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Zinc Saves Kids on the Ground in Nepal

In Nepal, almost 50% of children under the age of five years currently suffer from chronic malnutrition. Also of great concern is that almost half of the under-five child population and approximately 75% of the under-two child population suffers from anemia. A large proportion of children also suffer from concurrent zinc deficiency. Stunting is the proxy indicator for zinc deficiency. With 50% of children suffering from stunting, the government has recognized the need for an approach to improve zinc status in children to aid stunting reduction.

For most families in Nepal, regular access to micronutrient-rich foods is a distant reality, and as micronutrient fortification initiatives are in early stages of development there is a need for preventive multiple micronutrient supplementation.

Zinc intervention as treatment is also critical for child survival. Diarrhea and pneumonia are the current leading causes of under five child deaths in Nepal. Use of zinc tablets as part of diarrhea management can enhance a child’s immunity and reduce severity of illness as well as decreasing the risk of future diarrheal episodes.

In 2005, after adopting the new WHO and UNICEF guidelines on clinical management of acute diarrhea in children under five, the Nepalese Ministry of Health started administration of zinc tablets as part of diarrhea treatment. As per the protocol, any child suffering from diarrhea is to be provided with a ten-day supply of zinc tablets alongside low osmolar oral rehydration salts. The target of the zinc program is to have at least 80% of diarrheal cases treated with zinc supplementation. Nepal comprises of 75 health districts. The intervention was initiated in two districts in 2006 and was rolled out to 68 districts by 2009. Though nationwide implementation is very near, zinc coverage is far from optimum. A survey recently conducted in 40 districts has found coverage to be approximately 7% including both public and private distribution. Major reasons for low coverage include erratic and inadequatesupply of zinc tablets; poor logistics management; lack of awareness concerning the intervention in the community; inadequate understanding of the treatment amongst health service providers; and a large proportion of mothers seeking treatment throughthe private sector which is presently notpromoting zinc. Another issue that warrants attention is the poor awareness, and low acceptance of the intervention in communities. At present, there is no Behavior Change Communication strategy regarding the program and no media campaigns are in place for increasing program awareness. There are anecdotal evidences that healthworkers have not fully internalized the importance of the intervention and are not pro-actively promoting the intervention. Poor training and lack of review with health staff has resulted in this situation. Although there are three local pharmaceutical firms within the country now manufacturing and marketing various zinc formulation brands, availability of these products needs to improve.Many chemists are also still recommending anti-diarrheal as the first line of drugs. A key underlying factor is the higher profit margin of the latter treatment. This situation is leading to irrational use of anti-diarrheal and also creating unnecessary economic burden for families. Promotion of zinc aims to reduce household spending on anti-diarrheal and antibiotics and is critical for preventing resistance build-up to these drugs. UNICEF will focus on public sector distribution. UNICEF’s technical and coordination support aims to improve and sustain performance by supporting awareness-creation, through reviewing and strengthening activities in place (e.g. improved quality training and supply logistics to enhance the capacity of health workers and community volunteers).

UNICEF in collaboration with its partners including IZA will support the Government to initiate and expand the approach in 30 districts by 2012. Thereafter, the Government will utilize its resources from health sector pool funds to scale up and sustain the approach in the remaining 45 districts. IZA funds will be used to fund the pilot in four out of six districts and roll out in 15 districts. The remaining 15 districts will be covered through funding by the European Commission (EC).

Within the national scale-up of the program, it is envisaged that approximately two million children under two years of age will be reached with zinc supplementation. As part of the program, infant and young child feeding will also be promoted to improve the growth and nutritional status of approximately 3.8 million children aged below five years. In the long term (by 2015), anemia in children under two years of age is expected to reduce by at least 70%, lowering the overall prevalence of anemia in children under five years from 48% to approximately 15%.

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