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.

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 marketbased model where frontline-workers (FLW) sell MNPs at home visits, and provide IYCFcounseling. 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.

Adopting integrated management of childhood illness module at local level in Bangladesh: implications for recurrent costs.

This study estimated the recurrent cost implications of adopting Integrated Management of Childhood Illness (IMCI) at the first-level healthcare facilities in Bangladesh. Data on illnesses of children who sought care either from community health workers (CHWs) or from paramedics over a four-month period were collected in a rural community. A total of 5,505 children sought care. About 75% of symptoms mentioned by mothers were directly related to illnesses that are targeted in the IMCI. Cough and fever represented 64% of all reported complaints. Referral of patients to higher facilities varied from 3% for the paramedics to 77% for the CHWs. Had the IMCI module been followed, proportion of children needing referral should have been around 8%. Significant differences were observed between IMCI-recommended drug treatment and current practice followed by the paramedics. Adoption of IMCI should save about US$ 7 million on drugs alone for the whole country. Proper implementation of IMCI will require employment of additional health workers that will cost about US$ 2.7 million. If the current level of healthcare use is assumed, introduction of IMCI in Bangladesh will save over US$ 4 million.