Assessing and improving the quality of health care was, until recently, a low priority, both for policy makers in developing countries, and for technical agencies. The authors review the reasons for this long neglect of quality of care, which include: (i) a perceived priority of extending coverage at the expense of quality; (ii) the view that quality is difficult to assess in the absence of reliable documentation and health information systems; and (iii) the perception that improving quality is tantamount to increasing inputs, thus costly and not affordable for many countries. The authors strongly suggest that focusing on improving the process of care through quality assurance (QA) is the most promising avenue to improved quality of care in these countries. They review the current state of the art of QA in developing countries and formulate some policy suggestions: they call for a national commitment and leadership that provides a legal and institutional framework for QA and supports QA teams in the areas of setting professional standards, training, supervision, and information. The authors stress that the focus on process should not lead to a neglect of improving inputs. We conclude by suggesting future research in four broad areas: (i) development, testing and evaluation of new ways to implement QA through operational research; (ii) the links between process as well as inputs and outcomes; (iii) the relationship between quality and other health system variables, such as demand, costs, revenues and equity; and (iv) development of comprehensive quality indicators based on a score of process, input and outcome variables that allow researchers and policy makers to compare quality across time, space and different types of care providers.

An effective delivery strategy coupled with relevant social and behaviour change communication (SBCC) have been identified as central to the implementation of micronutrient powders (MNP) interventions, but there has been limited documentation of what works. Under the auspices of “The Micronutrient Powders Consultation: Lessons Learned for Operational Guidance,” three working groups were formed to summarize experiences and lessons across countries regarding MNP interventions for young children. This paper focuses on programmatic experiences related to MNP delivery (models, platforms, and channels), SBCC, and training. Methods included a review of published and grey literature, interviews with key informants, and deliberations throughout the consultation process. We found that most countries distributed MNP free of charge via the health sector, although distribution through other platforms and using subsidized fee for product or mixed payment models have also been used. Community‐based distribution channels have generally shown higher coverage and when part of an infant and young child feeding approach, may provide additional benefit given their complementarity. SBCC for MNP has worked best when focused on meeting the MNP behavioural objectives (appropriate use, intake adherence, and related infant and young child feeding behaviours). Programmers have learned that reincorporating SBCC and training throughout the intervention life cycle has allowed for much needed adaptations. Diverse experiences delivering MNP exist, and although no one‐size‐fits‐all approach emerged, well‐established delivery platforms, community involvement, and SBCC‐centred designs tended to have more success. Much still needs to be learned on MNP delivery, and we propose a set of implementation research questions that require further investigation.

This study assesses the impact of an integrated infant and young child feeding (IYCF) and micronutrient powder (MNP) intervention on children’s risk of anemia and IYCF practices in Madagascar. Quantitative baseline and endline surveys were conducted in representative households with children 6–23 months from two districts, where an 18-month IYCF-MNP intervention was implemented. Relative risks comparing children’s risk of anemia and maternal IYCF knowledge and practices at baseline versus endline, and also at endline among MNP-users versus non-users were estimated using log-binomial regression models. 372 and 475 children aged 6–23 months were assessed at baseline and endline respectively. Prevalence of anemia fell from 75.3% to 64.9% from baseline to endline (p = 0.002); the reduction in the risk of anemia remained significant in models adjusting for sociodemographic characteristics (ARR (95% CI): 0.86 (0.78, 0.95), p = 0.003). In endline assessments, 229 out of 474 (48.3%) of children had consumed MNPs. MNP-users had a lower risk of anemia (ARR (95% CI): 0.86 (0.74, 0.99), p = 0.04) than non-users, after controlling for child’s dietary diversity and morbidity, maternal counseling by community-health-workers, and sociodemographic characteristics. Mothers interviewed at endline also had greater nutrition knowledge and were more likely to feed their children ≥4 food groups (ARR (95% CI): 2.92 (2.24, 3.80), p < 0.001), and the minimum acceptable diet (ARR (95% CI): 2.88 (2.17, 3.82), p < 0.001) than mothers interviewed at baseline. Integration of MNP into IYCF interventions is a viable strategy for improving children’s consumption of micronutrients and reducing risk of anemia. The addition of MNP does not negatively impact, and may improve, IYCF practices.

Global recognition that the complex and multicausal problems of malnutrition require all players to collaborate and to invest towards the same objective has led to increased private sector engagement as exemplified through the Scaling Up Nutrition Business Network and mechanisms for blended financing and matched funding, such as the Global Nutrition for Growth Compact.The careful steps made over the past 5 to 10 years have however not taken away or reduced the hesitation and scepticism of the public sector actors towards commercial or even social businesses. Evidence of impact or even a positive contribution of a private sector approach to intermediate nutrition outcomes is still lacking. This commentary aims to discuss the multiple ways in which private sector can leverage its expertise to improve nutrition in general, and complementary feeding in particular. It draws on specific lessons learned in Bangladesh, Côte d'Ivoire, India, Indonesia, and Madagascar on how private sector expertise has contributed, within the boundaries of a regulatory framework, to improve availability, accessibility, affordability, and adequate use of nutritious foods. It concludes that a solid evidence base regarding the contribution of private sector to complementary feeding is still lacking and that the development of a systematic learning agenda is essential to make progress in the area of private sector engagement in nutrition.

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Based on experience in Nepal from 1996-2001, this paper presents a six-element framework to support governments in poor countries in developing and implementing reproductive health programmes. The six elements of the framework are: (i) collaborative planning and programming; (ii) strategic assessment; (iii) policy and strategy development; (iv) guideline and material development; (v) reproductive health programme management; and (vi) policy review. Its implementation calls for collaborative work between policymakers and programme managers at all levels of the health system, external donors and development agencies. Change in Nepal is constrained by poor human and financial resources, extremely difficult geography and strong cultural, religious and social traditions. An informal assessment at district level and below found that information tools, clinical protocols and operational guidelines were highly relevant, though problems with utilisation and motivation were noted. Utilisation of strategy and policy documents and tools was reported to be high at national level, but no causal link can be drawn between instruments in the framework and changes in reproductive health indicators. However, access to the tools described in this article can contribute to improvements in coverage and quality of reproductive health services in the hands of motivated people; improved indicators in family planning use, antenatal care and assisted delivery in Nepal in this period support this view.