Pokharel_Intensification of Iron/Folic Acid Supplementation Program in Nepal

7/31/2019 Pokharel_Intensification of Iron/Folic Acid Supplementation Program in Nepal

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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



Source: NMSS-1998 and NDHS-2001

0

20

40

60

80

Pregnant women Non-pregnant women

p e r c e

n t ( % )

Women suffering from Anaemia

75 67

In 1998,

Anemia was a severe public health concern

•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



Duration of Iron Supplementation

During Pregnancy

( NDHS 2001)

None

77%

1-59 days

14%> 90 days

3%60-89 days

6%



Policy was there…

Why was implementation so poor?

Government policy on “Pregnancy Iron Supplementation”

is to provide one iron/folic acid tablet daily from second

trimester till 45 days after delivery



Main Problems

• Lack of awareness about need for iron

supplementation during pregnancy and

lactation

• Iron tablets not accessible to most women



6

Activities undertaken in early 2000

• Review of anemia control programme, including KAP

study to identify underlying factors and bottlenecks forpoor 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 anemiaprevalence and poor IFA supplementation amongpregnant women, the Nepal government

launched the first phase of its Iron IntensificationProgram (IIP) in 5 districts in 2003

– Also called ‘Intensification of Maternal and NeonatalMicronutrient Program’ (IMNMP)

•Based on effectiveness of the intensified model,the program expanded to other districts graduallyin later years



Objectives of Iron Intensification Program

1. Increase coverage and compliance of ironsupplementation during antenatal and postpartum

period

2. Increase coverage of deworming among

pregnant women3. Increase use of antenatal health services at the local

health facilities

4. Increase coverage of high dose Vitamin A capsule

supplementation during the postpartum period

5. Promote dietary diversification for increasingconsumption of micronutrient rich foods including

adequately iodized salt among pregnant and

postpartum women



9

District level iron intensification

activities

Increase awareness through media and

community based promotion activities

Improve access through communitydistribution by FCHV

Ensure adequate supply

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 FCHVs2. 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



12

Mountain

Hills

Terai

Nepal

75 districts

Each district

consists ofVDC

Each VDC has nine

wards, Health Facilityand school

FCHV

Mothers group

Each ward has 80-100 households andthere is a Female Community Health

Volunteer (FCHV) who provides maternaland child care services in the community.In each ward there is also a mother group

coordinated by FCHV for communitymobilization

1

2

3

5

7

4

9

6

8

Settlement

NepalAdministrative and

Health Structure

Structure of FCHV Network



13

Community Level Training

• FCHVs trained to counsel pregnant mothers,distribute iron tablets, record keeping andreporting



14

After receiving training, FCHVs

conducting a mothers’ groupmeeting to inform the community

about the importance of iron

supplementation and related

interventions

Mobilization of FCHVs

Key messages for the Community:

•“Eight of ten pregnant women suffer from lack of blood”

Maternal

complication

and poor

mental

development

of the baby

Low

intake

Iron

Inadequate

blood.Deprives of

oxygen and

nutrients to

mother and

fetus



15

Intensive Monitoring

• Pregnant Women are registered by FCHVs in the Micronutrient

Register• Each pregnant woman received 30 tablets iron

• Each pregnantwoman wasprovided acompliance card

to filled bysomeone in thefamily



16

• 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 andreviewing iron compliance cards

Support from School Students

School children mobilized as community advocates



Outcomes of Iron Intensification Program

1. Increased awareness among community on the

importance of micronutrients for pregnant andpostpartum 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 andFemale 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











Districts Covered by Iron Intensification Program(as in May 2012)

RASUWA

Kathmandu

Tibet / China

IndiaJHAPA

Intensification of IFA



Modality of Scale Up

•Conduction of one-time initial training at district andcommunity 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

23

59

80

0

10

20

30

40

50

60

70

80

90

NDHS 2001 NDHS 2006 NDHS 2011

% of pregnant who took

any IFA tablet



Compliance of IFA Supplementation and Deworming

Among Pregnant Women

7

38

20

55

0

10

20

30

40

50

60

NDHS 2006 NDHS 2011

% of women who took

full dose (180) IFA

tablets

% women who took

deworming tablet



Coverage of Deworming During Pregnancy

2

5255

0

10

20

30

40

50

60

DHS-2001 DHS-2006 DHS-2011

P e r c e n t



Anemia Among Pregnant Women

75

4248

35

40

45

50

55

60

65

70

75

80

85

NMSS 1998 NDHS 2006 NDHS 2011

% of Anemic Pregnant

Women



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 approachincluding:

- 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 andsupply through well established existing logisticmanagement 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 andmonitoring/supervision

• Study on etiology of anemia among pregnant women and

other target groups in Nepal



Acknowledgements

Female

Community

Health

Volunteers inNepal- the key

factor to the

success !!

Government of Nepal received support from MI,

UNICEF (USAID & CIDA), WHO and Plan



Documents

Pokharel_Intensification of Iron/Folic Acid Supplementation Program in Nepal