Delivery of Micronutrient Powder (MNP) Sachets through Sales by Frontline Health Workers (FLW) Enables High Reach, but Upstream Supply, Household (HH) Poverty and Variability in MNP Awareness are Challenges to Effectiveness

Abstract

Objectives: Little is known about how different delivery platforms can be used to reach at-risk populations with micronutrient-powders (MNPs). We conducted a process-evaluation of a market-based model where frontline-workers (FLW) sell MNPs at home visits, and provide IYCF-counseling. We sought to understand factors influencing sales of MNPs, household awareness, purchase, and use. Methods: Within a cluster-randomized evaluation design where 5 sub-districts were assigned to the MNP+IYCF intervention and 5 sub-districts to the MNP-only intervention, we conducted surveys among FLWs and mothers with children 6-24-months in 2012 (n=462) and 2013 (n=500). Results: In the MNP+IYCF group, FLW awareness of MNP was high, and >90% reported having sold MNPs in 2013. However, intermittent gaps in upstream supply were a constraint to sales. Reach of the FLW-network was higher in the MNP+IYCF group (92%) compared to the MNP-only group (23%). Maternal MNP awareness was variable (68% in the MNP+IYCF group and 43% in the MNP-only group). Any purchase of MNPs from FLWs was higher in 2013 compared to 2012, ranging from 5-37%, with higher purchase in the IYCF+MNP group, and among higher SES households.  In the IYCF+MNP group, households purchased a mean of 33 sachets during the previous 6-months, half the program recommendation. Qualitative research further indicates that child illness, and confusion around the recommended dose and appropriate use affect sustained use. Conclusions: Increases over time, in sales, awareness and purchase highlight the potential for this delivery model to succeed. However, strategies to raise awareness and messaging to support routine use appear necessary to achieve impact.