Nutritional Supplements’ Effects on Health Systems: The Case of Nutributter in Nicaragua

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Anita Chary

Anita Chary

Anita Chary, MD PhD, is an anthropologist and resident physician at the Harvard Affiliated Emergency Medicine Residency. She is Research Director of the non-governmental organization Maya Health Alliance | Wuqu' Kawoq, which provides health care and development services in rural indigenous communities of Guatemala.
Photo credit Nicole Henretty.

A mother and her child at a child nutrition campaign in rural Nicaragua. Photo credit Nicole Henretty.

 

Plumpy’nut, Medika Mamba, Nutributter—many of us have heard of these peanut-butter based nutritional supplements, which have, in many ways, revolutionized childhood nutrition interventions in low- and middle-income countries (LMICs). To name only a few benefits of these products, ready-to-use therapeutic foods (RUTFs) like Plumpy’Nut allow treatment of acute child malnutrition to occur in the home rather than in the hospital, reducing health care costs and promoting family integrity and caregiving. Lipid-nutrient supplements (LNSs) like Nutributter help fortify diets of chronically malnourished children whose nutrient needs and dietary diversity requirements are not met under the constraints of poverty. These products can also be produced locally, creating opportunities for employment and encouraging local ownership and involvement in urgent health issues. The list of benefits goes on and on.

 

Generally, we know that RUTF- and LNS-based interventions are efficacious in helping children recuperate from undernutrition, and they tend to be well-accepted by local populations. Less is known, however, about the effects that these products can have on health systems. In the last few decades following structural adjustment policies and health care reforms in many LMICs, public-private partnerships have become one of the most salient features of the contemporary global health landscape. It is through these collaborations that many nutritional supplementation programs operate: trials and interventions involving RUTFs and LNSs often involve a diverse array of institutions, including Ministries of Health, non-governmental organizations (NGOs), university researchers, large development institutions, and non-profit supplement manufacturers. This poses the question: what types of effects might RUTFs and LNSs have on health care systems and infrastructure in LMICs?

This post attempts to offer some preliminary answers to this question. Recently, I worked with Edesia Inc., the manufacturer of Nutributter, on a qualitative study in Nicaragua examining the roles of the public, civil, and NGO sectors in large-scale distribution of Nutributter. Specifically, we studied the SALTAR (Seguridad ALimentaria: Tecnicas y Apoyo para Resultados / Food Security: Skills and Support for Results) program in Jinotega, one of the poorest, most rural departments of Nicaragua with the highest rate of chronic childhood stunting countrywide. The situation in Jinotega is quite familiar to those working in rural areas of Central America and other LMICs: there is a large population of agricultural laborers who are seasonally employed and poorly-compensated; family sizes are large and birth spacing minimal; food insecurity is rampant.

For several years, the SALTAR program distributed Nutributter to thousands of children six to 23 months of age as part of Ministry of Health (MOH)-sponsored child health programming. The program partners involved the Nicaraguan MOH, 500 volunteer community health workers, a large international NGO (Project Concern International, PCI), and Edesia (the manufacturer of Nutributter). PCI received a grant to purchase Nutributter from Edesia, supplied the MOH with Nutributter, and was responsible for storing the products in warehouses, maintaining an inventory, and ensuring the product stock. MOH personnel at 28 health posts and centers, as well as the volunteer community health workers, were responsible for growth surveillance and monitoring of the children, providing nutrition education to caregivers, and distributing the Nutributter to beneficiaries. Distribution occurred on a monthly basis, both within MOH facilities (during visits for child health care, growth monitoring, and vaccinations), and within rural communities themselves, in conjunction with nutrition education and counseling.

 

We interviewed a variety of stakeholders from each of these sectors about their work and conducted focus groups with program beneficiaries about their experiences with Nutributter. A few of the major results are worth mention:

 

Nutributter had some interesting effects on the Nicaraguan health system.

  • Increased health service utilization.
    MOH personnel—nurses, doctors, and health educators—reported that once they began distributing Nutributter to children’s caregivers visiting the health centers and posts, those caregivers were likelier to use other MOH services such as family planning, prenatal care, and vaccinations. That is, Nutributter seemed to help incentivize, or at least encourage, forms of care-seeking aside from child nutrition check-ups and monitoring. As one staff member at a health post described, “It has helped us…increase coverage, because by distributing this small packet, more mothers are now attending the vaccination campaigns with their children, which is helping us attract new children who we were previously not able to follow up on for 3-5 months.” Another staff member said that the health post was “taking advantage of [the] opportunity” to offer “more prevention, more care, more training and counseling,” particularly as related to “integrated maternal and child care.”
  • Facilitating inter-health sector relationships.
    Nicaragua has a history of community health organizing and a strong presence of volunteer community health workers (CHWs). As in many settings, CHWs play important roles within their communities and often represent a first point of consultation for the sick. However, CHWs tend to be fairly low within biomedical hierarchies and are often undervalued. In the SALTAR program, because of their crucial roles in Nutributter distribution, CHWs gained visibility both within their communities and MOH posts. The program facilitated relationships between MOH staff and volunteer community health workers, as they had to work together closely to distribute the product and maintain program records. As exposure to and interaction with CHWs increased, both community beneficiaries and MOH personnel expressed greater appreciation and respect for the CHWs.

 

There were also important challenges involved with distributing Nutributter.

  • Extra burdens for health care workers.
    Incorporating products such as Nutributter into routine care can pose an extra burden for MOH staff, who already tend to be overwhelmed with clinical duties within health facilities, and for CHWs, who are uncompensated for their work. As anthropologists like Alex Nading point out, expecting CHWs to volunteer their time and labor within a context of poverty and scarcity is an unrealistic expectation. Several CHWs had used their own money to transport Nutributter from MOH facilities to their own communities. Even if programs do not pay salaries to CHWs, they should anticipate and budget for this type of expense. Ultimately, in Nicaragua, PCI was able to make transportation accommodations to prevent further out-of-pocket expenses like this.
  • Sustainability.
    Multiple parties expressed fears about what could be glossed as the “sustainability” of using products like Nutributter. RUTF and LNS products are often provided to beneficiaries free of charge, thanks to funding from international NGOs, bi- and multilateral institutions like USAID and UNICEF, and large research grants. MOH staff feared that once the Nutributter project ended, utilization of health care services would drop back down to its pre-program rate. Community members worried about what would happen to their children’s health once the program ended, as caregivers’ employment situations and earning potential, and therefore family diets, had otherwise remained unchanged. Recent movements to sell RUTF and LNS products, even at low and heavily-subsidized prices, may thus encounter difficulty on the ground. Community members’ concerns reflect the important truth that broader structural and political changes are needed to ensure that all human beings have access to sufficient food and diverse diets. RUTF and LNS products are excellent recuperative and preventive measures in health, but they represent only a partial solution to a problem with much deeper structural and social roots.

 

There are obvious limitations to this research. First, our findings depend on observations from health care personnel and community members, rather than quantitative measurements of health service utilization or formal assessments of interactions between CHWs and MOH personnel. Quantitative analysis of these phenomena might be a fruitful direction of future study. Second, our findings are context-specific, as not all RUTF or LNS distribution systems work through public-private partnerships of this nature. Indeed, this type of system may not work all that well in countries lacking the robust tradition of community health organizing that characterizes Nicaragua. However, in many LMICs, NGOs and CHWs are involved to some degree in the roll-out and scale-up of supplement-based nutrition programs, whether in conjunction with or independent from the MOH. Therefore, we hope to have provided at least some insights about these types of programs.

 

The above is based on a report entitled, “Qualitative Analysis of the Use of Nutributter® in PCI’s SALTAR Program in Nicaragua,” co-authored with Graciella Marsal and Dr. Alba Alvarado. Please email anita@globalhealthhub.org if you’d like a copy of the full report (in English).

Special thanks to Nicole Henretty.  This study was funded by Edesia Inc.