Africa’s vitamin A supplementation (VAS) programs are at a crossroads. Even before the polycrisis wreaked havoc on national health systems, VAS coverage had been dropping across the continent. The reason? Countries have increasingly struggled to secure funding for the high-coverage campaigns they have historically relied on to ensure children 6 to 59 months of age receive their twice-yearly dose. The result has been clear and worrisome as countries have been forced to rely on existing, routine primary healthcare contact points for their VAS delivery, without the plans or resources needed to deliver VAS alongside other essential nutrition and health services.

There is consensus that the path to sustainable, high-coverage vitamin A programs means integrating VAS into primary healthcare systems. However, more technical leadership is needed – not just how to plan for the necessary transition toward full integration, but also what it means for a country in practical, real terms to operationalize the transition while strengthening the health system along the way. This includes guidance on what structures need to be further supported, how to plan for, resource, and deliver VAS with the necessary quality at subnational and community levels, and how these services are to be monitored and evaluated.

Nutrition International convened a regional technical meeting in Dakar, Senegal in January 2023 to respond to an expressed need for technical assistance from countries. The meeting aimed to build participants’ capacity through South-South learning and sharing of technical tools and frameworks developed by Nutrition International and implemented in three Nutrition International-supported countries, and the varied country experiences to-date – all designed to lead to co-creation of viable strategies moving forward. The meeting was attended by 100 high-level delegates, representing nutrition, immunization, and health information department heads, and decision-makers from Ministries of Health from 16 countries[1] across Africa, as well as country, regional and global-level technical partners, including UNICEF and Helen Keller International.

While there is no one-size-fits-all solution, as a global leader in VAS, Nutrition International is uniquely placed to offer leadership and technical assistance to countries dedicated to improving their VAS coverage rates. Here are five ways that we’ll be supporting action on vitamin A this year and beyond:

1. Advocating for the fully protected child. The last three years have seen a surge in polio and measles outbreaks. In response, the international community has doubled down on routine immunization efforts. And whenever there is a challenge, there is also an opportunity. Immunization and nutrition target the same children in the same places and yet, all too often, interventions are planned, funded, delivered and monitored independently. In countries across sub-Saharan Africa, coverage of immunization is higher than many crucial nutrition interventions. In practice, this means that children are being reached with their scheduled vaccination from a health worker but are not receiving their age-appropriate VAS doses, representing a missed opportunity to advance from “fully immunized” to “fully protected”. Expanding this approach out to delivery platforms designed to reach older children, past the ages of 12 and 18 months, is also critical to ensure children receive all nine life-saving doses of vitamin A.

2. Integrating VAS into existing delivery platforms and sectors. VAS should be integrated into existing platforms within the health system already designed to deliver services to children under five, such as growth monitoring and promotion, and nutrition screening. In addition, where they exist, early childhood development centres can be optimized to be an additional outreach contact point to ensure children over the age of three in the most vulnerable situations are not missed. In Kenya, Nutrition International took a “no missed opportunities” approach, working closely with County Health Management Teams to assess the opportunities and challenges of all the platforms within the health system that were recommended as contact points for reaching children 6-59 months of age with VAS according to the national policy. Through a three-year optimization effort, Nutrition International supported counties to not only strengthen their delivery platforms to reach children with VAS, but to operationalize the “how” to deliver VAS through those platforms with quality without letting coverage drop: routine immunization, fixed site health system contact points; the community health platform; and early childhood development centres to mop up coverage gaps.

3. Building on best practice. Pathfinder countries have shown us that, when done well, VAS delivered through the routine health system can achieve and sustain high coverage – even when the system is challenged. During the COVID shutdowns, not only did VAS coverage not drop in Kenya, but it actually increased by 10 percentage points, owing in large part to the strength of the community health platform.

4. Recognizing that the transition to routine delivery takes time and needs to be data driven. A phased, systematic, data-driven approach that considers strengths and weaknesses of the health system both at national and sub-national levels is required to ensure that VAS programs are context-specific and sustainable. Consistent high-quality data collection is essential to understanding where gaps exist, what needs to be strengthened, and how to work systematically toward success. One of the first examples of this approach was in the late 2000’s in Ethiopia where, with Nutrition International’s support, the Ministry of Health planned for and then gradually transitioned woredas one-by-one from a “campaign” model to providing VAS through the routine system. Nutrition International worked with the Ministry of Health to identify woredas for inclusion using success criteria and provide woreda-specific technical and operational support including refresher training for health extension workers, supportive supervision and review meetings, behaviour change activities, monitoring and evaluation, and ensuring the availability of capsules. Between 2012 and 2016, all 460 Nutrition International-supported woredas delivering VAS via the government’s community-level routine health extension program achieved the same high coverage – more than 80% – as the woredas delivering VAS via campaigns. With Nutrition International’s experience, we know this timeline to success can be shortened.

5. Strengthening leadership to build a stronger, more resilient future. Ministries of Health need to take the lead in implementation, and work to ensure high uptake and coverage of essential nutrition and health services. But there is no one-size-fits-all approach to achieve high coverage in the most cost-effective way. Each country has unique strengths and challenges, in some settings a transition to routine is warranted, while different strategies will be needed for others. Nutrition International has an important leadership role to play by keeping a laser focus on increasing and maintaining coverage, while also supporting the development of multi-year, costed, context-specific strategies and plans to build sustainable, resilient VAS programs anchored in the health system.

As we reflect on lessons learned and look ahead to the future, we know that making faster, smarter, more strategic, and sustainable progress towards integration of VAS into routine health systems is possible. To do this, we need to scale up what works (and acknowledge what doesn’t), support countries to plan and deliver integrated child health and nutrition packages, and further build the evidence base for how to do this well. As we head into 2023, amidst all the turbulence, complexity, and noise, it’s time to refocus attention on what matters most – the unfinished child survival agenda.

[1]Countries that were represented include: Angola, Cote D’Ivoire, Chad, DRC, Ethiopia, Kenya, Mali, Madagascar, Malawi, Mozambique, Nigeria, Senegal, Tanzania, Togo, Uganda and Zimbabwe.

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