UN Children’s Fund ,International Consultant to provide technical Supprt to MOH- Home Fortification in Rwanda

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Background

UNICEF Rwanda is
supporting the Government of Rwanda’s efforts to reduce malnutrition in
children. This support includes interventions targeted at reducing at anaemia,
including the Home Fortification program using micronutrient powders (MNP)
targeted at children 6-23 months, which has been introduced in 19 districts. To
ensure sustainability of the program and to lay the foundation for national
scale up, it is suggested to contract a consultant to support the integration
of MNPs into national systems in agreement and close collaboration with the
MoH.

While Rwanda has
made progress between 2010 and 2015 in reducing under-nutrition among children
as measured by stunting (44% vs. 38%, respectively), the same gains have not
been seen with the prevalence of anaemia only reducing by one percent (38% vs.
37%, respectively) in the same time period.

Findings presented
in the 2015 Rwandan DHS, show that 3% of children 6-59 months in Rwanda are
anaemic. Prevalence of anaemia decreases as age increases; infants 6-8 months
had a 72% prevalence rate, which decreased to 21% in children 48-59 months[1].
The WHO considers anaemia prevalence over 40% in a population to be a major
health problem[2] and recommends micronutrient supplementation when the
prevalence of aneamia in preschool and school aged children is at 20 per cent
or higher[3].

Iron deficiency,
iron deficiency anaemia and anaemia are often incorrectly used as synonyms.
Iron deficiency anaemia is defined as occurring when individuals are both
anaemic, based on low haemoglobin (Hb) concentrations, and iron deficient,
based on an indicator of iron status. In developing countries approximately 50%
of all anaemia is attributed to iron deficiency. It is further estimated that
the frequency of iron deficiency is about 2.5 times that of anaemia, and when
anaemia prevalence exceeds 40%, it is assumed that the entire population is
suffering from some degree of iron deficiency2.

It is well
established that iron deficiency has adverse health consequences even before
anaemia develops. These include cognitive impairment, decreased physical
capacity and reduced immunity. In general, the negative effects of iron
deficiency on health, physical capacity, cognitive performance and behaviour
can be corrected by providing adequate iron, as severe iron deficiency left
untreated at a young age can lead to irreversible brain damage and impaired
cognitive development[4].

In Rwanda the most
common causes of anaemia are inadequate dietary intake of iron, malaria and
intestinal worm infection. To address these, emphasis is placed on improved
infant and young child feeding (IYCF) practices, promotion of the use of
insecticide-treated bed nets and bi-annual deworming for children aged 1-5
years.

While current
strategies to improve micronutrient status in Rwanda have placed emphasis on
increasing the variety of foods in the diet and increasing knowledge of
iron-rich foods, the amount of iron available from the rural Rwandese diet is
not adequate to meet most young children’s requirements even if feeding
practices are improved[5].

Dietary sources of
iron tend to be expensive for bioavailable forms (heme iron in animal foods)
and non-heme iron is poorly absorbed and has not been found to improve measures
of anaemia among children. Fortifying the widely consumed food items, such as
maize or wheat, with micronutrients is a valid strategy for adults where, but
this strategy is not adequate for young children, whose physiological iron
requirements are highest at a time of life when they have limited stomach
capacity, consume only small amounts of these foods, and the concentration of
bioavailable iron in these products is too low to be effective at combatting
anaemia in this most vulnerable group. Fortified commercially prepared infant
foods, such as SoSoMa, are an option but are relatively expensive and are not
affordable for most Rwandan families with children at the highest risk of
micronutrient deficiencies, particularly iron deficiency anaemia.

An alternative
strategy to dealing with childhood micronutrient deficiencies is through ‘Home
Fortification’, which provides vulnerable populations with a vitamin and
mineral preparation that can be easily added directly to children’s foods
prepared in the home. These preparations are called Micronutrient Powders, or
MNP, and are provided in small packets containing the recommended daily
allowance for iron for children 6-23 months of age, along with 14 other
vitamins and minerals. MNP has been demonstrated through extensive research to
be acceptable, efficacious, and effective at reducing and preventing anaemia in
young children at scale and are endorsed by the WHO and UNICEF[6].

While MNP are
primarily designed to control micronutrient deficiencies, their introduction
provides an opportunity to accelerate implementation of appropriate IYCF
practices, which can ultimately contribute to a reduction in stunting, wasting,
and underweight among young children in Rwanda. This has been demonstrated in
large-scale effectiveness studies in multiple countries including Ghana, Haiti,
South Africa, and Mongolia as reviewed in a meta-analysis of Home Fortification[7].
Therefore, MNP in combination with appropriate complementary feeding, may not
only reduce micronutrient deficiencies but may indirectly impact overall
nutritional status.

Justification

In view of the high
prevalence of anaemia in young Rwandese children, the risk of irreversible
consequences related to untreated iron deficiency before the age of two years,
and a lack of interventions targeting iron deficiency and anaemia, the Ministry
of Health along with numerous partners have worked since 2011 to develop and
implement a programme to combat micronutrient deficiencies in the first 1000
days, or the ‘window of opportunity’, through introduction of home
fortification using MNP. This program and the MNP product is known as the
Ongera programme in Rwanda.

Since initial
implementation of the Ongera programme in two districts in November 2014, the
programme, with support from implementing partners including the Micronutrient
Initiative (University of British Columbia (UBC)), has been expanded through a
phased approach and now reaches approximately 300,000 children 6-23 months in
19 out of 30 districts.

High acceptability
and demand from caregivers was found during a caregiver survey conducted in
April 2016 by the Micronutrient Initiative (UBC) and can be attributed to the
positive changes caregivers observed in their child’s health after the
introduction of Ongera to their child’s diet.

The next phase of
programme will see several key changes to the current implementation strategy
as the Ministry of Health looks to further integrate MNP into existing
government systems with the goal of achieving a more sustainable national
programme. Moving forward, MNP will be distributed by Medical Procurement and
Production Division (MPPD), the MoH’s commodity management central, rather than
UNICEF and follow the same supply chain utilized for essential medicines.
District pharmacies will manage MNP stock and health centres will be
responsible for initiating orders as per their needs in line with existing
systems for other health and nutrition commodities. This will require
integration of MNP into MPPD’s electronic logistics management information
system (eLMIS). Furthermore, Ongera related indicators will be integrated into
monthly community-based nutrition programming (CBNP) monitoring reports through
the health management information system (HMIS). Finally, the programme may be
scaled up to cover more districts in the coming years. To facilitate these
processes, support to the MoH and partners will be essential. Hence this
consultancy will support a smooth continuation of the scale up of Home
fortification.

Objective

The main objective
of the consultancy is to provide continued technical support to the Ministry of
Health, implementing partners and district staff in the full integration and
further scale up of the Ongera Home Fortification Programme into government
systems. Emphasis will be placed on the monitoring of the introduction of MNP
into the MPPD supply chain and further integration of Ongera into existing
reporting systems for increased sustainability.

Methodological
Approach

This consultancy
will be done with different approaches: consultative meetings with

RBC and MPPD,
orientation meetings with health centers and district pharmacy staff, workshop
trainings for capacity building and will follow the national M&E system.

Major Tasks,
Deliverables, & Timeframe

The following main
tasks and responsibilities of the consultant will be to:

• District
  pharmacy staff curriculum
• Introduction
  to adjusted reporting tools and processes (refresher for those already
  trained)

Support
monitoring and evaluation of key components of the Home Fortification programme

Deliverables

Timeframe

Month 1 & 2

o Introduce new
reporting tools and processes;

o procedures for
ordering MNP through the district pharmacy and reporting tools and processes;

o Familiarize
participants with the training module for district and health centre pharmacy
staff to capacitate them to carry out cascade trainings.

Month 3&4

o Field reports from
monitoring visits to districts on initial successes and challenges of
introduction of MNP into MPPD supply chain and associated reporting, including
recommendations, drafted and shared with UNICEF and the MoH.

Month 5

o Strategic in-Home
fortification programme document drafted and shared with UNICEF, MoH and key
partners for inputs.

Month 6

o Strategic in-home
fortification programme document finalized.

Month 7

o Final report
documenting the integration of MNP into supply chain for essential medicines
with measures put in place to address identified bottlenecks, including
recommendations

Month 8

Qualification
and Requirements

The consultant
should possess following qualifications:

• Advanced
  university degree in any of the following fields: Public Health,
  Nutrition, Health sciences, international health and Nutrition or a
  related technical field;
• Prior
  involvement with Home Fortification initiatives in other countries with a
  minimum of three years’ experience, this include MNP programming,
  implementation, monitoring and evaluation, and strategy development.
  Working in Rwandan is an asset;

Supervision

The consultant will
be under the supervision of the Nutrition Specialist and the Head of Nutrition
unit but will also be expected to work closely with RBC/MoH and supported
district in the Home Fortification intervention. Progress and final reports
will be validated by the FNTWG and sent to both UNICEF and MoH.

Terms and
conditions

• Travel
  arrangements (airfare ticket by the most direct flights in economy class):
• On-field
  in-country transport will be provided by UNICEF:
• The
  financial proposal should be all-inclusive monthly lump sum, including
  ticket and subsistence allowance.

[1] Rwanda DHS 2015

[2] WHO/UNICEF/UNU,
Iron Deficiency Anemia Assessment, Prevention, and Control. Geneva. 2001.

[3] WHO, Guideline:
Intermittent iron supplementation in preschool and school-age children. Geneva,
2011.

[4] Lozoff, B.,
Jimenez, E. & Wolf, A. 1991. Long-term developmental outcome of infants
with iron deficiency. N.
Engl. J. Med., 325: 687-694.

[5]
http://www.fao.org/economic/ess/ess-fs/fbs/en/

[6] WHO. Guideline:
Use of multiple micronutrient powders for home fortificatin of foods consumed
by infants and children 6–23 months of age. Geneva, World Health Organization,
2011.

[7] De-Regil LM et
al. Home fortification of foods with multiple micronutrient powders for health
and nutrition in children under 2 years of age. Cochrane Database of Systematic
Reviews 2011; 9:CD00895.

Interested qualified
candidate can apply on this consultancy by clicking on the link below:

https://secure.dc7.pageuppeople.com/apply/671/gateway/Default.aspx?c=app…

Please
indicate your ability, availability and daily/monthly rate (in US$) to
undertake the terms of reference above (including travel and daily subsistence
allowance, if applicable). Applications submitted without a daily/monthly rate
will not be considered.

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to diversity and inclusion within its workforce, and encourages qualified
female and male candidates from all national, religious and ethnic backgrounds,
including persons living with disabilities, to apply to become a part of our
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