The Global Micronutrient Goals: lessons learned, analysisudand the way forward (1990-2005)

摘要

Micronutrient malnutrition, deficiencies of vitamins and minerals, affects one in threeudchildren in the world today, more than 2 000 million people, resulting in an enormousudpublic health impact on the numbers of premature deaths in women and childrenudparticularly. These deficiencies, and their interaction with other health and care modalities,udcause widespread morbidity, reduced intellectual potential, and an overall negative impactudon national development and economic growth. To address this, global goals wereudestablished for the elimination or significant reduction of the prevalence of theseuddeficiencies. The three micronutrient deficiencies of current greatest public healthudsignificance are iron, vitamin A and iodine, although zinc is receiving increasing attention,udas is folate, vitamin B12 and other micronutrients in emergency situations. The thesisudemphasized vitamin A as an example, while recognizing that different approaches toudprevention and control will also be needed to adequately address other micronutrients.udOne aim of the thesis was to identify constraints and facilitating factors contributing to theudsuccess, or otherwise, towards achieving the first set of international micronutrient goalsudby the stated date of the end of the previous decade (2000). The programmes and policyuddecisions used in addressing micronutrient malnutrition were described and criticallyudexamined. This analysis was then used to examine this current decade (2000-2010) andudthe new decade goals of the UN Special Session of the General Assembly on Children.udSince then the Millennium Development Declaration and Goals have to a large extentudbecome the overarching global framework of goals, with the earlier goals being the basisudfor work planning and implementation. The hypothesis that the first set of internationaludmicronutrient goals was not reached globally because identifiable steps and pre-conditionsudwere not met was addressed through access to a variety of sources, including a literatureudreview through Medline and the search machines used by the Library systems of UNICEF,udColumbia University and the University of Tasmania, with follow-up of likely articles oruddocuments found from these identified articles. These were supplemented by national andudUnited Nations system reports (especially WHO and UNICEF but also UNDP, World Bankudand WFP), and the author’s current daily work activities contributed significantly to the finaludproduct. Based on this approach, identification of trends, commonalities, and differences,udwere part of the analysis, taking into account cultural, socio-economic, resources andudepidemiological variety of the many countries involved. This analysis led to a suggestedudre-interpretation of why micronutrients have over the last decade and a half become so prominent in international public health priorities; to a compilation and analysis ofudconstraints and facilitating factors. There is no doubt there has been enormous progress,udparticularly over the last two decades. Both constraints and facilitating factors wereudsummarized, using the UNICEF Nutrition framework under four broad areas: basic orudglobal (mega-) factors; underlying or national (macro-) factors; underlying or sub nationalud(meso-) factors; and, proximal or immediate community and household factors (micro-),udand by matrices. In essence the main factors included: (i) demonstrated commitment byudgovernment and a relevant policy in place; (ii) a knowledge of the magnitude of theudproblem; (iii) an awareness of the public health and social consequences by all levels; (iv)udan intersectoral approach; (v) an awareness of the direct link to poverty, socio-economicudand politico-social issues, and hence the need to address these specifically, as part ofudmicronutrient deficiencies prevention and control programmes; (vi) initial presence ofudexternal funding; and, (vii) a ‘champion’ both internationally and nationally. National andudlocal factors also played different roles in different settings. Firstly, micronutrientudinterventions were often not integrated at the community and district level e.g. vitamin Audcapsules and immunization were very infrequently integrated, except for the relativelyudshort-lived National Polio Immunization Days, including having separate reporting systemsudand being implemented by different sections of the Health Ministry. Secondly, theudmicronutrient programmes, including universal salt iodization (USI), were often seen asudexternally driven e.g. by donors, or in the case of USI as a ‘UNICEF Programme’. As partudof this, the goals were sometimes seen as an external, international goal, not necessarilyudas relevant to the perceived or documented needs of the country, despite virtually alludcountries having signed off on them. Thirdly, clearly ineffectual programmes continued toudbe promoted e.g. iron/folic acid supplementation. Fourthly, inadequate health and otherudsystems with poor infrastructure and inadequate staffing have made delivery of manyudhealth interventions, including micronutrient supplementation, difficult. Finally, in the faceudof continuing and often increasing social disparities and other inequities, for most poorudpopulations, diets are unlikely to improve sufficiently, and in the short run at least, neitherudwill delivery systems.