS through the
MIYCAN programme is therefore high, population
coverage of women reached with any kind of ANC
services remains low, at 31%. The MMS supply
chain has been reasonably stable under UNICEF’s
management and the distribution systemestablished both through health facilities andcommunity platforms, where staff and resources
allow, works well.

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However, there were some MMS supply breaks
during 2023 due to funding challenges; UNICEF
is working with the government on resource
mobilisation to help address these.
An earlier strategy (the Somalia National
Micronutrient Deficiency Control Strategy 2014–2016), dedicated to micronutrient deficiency
control in Somalia, did feature the use of MMS for
pregnant and breastfeeding women as one ofthe priority interventions to be implemented andreferred to the United Nations 2007 joint statement
on MMS use in emergencies. It is unclear why
MMS was not written into the updated (2020)
national nutrition and linked strategies, but thisdoes not appear to have affected its inclusion
in ANC components of the national nutrition
programme. It is likely, however, to have limited
the development of clear programme guidance
and protocols for the use of MMS, both of which
need considerable improvement. There is now
work ongoing that will help with this, including an
update to the Reproductive, Maternal, Neonatal,
Child and Adolescent Health Strategy 2020–2024
by the Ministry of Health and the development of
updated guidance for the current national MIYCAN
programme.
Key informants suggested that the primary reasonsfor the low population coverage of ANC services
include the need for more financial resources
and community-based staff who can accessand mobilise women to increase demand for,and access to, these ANC services. However, key
informants felt that if demand were to increase,it may be a challenge to ensure sufficient supply,
particularly as current stocks are entirely donor-/
UNICEF-dependent.
In summary, the key issues to address for scaling up
MMS in Somalia include the following: the revisionof national strategy and improving programme
guidance to clarify the protocols for MMS within
ANC provision; improving health worker motivation
and understanding to prioritise nutrition and MMS
within services for pregnant and breastfeeding
women; increasing demand among women
through more community mobilisation andimproved access to ANC services; stabilisation of
supply issues through support for buffer stocksof MMS at facility level; and more reliable funding
support from donors for the prevention of
micronutrient deficiencies and poor pregnancy
and birth outcomes.

Pakistan
Pakistan, the world’s fifth most populous country,
has shown progress in recent years with reducing
poverty, mortality rates, and increasing primaryschool enrolment and immunisation coverage.
However, persistent challenges such as population
growth and underdevelopment are being
intensified by recurring emergencies related to foodinsecurity, climate change, and the recent COVID-19
pandemic. In 2022, severe monsoons affected over
33 million people, leaving 20.6 million, including 9.6
million children, in need of humanitarian assistance.
Also in 2022, heavy rainfall in the southwest led to
flash floods, fatalities, and infrastructure damage,compounding vulnerabilities. Gender inequality,
exceptionally high fertility rates, particularly inthe poorest wealth quintiles, and limited accessto essential services further impacted child andmaternal nutrition and mortality outcomes.
Whilst Pakistan is in the early stages of programmingfor MMS, a strong enabling environment has recently
shaped political, institutional and policy processes
for improving maternal nutrition. Pakistan’sMaternal Nutrition Strategy 2022-2027 aims toprotect and promote diets, practices and services
that support the optimal nutrition, health, andwell-being of all women. The provision of MMS isa core intervention outlined in this strategy, which
includes a target to reach 50% of all women with
MMS programming by the end of 2027.
As part of health and nutrition services in Pakistan,
all MMS programming is overseen by the Ministryof National Health Services, Regulations, andCoordination (MoNHSR&C). There are several
organisations that have supported MoNHSR&C todeliver MMS as part of wider maternal nutrition
programming to date, including UNICEF,
Nutritional International, the Bill and Melinda Gates
Foundation, and many implementing partners. MMS
programming in districts experiencing humanitarian
emergencies have been delivered through routine
ANC services and as a separate emergency response.
Routine ANC programming delivered through thecountry’s health service and supported by UNICEF,
Nutrition International and other implementing
partners have delivered MMS across some of
the flood-affected districts and in Polio high risk
Union Councils (scattered across several districts).
Sufficient MMS to cover 500,000 pregnant women
was procured and distributed. Ongoing support forroutine ANC programming has spanned the nexus
between humanitarian and longer-term maternaland child nutrition programming.
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Distribution of MMS, as part of the emergency
floods response across two Provinces (Sindh andBalochistan), started at the beginning of 2023. Kirk
Humanitarian donated sufficient MMS to cover 2.2
million pregnant women. Over half of this donation
was distributed initially through small pilot
studies across seven districts, and then throughthe National Disaster Management Association(NDMA) of Pakistan as part of the emergency
response. The delivery of this MMS was initiallyorganised by the provincial level health directorate
to all pregnant women without being integrated
into ANC platforms. However, subsequently it has
been agreed that the remaining supply (sufficient
MMS to cover 1 million pregnant women) will
be delivered through the MoNHSR&C to ensure
standard protocols for MMS programming within
ANC programmes can be followed.

This is a real opportunity to improve the quality,
coverage and demand for ANC services, andstakeholders in Pakistan have identified key
priorities to support this. Resource mobilisation is
critically important and will require the leveraging
of mechanisms such as the nutrition match funds
and emergency donor support. Integrating MMS
programming into the existing health system
will need the development of clear guidance andcapacity building of health workers (both facility
and community based) to support the switch fromiron-folic acid to MMS. The inclusion of MMS on thenational essential medicines list that was achievedin December 2023, should support procurement,
financing and supply management, and key
informants are hopeful that initial explorations oflocal MMS production could potentially start tobring costs of the product down.

Important learning for MMS programming acrossall settings in Pakistan is emerging from theemergency distribution of MMS, alongside several
implementation research studies. The challenge
now is to translate the momentum on MMS
programming into policy and strategy, ensuringthat any learning is embedded into updated
programme guidance, along with effective delivery
within ANC programming across a complex
devolved health system.

Through collaborative efforts and strategic
prioritisation, Pakistan can continue to strengthenand scale up ANC services, including MMS
programming, and hence have a positive impact on
the nutritional status of women and their children
across all the diverse regions of the country.

Photo credit: © WFP/Arete/Saiyna Bashir28Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Photo credit: © WFP/Samantha Reinders

Section 4: Summary of
key findings
The key findings from the survey, case studies andadditional key informant interviews are compiled
and summarised here by WHO health systembuilding block. While all of the barriers identified
here were described by key informants in thecontext of humanitarian emergencies, they are notnecessarily exclusive to these settings but rather
reflect recurring themes found across the spectrumof humanitarian and development contexts.

Building block 1
Leadership and governanceAccording to most key informants, MMS
programming is increasingly recognised bygovernments as important for addressing
micronutrient deficiencies among women.

Support from non-government actors, such as
United Nations agencies, NGOs, researchers,
and donors with expertise in nutrition andmicronutrient supplementation, is often key
to supporting governments in many countries
to integrate MMS programming into national
nutrition policy and strategy.

Barriers
While the absence of MMS programming in
national policy and strategy has not always
prevented its programming in humanitarian
emergencies (e.g., in Somalia), it has often been
mentioned as a barrier to the development of clear
protocols and implementation guidance. Survey
respondents ranked inadequate country policy
and protocols as one of the top three barriers
to the programming of MMS in humanitarian
emergencies in 15 out of 28 countries.

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Key informants from some countries described
how current global guidance was confusing,ranging from stipulating that MMS should
only be used in ANC within the context ofrigorous research, to describing its use withinhumanitarian emergencies in addition to IFA(Section 1). They reported that this confusion
may be contributing to the lack of progress on
integrating MMS programming into national policy.
In turn, unless national policy indicates the use of
MMS, it can be difficult to scale up programmingeven in humanitarian emergencies, especially thosemanaged domestically.
Concerns that providing MMS to women in somecontexts may lead to over-supplementation or
micronutrient toxicity can act as a potential barrier
to including MMS programming in national policy.
Such concerns were raised by two key informants
in countries where, in some refugee settings, fooditems were already fortified with micronutrients,
such as iron and vitamin A, or other fortified
supplementary food items were used. According
to one of the key informants, these concerns werealso relevant to higher-income urban settings,
where women have access to higher-dose, overthe-counter micronutrient supplements in private
pharmacies. However, all other key informants
confirmed that they had no concerns about the riskof over-supplementation, especially in the context
of humanitarian emergencies.

Opportunities
The recent integration of MMS into national
policy, strategy and guidelines in many countries
is an important step towards scaling up delivery
and improving programme guidance for bothhumanitarian and development settings. Thereis increasing evidence (Section 1) and information
available on the benefits of switching from IFA
to MMS. Tools such as HMHB’s recently released
advocacy brief (36) can help to galvanise support
for MMS at national level.

national policy indicates“Unlessthe use of MMS, it can be difficult
to scale up programming evenin humanitarian emergencies,
especially those managed
domestically.

To support the development of clear
national guidance, it is important to update
and improve global guidance. This would
help to clarify protocols for both routine andhumanitarian settings and address concerns
such as over-supplementation in the context of
the range of programmes and services delivering
micronutrients. Some of this guidance is beginningto emerge, including the newly released interim
guidance on integrating antenatal MMS withanaemia treatment in pregnant women (37).
Since 2022, UNIMMAP MMS has been included
on the WHO global EML, which several key
informants reported makes it easier for MMS to be
procured, especially in the context of international
humanitarian responses. MMS is also beginningto be integrated into national EMLs – although inmany countries this is still in process. There is broad
understanding that this will support the scaleup of MMS more generally through leveraging
domestic resources for its purchase where there
is sufficient fiscal space, and by mobilising further
political commitment for its integration into ANC
programming. This could also help to address
breaks in MMS supply chains (see below).

Building block 2
Service delivery
Information from case studies and interviews
indicates that micronutrient supplementationis almost always integrated into health service
provision, mainly ANC. This is the case both ininternational humanitarian response and domestic
crisis management. Even during humanitarian
emergencies, micronutrient supplementation
often continues to be delivered via health facilities
that are generally government-run. Apart from
Somalia and the DRC, where MMS is programmed
at scale through the national health and nutrition
programme, MMS is largely delivered by smallerscale programmes and implementation researchor pilot projects, and is not yet part of routine
government programming at a national scale.
For example, many countries have a national IFA
programme and smaller-scale MMS programming/
implementation research or pilot projects in several
subnational locations – such as in Bangladesh,
Ethiopia, Madagascar, Nigeria, Sri Lanka andPakistan.

”



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All key informants stated that MMS is currently
provided free of charge in their countries
through humanitarian programming, and ismost commonly distributed for the prevention of
micronutrient deficiencies to pregnant women ona monthly basis as part of routine ANC. Frequency
of distribution can vary when access is restricted(e.g., in Somalia), when a two- or three-month
supply is given in some locations to overcome
access issues. The target group for MMS also
includes breastfeeding women up to six months
post-partum in many countries, and this is mostcommonly a continuation of supplementation thathas started during pregnancy. A much smaller
number of survey respondents suggested that
MMS has also been given to other groups, suchas non-pregnant women in some areas, althoughfollow-up would be needed for confirmation of theexact circumstances.

Barriers
Coverage of MMS among pregnant andbreastfeeding women in many humanitarian
programmes is limited due to a combination ofdifferent factors, many of which are similar to thebarriers faced by other interventions (particularly
IFA supplementation) delivered in these settings:•	Inadequate awareness among both
healthcare workers and target populationsof the importance and benefits of taking
micronutrients while pregnant. This was
identified as one of the top three barriers to MMS
programming in humanitarian settings in 13 outof 28 countries (see Figure 2).
•	Restricted access: both communities’ accessto health services and health staff’s access topopulations.
•	The generally poor quality of ANC services,
through which much of the MMS in
humanitarian emergencies is delivered.
•	Breaks in the MMS supply chain (see building
block 5 below).
• Inadequate financing (see building block 3).
•	Fears/misconceptions among pregnant andbreastfeeding women and their families aroundthe risks of supplementation increasing thesize of their baby and around the side effects ofsupplementation (although, as discussed below, inpractice this appears to be less of a problem thanfears and misconceptions associated with IFA).

There is also some confusion at service delivery
level over the different uses of MMS versus IFA for
prevention and treatment of anaemia. This is linked
to the lack of clear implementation guidance for
MMS in many countries (see above) and healthworker capacity challenges (see building block4 below), especially around issues such as theeffective diagnosis of, and treatment protocols for,anaemia at community level.

Opportunities
Improving guidance for MMS programming at
global level, along with the integration of MMS
into national strategies, would help to support
the development of improved implementation
guidance at national level, where this does not
currently exist.
There is broad agreement among implementersfrom many countries that once women are reachedthrough outreach and informed mobilisation, they
are keen to participate in, and are able to understandthe value of, broader ANC services, and they
understand the importance of taking micronutrientsduring pregnancy. There are examples, particularly
from Somalia and Madagascar, of leveraging
existing community health worker infrastructure
to improve mobilisation and outreach for ANC.
Some key informants stated the inclusion of MMS
in ANC packages reportedly encourages women
to attend health facilities. Furthermore, some key
informants provided anecdotal evidence suggesting
women prefer MMS over IFA due to fewer reportedside effects; e.g., key informants from Madagascar,
DRC, Somalia and Pakistan. This has also been noted
elsewhere (38), a contributing factor is likely to bethat UNIMMAP MMS contains a lower level of iron
(30 mg of elemental iron per tablet) than IFA, whichusually contains 60 mg of elemental iron per tablet.

key informants stated that“All
MMS is currently provided free ofcharge in their countries throughhumanitarian programming, andis most commonly distributed forthe prevention of micronutrient
deficiencies to pregnant women
on a monthly basis as part ofroutine ANC.

”

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Building block 3
Health system financing
Currently, resources to support all aspects of MMS
delivery through ANC in humanitarian programmingare largely donor-dependent. MMS supplies areusually resourced through non-government
agencies, such as UNICEF (Somalia, Madagascar,
Nigeria, Chad, Afghanistan, Ethiopia, Sri Lanka), andKirk Humanitarian (often via NGOs) (Sri Lanka, Chad,
Afghanistan, DRC, Pakistan). The survey findings
indicate that financing is by far the mostcommonly reported barrier (see Figure 2), withrespondents in 24 out of 28 countries placing
it in the top three barriers to taking MMS
programming to scale in humanitarian settings.
Lack of adequate financing impacts allcomponents of MMS programming, including
the ability to purchase supplies and providing
adequate health worker training.

Barriers
Some key informants from the case studies
described how meeting financial requirementsfor programming MMS within humanitarian
emergencies is challenging, explaining that there
were other critical nutrition programmes, suchas those treating child wasting, also remaining
underfunded. Sustainable funding opportunities
for MMS programming within ANC is therefore
an urgent priority, recognising that this willneed to part of a wider discussion on how toprioritise which interventions to fund in complex
situations with constrained resources.
At the time of writing, the majority of MMS tablets
distributed at country level are imported fromoverseas suppliers (see building block 5). Key
informants reported that the cost of purchasing
MMS is considerably higher than IFA. The factors
underlying this vary by country, but commonly
include the additional cost of MMS, which contains
15 different micronutrients (versus only two in IFA),
the need to import MMS (versus IFA, which is often
locally produced), and importation tax on MMS insome countries.

Opportunities
In recent years, increased attention has been given
to, and there has been increased understanding of,
the need for the prevention of child undernutritionin humanitarian contexts, among both researchers,
donors and practitioners (39).

Correspondingly, there is growing momentum
and evidence generation on the role of improved
maternal nutrition to reduce the risks of wastingand stunting in early childhood by reducing theprevalence of poor birth outcomes, such as low
birth weight (40). Scaled-up MMS provision could
play a vital role in prevention efforts.
Funding initiatives are emerging, such as
UNICEF’s Child Nutrition Fund (Box 6), that could
help to mobilise domestic funds for nutritioncommodities including MMS. There is also ongoing
research in some countries (e.g., Pakistan and
Nigeria) that is beginning to explore the feasibility
and cost advantage of local production of MMS.

Box 6: The Child Nutrition Fund
UNICEF’s Child Nutrition Fund (CNF) is a new
initiative that unites governments, donors
and implementing in supporting countrydriven initiatives that focus on the prevention,
identification, treatment, and ultimate
eradication of child wasting.
The fund support five key actions in 23 countries
affected by a high prevalence of child wasting:•	Weight gain monitoring, nutrition counselling,
micronutrient supplements (including MMS),
deworming, and malaria control for women,
particularly during pregnancy.
•	Support for exclusive and continued
breastfeeding in the first two years of life.
•	Adequate complementary foods, withmicronutrient supplements.
•	Food supplements for young children underfive years of age and for women – particularly
those who are pregnant and breastfeeding.
•	Early detection of child wasting and treatment
with ready-to-use therapeutic foods.
Several of the 23 countries have pockets ofhumanitarian crises, many of which are/will be
managed domestically. While the CNF does
not have a specific funding initiative tied tohumanitarian emergencies, governments thatreceive matching funds from the CNF could
leverage these resources in crisis-affected areasof their countries.
For more information, see:https://www.childnutritionfund.org/

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Building block 4
Health workforce
In many humanitarian emergencies MMS isdelivered through ANC services, usually provided
by government health staff. Occasionally – e.g., inPakistan and Somalia – staff in some locations arerecruited and supported by NGOs/United Nations
agencies where government health service capacity
is reduced. Regardless of which agencies areleading the health service response in humanitarian
emergencies, some common themes related tothe health workforce emerged in the key informant
interviews, and these are summarised below.

Barriers
In humanitarian emergencies, health staff
knowledge on the benefits of, and delivery protocols
for, MMS within ANC (and how this is integrated withor replaces IFA programming) is currently highly
dependent on in-service training and support.
However, this training and support tends to belimited, often only covering a small proportion of theoverall need, and is largely reliant on NGO-/United
Nations agency-funded programmes that include
an ANC/MMS support component.
As highlighted above in relation to building block
1, training and orientation for the delivery of MMS
in humanitarian programmes is challenging in
the absence of national strategy, protocols and/or guidance to support this, and this has led toconfusion around delivery protocols in some places.
Health staff capacity (both in terms of availabilityof staff, their existing workload and taskprioritisation) for a preventive intervention suchas MMS was flagged by key informants as achallenge in many countries. This is particularly
evident in humanitarian emergencies where
sometimes staff have had to make the choice toprioritise life-saving interventions, such as treatmentof wasting, and have needed to de-prioritiseinterventions such as prevention of micronutrient
deficiencies due to the limited funding and staff
capacity. Several key informants described how
community health outreach staff, who constitutea critical resource for mobilisation and improving
coverage of MMS, already have heavy workloads.
Further, in countries where additional nutritioninterventions have previously been implemented
along with incentives, it can be difficult to
integrate new activities when the remunerationof community outreach health staff is inadequate.



Opportunities
Improved in-service training, implementation
guidance and updated job descriptions could
help to strengthen health worker capacity todeliver MMS, with associated nutrition educationand counselling as a key component of ANC.
Similar to the opportunities with financing, therecent increased focus on the prevention of childundernutrition in humanitarian settings (seebuilding block 3) could be leveraged here. This
would provide opportunities for the scale-up of
support for the delivery of MMS through bothfacility-based and community-based workforces.

Building block 5
Supplies and technology
Information gathered for this report suggeststhat MMS used in humanitarian programmes iscurrently wholly imported from overseas, sourced
either through the UNICEF supply chain or via
Kirk Humanitarian, and then procured by UNICEF
country offices and NGOs, such as the Vitamin
Angels Alliance, in-country. Where funding is not an
issue and UNICEF or other international agencies
manage the procurement and distribution to
government and implementing partner facilities
and programmes, the supply chain works relatively
well: for example, in Somalia. However, there werealso reports from three key informants describing
situations where demand has grown quickly andsupply has struggled to keep up and/or takes time
to reach programme locations. Additionally, survey
respondents ranked inadequate supply chain as
one of the top three barriers to the programmingof MMS in humanitarian settings in 14 out of
28 countries (see Figure 2).

Barriers
Breaks in the supply of MMS at programme level are
relatively common in some places (e.g., Ethiopia andNigeria) but less so in others (e.g., Somalia and Sri
Lanka). Supply chain breaks are most commonly
linked to insufficient availability on the global
market, funding challenges (see building block 3
above), and/or to challenges with reporting andestimating need at health service level.
MMS tablets are supplied in bottles of 100 tabletsfrom the UNICEF supply catalogue and in bottlesof 180 tablets by Kirk Humanitarian. Many countries
adopt a protocol according to which the whole bottle
is given at once, so that the desiccant inside the bottle
continues to keep the tablets dry, and so as to reduce
the risk of tablets becoming discoloured over time.
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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

However, some key informants described how inorder to align distribution with eight ANC contacts(i.e., monthly visits during pregnancy), sometimes
the tablets from the bottles are decanted into
smaller packages at facilities for distribution, adding
to health staff workload. While blister packs of 30
are available through the UNICEF supply catalogue,
they are more expensive than the bottles, and thiscan be a barrier to their purchase.

Opportunities
There is considerable work being undertaken by
UNICEF Supply Division and key partners, including
Kirk Humanitarian and the Bill & Melinda Gates
Foundation, to develop a more reliable global supplyof MMS. Key actions needed include investment
to strengthen and support a network of regional
producers, the adoption of a global set of common
product standards (41), and encouraging moreprocurement commitments through mechanisms
such as the Child Nutrition Fund (Box 6). Linked
to this, the ongoing efforts in some countries todevelop local production of MMS (see building block3) could help to shorten the supply chain and easesome of the supply challenges. As demand for MMS
increases from countries that become interested in
MMS programming, this may encourage suppliers
to increase their production capacities.
To help alleviate breaks in supply at health facility
level due to unforeseen increases in demand and/or reporting issues, a buffer stock of MMS, heldby facilities/pharmacies, could offer a potential
solution, accompanied by proper forecasting andtraining on supply chain management.
The inclusion of MMS on national EMLs could
facilitate the procurement and distribution of the
supplement as part of national health and nutrition
programmes (see building block 1). This is of particular
relevance for humanitarian emergencies that are
responded to by domestic crisis management andtherefore follow national government protocols.

Building block 6
Information systems
Monitoring of the coverage of MMS programmingis only just beginning to be integrated into
national health information systems in a few
humanitarian settings, e.g., Somalia. In most places,
where it exists, monitoring and evaluation for MMS
programming relies on programme data collection
and reporting, usually put in place by UNICEF, andthis can be parallel to government systems.



Monitoring and evaluation of MMS was ranked as
the least common barrier to the programmingof MMS in humanitarian settings by survey
respondents (see Figure 2). This may be due tomost countries being in the early stages of MMS
programming, when addressing the issue of delivery
is perceived as more of a priority than monitoringand evaluation.

Barriers
Data from parallel (to government) systems forreporting on MMS in programmes – i.e., thosemanaged by non-governmental agencies – arereportedly not always easy to access for some
implementing partners. There were also reports
from some key informants of MMS and IFA being
reported under the same indicator – for example,
through UNICEF reporting systems in Pakistan– which can make it challenging to interpret thedata that is available. National surveys, such as the
DHS and national nutrition surveys, currently only
examine availability and self-reported adherenceof iron-containing tablets/syrups for pregnant
women. In addition, there were no reports fromstakeholders interviewed for this report of systems
in place to collect qualitative data on underlying
determinants of adherence to MMS.
All of this means that there are currently large
gaps in data, and therefore in our knowledgeof the coverage of MMS, at both national andhumanitarian programme level. Given that HRPs
rely first and foremost on an estimation of thenumber of people in need, these data gaps could
be a barrier to ensuring MMS programming is built
into HRPs, fundraised for, and delivered.

Opportunities
The integration of MMS into DHIS2 in all countries
where it is programmed, as well as into relevant
national surveys, is important to strengthen our
understanding of coverage of MMS programming.
This is already beginning to happen in some places– e.g., Somalia and Pakistan – and these earlyexperiences and pilots will hopefully contributelearning for other countries. In humanitarian
emergencies, improved monitoring andevaluation should lead to better forecasting,better inclusion in HRPs and a greater chanceof MMS programming being funded. Developing
approaches to monitor adherence to MMS will bealso important to understand the effectiveness of
MMS programming within ANC.
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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Photo credit: © UNICEF Somalia

Section 5: Summary andconclusions
The overlap between
humanitarian and development
programming for MMS
The information compiled for this report highlights
a significant and growing interest in MMS
programming in humanitarian emergencies, yet
MMS programming is currently not being deliveredat scale in these contexts. We have summarised
the key themes coming from the survey, casestudies and key informant interviews, all in thecontext of humanitarian emergencies. As previously
mentioned, these themes are not necessarily
exclusive to these humanitarian emergencies,
as they describe recurring topics found acrossthe spectrum of humanitarian and development
contexts. Furthermore, when humanitarian crises
are responded to under government-led (i.e.,
domestic) crisis management approaches, theactivities are largely based on national protocols.
Whether domestically led or nutrition cluster-led
under an international humanitarian response, theplatforms for MMS delivery are largely the same,with some nuances in staffing, procurement,planning and funding details.
All of this means that there is a large overlap in thechallenges to, and opportunities for, micronutrient
supplementation within humanitarian
emergencies and routine programming. To
illustrate this point further, Table 3 provides asummary of the key themes explored in this reportand provides two scenarios: the first assumes anentirely internationally led humanitarian response
through the nutrition cluster system, using MMS
programming; the second assumes the opposite
end of the spectrum, where a government is fully
leading the response with domestic management
and resourcing. We then provide a ‘reality check’in a separate column to illustrate the real-lifecomplexities and variations found. In a final column,
we describe how, regardless of the modality ofhumanitarian response, the key messages arebroadly similar.

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Table 3: Summary of MMS programming by different types of humanitarian response and associated key messages

Leadership and governance

Theme



What the reality can look like:Key messages

Scenario A:

Scenario B:

100% international
humanitarian response

100% domestic crisis
management

Hypothetical scenario
where MMS is used

Hypothetical scenario
where MMS is used

Who leads the
response?

Nutrition Cluster, mostly
UNICEF-led, UNHCR in
refugee settings.

Government, ministryof health/nutrition
departments.

Wide variety of leadershiprepresentation andcombinations; e.g., governmentled with UNICEF secondments
filling capacity gaps; UNICEF-led
with close government support;
technical advisory groups madeup of government and nongovernment members; etc.

Whoever is leading overall,
it is essential for relevant
nutrition and health teams toclosely coordinate to ensure
programming of MMS isadequately planned for,budgeted and resourced within
ANC services.

What
guidelines/
protocols areapplicable?

2007 United Nations jointstatement.

National ANC guidelines
and protocols.

The 2007 United Nations jointstatement is inconsistently
applied, even in Nutrition
Cluster-led approaches. Choiceof micronutrient supplement
used varies according todecision-making by country
nutrition cluster-leads.

MMS programming needs tobe written into national ANC
protocols if it is to be scaledup, especially in governmentled responses to humanitarian
emergencies.

Topic

Regardless of scenario

Global (WHO) ANC guidelines
influence national ANC guideline
development to varying
degrees – some countries takethe lead from global WHO
guidelines; other countries
have already updated national
ANC guidelines to include MMS
implementation.

ANC guidelines at global levelalso need updating. Increased
clarity within global WHO
ANC guidelines on the use of
MMS in general, as well as forhumanitarian emergencies, will
help reduce potential confusion.
User-friendly implementation
guidance for MMS programmingis required for healthcare
workers.

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Table 3: Summary of MMS programming by different types of humanitarian response and associated key messages continued
Theme

Topic

Service delivery

Who istargeted
with MMS
programmingand how often?

What delivery
platforms areused?

Scenario A:

Scenario B:

100% international
humanitarian response

100% domestic crisis
management

Hypothetical scenario
where MMS is used

Hypothetical scenario
where MMS is used

Pregnant women andadolescent girls.

Pregnant women andadolescent girls.

MMS tablets procured inbottles of 100/180 tablets orblister packs of 30 tablets.
Mainly monthly supplies
are distributed, occasionally
three-monthly supplies inareas with poor access tohealthcare.

MMS tablets procured inbottles of 100/180 tablets orblister packs of 30 tablets.
Mainly monthly supplies
are distributed, occasionally
three-monthly supplies inareas with poor access tohealthcare.

Through ANC at healthfacility level: NGO or United
Nations-run.

Through ANC at healthfacility level; governmentrun.

Limited use of community
health worker (CHW)
distribution at household
level; NGO or United
Nations staff.

Limited use of CHW
distribution at household
level; government staff.

What the reality can look like:Key messages
Regardless of scenario

There is very little data on who istargeted for MMS programmingin humanitarian emergencies
and what the coverage is.
Adolescent girls are often notdisaggregated in available data.
Often, larger bottles (100 or 180
tablets) of MMS are procured;reports in some countries oftablets being decanted into
smaller monthly batches, unlessmonthly blister packs are used.
Community-level mobilisation
for MMS programming iscurrently weak; use of CHWs todeliver MMS at household levelis still largely at implementation
research level.
Training and orientation fordelivery of MMS is challenging in
the absence of guidance basedon national protocols.

The current reality is that
MMS programming is not
being delivered at scale inhumanitarian emergencies.
IFA is more commonly usedat national scale, with MMS
being used in some subnational
pockets of high need, or in
implementation research.

Increased investment in, and useof, community-based healthcare
structures is needed to improvecoverage of MMS programming.
Clear guidance and job aids foruse by frontline health workers
are required.

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Table 3: Summary of MMS programming by different types of humanitarian response and associated key messages continued
Theme

Topic

Who funds
MMS
programming?

Scenario A:

Scenario B:

100% international
humanitarian response

100% domestic crisis
management

Hypothetical scenario
where MMS is used

Hypothetical scenario
where MMS is used

United Nations and other
donors.

Government, United
Nations and other donors.

Financing

HRPs

National nutrition plans

Key messages
Regardless of scenario

Currently, all MMS programming
is financed by United Nations,
NGOs and philanthropies suchas Kirk Humanitarian, althoughmatch fund initiatives areunderway that may provide
mixed government and donor
funding for MMS programming,
including in areas that arevulnerable to humanitarian
emergencies.
In some countries that currently
use IFA at the national scale,government funding is used, withoccasional top-up from donors
in acute emergencies. In othercountries, IFA programming is
still donor-dependent.

How areresources
planned for,budgeted andfundraised for?



What the reality can look like:

Too often the nutritional needsof women and adolescent girls
are not adequately quantified
in planning documents forhumanitarian responses. Without
better data and documentationof the needs it is then difficult – oreven impossible – to adequately
cost and fundraise for theidentified needs, especially where
funding is limited.

If MMS programming is
to be scaled up across all
humanitarian emergencies,
sustainable financing will bea critical issue given the levelof current donor dependence.
Match funds, such as the Child
Nutrition Fund, will hopefully
provide opportunities fordomestic and donor funds to be
directed towards MMS supplies
and programming costs.

Whether in humanitarian or
national plans, the nutritional
needs of women and adolescent
girls should be consistently
captured in documents that areused for fundraising and activity
prioritisation purposes.
Funding is also required
for nutrition surveys/needs
assessments, to underpin theestimation of realistic targets.

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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Table 3: Summary of MMS programming by different types of humanitarian response and associated key messages continued

Information systems

Supplies andtechnology

Theme



Topic

Who supplies
the MMSand how is it
procured?

How is MMS
coveragemonitored?

Scenario A:

Scenario B:

100% international
humanitarian response

100% domestic crisis
management

Hypothetical scenario
where MMS is used

Hypothetical scenario
where MMS is used

Largely sourced from
Kirk Humanitarian and/or UNICEF and delivered
through non-government
implementing partners.

Largely sourced by Kirk
Humanitarian and/or
UNICEF and delivered
through government
health staff.

All MMS procured
internationally; MMS now
on global EML, which is
helpful.

All MMS procured
internationally, MMS now
on some national EMLs,
which is helpful.

DHIS-2, where MMS
coverage indicator is
included.

DHIS-2, where MMS
coverage indicator is
included.

Parallel United Nations or
NGO monitoring systems.

What the reality can look like:Key messages
Regardless of scenario

In many countries, MMS is not
yet on the national EML. Somecountries want to scale up MMS
programming, including inhumanitarian emergencies, but
are concerned that global supply
is a bottleneck.

Regional/local production of
MMS could ease issues with
import and procurement fromthe global market.

The reality is that not all
countries have updated
DHIS-2 nutrition modules tocapture MMS coverage. DHS
and Standardised Monitoringand Assessment of Relief andTransitions (SMART) surveys do
not collect information on MMS
coverage or adherence. either

DHIS-2 should be updated toinclude an indicator on MMS
coverage and training should be
provided for health staff on useof the DHIS-2 nutrition module
at different levels of data entry
and analysis.

Including MMS in national EMLs
may also help with procurement
and national supply chain issues.

Inclusion of MMS coverage
indicators in SMART and DHS
surveys will also help withgenerating required datafor planning, scale-up andmonitoring.

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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Conclusions
MMS, a much-improved product in terms ofeffectiveness for improving nutrition, is seen
by many as a welcome opportunity to improvematernal health and pregnancy outcomes, including
through the opportunity to revitalise quality ANC
services more generally. However, replacing IFA
with MMS cannot happen successfully without
investment in overcoming numerous barriers
that span programming across the humanitariandevelopment nexus (see Table 3).
Some of the most critical actions required toovercome these barriers include:•	integrating MMS programming into national
policy and strategy;

In conclusion, while humanitarian emergencies
undeniably present additional, complex barriers
to MMS programming coverage, what is neededto address them in these contexts remains
fundamentally the same as what is needed in all
settings: namely, using the lens of health systems
strengthening to make MMS programming aseffective as possible within quality ANC services.
The opportunities this will bring are essential for theoverall health and well-being of pregnant womenand adolescent girls, and will help ensure we fulfil
our obligations to fully support their human right toadequate nutrition.

•	investing in training health staff and sensitisingtarget populations on the significant benefits of
MMS for both maternal and birth outcomes.

Box 7: Ways for readers to share theirexperiences of MMS programming inhumanitarian emergencies

Reducing the costs of, and improving the overall
financing for, MMS programming is essential
for improving coverage, and, as part of this,improvements in the global supply chain andfurther exploration of regional and local production
are needed. Recognition of the importance of, andimprovements in, monitoring and evaluation tomeasure MMS coverage is also required. This will help
produce more accurate estimates of the number ofpeople in need and related costings for inclusion inhumanitarian response planning, national nutrition
plans, and associated funding cycles.

If you are involved in programming MMS
in humanitarian emergencies and see thatyour mode of programme delivery or specifichumanitarian context has not been captured inthis report, we would love to hear from you sothat your learning can be shared with others.

Addressing these barriers is, of course, daunting inhumanitarian emergencies, yet there is relevant
documentation from implementation researchfrom several countries, including Madagascar (5),Haiti and Ethiopia (38), that is helping to generatecontext-specific evidence on what works that
others can learn from. Furthermore, the MMS
programming constraints and opportunities
described here are not new – there is a large
amount of learning already generated around thechallenges of IFA programming that is particularly
relevant, given that the platforms for delivery of
both IFA and MMS are the same (42).
This report has provided a snapshot of the state of
MMS programming in humanitarian emergencies
but undoubtedly has not captured all relevant
programme experiences and contexts. We
encourage readers to engage with us to shareadditional experiences and thoughts: somesuggested ways to do so are outlined in Box 7.
You could submit an article to Field Exchange,
our technical publication that shares experiencesin nutrition programming and policymaking, orfeel free to tag us on X (Twitter@ennonline) or
LinkedIn to start a conversation. We look forward
to hearing from you.

humanitarian emergencies“Whilepresent complex barriers to MMS
programming, what is needed toaddress them remains fundamentallythe same as in all settings: namely,using the lens of health systems
strengthening to make MMS
programming as effective as possible
within quality ANC services.

”

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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

References
1.	WHO, WFP, UNICEF. (2007). Preventing andcontrolling micronutrient deficiencies in
populations affected by an emergency: multiple
vitamin and mineral supplements for pregnant
and lactating women, and for children aged 6 to
59 months. https://www.who.int/publications/m/
item/WHO-WFP-UNICEF-statementmicronutrients-deficiencies-emergency
2.	Mates, E., Khara, T. (2012). Maternal Nutrition
in Emergencies. Summary of the state of play
and key gaps. Emergency Nutrition Network.
https://www.ennonline.net/ourwork/othermeetings/
maternalnutrition
3.	James, P.T., Wrottesley, S.V., Lelijveld, N.,
Brennan, E., Fenn, B., Menezes, R., & Mates,
E. (2022). Women’s nutrition: A summaryof evidence, policy and practice including
adolescent and maternal life stages. Emergency
Nutrition Network. https://www.ennonline.net/
womensnutritionasummarytechnicalbriefingpaper
4.	Lelijveld, N., Brennan, E., Akwanyi, B., Wrottesley,S., & James, P. (2022). Nutrition of womenand adolescent girls in humanitariancontexts: current state of play. Emergency
Nutrition Network. https://www.ennonline.net/
humanitariannutritionforwomen
5.	Akwanyi B., & Wrottesley, S.V. (2022). Nutrition of
women and adolescent girls in humanitariancontexts – Case study: Madagascar. https://www.
ennonline.net/humanitariannutritionforwomen_
madagascar
6.	van Liere, M.J., Mwangi, M.N., & James, P. (2023).
Accelerating the Delivery and Use of MMS in
Humanitarian Contexts. Sight and Life Special
Report: Focusing on Multiple Micronutrient
Supplements in Pregnancy: Second Edition. Sight
and Life Foundation. https://sightandlife.org/
resource-hub/magazine/mms-second-edition
7.	UNICEF (2022). Multiple Micronutrient
Supplementation (MMS), an approach to
improving the quality of nutrition care for mothers
and preventing low birthweight.
8.	MMS-TAG (2023). Update on the Scientific Evidence
on the Benefits of Prenatal Multiple Micronutrient
Supplements. Sight and Life Special Report;
Focusing on Multiple Micronutrient Supplements
in Pregnancy: Second Edition. Sight and LifeFoundation. https://sightandlife.org/resource-hub/magazine/mms-second-edition

9.	Keats, E.C., Das, J.K., Salam, R.A., Lassi, Z.S., Imdad,A., Black, R.E. et al. (2021). Effective interventions toaddress maternal and child malnutrition: an updateof the evidence. The Lancet Child & Adolescent
Health, 5(5), 367–84. https://doi.org/10.1016/S23524642(20)30274-1
10.	Gomes, F., Agustina, R., Black, R.E., Christian, P.,
Dewey, K.G., Kraemer, K. et al. (2022). Multiple
micronutrient supplements versus iron-folic acidsupplements and maternal anemia outcomes:
an iron dose analysis. Annals of the New York
Academy of Sciences, 1512(1), 114–25. https://doi.
org/10.1111/nyas.14756
11.	Smith, E.R., Shankar, A.H., Wu, L.S.F., Aboud, S.,
Adu-Afarwuah, S., Ali, H. et al. (2017). Modifiersof the effect of maternal multiple micronutrient
supplementation on stillbirth, birth outcomes,
and infant mortality: a meta-analysis of individual
patient data from 17 randomised trials in lowincome and middle-income countries. The
Lancet Global Health, 5(11), e1090–100. https://doi.
org/10.1016/S2214-109X(17)30371-6
12.	Liu, E., Wang, D., Darling, A.M., Perumal, N., Wang,
M., Ahmed, T. et al. (2022). Effects of prenatal
nutritional supplements on gestational weightgain in low- and middle-income countries: a metaanalysis of individual participant data. Am J Clin
Nutr, 116(6), 1864–76. https://doi.org/10.1093/ajcn/
nqac259
13.	Keats, E.C., Akseer, N., Thurairajah, P., Cousens, S.,& Bhutta, Z.A., Global Young Women’s Nutrition
Investigators’ Group (2022). Multiple-micronutrient
supplementation in pregnant adolescents in lowand middle-income countries: a systematic review
and a meta-analysis of individual participant data.
Nutr Rev., 80(2), 141–56. https://doi.org/10.1093/nutrit/
nuab004
14.	Hoddinott, J., Larsen, B., & Razvi, S. (2023).
Nutrition Halftime: Best investments for the
SDGs. Copenhagen Consensus Center. https://copenhagenconsensus.com/sites/default/
files/2023-03/Nutrition%20Best%20Investment%20
Manuscript%20230211.pdf

41

Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

15.	Flaxman, A.D., Bowman, A., & Young, N. (2023)
Cost-effectiveness of multiple micronutrient
supplementation compared to iron and folic acidsupplementation in India, Pakistan, Mali andTanzania: Results of a microsimulation study.
Sight and Life Special Report; Focusing on
Multiple Micronutrient Supplements in Pregnancy:
Second Edition. Sight and Life Foundation.
https://sightandlife.org/resource-hub/magazine/
mms-second-edition
16.	World Health Organization (2016). WHO
recommendations on antenatal care for a positive
pregnancy experience. https://www.who.int/
publications/i/item/9789241549912
17.	World Health Organization (2020). WHO antenatal
care recommendations for a positive pregnancy
experience: nutritional interventions update:multiple micronutrient supplements during
pregnancy. https://www.who.int/publications/i/
item/9789240007789
18.	United Nations Office for the Coordination of
Humanitarian Affairs (2023). Global Humanitarian
Overview 2023. https://www.unocha.org/
publications/report/world/global-humanitarianoverview-2023-july-update-snapshot-31-july-2023
19.	UNFPA (2023). Humanitarian Appeal 2023.
https://www.unfpa.org/HAO2023-appeal
20.	UNHCR (2023). Global Trends: Forced
Displacement in 2022. https://www.unhcr.org/
global-trends-report-2022
21.	UNICEF (2023). Undernourished and Overlooked:
A Global Nutrition Crisis in Adolescent Girls andWomen. UNICEF Child Nutrition Report Series.
https://www.unicef.org/reports/undernourishedoverlooked-nutrition-crisis
22.	Fuhrman, S., Kalyanpur, A., Friedman, S., Tran, N.T.
(2020). Gendered implications of the COVID-19
pandemic for policies and programmes inhumanitarian settings. BMJ Global Health, 5(5),e002624. https://doi.org/10.1136/bmjgh-2020-002624
23.	O’Brien, M., Tolosa, M.X. (2016). The effect of the2014 West Africa Ebola virus disease epidemic on
multi-level violence against women. International
Journal of Human Rights in Healthcare, 9(3),151–60. https://doi.org/10.1108/IJHRH-09-2015-0027

25.	Singh, N.S., Ataullahjan, A., Ndiaye, K., Das, J.K.,
Wise, P.H., Altare, C. et al. (2021). Delivering healthinterventions to women, children, and adolescentsin conflict settings: what have we learned from ten
country case studies? Lancet, 397(10273), 533–42.
https://doi.org/10.1016/S0140-6736(21)00132-X
26.	UN General Assembly (1948). Universal
Declaration of Human Right. Sect. 217 A (III)1948. https://www.un.org/en/about-us/universaldeclaration-of-human-rights
27.	UN General Assembly (1966). International
Covenant on Economic, Social and Cultural Rights.
Sect. Treaty Series, Vol. 993. https://treaties.un.org/
doc/Treaties/1976/01/19760103%2009-57%20PM/
Ch_IV_03.pdf
28.	UN General Assembly (1966). International
Covenant on Civil and Political Rights.
https://www.ohchr.org/en/instrumentsmechanisms/instruments/international-covenantcivil-and-political-rights
29.	UN General Assembly (1974). Universal Declarationon the Eradication of Hunger and Malnutrition[Internet]. Sect. 3348 (XXIX). https://www.ohchr.
org/en/instruments-mechanisms/instruments/
universal-declaration-eradication-hunger-andmalnutrition
30.	UN General Assembly (1979). Convention on the
Elimination of All Forms of Discrimination against
Women. https://www.ohchr.org/en/instrumentsmechanisms/instruments/convention-eliminationall-forms-discrimination-against-women31.	UN General Assembly (1986). Declaration on the
Right to Development. https://www.ohchr.org/en/
instruments-mechanisms/instruments/declarationright-development
32.	UN General Assembly (1989). Convention on
the Rights of the Child]. Sect. Treaty Series, vol.
1577. https://www.ohchr.org/en/instrumentsmechanisms/instruments/convention-rights-child33.	FAO (2005). Voluntary Guidelines to Support theProgressive Realization of the Right to Adequate
Food in the Context of National Food Security.
https://www.fao.org/3/y7937e/y7937e.pdf

24.	Salari, N., Hosseinian-Far, A., Jalali, R., Vaisi-Raygani,A., Rasoulpoor, S., Mohammadi, M. et al. (2020).
Prevalence of stress, anxiety, depression among
the general population during the COVID-19
pandemic: a systematic review and meta-analysis.
Globalization and Health, 16(1), 57. https://doi.
org/10.1186/s12992-020-00589-w

42

Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

34.	Wessells, K.R., Young, R.R., Ferguson, E.L.,
Ouédraogo, C.T., Faye, M.T., Hess, S.Y. (2019).
Assessment of Dietary Intake and Nutrient
Gaps, and Development of Food-Based
Recommendations, among Pregnant andLactating Women in Zinder, Niger: An Optifood
Linear Programming Analysis. Nutrients, 11(1), 72.
https://doi.org/10.3390/nu11010072
35.	ALNAP (2022). The State of the Humanitarian
System (SOHS). https://sohs.alnap.org/2022the-state-of-the-humanitarian-system-sohs%E2%80%93-full-report [Cited 13 December 2023].
36.	HMHB Consortium (2023) Nutrition resilience ofmothers and their babies. Antenatal MMS: Oneof the best bets for global development. Healthy
Mothers Healthy Babies and the Micronutrient
Forum (Advocacy Brief). https://hmhbconsortium.
org/read-the-new-advocacy-brief-on-mms-one-ofthe-best-bets-for-development/37.	MMS TAG (2023). Interim Guidance for Concurrent
Antenatal Multiple Micronutrient Supplementation
and Anemia Treatment in Pregnant Women.
HMHB Consortium https://impekacdn.s3.us-east-2.
amazonaws.com/hmhbconsortium.org/content/
user_files/2023/10/09064704/HMHB_GuidanceMMS-Anemia_WEB.pdf

40.	Mertens A, Benjamin-Chung J, Colford JM, Coyle J,van der Laan MJ, Hubbard AE, et al. (2023). Causes
and consequences of child growth faltering in lowresource settings. Nature, 621, 568–576. https://doi.
org/10.1038/s41586-023-06501-x
41.	Ajello, C.A., Atwater, J.B. & de Lange, J. (2023).
Product standardization and verification: Criticalto UNIMMAP MMS availability and accessibility.
Sight and Life Special Report: Focusing on Multiple
Micronutrient Supplements in Pregnancy:
Second Edition. Sight and Life Foundation.
https://sightandlife.org/resource-hub/magazine/
mms-second-edition
42.	MoNHSR&C, Nutrition International, UNICEF(2022). Iron Folic Acid Bottleneck Analysis Report.
Nutrition Wing, Ministry of National Health Services,
Regulation and Coordination, Government ofPakistan, Nutrition International & UNICEF.
Available from: https://www.unicef.org/pakistan/reports/iron-folic-acid-bottleneck-analysis-report38.	Sight and Life Foundation (2023). Focusing on
Multiple Micronutrient Supplements in Pregnancy.
Sight and Life Special Report. https://sightandlife.
org/resource-hub/magazine/mms-second-edition
39.	WHO, WFP, UNICEF (2020). Global Action Planon Child Wasting: A Framework for Action to
Accelerate Progress in Preventing and Managing
Child Wasting and the Achievement of the
Sustainable Development Goals. https://www.who.
int/publications/m/item/global-action-plan-onchild-wasting-a-framework-for-action

43Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Annex 1: Collation of selected MMS resources

Resource title

Resource
type

Year ofpublication

Institution (name of authors)

Link

Antenatal multiple micronutrient supplements versus iron‐folic acidsupplements and birth outcomes: Analysis by gestational age assessment
methodOriginal article

2023

Filomena Gomes, Sufia Askari, Robert E. Black et al.

Link

Interim Guidance for Concurrent Antenatal Multiple Micronutrient
Supplementation and Anemia Treatment in Pregnant Women

Guidance

2023

HMHB and MMS-TAG

Link

Addressing micronutrient deficiencies amongst women and girls inhumanitarian or emergency contexts

Policy brief

2023

HMHB and Micronutrient Forum

Link

Small Vulnerable Newborns

Journal series

2023

The Lancet

Link

Undernourished and Overlooked: A global nutrition crisis in adolescent girls
and women

Report2023

UNICEF

Link

Women’s nutrition: A summary of evidence, policy and practice including
adolescent and maternal life stages

Review

2022

ENN

Link

Nutrition of women and adolescent girls in humanitarian contexts – Case study:
Madagascar

Case study

2022

ENN

Link

Nutrition of women and adolescent girls in humanitarian contexts: Current
state of play

Review

2022

ENN

Link

Micronutrient supplements in pregnancy: an urgent priority

Correspondence

2022

Filomena Gomes, Robert E Black, Emily Smith et al., onbehalf of the MMS-TAG

Link

Multiple micronutrient supplements versus iron-folic acid supplements andmaternal anemia outcomes: an iron dose analysis

Original article

2022

Filomena Gomes, Rina Agustina, Robert E. Black et al.

Link

Effect of multiple micronutrient supplements v. iron and folic acid supplementson neonatal mortality: a reanalysis by iron dose

Commentary2022

Filomena Gomes, Rina Agustina, Robert E. Black et al.

Link

Multiple Micronutrient Supplementation: Frequently Asked Questions

FAQs

2022

HMHB

Link

Advocating for Safe, Affordable, and Cost-effective Nutrition Interventions to
Improve Maternal Health

Advocacy brief

2022

HMHB

Link

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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Resource title

Resource
type

Year ofpublication

Institution (name of authors)Link

MMS Advocacy Slide Deck

Advocacy slide
deck

2022

HMHB

Link

UNIMMAP MMS for National Health Systems: Considerations for Developing a
Supply Strategy

Guidance
document

2022

Kirk Humanitarian

Link

Focusing on Multiple Micronutrient Supplements in Pregnancy: Second Edition

Special report2022

Sight and Life

Link

Maternal Nutrition: Prevention of malnutrition in women before and during
pregnancy and while breastfeeding

Programming
guidance

2022

UNICEF

Link

Counselling to Improve Maternal Nutrition: Considerations for programmingwith quality, equity and scaleTechnical brief

2022

UNICEF

Link

Multiple Micronutrient Supplementation: An approach to improving the qualityof nutrition care for mothers and preventing low birthweight

Advocacy brief

2022

UNICEF

Link

Formative Research Guidance: Introducing Multiple Micronutrient
Supplements (MMS)

Guidance
document

2022

UNICEF

Link

Formative Research to Tailor Maternal Nutrition Services: Introducing Multiple
Micronutrient Supplements (MMS) for Pregnant Women in Rural Madagascar

Poster abstract

2022

UNICEF

Link

Global anaemia reduction efforts among women of reproductive age: impact,
achievement of targets and the way forward for optimizing efforts

Desk review

2022

WHO

Link

Interventions to increase adherence to micronutrient supplementation during
pregnancy: a systematic review

Systematic
review

2021

Filomena Gomes, Shannon E. King, Diana Dallmann et al.

Link

A Step Forward for Women’s Nutrition During Pregnancy Multiple
Micronutrient Supplementation (MMS): The WHO’s Model List of Essential
Medicines (EML) An FAQ and Advocacy Brief for Inclusion of MMS into theWHO’s Model List of Essential Medicines

FAQs andadvocacy brief

2021

HMHB, MMS-TAG, and the New York Academy of Sciences(NYAS)

Link

Maternal Nutrition and Multiple Micronutrient Supplementation: A
Commitment Guide for Tokyo’s 2021 Nutrition for Growth Summit

Commitment
guide

2021

HMHB

Link

Multiple-micronutrient supplementation in pregnant adolescents in low- andmiddle-income countries: a systematic review and a meta-analysis of individual
participant data

Systematic
review

2021

Emily C. Keats, Nadia Akseer, Pravheen Thurairajah et al.

Link

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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Resource title

Resource
type

Year ofpublication

Institution (name of authors)Link

A tool to aid decision-making transitioning from IFAS to MMS

Learning
resource

2021

Nutrition International

Link

Impact of scaling up prenatal nutrition interventions on human capitaloutcomes in low- and middle-income countries: a modelling analysis

Research article

2021

Nandita Perumal, Mia M. Blakstad, Günther Fink,
Mark Lambiris, Lilia Bliznashka, Goodarz Danaei, andChristopher R. Sudfeld

Link

Harnessing Participatory Formative Research to Inform Women’s Preferences
on Multiple Micronutrient Supplement (MMS) Design Considerations Across
Four Country Contexts

Poster abstract

2021

UNICEF

Link

Multiple Micronutrient Supplements (MMS) for Pregnant Women
Considerations for Accessing MMS Product Supplies for National Programs

Presentation

2020

Clayton A. AjelloLink

Impact of Antenatal Multiple Micronutrients on Women’s Health andPregnancy Outcomes

Presentation

2020

Robert E. Black

Link

Global policy and update: translating evidence to action

Presentation

2020

Parul ChristianLink

A Landscape Analysis of Multiple Micronutrient Supplementation Legislation,
Activity, and Priorities

Stakeholder
consultation

2020

Kirk Humanitarian and Micronutrient Forum

Link

Multiple Micronutrient Supplementation: Webinar series

Presentation

2020

Micronutrient ForumLink

The use of multiple micronutrient supplementation (MMS) for maternal
nutrition and birth outcomes during the COVID-19 pandemic

Brief

2020

MMS-TAG

Link

Expert consensus on an open-access United Nations International Multiple
Micronutrient Antenatal Preparation–multiple micronutrient supplement
product specification

Technical
consultation

2020

MMS-TAG and Micronutrient Forum

Link

Cost-effectiveness analyses for the WHO review on multiple micronutrient
supplements during pregnancy: Technical Report

Technical report

2020

Nutrition International

Link

WHO recommendations on antenatal nutrition: an update on multiple
micronutrient supplements

Editorial

2020Özge Tuncalp, Lisa M Rogers, Theresa Anne Lawrie et al.

Link

Nutrition, For Every Child: UNICEF Nutrition Strategy 2020–2030

Strategy

2020

UNICEF

Link

Core Commitments for Children

Strategy

2020

UNICEF

Link

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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Resource title

Resource
type

Year ofpublication

Institution (name of authors)

Link

Essential Medicines List Application for Multiple Micronutrient Supplements
During Pregnancy

Application forinclusion of MMS
in EML

2020

Vitamin Angel Alliance, NYAS MMS-TAG and theMicronutrient Forum

Link

Protecting Maternal Diets and Nutrition Services and Practices in the Context of
COVID-19

Brief

2020

WFP, UNICEF, GNC and The Global Technical AssistanceMechanism for Nutrition (GTAM)

Link

WHO antenatal care recommendations for a positive pregnancy experience.
Nutritional interventions update: multiple micronutrient supplements during
pregnancy

Guideline

2020

WHO

Link

Benefits of supplementation with multiple micronutrients in pregnancy

Commentary

2019

Robert E. Black and Kathryn G. Dewey

Link

Antenatal multiple micronutrient supplementation: call to action for change inrecommendation (letter to the editor)

Letter to editor

2019

Megan W. Bourassa, Saskia J.M. Osendarp, Seth AduAfarwuah et al.

Link

Review of the evidence regarding the use of antenatal multiple micronutrient
supplementation in low- and middle-income countries

Review

2019

Megan W. Bourassa, Saskia J.M. Osendarp, Seth AduAfarwuah et al.

Link

Multiple Micronutrient Supplementation to Support a Healthy Start in LifeWhite paper

2019

DSM

Link

The upper level: examining the risk of excess micronutrient intake in pregnancy
from antenatal supplements

Review

2019

Alison D. Gernand

Link

Setting research priorities on multiple micronutrient supplementation inpregnancy

Research article

2019

Filomena Gomes, Megan W. Bourassa, Seth Adu-Afarwuah
et al.

Link

Multiple‐micronutrient supplementation for women during pregnancy

Review

2019

E.C. Keats, B.A. Haider, E. Tam, Z.A. Bhutta

Link

eBriefing: Improving Birth Outcomes with Multiple Micronutrient
Supplementation

Brief

2019

MMS-TAG and NYAS

Link

New Evidence Should Inform WHO Guidelines on Multiple Micronutrient
Supplementation in Pregnancy

Report2019

Christopher R. Sudfeld and Emily R. Smith

Link

Situation analysis of procurement and production of multiple micronutrient
supplements in 12 lower and upper middle‐income countries

Supplement
article2018

Eva C. Monterrosa, Kalpana Beesabathuni, Kesso G. van
Zutphen.

Link

Multiple micronutrient supplements in pregnancy: Implementationconsiderations for integration as part of quality services in routine antenatalcare. Objectives, results, and conclusions of the meeting

Supplement
article2018

Maria Nieves Garcia‐Casal, Diana Estevez, Luz Maria De‐
Regil.

Link

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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Resource title

Resource
type

Year ofpublication

Institution (name of authors)

Link

Antenatal multiple micronutrient supplementation: benefits beyond iron-folicacid alone

Commentary

2017

Jeannine Baumgartner

Link

Multiple-micronutrient supplementation: Evidence from large-scale prenatal
programmes on coverage, compliance and impact

Supplement
article2017

Cristiana Berti, Michelle F. Gaffey, Zulfiqar A. Bhutta, Irene
Cetin

Link

Modifiers of the effect of maternal multiple micronutrient supplementation
on stillbirth, birth outcomes, and infant mortality: a meta-analysis of individual
patient data from 17 randomised trials in low-income and middle-income
countries

Meta-analysis

2017

Emily R. Smith, Anuraj H. Shankar, Lee S-F Wu et al.

Link

Supplementation with multiple micronutrients for breastfeeding women forimproving outcomes for the mother and baby

Review

2016

Abe, S.K., Balogun, O.O., Ota, E., Takahashi, K., Mori, R.

Link

Effect of multiple micronutrient supplementation during pregnancy onmaternal and birth outcomes

Systematic
review

2011

Batool Azra Haider, Mohammad Yawar Yakoob, Zulfiqar A
BhuttaLink

Preventing and controlling micronutrient deficiencies in populations affectedby an emergency

Joint statement

2007

WHO, WFP and UNICEF

Link

Multiple micronutrients in pregnancy and lactation: an overview

Overview

2005

Lindsay H Allen

Link

Composition of a multi-micronutrient supplement to be used in pilot
programmes among pregnant women in developing countries

Technical
document

1999

UNICEF, United Nations Universities and WHO

LinkInterim Country-level Decision-making Guidance for Introducing Multiple
Micronutrient Supplementation for Pregnant Women

Guidance
document

OnlineundatedarticleMMS-TAG

Link

Technical Reference Materials: Logistics of implementation MMS in Pregnancy

Technical
referencematerial

OnlineundatedarticleThe Sacklers Institute for Nutritional Sciences, Bill andMelinda Gates Foundation (BMGF), UNICEF and Vitamin
AngelsLink

Formative Research Guidance Introducing Multiple Micronutrient Supplements(MMS)

Guidance

OnlineundatedarticleUNICEF, Penn State, and Sight and Life

Link

Frequently Asked Questions to address often-raised concerns about theswitch from iron and folic acid supplementation to multiple micronutrient
supplementation

FAQs

OnlineundatedarticleVitamin Angels

Link

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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Annex 2: Key informant interview guides
Background on humanitarian setting
1. To start, could you give a brief summary of the humanitarian setting in which you are delivering MMS?

Programme delivery
Now I would like to learn more about the MMS programme supported by your agency.
2. Who is/are the target population(s) of the programme?
3. Where is the programme located (i.e., in what geographical area(s) is MMS being distributed)?
4.	What is the scale of each programme (i.e., roughly how many women are reached through eachprogramme?)
5.	Through what platform(s) is MMS delivered (e.g., facility-based, community outreach by community
health workers, private hospitals, private pharmacies or dispensaries, food distributions)?
a. Are other women’s health interventions delivered alongside the MMS (e.g., ANC) or is it stand-alone?
b.	How are pregnant women identified in this setting (e.g., visual assessment, history of last menstrual
period)?
6.	What is the format of the MMS delivered in your programme (e.g., number of tablets per bottle,
monthly blister packs, etc)?
a. What is the frequency of distribution (e.g., one-time distribution, multiple visits)?
b. What is the recommended dose (e.g., 90+ tablets throughout pregnancy)?
7. How are pregnant women encouraged to adhere to consuming MMS?
a. What is the level of uptake of MMS among pregnant women? (Probe for reasons why high or low)
8. Are you able to provide any reports or data linked to this programme?
9.	Who are the main partners that you work with in MMS programmes – for example, government,
other United Nations agencies, implementing partners?
a. What roles is each partner expected to play?
10.	Do you know about any other agency that supports the delivery of MMS in programmes in[insert country name]?
a. If yes, ask for contact information

Challenges and opportunities for scaling up MMS
Now I would like to ask about challenges to, and opportunities for, scaling up MMS programming in[insert country name].
11.	First, could you give some examples of successful practices in MMS programming (or support for
programming) that have helped to overcome any barriers/challenges to implementation and allowed
the programme to be successful in [insert country name]?
12.	Now could you tell me what you think are the remaining challenges/barriers to scaling up MMS
programming in [insert country name]?
13.	Do you have any thoughts on how some of these key remaining challenges/barriers might be
addressed?

Other questions (if time allows)
14.	If MMS is delivered as part of ANC, do you feel that it helps improve adherence to other aspects of ANC?
a. Are healthcare providers trained on the importance of MMS?
b. Do healthcare workers promote MMS to their patients?
15.	What kind of monitoring and evaluation system is in place for MMS in [insert country name]?
a.	What is the routine data collection process on MMS? (Hint: any indicator to capture MMS
consumption data in DHIS or under routine nutrition programming)49

Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

Annex 3: Terminology referring to humanitarian emergencies
Term

Definition

SourceComplexemergency

A humanitarian crisis in a country, region or society where
there is a total or considerable breakdown of authority
resulting from internal or external conflict, and which
requires an international response that goes beyond the
mandate or capacity of any single agency and/or theongoing United Nations country programme.

IASC

DisasterA serious disruption of the functioning of a community ora society, causing widespread human, material, economicor environmental losses which exceed the ability of theaffected community or society to cope with using its own
resources.

ReliefWeb glossaryof humanitarianterms

Emergency

A sudden and usually unforeseen event that calls
for immediate measures to minimise its adverse
consequences.

ReliefWeb glossaryof humanitarianterms

Humanitarian crisis

Any circumstances where humanitarian needs are
sufficiently large and complex to require significant
external assistance and resources, and where amultisectoral response is needed, with the engagementof a wide range of international humanitarian actors. This
may include smaller-scale emergencies: in countries withlimited capacities, the threshold will be lower than incountries with strong capacities.

UNICEFAn event or series of events that represents a critical threat
to the health, safety, security or well-being of a community
or other large group of people, usually over a wide area.

Humanitarian
Coalition

Humanitarian
emergency

UNHCR

Other agencies
that use this term:
UN Human Rights

Other agencies
that use this term:
UNFPA, WHOMan-madeemergency

Armed conflict, plane and train crashes, fires andindustrial accidents.

Humanitarian
Coalition

Natural disaster

Geophysical (e.g., earthquakes, tsunamis and volcanic
eruptions), hydrological (e.g., floods, avalanches),climatological (e.g., droughts), meteorological (e.g., storms,
cyclones), or biological (e.g., epidemics, plagues) disasters.

Humanitarian
Coalition

Protracted
emergency

Characterised as a situation where “a significant part ofthe population is acutely vulnerable and dependent on
humanitarian assistance over a prolonged period of time”.

Danish RefugeeCouncilSlow-onset crisis

A disaster that happens gradually over time, often
resulting from several factors rather than a distinct event:for example, a drought.

Danish RefugeeCouncil

Sudden-onset crisis

A disaster (natural or man-made) that is triggered by ahazardous event that emerges quickly or unexpectedly.

Danish RefugeeCouncil

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Multiple Micronutrient Supplements in Humanitarian Emergencies A State of Play Report | March 2024

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