I. RATIONALE

Several developments have taken place since the current version of the Micronutrient Supplementation (MS) Guideline was formulated five years ago. New preparations of micronutrient supplements that could lead to control of the deficiencies have been developed and are now available in the country. In 2007, zinc supplementation was introduced as an essential adjunct to oral rehydration therapy (ORT) in the management of diarrhea among children. New scientific evidence on the efficacy of specific MS, changes in the nutrient adequacy levels of the population and both national prevalence surveys require that a review and updating of the current policy on targeting and prioritization of MS be undertaken. It is necessary that the target populations for micronutrient supplementation identified in the past be updated given the new data on the prevalence of micronutrient deficiencies.

MS alongside with diet diversification and food fortification comprise the three- pronged strategy identified by the government to combat micronutrient deficiency problems in the country. The MS Program is dependent on the progress of diet diversification, food fortification efforts, and the level of public health significance of the prevailing micronutrient deficiencies. Diet diversification which aims to provide essential micronutrients needed by the body through diet enhancement remains the cornerstone of this strategy. The use of fortified foods on the other hand remains uneven among the general population. Since both interventions have yet to generate the desired level of micronutrient adequacy among the general population, there is a need to further strengthen the micronutrient supplementation with the aim of contributing to the overall improvement of nutritional status of Filipinos. In that light, the DOH ™s current policies and guidelines pertinent to its MS Program need to be updated.

II. DECLARATION OF POLICY

This issuance reiterates the provisions of AO No. 2007-0045 Zinc Supplementation and Reformulated Oral Rehydration Salt in the Management of Diarrhea and complements the provisions of DOH AO No. 2008-0029 on the Health Reforms for Rapid Reduction of Maternal and Neonatal Mortality. It also supersedes AO No. 119, s. 2003 on the Updated MS Guide issued in December 2003.

III. GUIDING PRINCIPLES

The updated MS Policy and Guidelines is governed by the following principles:

A. Rights-Based Approach. MS in the country is anchored on our respect of the rights of children and women as stipulated in our Philippine Constitution, the Convention on the Rights of the Child and the Convention on the Elimination of All Forms of Discrimination Against Women.

B. Systems Approach. Sustained MS provision is contingent on the adoption of a systems approach that institutes fundamental reforms in health service delivery, governance, financing and regulations.

C. Life-Cycle Based Intervention. The MS policy must be aligned with the requirements and conditions of individual clients at various stages of the life-cycle.

D. Equity. Population groups with the least capacity to access MS and those most vulnerable to the deficiency must be given top priority in MS assistance.

E. Complementation of Interventions. MS yields maximum results if complements other parallel but integrated interventions like deworming, environmental sanitation, healthy lifestyle promotion, immunization and other relevant measures.

F. Evidence-Based Interventions and Approaches. Policies and guidelines shall be developed based on recent data gathered through prevalence surveys, efficacy studies and other research findings done locally and globally. Recommendations from international organizations will also be utilized but in consideration of the appropriateness with the local context.

G. Integrated Service Delivery. Service integration in MS delivery must be observed in four tracks. First is the alignment of MS with the other existing public health program packages cascading from the national to local level. Second is the conscious and purposive integration of MS at each service delivery point and interface between the health care provider and client both in public and private facilities. Third is the continuity in provision of MS through appropriate referrals and follow-up of clients especially those that require extended period of supplementation over time. Fourth is for MS provision to take place in the health and non-health sector settings, particularly in schools, workplaces, malls, etc.

IV. OBJECTIVES

In general, this policy and guide aims to ensure the appropriate provision of quality MS in the country. Specifically, it aims to:

(1) Guide health workers and providers in administering micronutrient supplements to identified population groups and client needs;

(2) Promote the compliance and adherence among DOH offices, the LGUs and private sector to the revised policy and guidelines; and

(3) Generate the support of other stakeholders in implementing the MS policy and guide throughout the country.

V. SCOPE OF APPLICATION

This order shall apply to all national, regional and local government offices, public and private health facilities, NGOs, development partners and other stakeholders whose functions and activities contribute to the delivery and provision of MS nationwide.

VI. DEFINITION OF TERMS

1. Diet Diversification - It is the changing of diet practices that affect young children, pregnant and lactating mothers, toward consumption of foods adequate in energy and rich in micronutrients, especially those in short supply in the current diet carried out through nutrition information and education.

2. Emergency - It is an extraordinary situation wherein people are unable to meet their basic survival needs, due to serious and immediate threats to human life. These usually result from disaster, environmental degradation, among others.

3. Elderly - These are persons who are more than 60 years old as defined by the Senior Citizen ™s Act in the Philippines.

4. Food Fortification - It is one of the interventions to reduce micronutrient deficiencies. It is the œprocess whereby nutrients are added to foods to maintain or improve the quality of the diet of a group, a community or a population. Examples are flour fortified with Vitamin A and iron, sugar and oil with Vitamin A, rice with iron, and salt with iodine.

5. Health Providers - Refers to individual health staff or any health care facilities (BHS, RHU/health center, private clinics, hospitals, lying-in/birthing clinics, school clinics, corporate clinics, etc.) that provides MS.

6. Iodine Deficiency Disorders - Refers to the ill-effects of iodine deficiency in a population that can be prevented by ensuring that the population has adequate intake of iodine. It is the most common cause of preventable mental retardation. It also affects the mother ™s reproductive functions and impedes children ™s learning ability.

7. Iron Deficiency Anemia - It is a disorder resulting from the decrease in the number of red blood cells due to lack of iron. It is the most common nutritional deficiency in the world and occurs if the amount of iron absorbed is too little to meet the body ™s needs.

8. Micronutrient - A dietary element essential only in small quantities.

9. Micronutrient Supplement - Vitamin and mineral supplements are sources in concentrated forms of those nutrients alone or in combinations, marketed in forms such as capsules, tablets, powders, solutions, etc. that are designed to be taken in measured small-unit quantities but are not in a conventional food form and whose purpose is to supplement the intake of vitamins and/or minerals from the normal diet.

10. Micronutrient Supplementation - It is a short term intervention intended to correct high levels of micronutrient deficiencies by providing large doses of micronutrients immediately until more sustainable food-based approaches (e.g. food fortification and diet diversification) are put in place and become effective.

11. Public Health Importance - Refers to the cut-off points recommended by WHO where a micronutrient deficiency is to be considered a public health concern necessitating the state or country to intervene.

- for Iron Deficiency Anemia^[i] -

Category of Public Health Significance Prevalence of Anemia Severe > 40% Moderate 20.0 - 39.9% Mild 5.0 - 19.9% Normal < 5.0%

- for Vitamin A Deficiency^[ii] - More than 15% deficient to low with Vitamin A is considered of public health importance.

Deficient: Plasma retinol (Vitamin A) less than 10 ug/dL/0.35 Umol/L
Deficient to Low: Plasma retinol (Vitamin A) less than 20 ug/ dL/ 0.70 umol/L

- for Iodine Deficiency Disorders - The indicator of iodine deficiency œelimination  is a median value of 100 ug/L, in the general population, and not more than 20% of the UIE should be below 50 ug/L (ICC-IDD). The UIE levels for adequacy among pregnant women is 150 ug/L.

12. Vitamin A Deficiency - A level of depletion of total body stores of retinol and its active metabolites such that normal physiologic function is impaired.

13. Xeropthalmia - A term used to include all signs and symptoms affecting the eye that can be attributed to Vitamin A Deficiency.

VII. GENERAL GUIDELINES

A. Micronutrient supplementation shall be adopted as an intervention to address micronutrient deficiency given the following conditions:

• population groups with micronutrient deficiency prevalence that is at a level of public health importance,
• micronutrient needs of population groups cannot be met through regular diet and use of fortified foods,
• use of MS is proven efficacious and safe; and
• administration of MS has significant effects on health and welfare at each stage in the life cycle and on the next generation.
  

B. Micronutrient supplementation is recommended for the following priority age and physiological groups:

• 0-59 months old children
• pregnant and lactating women
• non-pregnant and non-lactating women of reproductive age (15-49 years old)

C. A package of micronutrient supplements in the right dosage, timing, frequency and duration shall be provided to the above priority groups according to their needs at various stages of their life cycle.

D. Priority shall also be given to population groups and individuals in special situations or with particular conditions:

• during emergencies
• those residing in areas endemic with malaria and schistosomiasis
• individuals who are clinically diagnosed with micronutrient deficiencies
  e.g. xeropthalmia

E. Therapeutic dosage may be given to individuals with established deficiencies even if micronutrient supplementation is not recommended for the following age groups:

• 5-9 years old children
• adults, 50-60 years old
• elderly, > 60 years old

F. Delivery of the MS Packages shall be integrated into the existing Maternal, Newborn and Child Health and Nutrition (MNCHN) service delivery channels and through other avenues that could best reach the targeted clients. These may include non-traditional service settings such as the schools, the workplaces, etc. to widen reach and coverage.

G. LGU ™s capacity to provide quality MS to priority population groups shall be enhanced particularly in the area of MS program management, diagnosis and MS administration, counseling and information, and systems design and establishment for client referral, recording and reporting, follow-up and tracking.

H. Financing of essential MS must be sustained and secured.

I. MS information management shall be strengthened for better planning and implementation.

J. Promotion of MS shall be intensified to generate the desired behaviors of targeted clients and other groups of stakeholders. Promotion efforts shall be focused towards improving the targeted clients ™ awareness and appreciation of MS benefits and its negative consequences if deficiencies remained uncorrected, wider adoption by LGUs of the recommended MS packages.

K. Continuous availability of MS supply shall be ascertained at the local level.

L. Monitoring and evaluation of the MS program must be improved by expanding the coverage of scope to be tracked, integrating MS as part of the regular supervision visits at the local level, and inclusion of the review of the MS intervention in the regular Program Implementation Review (PIR).

A Manual of Operations on Micronutrient Supplementation shall be developed to detail the standards and protocols to operationalize the above policies and guidelines.

VII. ROLES AND RESPONSIBILITIES

A. Department of Health at the National Level

1. National Center for Disease Prevention and Control (NCDPC)

The DOH-NCDPC is primarily responsible in the overall execution of the revised policy and guidelines on Micronutrient Supplementation. It will undertake the following tasks:

1.1 Lead in the dissemination of the Revised MS Policy and Guide and advocate for its adoption and implementation among concerned stakeholders;

1.2 Coordinate and provide technical inputs in the design, installation and operationalization of management systems (e.g. staff training, logistics management, recording/reporting system, referral, etc.) and other MS initiatives (e.g. Garantisadong Pambata, health promotion for MS);

1.3 Allocate funds for micronutrient supplement requirements based on National Objectives for Health (NOH) targets that should be interpreted yearly and on the Medium Term Expenditure Framework (MTEF);

1.4 Include micronutrient package in its procurement plan and submit the necessary documents (annual procurement plan [AAP], allocation list, among others) in a timely manner to the DOH- Procurement Service to ensure timely procurement, allocation and delivery of MS to CHDs;

1.5 Coordinate with FDA, pharmaceutical industry and other concerned agencies to facilitate the availability and accessibility of affordable and quality MS nationwide;

1.6 Monitor LGU compliance to the revised MS Policy and Guide together with CHDs;

1.7 Review and revise MS Policy and Guide based on body of technical evidences;

1.8 Organize panel of MS experts and other relevant multi-sectoral body to provide support in reviewing and updating policies, directions and technical guides on MS.

2. National Center for Health Promotion

2.1 Develop prototype materials on MS in coordination with DOH-NCDPC;

2.2 Provide technical assistance to CHDs to help LGUs adopt and implement behavioral change measures towards desired MS behaviors.

3. Procurement Service/Material Management Division

3.1 Ensure timely procurement of micronutrient supplements;

3.2 Ensure proper storage, timely distribution and deliver y of commodities to all CHDs.

4. Food and Drug Administration

4.1 Facilitate registration of MS products as deemed appropriate;

5. PhilHealth

5.1 Review the use of MS provision as a quality parameter during the assessment of renewal of the health facilities ™ accreditation to Outpatient Benefit Package (OPB);

5.2 Intensify promotion for LGUs ™ enrolment to PhilHealth, and to buy-in to the accreditation for various benefit packages;

5.3 Promote accreditation of all Rural Health Units for Mother and Child Package and Out Patient Benefit packages;

5.4 Intensify enrollment campaign for sponsored program and individually-paying program.

6. National Nutrition Council

6.1 Mobilize resources in support to MS;

6.2 Coordinate nutrition activities as these impact on the MS program and vice versa;

6.3 Evaluate progress of the MS Policy and Guide implementation as part of Monitoring and Evaluation of Local Level Plan Implementation (MELLPI);

B. Food and Nutrition Research Institute

1. Undertake Research and Development (R and D) and Science and Technology (S and T ) activities related to micronutrient deficiencies;

2. Generate resources to conduct national nutrition surveys and other R and D and S and T activities/studies;

3. Disseminate results of R and D and S and T activities to all concerned partners as basis for development planning;

4. Participate in the review and update of the MS Policy and Guide.

C. Centers for Health Development (CHD)

1. Disseminate the revised Policy and Guidelines on Micronutrient Supplementation and advocate for its adoption and implementation by LGU health systems in the different localities within their respective regions;

2. Ensure availability of micronutrient supplements in coordination with the DOH-NCDPC and LGUs by: (i) facilitating the distribution of supplements according to the allocation requirements; (ii) quarterly monitoring of supplement stocks and utilization; and (iii) maintaining stock of micronutrients for emergency situations;

3. Provide technical assistance to LGUs in organizing MS activities and developing relevant technical references and IEC materials;

4. Generate additional resources to strengthen the implementation of the revised policy and guidelines;

5. Formulate and implement advocacy plans to generate stakeholders ™ support, particularly the local officials;

6. Monitor the implementation of the revised policy and guide in both public and private hospitals, and in different localities in their respective regions;

7. Undertake regular review with LGUs on the progress of the MS policy and guide.

D. Local Government Units

1. Provincial/City Health Office (P/CHO)

1.1 Orient/train private and public health workers on the revised MS policy/guide;

1.2 Advocate with municipalities/cities and other concerned agencies and stakeholders to adopt and implement the revised policy and guidelines;

1.3 Generate and allocate resources in support to MS provision (e.g. counterpart funds for training, procurement of additional MS, etc.);

1.4 Ensure proper storage, regular inventory of stocks, allocation and timely distribution of MS hospitals and municipalities/cities;

1.5 Ensure hospitals to include MS guides in the hospitals treatment/care protocols;

1.6 Ensure timely reporting of utilization and coverage;

2. Rural Health Units/Health Centers

2.1 Prepare/update masterlist of targeted clients;

2.2 Screen and identify clients to be given micronutrient supplementation;

2.3 Provide the necessary micronutrient supplements according to protocol;

2.4 Identify other service channels where MS provision can be integrated;

2.5 Organize health staff and mobilize all concerned to participate in GP;

2.6 Forecast MS requirements of identified targets and develop a plan for meeting the MS requirements, and incorporate into the annual operational plan;

2.7 Advocate among LCEs and other local officials to allocate budget for MS;

2.8 Segment if necessary clients to be fully subsidized from those who could pay;

2.9 Ensure proper storage of MS supply and do regular inventory of stocks;

2.10 Train health staff and community volunteers on MS;

2.11 Ensure proper recording of MS provision and utilization and the timely submission of reports to appropriate levels;

2.12 Disseminate essential information on MS to clients and community members;

2.13 Monitor and supervise provision, utilization and coverage of MS.

E. Regional, Provincial and District Hospitals

1. Integrate the updated MS policy and guide into their treatment protocols;

2. Provide budgetary allocation for the procurement of MS;

3. Participate in the nationwide campaign - Garantisadong Pambata;

4. Conduct orientation/training of hospital staff on the MS policy and guide;

5. Conduct integrated nutrition education activities to patients;

6. Coordinate with PHO/RHUs on referral and follow up of clients.

F. Development Partners (professional societies, donors, NGOs, civic organizations, academe, private partners, etc.)

1. Participate in the review and revision of the MS Policy and Guide;

2. Help promote PIPH process at the local level as basis for determining LGUs ™ requirements for MS assistance;

3. Mobilize or provide resources to augment MS supply at the local level;

4. Assist in the review and update of training programs on MS;

5. Participate in monitoring the utilization and coverage of MS;

6. Support the national MS campaigns like GP;

VIII. REPEALING CLAUSE

Administrative Order 19, s. 2003 and all other orders and related issuances inconsistent with the provisions of this issuance are hereby rescinded.

IX. EFFECTIVITY

This order takes effect immediately.

  (SGD.) ESPERANZA I. CABRAL, MD
  Secretary of Health

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^[i] Iron Deficiency Anaemia Assessment, Prevention, and Control A guide for programme managers. WHO/ UNICEF 2001.

^[ii] Philippine Nutrition, Facts and Figures 2003. Food and Nutrition Research Institute, Department of Science and Technology