Roche_From Policy to Practice the Scale Up of Community Based Delivery of Iron Folic Acid in Nepal

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


2/22





Source: NMSS-1998 and NDHS-2001

7567

Situation Assessment:

Anemia was recognized as a severe public health

concern in Nepal, in 1998


3/22





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


4/22





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


5/22





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


6/22





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


7/22



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


8/22





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


9/22



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


10/22





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


11/22





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


12/22





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


13/22





Program Scale-up pace:

2003: First phase program introduction in 5 districts

2004: Expansion to 3 districts (8 total)



2007: Expansion to 11 districts (43 total)2008: Expansion to 9 districts (52 total)





Program implemented in 74 districts out of total 75 by May

2012


14/22





Scale-up: Districts Covered by Iron

Intensification Program (as in May 2012)

Pokharel et al. 2011


15/22





Trends in Coverage over Project

Implementation *


16/22





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


17/22





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


18/22





Estimating Program Impact


19/22





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


20/22





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


21/22





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


22/22





Namaste

Acknowledgements

A2Z, CIDA, FHI360, MI,

NFHD, NMOH, NTAG,

Plan, UNICEF, USAID,WHO

Date post:	14-Apr-2018
Category:	Documents
Upload:	newborn2013
View:	219 times
Download:	0 times

Roche_From Policy to Practice the Scale Up of Community Based Delivery of Iron Folic Acid in Nepal

Documents