Micronutrient Policy Issues
Micronutrient Deficiencies in Developing Countries
Micronutrients are key to promoting and sustaining life and development, and the prevalence of micronutrient deficiencies in developing countries is widespread (1). Prevalence rates for some micronutrients can vary spatially, suggesting that in some cases, subnational intervention programs may be the most effective, and cost-effective. The map below depicts vitamin A deficiencies among young children in Cameroon, by region.
Several micronutrients have been identified by the international community as especially critical, in part because of their effects on the growth and development of young children. For example, the World Health Assembly has set a 50% reduction, by 2025, in anemia among women of reproductive age as one of its Global Nutrition Targets. A second target is a 40% reduction in the number of children under 5 years of age who are stunted – addressing micronutrient deficiencies may have an important role to play in achieving this target in some populations.
Consequences of Unmet Needs
The effects of micronutrient deficiencies can be substantial, long-lasting, and have large economic consequences (2, 3). For example, reducing iron deficiencies in Haiti by fortifying wheat flour over a 12-year period is estimated to have a cost-benefit ratio of approximately 24 (4), suggesting the returns to investing in wheat flour fortification far outweigh the costs.
Policy Objectives Associated with Needs
Once an agreed-upon set of micronutrient deficiencies has been established for policy action, the next critical step is to identify the measure, or measures, of impact that will be monitored and used to assess the success of selected intervention programs. Candidate measures of success include (5):
- Reach: the number (or %) of the target population (deficient or not) that consume more of a given micronutrient.
- Coverage: the number (or %) of the target population that is deficient and that consume more of a given micronutrient.
- Effective coverage: the number (or %) of the target population that is deficient and that consume a sufficient additional amount of a given micronutrient to reach sufficient status.
- Minimum adequate intake: the number (or %) of the target population (deficient or not) that consume at least a specific additional amount of a given micronutrient (regardless of whether or not sufficient status is achieved).
- Lives saved: the number (or %) of the target population whose lives are saved due to increased consumption of a given micronutrient (6).
Policy Instruments for Meeting Needs
There are many, often competing, ways of addressing micronutrient deficiencies; the expected impacts (however measured) and costs of these alternative intervention programs generally vary over space and time. Some examples of intervention programs include:
- Large-scale fortification of staple foods and condiments
- Biofortification of staple crops
- Distribution of high-dose vitamin A capsules to young children
- Social and behavior change communication to promote breastfeeding
- Promotion of the production and consumption of micronutrient-rich foods
The Costs of Micronutrient Intervention Programs
Nothing is free. All micronutrient intervention programs require upfront investments during the establishment phase, and funds to cover operational cost and monitoring and evaluation expenses. As with intervention program benefits, program costs can also vary over space and time. For example, regarding spatial variation, the map at right reports the region-specific costs of two Child Health Day campaigns in Cameroon, during which high-dose vitamin A capsules (and other products and services) were distributed (7).
MINIMOD Approach to Choosing Cost-effective Sets of Micronutrient Intervention Programs
Finally, once decision-makers know the expected benefits and costs of all alternative combinations of national and sub-national micronutrient intervention programs, they must choose which ones to implement. However, choosing among potentially many hundreds of combinations of national and subnational program options can be very challenging, especially if some candidate interventions generate non-uniform benefits, or face non-uniform costs over space and time.
The MINIMOD project solves this problem by developing an economic optimization model that ‘searches’ over all possible combinations of candidate interventions and, using cost-effectiveness as its decision criterion, chooses the most cost-effective set of programs for achieving an agreed-upon objective. The cost savings associated with selecting more cost-effective intervention packages can be substantial (8).
- Bailey RL, West Jr KP, Black RE. The epidemiology of global micronutrient deficiencies. Ann Nutr Metab 2015;66(Suppl. 2):22-33.
- Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, Ezzati M, Grantham-McGregor S, Katz J, Martorell R, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. The Lancet 2013;382(9890):427-51.
- Hoddinott J, Behrman JR, Maluccio JA, Melgar P, Quisumbing AR, Ramirez-Zea M, Stein AD, Yount KM, Martorell R. Adult consequences of growth failure in early childhood. Am J Clin Nutr 2013;98(5):1170-8. doi: 10.3945/ajcn.113.064584.
- Engle-Stone R, Stewart CP, Luo H, Vosti SA, Adams KP. Preventative nutrition interventions. Copenhagen Consensus, Haïti Priorise, 2017. Available from: http://www.copenhagenconsensus.com/sites/default/files/haiti_priorise_nutrition_-_english.pdf.
- Engle-Stone R, Nankap M, Ndjebayi AO, Vosti SA, Brown KH. Estimating the effective coverage of programs to control vitamin A deficiency and its consequences among women and young children in Cameroon. Food Nutr Bull 2015;36(3_suppl):S149-S71. doi: doi:10.1177/0379572115595888.
- Engle-Stone R, Perkins A, Clermont A, Walker N, Haskell MJ, Vosti SA, Brown KH. Estimating lives saved by achieving dietary micronutrient adequacy, with a focus on vitamin a intervention programs in Cameroon. J Nutr 2017. doi: 10.3945/jn.116.242271.
- Kagin J, Vosti SA, Engle-Stone R, Rettig E, Brown KH, Nankap M, Ndjebayi A. Measuring the costs of vitamin A interventions. Food Nutr Bull 2015;36(3_suppl):S172-S92. doi: 10.1177/0379572115598445.
- Vosti SA, Kagin J, Engle-Stone R, Brown KH. An economic optimization model for improving the efficiency of vitamin A interventions. Food Nutr Bull 2015;36(3_suppl):S193-S207. doi: 10.1177/0379572115595889.