Intensification of Iron/Folic Acid Supplementation Program In Nepal

Raj Kumar Pokharel

Nutrition Section/Child Health Division
Department of Health Services Ministry of Health and Population, Nepal

In 1998,
Anemia was a severe public health concern
Women suffering from Anaemia
80 60 40 20 0 Pregnant women

percent (%)

75

67
Non-pregnant women

Three out four pregnant women were anaemic Worm infection extremely high-Hookworm infection as high as 80% in some areas Only 23% were taking any IFA tablets
Source: NMSS-1998 and NDHS-2001

Duration of Iron Supplementation During Pregnancy

None 77%

> 90 days 3%

60-89 days 6%

1-59 days 14%

( NDHS 2001)

Government policy on Pregnancy Iron Supplementation is to provide one iron/folic acid tablet daily from second trimester till 45 days after delivery

Policy was there Why was implementation so poor?

Main Problems
Lack of awareness about need for iron supplementation during pregnancy and lactation Iron tablets not accessible to most women

Activities undertaken in early 2000

Review of anemia control programme, including KAP study to identify underlying factors and bottlenecks for poor iron supplementation Effectiveness trial on community based distribution of iron tablets to pregnant women National Anemia Control Strategy and Plan developed Initiation of deworming of preschool children and pregnant women Initiation of Integrated Iron Intensification Program

Introduction of Iron Intensification Program

Considering the alarmingly high anemia prevalence and poor IFA supplementation among pregnant women, the Nepal government launched the first phase of its Iron Intensification Program (IIP) in 5 districts in 2003
Also called Intensification of Maternal and Neonatal Micronutrient Program (IMNMP)

Based on effectiveness of the intensified model, the program expanded to other districts gradually in later years

Objectives of Iron Intensification Program

1.

2. 3. 4. 5.

Increase coverage and compliance of iron supplementation during antenatal and postpartum period Increase coverage of deworming among pregnant women Increase use of antenatal health services at the local health facilities Increase coverage of high dose Vitamin A capsule supplementation during the postpartum period Promote dietary diversification for increasing consumption of micronutrient rich foods including adequately iodized salt among pregnant and postpartum women

District level iron intensification activities

Increase awareness through media and community based promotion activities Ensure adequate supply Improve access through community distribution by FCHV Intensive monitoring and supervision Strengthen complementary measures such as Deworming during pregnancy, dietary promotion and fortification at national level

Components of Iron Intensification Program

1. Initial training and orientations One-day orientation to district stakeholders One-day training to district level supervisors and health facility in-charges Two-days training to health workers and FCHVs 2. Use of IEC materials such as flip charts and posters for counseling and awareness creation 3. Use of repackaging bottles for iron tablet distribution Introduction of blister packs since 2011 4. Providing registers to FCHVs to keep records

Initiation of the Iron Intensification Program

Community based delivery mechanism was launched immediately after community level training to health staff and FCHVs

Structure of FCHV Network

Nepal Administrative and Health Structure Each VDC has nine wards, Health Facility and school
6 7 8 5 1

FCHV

9
3 4 2

Each district consists of VDC

Mothers group
Settlement

Nepal
75 districts

Mountain Hills Terai

Each ward has 80-100 households and there is a Female Community Health Volunteer (FCHV) who provides maternal and child care services in the community. In each ward there is also a mother group coordinated by FCHV for community mobilization

12

Community Level Training

FCHVs trained to counsel pregnant mothers, distribute iron tablets, record keeping and reporting

13

Mobilization of FCHVs
After receiving training, FCHVs conducting a mothers group meeting to inform the community about the importance of iron supplementation and related interventions
Key messages for the Community: Eight of ten pregnant women suffer from lack of blood
Low intake Iron Inadequate blood. Deprives of oxygen and nutrients to mother and fetus Maternal complication and poor mental development of the baby

14

Intensive Monitoring
Pregnant Women are registered by FCHVs in the Micronutrient Register Each pregnant woman received 30 tablets iron

Each pregnant woman was provided a compliance card to filled by someone in the family

15

Support from School Students

School children keep information about new pregnant women at their dwellings FCHV visits the schools and collects the information from the register Mothers group members and school children monitor pregnant women on consumption by visiting houses and reviewing iron compliance cards

School children mobilized as community advocates

16

Outcomes of Iron Intensification Program

1. Increased awareness among community on the importance of micronutrients for pregnant and postpartum women and their neonates 1. Increased access to IFA tablets through community based distribution in addition to health facilities 2. Enhanced counseling skills of health workers and Female Community Health Volunteers in relation to IFA supplementation 3. IFA tablets appealing to users through proper packing and counseling 4. Developed managerial capacity of health workers especially in relation to supplies, reporting, monitoring and supervision etc.

Program Scale Up Milestones: Program implemented in 74 districts out of total 75 by May 2012
2003: First phase program introduction in 5 districts 2004: Expansion to 3 districts 2005: Expansion to 12 districts 2006: Expansion to 12 districts 2007: Expansion to 11 districts 2008: Expansion to 9 districts 2009: Expansion to 10 districts 2010: Expansion to 6 districts 2011: Expansion to 2 districts 2012: Expansion to 4 districts

Districts Covered by Iron Intensification Program

(as in May 2012)

Intensification of IFA

Kathmandu

RASUWA

Tibet / China

India

JHAPA

Modality of Scale Up
Conduction of one-time initial training at district and community level for all health workers and FCHVs with funding support from external development partners
MI (64 districts), UNICEF (8 districts), WHO (1 district), and Plan (1 district)

Procurement of entire quantity of IFA tablets by government Recording and reporting of IFA among pregnant and postpartum women through routine Health Management Information System (HMIS) Monitoring under routine integrated monitoring supervision system of health facilities

Has the program been successful?

IFA Supplementation Coverage During Pregnancy

90 80 70 60 50 40 30 20 10 0 NDHS 2001 NDHS 2006 NDHS 2011 23 % of pregnant who took any IFA tablet 59 80

Compliance of IFA Supplementation and Deworming Among Pregnant Women

60
55 50 40 30 20 10 0 NDHS 2006 NDHS 2011 20 7 38 % of women who took full dose (180) IFA tablets % women who took deworming tablet

Coverage of Deworming During Pregnancy

60

52
50

55

40
Percent

30

20

10

2
0

DHS-2001

DHS-2006

DHS-2011

Anemia Among Pregnant Women

85 80 75 70 65 60 55 50 45 40 35 NMSS 1998 NDHS 2006 NDHS 2011 % of Anemic Pregnant Women

75

42

48

Challenges
Identifying hard to reach groups and increasing coverage and compliance of IFA among them Identifying pregnant women at an early stage so that they could start taking IFA tablets from commencement of second trimester to improve compliance Increasing coverage and compliance of IFA among postpartum women Prevalence of Anemia slightly increased in 2011 compared to 2006 (Nepal Demographic and Health Surveys) Maintain and sustain IFA distribution and deworming

Conclusions
The reduction has been possible due integrated approach including: - Community based distribution of iron supplements - Constant monitoring of pregnant women - Community based awareness creation activities - Improved logistic supply (including packaging) - Promotion of complementary measures such as deworming to pregnant women after 2nd trimester Nearly covered all 75 districts as aimed by Government Government ownership of total IFA procurement and supply through well established existing logistic management system

Next Steps
Refresher training to health workers and FCHVs for enhancing skills and sustaining motivation Strengthening recording/reporting of IFA supplementation under HMIS, supply chain management and monitoring/supervision Study on etiology of anemia among pregnant women and other target groups in Nepal

Acknowledgements
Female Community Health Volunteers in Nepal- the key factor to the success !!
Government of Nepal received support from MI, UNICEF (USAID & CIDA), WHO and Plan