Practice-Based Implementation Research on the National Scale-Up of Micronutrient Powders in Bolivia

Abstract

Objectives: Bolivia is among few countries to have scaled-up Micronutrient Powders (MNPs) for children to the national level. Here we explore Bolivia’s experience as an early-adopter and in doing so, identify enabling conditions and stakeholders that led to scale-up, and barriers to increasing coverage and adherence. Methods: We reviewed a wide variety of documents spanning several years of program implementation (2006-2012) and communicated with those involved with the program.  We defined scale-up as the process of increasing coverage to benefit more children and used a health system model to identify programmatic components. Results: Bolivia replaced iron syrup for children 6-23 months of age with MNPs in 2006. In 2012, MNP coverage reached 65% of Bolivia's approximately 536,000 children in this age group. Adherence rates in 2010 for children consuming all 60 sachets were 45% and 52% in urban and rural areas, respectively. Enabling political factors included integrating MNPs into the existing public health system. Politicians and policy makers helped accelerate scale-up by including MNPs within the national development plan and prioritizing effective coordination, including private sector engagement. Training of healthcare providers, support for supply chain management, communications, and program monitoring remain critical components of MNP scale-up.  Behaviour change and demand creation strategies targeting the healthcare provider and caregiver were identified as key factors to sustain and increase coverage and adherence rates. Conclusions: Countries considering replacing iron syrup and transitioning to MNP implementation can benefit from Bolivia’s experience, particularly in creating an enabling environment whereby MNPs can be integrated within existing health and nutrition programs.