National and Sub-National Delivery of Balanced Energy and Protein (BEP) Supplements to Pregnant and Lactating Women in LMICs: Lessons from Multi-Country Implementation Case Studies

The World Health Organization recommends the use of balanced energy protein (BEP) supplements during pregnancy in settings with a ≥ 20% prevalence of underweight women of reproductive age to reduce the risk of adverse health outcomes. Several countries are implementing BEP supplementation in varied formats. However, the implementation and monitoring of outcomes remain poor across countries. This qualitative study explores the experiences, opportunities, and challenges related to implementing national and sub-national BEP supplementation programs in nine countries (12 countries originally invited) to inform best practices. In sum, two distinct implementation pathways emerged: government-led models characterized by policy integration, national ownership, and more stable systems, and humanitarian or donor-led models shaped by crisis response, external dependency, and non-committal challenges. Successful implementation of BEP supplements depends on the presence of effective policies, context-adapted design, integration into health systems, consistent funding, and effective monitoring. There is a need for implementation research to generate evidence on best practices when implementing BEP supplementation programs.