A healthier start for every baby: Six lessons for introducing and scaling MMS in antenatal care
When pregnant women don’t get the nutrients they need, babies are born too small, too soon, or too vulnerable to thrive. Micronutrient deficiencies and maternal undernutrition are strongly linked to low birth weight, babies born small for gestational age, and preterm birth.
For decades, many countries have relied on iron and folic acid (IFA) supplements in antenatal care — a critical intervention to prevent iron deficiency anemia and support healthy fetal development. But in settings where women enter pregnancy with multiple nutrient gaps, IFA alone isn’t enough.
That’s why Multiple Micronutrient Supplements (MMS) are gaining traction globally as an evidence-based alternative to IFA. Delivering 15 essential vitamins and minerals, including iron and folic acid, MMS addresses anemia risks while also tackling other common deficiencies that undermine pregnancy outcomes.
But switching standard supplement practices isn’t always easy or straightforward. As countries adopt MMS, it is essential to develop strong product introduction and scale-up plans to support a smooth transition from IFA to MMS. Without a clear plan for purchasing, distributing, and ensuring demand for MMS, the product may remain unused in warehouses instead of reaching the pregnant women who need it most.
As part of the Market Shaping for MMS for Antenatal Care Initiative, funded by the Gates Foundation, R4D partnered with governments in Ethiopia and Nigeria to develop roadmaps with detailed and costed implementation plans for introducing and scaling MMS.3 These roadmaps serve as multi-year strategic guides for integrating MMS into national health systems, and identify the funding required to do so.
In this blog, we share six practical lessons learned from creating costed roadmaps for MMS in partnership with governments. These lessons highlight how government leadership, locally contextualized evidence, robust stakeholder engagement, realistic implementation planning, integration with existing systems, and advance financial planning are critical for translating policy vision into effective implementation and measurable outcomes. Given the increasing number of countries moving from IFA to MMS, we believe that these lessons will help other governments and implementing partners create practical, achievable and realistic roadmaps, ultimately improving health outcomes for women and newborns.
1. Government ownership is essential for driving and sustaining product introduction progress
Government ownership provides the leadership, legitimacy, and direction needed to design and implement an effective product introduction plan. When secured early on, government buy-in ensures that the initiative is aligned with national priorities, embedded within existing health systems, and backed by a strong mandate that encourages stakeholder coordination and shared accountability. This foundation not only strengthens the quality of the roadmap but also accelerates momentum throughout the introduction and scale-up process.
In Ethiopia, the Ministry of Health (MOH) demonstrated strong government leadership by co-designing every phase of the roadmap. From the outset, the MOH and R4D worked together to develop the roadmap, and MOH team members consistently engaged through regular check-ins, provided detailed feedback on drafts, and co-facilitated workshops. This hands-on involvement reinforced national ownership of both the process and final output, and ensured the roadmap reflected government priorities and realities.
In Nigeria, government leadership was channeled through the Department of Nutrition at the Federal Ministry of Health and Social Welfare (FMoHSW), and their establishment of a National MMS Taskforce. Led by the FMoHSW and comprised of a select group of technical partners, the National MMS Taskforce outlined clear targets, aligned with the government’s priorities, to be achieved through the roadmap. As a key technical partner and member of the taskforce, R4D advised on roadmap development and implementation planning. Continued collaboration between the government and partners enabled seamless decision-making, steady progress, and a collective sense of responsibility for driving the work forward.
“Strong government leadership and broad stakeholder engagement were pivotal in ensuring the MMS roadmap’s resilience, sustainability, and national relevance.”
– Dr. Wossen Negash, Associate Director (Nutrition) at R4D Ethiopia
2. Contextualizing global evidence to local realities strengthens credibility and enables informed decision-making
A strong evidence base is essential for building confidence in the shift from IFA to MMS, but evidence is most persuasive when it reflects local realities. Stakeholders need to understand not only the global science, but also how MMS performs in contexts similar to their own. Establishing this local relevance early on helps address questions and concerns, grounds planning in locally credible data, and creates a shared foundation for informed discussions and decision-making.
For example, in Ethiopia the MOH initially planned to wait for the completion of an MMS implementation research study before deciding whether to switch from IFA to MMS. However, following the first African Regional Meeting on Maternal Nutrition and MMS held in Addis Ababa in 2023, and exposure to evidence and experiences from other countries, political support for transitioning to MMS in Ethiopia gained momentum. As an initial step toward developing a roadmap, the MOH asked R4D to synthesize both global and local evidence about MMS. R4D engaged a local consultant to create an evidence synthesis report and present global findings in a way that was locally relevant. This effort played a pivotal role in supporting informed discussions among decision-makers and securing buy-in for MMS in Ethiopia.
In Nigeria, the FMoHSW also wanted to better understand the feasibility and acceptability of MMS in Nigeria, particularly in areas with high rates of anemia. Initially, they intended to undertake implementation research to prove the efficacy of MMS prior to its introduction in the country. However, following knowledge-sharing from development partners, in addition to leveraging ongoing implementation research already underway by Nutrition International in Bauchi State and operational research from Evidence Action the FCT and Oyo State, the decision was made to forego new research. Instead, as part of their role on the MMS Taskforce, R4D supported the FMoHSW in undertaking a landscape assessment to document all relevant global and local evidence, which provided the foundation for developing the national MMS roadmap.
3. Early and continuous engagement with diverse stakeholders builds alignment and underpins successful implementation
Effective product introduction planning requires working across the full ecosystem of actors involved in nutrition and antenatal care services. Engaging stakeholders early and consistently helps surface differing perspectives, clarifies misconceptions, and builds a shared understanding of what MMS introduction entails. When inclusive and robust, this process leads to stronger alignment and reduces downstream resistance that could hinder rollout.
In Nigeria, close engagement with professional associations helped identify and address concerns early. For example, the Society of Obstetrics and Gynecology initially perceived MMS as replacing IFA entirely, raising questions about efficacy for treatment of iron deficiency anemia. By creating space for open dialogue and agreeing to incorporate their concerns into forthcoming antenatal care guidelines, pending additional evidence, the National MMS Taskforce built trust and ensured the guidance reflected a range of expert views.
In Ethiopia, R4D used a co-creation approach to bring together partners from government, implementing organizations, and technical working groups. Through four workshops co-facilitated by R4D and the government, plus ongoing consultation, stakeholders contributed directly to shaping the roadmap. This inclusive process broadened the evidence base for decision-making, strengthened alignment across actors, and built a sense of shared responsibility for the final product.
“One of the most beneficial elements of developing the MMS roadmap was the co-creation approach. We were able to create a dynamic and inclusive environment by working with a wide range of stakeholders, including academic institutions, professional associations like the Midwife Association, other government agencies like EPHI and EFDA, development partners, and pharmaceutical companies. This diversity made the conversations more in-depth and guaranteed that the roadmap took operational and policy-level realities into account.”
– Tadele Deres, Nutrition Specialist, Ministry of Health, Ethiopia
4. Clear, realistic objectives and implementation plans are essential for providing cost estimates and guiding effective rollout
The implementation plan is the heart of a roadmap and the foundation for costing. If the activities in the plan are not specific, time-bound, and realistic, the costing exercise will not yield accurate results. Clear implementation plans with concrete activities help stakeholders anticipate what’s needed — logistically, financially, and operationally — at each stage of rollout. Conversely, vague or overly broad plans lead to unreliable costing and make it difficult for stakeholders to coordinate efforts or track progress.
In Ethiopia, stakeholders worked through a structured co-creation process to define the roadmap’s objectives, priority actions, and detailed activities. Using a funnel-like approach, each step became increasingly specific, with clear guidance that activities needed to be concrete enough to break down into cost elements (e.g., for a specific training, defining the anticipated number of participants, duration in days, whether it will need to be repeated and if so, at what frequency). This level of specificity enabled the team to build an implementation plan that was operationally meaningful and had an accurate price tag.
In Nigeria, stakeholders at the national and sub-national levels were engaged in technical sessions on implementation planning and SMART4 activity design. These sessions guided stakeholders to iteratively break down complex activities until they were precise enough to be assigned individual cost elements. Similar to Ethiopia, this specificity allowed for seamless integration in R4D’s MMS costing tool as well as made the implementation plans realistic and actionable.
In both Ethiopia and Nigeria, governments opted for a phased transition from IFA to MMS over five years, providing a realistic framework for implementation. This stepwise approach helped define measurable, time-bound goals and allowed teams to test feasibility, assess acceptance, and refine strategies before scaling. The phased plans supported more accurate costing and created a manageable pathway from introduction to full-scale implementation.
“R4D’s support has been invaluable in helping our state develop a practical and results-oriented MMS implementation plan. The structured facilitation, especially the stakeholder mapping and prioritization exercises, enabled us to align our goals with our specific state context. [The process] provided clarity on feasible interventions, allowing our team to translate broad ideas into concrete, achievable steps.”
– Dr Shehu Usman Abdulahi, Director, Medical Services, Kano State Ministry of Health, Nigeria
5. Integrating MMS into existing systems promotes sustainability, reduces costs, and strengthens long-term implementation
When introducing a new product, implementers may feel pressure to create parallel, product-specific systems — such as dedicated tools, standalone trainings, or separate supply chains — to show quick results, meet donor requirements, or maintain tighter control over processes. Although these approaches can appear faster or simpler in the short-term, they typically increase costs, fragment service delivery, and overburden health workers. They also risk creating structures that governments cannot sustain once external funding or technical assistance ends. Integrating MMS introduction into existing platforms and processes ensures greater efficiency, reduces duplication of efforts, and supports long-term sustainability.
In Ethiopia, the MOH and R4D systematically mapped all roadmap activities to identify opportunities for integration. This process highlighted where MMS-specific actions could be incorporated into established workflows, such as embedding MMS content into existing maternal nutrition trainings for health workers. Built into the roadmap is also a plan to gradually transition procurement and supply chain management responsibilities from UNICEF to the Ethiopian Pharmaceutical Supply Service, reinforcing long-term country ownership and sustainability. Together, these decisions reduced incremental costs and strengthened alignment with existing systems.
Nigeria similarly emphasized leveraging existing systems rather than creating standalone MMS mechanisms. Stakeholders reviewed current platforms and training programs to determine how MMS activities could be embedded within them, minimizing the need for new structures. By integrating roadmap activities wherever feasible, the additional funding required for implementation was substantially reduced and alignment with government priorities was reinforced.
6. Costing and financial planning make the roadmap realistic and implementable
A roadmap is only as useful as it is financially realistic. Treating costing as an integral part of roadmap development, rather than a box to tick, helps countries refine their plans based on what is achievable within existing budgets and potential external support. Advance financial planning prevents the creation of overly ambitious or unfunded strategies and turns the roadmap into a practical tool for guiding implementation, budgeting, and resource mobilization.
In Ethiopia, financial considerations began early. The team considered which activities could be absorbed into existing government budgets and which would require additional funds. This early costing allowed the roadmap to be refined before it was finalized, ensuring that proposed actions reflected what could realistically be implemented.
In Nigeria, the roadmap process surfaced the true cost of implementation and prompted teams to systematically identify potential financing sources at both federal and state levels. Rather than leaving the roadmap as an aspirational plan, this process turned it into a practical financing tool. In both Kano and Kaduna states, for example, the roadmap was referenced during state-level annual operational planning and budgeted meetings, ensuring that costed MMS activities were incorporated for the forthcoming fiscal year.
R4D also encouraged both governments to use the MMS costing tool as a living document, enabling teams to update assumptions, model multiple scenarios, and adapt plans to available resources. By embedding costing and financing strategies early — through government budget alignment and proactive donor engagement — the roadmaps evolved into operational plans that were both fundable and executable.
“The costed roadmap provides the financial details we need to realistically plan for MMS within the state’s Annual Operational Planning (AOP) process… Costing ensures that MMS is not just included as an activity but is properly budgeted for, making it easier to advocate for resources during the AOP discussions. It also allows us to prioritize MMS alongside other nutrition interventions, ensuring that it receives attention during budget negotiations with decision-makers.”
– Aishatu Suleiman, State Nutrition Officer for Kano State, Nigeria
The insights shared above, drawn from R4D’s experience in Ethiopia and Nigeria, illustrate that turning policy into practice requires more than technical plans — it demands collaboration, specificity, and sustained commitment. By embedding these lessons in planning for countries undertaking the transition from IFA to MMS, governments and implementing partners can be sure to create roadmaps that deliver on their policy goals and ultimately, deliver health improvements for women and newborns.
To date, R4D has supported Ministries of Health and implementing partners in ten countries across sub-Saharan Africa and Southeast Asia to introduce or expand access to MMS. To learn more about how R4D can support MMS introduction or scale-up in your country, please reach out to Danielle Harris, Senior Program Officer for R4D’s Market Shaping Practice.
