Interagency activities to assure Nutrition Product quality Background and Progress Update

Timeline : Quality Assurance development of Nutritional Products 2005 Scale up of CMAM 2011 Interagency Group Established WFP, UNICEF, MSF 2012 System strengthening in QA 2011 C. Sakazakii Issues in RUTF and RUSF 2012 F AO/WHO 1st consultation – Focus on EB and Salmonella 2013 Interagency QA Group includes USAID 2013 Best practice in QA applied to strategic products 2013 QA monitoring GMP Inspection strengthening 2013 F100 Recall due to increased monitoring nd FAO/WHO consultation on RUTF/RUSF Further systems strengthening amongst interagency group Joint Inspections UNICEF and MSF

Interagency Group participation :  Interagency Group consists of the major purchasers of nutritional products and collaborates closely on Quality matters of common nutritional products  Collaboration also extends to partner UN agencies FAO and WHO when specific expertise is needed. UNICEFInteragency activities to assure Nutrition product quality. Alison Fleet UNICEF Supply Division

TOR - Under development Interagency group focused on product related activities Work-streams include: I.Specification development and common specs if possible II.Normative / regulative work (Codex, WHO consultations) on common products III.Shared inspections of manufacturers IV.Alignment with communication to partners and governments V.Product improvements UNICEFTOR for Interagency Group

Feedback?  How can the interagency best get feedback from the GNC on products?  How can the interagency best communicate with partners so that information flows ? UNICEFType your title in this FOOTER area and in CAPS

Current Interagency Activities: LNS Products 1.LNS – ingredient optimization at the factory level  RUTF, RUSF, MQ-LNS and SQ – LNS are made of similar ingredients  WFP leading work to optimize pre-mix used in these formulae to help local manufacturers  Current nutrient levels on label remain unchanged  Starting work with MQ-LNS (PlumpyDoz) and RUSF  Food safety tests for LNS to be aligned with best industry practice following FAO/WHO expert consultations UNICEFType your title in this FOOTER area and in CAPS

Current Interagency Projects : Therapeutic Milks 2.Therapeutic milk specs:  Original product specification not exactly aligned with WHO guideline for inpatient care of SAM  MSF and UNICEF working together to amend the spec so the product delivers the nutrient levels from ‘Appendix 5’  Other changes investigating – GNC feedback  Scoops for TM  Tins as an alternative packaging format to sachets UNICEFType your title in this FOOTER area and in CAPS

Nutrition: Major projects 2015 Focused goal of Interagency harmonization of auditing standards, specifications for common products and quality standards Implementation of FAO/WHO expert group recommendations and new microbial specification for RUTF and RUSF. Surveys on Therapeutic Milk preparation and use within inpatient facilities new guidance on preparation of milk in inpatient care Collaboration with WHO on Therapeutic milk reformulation as a results of new ‘hot water’ preparation step Further system strengthening of Quality assurance both within agencies and also with suppliers.

PLANNED NEEDS ASSESSMENT FOR RUTF Survey on RUTF recipe, its appropriateness Alison Fleet UNICEF Supply Division, 1 July 2015

BACKGROUND We want a local product Foods should be aligned with cultural practices We don’t want imported, foreign foods given to our children A product made from local foods will be more sustainable A local product will be cheaper

PURPOSE OF THE SURVEY  To inform Unicef’ s strategic focus on developing new recipes for specific countries and regions  Identify countries and regions that could benefit from new a new RUTF recipe  To increase coverage in countries where the current recipe is a road block to SAM treatment  Improve access and affordability of RUTF in a local or regional context

MULTI-LEVEL SURVEY CONDUCTED IN ALL REGIONS WHERE RUTF IS SUPPLIED  Nutrition officers in each region  Ministries of health  UNICEF’s major partners in implementing CMAM programs  End user feedback (those that work in Community heath centres administering RUTF)

SNAPSHOT OF THE SURVEY  Total: 576  15 were hand-written and 561 were completed online (survey monkey)  Total included for analysis: 520  51 % of 135 countries in the UNICEF regions responded  80% of the responses came from the 15 countries with the highest ‘Global burden of SAM’  Chad, Bangladesh and the region of South East Asia are very interested in using the FOND tool to develop their own recipe  Data analysis is ongoing

WHO RESPONDED? OrganisationNo. Respondents MOH12222% UNICEF9317% Another UN organisation224% Health Facility101.5% Research Institution356% NGO (various)13224% MSF101.5% Save the Children5310% ACF5510% Concern Worldwide122% Independent consultants91% TOTAL553100%

WEST AND CENTRAL AFRICA  Countries are quite happy with this recipe – peanut based, the same in every country, the taste is acceptable  Should be more investment in supply chain infrastructure (sugar, oil, peanuts)  Governments need to understand the added value if the product locally produced  Local production is more expensive in most cases  Local suppliers have difficulties in producing at a large scale  Lead time is an issue – this would be helped if production was closer to recipients in some of the harder hit countries

EASTERN AND SOUTHERN AFRICA  Issues with supply chain – Need exceeds supply  Faced with continual emergencies – many of the countries with are medium to high risk countries – floods, drought, political unrest  Does not have the impression that new formulations are needed  Rather there is a need for improvements to the supply chain management - for those already producing – Quality and Capacity  Study being conducted at the moment on RUTF supply chain management

SOUTH EAST ASIA AND THE PACIFIC

SOUTH EAST ASIA AND PACIFIC REGION  Indonesia : Priority Country – 9.5% SAM burden. Will not accept imported RUTF  Most countries in this region have very little infrastructure for CMAM programs  Linked with their health care system – community based health an uncommon model  Inappropriate inpatient treatment prevalent (eg providing F100 for parents to use with children at home; length of SAM treatment not long enough for full recovery)  Many countries don’t have funds for RUTF – major bottle neck  Vietnam has successfully developed their own recipe, based on Moon Cake. This is preferred to the original peanut based RUTF. Vietnamese government purchase and run programs using this product.  Regulation of RUTF is challenging for this region, is it a food or is a medicine? Need to first classify the product before allocation of MOH funds, and inclusion on the countries essential medicine list. Funding foods presents challenges.