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From policy to practice: the scale up of community based delivery of iron folic acid in Nepal

Marion Roche, PhD, Raj Kumar Pokharel & Macha Raja Maharjan Johannesburg, April 14th, 2013

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Situation Assessment: Anemia was recognized as a severe public health concern in Nepal, in 1998

75

67

Source: NMSS-1998 and NDHS-2001


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Policy Environment vs. Implementation

Policy

IFA supplementation from 2nd trimester to 45 days postdelivery

Practice
23% coverage IFA

Required Women to go to Health Center and given out by Health Worker

Reality- challenge accessing health center, and little demand for IFA, supply issues also a challenge

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Objectives of Iron Intensification Program (IIP)


1. Increase coverage and adherence for iron folic acid 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 postpartum period Promote dietary diversification for increasing consumption of micronutrient rich food including adequately iodized salt among pregnant and postpartum women

2. 3. 4.

5.

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Pilot- Policy Change: Community Based Delivery by Female Community Health Volunteers (FCHVs)
Intensification of Maternal and Neonatal Micronutrient Program (IMNMP) 1988 FCHV program began as health promoters 1990s brief pilot and then modification to policy so the FCHVs could distribute vitamin A

2003 Pilot of working with FCHVs to distribute Iron in 5 districts

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Components of the Iron Intensification Project: The Social Marketing Mix: 4Ps
Product: Promoted behaviours, packaging, labels Price: Costs, time, resources, stigma, social Place: Access & delivery point Promotion: Messages, Communication channels, branding

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Product
IFA tablets wrapped in paper
Refillable Plastic Containers

Developed managerial capacity of health workers especially in relation to supplies, reporting Have since began transitioned to blister packaging since 2011 Pokharel et al. 2011
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Price
Decrease time it takes pregnant women to get Iron Tablets Increase perceived value of IFA with packaging
Motivation of the perceived benefits of taking IFA with local messages around anemia and lack of blood using local understanding of altitude and lack of oxygen

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Place: Community Based Delivery Channel


FCHVs are trusted and honoured as they are selected by peers in mothers group Distribution by FCHVs in community (30 IFA) FCHV aware of pregnancy earlier and refers pregnant woman to ANC at health center

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Promotion: 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 15 day training focus on health messages and counseling skills and group facilitation 2. Use of IPC material such as flip charts and posters

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Mobilization and Motivation of FCHVs


Honour and Recognition in Community FCHV allowance/honorarium Training & Supportive Supervision FCHV endowment fund Sari/dress as uniform Branding of Program FCHV logo FCHV radio drama National FCHV day

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Structure and Reach of FCHV Network


Nepal Administrative and Health Structure Each VDC has nine ward , Health Facility and school
6 7 8 5 2 1

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FCHV

9 3 4

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 mobilisation

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Program Scale-up pace:


2003: First phase program introduction in 5 districts 2004: Expansion to 3 districts (8 total) 2005: Expansion to 12 districts (20 total) 2006: Expansion to 12 districts (32 total) 2007: Expansion to 11 districts (43 total) 2008: Expansion to 9 districts (52 total) 2009: Expansion to 10 districts (62 total) 2010: Expansion to 6 districts (68 total) 2011: Expansion to 2 districts (70 total) 2012: Expansion to 4 districts (74 total) Program implemented in 74 districts out of total 75 by May 2012
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Scale-up: Districts Covered by Iron Intensification Program (as in May 2012)

Pokharel et al. 2011


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Trends in Coverage over Project Implementation *

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IFA Supplementation Coverage during Pregnancy


90 80 70 60 50 40 30 23 % of pregnant who took any IFA tablet 59 80

20 10
0 NDHS 2001 NDHS 2006 NDHS 2011

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Reported Compliance of IFA Supplementation and Deworming Among Pregnant Women


60 50 55

40
30 20 10 0 7 20

38 % of women who took full dose (180) IFA tablets % women who took deworming tablet

NDHS 2006

NDHS 2011

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Estimating Program Impact

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Anemia Among Pregnant Women


85 80 75 70 65 60 55 50 45 40 35 NMSS 1998 NDHS 2006 NDHS 2011 42 48 75

Scale up to 20 districts only

Scale up to 74 districts

% of Anemic Pregnant Women

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Rationale for MI IFA Qualitative Evaluation


Global need for evidence of effective IFA Programs at Scale
Coverage Rates of Program Suggest Effective Delivery through FCHVs, Adherence data lacking & Contradiction of DHS anemia data with the Coverage data Indentifying Barriers and Enablers from Key Stakeholders at National, District, Health Centers, FCHVs and Pregnant Women Enabling Environment Demand Side Supply Side

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Preliminary Results of MIs 2012 IIP Qualitative Evaluation


Enabling Environment: IIP was seen as an integrated approach with Policies, technical and financial commitments across government ministries Intrinsic and external motivation and are key reasons for low FCHV turnover, and high commitment (Culture & Social value of women volunteers, National Recognition of FCHVs) Demand Side: Program based on a sound situation assessment with strong technical support for implementation All stakeholders see FCHVs as key to success of IIP as trusted delivery, but also the lifeline of the health system Challenge confusion of food based and IFA messages

Supply Side: Technical support in monitoring and logistics management Continual product improvement, Blister pack challenges being resolved Health System Constraints and Limits for supportive supervision While FCHVs and investments in the program have been far reaching, the health system and centers have not been strengthened at the same rate Debate for role for FCHVs going forward and optimal balance of workloadwww.micronutrient.org and skills needed

Namaste

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Acknowledgements A2Z, CIDA, FHI360, MI, NFHD, NMOH, NTAG, Plan, UNICEF, USAID, WHO

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