Q&A: Improving maternal health with a new multiple micronutrient supplementation costing tool

In August, Results for Development (R4D) introduced a new customizable, interactive costing tool designed to support the introduction and scaling up of multiple micronutrient supplementation (MMS) nationally and sub-nationally. The Excel-based tool, developed in collaboration with kupara consulting and with funding from the Gates Foundation, assists stakeholders in estimating the costs of all activities necessary for a successful transition from iron folic acid (IFA) supplementation to MMS.

R4D Market Shaping Practice Lead Bhavya Gowda, Associate Director Amy Roberts, Program Officer Brighid Morgan and kupara consulting Managing Director Rajnee Singh spoke with R4D Senior Content Manager Alexander McCall about the new tool, its necessity and development, and the impact it could have on maternal health in countries around the world.

Why should countries transition to MMS, and how many countries are actively pursuing this type of transition?

Bhavya Gowda: This question has come up a lot, and there is compelling evidence that supports the transition.

Specifically, there is strong evidence that shows the United Nations International Multiple Micronutrient Antenatal Preparation of Multiple Micronutrient Supplements (UNIMMAP MMS, referred to as MMS), which contains 15 essential nutrients compared to just two in IFA, is better than IFA at preventing preterm births, low birth weight and stillbirths.

In anemic or underweight women, MMS offers even greater benefits. It is as effective as IFA in preventing maternal anemia, despite having a lower iron content.

A recent study by the Copenhagen Consensus revealed that shifting from IFA to MMS offers the most advantageous benefit-cost ratio among nutrition interventions, projecting an impressive return of $37 for every $1 invested.

As of now, more than 25 countries are actively engaged in introducing MMS and planning for its eventual scale-up. Another 25 have expressed interest in adopting MMS in the near future. We also applaud UNICEF and other partners for launching the “Improving Maternal Nutrition Acceleration Plan” earlier this year. It outlines a strategy for reaching 16 million women in 16 countries with essential nutrition services.

The World Health Organization recommends IFA supplementation for pregnant women, but coverage remains low. Why is that?

Brighid Morgan: There are several factors contributing to low IFA coverage. Some are universal: adherence is poor, partly due to gastrointestinal side effects associated with IFA, and awareness among pregnant women remains inadequate.

Other barriers are context specific: many women delay or attend antenatal care (ANC) visits irregularly due to accessibility and/or cultural taboos, missing key opportunities to receive ANC supplements. In some countries, there are also challenges with supply planning, which can lead to procurement inefficiencies and market asymmetries that hinder suppliers’ ability to estimate demand.

Additionally, inconsistent and insufficient government funding for the product fails to meet the quantified need. We suspect the issue of insufficient funding will also inhibit introduction and scale-up of MMS if it is not addressed.

With that knowledge and understanding, what would make for a successful transition? What do countries and leaders need to consider?

Amy Roberts: To successfully introduce and scale up MMS, countries and leaders must start with a clear vision — and an understanding of that vision’s cost.

Supporting healthy pregnancies will include ensuring widespread and sustainable access to UNIMMAP MMS. MMS scale-up should be viewed not as a standalone product switch but as part of a broader strategy to enhance antenatal care. Improved ANC is about more than better commodities; it requires improving service delivery, increasing visit attendance and increasing uptake of health-promoting practices such as ANC supplementation. This requires dedicated resources to strengthen supply chains, train health care workers and implement market-shaping interventions where necessary.

Additionally, since we’re discussing resources, it’s essential to develop a sustainable financing plan that ensures there can be a gradual transition from donors covering the cost of this product to governments eventually purchasing MMS as external financial support decreases. Equally important is raising awareness of MMS and its benefits to consumers and public health practitioners to stimulate demand and drive widespread adoption.

This is where this new costing tool comes into play. What factors did you consider when developing the tool, and what was the development process like?

Rajnee Singh: We wanted the costing tool to be simple and intuitive to use while also balancing the comprehensive needs of what a new product introduction and scale-up plan involves.

Input from colleagues in Ethiopia, Nigeria and Pakistan was critical to identifying the tool’s primary objectives and needs and determining its use-case scenario for analysis, advocacy and resource mobilization. To develop the tool, it was important to leverage the expertise and experience of R4D’s other maternal health- and nutrition-related work, as well as insights from in-country costing work already underway by other organizations, like Nutrition International.

Lastly, finding a sweet spot between standardizing the costing methodology and approach, while enabling adaptability of the tool to different country contexts was continuously considered in development. In this way, for example, we have standardized nine “cost categories,” such as Product Procurement or Training & Service Delivery, but have not prescribed specific activities or how they must be slotted, which is dependent on a country’s individual MMS implementation plan.

How did you test the tool?

Rajnee Singh: The tool was tested during development with targeted feedback sessions with R4D and partner colleagues.

We held an interactive workshop in late June 2024 with stakeholders from Ethiopia, Nigeria and Pakistan and their respective Ministries of Health and/or in-country technical partners, including R4D, UNICEF, Nutrition International, and Alive & Thrive/FHI 360, with support from the Gates Foundation.

During this workshop, we walked through the tool, tested it as a group for the different country contexts, and gathered input and feedback that was then incorporated in July 2024.

Testing the tool with this group of on-the-ground users enabled us to confirm that it was both comprehensive and simple enough to be user-friendly. We then prioritized updates based on real-time user feedback. Some of these updates included the highest-demand output visuals, a funding tracker and gap analysis element, and an add-on template for large countries to enable them to add up the costs of their sub-national geographies in an easy way.

You’re actively updating the tool and iterating as you receive more feedback, right? How do you anticipate it may evolve?

Rajnee Singh: Absolutely. Recognizing the tool is new and live, we are listening and incorporating ongoing feedback and suggestions, especially over the next few months, as country stakeholders complete their MMS implementation plans and proceed with costing them.

The latest version will always be on the R4D website, accordingly, along with the recorded tool demos that users can watch on YouTube.

We anticipate that the tool may evolve to be even more intuitive, accessible and user friendly as real implementation plans are inputted — for example, ensuring that all activity-based costing data can be segmented and reflected as clearly as possible and/or incorporating suggestions around the visual elements (graphs, cost breakdowns, comparisons, etc.).

Looking forward, what do you think the MMS transition process looks like five — or even 10 — years from now? What are your hopes?

Bhavya Gowda: We share a common vision with partners supporting MMS scale-up: ensuring that every pregnant woman has access to affordable, high-quality antenatal care supplements, ultimately leading to improved pregnancy and birth outcomes.

Looking ahead to 2030, we hope that at least 60% of pregnant women have access to MMS in line with the MMS Investment Roadmap. With complementary efforts to enhance ANC services, we anticipate a significant increase in the coverage of antenatal supplementation.

In 10 years, we hope to see a sustainable and healthy market where governments are fully financing MMS procurement and securing sufficient supplies to meet the needs of pregnant women, suppliers, including local manufacturers, are producing MMS to meet demand, and a pregnant woman, regardless of where she lives, can access and experience the benefits of this transformational product for herself and her child.