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7/30/2019 Roche_From Policy to Practice the Scale Up of Community Based Delivery of Iron Folic Acid in Nepal
1/22
www.micronutrient.org
Solutions for hidden hunger
From policy to practice: the scale up of communitybased delivery of iron folic acid in Nepal
Marion Roche, PhD, Raj Kumar Pokharel &Macha Raja Maharjan
Johannesburg, April 14th, 2013
7/30/2019 Roche_From Policy to Practice the Scale Up of Community Based Delivery of Iron Folic Acid in Nepal
2/22
Solutions for hidden hunger
www.micronutrient.org
Solutions for hidden hunger
www.micronutrient.org
Source: NMSS-1998 and NDHS-2001
7567
Situation Assessment:
Anemia was recognized as a severe public health
concern in Nepal, in 1998
7/30/2019 Roche_From Policy to Practice the Scale Up of Community Based Delivery of Iron Folic Acid in Nepal
3/22
Solutions for hidden hunger
www.micronutrient.org
Solutions for hidden hunger
www.micronutrient.org
Policy Environment vs. Implementation
IFAsupplementationfrom 2nd trimesterto 45 days post-delivery
Required Womento go to Health
Center and givenout by HealthWorker
Policy
23% coverage IFA
Reality- challengeaccessing healthcenter, and little
demand for IFA,supply issues alsoa challenge
Practice
7/30/2019 Roche_From Policy to Practice the Scale Up of Community Based Delivery of Iron Folic Acid in Nepal
4/22
Solutions for hidden hunger
www.micronutrient.org
Solutions for hidden hunger
www.micronutrient.org
Objectives of Iron Intensification Program (IIP)
1. Increase coverage and adherence for iron folic acid supplementationduring antenatal and postpartum period
2. Increase coverage of deworming among pregnant women
3. Increase use of antenatal health services at the local health facilities
4. Increase coverage of high dose Vitamin A Capsule supplementation during
postpartum period
5. Promote dietary diversification for increasing consumption of
micronutrient rich food including adequately iodized salt among pregnant
and postpartum women
7/30/2019 Roche_From Policy to Practice the Scale Up of Community Based Delivery of Iron Folic Acid in Nepal
5/22
Solutions for hidden hunger
www.micronutrient.org
Solutions for hidden hunger
www.micronutrient.org
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
7/30/2019 Roche_From Policy to Practice the Scale Up of Community Based Delivery of Iron Folic Acid in Nepal
6/22
Solutions for hidden hunger
www.micronutrient.org
Solutions for hidden hunger
www.micronutrient.org
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
7/30/2019 Roche_From Policy to Practice the Scale Up of Community Based Delivery of Iron Folic Acid in Nepal
7/22
Solutions for hidden hunger
www.micronutrient.org
ProductIFA tablets wrapped in
paperRefillable 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
7/30/2019 Roche_From Policy to Practice the Scale Up of Community Based Delivery of Iron Folic Acid in Nepal
8/22
Solutions for hidden hunger
www.micronutrient.org
Solutions for hidden hunger
www.micronutrient.org
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
7/30/2019 Roche_From Policy to Practice the Scale Up of Community Based Delivery of Iron Folic Acid in Nepal
9/22
Solutions for hidden hunger
www.micronutrient.org
Place: Community Based Delivery
ChannelFCHVs 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 ANCat health center
7/30/2019 Roche_From Policy to Practice the Scale Up of Community Based Delivery of Iron Folic Acid in Nepal
10/22
Solutions for hidden hunger
www.micronutrient.org
Solutions for hidden hunger
www.micronutrient.org
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 trainingfocus on health messages and
counseling skills and group facilitation
2. Use of IPC material such as flip chartsand posters
7/30/2019 Roche_From Policy to Practice the Scale Up of Community Based Delivery of Iron Folic Acid in Nepal
11/22
Solutions for hidden hunger
www.micronutrient.org
Solutions for hidden hunger
www.micronutrient.org
Mobilization and Motivation of
FCHVs
Honour and Recognition in Community
FCHV allowance/honorarium
Training & Supportive SupervisionFCHV endowment fund
Sari/dress as uniform
Branding of Program FCHV logo
FCHV radio dramaNational FCHV day
11
7/30/2019 Roche_From Policy to Practice the Scale Up of Community Based Delivery of Iron Folic Acid in Nepal
12/22
Solutions for hidden hunger
www.micronutrient.org
Solutions for hidden hunger
www.micronutrient.org
Structure and Reach of FCHV Network
12
Mountain
Hills
Terai
Nepal
75 districts
Each district
consists of
VDC
Each VDC has nine
ward , Health Facility
and school
FCHVFCHV
Mothers groupMothers group
Each ward has 80-100 households and
there 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 community
mobilisation
1
2
3
5
7
4
9
6
8
Settlement
Nepal
Administrative and
Health Structure
7/30/2019 Roche_From Policy to Practice the Scale Up of Community Based Delivery of Iron Folic Acid in Nepal
13/22
Solutions for hidden hunger
www.micronutrient.org
Solutions for hidden hunger
www.micronutrient.org
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
7/30/2019 Roche_From Policy to Practice the Scale Up of Community Based Delivery of Iron Folic Acid in Nepal
14/22
Solutions for hidden hunger
www.micronutrient.org
Solutions for hidden hunger
www.micronutrient.org
Scale-up: Districts Covered by Iron
Intensification Program (as in May 2012)
Pokharel et al. 2011
7/30/2019 Roche_From Policy to Practice the Scale Up of Community Based Delivery of Iron Folic Acid in Nepal
15/22
Solutions for hidden hunger
www.micronutrient.org
Solutions for hidden hunger
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Trends in Coverage over Project
Implementation *
7/30/2019 Roche_From Policy to Practice the Scale Up of Community Based Delivery of Iron Folic Acid in Nepal
16/22
Solutions for hidden hunger
www.micronutrient.org
Solutions for hidden hunger
www.micronutrient.org
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
7/30/2019 Roche_From Policy to Practice the Scale Up of Community Based Delivery of Iron Folic Acid in Nepal
17/22
Solutions for hidden hunger
www.micronutrient.org
Solutions for hidden hunger
www.micronutrient.org
Reported 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
7/30/2019 Roche_From Policy to Practice the Scale Up of Community Based Delivery of Iron Folic Acid in Nepal
18/22
Solutions for hidden hunger
www.micronutrient.org
Solutions for hidden hunger
www.micronutrient.org
Estimating Program Impact
7/30/2019 Roche_From Policy to Practice the Scale Up of Community Based Delivery of Iron Folic Acid in Nepal
19/22
Solutions for hidden hunger
www.micronutrient.org
Solutions for hidden hunger
www.micronutrient.org
Anemia Among Pregnant Women
75
42 48
35
40
45
50
55
6065
70
75
80
85
NMSS 1998 NDHS 2006 NDHS 2011
% of Anemic Pregnant
Women
Scale up to
20 districts
only Scale up to
74 districts
7/30/2019 Roche_From Policy to Practice the Scale Up of Community Based Delivery of Iron Folic Acid in Nepal
20/22
Solutions for hidden hunger
www.micronutrient.org
Solutions for hidden hunger
www.micronutrient.org
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
7/30/2019 Roche_From Policy to Practice the Scale Up of Community Based Delivery of Iron Folic Acid in Nepal
21/22
Solutions for hidden hunger
www.micronutrient.org
Solutions for hidden hunger
www.micronutrient.org
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 workload and skills needed
7/30/2019 Roche_From Policy to Practice the Scale Up of Community Based Delivery of Iron Folic Acid in Nepal
22/22
Solutions for hidden hunger
www.micronutrient.org
Solutions for hidden hunger
www.micronutrient.org
Namaste
Acknowledgements
A2Z, CIDA, FHI360, MI,
NFHD, NMOH, NTAG,
Plan, UNICEF, USAID,WHO