Iron-Plus-Initiative NIPI scheme of India for Anema free
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The National Iron Plus Initiative (NIPI) in Odisha has significantly reduced anemia prevalence among children and reproductive-age women through coordinated efforts among multiple government departments. Despite improvements, challenges remain in community awareness and the implementation of anemia control programs, highlighting the need for further training and engagement. The process documentation provides insights into effective strategies and barriers in controlling anemia, aiming to refine future interventions.
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1. POLITICAL COMMITMENT AND OWNERSHIP
Many officials and frontline workers expressed strong political commitment to increasing coverage
and strong service delivery of the NIPI programme – from all levels, state to field; all three
Departments, Health, ICDS and Education; and all districts. Presented below are the types of
comments made by respondents indicating political commitment to the NIPI programme by
Department, followed by a few comments indicating lack of political commitment, for contrast.
Comments tended to fall into categories of feeling pride in progress made, describing successful
ways to mobilise beneficiaries and others, and for senior health officials issuing key government
lettersorembracingnewgovernmentstrategies.
Three senior health officials mentioned the programme clarity that can result from a government-
issued letter or strategy. An Odisha State Medical Corporation Limited (OSMCL) official said that a
“Letter has been sent from Commissioner cum Secretary, S&ME Department to each District
Education Officer (DEO) and Block Education Officer (BEO) for monitoring the program at school for
betterment of NIPI function at school.”A DMRCH described that political commitment can be built
sometimes by just getting the paperwork straight so people feel comfortable.“We talked on report
[in convergence meeting]. We talked on 100% implementation… There will be one letter sent for
report collection”. And a district health official said that:“Now the government of Odisha is going to
have a new programme… to facilitate the reduction of IMR-MMR, a strategy has been developed.
Kalahandi is one of the districts. And one of the most important interventions is the strengthening
of VHNDsites.”
Several sets of ASHAs showed their ownership through their pride of progress of their work in the
communities. One group of ASHAs said: “Many changes took place after the posting of ASHAs.
ASHAs make the maximum home visits. Even children call us to go to their houses. Now nobody is
interested for more than 2 children. I have joined for 7 years and since my joining I have not seen a
maternaldeath.Wedon'thavehomedeliveryatallnow.”
BPMs, ANMs and ASHAs spoke of the hard work and accomplishments from mobilizing
participationinNIPIthroughouttheircommunities.ABPMsaidaboutteachersthat:“Atsomeplaces
they don't cooperate. Most of the time when we go to school, we find that maximum 10% teachers
don't cooperate. We have to sensitize them. They say that guardians will not agree. Consuming
these medicines may create some harm. We mobilise them by telling that we are here, keep our
number and call us if there is any requirement. We tell them that the CHC is here to support you”. A
group of ANMs said: “According to case we provide counseling. We are trying in different ways to
makethemunderstand.Wearedoingitnonstoptojustinvolvethemintheprocess.”Anothergroup
HEALTH
R E S U L T S](https://image.slidesharecdn.com/iron-plus-initiativenipi-240801104721-4f20d64f/85/Iron-Plus-Initiative-NIPI-scheme-of-India-for-Anema-free-53-320.jpg)
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mothers fat, delivers only girl child etc. But now those days are gone. Everybody is accepting the
tablets.” Also, in a discussion with an ANM, ASHA and AWW, they were unequivocal that the
husbands are very co-operative, supportive and involved. Mothers-in-law and husbands are also
very cooperative when health-related services are to be delivered. Increasingly, fathers are more
interestedintheAWCservices,ensuringthatfamilymemberscometoAWCforfoodandmedicines.
A few decades earlier, there were families in which males did not cooperate, did not allow children
orwomentocometoAWCs,butnoweveryoneco-operates,andrespectstheworkerstoo.Theysaid
thatifyougotoremotetribalareas,especiallyamongtheJuangandMunda,mendonotcooperate
with AWW or allow family members to take services from VHND or AWC. However, when they mix
with non-tribal communities, they slowly start accepting the importance of services and accessing
them.
Building support among husbands and mothers-in-law is crucial to NIPI success, as with parents,
and examples indicate how frontline workers approach increasing it. One group of AWWs said that
“Some mothers [in-law] are telling that the child in the womb will be big. It will be difficult to give
birth.We tell them that this is not true.”Regarding a role for husbands, a pregnant woman told that
“When my test result came back 7, the ASHA asked my husband why he was not reminding me to
take tablets. Now he keeps asking me.”Also regarding husbands, an ASHA Facilitator said:“If a wife
does not take the medicine, then husband will have to understand the benefits of the tablets and
tell her to eat it. He will also observe whether his wife is eating the medicines or not.There are many
husbands who come to us if any problems occur. We discuss with the husbands and make them
understandafterpregnancyregistration.”
A couple of respondents also told about husbands who were not yet fully supportive of IFA
distribution to their wives. A set of ICDS Supervisors reported that“The major problem in our area is
that husbands are drinking so much of alcohol.They even forcefully use the money [given
for full antenatal, delivery and postnatal care]. They are also creating disturbances in VHND and
threatening their wives to come out of the session.”And a set of ANMs reflected that not all yet give
their full support, saying that a few husbands/mothers-in-law still believe in myths about IFA and
asktheirwives/daughters-in-lawtonotconsumethematall.
A variety of community leaders were mentioned as potential contributors to continued NIPI
success,thoughtheywereonlymentionedaskeypotentialsupportersonceortwice–theSMC,the
, village tribal heads ( ), self-help groups (SHGs), and the RBSK Teams. (The role of
RBSKTeamsinpromotingNIPIwasmentionedmorefrequently.)
Regarding the role of SMC in NIPI, groups of SMCs in two districts and a set of CRCCs in another
described that the interaction of the teachers with this committee is organized monthly. At their
meetings,theydiscussissueslikeschoolinfrastructure,qualityofMDM,qualityofteaching,teacher
vacancy, school environment, and water and sanitation services, but NIPI is rarely on their agenda
Mamata
sarpanch mukhiya
SMCandCommunityLeaders](https://image.slidesharecdn.com/iron-plus-initiativenipi-240801104721-4f20d64f/85/Iron-Plus-Initiative-NIPI-scheme-of-India-for-Anema-free-60-320.jpg)
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IFAlargebluetabletstabletsforout-of-schooladolescentgirls:
CDMO/DistPharm CHCPharm/MOIC/BPM CDPO ICDSSup AWW
IntheblockinKalahandi,theIFAblueispickedupattheCDMOofficebytheCDPO,skipping
theCHCbecausetheycannotmakethedelivery.
In Kujang block, Jagatsinghpur, the CDPO requests that the MO I/C not send the IFA blue
supply to their office, but instead that the MO I/C to send to the sub-centre/ANMs, who then
givetotheAWWs.
IFAsyrupforchildren6months-5years
InBhadrakonly:
CDMO/DistPharm CHCPharm/MOIC/BPM CDPO ICDSSup AWW(forCh3-5)
AndAWW ASHA(forCh<3)
ThereasonforIFAsyrupgoingthroughtheICDSinsteadoftheANMchannelinBhadrak
isnotknown,butaBlockPharmacisttheresaid“Wecan'tgive[syrup]totheANMs”.
officialsdescribedtheirsupplychainas:
IFAlargebluetabletstabletsforin-schooladolescentgirlsandboys:
CDMO/DistPharm CHCPharm/MOIC/BPM (BEO )CRCC Headmasters
Sometimes in Kalahandi and Bhadrak, the BEOs are added to the supply chain to deliver
suppliestotheCRCCsinsteadoftheCHCPharmacist.
The primary supply chain paths reported above matched those laid out in the NIPI guidelines, with
the only exceptions being more officials involved in the block in practice (CHC Pharmacist and BPM
in addition to MO I/C) and less copying to Education officials in practice, compared to the NIPI
guidelines.
According to interviewees from all 4 districts, from all levels from district to field, and from all 3
departments (Health, ICDS and Education), vehicles are available at a number of levels, so the
transportation of the supplies from district to field generally flows well and in a timely fashion.The
interviewees reported that the District Pharmacists and Block Pharmacists have vehicles, including
some new ones allocated by OSMCL. The District Pharmacist transported medicines to CHC/Block
Pharmacists in three districts while the Block Pharmacists pick up medicines from the District
Pharmacist in fourth district. The District can only transport programme medicines, like IFA and
albendazole in the NIPI programme, as far as the CHC at block level, whereas the District can
Z Z Z
Z Z Z
Z
Z Z Z Z
Education
Transportation in the Flow of Supply](https://image.slidesharecdn.com/iron-plus-initiativenipi-240801104721-4f20d64f/85/Iron-Plus-Initiative-NIPI-scheme-of-India-for-Anema-free-73-320.jpg)
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trained at block level in 2015, and then they trained the ASHAs at a sub-centre meeting on how to
give IFA syrup and other aspects of the NIPI programme. ASHAs in one district reported that they
were trained in NIPI as part of a 5-day session on a variety of topics, 6-7 modules covered, likely their
induction training. It included video about breathing problems in anaemic children and about
anaemic women.There is not training on iron, they say, rather that they learn on-the-job about IFA
syrupfromtheANMs.
A DSWO said that training on anaemia had been given to them through the SABLA programme,
being conducted in 9 districts. A CDPO reported a regular meeting as training, saying that they
receive training twice each month with the CDMO in the district, and that they discuss there.
AnotherCDPOsaidtheyhadreceivedtrainingfromanMOI/Conironandalbendazole.
ICDS Supervisors reported that there had been no earlier training, but there had been NIPI
orientation in the block in the previous month – medical team (MO I/C, BPM, RBSKTeam) had given
the training to field level workers (AWWs and ASHAs). Also, the ANMs are trained, and the AWWs
learn from them by seeing them give syrup at VHNDs. Some ICDS Supervisors also reported
receiving a 2-day training on adolescent
anaemia control in 2012 before NIPI as a
training-of-trainers,butnotrainingrecently.
Both state and district level officials agreed that
it was difficult for them to ensure that NIPI
trainings percolated down from DEOs, BEOs
and ABEOs to headmasters and teachers,
though, the official agreed, headmasters and
teachersneedtobeoriented.
District Welfare Officers (DWOs) across districts reported having never been trained on NIPI and
anaemia control interventions. Two DEOs reported that all DEOs and BEOs in Odisha had received
training in Bhubaneswar. He said that he held a similar workshop in his district with BEOs and
Assistant Block Education Officers (ABEOs). He added that the CRCCs and headmasters were
providedwith“CDstoshowwithaprojector”[trainingDVD]toteachabouttheNIPIprogramme,but
he said that“I am not sure to what extent it has been done.” Instead, he said, CRCCs learn about NIPI
throughtheBEOmonthlymeetingsandthatCRCCsmeetwiththeBEOandABEOregularly.
Education officials in one district said that CRCCs and headmasters were called to hospital for a
1-day training at the block level before the National Deworming Day. The training included
informationonIFAinadditiontodeworming.
ICDS
EDUCATION](https://image.slidesharecdn.com/iron-plus-initiativenipi-240801104721-4f20d64f/85/Iron-Plus-Initiative-NIPI-scheme-of-India-for-Anema-free-77-320.jpg)
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received their IFA syrup on Tuesdays and Fridays after meals in several different ways: 1) from their
mothersathomewiththeASHAsvisitinghomestocheckthatitwasgiven;or2)directlyfromASHAs
whenASHAsvisitedtheirhomestwiceperweek;or3)fromASHAsatAWCs,wheretheycallmothers
andchildrentoreceiveallatonce,thenvisittherestattheirhomes.Theguidancesuggestsonlythat
the ASHA should support consumption by the youngest children, which leaves open all these
options. In most cases, the bottle is stored with the mother at the children's homes. There was no
resistance reported from parents or others to their children 6 months-3 years receiving IFA syrup. In
one district where respondents told that mothers gave the IFA syrup to their children and ASHAs
visit their homes to check, thinking that the guideline was more rigid, an MO I/C said“Though the
guideline says the ASHA should give”, it is not possible for them to reach all the children twice each
week.”
SomeofthevariationinwhoadministersIFAsyruptochildren,seenindifferentblocksanddistricts,
may have come from workload – one ASHA said she had 115 children 6 months-3 years and would
not be able to reach all unless she called them to the AWC. Some of the variation may have come
from variations in available IFA syrup stock with ASHAs. Giving mothers the responsibility of
administering IFA syrup, with ASHAs playing a supervision and handholding role would only be
possibleifASHAshadsufficientnumberofbottles(oneperchild)tohandovertoallmothers. Inone
area,mothersreportedthattheygavethesyruptotheirchildreneveryday(insteadofjusttwiceper
week),indicatingtheimportanceoftheASHAmonitoringadministrationathome.
There did not seem to be advice from frontline workers or Health/WCD officials about action to be
taken for a missed dose of syrup amongst children 6 months-3 years. One group of women said:
“And if we forget giving then we tell didi [ASHA] that we have not given and we are forgetting, and
she asks why we didn't give…”but she doesn't mention taking the missed dose on another day. In
the other categories of children and adolescents, frontline workers know how to advise about
misseddoses.
ASHAs are supposed to be“suitably incentivized”for providing or directly supervising the provision
of IFA syrup to children 6 months-3 years twice each week . The incentive is meant to be Re. 1 for 8
visitsperchild(overonemonth).IncomparisontootherincentivesforASHAs,severaldistricthealth
officialscommentedthattheRe.1incentivefor8homevisitsperchildpermonthwastoosmalland
shouldberaised.
Most of the respondents across all four districts, all levels from district to field, and in the Health and
ICDS Departments agreed that ASHAs have never received this incentive. Many (from a number of
levels, e.g., a DMRCH and BPM) confirmed that ASHAs are supposed to receive this incentive. One
BPM concluded that“There is an official communication, but no mechanism has been decided to
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Incentiveto ASHA foradministering IFA syrupin homes
36
Guidelines for Control of Iron Deficiency Anaemia: NIPI, NRHM, 2013.](https://image.slidesharecdn.com/iron-plus-initiativenipi-240801104721-4f20d64f/85/Iron-Plus-Initiative-NIPI-scheme-of-India-for-Anema-free-81-320.jpg)
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With programme experience, those involved in giving IFA supplementation also know to wait a
short while before determining whether a medical person should be consulted. A CRCC explained:
“We advise… there will be some side effects like black stools, vomiting…. Do not get tensed…
within30-45minutesthesethingswillgraduallyresolve."Ifitdoesnot,thentheyshouldcontactthe
medical team, the contact numbers of which are already provided to every school teacher on the
[IFArecording]form.AnICDSofficialtoldthat:“Acallto108[ambulance]doesnotconnecteasily.So
whenevermothersarehavingaproblem,ourAWWstakemoneyfromthe (GKS),
andbookanautoandtakethemtohospital.Theyarealsotakingchildrenlikethat.”Morecommonly,
AWWssaid,theASHAwouldbetheonetogowithPLWoryoungchildren.
A DMRCH described a more formal response mandated by GOI and state government and
mandated per guidelines issued in October 2015 : “We have a committee to oversee the
management of any adverse effects from IFA consumption. A letter has come from government to
form this committee. Similar committees have been constituted at district and block level. Quality
assurance committees, district executive committee, governing body committee are also there.”
This mechanism is perhaps not as effective in the moment as the phone calls and trips to the
hospital,butcouldperhapsplayamoreformalrole.
The vast majority of respondents in all districts reported that they had not been involved with any
NIPI beneficiary who had experienced an adverse effect of IFA or albendazole for which medical
attentionwasrequired.
There were incidents surrounding IFA consumption among students in Puri and Junagarh blocks in
Kalahandi in 2014 that received attention in the media, and are even now associated with higher
degrees of fear and reluctance to give tablets in schools throughout that state. As a district health
official described the incidents:“After taking up the iron tablet, children began to vomit and had to
be taken to the hospital. When this happened in Junagarh, the nearby schools stopped giving
medicines, saying 'who will take this type of headache'. In that case we need to go that place, and
sensitize them in order to bring the programme back on track. This, however, becomes quite
difficult to do.” Another district health official also said: “10-15 secondary school students were
hospitalizedintheJunagarhincident,inearly2014.Thereisstillresistanceinthosetwoblocks.”
There was also an incident surrounding albendazole consumption in one student. A CRCC in
Keonjhar told that one child had to be taken to the hospital recently after taking albendazole. The
child got very sick in the night. The parent scolded the headmaster and locked up the school, and
then took his child to the hospital. A test showed that the child had so many worms that one tablet
in school was not enough. He was given a second albendazole tablet in the hospital, and felt better.
However, the following day, only the side effects were featured in the newspaper, spreading fear
acrossthestate.
GaonKalyanSamiti
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43
Operational Guidelines on “Emergency Response Syste” for any Adverse Event following IFA Supplementation &
DeworminginOdisha,26October2015.](https://image.slidesharecdn.com/iron-plus-initiativenipi-240801104721-4f20d64f/85/Iron-Plus-Initiative-NIPI-scheme-of-India-for-Anema-free-105-320.jpg)
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Formats and Mechanisms of Reporting
Health
ICDS
Education
For the IFA red tablets administered to pregnant women (but not lactating), ANMs report
consumptionthroughtheHMISonamonthlybasis.Unfortunately,thetemplatestillaskedwhether
a woman is taking 100 or 200 tablets instead of asking whether she is taking 180 or 360 tablets per
thenewguidelines.
Many respondents said that there is no format on which to report consumption of IFA syrup for
childrenunder5,noraretherequestionsaboutIFAsyrupintheHMIS.ASHAsandAWWsrecordeach
doseofsyrupconsumedoneachchild'sMCPcardandtheykeeptheirownregister(andASHAskeep
their own diaries), and any compiling and reporting is tallied without the benefit of an established
form.
Also, when women take IFA tablets at home they mark on the MCP card. ASHAs noted that earlier
cardshadnoprovisionformarkingcomplianceinconsumptionofIFAtablets,butinthecurrentcard
there is a page with circles to be filled each time a woman consumes her tablet(s).Women bring the
cardtotheVHND,andifregularconsumptionisnotindicated,theASHAsareremindingthewomen.
Theyarealsocheckingtheircardswhenwemakehomevisits.
IFA consumption is not recorded in the ICDS Monthly Progress Report (MPR), the AWWs main
reporting mechanism, a monthly form for tallying other items to discuss in the monthly
convergence meetings, and ICDS Supervisors suggest that it be added. According to a PO &
consultant, anaemia is part of both the SABLA and Adolescent Anaemia Control Programme, but
theyhavedifferentreportingmechanisms.
The teachers typically keep two registers. One in which they tick off students who consumed an IFA
tablet each week, and a stock register, where supply of IFA tablet is noted, including amount
consumedeachMondayandtheamountofstockleft.
The CRCCs report on IFA consumed in the Samikshya format and meals consumed in the MDM
format. As one said: “There is no register from the government… [the teachers] do as per our
instruction…. It would be better if the government would supply a register or format…. If they take
seriously,itwouldbebetter.”
An important finding is about a gap in the NIPI reporting format itself that could be relatively easily
remedied. CRCCs describe that there is a place to record IFA consumption alongside MDM
consumption in their Samikshya reporting form at the S&ME schools. However, there is no place to
record IFA consumption on the Samikshya forms that are sent about MDM consumption to the
block, district or state level. Many officials recommended that the IFA consumption data have a
place to be recorded in the Samikshya MDM consumption format so that it can be more easily
compiledandreportedtotheblock,districtandstatelevelsoftheEducationdepartment.](https://image.slidesharecdn.com/iron-plus-initiativenipi-240801104721-4f20d64f/85/Iron-Plus-Initiative-NIPI-scheme-of-India-for-Anema-free-112-320.jpg)
Iron-Plus-Initiative NIPI scheme of India for Anema free
- 3. Process Documentation on National Iron Plus Initiative (NIPI) in Odisha
- 7. Yumi Bae Chief, Field Office UNICEF, Odisha FOREWORD Anemia is a key condition of under-nutrition that pervades all life stages, especially damaging in children, adolescent girls and pregnant women. Over the last decade, Odisha has done a lot of work to arrest the prevalence of anemia. The latest National Family Health Survey (2015-16) is evidence that a meaningful reduction took place in Odisha in the prevalence of anemia among children and women of reproductive age in the state. There is immediate interest in what Odisha did right to reduce anemia. One thing for sure is that it took strong coordinated efforts from four departments of the Government of Odisha throughtheNationalIronPlus Initiative(NIPI) program. This process documentation began in 2016 well before data emerged in NFHS-4 of the progress made in controlling anemia in Odisha. It intended to look deep into how NIPI was being implemented - its challenges and barriers - and strengthen anemia control programming in the state based on knowledge. The document today takes on an added interest, a first step into analyzing the ingredients of successful programming that helped reduce anemia and identifying barriers that we need to remove now to further accelerate the reductionofanemia. I sincerely thank Dr.Vikas Bhatia and his team fromAIIMS Bhubaneswar and Dr. Kathleen Kurz, independent consultant, for carrying out this study on the implementation of NIPI programme in Odisha. I thank the Government of Odisha for initiating this documentation withUNICEF. Yumi Bae
- 9. Contributors 1. 2. , 3. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Dr. Vikas Bhatia, Dean, Dr. Preetam Mahajan Dr. Swayam Pragyan Parida, Mr. Sourav Bhattacharjee, Dr. Shweta Sharma, Dr. Jee Hyun Rah, Ms. Preetu Mishra, Dr. Sanjay Kumar Sahoo, Ms. Sanjeeta Raut, Mr. Nayan Mishra, Mr. Priyabrata Das, Mr. Satyaswar Nayak, Mr. Sudip Das, Dr. Kathleen Kurz, AIIMS, Bhubaneswar UNICEF OTHERS Professor and Head, Dept. of Community and Family Medicine, AIIMS, Bhubaneswar Asst. Professor, Dept. of Community and Family Medicine, AIIMS, Bhubaneswar Asst. Professor, Dept. of Community and Family Medicine, AIIMS, Bhubaneswar Nutrition Specialist, UNICEF Odisha Nutrition Officer, UNICEF Odisha Nutrition Specialist, UNICEF New Delhi Nutrition Officer, UNICEF New Delhi Consultant – Anaemia Control, UNICEF Odisha Consultant – MDM, UNICEF Odisha Consultant – Tribal Nutrition, UNICEF Odisha Nutrition Coordinator (RDC, Northern Division), UNICEF Odisha Nutrition Coordinator (RDC, Southern Division), UNICEF Odisha Nutrition Coordinator (RDC, Central Division), UNICEF Odisha Independent Consultant
- 11. List of Abbreviations 1 Executive Summary BACKGROUND 11 METHODOLOGY 29 RESULTS 41 3 Anaemia Government Policies and Schemes for Anaemia Control Rationale for NIPI process documentation in Odisha NIPI Programme Guidelines Study Design Sampling Preparatory Activities Recruitment and Training of Data Collectors Development and Pretesting of Interview Questions and Tools Ethical Approval and Informed Consent Data Collection and Quality Assurance Data Cleaning, Entry, and Management Data Analysis Health ICDS Education Lack of political commitment Coordination and Convergence among Government Departments Coordination with Stakeholders Microplanning Indenting of IFA and albendazole Procurement of IFA and albendazole Supply Chain Management Do staff and workers think they should get trained further? Administration of IFA Supplements Quantitative Survey: Coverage, Knowledge, providers Quantitative Survey: Prevalence of Anaemia Diagnosis, Treatment, Referral, Follow-up, and Perceptions of Prevalence Health ICDS Education Supportive Supervision & Monitoring Recording and Reporting Mechanisms Political Commitment and Ownership 41 Planning and Coordination 44 Administration of the Intervention 67 Logistics Management 51 Training 64 Supportive Supervision, Monitoring and Reporting 94 Table of Contents
- 12. Knowledge of parasitic worms with anaemia Mechanisms of the intervention Malaria and Filariasis Knowledge of anaemia is increasing: Respondents describe the condition, consequences, symptoms, and causes Sources of the information messengers, media, IEC Invisibility of anaemia Handling the early resistance Demand for NIPI and nascent programming innovations Remoteness Distance far from main roads, and from government attention Language Tribal issues and customs Low education levels Social Mobilisation Administering the Intervention Logistic Management Diagnosis, Treatment, Referral and Follow-up Monitoring and Supervision Training Hard-to-reach NIPI beneficiaries Deworming 101 Social Mobilization and Community Awareness for Anaemia and NIPI 102 Hard to Reach Areas 109 CONCLUSIONS, DISCUSSION AND RECOMMENDATIONS 112 ANNEXURE -1 121 Analysis of Indenting, Procurement, Specifications of IFA/ Albendazole Formulations ANNEXURE -2 127 Recent developments in implementation design of NIPI in Odisha
- 13. AACP Adolescent Anemia Control Programme ABEO Assistant Block Education Officer ANC Antenatal Care ANM Auxiliary Nurse Midwife ASHA Accredited Social Health Activist AWC Anganwadi Centre AWW Anganwadi Worker BDM Block Data Manager BDO Block Development Officer BEO Block Education Officer BMI Body Mass Index BPM Block Programme Manager CDMO Chief District Medical Officer CDPO Child Development Project Officer CHC Community Health Centre CRCC Cluster Resource Centre Coordinator DEO District Education Officer DEFF Design effect DFW Director, Family Welfare DHFW Department of Health and Family Welfare DM District Magistrate DMRCH Deputy Manager Reproductive and Child Health DPC-SSA District Project Coordinator-Sarva Shiksha Abhiyan DPM District Programme Manager DSWO District Social Welfare Officer DWO District Welfare Officer ERS Emergency Response System FA Folic Acid FGD Focus Group Discussion FRU/DH First Referral Unit/District Hospital GKS Gaon Kalyan Samiti GoI Government of India GoO Government of Odisha Hb Haemoglobin ICDS Integrated Child Development Services IDI In-depth interview IEC Information Education and Communication IFA Iron and Folic Acid MCP card Mother and Child Protection Card MDM Mid Day Meal MoHFW Ministry of Health & Family Welfare MHT Mobile Health Team List of Abbreviations 1
- 14. MHU Mobile Health Unit MO I/C Medical Officer in-charge MO PHC Medical Officer Primary Health Centre NHM National Health Mission NIPI National Iron Plus Initiative NRC Nutrition Rehabilitation Centre NRHM National Rural Health Mission OSMCL Odisha State Medical Corporation Limited PHC Primary Health Centre PIP Programme Implementation Plan PLW Pregnant and Lactating Women RBSK Rashtriya Bal Swasthya Karyakram RDC Revenue Divisional Commissioner RI Routine Immunization SABLA Scheme for Empowerment of Adolescent Girls SC/ST Scheduled Caste & Scheduled Tribe SC Subcentre SDMU State Drug Management Unit SHG Self Help Group SIMT State Integrated Monitoring Team SMC School Management Committee S&ME School and Mass Education SNO-MDM State Nodal Officer, Midday Meal THR Take Home Ration VHND Village Health and Nutrition Day WASH Water Sanitation Hygene WCD Women and Child Development WIFS Weekly Iron and Folic Acid Supplementation WRA Women of Reproductive Age and 2
- 15. 3 BACKGROUND RATIONALE AND METHODOLOGY The National Iron Plus Initiative (NIPI) is the most ambitious and comprehensive anaemia control programme in the world. Its beneficiaries span life cycle groups from adult women to infants – pregnantandlactatingwomen, adolescentgirlsandboysinsecondaryschoolandadolescentgirls out-of-school, pre-adolescent school-going girls and boys in primary school, and young children 6 months to 5 years.To reach them, implementation of NIPI spans three main ministries – Health and FamilyWelfare in the lead role;Women and Child Development and Education.The components of the programme are the provision of Iron Folic-Acid (IFA) supplementation to boost iron status (shown in the table), the biannual provision of deworming medicine to reduce blood and iron loss from intestinal helminth infections like hookworm, and the promotion of iron-rich diets and of hygienepractices. NIPI was inaugurated in 2013. After two years of programme experience, the GoO wanted to investigate how the programme was progressing , and chose to conduct a process documentation in the state. From March to July 2016 a quantitative survey was conducted and blood was drawn for assessment of haemoglobin and anaemia among 4800 beneficiaries and frontline workers, and a set of qualitative interviews was conducted among 170 beneficiaries and officials from the state, district, block, sector and field levels. Within Odisha, four districts were purposively selected to cover a variety of characteristics, including their performance reporting on NIPI – Bhadrak, Jagatsinghpur, Kalahandi and Keonjhar. Blocks were chosen similarly to provide variety – two blocks each in Jagatsinghpur and Keonjhar, and one block each in Bhadrak and Kalahandi. Data for the qualitative interviews were collected until no new information emerged. The different components of NIPI were being phased in gradually, and there was adequate programme experience to document the process among pregnant and lactating women, adolescent girls and boysinsecondaryschool,adolescentgirlsout-of-school,andchildrenunder5years(butnotWRAor children in primary school).There were far more results that were similar amongst the districts and blocksthandifferent. ProvisionofIFAsupplementationbylifecyclegroup,ministryandprovider EXECUTIVE SUMMARY Children 6mo-3yr Children 3-5yr Children in primary school Adolescents in secondary school Adolescent girls out- of-school Pregnant & lactating women Ministry responsible Health Health, WCD Health, Education Health, Education Health, WCD Health Worker responsible ASHA at home AWW at AWC Teacher at school Teacher at school AWW at AWC Self at home IFA supplement Syrup 2x/week Syrup 2x/week Pink tablet 1x/week Blue tablet 1x/week Blue tablet 1x/week Red tablet daily
- 16. 4 RESULTS PoliticalCommitmentandOwnership PlanningandCoordination LogisticManagement Many officials expressed strong political commitment to increasing coverage and strong service delivery of the NIPI programme – from all levels, state to field; all three Departments, Health, ICDS and Education; and all districts. Political commitment and ownership was expressed in different ways - feeling pride in progress made, describing successful ways to mobilise beneficiaries and others,andforseniorhealthofficialsissuingkeygovernmentlettersorembracingnewgovernment strategies. In some areas, the programme continues to face challenges due to poor community demand and lack of community support, and the importance of community support was highlighted by multiple respondents at various levels. Parents, husbands and mothers-in-law, School ManagementCommitteesandcommunityleaders,whowerekeystakeholdersinthepromotionof IFAsupplementationacrossthelifecyclegroups,reportedthattheysupportedNIPI.Howeverthere is much scope for strengthening engagement with these supportive stakeholders for NIPI programmesuccess. From the qualitative interviews, it was clear that coordination between the Health and Education Departments had improved greatly since the beginning of NIPI. While the working relationship betweenpersonneloftheHealthandWCDDepartmentsatalllevelswaswell-establishedandwell- functioning,thatbetweenHealthandEducationwasnew.AtthebeginningoftheNIPIprogramme, teachers and Education officials were reluctant to provide the IFA supplements to students, fearing that they would not be able to handle their side effects, and claiming that Health Department personnel should be the ones to distribute tablets. By 2016, however, most reported that they had grown accustomed to providing the IFA tablets and coordination between Education and Health departments had improved. Important to the improved coordination on NIPI was emerging leadershipandsupportivesupervisionbyEducation,aswellasHealthandICDSofficialsatalllevels, spearheadedfromstate. Microplanning seemed to be carried out well according to reports from the interviews -- RBSK health check-ups and other officials' supportive supervision visits were scheduled and carried out efficiently. A key reason the State of Odisha created the OSMCL was to ensure that high quality drugs were procuredandsupplied,andtheprocurementandsupplychainwerestreamlined.Supplementsand medicine were procured and sent into the supply chain in installments against an annual indent. Although transportation options were almost always available to send supplies to the next level, butmostofthetimesthistook1-2months. There were no reports of expired medicine being provided to beneficiaries and adherence to formulation was high. If anything, teachers and others had been warned so effectively to watch for the expiration date that they feared giving supplements several months in advance. No reports of substitutingsupplementformulations,werefoundatthetimeofthequalitativeinterviews.
- 17. 5 Training Administrationofintervention Most of the respondents had received some form of instruction on NIPI.While district level officials described the instruction as“training”, most block and field level functionaries said they had only received information through regular meetings. Although cascaded training was expected per the guidelines,therewerechallengestoensuringthatithadactuallyoccurred. Respondents recommended further training, especially for those implementing the programme at field level like teachers and AWWs. High proportions of field level workers mentioned that they felt theneedformoretraining. RBSK MHTs – a critical stakeholder in anaemia screening – however mentioned that they had never received specific training on NIPI, but only knew about the programme through discussions in monthly meetings. Other important stakeholders in NIPI implementation who have yet not been covered under organized trainings on NIPI include – district/block pharmacists, SMC members and DWOs/WEOs. Even with strong awareness among service providers on the need to administer IFA tablets to pregnantwomen,mostwomenseemedtonotbegettingthefullcomplementofIFAtabletsduring pregnancy. The focus on getting IFA red tablets daily to women during the 1 six postpartum monthsismuchlowerthanduringpregnancy. Children 6 months-3 years received their IFA syrup in two different ways.While some children were administered IFA syrup by their mothers at home, with the ASHAs making monitoring visits as recommended, others were administered directly by ASHAs twice per week, especially in cases whereASHAsdonothavesufficientIFAsyrupbottlestohandovertoallmothers. While coverage under IFA supplementation among adolescents is improving gradually, it drops during vacations for in-school adolescents and was also found to be irregular for out-of-school adolescentgirls.Mostrespondentsexpressedthatmoreout-of-schooladolescentgirlswouldcome totheAWCforSaturdaysessionsifthereweremoreincentives,e.g.,amealwasserved,ortakehome rationsoreggsweregiven,orHbtestwasdone. Teachers and others in the Education sector in a few areas still fear that giving IFA tablets may cause ill effects among their students, draw media attention, cause black stools, or that the tablets may reach their expiry date and then be dangerous. Their fear sometimes resulted in low compliance among the students and other times the teachers gave tablets to their students despite lingering doubts. Biannualdewormingtreatmentwithalbendazolewasreadilyacceptedacrosstheagerangesofthe NIPI programme, in schools, AWCs and VHND settings. Beneficiaries said that the medicine tasted good, and tablet distribution occurred twice per year.While deworming with albendazole is widely practiced,thepromotionofhygieneanddietarypracticesisacceptedbutnotfullyachievable. Interestingly, in light of their initial reluctance about IFA, teachers did not report being reluctant to provide deworming medicine, which is popular with them and their students. Possible reasons are thatthedewormingmedicineactsrapidly,givingvisiblerelieffromtheintestinalworms,thetablets tastedsweet,andthemedicineisprovidedonlytwiceeachyear. st
- 18. 6 Communityawarenessandperceptions CoverageofIFAsupplementationandPrevalenceofanaemia Adverseevents SupportivesupervisionandMonitoring Community awareness and knowledge regarding anaemia was low. A major constraint to raising awareness about the importance of reducing anaemia is that most respondents, from state level through to beneficiaries, did not perceive anaemia as a prevalent health issue. Most respondents claimed they did not know anyone who was anaemic. Of those who had heard of anaemia, only 20% could name any symptoms, most commonly giddiness, weakness and tiredness. Even fewer coulddescribelong-termconsequencesofanaemialikepoorscholasticperformance.Only50-62% ofbeneficiariesinterviewedknewofanybloodtestforanaemiadiagnosis.Amongthosewhoknew thattherewasabloodtestforanaemia,mostsaidtheywouldprefervisitingagovernmentdoctorat ahealthcentrefortreatment(85%-95%). Despite the improving process, reported coverage of IFA supplementation in the previous month from the quantitative survey was generally low, as reported by the beneficiaries or mothers of children under 5 years. Among beneficiaries interviewed, only 38% of adolescent girls, 16% of adolescent boys, 46% of lactating mothers and 52% of under-five children were reported to have consumed IFA tablets/syrup in the previous month. Pregnant women were the only exception with reportedcoveragethatwashigher(73%). Not surprisingly then, the haemoglobin assessment results indicated that anaemia was highly prevalentamongwomenandadolescentgirls(68-77%,dependingonthebeneficiarygroup).Most were mildly anaemic (39-58%), many were moderately anaemic (7-20%), and only a few were severely anaemic (1-3%). These results were similar to the prevalence in Odisha from the representative sample in the national Annual Health Survey of 2014, except that severe anaemia waslower. An important aspect of resistance to IFA at the beginning of NIPI was that many associated with the Education Department – teachers, headmasters, SMCs, CRCCs and others – were reluctant to implementamedicalintervention.Theyfearedbeingonthefrontlineandbeingperceivedasbeing responsible if students experienced side effects from the IFA, which they thought of as medicine. The situation seemed to have significantly improved since then, reportedly due to a number of specialeffortsmadetocombattheresistancetoIFAconsumptionatschools. Very few cases of adverse events were reported by respondents under the study and the vast majority of respondents in all districts reported that they had not been involved with any NIPI beneficiary who had experienced an adverse effect of IFA or albendazole for which medical attention was required. Although a formal response mechanism mandated by GoO in form of ERS committee exists, this mechanism is perhaps not as effective in the moment as the phone calls and tripstothehospital,butcouldperhapsplayamoreformalroleinfuture. Thestructureformonitoringandsupervisionisprimarilythroughfieldsitesandreviewingprogress during meetings. There was evidence that the visits and meetings occurred, but there was little clarity on the content or quality of the monitoring and supervision and if/what actions were taken
- 19. 7 during or after as a result. The notion of monitoring exists strongly among staff of all three departments,howeverNIPIhasnotyetbecomeamonitoringpriority. For the IFA red tablets administered to pregnant women, ANMs report consumption through the HMIS on a monthly basis. Many respondents said that there is no format on which to report consumption of IFA syrup for children under 5, nor are there questions about IFA syrup in the HMIS. IFA consumption is not recorded in the ICDS Monthly Progress Report (MPR), the AWWs main reporting mechanism, a monthly form for tallying other items to discuss in the monthly convergencemeetings,andICDSSupervisorssuggestthatitbeadded. At minimum, data is recorded and reported to show accountability for having distributed the IFA tabletsandsyrup.Purposesbeyondthisminimumcanhelpshapetheformatandfrequencyofhow the data should be reported.There was lack of clarity among respondents on how the reports were being analyzed as there was almost always no feedback from higher levels on quality or accuracy of reports. The pallor technique is applied to children once/twice per year by the RBSK team to detect severe anaemia.This technique has reasonable accuracy for detecting severe anaemia, but is not accurate for mild and moderate. As haemoglobin of the children is not assessed and therefore mild and moderateanaemiacannotbedetected,thismakesimplementationofthetherapeuticprotocolsfor mild/moderateanaemiadifficult.Thisisalsoevidentfromthefactthatprescriptionsfordailyironto children with mild or moderate anaemia were not mentioned by any group of respondents under thestudy. Mobilization of the NIPI programme and consumption of IFA, from the state level to beneficiaries, has increased steadily over the 3 years since NIPI was started. IFA consumption was initially not well accepted, but after much effort has improved steadily. This is due to the diligence and persuasion across the Health, Women and Child Development, and Education Departments and coordinated fromstate,district,block,sector,fieldandbeneficiarylevels. Fullownershipofprogramme,however,islacking,andIECinitiativescouldbuildenthusiasmforthe programme. Sources of information are mostly interpersonal, some radio (Meena), and limited TV and print. Largest gap is that anaemia is invisible – respondents do not think they are anaemic, nor dotheyknowanyonewhois,exceptsevereanaemia. Many respondents from all levels reported that they did not currently have NIPI IEC materials.There had been materials earlier. Many said that some printed NIPI IEC booklets were distributed at the beginningofNIPI–butnonemorerecently. Four factors due to which beneficiaries were perceived to be hard-to-reach were: remoteness from mainroadsandgovernmentattention,language,tribalcustoms,andloweducationlevel.Engaging with tribal leaders to promote IFA and deworming, diet and hygiene; and development and use of IEC materials in the major local tribal languages are strategies which can support the programme in hard-to-reachareas. Recordsandreporting Managementofanaemia SocialMobilisation
- 20. 8 CONCLUSION AND RECOMMENDATIONS While some key programme components are in place - especially improving coordination among the Health, ICDS and Education departments for the provision of IFA supplements, successful biannualprovisionofdewormingmedicinetoallbeneficiaries,andawell-functioningsupplychain of IFA supplements -- coverage of IFA supplementation lags behind. Other components were discovered that could be enhanced to increase the coverage of IFA supplements, as well as to further promote iron-rich diets and hygiene practices, and ultimately reduce the prevalence of anaemia. Recommendations regarding these components are offered below, with more detailed recommendationsavailableinthelastsectionofthisreport. : While initial resistance to IFA supplementation in the schools has subsided, the NIPI programme has a long way to go to reduce anaemia's invisibility (few beneficiaries think they are anaemic, despite 75% prevalence), to explain its long-term consequences (few understood that anaemia limits scholastic performance, reduces work productivity, and compromises delivery outcomes), and to build enthusiasm for its interventions (for example, recognitions and awards). An enhanced strategy for social mobilization shouldbedevelopedandinclude: – messages on the following themes could be developed, for example: 75% of the life cycle groups from infancy to adulthood are anaemic; improving iron status throughout the life cycle leads to good long-term outcomes; and IFA is a food supplement, notamedicine,hencefewsideeffects. Enhance efforts to continue promoting iron-rich diets and good hygiene practices. In the long term, beneficiaries consuming IFA supplements should experience less anaemia. To maintain good iron status, an iron-rich diet should be the norm, starting while they are receiving IFA supplements. Respondents from the qualitative interviews were often not clear what comprised an iron-rich diet. IEC materials and school lessons should be developed to convey diet messages alongside others in the enhanced social mobilisation efforts. – fathers and community leaders could be educated on the benefits of reducing anaemia so they encourage their wives, children and community members to consume IFA supplements and iron-rich diets, and practice good hygiene behaviours. – RBSKTeams, with medical staff and credibility, and already with a regular presence in schools, could take a larger role in educating parents and school-aged childrenabouthowtocombatanaemia. -- beneficiaries and officials should hear about NIPI from numerous sources to reinforce its messages, for example, awards, competitions and events to raise awareness;mediatofeatureNIPIbenefitsandprogress;andnewIECmaterials. Significantly enhance NIPI social mobilisation efforts New Messages NewaudiencesforNIPImessages Enlarged messenger role Multiple channels StrengthenSocialMobilisation â â â â â
- 21. 9 Strengthensupply-chainforallIFAformulations Strengtheningadministrationofintervention Strengtheningdiagnosisandmanagementofanaemia â â â â â â â Makingprovisionsfortrackingsupplyuptosub-districtlevelsthroughOSMCLsoftware: Introducing more incentives for out-of-school adolescent girls Provisioning higher incentives for ASHAs for IFA syrup administration and increasing utilization of the same Strengthen messaging around IFA administration among in-school adolescents during vacations: MakehaemoglobinometersavailabletoRBSKTeamstoassessstudents'anaemiastatus,and develop a strategy to monitor whether haemoglobin levels are improving over time. Despite a strong supply chain, respondents did describe few instances of stock-outs of IFA tablets/syrup. At the time of study, two specific stock-outs in field were identified – for IFA Red tablets and IFA syrup. While the major reason for stock-out of IFA red tablets was inadequate procurement by state, in case of IFA syrup, the supply-chain below district level faced disruptions due to delayed/inadequate indenting and supply. Such supply disruptions could be identified and prevented if systems for tracking supply position and distributionuptoblocklevelareavailablethroughtheOSMCLsoftware. Inform pharmacists more about the NIPI programme so that they can understand anaemia andmorefullyengagewithcombattingit. Expand and improve storage space for IFA and albendazole among other essential drugs at district,blockandPHCs. : Coverage of IFA supplementation was low among all groups except pregnant women. Adolescent girls out- of-school and in junior college reported having difficulty reaching the AWC every Saturday after a meal to receive an IFA blue tablet. Introducing incentives, like take home rations/meals/eggsorHbassessmentscouldbeconsidered. : Although incentive has been provisioned for IFA syrup administration by ASHAs at rate of Re.1 per 8 doses for each child, the utilization of this remainspoor.Onereasonreportedforpoorutilizationisthatthecurrentincentiveistooless. Multiple respondents from Education department expressed uncertainty over protocols and process of distributing IFA supplements during school holidays. Strengthening messaging and guidance around this is therefore recommended, so as to bringmoreclarityamongprogrammeimplementersonguidelinesandprotocols. Moderate anaemia is prevalent among adolescents in Odisha and throughout India, but it is difficulttodistinguishthosewithmoderatefromthosewithmildornoanaemiaunderNIPI– only severe anaemia can be distinguished with the skin pallor technique. Making haemoglobinometers available to RBSK Teams so they may determine the degree of anaemia is recommended. Once haemoglobin levels can be assessed, developing a mechanism to provide adequate doses to manage mild/moderate anaemia is recommended. Health check-up and haemoglobin assessment is also recommended for adolescentgirlsout-of-school.
- 22. 10 Strengtheningmonitoringandreporting Strengtheningscopeandqualityoftrainings StrengtheneffortstosupportNIPIimplementationinhard-to-reachareas: â â â â â â â Sharing feedback on reports Review content of NIPI discussion in various meetings: EnhanceeffortstofurtherextendtheNIPIprogrammetohard-to-reachareas Increased incentives for IFA syrup administration in geographically hard-to-reach areas: : At all levels, increase the frequency of giving feedback on reports to those submitting it. Make widely available a summary of results comparing districtandblocks. Although NIPI was reported to be discussed during various district, block/project and sector level meetings, it is recommendedthatmoreemphasisbegiventoreviewingthequalityofthesediscussions.It is further recommended to review whether the participants and frequency of meetings in which NIPI is adequately discussed is sufficient for its monitoring, implementation review andproblemsolvingandalsoforupdatingparticipants. Additional special training is recommended for those implementing the programme at communitylevel–teachers,AWWs,ASHAsandANMs.Itisfurtherrecommendedtoincrease the scope of coverage of training programmes on NIPI to include RBSK teams, School Management Committee members, pharmacists and officials from ST&SC development department. Apart from special trainings for the implementing officials, a more sustainable approach would be to include information on NIPI as part of regular induction/refresher trainings of thesevariousfunctionariesincludingteachers,SMCs,FLWs. As findings showed challenges in organizing and monitoring down-the-line cascade trainings for functionaries below district level, it is recommended that standard audio- videos and resource materials be developed to support these orientations and refresher trainings. Focus on tracking whether the cascade trainings are happening and quality of thesetrainingsneedstobestrengthened. .Manycasesof health services not reaching hard-to-reach areas were reported, and many potential beneficiaries had not heard of anaemia or received IFA supplements. Having NIPI IEC materials written in the major local tribal languages is also recommended to overcome the language barrier for non-Odia speakers. Furthermore, strengthening the involvement of local village tribal heads in the NIPI programme to minimize local resistance is also recommended. There was a general finding that officials considered incentives proposed for ASHAs for administration of IFA syrup to under-three children too low. In hard-to-reach areas with sparsely located populations and difficult terrains, these incentives seemed highly insufficient to motivate ASHAs to monitor IFA administration. It is therefore recommended thattheincentivesbeincreased,atleastforASHAsservinginhard-to-reachareas.
- 23. ANAEMIA Anaemia is a widely prevalent disorder affecting over half a billion women of reproductive age (WRA) and over quarter of a billion children under 5 years old worldwide. It is a condition in which red blood cells have fewer haemoglobin molecules than normal, or fewer red blood cells overall, and thus less ability to carry oxygen to tissues in the body.The word anaemia derives from ancient Greek meaning “lack of blood” and blood haemoglobin concentration is the most reliable and commonlyusedsingleindicatorofanaemia.Iron(“haeme”)iscentraltothehaemoglobinmolecule. A worldwide systematic analysis indicated that the global prevalence of anaemia among children under 5 years was 47%, pregnant women 43%, and non-pregnantWRA 33%, while the prevalences in South Asia were much higher: children under 5 years 70% and both pregnant and non-pregnant WRA53% . Anaemia causes fatigue and low productivity and adversely affects cognitive and motor development. It contributes to over 100,000 maternal and almost 600,000 perinatal deaths worldwide each year, as well as risk of pre-term delivery and low birth weight in newborns and reduced cognitive development and therefore school performance in children. These in turn lead tosocialandeconomiclosses,thelatteramountingtoabout4%ofGDPglobally. Iron deficiency from diets poor in iron account for around 50% of anaemia. A study estimated that 25% of all anaemia among children under 5 years and 37% among non-pregnant WRA was due to iron deficiency. Others estimated that 42% of anaemia in children would be amenable to iron 1 2 3 4 5 6 7,8 1 2 3 4 5 6 7 8 WHO.Theglobalprevalenceofanaemiain2011.Geneva:WorldHealthOrganization;2015. Klemm R, Sommerfelt AE, Boyo A, Barba C, Kotecha P, Steffen M, and FranklinN. Are We Making Progress on Reducing Anemia in Women? Cross-country Comparison of AnemiaPrevalence, Reach, and Use of Antenatal Care and Anemia ReductionInterventions.AED,June2011. Stevens GA, Finucane MM, De-Regil LM, Paciorek CJ, Flaxman SR, Branca F, Peña-Rosas JP, Bhutta ZA, Ezzati M on behalf of Nutrition Impact Model Study Group (Anaemia). Global, regional, and national trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for 1995-2011: a systematicanalysisofpopulation-representativedata.LancetGlobalHealth(1)e16-25,2013. IbidWHO,Klemmetal.,Stevensetal. Horton S, Ross J. The economics of iron deficiency. Food Policy 28:51-75, 2003. DeMaeyerE,Adiels-TegmanM.Theprevalenceofanaemiaintheworld.WorldHealthStatisticsQuarterly,1985. PetryN,OlofinI,HurrellRF,BoyE,WirthJP,MoursiM,DonahueAngelM,RohnerF.TheProportionofAnemiaAssociated withIronDeficiencyinLow,Medium,andHighHumanDevelopmentIndexCountries:ASystematicAnalysisofNational Surveys.NutrientsNov2;8(11),2016. Ozkasap S,Yarali N, Isik P, Bay A, Kara A, Tunc B. The Role of Prohepcidin in Anemia due to infection. PediatrHematolOncol2013. Helicobacter Pylori 11 B A C K G R O U N D
- 24. supplementation and 50% in women could be eliminated with iron supplementation. Beyond diet-based iron deficiency, anaemia is caused by hookworm, malaria and other parasitic and diarrhealinfectionsthatcausebloodloss,interferewithredbloodcells,orlimitnutrientabsorption, as well as other nutrient deficiencies such as folate, vitamin B12 and vitamin A, and haemoglobinopathies such as sickle-cell. These suggest that a multi-faceted approach is needed to reduce anaemia, as in India's programme to provide iron and folic acid and promote consumption of iron-rich dietary sources, to control hookworm and other helminth infections, and topromotesafewaterandsanitationforpreventingdiarrheaandotherinfections. A global review of anaemia prevalence among pregnant and non-pregnant women with representative DHS/NFHS data for 24 countries with multiple assessments between 1998 and 2008 indicated that anaemia in women remains a serious public health threat with unacceptably high rates and little progress. While the traditional focus of anaemia programmes for women was during pregnancy, an additional focus on non-pregnant women is fruitful because the non- pregnancy period forWRA is longer than pregnancy, allowing time to improve the quality of life as wellastoprepareforthefirstorsubsequentpregnancies. Among the 24 countries in the global review, anaemia prevalence in the mid-2000s among pregnant women was >50% in 13 countries, including India, was 30-49 % in 10 countries, and was <30% in only one country (Haiti). In 5 of the 11 countries for which there were multiple haemoglobin assessments between 1998 and 2008, anaemia prevalence actually increased, including a 9% increase in India, while it remained unchanged in 3 countries, and decreased in 3 (Nepal,32%decrease,Haiti13%,andCambodia8%). The anaemia prevalence among non-pregnant women in the mid-2000s, while a bit lower than among pregnant women, was also seriously and unacceptably high -- >40% in 14 countries, including India, 20-39% in 9 countries, and <20% in only one (Honduras). In 7 of the 11 countries with multiple haemoglobin assessments, anaemia prevalence actually increased, including a 3% increaseinIndia,whileitdecreasedintheother4,ledbya30%decreaseinNepal. 9,10 11 12 9 10 11 12 De-Regil LM, Jefferds ME, Sylvetsky AC, Dowswell T. Intermittent iron supplementation for improving nutrition and developmentinchildrenunder12yearsofage.CochraneDatabaseSystRev(12),2011. Fernández-Gaxiola AC, De-Regil LM. Intermittent iron supplementation for reducing anaemia and its associated impairmentsinmenstruatingwomen.CochraneDatabasedSystRev.(12),2011. IbidWHO,Stevensetal,Klemmetal IbidKlemmetal.2011 12
- 25. GOVERNMENTPOLICIESANDSCHEMESFORANAEMIACONTROL To provide context on India's anaemia control programme, evaluation results from successful country supplementation programmes for pregnant women in Nicaragua and Thailand were reviewed. In Nicaragua, country-wide prevalence reduced from 34% to 24% to 11% from 1993 to 2000 to 2003-2005, respectively. In Thailand, prevalence reduced from 40% to 16% and then increased to 26% from 1986 to 1995 to 2003, respectively. Key features of the programmes identifiedwere: Awarenessraisedamongchildren,mothersandofficialsinvolvedintheprogramme Demandforironfolicacid(IFA)created Clearpolicyinplace Enjoyedstrongpoliticalwill Deliveredthroughhigh-qualityservices Suppliesavailable Activehealthvolunteersinplace India has had a written national policy to reduce nutritional anaemia and a National Anaemia Control programme. Targets in the 12 Five Year Plan (2012-2017) are to prevent and reduce anaemia among women aged 15-49 years to a prevalence of 28% by 2017 (down from over 50%), and also to reduce anaemia in girls and women by half. Prior to NIPI, the strategy described in the Nutritional Anaemia Prevention Programme included IFA supplementation for pregnant women and postpartum/lactating women – 1 tablet daily for 100 days containing 100 mg elemental iron and500mcgoffolicacidduringpregnancyandduringlactation(tabletscalledFolifer). Thiswasa dose similar to NIPI but with a smaller number of tablets (100 rather than 180 during pregnancy) and no specification prior to NIPI regarding different number of tablets for anaemic and non- anaemic women. The programme was implemented through Primary Health Centres (PHCs) and their sub-centres, with female multipurpose workers giving IFA supplements to women and also children 1-5 years old who came to the centres. Anganwadi Workers (AWWs) within the Integrated 13 14 15 th â â â â â â â IndiaanaemiacontrolpolicypriortoNIPI 13 14 15 Dary O, Harvey P, Houston R, Rah, Jee. The Evidence on micronutrient programs: A selected review. Micronutrient Forum,USAID,A2Z,AED,2008 Twelfth Five Year Plan (2012-2017), Volume III Social Sectors. Planning Commission GOI, Sage Publications India Pvt Ltd,2013. IbidKlemmetal2011 13
- 26. Child Development Services (ICDS) programme assist in distributing iron tablets to children and mothers. The Department of Food in the Ministry of Food and Civil Supplies promoted consumptionofiron-richfoods. There was no national policy on hookworm control prophylaxis for pregnant women, and women who presented at health centres with complaints consistent with intestinal worms would be treated.The National Malaria Control programme had no link to pregnancy care, and women were advisedtogetabloodsmeariftheyhadfever. Regarding procurement of IFA tablets, the Government of India (GOI) procured reproductive and childhealthkitsthatcontained15,000tablets.Thecentrallypurchasedtabletsweresenttodistricts according to their number of sub-centres, and the number was often underestimated. However, duetopoorcomplianceofIFAconsumption,stock-outswererare. Formative research had identified primary barriers to IFA adherence in pregnancy: inadequate logistics, late and infrequent use of antenatal care (ANC) services, and lack of awareness of the benefits of using ANC services and reducing anaemia. Regarding monitoring, the HMIS format included information on pregnant women registered for ANC, but HMIS reports were either not generated or were of poor quality. Demand generation activities related to maternal anaemia did not exist at the national level, though messages about registering a pregnancy included information on pregnancy care and consuming 100 IFA tablets. Overall, anaemia was not a focused topic. In addition to pregnant women and young children, India pays more attention to the health and development of adolescents than other countries, and since 2000 has had programmes that included anaemia control among adolescent girls. A summary of the programmes that address adolescent anaemia before NIPI is shown in Table 1. NIPI seemed to replace the AACP. The Scheme for Empowerment of Adolescent Girls (SABLA) scheme merged the KSY and NPAG schemes and is implemented concurrent to NIPI, in selected districts (in Odisha, Bhadrak and Kalahandi and 7 others). 16 IbidKlemmetal.2011. 16 14
- 27. Scheme Year of Operation Target group Services provided Koshori Shakti Yojna (KSY) 2000 Adolescent girls 11- 18 years · Knowledge and skills to improve decision making · Vocational skills · Promotion of health, hygiene and nutrition · Encouragement to participate in community activities · IFA supplementation and deworming Nutrition Programme for Adolescent Girls (NPAG) 2002-2003 Adolescent girls 11- 19 years (<35 kg) · 6 kg of food-grains/mo/beneficiary, provided quarterly · Nutrition and health education to improve intra-family food distribution patterns Adolescent Anaemia Control Programme (AACP) 2000 (Selected districts in Odisha) Adolescent Girls 10- 19 years out-of- school · Weekly IFA supplementation (WIFS) – 100 mg elemental iron and 500 mcg FA · Albendazole deworming medicine 2x/yr (400 mg) · Counselling on iron-rich foods SABLA scheme, through the ICDS platform 2011, selected districts Adolescent Girls 11- 18 years Out-of-school girls 11-18 years · Take Home Ration (THR) – 5 kg/mo sattu/chhatua · IFA supplementation · Health check-up and referral services · Nutrition and health education · Guidance on family welfare, ARSH, child care · Life Skills Education and accessing public services · Vocational training (16-18 year olds only) In-school girls 11-18 years · Nutrition and health education · Guidance on family welfare, ARSH, child care · Life Skills Education and accessing public services Table 1. Snapshot of Government Schemes for Anaemia Control (adapted from UNICEF, AdolescentAnaemiaControlProgramme,2013 ) 17 UNICEF, Addressing Anaemia among Adolescent Girls in Odisha, March 2013 17 15
- 28. RATIONALE FOR NIPI PROCESS DOCUMENTATION IN ODISHA The NIPI programme was designed to weave together the previous schemes to control anaemia according to a comprehensive strategy across the life cycles (children under 5 years, young school children, adolescents in and out of school, pregnant and lactating women, and WRA who are not pregnant or lactating). NIPI also incorporates both preventive and therapeutic approaches to controlling anaemia. The guidelines clearly articulate the modalities for and formulations of iron folicacid(IFA)supplementationtobeprovidedtobeneficiariesthroughthelifecycle. When theWIFS portion of the NIPI programme was rolled out in schools and in Anganwadi Centres (AWCs) for adolescent girls out-of-school, many states reported complaints of IFA side effects. Administration of WIFS was suspended after the first dose in Haryana and Delhi. When it was re- launched several months later, UNICEF systematically tracked the complaints over 3 weeks and 3 weekly doses. The vast majority of those with side effects had not taken their IFA supplement with a meal or snack or with water, and many had chewed their tablet. As the WIFS portion of the NIPI programmewentforward,swallowingIFAtabletswithfoodandwaterwereemphasised. Nearly three years after the launch of WIFS/NIPI and the re-emphasis of taking IFA with food and water, the process documentation was envisioned to investigate in March-May 2016 whether NIPI was being implemented well and in which aspects was there still room for improvement. Odisha waschosenbecauseitwasaforerunnerofNIPIimplementationamongthestates,andalsobecause theprevalenceofanaemiaandsevereanaemiaareveryhigh,deservingattention(Tables2-3). 18 Table2.PrevalenceofanaemiainOdisha accordingtoagegroupanddistrict(AHS2014 ) 19 Odisha Keonjhar Jagatsinghpur Bhadrak Kalahandi 6-59 mo 70.8 79.9 76.1 72.3 74.3 5-9 yr 81.2 93.5 87.2 79.3 78.6 10-17 yr, male 70.5 82.3 83.3 73.0 67.8 10-17 yr, female 78.4 89.5 88.1 79.0 81.6 18-59 yr, female 77.7 88.6 84.3 79.5 76.6 18 19 UNICEF.Incidenceanddeterminantsofundesirableeffectsfollowingironandfolicacidsupplementation:Evidencefrom the Weekly Iron and Folic Acid Supplementation Programme for Adolescents in Delhi and Haryana. Nutrition Reports, Issue3,NewDelhi:UNICEF,2014. (AHS).Clinical,AnthropometryandBiochemical(CAB)Factsheet,Odishasection,2014. AnnualHealthSurvey 16
- 29. Table 3. Prevalence of severe anaemia in Odisha according to age group and district (AHS 2014 ) 20 Odisha Keonjhar Jagatsinghpur Bhadrak Kalahandi 6-59 mo 0.2 0 --- 0 0 5-9 yr 3.3 --- 8.8 6.1 3.0 10-17 yr, male 2.4 --- 5.4 8.1 1.8 10-17 yr, female 3.1 2.6 5.0 8.4 2.0 18-59 yr, female 3.1 2.4 6.3 6.8 2.3 Therefore, the Department of Health and Family Welfare, Government of Odisha, in partnership with UNICEF aimed to review the current implementation status of childhood, adolescent and pregnant and lactating mothers' anaemia components of NIPI in the state, with the purpose of documenting the successes, challenges, bottlenecks, lessons learned and making concrete recommendations for future actions. It is envisaged that the process document will serve as a robust resource and provide an in-depth understanding of the qualitative aspects of the implementationofanaemiacontrolstrategiesinOdisha,elucidateconcreterecommendationsand aid replication and scaling up of the intervention within the state and in other parts of the country. In addition, it will help Odisha identify and eliminate flaws in the implementation, decrease costs, betterallocateresources,improvetheefficiencyandoverallqualityoftheInitiative. Theobjectivesoftheprocessdocumentationareto: 1. Document key state and district experiences in implementing the NIPI programme in Odisha,focusingonunderstandingtheprocurementprocess,supplychainanddistribution management, coordination among stakeholders, planning, training, social mobilisation and communication efforts, including in response to adverse effects, compliance, and monitoringandsupervisingtheimplementation. 2. Document the critical success factors, challenges, bottlenecks and lessons to ensure effectiveandsustainableprogrammeimplementation,includinginhard-to-reachareas. 3. Exploretheprogrammaticlapsesthatcanbeavoidedtoimproveprogrammeperformance. 4. Compile recommendations for future actions to ensure demand generation and high coverage. Objectives 20 Annual Health Survey (AHS). Clinical, Anthropometry and Biochemical (CAB) Factsheet, Odisha section, 2014. 17
- 30. NIPI PROGRAMME GUIDELINES NIPI Operational Guidelines direct the implementation of the supplementation programme as follows and summarised inTable 4. The main components are administering the IFA supplements and administering the deworming medicine, the guidelines for which are described below.Two set of behaviours are also related to the NIPI programme: increasing hygienic practices to prevent worms and dietary practices to enhance iron intake. Results on promoting these are discussed in theSocialMobilisationsection. Guidelines for children 6 months-5 years are: Children are to receive 1ml of IFA syrup containing 20mg elemental iron and 100 mcg of folic acid twice each week in the year, onTuesdays and Fridays from a 50 ml bottle with an auto-dispenser half hour after eating, with Accredited Social Health Activists(ASHAs) or AWWs telling the benefits and warning of minor side effects such as black stools. Auxiliary Nurse Midwives (ANMs) are to demonstrate the dispensing technique and give the first dose, then turn the bottle over to the mother in the case of children 6 mo – 3 yr and to the AWW in the case of children 3-5 yr. IFA syrup is to be given to children 6 months-3 years with supportfromtheASHAanditsconsumptionnotedontheMaternalandChildProtectionCard(MCP) card, whereas AWWs are to ensure a supervisory dose of IFA syrup for children 3-5 years, typically after the ICDS meal at the AWC (Women and Child Development (WCD) Guidelines) . Prophylaxis with iron should be withheld in case of acute illness (fever, acute diarrhea, pneumonia, etc.), severe acutemalnutrition,knowncasesofhaemogobinopathy,orrepeatedbloodtransfusions. 21 22,23,24 25 26 Administering IFA Supplements Children 6Months-5Years 21 22 23 24 25 26 GuidelinesforControlofIronDeficiencyAnaemia:NIPI,NRHM,2013 Ibid OperationalGuidelinesforHealthDept.onNIPIProgramme,Odisha,30November2015. OperationalGuidelinesforWCD.OdishaonIFAsupplementationwithDeworming,30November2015. 50mlbottlesofIFAsyruparecalledforintheEnclosuretoanMHFWletterof1stOctober2014.Previously,accordingto the2013GuidelinesforControlofIronDeficiencyAnaemia,100mlbottlesweremandated. Regarding who administers the IFA syrup to children 6 months – 3 years, a DFW letter of April 2014 said that “mother/caregiver is to administer 1 ml IFA syrup to the child and ASHA would facilitate compliance through home visits beweekly”(Directorate of FamilyWelfare letter, 2 April 2014, Subject Distribution of IFA (blue) large & small tablets andIFASyrupunderIronPlusInitiative),whereasthemorerecentOperationalGuidelinesforHealth,30November2015 saysonlythat“ASHAtosupportforadministration”ofIFAtothisagegroupbutnotspecifyingwhoadministers. 18
- 31. Adolescents 10-19 Years Guidelines for implementing NIPI among adolescent girls and boys in secondary school are: They are to receive one IFA large blue tablet containing 100 mg elemental iron and 500mcg of folic acid once per week on Mondays by teachers at their schools. Teachers are to consume an IFA tablet each week along with the students). Prophylaxis with iron should be withheld in case of acute illness (fever, acute diarrhea, pneumonia, etc.), severe acute malnutrition, and known cases of haemoglobinopathy or repeated blood transfusions. During the school holidays tablets will be provided to the students with counseling for consumptionathome. Guidelines for adolescent girls out-of-school (ages 10-19) and girls in junior college (Standards 11- 12, ages 16-19) are: Girls 10-19 not in school or in junior college are to receive the same large blue tablet containing 100 mg elemental iron and 500mcg of folic acid once per week on Saturdays by AWWs at the AWC, who also inform about the benefits and warning of minor side effects such as blackstools. 27,28 29 27 28 29 GuidelinesforControlofIronDeficiencyAnaemia:NIPI,NRHM,2013 Operational Guidelines for Weekly Iron & Folic Acid supplementation in Schools, Odisha, 30 November 2015 and OperationalGuidelinesforWCD.OdishaonIFAsupplementationwithDeworming,30November2015 Implementation of IFA blue tablets to adolescent children in Standards 6-10 were investigated in this process documentation, but not IFA pink tablets to children in Standards 1-5 because the implementation of this component of the NIPI programme was at a nascent stage when the process documentation was conducted. It is hoped that many lessonsfromimplementationamongtheadolescentscouldapplytotheyoungerstudents. 19
- 32. Table 4. Administering IFA supplementation across the life cycle Life cycle & age group Department responsible for distribution IFA dose Frequency of dose Where taken & stored Who gives Children 6mo-3yr Health 1 ml syrup, 20mg elem Fe, 100mcg FA** 2x/wk, Tues/Fri Home ASHA supports administration Children 3-5yr ICDS 1ml syrup, 20mg elem Fe, 100mcg FA** 2x/wk, Tues/Fri AWC AWW Children 5-10yr in school (Std 1-5)* Education Pink tablet, 45mg elem Fe, 400mcg FA 1x/wk, Mon School Teacher Adolescents 10-19yr in school (Std 5-12) Education Large blue tablet, 100mg elem Fe, 500mcg FA 1x/wk, Mon School Teacher Adolescents 10-19yr on school holiday Education Large blue tablet, 100mg elem Fe, 500mcg FA 1x/wk, Mon Home Self Adolescents 10-19yr out-of- school ICDS Large blue tablet, 100mg elem Fe, 500mcg FA 1x/wk, Sat AWC AWW Pregnant Women Health Red tablet, 100mg elem Fe, 500mcg FA Daily Home Self Lactating Women Health Red tablet, 100mg elem Fe, 500mcg FA Daily Home Self WRA* Health Red tablet, 100mg elem Fe, 500mcg FA 1x/wk Home Self *ThislifecyclegroupnotreviewedinthisreportbecauseIFAdistributiontothemwasnascentorhadnotbegun **At beginning of NIPI programme, IFA syrup was dispensed from 100ml bottles; per guidelines in October 2014,bottleswereintendedtohaveonly50mlofIFAsyrup 20
- 33. Pregnant and Lactating Women (PLW) The guidelines for non-anaemic pregnant women are that they should receive daily IFA red tablets for 180 days (1 tablet per day for the 30 days of each month, for the 6 months of the 2 and 3 trimesters).They should also take 180 tablets during the first 6 postnatal months of lactation.When women are anaemic (haemoglobin (Hb)<11.0), they should double the daily dose, during pregnancyandduringlactation(MinistryofHealth&FamilyWelfare(MoHFW)letter,19Nov2014 ). If anaemic throughout, this means they would consume a maximum of 720 IFA red tablets, 360 during pregnancy and 360 during early lactation.The guidelines for 180/360 tablets were issued in late 2014 after NIPI began. Beforehand, 100 tablets were recommended during pregnancy and 100 duringlactation,200eachifwomenwereanaemic. AsapartoftheNIPIprogramme,albendazoledewormingmedicineisdistributedthroughthesame venues as IFA syrup and tablets, and distributed to most of the same beneficiaries (Table 5). Pregnantandlactatingwomendonotreceivealbendazole,andyoungchildrenstartbeinggivenat 1yr,notat6moaswiththeIFA.Thedosesaregiventwiceperyeartoallthebeneficiaries,sixmonths apart. Beneficiaries receive 400 mg each time, except children 1-2 years old, who receive 200 mg. Children1-5yearsoldreceivealbendazoleinsyrupform,andothersastablets. nd rd 30 Administering Deworming Medicine Life cycle & age group Department responsible for distribution Albendazole dose Frequency of dose Where taken & stored Who gives Children 1-2yr Health and ICDS 5ml syrup, 200mg 2x/yr RI site/ AWC ANM & AWW Children 2-5yr Health and ICDS 10ml syrup, 400mg 2x/yr RI site / AWC ANM & AWW Children 5-10yr in school (Std 1-5)* Education Tablet, 400mg 2x/yr School Teacher Adolescents 10-19yr in school (Std 5-10) Education Tablet, 400mg 2x/yr School Teacher Adolescent girls out-of-school ICDS Tablet, 400mg 2x/yr AWC AWW Pregnant Women ---- ---- ---- ---- ---- Lactating Women ---- ---- ---- ---- ---- WRA* Health Tablet, 400mg 2x/yr Home ASHA Table 5. Administering albendazole across the life cycle *This life cycle group not reviewed because IFA distribution was nascent or had not yet begun by March-May 2016. 30 Ministry of Health and Family Welfare (MHFW) letter, 19 Nov 2014, Subject: Revised Operational strategy for the Oral IronforPregnantWomen-reg. 21
- 34. Indenting, Supply Chain And Reporting SummarisedfromthesamesetofOperationalGuidelinesasreferencedabove,thefollowingarethe recommended channels for supply chain, and reporting IFA consumption within the NIPI programme. These are compared to the channels and mechanisms in practice as reported by respondentsinResultssections. Health officials' indenting compiled across field level into sector and across sectors into block was describedintheNIPIguidelinesas: IFAredtabletsforPLWand IFAsyrupandalbendazolesyrupforchildren6months-5years(1-5yearsforalbendazole): ANM LHV MOI/C CDMO DFW(copytoMD-NHM) SDMU ICDS officials' indenting compiled across field level into sector and across sectors into block was describedintheNIPIguidelinesas: IFAlargebluetabletsandalbendazoletabletsforout-of-schooladolescentgirls: AWW ICDSSupervisors CDPO DSWO(copytoMOI/C) Education officials' indenting compiled across field level into sector and across sectors into block wasdescribedintheNIPIguidelinesas: IFAlargebluetabletsandalbendazoletabletsforin-schooladolescentgirlsandboys: Headmasters CRCC BEO DEO(copytoBPM) SNO-MDM(copytoCDMO) DFW(copytoMD-NHM) SDMU Healthofficials'NIPIguidelinesfortheirsupplychainperformulationare: IFAredtabletsforPLWandIFAsyrupforchildren6months–5years: SDMU CDMO/DistPharm MOIC ANM ASHA(forCh<3) AndANM AWW(forCh3-5yr) ICDSofficials'NIPIguidelinesfortheirsupplychainperformulationare: IFAlargebluetabletstabletsforout-of-schooladolescentgirls: SDMU CDMO/DistPharm MOIC CDPO ICDSSup AWW Educationofficials'NIPIguidelinesfortheirsupplychainare: Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Indenting Supply Chain 22
- 35. IFAlargebluetabletstabletsforin-schooladolescentgirlsandboys: SDMU CDMO/DistPharm MOIC(copytoDEO) CRCC(copytoBEO) Headmasters(copytoBEO) Health officials' NIPI guidelines for reporting are to compile across field level into sector and across sectorsintoblockasfollows: IFAredtabletsforPLWIFAsyrupforchildren6months-5years: ANM LHV MOI/C CDMO(copytoDSWO) DFW(copytoMD-NHM) ICDS officials' NIPI guidelines for reporting are to compile across field level into sector and across sectorsintoblockasfollows: IFAlargebluetabletsforout-of-schooladolescentgirlsonly: AWW ICDSSup CDPO DSWO(copytoMOI/C) WCDDirector (copytoCDMO) DFW(copytoMD-NHM) Education officials' NIPI guidelines for reporting are to compile across field level into sector and across sectors into block are two-fold, as follows. The first line through the levels in the Education Department was the only guidelines as of November 2015 , and the second line through the levels oftheHealthDepartmentwasaddedviaaDFWletterofDecember2015 . IFAlargebluetabletsforin-schooladolescentgirlsandboys: 1) Headmaster (Health Worker Male added Dec 2015) CRCC BEO DEO (copy to MO I/C) SNO-MDM(copytoCDMO) DFW(copytoMD-NHM),aswellas 2) Headmaster HealthWorkerMale MOI/C CDMO DFW The guidelines for cascade training/capacity building are outlined in the Health Operational Guidelines andspecifythefollowingtrainings: a one-day orientation for district officials of four departments (Health, WCD, S & ME, and ST/SCDevelopment)in-personfacilitatedbystatehealthofficials Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z 31 32 33 Reporting Training â OperationalGuidelinesforWeeklyIron&FolicAcidsupplementationinSchools,Odisha,30November2015 Directorate of Family Welfare letter, 7 December 2015, Subject: Involvement of HW(M) and RBSK Mobile Health Teams(MHTs)instrengtheningNationalIronPlusInitiative(NIPI)interventioninOdisha. 31 32 Operational Guidelines for Health Dept. on NIPI Programme, Odisha, 30 November 2015. 33 23
- 36. â â â a one-day orientation for block officials of the four departments in-person or via training DVDfacilitatedbydistrictofficials orientationthroughmonthlymeetingsandthetrainingDVDforsector/clusterpersonnelby blockofficialsandforfrontlineworkersandheadmastersbysectorpersonnel orientation at school for teachers, School Management Committee (SMC), PTA, and the schoolANMbyheadmasters The monitoring expectations are also listed in the Health Operational Guidelines -- from officials from the state to the sector/cluster level in terms of visits per geographic unit (e.g., district, block) per month to AWCs and schools (but visits toVillage Health and Nutrition Daysettings (VHNDs) and homes are not listed)(Table 6). The Health Department is responsible for monitoring WCD and Education sites, whereasWCD and Education are responsible to visit sites only in their department. Monitoring checklists are available for the visits for each level and regarding both AWCs and schools. Monitoring Table 6. Guidelines for monitoring the NIPI programme from state to sector/cluster levels Level Department Persons monitoring Frequency of monitoring (# visits) State Multiple SIMT with DHFW, SNO-MDM & SC/ST Nodal Officer 10 districts/mo to see 2 AWCs & 2 schools ea District Health ADMO-FW, DPM, DMRCH, Asst Mngr ASHA, DPHCO, ADPHCO, DPHNO, RBSK Team 4 block-visits/mo to see 4 AWCs, 4 S&ME schools, and 2 SC/ST schools across the 4 blocks WCD DSWO, Programme Officer 4 block-visits/mo to see 8 AWCs Education S&ME DEO, DPC-SSA 4 block-visits/mo to see 8 schools Education SC/ST DWO, ADWO 4 block-visits/mo to see 2 schools Block Health MO I/C, BPM, PHEO 2 sector/cluster-visits/mo to see 2 AWCs, 2 S&ME and 1 SC/ST schools WCD CDPO 2 sector-visits/mo to see 4 AWCs Education S&ME BEO 2 clusters/mo to see 4 schools 24
- 37. Education S&ME BEO 2 clusters/mo to see 4 schools Education SC/ST Education SC/ST Welfare Extension Officer Welfare Extension Officer 2 clusters/mo 2 clusters/mo to see 2 schools to see 2 schools Sector/ Sector/ Cluster Cluster Health Health LHV, MPS LHV, MPS 2 field visits/mo 2 field visits/mo to see 4 AWCs, 4 S&ME and 1 to see 4 AWCs, 4 S&ME and 1 SC/ST schools SC/ST schools WCD WCD ICDS Supervisors ICDS Supervisors 2 field visits/mo 2 field visits/mo to see 8 AWCs to see 8 AWCs Education S&ME Education S&ME CRCCs CRCCs 2 2 field visits/mo field visits/mo to see all schools in their cluster to see all schools in their cluster TherapeuticApproachtoAnaemiaReduction–Treatment,ReferralandFollow-up The therapeutic approach complements the supplementation approach to make higher amounts of IFA available to those throughout the life cycle who are anaemic according to their degree of anaemia – mild, moderate, severe (Tables 7-9).Therapeutic treatment is daily, with follow-up every 14 days or month, and referral to the First referral unit/District Hospital (FRU/DH) in the cases of severeanaemiaandifanaemiaisnotcorrectedin2-3monthsofdailytreatment. The limitation to this therapeutic approach is that Hb concentration is only assessed among pregnant and lactating women, or if children and adolescents are taken to a health centre for an assessment. A health centre visit for mild or moderate anaemia is unlikely. School children and adolescents are only assessed in school by a visual assessment of pallor, which detects only severe anaemia.Andchildren6months–5yearsarenotroutinelyassessed. 25
- 38. Table 7. Management of anaemia based on heamoglobin levels in children 6 months – 10 yr* Hb level Treatment Follow-up Referral No Anaemia (>11 g/dl for ch 6mo-5yr; >11.5 g/dl for ch 5-10 yr) For children 6 mo-5 yr, 20 mg elemental iron and 100 mcg folic acid (FA) 2x/week For children 5-10 yr, 45 mg elemental iron and 400 mcg FA 1x/week Mild Anaemia (10-10.9 g/dl for Ch 6mo-5yr; 11-11.4 g/dl for Ch 5- 10yr) 3 mg iron/kg/day for 2 mo ANM follows up every 14 d Hb reassessed after 2 mo If Hb not responded in 2 mo, refer to FRU/DH with physician Moderate Anaemia (7-9.9 g/dl for Ch 6mo-5yr; 8-10.9 g/dl for Ch 5-10 yr) 3 mg iron/kg/day for 2 mo ANM follows up every 14 d Hb reassessed after 2 mo If Hb not responded in 2 mo, refer to FRU/DH with physician Severe Anaemia (<7 g/dl for Ch 6mo-5yr; <8 g/dl for Ch 5-10 yr) Refer urgently to FRU/DH** *adapted from Guidelines for Control of Iron Deficiency Anaemia: NIPI, National Rural Health Mission(NRHM),2013 **See the Guidelines for detailed assessment and treatment at the FRU/DH in the case of severe anaemia Table 8. Management of anaemia based on haemoglobin levels in adolescents 10-19 years Hb level Treatment Follow-up Referral No Anaemia (>12 g/dl 100 mg elemental iron and 500 mcg FA 1x/week Mild Anaemia 11-11.9 g/dl 60 mg/ day elemental iron for 3 mo Follow-up every month; Hb reassessed after 3 mo If Hb not responded in 3 mo, refer to FRU/DH with physician Moderate Anaemia 8-10.9 g/dl 60 mg/ day elemental iron for 3 mo Investigate; Follow-up every 14 days; Hb reassessed after 3 mo If Hb not responded in 3 mo, refer to FRU/DH with physician Severe Anaemia <8 g/dl Refer urgently to FRU/DH** *adapted from Guidelines for Control of Iron Deficiency Anaemia: NIPI, NRHM, 2013 **See the Guidelines for detailed assessment and treatment at the FRU/DH in the case of severe anaemia 26
- 39. Table 9. Management of anaemia based on haemoglobin levels among pregnant and lactatingwomen* 27 Haemoglobin level Level of facility 9-11 gm/dI 7-9 gm/dI Therapeutic regimen Sub-centre Signs and symptoms (generalised weakness, giddiness, breathlessness, etc.) Clinical examination (pallor eyelids, tongue, nail beds, palm, etc.) Confirmation by laboratory testing PHC/CHC Signs and symptoms (generalised weakness, giddiness, breathlessness, etc.) Clinical examination (pallor of eyelids, tongue, nail beds, palm. etc.) Confirmation by laboratory testing Hblevelbetween9-11gm/dI l l l 2 IFA tablets (1 in the morning and 1 in the evening) per day for at least 100 days (at least 200tabletsofIFA). Hb levels should preferably be reassessed at monthly Intervals. If on testing. Hb has come up tonormallevel,discontinuethetreatment. If it does not rise in spite of the administration of 2 tablets of IFA daily and dietar y supplementation, refer the woman to the next higherhealthfacilityforfurthermanagement. Hblevelbetween8-9gm/dI Hblevelbetween7-8gm/dl l l l l l l l Beforestartingthetreatmentthewomenshould beinvestigatedtodetectthecauseofanaemia. Oral IFA supplementation as for Hb level 9-11 gm/dl. Hbtestingtobedoneeverymonth. Depending on the response to treatment same course of action as prescribed for Hb level between9-11gm/dl. Beforestartingthetreatmentthewomanshould be investigated to diagnose the cause of anaemia. Injectable IM iron preparations (parenteral iron) should be given if iron deficiency is found to be thecauseofanaemia. IM iron therapy in divided doses along with oral folic acid daily if women do not have any obstetric or systemic complication; repeat Hb after 8 weeks. If the woman has become non- anaemic,nofurthermedicationisrequired:IfHb level is between 9-11 gm/dl, same regimen of oralIFAprescribedforthisrange. If women with Hb between 7-8 gm/dl comes to PHC/CHC in the third trimester of pregnancy, refertoFRU/MCformanagement.
- 40. * Source: Guidelines for Control of Iron Deficiency Anaemia: NIPI, NRHM, 2013 28 Haemoglobin level Level of facility <7 gm/dl Therapeutic regimen FRU/DH/MC Signs and symptoms (generalised weakness, giddiness, breathlessness, etc.) Clinical examination (pallor eyelids, tongue, nail beds, palm, etc.) Confirmation by laboratory testing Multipledoseregime Intramuscular(IM)-Testdoseof0.5mlgivendeepIM andwomanobservedfor1hour.Irondextranoriron sorbitolcitratecomplexgivenas100mg(2ml)deep IM in gluteal region daily. Recommended dose is 1500-2000 mg (IM in divided doses ) depending uponthebodyweightandHblevel If parenteral iron theraphy is contraindicated e.g. in C H F, H / O a l l e r g y , a s t h m a , e c z e m a : Haemochromatosis., liver cirrhosis, rheumatold arthritis and acute renal failure etc, refer the woman toFRU/MC Hblevelbetween5-7gm/dI Hblevellessthan5gm/dl l l l l l Continue parenteral iron therapy as for Hb level between7-8gm/dl.Hbtestingtobedoneafter8 weeks If the woman becomes non-anaemic, no further medication is required: If Hb level is between 9- 11 gm/dl, same regimen of oral IFA prescribed forthisrange Depending on the further response to treatment same course of action as prescribed forHblevelbetween9-11gm/dl Evidence for injectable IV sucrose preparation: underRandomisedControlTrialofGOI Immediate hospitalisation irrespective of period of gestation in hospitals where round-the-clock specialist care is available for intensive personalised care and decision for blood transfusion(packedcelltransfusion)
- 41. The process documentation team conducted 170 interviews in March, April and May 2016 among officials and frontline workers at state, district, block, sector/cluster and field levels and among NIPI beneficiaries. To achieve variation in responses, hence as full a set of information on how NIPI was being implemented, process documentation and survey data were collected in four districts -- Keonjhar, Jagatsinghpur, Bhadrak and Kalahandi. The quantitative survey team conducted 4809 surveyinterviewsfromApriltoJuly2016inthesame4districts. To achieve variation in data collected within districts for the process documentation, two blocks each were chosen and interviews conducted in Keonjhar and Jagatsinghpur Districts (Harichandanpur 10-18 March 2016 and Banspal 26-29 April in Keonjhar District, and Raghunathpur 7-12 April and Kujang 18-21 April in Jagatsinghpur District). The documentation team was also prepared to conduct interviews in two blocks each in Bhadrak and Kalahandi, but limited to one block because no new information was being gleaned from interviews (Bhandari PokhariBlockinBhadrakDistrictandLanjigarhBlockinKalahandiDistrict). To understand the scenario of Odisha as a whole, it was decided to take one district from each Revenue Division, so that the regional variation would be well documented. As per the AHS 2012- 13, districts of Odisha were ranked by taking the average percentage of consumption of IFA by mothers (mothers who consumed IFA for 100 days or more) and children (Children, aged 6-35 months, who received IFA tablets/syrup during last 3 months). One district from each Revenue Division, which poorest performance on these indicators was selected for the process documentation. In order to understand the variations among good performing and poor performing districts, the best performing district as per AHS 2012-13 was selected as the fourth district under the study. Thus, the following four districts were selected for the process documentation: 1. BhadrakDistrictfromCentralDivision 2. KeonjharDistrictfromNorthernDivision 3. KalahandiDistrictfromSouthernDivision 4. JagatsinghpurDistrictasbestperformingdistrictinthestate Within the selected districts, one good and one badly performing block were purposively selected. This was done based on inputs from District Collectors, CDMO/ADMO and district officials from otherlinedepartments. STUDY DESIGN Selection of Districts SelectionofBlocks 29 M E T H O D O L O G Y
- 42. In some cases, someone in a position was interviewed once, but deemed not to have much of a role in NIPI or much information about it, and so was not interviewed in all districts or blocks, e.g., Block Data Manager(BDM), Programmer midday meal(MDM), Medical Officer Primary Health Centre(MO PHC), PHC Pharmacist, and private pharmacist. For the others, an effort was made to interview the personsorgroupsinthepositionsineachdistrictandblock. On occasion during an FGD, one participant was asked if the team could ask additional questions individually, as an IDI, either because they spoke up knowledgeably during the FGD, or because they did not say much in the group but seemed to have different opinions, e.g., a teacher, a CRCC, andanAWW. In-depth interviews (IDIs), focus group discussions (FGDs) and observations were the qualitative techniqueschosenfortheprocessdocumentation.Officialsatstate,districtandmanyatblocklevel were interviewed individually during IDIs. Groups of sector/cluster officials, field workers and beneficiaries were interviewed during FGDs. In addition, observations were made of records of IFA distribution at VHNDs, AWCs and schools, as well as the actual distribution of IFA at VHNDs and schools. For the process documentation, respondents were purposively chosen to provide information on the planning and implementation of NIPI from a variety of perspectives – state, district, block and sector/cluster officials, field workers, other stakeholders like fathers, and beneficiaries. There were 170 respondents – 12 state officials, 27 district, 32 block, 16 sector/cluster, 49 field workers, and 34 beneficiaries – with district officials chosen evenly across the four districts, and block and sector officials, field workers, and beneficiaries chosen evenly across the six blocks (Tables 10-15). According to the three Departments jointly implementing NIPI, the most respondents were associatedwiththeHealthDepartment'simplementation(70),thesecondlargestgroupassociated withtheEducationDepartment(55),andthesmallestgroupfromtheICDSDepartment(35),aswell as10others. SAMPLING Qualitativesurvey 30
- 43. Table 10. State-level Respondents for Process Documentation (all IDIs) Title State Sub-total state State-Health 8 HFW Principal Secretary X NHM Joint Technical Director X OSMCL (MD, GM Logistics, IT Manager e-Aushadi) 3 NIPI Consultants to UNICEF/GOI 3 State-ICDS 2 WCD Commissioner-cum-Secretary X X State-Education 2 S&ME Secretary X SNO MDM X Sub-total State 12 12 Table 11. District Respondents for Process Documentation (all IDIs) Title Keonjhar Jagatsinghpur Bhadrak Kalahandi Sub-Total District District-Health CDMO X 1 DMRCH a/o DPM X X X X 4 Dist Pharmacist X X X X 4 District-ICDS DSWO a/o PO X X X 2 5 District- Education DEO X X X 3 DPC-SSA X 1 DWO X X X 3 Programmer MDM X 1 Other DM-Collector X X X X 4 Zila Parishad member X 1 Sub-Total District 6 7 6 8 27 31 Joint Secretary ICDS
- 44. Table 12. Block Respondents for Process Documentation (IDIs and FGDs) Title Keonjhar Jagatsinghpur Bhadrak Kalahandi Sub- Total Block Harichandanpur Banspal Raghunathpur Kujang Bhandari Pokhari Lanjigarh Block-Health MO I/C (IDI) X X X 3 BPM (IDIs) (FGDs) X X X X X 5 RBSK Team (FGDs) X X X X X X 6 Block Pharmacist (IDI) X X X X X X 6 BDM (IDI) X 1 Block-ICDS CDPO (IDI) X X X X X X 6 Block- Education BEO a/o ABEO (IDI) X X X X X 5 Sub-Total Block 6 4 6 5 6 5 32 Table 13. Sector/Cluster Respondents for Process Documentation (FGDs and IDIs) Title Keonjhar Jagatsinghpur Bhadrak Kalahandi Sub- Total Sector/ Cluster Harichandanpur Banspal Raghunathpur Kujang Bhandari Pokhari Lanjigarh Sector-Health MO PHC AYUSH (IDI) X 1 PHC Pharmacist (IDI) X 1 Sector-ICDS ICDS Supervisors (FGDs) X X X X X X 6 Cluster- Education CRCC (IDIs) (FGDs) X X 2 X X X X 8 Sub-Total Sector/Cluster 4 2 3 2 2 3 16 32
- 45. Table 14. Field Level Respondents for Process Documentation (FGDs, IDIs and observations) Title Keonjhar Jagatsinghpur Bhadrak Kalahandi Sub- Total Field Harichandanpur Banspal Raghunathpur Kujang Bhandari Pokhari Lanjigarh Field-Health ANMs (FGDs) X X X X X X 6 ANM in school (IDI) X 1 ASHAs (FGDs) X* X X X X X 6 Private Pharmacist (IDI) X 1 VHND Obs (obs) X X X 3 Field-ICDS AWWs (FGDs) (IDI) X X X X X X X 7 AWC Records (obs) X 1 Field- Education Teachers (FGDs) (IDI) X X X X X X 2 8 Headmaster (IDI) X 1 SMCs (FGDs) X X X X X 2 7 School Records/IFA distribution (obs) X X X 3 Other Fathers (FGDs) 2 X X X 5 Sub-Total Field 11 7 9 8 5 9 49 *ASHA Facilitators 33
- 46. Table 15. Beneficiaries for Process Documentation (all FGDs) Title Keonjhar Jagatsinghpur Bhadrak Kalahandi Sub- Total Benef’s Harichandanpur Banspal Raghunathpur Kujang Bhandari Pokhari Lanjigarh Beneficiaries- Health PLW X X X X X X 6 Mother w. ch <5 yr 2 X X X 2 7 Beneficiaries- ICDS Adolescent Girls Out-of- School 2 X X 2 X X 8 Beneficiaries- Education Adolescent Girls in School X X X 2 X X 7 Adolescents Boys in School X X X X X X 6 Sub-Total Beneficiaries 7 5 5 7 4 6 34 Quantitative Survey Alinelistofallthesubcentresfromwithintheselected8blocksin4districtswasprepared.Fromthis were selected 50 sub-centres using probability proportionate to size (PPS) sampling method. Figure 1 shows the distribution of samples selected for the facility survey and the stakeholder interviews. 34
- 47. Figure 1. Sample selection and size for the quantitative study 35 CHC-8 (@ 2 blocks/District) PHC-24 (@ approx 2 sectors per block) Sub-centre-50 (@ approx. 2 SC per sector) Facility survey Sample size VHND sites - 48 (@ approx. One per sub centre) Schools - 99 AWC - 90 (@ approx. 2 per sub centre) From each selected sub centre Stakeholders were chosen for beneficiary and provider interviews as shown below ASHA-235 ANM-39 ANM-39 Pregnant women-786 Women 15-45y-800 Lactating mother-788 Adolescent Girls-800 AWW-245 Adolescent Boys-800
- 48. For choosing respondents within each sub-center, the sample of 800 was divided among 50 subcentres,16respondentsineachsubcentre.Foreg.iftherewereeightvillagesinasubcentre,two girls from each village were chosen. For random selection, a bottle was spun at the center of the village to determine the direction in which to walk. Households were checked until one with an adolescent girl in residence was encountered. If there were more than two persons in the same house, KISH method was used to select one of these randomly and the next adjacent house was visited to recruit the second respondent. This process was repeated for adolescent boys andWRA, whereas pregnant and lactating women were chosen randomly from the line list available from the frontlineworkerofthatvillage. The team reviewed a broad range of background documents and national/state level letters outlining aspects of the NIPI programme. In addition, a state inception meeting was held on 8 March 2016 in Bhubaneswar to launch the NIPI process documentation. Representatives of District Collectors and Chief District Medical Officers (CDMOs) from the four districts provided district contextonanaemiaandimplementationoftheNIPIprogrammetodate. Data collectors had either a Master's degree in public health or in social work. A 6-day phase-wise training was provided to them in qualitative and quantitative methods through workshops, group works, and field exposure. Data collectors were taught cluster sampling methods, techniques forqualitative and survey-based interviews, Hemocue 201 for Hb estimation, and Epidata entry software for data entry. Supervisory visits were made to retain quality throughout the data collectionperiod. Questionnaires for the quantitative survey were prepared by the research team, translated in the vernacular, and validated in the field. Separate questionnaires were developed for adolescent girls, PREPARATORY ACTIVITIES RECRUITMENT AND TRAINING OF DATA COLLECTORS DEVELOPMENT AND PRETESTING OF INTERVIEW QUESTIONS AND TOOLS 36
- 49. adolescent boys, WRA, pregnant and lactating women, and frontline workers. Facility survey formats for various platforms of delivery of IFA interventions and treatment of anemia like health centres,schools,andVHNDwerealsodevelopedandimplemented. The process documentation protocol was approved by the ethical committee of AIIMS Bhubaneswar. Informed consent was taken from all the study participants. Confidentiality was maintained. All those detected with anemia were advised to visit the nearest health centre or AIIMS forfurthermanagement. For the process documentation, the plan for one day's interviews was made the evening before as part of the review of that day's interviews. As often as possible, the plan would include officials/frontline workers from the Health, ICDS and Education Departments, as well as beneficiaries. Once the plan was complete, the documentation team would visit or phone officials toarrangeappointmentsandtogivecriteriaforfocusgroupparticipantstobeinvited. IDIs were conducted in private with respondents, usually in offices, sometimes outside in a private setting. FGDswereconductedamongagroupofsimilarpeople,i.e.withouttheirserviceproviders, their supervisors or elders in the community who could influence their responses. Groups were planned to be a maximum of 12 people, and sometimes grew to 15. If a group was initially not homogeneous enough or was too big, FGD facilitators politely asked some to leave, explaining the purpose and method of the FGD. IDIs and FGDs were held for a maximum of 60 minutes. ObservationsweretypicallyarrangedbyonepersonattheVHND,AWCorschool.Picturesofrecords weretakenandnotesonactualservicedeliveryweremade. FGDswereconductedprimarilyinOdia,sometimesinHindiiftheFGDfacilitatordidnotspeakOdia, and occasionally in a tribal language. IDIs were conducted primarily in Hindi or Odia, sometimes in English. Interviews were conducted up to four days per week.Typically two teams would each conduct 3-4 interviews (combination of FGDs and IDIs) in a day. Several days were devoted to interviewing state officials because they were in Bhubaneswar, some distance from the districts. Similarly, days were devoted to interviewing districts officials in the district headquarters town. Sometimes days were devotedtointerviewingblockofficialsandsometimesblockofficialswereinterviewedonthesame day as officials and workers at sub-centre/cluster, frontline and beneficiary interviewees, dependingonthedistancesbetweenlocations. Every evening at the end of interview days, the team of interviewers met to review results and list questions that emerged to be asked during future interviews. Also discussed in the review setting were how to follow-up on and resolve any responses that lacked credibility – for example, any ETHICAL APPROVAL AND INFORMED CONSENT DATA COLLECTION AND QUALITY ASSURANCE QualitativeSurvey 37
- 50. respondents suspected of giving the “right answer” or the answer respondents thought the interviewers wanted to hear – as well as responses that seemed to differ markedly among interviewees. Thequantitativesurveycomprisedoftwoportions,thefacilitysurveyandstakeholderinterviews. The following were interviewed: Medical Officer in-charge (MO I/C) or Block Programme Managers (BPMs) at Community Health Centres (CHCs), MO PHCs, ANMs at subcentres, headmasters or nodal teachers at schools, AWWs in AWCs, ANMs at VHND sites. Also observations were recorded using facilitychecklistspreparedinthedepartment. As per the sample size calculations for cross-sectional studies, assuming prevalence of anemia as 50%,DEFFof2and4%non-response,thesamplesizeshouldbe800eachfor4beneficiariesnamely adolescent boys and girls, and pregnant and lactating women. In addition 800 WRA were chosen as eventually the programme would be rolled out among them and since 50% reduction in anemia in WRA is also one of the nutritional targets to be achieved globally by 2025 compared to anaemia prevalence in 2011. The ANMs of selected sub-centres and ASHA/AWW of selected villages were approached within the subcentre for interviews using a pretested and semi- structured interview schedule.Hemocue201wasusedtoestimateHblevelsofadolescentgirls,boys,WRA,pregnantand lactatingwomen,andfrontlineworkers. The members of the survey team were trained in conducting interviews, handling HEMOCUE 201, and using EPIDATA for data entry. Supervisory visits were paid by the investigators frequently to identify errors and take early corrective actions. At the end of every day debriefing meetings were held among the survey staff to manually check the proformas for any missing data and collect it the nextdayfromtherespondents,andtroubleshootasneeded. Forthequalitativesurvey,mostinterviewsweretaperecordedandtheelectronicaudiofilelabelled with date, time, position (e.g., Block Programme Manager, ASHAs, teachers), and place and type of interview (FGD, IDI or observations). Records about each interview were made each data collection day in an Excel file to manage the data. Sets of interview files were sent for transcription and translationintoEnglish,andastheywereprocessed,thefilenamewasretained.Initially,noteswere taken of IDIs by two rapporteurs instead of recordings, and the notes written up and cross-checked by the interviewers during the evenings of data collection.This proved to be too time-consuming, however,andafterthefirstblockofinterviews,allwererecorded. QuantitativeSurvey Facility Survey Stakeholder Interviews Quality Assurance DATA CLEANING, ENTRY, AND MANAGEMENT 38
- 51. For the quantitative survey, Epidata 3.1 was used for data entry. Checks were built in to avoid errors while entering the data. After completion of data entry, Excel files were examined for any missing dataorincorrectentriesandverifiedagainstrecords. The English translated transcripts were entered into the Nvivo qualitative research software programme. All the interview text was read and coded (highlighted and marked) according to the 15 main topics of the interviews (Box 1). Some text was coded formultipletopics,asrelevant. Text on each topic was read and analyzed, categorizing quotes and notes of emerging themes and searching for variations among the levels from state to beneficiaries, among the Health, ICDS and Education Departments, and according to other variables. The analysis was largely descriptive, reviewing text by theme for patterns, consistencies and inconsistencies. When required for clarity, responses by category were counted, though reported only as “most”, “many”, “some” because the respondents were purposively chosen, or were therefore not representative of the larger population. Material for report sections was distilled from the detailed analysis text. All coding and analysiswasconductedbyoneteammember. The title and district/block of each person was noted with their quote or note, but not used as specifically in the write-up of analysed results to protect confidentiality. The order of districts and blocks was varied when reviewing coded material from respondents for each topic. Since more quotes and information were inevitably used from coded material from the first block reviewed, with repetition in successive blocks, this ensured that no one block dominated materialcontributedtotheresults. DATA ANALYSIS QualitativeSurvey 39 Box 1. Topics for Qualitative Coding and Analysis IFA administration & compliance Social mobilisation Procurement & supply chain Diagnosis, treatment, referral Supportive supervision & monitoring Adverse effects & emergency response Recording & reporting Coordination - government Coordination - stakeholders Deworming & other programme components Training Political commitment Microplanning Hard-to-reach areas Distribution
- 52. The nature of the qualitative and quantitative data collection was different and complementary, the qualitative seeking to describe the perceptions of the respondents about the NIPI programme and its implementation, and the quantitative seeking to count the extent of certain outputs and outcomes. The qualitative and quantitative results are largely reporting on separate findings, but theyarecomparedwhentheyreportonsimilarvariablesortopics. Data were analyzed using Microsoft Excel. Continuous data was summarized using mean (SD) and Median(IQR),andcategoricaldatawaspresentedasfrequencies. QuantitativeSurvey 40
- 53. 41 1. POLITICAL COMMITMENT AND OWNERSHIP Many officials and frontline workers expressed strong political commitment to increasing coverage and strong service delivery of the NIPI programme – from all levels, state to field; all three Departments, Health, ICDS and Education; and all districts. Presented below are the types of comments made by respondents indicating political commitment to the NIPI programme by Department, followed by a few comments indicating lack of political commitment, for contrast. Comments tended to fall into categories of feeling pride in progress made, describing successful ways to mobilise beneficiaries and others, and for senior health officials issuing key government lettersorembracingnewgovernmentstrategies. Three senior health officials mentioned the programme clarity that can result from a government- issued letter or strategy. An Odisha State Medical Corporation Limited (OSMCL) official said that a “Letter has been sent from Commissioner cum Secretary, S&ME Department to each District Education Officer (DEO) and Block Education Officer (BEO) for monitoring the program at school for betterment of NIPI function at school.”A DMRCH described that political commitment can be built sometimes by just getting the paperwork straight so people feel comfortable.“We talked on report [in convergence meeting]. We talked on 100% implementation… There will be one letter sent for report collection”. And a district health official said that:“Now the government of Odisha is going to have a new programme… to facilitate the reduction of IMR-MMR, a strategy has been developed. Kalahandi is one of the districts. And one of the most important interventions is the strengthening of VHNDsites.” Several sets of ASHAs showed their ownership through their pride of progress of their work in the communities. One group of ASHAs said: “Many changes took place after the posting of ASHAs. ASHAs make the maximum home visits. Even children call us to go to their houses. Now nobody is interested for more than 2 children. I have joined for 7 years and since my joining I have not seen a maternaldeath.Wedon'thavehomedeliveryatallnow.” BPMs, ANMs and ASHAs spoke of the hard work and accomplishments from mobilizing participationinNIPIthroughouttheircommunities.ABPMsaidaboutteachersthat:“Atsomeplaces they don't cooperate. Most of the time when we go to school, we find that maximum 10% teachers don't cooperate. We have to sensitize them. They say that guardians will not agree. Consuming these medicines may create some harm. We mobilise them by telling that we are here, keep our number and call us if there is any requirement. We tell them that the CHC is here to support you”. A group of ANMs said: “According to case we provide counseling. We are trying in different ways to makethemunderstand.Wearedoingitnonstoptojustinvolvethemintheprocess.”Anothergroup HEALTH R E S U L T S
- 54. 42 of ANMs praised ASHAs in their mobilizing role:“If the programme is running in the periphery, then it's due to ASHA workers. They obey whatever we tell them…We are not able to give time in all the villages…Theyarecallingandinformingusifanythinghappenedtoanypregnantladyoranychild. Wefollowupthecasesthroughthem.Wedoeverythingthroughthem.” The comments of several at ICDS were from block, sector and frontline worker level, expressing prideofprogressoftheirworkinthecommunities.AChildDevelopmentProjectOfficer(CDPO)said that: The AWWs“have never been reluctant in doing any work for ICDS or health. They resist other works given to them by the block or from outside. But they have never complained about any work relatedtoICDSorhealth.” One set of AWWs talked of the progress they have seen over the years, and sentiment that could perhapsbepromotedtogenerateexcitementandfurthercommitment:“Atthattimemothersused tohidetheirchildren.Whenweusedtogoformeasuringweights,theywouldhidethechild.Evenif wegohousetohousetodoit,theywouldsaynothechildisnotathome.Theyusedtohide.Butnow they come to VHND program with their own will to weight the child, and they come like we go to visit someone they dress up so much.They used to not even takeTT properly. Now when it has not evenbeen2-3months,theycomeandaskustomaketheirentry.Sir,isnotthatourVHND'sresult?” The political commitment from Education officials is tinged with the flavor of having recently been persuaded to take up the mantle of Education's role in NIPI. The recent conversion is a recurring themeintheinterviews,i.e.,“Wewereopposingearlier,butwearenotopposingnow…”Comments from the state, district, block, and cluster levels emphasised the importance of mobilizing beneficiaries to participate in NIPI. A state Education official said that the state and district level functionaries those who are responsible for the implementation of the programme were not convinced. So a capacity building programme was planned for them by Government with support of UNICEF. This has changed their outlook towards the programme. In general, NIPI ownership among Education department officials has improved gradually, he said, with 50% of the districts reporting; teachers administering the tablets, and reporting and maintaining records also. He also said the factors responsible are the training programme, constant monitoring, and Video conferencechairedbytheCommissionerofS&ME. A DEO in another district also described mobilising participation: “With the persuasion and instruction of state nodal officer we conducted timely meetings with the BEOs and we had also taken it positively in CRCC meetings. Initially I had observed that programme was not being implementedproperlybutnowitiseffectivelybeingimplementedandisgoingoninalltheblocks.” ICDS EDUCATION
- 55. 43 AlsoaBEOsaidaboutmobilisingNIPIparticipation:“Therewasresistance.Slowlywehavemanaged it. This has been done under the chairmanship of the Block Development Officer (BDO). Medical Officer of our block was there.We called him… Gradually the awareness has been increased.We are conducting two meetings at cluster level. Review is done at CRCC level. We discussed about the practical problems for which the programme was not properly implemented.We used the material of the conference held in Bhubaneswar… Actually in our state the status is low. There is more possibility of anemia for all families, they may be rich or poor. After knowing this we have created awareness. My block and district was one of the defaulters in providing reports. But last year we havebeenabletogivethereports.Nowtheprogrammeisrunningsmoothly.Almostallschoolsare beingcovered.” In addition, a CRCC talked about mobilising efforts to increase participation in NIPI: “The block meeting with the school teachers regarding iron and folic acid supplementation happens every month in two shifts. Every shift has nearly 100 plus teachers.They discuss with school headmasters and block MO PHCs regarding various issues like Swachha Bharat Abhiyan, iron tablet and syrup supplementation,andmiddaymeal….” A DEO and a set of teachers also showed pride in their efforts to expand NIPI participation.The DEO said:“Whenever MDM meetings were conducted in the district, there will be BEOs, DEO and CRCC members, then we will discuss there. I will tell them that 'if it is being provided in all the districts and there aren't any complaints anywhere about children feeling dizzy or anything then why don't we give and why should we be backward. Our district should also move ahead.' I told them this repeatedly.”And teachers expressed that: “We have a feeling that these are our children and they should grow. Health is strongly associated with education. How they can study if they will not stay healthy?Withthismentalitywegivethemedicine.Weareresponsible.” There were also officials who expressed lack of political commitment to increasing coverage and strong service delivery of the NIPI programme – from senior levels, state to cluster; and from all the districts.The type of comments were about Education Department's reluctant participation in NIPI, aswellasoneaboutlackofcommunitysupportandoneaboutlackofgeneralsupport. A DC described that teachers are apprehensive and also have poor clarity regarding the program. So the program is not running well in schools. For the program to run smoothly, the teachers need to be more proactive. But they do not want to take risk. A BEO also complained that NIPI“is a new program.They attach S&ME Department with the Health Department to carry out this program. At stateanddistrictlevelwewereverballytoldaboutit,buttherewasnotrainingforteachers…Hence the technicalities of the program were not properly defined.”And a group of CRCCs said bluntly:“A teacher'sdutyistoteach.Teacher'sdutyisnottomakeallthethingscorrect.” Finally, a general lack of political commitment was expressed by a CDPO who said that the NIPI programmehadnopoliticalencouragementorpoliticalinvolvementbehindit. LACKOFPOLITICALCOMMITMENT
- 56. 44 2. PLANNING AND COORDINATION Explored in this section are elements of the convergence among the Departments of Health, WCD and Education (including ST/SC Development) to carry out the NIPI programme in health care sites, AWCs and schools; as well as coordination with programme stakeholders whose support is crucial to allow NIPI beneficiaries – from young children to school children to women – such as parents, husbands and mothers-in-law, SMC and other community leaders, and NGOs. Finally, the planning conducted by central NIPI implementers is described – mostly by RBSK Teams (Rashtriya Bal SwasthyaKaryakram),severalbyASHAs/AWWs,andoneeachfromateacherandaBPM. Leadership is required for successful coordination and convergence across Health,WCD, Education and ST/SC Development Departments with respect to NIPI, and the respondents in Odisha described leadership for NIPI convergence in a variety of forms at the various levels. At all levels, the HealthDepartmenttakestheroleofandisseenastheleadagencyforNIPI. Several of the state level officials reported that they thought inter-departmental convergence was good at their level. Three state-level coordination meetings had been held and minutised in the previous year, they said.They were concerned that it was not as good at district or block level. Some mentioned the importance at district and block level of issuing state guidelines under joint signature from the multiple departments involved in NIPI, especially Health's signature with Education's as a way to raise the importance of implementing NIPI in the schools. The letter launching the NIPI programme was sent under joint signature. Additional letters were sent in 2014 and 2015 under joint signature as small programme changes were made and communicated to staff(seelettersreferencedthroughoutthisreport). Thereweredivergentviewsaboutmonitoring,withsomeWCDofficialspreferringtoleavethemain responsibility for monitoring NIPI with the Health Department, while some Education officials preferred to receive more information from the reporting exercises (indenting, supplies, and consumption)tobeabletomonitorEducation'sprogressonNIPItoagreaterextent. Leadership at the district level for coordination and convergence on the NIPI programme varied among the districts, as described by district officials across the four districts. Block convergence is notnecessarilyconsistentwithdistrictconvergenceandsoissuesfrombotharepresented. NotedattheonsetisthatconvergencebetweentheHealthandICDSDepartmentsonNIPIisstrong inallfourdistrictsatalllevelsafteryearsofcoordinatingandhavingcomplementaryobjectives,and thus will not be described in detail. With NIPI, coordination is also required with the Education Department, and most of the issues that emerged from the respondents are related to this new partnership. COORDINATION AND CONVERGENCE AMONG GOVERNMENT DEPARTMENTS
- 57. 45 Mentioned explicitly by a CRCC, and implicitly by other respondents about the NIPI programme in all four districts, is that the RBSK role of Health staff visiting schools to conduct health screening of studentsisbydesignaHealth-Educationconvergencemechanism. Intwodistricts,respondentsdescribedgoodcoordinationandconvergenceatdistrictlevel. In two of these districts, respondents reported that the Collector is actively organising meetings with the district heads of department, and the district department officials appreciate the effort. A district education official said that the working relationship between Health and Education was not effective before 2016, “but those problems are gone because district administration…is directly involved now. So the coordination is now developed in between Health and Education departments.” The ST/SC development department district official, however, reports not having beencalledtoaconvergencemeetingwithpeoplefromtheHealthandICDSDepartments. In the remaining two districts, leadership at the district level is less apparent and a number of issues have emerged. As one health official described,“There is a monthly meeting in the ICDS and health atthedistrictlevelunderthechairmanshipoftheCollector.Butinallhonesty,thedistricteducation is absent.” A partial explanation for lack of education participation at the monthly convergence meetings is that district and block officials have the convergence meeting together, and the standing time for the multi-department convergence meeting conflicts with a standing meeting of block and sector education officials. In fact, a new district education official reported that he had started to attend himself and usually sent the Science Supervisor to convergence meetings to discuss NIPI, and a district health official concurred that education officials had attended meetings intheprevious4-5months. At the block level in one district, in contrast to the district level there, coordination with the Education Department was hardly mentioned, only the high level between Health and ICDS, reported by officials of both. One district health official said that while the multi-department convergence is occurring at the district level, “but at the block and sector levels hardly they are gettingtheopportunitytomeetandreviewtheissues.” Coordinationandconvergenceseemstobe going well at the block level in another district, similar to the district level there, with regular block convergencemeetingsofthreedepartments. In the other two districts, several respondents who were block health and education officials were disparagingaboutcoordinationandconvergencewithinthetwodepts.,bothduetoirregularblock convergencemeetingandparticipationfromEducationdepartmentnothappeningalways. District Level Block Level
- 58. 46 COORDINATION WITH STAKEHOLDERS Supportive stakeholders are critical for NIPI programme success. Stakeholders can block implementation within households or at the grassroots if they do not agree with the programme objectives or do not understand them, or they can support implementation, encouraging consumptionofIFAandalbendazoletabletsandenhancingdietarydiversityandWASHbehaviours. The key stakeholders identified in the analysis of interviews for the NIPI process documentation are parents of children taking IFA and albendazole syrup and tablets, husbands and mothers-in-law of pregnant and lactating women, and SMCs and community leaders. Only four NGOs were mentioned by respondents in Harichandanpur and Banspal blocks in Keonjhar District and in Kujang block in Jagatsinghpur District, with very few details given, and with anaemia only being addressedbyone. MostoftheparentsacrossthefourdistrictswhorespondedabouttheirchildrenreceivingIFAsyrup ortabletsweresupportive,encouragingtheirchildrentoconsumeit.Manyintervieweesinvolvedin the school administration of IFA tablets said that support of NIPI by parents was crucial, even if passive support, e.g., adolescents in school and adolescent girls out-of-school saying that their parentshadnoobjectiontotheirchildrentakingIFAtablets. Building support among parents is crucial to NIPI success, as examples from AWWs, CRCCs, RBSK Teams and BEOs indicate. One set of AWWs said that earlier mothers were concerned about black stools and vomiting among their young children, but “now they have understood”. One CRCC describedasituationinwhichparentsthoughttabletsgivenatschoolwereinferiortotabletsfroma health clinic, but he convinced them otherwise. One RBSK Team described that they take the initiative to hold coordination meetings with parents after the student health screenings in each school. In addition, a district education official described that all BEOs in the district have initiated discussion and conducted meetings with parents and teachers at school and block level. They reported that initially the program was accepted by only 20% of parents, but gradually now 70% parents have accepted it. They found that the most effective technique was providing a forum for parentswhoacceptedIFAtabletsfortheirchildrentotalkwiththosewhodidnot. School children are often at the frontline of building that support, as this typical description by adolescents conveys:“We tell our father that we have taken tablet at school. My father asks why this tabletisgiven.Itellthatitisgivenforanemia.Thenhetellsitisgoodtotakeit.”ACRCCreiteratesthis point:“The students inform in detail to their parents regarding the iron tablets given to them. The parents who are aware of the importance of IFA appreciate it and those having no knowledge also happilyaccepttheprogramme.” Among parents, fathers deserve special mention for future outreach efforts. During several focus groups, the interview team found fathers of adolescent girls easy to engage with on a variety of Parents
- 59. 47 topics. While they did not know much about anaemia, they told what they knew, and asked questions to learn more. In one group, fathers said frontline workers like AWWs, ASHAs and ANMs never counsel them regarding anaemia and the importance of IFA and albendazole, only the mothersoftheirchildren. SeveralrespondentstoldaboutparentswhowerenotyetfullysupportiveofIFAdistributiontotheir children in schools. One group of adolescent girls out-of-school said simply that some of their parents say not to take the tablets. Field staff use situations of lesser parental support to try to persuadeaboutIFAtablets.OnesetofAWWssaidthatadolescentgirls“aregoingtodolabourwork, loading and unloading work.They do not come on Saturday.They are called but they only come in the evening. We tell their parents that you are sending your child to work and she is not able to eat tablet.” One RBSK member said: “Parents do not agree easily for referral if there is severe anemia. When we detect any child with severe anaemia we ask the teachers to call their parents. In the AWC we also interact with parents if there is some problem. We cannot help if parents do not agree. If someone has problem we call the parents and talk to them. We tell them about the facilities and convincethemtogo.” Like the parents, most of the husbands and mothers-in-law across the four districts who responded abouttheirwivesanddaughters-in-lawreceivingIFAtabletsweresupportive,encouragingthemto consume it. Women told that they tell their husbands about the iron tablets, and the husbands support. A woman in another focus group said that her husband and her mother-in-law both support her taking IFA tablets at home, saying they are good. Another set of women said:“Our in laws never discouraged us to take the tablets.” One pregnant woman said that her husband and mother-in-law remind her to take her IFA tablets when she forgets, and that her mother-in-law is alsoconsumingIFA.AWWsinanotherdistrictsaidthatmothers-in-lawarealsoaskingforIFAtablets forthemselves,sayingthattheyfeelweak. Along the same lines, AWWs told that “Some mothers-in-law are cooperating and asking us to convince the pregnant women.” AWWs also told about husbands who come to the AWCs to see whattheAWWsaredoing:“Theyaskwhythefieldworkersarealwayscalling…threetimesamonth. We answer that we have VHND, meeting, food distribution etc.”. Interestingly, AWWs also talked of their husbands support for their work in promoting the IFA and otherVHND services:“Yesterday my husband went to call the adolescent girls. Our husbands are doing half of our work. They keep the record and maintain it.We cannot work if they don't support. If you will call suddenly they bring us withthebike.Theygiveusadvice.” Severalmentionedacommonthemeexpressedthroughouttheprocessdocumentation,thatthere had been misperceptions, but now those days are gone. ASHAs described that “Earlier husbands hadnoideaaboutIFAtabletsandsyrup.Noweverybodyknows.”ACDPOtoldasimilarstory:“Mostly the program is accepted across the block. Earlier there was this superstition that these tablets make Husbandsandmothers-in-law
- 60. 48 mothers fat, delivers only girl child etc. But now those days are gone. Everybody is accepting the tablets.” Also, in a discussion with an ANM, ASHA and AWW, they were unequivocal that the husbands are very co-operative, supportive and involved. Mothers-in-law and husbands are also very cooperative when health-related services are to be delivered. Increasingly, fathers are more interestedintheAWCservices,ensuringthatfamilymemberscometoAWCforfoodandmedicines. A few decades earlier, there were families in which males did not cooperate, did not allow children orwomentocometoAWCs,butnoweveryoneco-operates,andrespectstheworkerstoo.Theysaid thatifyougotoremotetribalareas,especiallyamongtheJuangandMunda,mendonotcooperate with AWW or allow family members to take services from VHND or AWC. However, when they mix with non-tribal communities, they slowly start accepting the importance of services and accessing them. Building support among husbands and mothers-in-law is crucial to NIPI success, as with parents, and examples indicate how frontline workers approach increasing it. One group of AWWs said that “Some mothers [in-law] are telling that the child in the womb will be big. It will be difficult to give birth.We tell them that this is not true.”Regarding a role for husbands, a pregnant woman told that “When my test result came back 7, the ASHA asked my husband why he was not reminding me to take tablets. Now he keeps asking me.”Also regarding husbands, an ASHA Facilitator said:“If a wife does not take the medicine, then husband will have to understand the benefits of the tablets and tell her to eat it. He will also observe whether his wife is eating the medicines or not.There are many husbands who come to us if any problems occur. We discuss with the husbands and make them understandafterpregnancyregistration.” A couple of respondents also told about husbands who were not yet fully supportive of IFA distribution to their wives. A set of ICDS Supervisors reported that“The major problem in our area is that husbands are drinking so much of alcohol.They even forcefully use the money [given for full antenatal, delivery and postnatal care]. They are also creating disturbances in VHND and threatening their wives to come out of the session.”And a set of ANMs reflected that not all yet give their full support, saying that a few husbands/mothers-in-law still believe in myths about IFA and asktheirwives/daughters-in-lawtonotconsumethematall. A variety of community leaders were mentioned as potential contributors to continued NIPI success,thoughtheywereonlymentionedaskeypotentialsupportersonceortwice–theSMC,the , village tribal heads ( ), self-help groups (SHGs), and the RBSK Teams. (The role of RBSKTeamsinpromotingNIPIwasmentionedmorefrequently.) Regarding the role of SMC in NIPI, groups of SMCs in two districts and a set of CRCCs in another described that the interaction of the teachers with this committee is organized monthly. At their meetings,theydiscussissueslikeschoolinfrastructure,qualityofMDM,qualityofteaching,teacher vacancy, school environment, and water and sanitation services, but NIPI is rarely on their agenda Mamata sarpanch mukhiya SMCandCommunityLeaders
- 61. 49 (sometimes nothing health-related is on the agenda). They know about NIPI informally from the headmaster, and because members of the SMC who are parents hear from their children receiving tablets at school. If they knew more, SMC members would support it strongly, according to the CRCCs, because IFA, albendazole and the anaemia education would benefit their children as well as raiseschoolachievement.OthersconfirmedthatNIPIwasnotontheSMCagenda. Regarding the , a CDPO commented on his interest in all programmes, including NIPI: “Whichever program is going on in the village, the will definitely know the entire programme.”And an MO I/C recommended that the and BDO be involved more in NIPI to buildcommunityunderstandingandsupportfortheprogramme. Regarding SHG, ICDS Supervisors suggested their support for NIPI would also be helpful: “SHG Members are the main leading persons in the society. Main thing is that if they would realise the problemofnottakingirontablets,itwouldbehelpful.”ACDPOconcurred:“Themothers'intheSHG groupshouldbeinvolvedinthissothattheycanworkalongwiththeworkerstomakeitbetter.” Regarding further RBSK involvement to increase support for the NIPI programme, a group of RBSK membersspokeaboutthis,acknowledgingtheirkeyroleofrepresentingtheHealthDepartmentin schools for health screening and promotion. They said the ground reality is that they cannot meet SMC members and parents.When they go to the teachers, they are teaching in their classes, so they meet the headmaster and try to inform and convince him about fully implementing NIPI, but they cannotdomoregiventheirschedule. The microplanning process was described by 4 RBSKTeams, 3 sets of ASHAs or AWWs, one teacher andoneBPM. One RBSK team talked of their 300 schools: “We have prepared microplan. We have divided the schools. As per that we go to that school. One school is visited once in a year.We have two teams…. One team is going to one area. Our planning is that we will go to AWC twice in a year and school will bevisitedonceinayear.”Theyhaveaformatfortheirmicroplan,recentlyupdated.Forinformingthe schools:“Cell phone number is there. We bring cluster-wise school list and the numbers of CRCCs from BEO.We inform about our plan to the CRCC and CRCC informs the teachers.”AWC is closed by 12pm, while school extends to 4pm, so we plan accordingly.“In our area there is always flood and cyclone,sosomeschoolsorAWCsremainunchecked.”Also,“IftherewillbeepidemicthenasperMO I/C instruction we go to that place in our vehicle. Sensitising for dengue takes three months.When theschoolwasclosedwescreenchildrenonlyinAWC.” Anotherteamgaveadditionalinformationrelatedtotheirplanning:“Wehavetwodoctors.Wehave to screen 90 children per day. According to the strength of the AWC, we are able to visit one or two sarpanch sarpanch sarpanch MICROPLANNING RBSK Teams
- 62. 50 centers in a day. In school we usually screen 120-150 students per school.” To inform“We give copy of microplan to BEO and CDPO.They inform schools and AWCs or sometimes we inform them over phone. We tell ASHA to inform AWC. We visit residential school quarterly once. We visit other schoolsonceinayear.WegotoAWConceeverysixmonths.Thecontactnumbersoftheschoolsare available with us.We contact them earlier. In the sector meeting we tell ASHA to inform them. We havemanyunreachableareas. A third RBSK team added: “If it is Anganawadi programme we reach at 8am and start at 9am. In schools we stay from 10am to 4pm.We have three divisions.We make microplan. If it is in the school we will do screening of 150 students. If we do in AWC then we do for 90 children.”They also know how to build in flexibility, when deviations occur:“Actually in every month we make advance tour plan.Wegotothatparticularcenterasperthedategiven.Supposetheschoolhasexaminationthen thereisadeviation.Supposethereisrainyseason,somespecialoccasionisthereinthatcasethereis deviation.We try to make it up on another date.”A fourth team also stressed that they call ahead to schools and AWWs so that they can request the headmaster and AWW to encourage every student andyoungchildtobepresentonthatday. One group of ASHAs described their planning in terms of a typical couple of days: “I have 80-85 children. I visit all of those children's houses and meet their mothers to ask them to come the next day to get their children weighed. And will also meet those who are pregnant or lactating mothers andaskthemtocome.IreachtheVHNDby10amattheAWC.Nextdaywewillstaywith till2pm, todoallthework.Tellingtheweightsofthechildren,howmuchdidthatchildweigh,howmuchdid thischildweigh,weoverseeeverything.”OnegroupofAWWsdescribedmuchthesame,andadded: “On the day before the VHND we prepare a list of how many children we have and who will take which dosage. That list would be here in the VHND register.” The other group of ASHAs concurred withthesedescriptions. A teacher described her planning process as the following: “When the stock comes I receive and calculate that in how many weeks it will be consumed and how much will be left and I keep the leftover stock in a proper place. I maintain a register in which I write the stock consumed and left duringeachweek.” didi ASHAs and AWWs, and Teachers
- 63. 51 3. LOGISTICS MANAGEMENT In this section the reports from interviewees about the processes of indenting and procuring IFA tablets and syrup and albendazole are reviewed, as well as the management of their supply chains, and distribution at field level. Indenting and supply chain results are divided by IFA formulation and life cycle stage where appropriate. This section also includes findings on the time interval between receipt of last IFA stock and its distribution to next level in the supply chain. Recommendations are offered in the final section of the report. See key messages inBox2. According to several District Pharmacists and state OSMCL officials, the Family Welfare section of the Health & Family Welfare Department at state level prepares the indent orders based on a formula of population estimates and dosages. This is the method for indenting “programme” drugs such as IFA large red/blue and small pink/blue and syrup. ICDSandHealthofficialsatfield,sectorandblockpositions in all four districts reported that they sent indents that included their requirements of IFA and albendazole based on their population counts – number of students enrolled atthebeginningoftheschoolyearandheadcountsofout- of-schooladolescentgirlsandchildren6months-5yearsin villages. To systematise the counts of children 6 months-5 years and adolescent girls out-of-school, the AWWs conduct a household survey twice each year. One BPM mentionedthatthesurveylistofchildren6months-5years is used for numerous purposes – eg, vaccinations and vitamin A. Regarding the number of students estimated, INDENTINGOFIFAANDALBENDAZOLE IndentNumbersBasedonPopulationEstimates Box2.KeyMessages (LogisticsManagement) · · · · IFA is procured through a good system, still in the process of being fully implemented. The single manufacturer model, however, allows vulnerability to a stock out if the IFA or albendazole product does not meet quality control standards, and a multiple manufacturer model or other strategy should be considered. The protocols for indenting IFA tablets and syrup and albendazole also seem strong, and are implemented consistently with only afewexceptions. The IFA and albendazole supply chain is managed well and consistently -- with only transport limitations -- and adherence to formulationsishigh. The degree of sharing information and stocks to avoid shortages and stock outs is impressive at a local field level, and could be expanded throughout the state, using the electronic supply chain software at blockanddistrictlevels.
- 64. 52 one DMRCH noted that enrollment can be considerably higher than the number of children attending on any given Monday to receiveIFAbluetablets,sosurplusisgenerated. The population estimates and indents of required IFA and albendazole supplies are used to allocate supply as it gets divided at the district level and distributed through block to sector to field to beneficiaries. One Block Pharmacist had a supply of IFA blue tablets delivered without a corresponding indent from Education, and described the difficulty of not knowing how to divide it among the clusters and schools. In addition, ANMs told us that they calculate the requirement/indent for pregnant and lactatingwomen,sincemostareanaemicandbeingencouragedtotake2IFAredtabletsperday,as 360 during pregnancy and 360 during lactation. Another group assumed 80% needed 360 tablets and 20% needed 180, and accounted for more women getting pregnant during the year of the indent.MOI/Csreportedthattheyaddeda10%buffertotheestimatetheycompiledatblocklevel. The vast majority of interviewees reported that they indented once per year for IFA tablets and syrup and, while they mentioned it less frequently, they tended to report annual indenting for albendazole as well. Annual indenting was reported to occur among officials in all 4 districts, at all levels from field to district, and from all 3 departments (Health, ICDS and Education). The indenting reports still tended to come slowly from Education Department, said one district Health official. Annual indenting throughout the levels from field to district matches the annual indent and procurement that the state places with a company for the IFA and albendazole supplies, as the OSMCL officials described.There were a few exceptions to annual indenting -- some officials reported that they indented 2 times per year (every 6 months), and they came from all districts and from a variety of levels (MO I/C, Block Pharmacist, ICDS Supervisors, AWWsandCRCCs).Onlyafewsaidotherwise–aCDPOandANMsaidtheyindented4timesperyear (every3months),andonesetofANMssaidtheyindentwhenevertheirstockisgone. Frequency of Indenting
- 65. 53 People Involved in the Flow of Indenting There was much consistency among the interviewees as they described their indenting process. Theirdescriptionswereconsistentacrossthefourdistrictsandacrossthelevelsofofficialsfromfield todistrict,withonlyafewexceptions. Health officials' indenting compiled across field level into sector and across sectors into block was describedbyrespondentswhowereinvolvedas: IFAredtabletsforPLW: ANM MOI/C BlockPharmacist(withASHAinputintoANMsindent) IFAsyrup andalbendazolesyrupforchildren6months-5years(1-5yearsforalbendazole): ANM MOI/Cusually(seealsoICDSindentingIFAsyrup) ICDS officials' indenting compiled across field level into sector and across sectors into block was describedbyrespondentswhowereinvolvedas: IFAlargebluetabletsandalbendazoletabletsforout-of-schooladolescentgirls: AWW ICDSSupervisors CDPO MOI/C(withcopytoDSWO) IFAsyrupandalbendazolesyrupforchildren6months-5years: AWW ICDSSupervisors CDPO MOI/C,withcopytoDSWO(followedin1district) (seealsoHealthindentingIFAsyrup) Education officials' indenting compiled across field level into sector and across sectors into block wasdescribedbyrespondentswhowereinvolvedas: IFAlargebluetabletsandalbendazoletabletsforin-schooladolescentgirlsandboys: Headmasters CRCC BEO BPM(copytoDEO) (andasoneABEOmentioned:Headmasters CRCC ABEO BEO BPM) Total indent compiled at block level across Health, ICDS and Education Departments, then compiled across blocks into district and across districts to the state was described by respondents whowereinvolvedas: Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z 34 34 Only 100 ml bottles of IFA syrup was mentioned during the interviews. 50 ml bottles were mentioned by a state level Consultant as a replacement to the 100 ml bottle to reduce chances of expiry, but they did not seem to be operational in householdsandAWCsatthetimeoftheprocessdocumentationexceptbyonegroupofANMsinKeonjhar.
- 66. 54 IFAredandlargebluetabletsandsyrup,andalbendazoletabletsandsyrup: MOIC/BPM (with help from Block Pharmacist) CDMO (with help from District Pharmacist) “State”(DFW OSMCL) Thepracticeofindentingasdescribedabovevariesonlyslightlyfromtheoperationalguidelinesfor indenting,asdescribedintheBackgroundsectiononIndenting: LHVs are not involved in the practice of indenting as per the guidelines, rather ANMs pass theirindenttotheMOI/C Bhadrak uses the ICDS workers and officials to indent for IFA syrup and albendazole syrup whereastheother3districtsusetheHealthworkersandofficials,aspertheguidelines The Block Pharmacist assists the MO I/C to prepare the indent, and the District Pharmacist assiststheCDMO The CDPO compiles the indent for the MO I/C (copy to the DSWO) in practice, instead of the opposite, the CDPO should compile it for the DSWO (copy to the MO I/C) as per the guidelines The BEO compiles the indent for the BPM (copy to the DEO) in practice, instead of the opposite,theBEOshouldcompileitfortheDEO(copytotheBPM)aspertheguidelines The indent is sent to the Health Department officials at the block level in practice, instead of passing from the BEOs to the DEOs to the State Nodal Officer for Midday Meal (SNO-MDM) andbeingsenttotheHealthDepartmentatthestateDFWlevelaspertheguidelines At field and sector level the indent is prepared by hand. Starting at the block level the indent is enteredonline,buttheBlockPharmacistsreportthattheyalsomaintainahand-writtencopyincase computersdonotworkfromlackofinternetorelectricity. Theexceptionstothetypicalflowoftheindentprocessdescribedabovearethat: SometimestheMOI/C's representativecomestoBEO'sofficetocollectthestudentnumbers fortheindent SometimestheDEOreportedbeinginvolvedtoassisttheBEOssendtheirindenttotheBPM Once in a district it was mentioned that the ANMs' indent passed through the hands of the SectorsupervisorsorPHCbeforebeingsenttotheMOI/C. Z Z Z Forthe Health Department: Forthe ICDS: Forthe Education Department: â â â â â â â â â
- 67. 55 PROCUREMENTOFIFAANDALBENDAZOLE Managing the Procurement -- OSMCL and Drug Companies A key reason the State of Odisha created the OSMCL was to ensure that high quality drugs were procured and supplied, and the procurement and supply chain were streamlined. It was created in August 2013, started in 2014, and filled its first purchase order in May 2015. Haemoglobinometres can also be purchased through OSMCL -- the first tender was awarded in Dec 2015 and suppliedinFeb2016. IFA and albendazole are purchased annually according to the following steps, as described by OSMCLstateofficials.BasedoncalculationsdoneatstatelevelasreportedintheIndentingsection, the Director of FamilyWelfare (DFW) shares an indent with the OSMCL, following which the OSMCL prepares a tender (about 10 days required), floats it online and receives technical bids (21 days), compiles the bids (around 15 days) and presents to the tender evaluation committee comprised of the corporation members, special members, representatives from state medical colleges, DFW, representativesfromhealthdepartment,financedepartmentexpertandothers. Once bids have been evaluated according to the technical criteria, OSMCL identifies the manufacturer with the lowest financial bid. Usually OSMCL negotiates the rate with more than one manufacturer, in case the manufacturer who is awarded the contract fails to deliver the supply of drugs. The tender is then awarded to one manufacturer and the purchase order with required quantities is placed for order. The manufacturer submits the letter of intent within 7 days, and supplies the drugs within 60 days. In case they are unable to supply within 60 days, 1% per week is chargedasliquidateddamageasperthepenaltyclause. The next step according to the OSMCL officials is to check Quality Control of the drugs. The manufacturer distributes IFA and other drugs to the districts (37 locations including 30 district headquarters, 3 medical colleges, a central warehouse and others), and then these centers send 3 sets of random samples back to OSMCL to be tested for dosage and quality at accredited laboratories across the country (Bangalore, Hyderabad, Chennai, Kolkata, Himachal Pradesh and elsewhere).This period of“quarantine”while drugs are tested takes 15-30 days according to OSMCL and confirmed by a District Pharmacist. Only after the quarantine are the drugs declared online as “activated”and distributed within the district. If the drugs do not meet quality control standards, theyarenotactivated,andshortagesinthefieldcanoccur,asdescribedbelowfortheSupplyChain. Indents, purchase order, quality control and supply chain information is entered online in the e- Aushadhi system (Figure 2), overseen by OSMCL's IT Manager in Bhubaneswar. The e-Aushadhi onlinesystemwasstartedaspartofanoperationalresearchone-governancesysteminIndiaacross 12statesincludingOdisha.ThesupplysystemisstillbeingstreamlinedbyOSMCL. OSMCL pharmacists are gradually replacing District Pharmacists and OSMCL officials reported that they have contributed several vehicles at district and block level to ease previous transportation Haemoglobinometres
- 68. 56 constraints along the supply chain. OSMCL has most of the system in place, but not yet the monitoringandtrackingmechanismtotracksupplyandutilizationofdrugsatfieldlevel. The manufacturer should supply 2-3 batches of IFA and albendazole in a year. According to OSMCL state officials and district pharmacists, supplies have been delayed since the start of NIPI, but all have eventually been delivered. Manufacturers are supposed to supply stock within 60days. They can extend for up to 28 days twice along with deductions in payment (A 1% per week deduction in paymentforthefirstextensionanda1.5%perweekdeductionforthesecond.)Ifthecompanydoes not deliver after 116 days, the order can be cancelled. However, there have been instances when stockforroutinemedicineswassuppliedafter116days. The conditions of the SDMU warehouses were typically inadequate – not enough space, racks, ventilation, or refrigeration. OSMCL is gradually upgrading them, including refrigerator for those drugs that require cold storage condition, but currently space is still severely limited. The OSMCL District Pharmacist in one district said that storage space could be rented outside if needed. The District Pharmacist in another said that even the new OSMCL warehouse does not have the ventilation and air conditioning as it should, and that other storehouses have done it better. Warehouse Maintenance Figure 2. Home page of i-MCS web portal of Odisha
- 69. 57 Nonetheless, a Block Pharmacist was looking forward to his new warehouse with ventilation, temperature control, sufficient space, and racks so no boxes of medicine would be stored on the ground. Since there are a variety of IFA formulations for the different beneficiaries of the NIPI programme, and therefore the chance that someone could be given a stronger dose than intended, adherence to formulation has been stressed. The interviews revealed a high degree of adherence, with only twoexamplesofsubstitution.In2014onegroupofASHAsgaveIFAsyruptopregnantwomenwhen IFAredtabletswerenotinstock(lowerdosageofironandfolicacid).Theyreportedthatthewomen did not like the taste of the syrup and would not take it, and then the IFA red tablets became available. In 2015 there were no IFA blue tablets at the AWCs for out-of-school adolescent girls, and so they instead received tablets from ASHAs atVHND sessions (presumably IFA red, same dosage of ironandfolicacid). A great number of interviewees reported that they had never experienced a stock out – across the four districts, across the levels of officials from field to district, and including almost all the beneficiarieswhowereasked.Manyhadtheimpressionthatthesupplywasgenerallygood. There were minor exceptions and one major exception. The following reports are examples of minorshortagesorthosethatoccurredlongago: From reports in two districts, a BEO said that there were no stock outs of IFA large blue amongst the students but occasional ones of the deworming medicine, and a block pharmacist and a CRCC reported that albendazole ran out in the middle of a distribution (though the CRCC said they gathered more from sub-centres and ANMs and finisheddistributingthealbendazolewithin15days). In two districts, ICDS Supervisors and otherICDSofficialsreportedshortagesofIFAlargeblueforout-of-schooladolescentgirls:in two blocks they reported that blue tablets were missing for 4-5 months in 2015, in another block they reported not being available for 10 months until the date of interview in April 2016, and importantly a group of adolescent girls in one block reported they only got IFA tablets at the Saturday morning programme only once;while in another district college girls were taking IFA large blue from an AWC on Saturdays whereas the ICDS official thought (possiblyincorrectly)thattheyshouldbereceivingthemfromtheircolleges. – From reports in three districts, a CRCC reported that there were no IFA large blue tablets in one cluster for the first year of NIPI, a DEO said there had been no IFA – – Adherence to Formulations Stock outs SUPPLYCHAINMANAGEMENT â â â Albendazole IFA large blue for ICDS out of-school adolescent girls IFA large blue in schools -
- 70. 58 blue in the schools of one block for two months, an ANM in a SC/ST school said they had no stockatthemoment,andaCRCCsaidIFAlargebluesometimeshadshortexpiry. In addition, supplies at the PHC– Reported in one district, a MO PHC and PHC Pharmacist explainedthattheyhadindentedfor10,000IFAredtablets,butdidnotreceiveany,sincethe PHCwasnotaprioritydestinationforprogrammedrugslikeIFAandalbendazole. A stock out of IFA syrup seemed to occur in three districts in early 2016. ASHAs, AWWs and ANMsreportednoIFAsyrupfor2-4months(eg,anANMinoneblockreportednonewstocks during their interviews in March-May 2016 since her last delivery on 15 November 2015). In the midst of the shortage, health workers in one district said that they had received some extra bottles with expiration dates within 2 months, which they used, but only for those months.Women in one of these districts also reported that they had not received IFA syrup fortheiryoungchildren. A major stock out of IFA red tablets was occurring at about the same time. Health officials and workers from the field level to the district reported no stocks of IFA red for 2-4 months. A Block Pharmacist in one district reported a full 7 months between deliveries (October 2015 to May 2016) thatusuallycame2-3timesperyear,whereasinanotherdistrictthespanbetweenzerobalanceand the next delivery of red tablets was only ½ month. This stock out was reported in all four districts. Interestingly as regards demand for IFA, one ANM recounted that “educated people” with low government IFA supply had gone to buy their own. One District Pharmacist explained that his IFA red tablets were quarantined for 8 months, June 2015 to February 2016, while another said his was quarantined3½months,bothwellbeyondthe45-60dayexpectedtime. TheOSMCLofficialsreportedthatwhiletheyindentforandpurchasedrugsandsuppliesonceeach year, they receive them in 2-3 installments throughout the year, e.g., 30%, 30% and 40% depending ontherequirementsandavailabilityofstoragespaceatwarehouses.Mostofficialsatdistrict,block, sectorandfieldlevelreportedreceivingtheirsuppliesabout2timesperyear. There were a few exceptions to how officials described receiving their installments, and also how quickly they can be received. One CRCC said they receive IFA large blue tablets 1 time per year and another 4 times per year. Two ANM said they receive IFA red tablets 4 times per year. Few SC/ST teacherssaidtheyreceiveIFAlargebluetablets1timeperyear. Despite this exception, the reports seem to fit the pattern of passing installments from district to block to sector to field, sometimes entirely (e.g., the District Pharmacist, Block Pharmacist, CDPO and ICDS Supervisors, and AWWs all having reported receiving their supply 2 times per year) and sometimes in part (e.g., the Block Pharmacist reported receiving his supply 2 times per year and the ANMs4timesperyear). â â Frequency of Receiving Supply
- 71. 59 Regarding how quickly stock is conveyed once the OSMCL has received the procurement from the manufacturer and after the Quality Control tests, a few elements of timing emerged. At all levels, actorstrytoseparateanddistributestocktothenextlevel1-3daysafterreceivingitthemselves.For example, a Block Pharmacist in Bhadrak, a BPM in Jagatsinghpur, and a CDPO in Keonjhar said they sent out drugs to the next level in 1-3 days. Also at all levels, actors take advantage of coming to a centralplaceforregularmeetingsinordertotransfersupplies.FortheCRCC,however,itcantakeup toonemonthtoreachallschoolsintheclusterwiththestockduetolimitedtransportation. When those who distribute IFA and albendazole to beneficiaries, as well as those tasked with monitoring their stock, feel they are short on supplies, they use several options to try and avoid a stock out.The first and most obvious is to receive one's indent in installments that are smaller than the original indent.That a subsequent installment will be delivered at some point in the indenting period is well understood throughout the supply chain. As one Block Pharmacist explained: “Requirement could be more, but as per the availability of drug, they send accordingly.”An AWW reflected the same understanding, saying that if they have adequate, they will give the indent amount and if not then they will give in installments. Thus, when stocks are low and the next installment has not come as soon as expected, the first option is to ask for it. This request for installmentisalsoreferredtoasan“indent”,thoughitisanindentwithintheoriginalindent. A second option is to ask for supplies from those who keep buffer stocks. One Block Pharmacist explained that they like to keep a buffer stock in case of a stock out in the field, though so much of theprogrammedrugsarepassedintheirentiretytothefieldworkersandschools,itisnotclearthat they pharmacists have buffer stocks. In one district, however, the PHC Pharmacist, who is not directlyinthesupplychainfortheprogrammedrugs,managestoprocureIFAlargebluetabletsand syrupinadditiontoIFAredtohaveasabufferandtotreatPHCpatients.ACRCCtheresaid:“Ifnoone abletogive,webringitfromPHC.” A third option, commonly practiced and mentioned in all 4 districts and at all levels from field to district, is the informal, local sharing of supply. The request for additional stock is made in the regular meetings and by phone. One ICDS Supervisor explained that when syrup stocks were low, they shared among AWCs shifting from one with stock of syrup bottles to those where bottles were needed. Information about stocks is also shared regularly. As another ICDS Supervisor said:“We tell them before the stock gets over. So we have the stock always. And in the sector meeting also it is reviewedastowhoishavinghowmanytabletsforhowmanydaysandlikewisewhohaslesscomes to office and takes the required amount, so there is no stock out.” Moving stock is even done preventively -- an ASHA described that they move extra bottles from one sub-centre to another as theypileup,withoutthinkingthattheyareaddressingafuturestockout. Whilethissystemworkswell,ithaslargelybeenlimitedtothelocallevel.Afourthoption,therefore, is sharing across the state, more broadly and systematically. There was only one cross-district Installments and Methods for Preventing Stock Outs
- 72. 60 example cited – the Pharmacist in a district was asked by another district. They used the “drug transfer”interface of OSMCL's e-Aushadi portal where overstocks can be matched with stock outs within the state. This will allow the systematic sharing of stocks during a stock out that goes well beyond sharing at a local level, but requires either access to computers and the internet in the sectors and the field, or a systematic way to gather stock information from the sectors and field to enteratblocklevelattheCHCs. Monitoring is central to all these options. While teachers, headmasters and other officials in the Education Department did not describe sharing of IFA blue tablets and albendazole across schools or clusters, they do have widespread and systematic monitoring of IFA stocks by the CRCCs and RBSKTeams (and RBSKTeams also monitor IFA syrup stock in AWCs). Monitoring of IFA stocks across all the formulations could be even more widespread, as BEOs, DEOs, DSWOs and others expressed an interest in knowing the progression of the stock and where the shortages and overstocks emerge. Therewasfullconsistencyamongtheintervieweesastheydescribedtheirpartsofthesupplychain process.Their descriptions were consistent across the four districts and across the levels of officials from field to district.The only exceptions were variations introduced to relieve a constraint, usually involvinglimitationsintransportingtheIFAandalbendazole supplies. officialsdescribedtheirsupplychainperformulationas: IFAredtabletsforPLW: CDMO/DistPharm CHCPharm/MOIC/BPM ANM AndanaddedstepinBanspalblock,Keonjhar,MOI/C sector/PHC SC/ANM IFAsyrupforchildren6months-5years InKeonjhar,JagatsinghpurandKalahandi(butnotBhadrak): CDMO/DistPharm CHCPharm/MOIC/BPM ANM ASHA(forCh<3) AndANM AWW(forCh3-5yr) AndanaddedstepinBanspalblock,Keonjhar,MOI/C sector/PHC SC/ANM officialsdescribedtheirsupplychainperformulationas: 2 Health ICDS Z Z Z Z Z Z Z Z Z Z People Involved in the Flow of Supply The people involved in the supply chain for albendazole were not mentioned often by interviewees, but presumably the deworming medicine is sent to ANMs, CDPOs and CRCCs alongside the IFA formulation as pertheagegroup.
- 73. 61 IFAlargebluetabletstabletsforout-of-schooladolescentgirls: CDMO/DistPharm CHCPharm/MOIC/BPM CDPO ICDSSup AWW IntheblockinKalahandi,theIFAblueispickedupattheCDMOofficebytheCDPO,skipping theCHCbecausetheycannotmakethedelivery. In Kujang block, Jagatsinghpur, the CDPO requests that the MO I/C not send the IFA blue supply to their office, but instead that the MO I/C to send to the sub-centre/ANMs, who then givetotheAWWs. IFAsyrupforchildren6months-5years InBhadrakonly: CDMO/DistPharm CHCPharm/MOIC/BPM CDPO ICDSSup AWW(forCh3-5) AndAWW ASHA(forCh<3) ThereasonforIFAsyrupgoingthroughtheICDSinsteadoftheANMchannelinBhadrak isnotknown,butaBlockPharmacisttheresaid“Wecan'tgive[syrup]totheANMs”. officialsdescribedtheirsupplychainas: IFAlargebluetabletstabletsforin-schooladolescentgirlsandboys: CDMO/DistPharm CHCPharm/MOIC/BPM (BEO )CRCC Headmasters Sometimes in Kalahandi and Bhadrak, the BEOs are added to the supply chain to deliver suppliestotheCRCCsinsteadoftheCHCPharmacist. The primary supply chain paths reported above matched those laid out in the NIPI guidelines, with the only exceptions being more officials involved in the block in practice (CHC Pharmacist and BPM in addition to MO I/C) and less copying to Education officials in practice, compared to the NIPI guidelines. According to interviewees from all 4 districts, from all levels from district to field, and from all 3 departments (Health, ICDS and Education), vehicles are available at a number of levels, so the transportation of the supplies from district to field generally flows well and in a timely fashion.The interviewees reported that the District Pharmacists and Block Pharmacists have vehicles, including some new ones allocated by OSMCL. The District Pharmacist transported medicines to CHC/Block Pharmacists in three districts while the Block Pharmacists pick up medicines from the District Pharmacist in fourth district. The District can only transport programme medicines, like IFA and albendazole in the NIPI programme, as far as the CHC at block level, whereas the District can Z Z Z Z Z Z Z Z Z Z Z Education Transportation in the Flow of Supply
- 74. 62 transport non-programme medicines to PHCs and SCs. Block Pharmacist vehicles, though, can and dotransportfurther,asdoCDPOvehiclesinonedistrictandBEOvehiclesintwodistricts.RBSK-MHU (Mobile Health Unit) vehicles are also used to transport supplies in one district, though they are not usedforthispurposeinotherdistricts. ADistrictPharmacistdescribedamajordeliveryofsupplies,includingIFAandalbendazole,toits12 blocks.Three persons go in the vehicle for a delivery, 1 driver and 2 attendants.There are 12 blocks and it can take 20-25 days, including holidays, to deliver a full installment of meds. If a block is big, then perhaps 2 vehicles (or 2 trips) will be needed to deliver all the meds. The 3 people can go to morethanoneblockinaday,dependingontherequirementsandspaceinthetruck. In addition to vehicles specifically for transporting medicines and supplies, ANMs, AWWs and headmasters from the 4 districts reported picking them up when they came to a central place for regularmeetings. CRCCs probably have the most notable constraints that slow the flow of supplies after they receive theirdeliveryfromtheirblock.First,theCRCCisoftenvisitingschoolsandisnotattheCRCtoreceive shipments that others bring. In one district it was found that the CHC Pharmacist may deliver to a headmaster at a lead school in the cluster instead of directly to the CRCC, and in another district the CRCC signs ahead of time and the delivery can be made to the CRC without them there. Once at the CRC cluster point, a school staff member typically comes to pick up the IFA blue tablet and albendazole supplies from the CRCC. The headmaster may also come to get them, especially if the supply arrives close to a regular meeting time at the CRC. In either case, the CRCC is the one responsible to distribute the supplies to the schools within their cluster, and they may deliver supplies to the schools on bike during their monthly visit, if needed, or seek assistance from the HealthWorkersMale(HWM). The discussions with various district and block health functionaries, especially pharmacists, provided an insight on the time intervals during flow of supply of IFA stock from district to block CHCandfromblockCHCtoCDPO/CRCC/SC. Atthedistrictlevel,everynewinstallmentofsupplytakesaminimumof2months,inmostcases3-4 months,beforeitgetsdistributedtoblockCHCs.Thiswasfoundtobethecaseforallformulationsof IFA tablets and IFA syrup.The main reason for this time lag was the wait for quarantine clearance for new batches of supply. Most pharmacists said that, after a sample is sent for testing, it takes a minimum of one month, and usually two months, for any new batch to get activated. Most pharmacists showed their dissatisfaction with the time taken for quarantine clearance and one districtofficialmentionedthatthesampleofredIFAtheysenton26 Dec2015wasclearedaslateas 15 April 2016.The shelf life of IFA stock at the time of distribution to CHCs was found to be in range of1year1monthto1year8months. th th Timeline in the Flow of Supply
- 75. 63 At the block level, every new installment of supply takes a minimum of 10 days, in most cases 1-2 months, before it gets distributed to CDPO/CRCC/SC. This was found true even in situations where officials were aware of the low stock availability of a particular IFA formulation at field level. Althoughmostpharmacistssaidtheytrytodistributethestockassoonastheyreceiveit,aperiodof 1-2months usually passed before any stock could be distributed down the line. Three instances were found when the stock received at block level was distributed to SC/CDPO/CRCC after almost 4months.The shelf life of IFA stock at the time of distribution from CHCs was found to be in range of 6months to 1year 7months.While in most cases, the shelf life at the time of distribution to field was atleast1year,oneinstancewasfoundwhenastockwassuppliedwithshelflifeofonly6months. There were hardly any reports from the interviewees about having expired stock. When there was, several mentioned that it was clear they should return it instead of throwing it away.“The district gave strict instruction to all not to distribute expired medicine to avoid any complications”, said a district education official. A block official confirmed that this happened. “If IFA is expired, schools inform us and they give back to us.They shouldn't dispose of expired tablets themselves, only give back to us so we can check and can record.”However, in one district it was found that some of the schoolsjustthrowexpiredtabletsaway. Expired Supply
- 76. 64 4. TRAINING The guidelines for cascade training/capacity building are elaborated in the Background, and they set a framework for cascaded training. Described below are respondents' perceptions about how they were trained, whether they thoughttheyorotherNIPIactorsshouldhaveadditionalor refresher training, and whether they thought they were expected to cascade training down to the next level, e.g., MOI/CandBPMstoANMs. Health, ICDS and Education staff and field workers were instructed about NIPI in a variety of ways, as described below. Orientation and sensitization on NIPI is being done majorly through dedicated trainings at district and block level, and through meetings at sector and field levels.Although cascaded training was expected per the guidelines, several findings showed that there were challenges to ensuring that cascaded training actuallyoccurred. District Health Officials said that refresher trainings at district level are conducted with dedicated funding from the Programme Implementation Plan (PIP) each year at state level. One DMRCH said he attended NIPI orientation from the state two times in 2014-2015, then came and oriented in the districtforWCDandseniorpeopleoftheblock. BPMs in one district said they were trained by the District Programme Manager (DPM) and DMRCH at the start of NIPI. Other BPMs in that district confirmed that block health officials discuss NIPI at sector and monthly meetings with ANMs. Most RBSK teams reported that no special NIPI training had been provided, but anaemia was sometimes discussed in district/block review meetings. An MO I/C also described his NIPI training differently, saying that he did not receive any, and says that the“Method of training is just verbal to improve the skill.”He also implied that he does not provide muchtrainingtoANMs,onlytellingthemthesymptomsofanaemia. ANMs in three districts said they were trained on IFA administration in 2013-2014 before the programme started. Since then they reported receiving no additional training, but they discuss at sector meetings. A group of ASHA Facilitators reported being trained on iron syrup distribution by BPM during a sector meeting. In addition, according to ASHAs in another district, ANMs were 35 HEALTH 35 Operational Guidelines for Health Dept. on NIPI Programme, Odisha, 30 November 2015. Box3.KeyMessages(Training) l l l l All respondents received instructiononNIPI S o m e d e s c r i b e d t h e instruction as“training” while some said they had only received information through regularmeetings Respondents recommended further training for those in theEducationDepartment While extensive trainings are not recommended, strategic and targeted ones would be useful.
- 77. 65 trained at block level in 2015, and then they trained the ASHAs at a sub-centre meeting on how to give IFA syrup and other aspects of the NIPI programme. ASHAs in one district reported that they were trained in NIPI as part of a 5-day session on a variety of topics, 6-7 modules covered, likely their induction training. It included video about breathing problems in anaemic children and about anaemic women.There is not training on iron, they say, rather that they learn on-the-job about IFA syrupfromtheANMs. A DSWO said that training on anaemia had been given to them through the SABLA programme, being conducted in 9 districts. A CDPO reported a regular meeting as training, saying that they receive training twice each month with the CDMO in the district, and that they discuss there. AnotherCDPOsaidtheyhadreceivedtrainingfromanMOI/Conironandalbendazole. ICDS Supervisors reported that there had been no earlier training, but there had been NIPI orientation in the block in the previous month – medical team (MO I/C, BPM, RBSKTeam) had given the training to field level workers (AWWs and ASHAs). Also, the ANMs are trained, and the AWWs learn from them by seeing them give syrup at VHNDs. Some ICDS Supervisors also reported receiving a 2-day training on adolescent anaemia control in 2012 before NIPI as a training-of-trainers,butnotrainingrecently. Both state and district level officials agreed that it was difficult for them to ensure that NIPI trainings percolated down from DEOs, BEOs and ABEOs to headmasters and teachers, though, the official agreed, headmasters and teachersneedtobeoriented. District Welfare Officers (DWOs) across districts reported having never been trained on NIPI and anaemia control interventions. Two DEOs reported that all DEOs and BEOs in Odisha had received training in Bhubaneswar. He said that he held a similar workshop in his district with BEOs and Assistant Block Education Officers (ABEOs). He added that the CRCCs and headmasters were providedwith“CDstoshowwithaprojector”[trainingDVD]toteachabouttheNIPIprogramme,but he said that“I am not sure to what extent it has been done.” Instead, he said, CRCCs learn about NIPI throughtheBEOmonthlymeetingsandthatCRCCsmeetwiththeBEOandABEOregularly. Education officials in one district said that CRCCs and headmasters were called to hospital for a 1-day training at the block level before the National Deworming Day. The training included informationonIFAinadditiontodeworming. ICDS EDUCATION
- 78. 66 SMCs in three districts said that they did not receive training about the iron tablet, but learned about NIPI from the headmaster and through meetings at schools. One SMC expressed dissatisfaction on their understanding of NIPI by saying: “We are the tribal people. There is no training for us...We are not told enough.”A general finding was that through school, the SMC gets training on a variety of topics, mostly management, not health, and so there is a platform on which NIPIinformationcouldbeadded. Most teachers said they did not receive training but their CRCC told them about the IFA side effects. They added that“When it became regular practice, there was no need for training. If there was any problem,wecouldaskthem.” Themostcommonreplytothisquestionwhenitwasdirectlysolicitedwasasimpleyes,butwithout elaboration or conviction, e.g.,“Yes more training would be good”or“Training is always needed, no matter how much one knows.”In the quantitative portion of the NIPI process documentation, high proportions of field level workers also answered that they felt the need for more training (81% of 37 ANMs,79%of219ASHAs,and83%of233AWWs). In addition, a group of ICDS Supervisors elaborated that“Training is required… but more than that practical exposure is required…like, ANM didi should come, ASHA should come, beneficiaries should also come...then after one day verbal training they should go to the medical and things can be demonstrated to them.” Also, an RBSK Team thought all teams should receive more training, includingabouttheirroleinNIPI,sincetheteamsscreenandreferasneededbutdonottreat. In one case only, an education official responded about training in a way that reflected educationists' early resistance to NIPI and to giving IFA supplements in school – he said he was not interested in training because it is a teacher's duty to teach, and IFA administration should be done byASHAsormedicalorAWWs. DO STAFF AND WORKERS THINK THEY SHOULD GET TRAINED FURTHER?
- 79. 67 5. ADMINISTRATION OF THE INTERVENTION This section reviews results from the qualitative study on administration of the IFA supplements, then quantitative results on coverage, knowledge and providers and also on the prevalence of anaemiaamongadolescentandadultbeneficiaries.Itthenreviewsadditionalqualitativeresultson the recording and reporting mechanism for IFA supplements and albendazole, on the diagnosis, treatment and referral of anaemia patients, and on the emergency response preparation for adverseevents. As described in the Background section, guidelines specify that non-anaemic pregnant women should receive daily IFA red tablets for 180 days (1 tablet per day for the 30 days of each month, for the 6 months of the 2 and 3 trimesters). They should also take 180 tablets during the first 6 postnatal months.When women are anaemic (Hb <11.0), they should double the daily dose during pregnancy and during lactation. If anaemic throughout, this means they would consume a maximum of 720 IFA red tablets, 360 during pregnancy and 360 during early lactation.Tablets were commonly described as being dispensed to pregnant women monthly – 30 at a time if not anaemic and 60 at a time if anaemic, occasionally 50 tablets given twice was reported if ANMs thought the totaltobegivenwas100. Earlier guidelines for IFA administration among pregnant and lactating women recommended a lessernumberoftablets--100duringpregnancyand100duringlactation,200eachifwomenwere anaemic. In three out of the four districts, more respondents (mostly ANMs, ASHAs, women and BPMs) were aware that 180/360 tablets should be given to women during pregnancy, whereas in onedistrictmorerespondentsthoughtthat100/200shouldbegiven. For the 6-month period of the 2 and 3 trimesters of pregnancy, some ANMs and ASHAs 1) reportedcorrectlythatthenumberoftabletstobeconsumedwas180or360ifanaemic,butothers did not, 2) mentioning the old dose of 100/200 tablets, or 3) mentioning that women would take tabletsforlessthan6months,or4)fallingshortof180/360duetomiscalculations. Women frequently reported taking two tablets per day during pregnancy, and they reported starting early at the beginning of the 4 month of pregnancy (after most register their pregnancy in the 1 trimester), yet most women did not report consuming 180/360 tablets. The number of daily tablets and the time women started taking them are not the limiting factors in their total consumption of tablets during pregnancy. The main gap seems to be in getting enough tablets to women throughout the 6 months of the 2 and 3 trimesters and ensuring their compliance. nd rd nd rd th st nd rd ADMINISTRATION OF IFA SUPPLEMENTS PLW--HealthDepartment Distribution and Consumption of IFA Tablets by Pregnant Women
- 80. 68 Possible reasons for the total number of tablets not reaching 180/360 could be: 1) periods without IFA consumption between one set of tablets and the next, 2) distribution of tablets limited to 3-4 months instead of 6 or to 100/200 tablets instead of 180/360, and/or 3) women do not consume IFA tablets regularly – pregnant women admitted forgetting to take, and not taking, though they may betellingtheASHAotherwise.Furtherclarifyingtheguidelines,themonitoring,andthepromotion of 180/360 tablets during the 6 months of the 2 and 3 trimester is warranted, with fieldworkers being encouraged to give the full amount and the sector, block and district officials reinforcing that theyshouldandreducinganyconstraintsinimplementation. Another way for women to get 180/360 tablets during pregnancy is to ask for more as soon as they finishtheirpreviouspacket.ThiswasonlymentionedoncebyanASHA--“WearegivinginVHND;ifit is over, they are asking for more”– but it was not confirmed in any group of PLW or mothers. Thus asking for more IFA tablets is probably not a common practice. This reflects that the demand from community for IFA tablets remains poor, which in turn identifies the gaps in improving community awareness on importance of IFA tablets. It is therefore warranted that awareness among PLW on importance of regular consumption of IFA tablets be built. This can gradually strengthen demand andwomenwilltheninformFLWswhentheyarenearlyattheendoftheirsupplyoftablets. The focus on getting IFA red tablets daily to women during the 1 6 postpartum months (double dose if anaemic, as in pregnancy) is much lower than during pregnancy. Several health officials expressed what BPMs in one district said: “For pregnant women, the programme goes well. After delivery it goes slow. The people have less practice. During pregnancy, ASHA is there to monitor. That is why it is a success.”Several sets of AWW and ASHA fieldworkers indicated the same, saying that generally women are enthusiastic to take IFA during pregnancy, but not after delivery during early lactation, and one group was specific about the perceived reason, saying“They hesitate to eat themedicineswithafearthattheirmilkmaygetdriedup.” Lactating women in two districts said they did not receive any IFA tablets for lactation, whereas those in two other districts said they received IFA tablets at delivery to take during lactation. Fieldworkers painted a similar picture about women getting tablets in some areas and not getting in others. In another district, ICDS Supervisors said that women would be given IFA tablets during lactation only if they were still anaemic and until the anaemia was gone, while AWWs there said anaemic women would be given just for one month after delivery, and ASHAs there said“Lactating womenhadnotyetbeengivenIFA.” The most comments about this age group and IFA syrup were about whether the mother or the ASHA administered the syrup to the children, and who kept the syrup. Children 6 months-3 years nd rd st During Lactation, Low Emphasis on IFA Consumption WhoAdministersthe IFA Syrup? Children 6months-3years --- Health Department
- 81. 69 received their IFA syrup on Tuesdays and Fridays after meals in several different ways: 1) from their mothersathomewiththeASHAsvisitinghomestocheckthatitwasgiven;or2)directlyfromASHAs whenASHAsvisitedtheirhomestwiceperweek;or3)fromASHAsatAWCs,wheretheycallmothers andchildrentoreceiveallatonce,thenvisittherestattheirhomes.Theguidancesuggestsonlythat the ASHA should support consumption by the youngest children, which leaves open all these options. In most cases, the bottle is stored with the mother at the children's homes. There was no resistance reported from parents or others to their children 6 months-3 years receiving IFA syrup. In one district where respondents told that mothers gave the IFA syrup to their children and ASHAs visit their homes to check, thinking that the guideline was more rigid, an MO I/C said“Though the guideline says the ASHA should give”, it is not possible for them to reach all the children twice each week.” SomeofthevariationinwhoadministersIFAsyruptochildren,seenindifferentblocksanddistricts, may have come from workload – one ASHA said she had 115 children 6 months-3 years and would not be able to reach all unless she called them to the AWC. Some of the variation may have come from variations in available IFA syrup stock with ASHAs. Giving mothers the responsibility of administering IFA syrup, with ASHAs playing a supervision and handholding role would only be possibleifASHAshadsufficientnumberofbottles(oneperchild)tohandovertoallmothers. Inone area,mothersreportedthattheygavethesyruptotheirchildreneveryday(insteadofjusttwiceper week),indicatingtheimportanceoftheASHAmonitoringadministrationathome. There did not seem to be advice from frontline workers or Health/WCD officials about action to be taken for a missed dose of syrup amongst children 6 months-3 years. One group of women said: “And if we forget giving then we tell didi [ASHA] that we have not given and we are forgetting, and she asks why we didn't give…”but she doesn't mention taking the missed dose on another day. In the other categories of children and adolescents, frontline workers know how to advise about misseddoses. ASHAs are supposed to be“suitably incentivized”for providing or directly supervising the provision of IFA syrup to children 6 months-3 years twice each week . The incentive is meant to be Re. 1 for 8 visitsperchild(overonemonth).IncomparisontootherincentivesforASHAs,severaldistricthealth officialscommentedthattheRe.1incentivefor8homevisitsperchildpermonthwastoosmalland shouldberaised. Most of the respondents across all four districts, all levels from district to field, and in the Health and ICDS Departments agreed that ASHAs have never received this incentive. Many (from a number of levels, e.g., a DMRCH and BPM) confirmed that ASHAs are supposed to receive this incentive. One BPM concluded that“There is an official communication, but no mechanism has been decided to 36 Incentiveto ASHA foradministering IFA syrupin homes 36 Guidelines for Control of Iron Deficiency Anaemia: NIPI, NRHM, 2013.
- 82. 70 work on it.” Only two group of ANMs in two districts made it sound like the incentive was being given to ASHA, saying: “The ASHAs maintain records in written format. They give a voucher. We checktheASHAdiary.” Asreportedbymany,AWWsgiveIFAsyruptochildren3-5yearsonTuesdaysandFridaysattheAWC afterthedailyICDSfeeding,aslaidoutintheguidelines.TheystoreIFAsyrupbottlesforthechildren at the AWC, in one case describing that bottles were dedicated to children, and in another case that separate bottles were not maintained for each child. AWWs give from the auto-dispenser, which is well-liked because of the ease of dispensing exactly 1ml of syrup to the children. There was no resistancereportedfromparentsorotherstotheirchildren3-5yearsreceivingIFAsyrup. WhilethequalitativedatacollectioncouldnotquantifyIFAcoverage,onecommentsuggestedthat not all children 3-5 years received the syrup. ANMs in one district said:“But some children are going to Sishu Mandir. How will they get? Their guardians are demanding…that they want a bottle for their home and they will administer it at home…. But we cannot give. If government will order then wewillgive.” IfanIFAsyrupdosewasmissedonaTuesdayorFriday,AWWs,ICDSSupervisors,mothersandothers reported alternatives. Children could receive after the next day's ICDS hot cooked meal, or they couldreceiveathomebyanASHAoranAWW. As a DSWO summarized about the Saturday sessions: The adolescent girls come every Saturday to the AWC after eating at home. From 2pm to 5pm an interactive session is organized every Saturday. At the beginning of this session, adolescent girls are given IFA tablets which they consume under supervision, per the NIPI guidelines. In the session under the SABLA programme, counselling on health and life skills is also provided.Weight and height are measured for BMI calculation.“They are eating. It has become a practice….They are telling that they feel active.Their menstrual cycles have become regular. Those who have black stool, are being assured by other girls saying that nothing worse will happen.”One set of girls, however, is not as positive, saying that they do not like the taste and smell of the IFA tablets, and it makes them nauseous. They are only taking because of being forcedbyparents. The main reasons many respondents cited for adolescent girls out-of-school not attending on Saturdays are that they live far from the AWC and they have responsibilities at home. For junior college girls, the reason is different. Since they take classes on Saturday, they can only reach the AWC afterward by 4pm and with an empty stomach. Girls who come to the AWC under this circumstance tend to take their tablets home and consume after a meal, while others girls do not cometotheAWC. Children 3-5 Years -- ICDS Adolescent Girls out-of-school (10-19yrs) -- ICDS
- 83. 71 The alternatives for getting IFA tablets to those who do not attend the session, as cited by the respondents were that: 1) AWWs would make a home visit to girls who had not attended a Saturday session and give them a tablet, 2) ASHAs would make a home visit to give them a tablet, along with homevisitstoPLWorchildrenU3,3)girlscouldcometotheAWCanotherdayoftheweektoreceive atablet,and4)tabletswouldbesenthomewithotherSaturdayparticipants. In non-SABLA districts most respondents also expressed that more girls would come to the Saturday sessions if there were more incentives, e.g., a meal was served, or take home rations or an egg were given.“There is nothing for adolescent girls, that's the problem”, said an ICDS Supervisor. Respondents also reminisced that the programme for adolescent girls at the VHND was better – they would receive overall health checkup and haemoglobin assessment, in addition to receiving theIFAtabletsandaninteractivecounsellingsession. The most comments on implementing the NIPI programme were heard about adolescent students consuming IFA blue tablets at school. While the Health and WCD Departments have been promoting IFA consumption or similar efforts for many years, and had coordinated on them together, the Education Department was new to implementing such programming in 2014, and in many blocks and clusters, was resistant to dispensing tablets, which they saw as the work of health officials. Much of the resistance has dissipated in the two years of implementation before the process documentation began, though some were still nervous. As one teacher expressed: “In 2014-2015itwasnotasuccess.WedidnotforcethechildrentoconsumeIFAtablets.Inthelastyears wehavegothabituated.From2015-2016,theprogrammeimplementationhasbeengoingwell.” A BPM said that a blue booklet was sent to each school in 2014 with information about administering NIPI in the schools. He told teachers that IFA is not a medicine, rather a food supplement. The BPM, numerous CRCCs and other educators consistently reported that children are to take IFA blue tablet on Mondays right after the MDM provided in Standards 6-8, and a tiffin meal packed from home in Standards 9-10, since those in Standards 9-10 do not receive the MDM. One set of teachers said they distributed tablets on Wednesdays because they had found that attendance was highest on Wednesdays. Also, school children bring their own water, and take plenty with the IFA tablet, because there are water problems at the schools. IFA blue tablets are not provided to junior college students (Standards 11-12) at the junior colleges, he said, but these girls can receive their tablets by attending the sessions for adolescent girls on Saturdays at the AWC alongsideout-of-schoolgirls.Additionally,aCRCCreportedthattheytellheadmastersandteachers not to give IFA tablets to any children who are sick, and teachers also reported that they do not give anIFAtablettoanystudentwhoissick. Adolescents11-19 – WIFS -- Education Department Basic Implementation
- 84. 72 Most groups of adolescent girls and boys confirmed that they are given IFA tablets every Monday after the MDM and that their consumption is recorded. They reported that the IFA tablets are blue and the deworming medicine they take twice each year is white – they swallow the IFA tablet with water and do not chew it. One group of adolescent girls revealed that IFA tablets were not being distributed in their school. Few other adolescent groups, who said IFA tablets were being distributed in schools and that they were consuming these, however, were unable to describe the colour of IFA tablets. These groups did describe the colour and process of taking albendazole tablets,whichseemedtobemorepopularacrossrespondentsandacrossdistricts,comparedtoIFA tablets. In a residential school with some day scholars, a headmaster explained that students who board receive IFA tablets after the prayer session and 10am meal at the hostel, whereas the day scholars receivethemaftertheMDMat1pm.ANMsdistributethetabletsinaresidentialschool. Teachers in some schools try to give dietary and hygiene counselling in addition to giving the IFA tablets and albendazole. “We tell them that, besides tablet you should also eat health foods regularly.Take nutrients in home. Only taking tablet will not work.You need to eat proper diet also. Along with taking albendazole, you also have to make sure you wear sandals when you go to the latrineandwashyourhandsproperlywithsoap.” If a student misses taking an IFA tablet on a Monday, many respondents said they would be given the next day at school. Only one set of boys and one set of teachers said that a tablet would be sent withafriendtodeliverintheafternoonattheperson'shousewithinstructionstotakeafterdinner. While all schools give IFA blue tablets every Monday, there are variations on who is responsible for organisingthedistribution,whodistributesthetablets,andwheretheyaregivenwithintheschool. Regarding the responsibility, in most S&ME schools there is a nodal teacher or coordinator organisingtheWIFSprogramme(andanotherforWIFSJunioramongthechildreninStandards1-5), but in one school the teachers shift the tasks among themselves and the headmaster is responsible foroversight.Inresidentialschools,anANMassignedtotheschoolistheoneresponsible. Results were mixed on whether the teachers consumed IFA in front of their students. One set of teachers who reported on this from a school said that they always eat in front of the students.Three sets of CRCCs also commented – one said the teachers they oversaw ate the tablets, another said that at first they were reluctant, but now they like to take, and the third saying that the students wouldnottakethetabletsunlessanduntiltheirteacherstook.Inonearea,eventheSMC,agroupof parents and some teachers who assist with school management issues and can oversee events like IFA distribution, reported taking IFA tablets on the Monday they were at school. However, all the How IFA Tablets are Distributed at School Are Teachers Consuming IFA?
- 85. 73 groupsofadolescentswhoreportedonthistopicsaidtheyhadneverseentheirteacherstakeanIFA tablet. Students in Standards 9 and 10 do not receive a MDM in school, but they receive IFA blue tablets on Mondays.There are several different times that these students are given the tablets so that they are not consuming on an empty stomach, which has the chance of causing dizziness. Many reported that they give or receive the tablet soon after arriving at school, after the prayer class, having eaten at home ahead of time.The teachers worry about giving tablets to students on an empty stomach, and so always check that they have eaten at home before giving. Interestingly, in one school, a trust brings additional lunch food, so that all students are offered food at lunch time. As an adolescent boy there explained, they receive MDM when there is surplus, and there is always surplus. Finally, in onecaseofdayscholarsataresidentialschool,theIFAtabletisgiventothestudentsonMondaysto takehomeandconsumeintheevening. Results from the 4 districts (6 blocks) were reviewed against the guideline for the major school holidays in May and June that the tablets are to be provided to the students with counseling for consumption at home . There was not a consistent practice of giving tablets during the school holidays. One to seven respondents in each block gave information about IFA during the holidays – adolescent girls and boys, teachers, headmaster, CRCCs, RBSK Teams, and others. Almost all respondents in one district told that they gave or received tablets for the school holidays, while in another district almost all said they did not give or receive, and in the other districts the responses were mixed. More clarity on guidelines and implementation of IFA consumption during the school holidaysisrecommended. Interestingly,theAWWandASHAwereinvolvedinthedistributionofIFAtabletsduringtheholidays in two areas. In one district, a group of school-going girls said they were receiving blue tablets on Saturdays at the AWC from AWWs, and that if they did not attend an AWW would visit them at their home to give the tablet. In another area, a CRCC said and an ASHA confirmed that the schools handed over tablets for the school holidays to the ASHAs or AWWs near the students' homes for distribution on Mondays. The ASHAs said they kept the tablets with them, and watched the studentsconsumethetabletinfrontofthemontheMondaysduringtheschoolholiday. Teachers and others in the Education sector in a few areas still fear that giving IFA tablets may cause ill effects among their students, draw media attention, cause black stools, or that the tablets may reach their expiry date and then be dangerous. Their fear sometimes resulted in low compliance 37 Consumption by Students in 9th-10th Standard School Holiday Fears and Low Compliance Still Exist 37 Ibid, Operational Guidelines for WIFS in schools.
- 86. 74 among the students and other times the teachers gave tablets to their students despite lingering doubts. Comments expressing fear came most frequently from three blocks, but they were expressedinallareas. The most classic and common comments about fear of the IFA tablets were, fortunately, about fear resolved. For example, one set of school-going adolescent girls estimated that at the beginning of the NIPI programme only 10 out of 71 students took the tablets, but gradually everyone began to consume, seeing the others take. In another example, a CRCC described:“No one was eating in the 1 year.The stock was just thrown out. Means we hide it, put in sacks and buried it in the ground.We toldteacherstothrowit.Why,becauseagain'NewsFuse'willcome.Donotthrowoutside,buryit.So it couldnot work out in the first year, coverage was very less, only 30% students ate it. It is working in the2 year--itis90-95%now.” Fearwasexpressedinthefollowingways: Teachers – “We give them the tablet to eat, then we give them water to drink. Still there remainsafearinthemind.Thechildrenmayfallintosomeproblem.” RBSKTeam –“In this block children do not go to school or AWC everyday. Even if they come, they do not eat medicine regularly. They are afraid about side effects and they do not eat tabletsoutofthisfear.” SMC – “Teachers are not willing to take the risk. They get afraid to give. We returned albendazole. In the TV it was told that children suffered due to albendazole. Then immediatelytheystopped.” BPM--“Butsometeachersarereluctanttotakerisksalongwiththeprogramguidelines.Like they fear some discrepancies may happen with medicine distribution. Because we get regular news about ill effects of medicines and we had cases here about the side effects of medicines.Hencetheywerescared.” RBSK Team – In some schools they are giving after MDM. In all schools it is not given. They are not ready to take the risk. Headmaster is telling like this…. We want to complete the medicinebeforeoneortwomonthsoftheexpiry.Itisdangeroustoeatinthelastmonth.” Teachers –We have no problem.We are doing the job well.We only get afraid when there is expiryinmedicine.Wegiveaftercheckingtheexpirydate.” And the following statements emerged about students not always taking IFA blue tablets on Mondaysatschool: CRCC–Duetotheirfear,teachersdonotinsistthatallthestudentswillconsumeit.Theyare onlygivingtothosewhoaskforit. RBSKTeam–“Around60%ofschoolsaregivingmedicine,rest40%arenot.” Adolescent girls and boys – Four sets of adolescents who were interviewed or referred to could not identify the colour of the IFA tablets they claimed to be taking. After the formal recording of one group's interview, girls admitted that they had never been given the IFA tablets. st nd â â â â â â â â â
- 87. 75 â â â Adolescent boys – One set of boys estimate that half of the boys they knew threw their tablets away through the window each week, and some also threw away their albendazole tablets. RBSKTeam – One team said that there is resistance to IFA tablets in schools throughout the block,withperhaps60%nottaking. DPC/SSA – Without giving a reason, the DPC/SSA estimated that only 30-40% of students aretakingtheIFAinhisdistrict. Two sets of adolescent students told of tricks used to pretend to take the IFA tablets. The girls said that in an earlier Standard, there were four students who did not want to take, so they would keep the tablet in their mouth, then spit it out later.The boys had a longer list of ways to pretend: put the tablet in one hand and pretend to take it with the other, put under the tongue or beneath the teeth and spit out when away from the teacher, and swallow it but then invoke a gagging reflex shortly afterward. While a few respondents still requested that medical staff distribute the IFA tablets in schools, as many had at the beginning of the NIPI programme, several more were requesting more involvement by the Health Department. For example, one set of teachers said they would like for health staff to visit their school on occasion. This would give credibility to the NIPI efforts and convince the parents. Indeed, this is the kind of effort reported that persuaded teachers, parents and other community members that the benefits of IFA and albendazole were great and the possiblesideeffectsmanageableinareaswheretheprogrammehashighcoverage. Reported in this section are results of the quantitative survey conducted during the NIPI process documentation exercise in Odisha April-July 2016. Interviews of beneficiaries – adolescent boys, adolescent girls, pregnant women, lactating women, and WRA – and of frontline workers – ANMs, ASHAs and AWWs -- were conducted to investigate the coverage of and compliance to NIPI interventions, beneficiaries' health seeking behaviour with regard to anaemia detection and treatment, and the preparedness of health facilities to diagnose and treat anaemia. Hb levels were assessedusingHemocue201,andcomparedtoWHOcut-offstoestimateanaemiaprevalence . Respondents were asked whether they had heard the term anaemia. Those who answered positively were then asked how they would know if they had this condition (symptoms). Less than 38 QUANTITATIVE SURVEY: COVERAGE, KNOWLEDGE, PROVIDERS Knowledge of Symptoms 38 http://www.who.int/ vmnis/indicators/ haemoglobin.pdf WHO, Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity, Geneva: WHO, Vitamin and Mineral Nutrition Information System (VMNIS), 2011. accessed16April2017.
- 88. 76 Figure 3. Knowledge of clinical presentation of anaemia among beneficiaries and frontline workers Pale appearance giddiness palpitations weakness tiredness reduction in work efficiency poor scholastic performance Adol boy 4% 14% 2% 13% 10% 2% 3% Adol girl 7% 17% 2% 18% 13% 4% 2% Pregnant 2% 19% 2% 20% 15% 4% 0% Lactating 3% 18% 3% 19% 15% 4% 0% WRA 11% 17% 3% 19% 15% 5% 1% ANM 33% 59% 33% 67% 64% 28% 3% ASHA 18% 64% 18% 78% 69% 20% 3% AWW 17% 18% 17% 78% 62% 16% 5% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Adol boy Adol girl Pregnant Lactating WRA ANM ASHA AWW Health-seeking Behaviour Respondents were asked for one thing they would do if they felt anaemic. Regarding health- seeking behaviour, 36% - 48% of respondents said they would inform either their parents, if adolescents, or their husbands, if PLW, when they suspected anaemia-related symptoms (Figure 4), 20% of these respondents reported knowing the symptoms of anaemia (Figure 3), despite the NIPI programme's intention that this be taught at all levels. The beneficiaries as well as the frontline workers, felt that the most common manifestations of anaemia were giddiness, weakness or tiredness. Hardly any beneficiaries or frontline workers, however, related poor scholastic performance with anaemia. A higher proportion of frontline workers had knowledge of anaemia symptoms than the beneficiaries. There was not much difference among beneficiaries in the proportion with correct knowledge.
- 89. 77 Figure 4.Preferred health-seeking behaviour of beneficiaries with anaemia-related symptoms 37% 36% 41% 36% 48% 56% 45% 54% 56% 51% 2% 3% 4% 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Adol boy Adol girl Pregnant Lactating WRA Home remedy Seek help for treatment Inform parents Inform Husbands Beneficiaries' preferred providers are shown in Figure 5.Those who said they would seek treatment wereaskedwhotheywouldseekitfrom.Thevastmajoritysaidtheypreferredagovernmentdoctor in a health centre (86-97%), while only a few said they preferred a private doctor (2-9%). The reported median distances of these government centres are around 5km from their residences (2- 10 km), while the offices of private doctors were even further, around 8 km (1-22km). Very few reportedpreferring frontlineworkerslikeASHA,ANM,orAWW(5-6%). Frontline workers were asked how they would respond if their clients approached them with signs and symptoms of anaemia. Most said they would give an IFA tablet (48-54%); 38% of ANMs and 6% of ASHAs and AWWs said they would conduct a Hb test; and the rest of the ASHAs and AWWs said theywouldreferthesepeopletohealthcentres(34-40%). suggesting parents and husbands are key targets for Information, Education and Communication (IEC)onanaemia.Evenmorerespondentssaidthattheywouldseektreatment.
- 90. 78 Figure 5. Preferred providers for anaemia-related symptoms 97% 97% 86% 87% 90% 2% 2% 9% 7% 4% 4% 3% 4% 1% 1% 1% 1% 1% 75% 80% 85% 90% 95% 100% Adol boy Adol girl Pregnant Lactating WRA ANM AWW ASHA Pvt doctors Govt doctors Haemoglobin Assessment: Knowledge and Coverage Facilities: Equipment and Stocks Only 50-62% of beneficiaries interviewed knew of any blood test for anaemia diagnosis. Among those who reported they would seek treatment for anaemia-related symptoms, however, a higher proportionknew(73%-82%).Amongthosewhoknewthattherewasabloodtestforanaemia,most saidtheywouldprefervisitingagovernmentdoctoratahealthcentrefortreatment(85%-95%). Of those who sought Hb testing in the last six months, the majority were pregnant women -- 55% were pregnant women, 37% lactating mothers, 9% adolescent girls, 4% adolescent boys, and 9% otherWRA. Insub-centresmanagedbyANMs,82%hadafunctionalSahli'shemoglobinometerforthepurpose of diagnosing anaemia. However, when pregnant women were tested, the test was conducted at VHNDs,andveryfewweredoneatsub-centres(average37permonthpersub-centre,with21%not conducting any Hb tests). The overall standard of care was difficult to assess, e.g., quantity of IFA tablet prescribed, referral status of anaemic patients, response to treatment, and attempts to rule out other causes of anaemia at sub-centre level, since only 26% of sites had anaemia referral registers. Also, none of the sites had IEC material on display. Regarding stocks, 41% of sub-centres hadastockofIFAsyrup,63%hadIFAtablets,andnonehadironinjectionsatthetimeofsurvey. This is not surprising given that the sub-centre is not designed to handle many referrals, and the ANMs basedatthesub-centresseepregnantwomenandotherbeneficiariesattheVHNDs.
- 91. 79 The PHCs reviewed in the survey had even less equipment and stocks of IFA available than the sub- centres. Only 41% of PHCs had an allopathic doctor available to provide care, and only 5% had laboratory technicians available for blood diagnostic services. None of the PHCs had a functional haemoglobinometer. Regardingstocks,nonehadanystockofIFAsyrup,only8%hadIFAtabletsfor treatment purpose, and only 5% had iron injections available at the time of the survey. Barely 4% PHCs had records of anaemia patients being referred out for further treatment and same number had some IEC material related to anaemia on display in the premises. Anaemia diagnosis was made in only about 2.7% of OPD patients during the previous month as per the OPD registers. This is consistentwithresultsfromthequalitativestudyinwhichnobeneficiarymentionedbeingreferred tothePHCforanaemiatreatment. CHCs, on the other hand, had more equipment, but their stocks were low. Most centres (88%) had a functional Sahli's hemoglobinometer. Regarding stocks, only 25% of CHC facilities surveyed had stock of IFA syrup, but this is consistent with reports from the qualitative study that all IFA syrup in thesupplychainwaspasseddowntotheANMsfordistributiontoyoungchildrenbytheASHAsand AWWs. Also, only 75% had stocks of IFA tablets. Although there had been a nearly state-wide shortage of IFA red tablets for a number of months prior to the qualitative interviews, all stocks shouldhavebeenreplenishedbythetimeofthequantitativesurvey,includingto100%ofCHCs. Coverage of IFA supplementation was estimated among adolescent and adult beneficiaries and frontline workers. Among beneficiaries interviewed, 38% of adolescent girls, 16% of adolescent boys, 73% of pregnant women, 46% of lactating mothers, and 52% of under-five children were reportedtohaveconsumedIFAtablets/syrupinthepreviousmonth. The most common reasons cited for not consuming IFA tablets among adolescent boys and girls who did not consume them were being on school holiday and that they were not informed (Figure 6). Given the many respondents from the qualitative study who reported they did not receive IFA tablets during the school holidays, and given that during one of three months of the quantitative survey (June) the school-going adolescents would have been on school holiday for the previous month (May), it is not surprising that about one-third of the students cited school holiday as a reason for not consuming IFA tablets. The“not informed”reason for not consuming IFA tablets, on the other hand, could have a variety of meanings among the students. Interestingly, the girls gave thereasonofdislikingthetasteofIFAtabletsmorethantheboys(17vs.4%).The“fearofsideeffects” reasonfornotconsumingIFAseemedsurprisinglylowcomparedtothefearsfrequentlymentioned inthequalitativestudy,andyetitisconsistentwiththeteachersandothereducationofficialsbeing themorefearfulonescomparedtothestudentsthemselves. PregnantandlactatingwomenwhoreportednotconsumingIFAtabletsalsocited“notinformed”as the most common reason for not consuming them (Figure 7), while mothers of children under five who did not consume the IFA syrup cited “not informed” (45%), house not being covered by the AWW (17%), child does not attend AWC (6%), or refused syrup (5%) as reasons for their child not receivingit. Coverage of IFA Supplements and Reasons for Low Coverage
- 92. 80 Not informed Dislike taste Fear of side effect Vacation Others Not reported Girls (N=494) 18% 17% 2% 31% 15% 18% Boys (N=671) 37% 4% 1% 28% 12% 19% 0% 5% 10% 15% 20% 25% 30% 35% 40% Girls (N=494) Boys (N=671) 21% 42% 7% 8% 6% 2% 15% 15% 14% 10% 37% 22% 0% 20% 40% 60% 80% 100% Pregnant Women (n=209) Lactating Mothers (n=426) Not informed Dislike taste Fear of side effect Not available Others Not reported Frontline Workers Providing to Beneficiaries Frontline workers reported on the beneficiaries they were responsible to supply with IFA syrup and tablets (Figure 8). Women mostly received IFA supplements from ASHAs (60%), but also from the AWWswhofrequentlyhelpedatVHNDsandhomevisits(23%,Figure6).ASHAsfrequentlysaidthey weretheoneswhoweresupposedtogiveIFAtowomen(60%),andsodidtheAWWs(23%). In addition, 51% of AWWs said they were ones to give IFA to school-going adolescent girls, which was surprising because the NIPI guidelines indicate that teachers should be the ones providing IFA at school. Some of the girls may have been reporting that they were provided IFA tablets during school holiday by AWWs, but this is unlikely to explain the full 51%, since adolescents are supposed to be given IFA at school beforehand and take it at home on their own during the weeks of the holiday. Figure6.ReasonscitedbyadolescentboysandgirlsfornotconsumingIFAtabletsduringthe lastmonth. Figure 7. Reasons cited by pregnant and lactating women for not consuming IFA tablets duringthelastmonth.
- 93. Frontline Worker Knowledge of IFA Dosages Frontline workers were asked the dosage of IFA to be given to each of the beneficiary groups under NIPI (Figure 9). Knowledge tended to be low. Only about 50% of AWWs knew the dosage of the beneficiaries to whom they administered, children 3-5 years old and adolescent girls who had dropped out of school, and even lower among adolescent girls in college (about 30%). Similarly, only about 50% of ANMs and ASHAs knew the dosage for young children 6 months-3 years old, though their knowledge of dosage was higher about the dosages for pregnant and lactating women(77-84%). 81 Also notable is that some ANMs and AWWs (10-17%) reported giving IFA tablets to boys (boys in school, boys who had dropped out of school, and boys in junior college), given that boys in school are supposed to receive IFA tablets from their teachers and the others are not included in the NIPI programme. It would be interesting to learn more about this, including whether it indicates demandbytheboysortheirfamiliesforIFA. Fig 8.Frontline workers and the beneficiaries groups to whom they dispense IFA syrup and tablets
- 94. Stocks ASHAs and AWWs were surveyed about their availability of IFA supplements according to beneficiary. In most cases, only a small proportion thought stocks were adequate. Among ASHAs, stocks of IFA syrup for children under 3 years were adequate according to 15% of them in Kalahandi ranging up to 49% in Keonjhar. Stocks of IFA tablets for PLW were adequate according to 27% of theminKalahandirangingupto81%inKeonjhar. AmongtheAWWs,stocksofIFAsyrupforchildren3-5yearswereadequateaccordingto4%ofthem in Kalahandi ranging up to 45% in Bhadrak. Stocks of IFA blue tablets for adolescent girls out-of- school were adequate according to 13% of them in Kalahandi ranging up to 64% in Jagatsinghpur. And stocks for girls in junior college were adequate according to 4% of AWWs in Kalahandi up to 36%inJagatsinghpur. Anaemia was high among all beneficiary groups and frontline workers whose Hb was assessed in the survey (Figure 10, blood samples were not drawn from young children). Among beneficiaries, it was most prevalent among lactating mothers (77%), followed by WRA (71%), pregnant women (69%), and adolescent girls (68%). Among the frontline workers, anaemia was most common QUANTITATIVE SURVEY: PREVALENCE OF ANAEMIA 82 Figure9.BeneficiaryknowledgeofIFAdosagetobeneficiaries
- 95. 83 among ASHAs (69%), followed by AWW (62%), and ANMS (53%). Anaemia may be less prevalent among pregnant women than among lactating and non-pregnant, non-lactatingWRAduetothemanyyearsof providing IFA tablets to pregnant women, but their prevalence is still unacceptably high. Fortunately, the prevalence of severe anaemia is low (1-3%), but the prevalence of moderate anaemia (7-20%) and of mild anaemia (39-58%) is very high. These prevalence estimates are consistent with the number of PLW women, frontline workers and other officials who reported during the qualitative study taking a double dose of IFA tablets during pregnancy following Hb assessment indicating anaemia.They are also consistent with a number of respondents saying that they hardly ever see a case of severe anaemia. It is notable that the prevalence of anaemia among adolescent boysisnotfarbehindthatofadolescentandadultwomen. Figure 10. Prevalence of anaemia among beneficiaries and frontline workers 35% 32% 31% 23% 29% 47% 31% 38% 58% 56% 54% 58% 56% 39% 47% 48% 7% 10% 13% 17% 12% 11% 20% 12% 1% 2% 1% 3% 3% 3% 2% 2% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Adol boy Adol girl Pregnant Lactating WRA ANM ASHA AWW Normal Mild anaemia Moderate Anaemia Severe anaemia
- 96. 84 Prevalence is also shown by district and the five main beneficiary groups (Figure 11). Among the districts, anaemia is most prevalent in Keonjhar (75-87%), but only a bit lower and similar amongst the other district-beneficiary groups in Jagatsinghpur, Bhadrak and Kalahandi (57-81%). Among the beneficiary groups taken together, anaemia prevalence is similar. Among the individual beneficiary-district groups, anaemia was of the lowest prevalence, but still high, among pregnant women in Jagatsinghpur (57%) and of the highest prevalence among lactating women in Keonjhar (87%). Figure11.Prevalencebydistrictandtypeofbeneficiaries 64% 57% 74% 71% 58% 68% 70% 68% 70% 61% 77% 78% 87% 75% 79% 63% 71% 81% 69% 65% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Adol Girls Pregnant women Lactating mother WRA Adol boys Jagatsinghpur Bhadrak Kheonjhar Kalahandi These prevalence estimates compare similarly to anaemia and severe anaemia data reported in the 2014 Annual Health Survey , despite using different methods for assessing haemoglobin (see TablesinBackgroundsection). 39 39 Annual Health Survey (AHS). Clinical, Anthropometry and Biochemical (CAB) Factsheet, Odisha section, 2014.
- 97. 85 DIAGNOSIS,TREATMENT, REFERRAL, FOLLOW-UP AND PERCEPTIONS OFPREVALENCE Information on this topic is divided first by life cycle – children, who are addressed largely through the screening work of the RBSK Teams, and women, who are addressed largely during VHNDs. Under each life cycle section are described how the RBSK or VHND mechanism works on anaemia, how the mechanism educates its beneficiaries, how it refers those who may be anaemic, and how anaemia is detected. A brief section showing the perceptions about anaemia prevalence is presented, as well as recommendations. See Box 4 for key messages. This section covers predominantly the young children who are screened by the RBSK team at the AWC and adolescentsinschoolwhoarescreenedbytheRBSKteam at schools. There were only a few comments on the adolescent girls out-of-school being screened by the AWWs, as specified in the guidelines, and these are featuredinthissection. RBSKTeams from the six blocks in which interviews were conducted as well as several CRCCs told us the following abouttheirworkscreeningchildreninsecondaryschools for any health conditions . If fully staffed, each team is composed of one male doctor, one female doctor, one nurse/ANMandonepharmacist.Ablocktypicallyhas2or 3 teams. Odisha state has 640 teams. A team can screen up to 150 students per day (or up to 90 children at an AWC). Adolescents not attending school are not screened.IfstudentsareabsentonthedaytheRBSKteam visits, a teacher can send for them at their homes so they canbecheckedbyadoctor.Duetovacantpositions,oneoftheRBSKteamscoveredunderthestudy was composed of only a doctor and a nurse, and they could only screen 75 students per day (and 45 atanAWC). 40 Children0-6YearsandAdolescents---RBSK HowRBSK WorksonAnaemia in Schools 40 Implementation of IFA blue tablets to adolescent children in Standards 6-10 were investigated in this process documentation,butnotIFApinktabletstochildreninStandards1-5becausetheimplementationofthiscomponentof the NIPI programme was at a nascent stage when the process documentation was conducted. It is hoped that many lessonsfromimplementationamongtheadolescentscouldapplytotheyoungerstudents. Box4.KeyMessages(Diagnosis) l l l Hb concentration is not tested among young children, school children or adolescents out-of- school, only among pregnant and perhaps lactating women; instead the visual pallor technique is used, whichdetectsonlysevereanaemia. Without assessing Hb concentration, it is difficult for RBSK Teams and AWWs to follow GOI NIPI Guidelines for treatment of mild and moderate anaemia among all children, 0-18 years. Recommendationsaretoexpandthe education role of the RBSK, upgrade the Hb assessment method from the pallor technique to an Hb test, p e r h a p s a f i e l d - b a s e d haemoglobinometer to identify all anaemic children in AWCs and schools, and also screen adolescent girlswhoareoutofschool.
- 98. 86 Students are screened for 38 conditions, and children in the AWCs for 30 conditions. Adolescent students get additional questions about menstruation and puberty. One team described the 4D's: “In our screen we have defects of birth, deficiency, disease and developmental review.”RBSKTeams donotconductanylaboratorytests,butlookforclinicalsigns.Theyhave27medicineswiththemto treat a limited set of conditions they find among the students and young children -- fever, cough and cold, and skin diseases. According to a Block Pharmacist, there is no guideline or rule about which medicines the RBSK Teams can use for treating children when they screen. He gives medicines to the RBSKTeams when they ask for them.TheTeams are demanding a greater number of medicines.“CDMO sir last time instructed me to give them more paediatric medicines.”All other serious illnesses or conditions are referred elsewhere, mostly to the CHC. The teams screen at schools 5 days each week and conduct a referral day on the 6 , transporting students and young childrenreferredduringtheweektothereferralcenter. The three teams in one block serve 269 schools, including residential schools, and 292 AWCs. According to guidelines and the RBSK Teams themselves, they visit S&ME schools once per year, SC/ST schools four times per year, and AWCs two times per year. Many respondents think that RBSK Teams visit S&ME schools twice per year. One team described how they organise themselves to screenatsomanyschoolsandcenters,sayingthatwhenevertheyvisitaschoolorAWC,theyinform the HM or AWW in advance of the date and time. Usually, when they visit a school they reach there by10amandstaytill4pm.ForAWCs,theyreachby8am. Another role of the RBSKTeam is to respond to a report of adverse effects from IFA. Occasionally, in schoolswithcomplaintsfromparentsandhesitationfromteachers,RBSKgivestheIFAsupplements to students in schools they visit on a Monday, the IFA distribution day in schools. They seek to be accessible in the schools, giving the headmasters and teachers their mobile numbers. If there is any medical emergency, they can call and the RBSK can facilitate transportation for the student and teachertotheCHC. In addition, MHU Teams were mentioned during interactions at Kalahandi and Keonjhar/Harichandanpur SC/ST residential schools. They preceded RBSK Teams, but still served the residential schools. In Kalahandi, a BPM reported that his block had 3 RBSK Teams and 2 MHU Teams. According to an ANM posted at a residential school, the MHU Team visited every two months, more frequently than RBSK Teams visit currently. In addition, they give a physical examination, give medicine as needed, and if a child is seriously sick, they refer for medical care, coming back to the school another day to transport the child, along with the ANM, to a CHC or elsewhereasneeded. ICDS Supervisors in one area reported that families are told the day ahead of time that RBSK will be at the AWC next morning. Children 6 months to 5 years are screened twice per year similar to the students in school, including anaemia detection with pallor technique. If they have a serious condition,theyarereferredtotheCHCordistricthospital,ifalessseriousconditionthentothePHC. th How RBSK Works at the AWC
- 99. 87 The RBSK Team discusses with ICDS Supervisors and AWW how to tell the mothers about keeping children clean and well fed. They provide transportation to the health centre for the child and a parent on referral day. ICDS Supervisors in another area said they appreciate the RBSK Team becausetheygivealotofsupport,includingscreeningandtransportationforreferrals. Anaemia and Hb testing for adolescent girls out-of-school was mentioned only a couple of times. A district health official in Keonjhar said that they have been tested for Hb in selective cases when there are clinical signs of anaemia, though was not specific about where this testing would occur. ANMs in Jagatsinghpur reported that, though not in the protocol, they also perform Hb blood tests on adolescent girls, whom they knew well from the programme for adolescents, before it was ended. Adolescent girls in Keonjhar who were out-of-school said that a few of them had had their Hb tested at the CHC and several more as part of a survey that came through their village. One in Jagatsinghpur reported that she had her Hb tested at a health fair. WhilegirlsbeingtestedforHbseemedtobetheexception,ICDSSupervisorsinKeonjhardescribed the normal method for them at AWCs on Saturday, having the pallor of their eyelids, nails, skin and palmsobservedbyAWWs. RBSK officials and teams and a CRCC from several districts described the following about education on anaemia and other health topics during their visits to schools.The RBSK teams are instructed to do some counseling and awareness campaign on anaemia after the screening at each school and AWC. At the end of their exams, the RBSKTeam talks with the headmaster and the CRCC, if present, for about half hour at school, and check the hygiene around the MDM cooking site.Then they call a meeting with the teachers and students. And sometimes after exams in the S&ME schools, people from the community are gathered and the RBSKTeam explains what they do, medicines they give, about the major illnesses like malaria, dengue, diarrhea, also iron and handwashing, and how to teachtheirchildrenofthese.Intheresidentialschools,wetalkwiththestudentsaboutthesethings. TheyreportedthatthiswasnotpossibleintheAWCstoparentsoftheyoungchildrenpresentingfor screening,butthereasonwasnotprovided. WhileeducationbytheRBSKwasnotmentionedmuch,itholdspromiseinaddressingthelowlevel of awareness and urgency surrounding the treatment and prevention of anaemia among children. It is appreciated by one group of adolescent school boys in Jagatsinghpur. When asked what the RBSK doctor does at the school, adolescent boys replied first that“…he teaches. We ask questions and he answers.”Even when they talked about the screening, they said that the doctor explained aboutthecommondiseases,takingadvantageofmomentstoeducate.OneRBSKTeaminKeonjhar wentfurthertorecommendthattheRBSKtrainingrolebeexpandedandformalized. Kishori Shakti Yojana (KSY) Adolescent Girls out-of-school – Limited Reports of ScreeningforAnaemia Education by the RBSK
- 100. 88 Referrals – Choices Transport for Referrals Blood transfusions are mentioned most often as the action that would be taken if a child was referred for anaemia. It was not reported as occurring often, but it was the referral action that respondents knew about. For example, an RBSK Team in Keonjhar said that during a referral for anaemia, the child will receive an Hb test.They will be told their Hb concentration, and should tell it to the teacher who gives them IFA at school. If the Hb concentration is 7 or 8, they said, the child will be given a blood transfusion. Parents' reaction to their child getting a blood transfusion varied, according to field workers. In one case of an anaemic child, the parents avoided a blood transfusion by taking the child from the hospital early, and he remains weak to this day, despite warnings to get moremedicalhelp.Inanothercase,theparentswantedandgotatransfusion,despiteobstacles. There was an exception to reporting blood transfusion as the only action following referral. An SMC in one district described that if the RBSKTeam suspects a child is anaemic but not in need of a blood transfusion,theycanmakeareferralforanHbtestattheCHC(orfromaprivatepractice)andwritea prescription for additional IFA tablets. The SMC was the only interviewee group to report referral andprescriptionfordailyIFA. Two issues stand out from the interviewee responses. First, prescriptions for daily iron to children with mild or moderate anaemia were hardly mentioned, despite it being the therapeutic protocol from the GOI NIPI Guidelines (see Tables in Background section). Second, haemoglobin of the children is not assessed and therefore mild and moderate anaemia cannot be detected, which makes implementation of the protocol nearly impossible. The pallor technique is applied to children twice per year by the RBSKTeam to detect severe anaemia.This technique has reasonable accuracyfordetectingsevereanaemia ,butisnotaccurateformildandmoderate . There were a number of responses that were specific to how children get transported to a health center for referrals. Interviewees who talked about transport were RBSK Teams in all four districts, teachers in two, and a BPM group and a group of adolescent beneficiaries.Transportation is critical for a successful referral – some teachers said that without transportation, students are unlikely to get checked at the CHC. The default transport for students and young children screened by RBSK teams is the RBSK team itself.They assign one day each week to transport any children/adolescents 41 42 41 42 Butt Z, Ashfaq U, Sherazi SF, Jan NU, Shahbaz U. 2010. Diagnostic accuracy of “pallor”for detecting mild and severe anaemiainhospitalizedpatients.JPakMedAssoc60(9):762-765; Stoltzfus,RJ,Edward-RajA,DreyfussML,Albonico,M,MontresorA,ThapaMD,WestJrKP,ChwayaHM,SavioliL,TielschJ. 1999. Clinical pallor is useful to detect severe anemia in populations where anemia is prevalent and severe. J Nutr 129(9):1675-1681. Buttetal.,ibid.; Chalco, JP, Huicho L, Alamo C, Carreazo NY, Bada CA. 2005. Accuracy of clinical pallor in the diagnosis of anaemia in children:ameta-analysis.BMCPediatrics5:46.
- 101. 89 referred during the week to the nearest CHC. If the CHC doctors cannot diagnose and/or treat the students' conditions, then the BPM or CHC staff takes the students to the district hospital. An ASHA typically accompanies the RBSK team during referrals, sometimes a teacher. Sometimes the ASHA accompanies a child/adolescent to the CHC on her own, in which case she uses public transportationandaccessesconveyancemoney.Andsometimestheparentstaketheirownchildto theCHCwithareferralslipfromtheRBSKteam. An RBSK Team explained that they detect anaemia among students by looking for pallor in the eyelids, nails and skin, and by hearing from the child that they experience head reeling and weakness.Teachers even reported knowing the symptoms, and would sometimes check the colour ofastudent'slowereyelid,thoughtheyarequicktoaddthattheyarenottrainedinhealth. An RBSK Team member explained that the pallor detection method is confusing, leaving them guessing whether students have moderate anaemia, which is not detected by the method, that may require more than weekly supplementation.They recommended that teams become enabled to perform haemoglobin tests among the students and young children on whom they conduct health screenings. A district health official summarized by saying: “Estimation of haemoglobin for all eligible beneficiaries is not happening.” Another RBSK Team recommended that a new technique is needed for diagnosis of anaemia--afield-basedhaemoglobinometer. For Hb testing issues that apply to children as well as women, see the Women's section on Hb testingandanaemiadetection. A range of health and ICDS actors from all 4 districts at block and field level described the basic information about how theVHND works to reduce anaemia among pregnant and lactating women (CDPOs, MO I/C, BPM, ANM, ASHA and AWWs). At monthlyVHND sessions, ANC, post-natal care and child health check-ups are done for pregnant and lactating (post-natal) women and children. The ANMs give a talk on a health topic, treat common illnesses, and give IFA syrup to preschool aged children and IFA tablets to pregnant and lactating women. Pregnant women are encouraged to come for 4 ANC visits, though most women report that they come only for two.The ASHAs find out intheircommunitywhoisnewlypregnantandencouragethemtoattendthesubsequentVHND. Many report that blood pressure and Hb are tested at the VHND session as well as at CHCs. Hb concentration of pregnant women is recorded in their MCP card and in the ANM's register. The ANMs said that if a pregnant or lactating woman has an Hb of less than 7, the ANM refers her (and Anaemia Detection and HB Testing HowVHNDandhome visits workforanaemia Pregnant and Lactating Women-- VHND
- 102. 90 alsoaskshertotake2IFAtabletsperday).IftheHbisbetween7and11,theysay,womenaregivena doubledailydoseofIFA,andif>11,theyaregivenasingledailydose. Although education and individual counseling during VHND sessions were mandated, there were fewcommentsaroundthis.ICDSSupervisorsreportedthatwomenwillcometoVHNDfortheexam, but about half leave without participating in the education session. Regarding individual counseling, the process documentation team observed an ANM counseling a first trimester pregnantwoman. A specific counseling message by an ANM to pregnant women in one district was explained by an AWW there. She said the ANM would explain the diagnosis and treatment of anaemia to pregnant women as: children are born with sufficient blood to sustain themselves for initial few months and the iron tablets provided compensate for the amount of blood the child will take from her. By explaining to women in a simple way, the AWW said, women were convinced to consume the IFA tablets. A DMRCH reported that only severe anaemia cases are referred for treatment, and there have been more cases detected and referred than before the NIPI programme began. An ICDS official said that if anaemia is severe in a pregnant woman or in a young child screened at aVHND session, she or the child could be referred to the CHC (and if the family cannot afford, they can be taken directly to the district hospital in which case they would be provided transportation). Another ICDS official said that when a woman was referred, an ASHA would accompany her. A MO-PHC said that there were no referrals from the ANM to the PHC. People come directly to the PHC for health care, but if a referralisgiven,itistotheCHCordistricthospitalorNRC. If referral for severe anaemia was made, the most common treatment protocol that health staff mentioned was blood transfusion. Also in one district, one pregnant woman was taken by an ASHA to the health centre in town for an ultrasound, an Hb test and a sickle cell test when she was 4 monthspregnant,andshereceivedcalciumtablets. What stands out from these responses is that the clinic-based actions (parenteral and IV) and close monitoring of pregnant and lactating women laid out in protocol from the GOI NIPI Guidelines (see TablesintheBackgroundsection)werenotreportedbytheinterviewees. On the other hand, an ANM in a district who assesses Hb during each of a pregnant woman's 4 ANC visits,saw2womenwithsevereanaemia(Hb<8).Shereferredthemtothedistricthospitalforblood transfusion but they did not go. Regarding follow-up, an ANM reported that after being treated at thedistricthospital,theywouldcontinuetomonitorwomenandtellthemtotake2IFAtabletseach day. Education and Counseling Referrals
- 103. 91 Haemoglobin Testing and Anaemia Detection There were several differing reports about whose Hb was tested. Frontline workers said that pregnant women get their Hb assessed atVHND, but not adolescent girls (The GOI NIPI Guidelines suggest that pregnant and lactating women should have a blood test for their Hb level, but adolescent girls at AWCs or at schools should be examined with the pallor technique only). There washardlyanymentionofAWWsexaminingtheadolescentgirlsout-of-schoolforpallor. There was also discussion about the number of times pregnant women were tested for Hb. A number of health officials and workers spoke of 4 ANC visits as the target, while the GOI NIPI Guidelines state that for women with mild anaemia (concentration of 9-11), “Hb levels should preferably be reassessed at monthly intervals”. An ANM informed that protocol required Hb of women to be tested 3 times during pregnancy, at the 12 , 14 and 32 weeks of gestation. Most pregnant and lactating women interviewed reported that they had had an Hb test only twice duringtheirpregnancies,andnonereportedhavingmorethantwo. An AWW said that the ANM she worked with usually tried to bring her instrument every time to VHNDs. It had not been working for 6-7 months, but then recently started working again in the month before her interview. While broken, she had asked the pregnant women to get the Hb test elsewhere (e.g., CHC), bring her the result, and then she would distribute to them IFA tablets and tetanus toxoid immunization. Further, a BPM in Jagatsinghpur said that if the haemoglobinometer breaks, a new one can be purchased in Cuttack, but the district does not have a purchase contract, and the state does not supply. Actually, the state can only supply in bulk as per the annual supply plan. Hb testing is also available at the CHC for any patient who might present with weakness suspected from anaemia, said a BPM. Other potential testing locations were also explored. At sector level, the MO-PHC explained that although there is a provision for a laboratory in PHCs, no laboratory was currently functional in his PHC. Also, though IFA tablets and syrup were supposed to be available at the PHC, none were in supply on the day the MO was interviewed, only folic acid tablets were available. Hence, the PHC wasnotareferralplaceforanaemia,butonlytheCHCanddistricthospital. th th nd
- 104. 92 Private Doctors Another player for diagnosis and treatment beyond the government system is the private doctors. So comments are extracted to describe in a small way the role of private doctors in ANC. An AWW said: “Some women do visit private doctors because Gynecologist doctor is not here in our PHC. PeoplecomeherefirstandafterbeingcheckedupatVHNDtheyvisittheprivatedoctors.Weinform them to tell the doctor not to write additional iron tablets because IFA tablets are being distributed atVHNDsandthereforeitisnotnecessarytopurchasethesetablets.” Theperceptionsofanaemiaprevalenceamongchildrenwerefoundtovarywidely–aBPMclaimed that the prevalence in his district was around 30%, while an RBSK team in the same district thought it was 80%. Most is mild anaemia, the RBSK team thought, some moderate, and hardly any severe cases. According to the RBSK team they could not identify mild cases with detection of pallor, but canguessonmoderate. However, many claim they have not seen any children with severe anaemia. For example, adolescent girls out-of-school have never seen anybody around us who is weak, always gets sick, or gets tired easily. A RBSK Team thought there used to be many referrals for anaemia, but now reduced, but the same team also thought that anaemia was worse in the SC/ST residential schools vstheS&MEschoolsortheAWCs. Pregnant and lactating women perceived that anaemia has reduced in recent years, though still highlyprevalent.GlancingataVHNDregisterforthepreviousmonth,anANMinKeonjharindicated that pregnant women's Hb was recorded in the range of 8.0-10.8. From a register in a CHC in Keonjhar,pregnantwomenwerelistedwithHbbetween7.4and9.5g/dl,andnoneabove10g/dl. Many respondents from every district and block had ready answers when asked what they would doiftheywereworriedwhetherachildwashavinganadverseeffecttoanIFAtabletoralbendazole. Theresponsesinvolvedcallingformedicalhelp(RBSKTeam,theBPMorothersattheCHC),callinga supervisor (ASHAs calling ANMs, AWWs calling ICDS Supervisors), calling an ambulance (if they were far from a hospital), and/or a teacher or ASHA taking the child to a hospital directly via local motorized or bicycle transportation (if they were close to a hospital). From schools, teachers or headmaster would also inform a parent at the same time. It was clear that respondents knew they had multiple options, and that they had phone numbers of health personnel whom they trusted in case they wanted to consult. The NHM provides all health officials with Close Users Group (CUG) mobile phone numbers, according to a DMRCH. As one ABEO said, reflecting many others: there wasnoproblem,butiftherewas,theywouldreporttomedical. Perceptions of Anaemia Prevalence Adverse Effects and Emergency Preparedness
- 105. 93 With programme experience, those involved in giving IFA supplementation also know to wait a short while before determining whether a medical person should be consulted. A CRCC explained: “We advise… there will be some side effects like black stools, vomiting…. Do not get tensed… within30-45minutesthesethingswillgraduallyresolve."Ifitdoesnot,thentheyshouldcontactthe medical team, the contact numbers of which are already provided to every school teacher on the [IFArecording]form.AnICDSofficialtoldthat:“Acallto108[ambulance]doesnotconnecteasily.So whenevermothersarehavingaproblem,ourAWWstakemoneyfromthe (GKS), andbookanautoandtakethemtohospital.Theyarealsotakingchildrenlikethat.”Morecommonly, AWWssaid,theASHAwouldbetheonetogowithPLWoryoungchildren. A DMRCH described a more formal response mandated by GOI and state government and mandated per guidelines issued in October 2015 : “We have a committee to oversee the management of any adverse effects from IFA consumption. A letter has come from government to form this committee. Similar committees have been constituted at district and block level. Quality assurance committees, district executive committee, governing body committee are also there.” This mechanism is perhaps not as effective in the moment as the phone calls and trips to the hospital,butcouldperhapsplayamoreformalrole. The vast majority of respondents in all districts reported that they had not been involved with any NIPI beneficiary who had experienced an adverse effect of IFA or albendazole for which medical attentionwasrequired. There were incidents surrounding IFA consumption among students in Puri and Junagarh blocks in Kalahandi in 2014 that received attention in the media, and are even now associated with higher degrees of fear and reluctance to give tablets in schools throughout that state. As a district health official described the incidents:“After taking up the iron tablet, children began to vomit and had to be taken to the hospital. When this happened in Junagarh, the nearby schools stopped giving medicines, saying 'who will take this type of headache'. In that case we need to go that place, and sensitize them in order to bring the programme back on track. This, however, becomes quite difficult to do.” Another district health official also said: “10-15 secondary school students were hospitalizedintheJunagarhincident,inearly2014.Thereisstillresistanceinthosetwoblocks.” There was also an incident surrounding albendazole consumption in one student. A CRCC in Keonjhar told that one child had to be taken to the hospital recently after taking albendazole. The child got very sick in the night. The parent scolded the headmaster and locked up the school, and then took his child to the hospital. A test showed that the child had so many worms that one tablet in school was not enough. He was given a second albendazole tablet in the hospital, and felt better. However, the following day, only the side effects were featured in the newspaper, spreading fear acrossthestate. GaonKalyanSamiti 43 43 Operational Guidelines on “Emergency Response Syste” for any Adverse Event following IFA Supplementation & DeworminginOdisha,26October2015.
- 106. 94 6. SUPPORTIVE SUPERVISION, MONITORING AND REPORTING SUPPORTIVESUPERVISIONANDMONITORING The structure for monitoring and supervision is primarily: 1) visiting field sites including VHNDs, AWCs and schools and 2) reviewing progress during meetings. There was evidence that the visits and meetings occurred, but it was less clear about the content or quality of the monitoring and supervisionandif/whatactionsweretakenduringorafterasaresult. Asdescribedbelow,therewasmuchevidenceof supervisors visiting sites at which the NIPI program is carried out, but only a couple of examples of specifying the content of the visits. One ANM told that she would be happy for senior officials to visit more often: If someone from senior management comes to visit, they said, they will see if there is a tick mark for every Tuesday and Friday indicating that the mother hasgivenIFAsyruptoherchild. At the block level, visiting was reported by MOICs, BPMs, an MO PHC and RBSKTeams. MOICs and BPMs reported that they make field visits 10 days each month. A BPM said that they mostly go to VHNDs, and regarding NIPI, they enquire whether the young children are receiving IFA syrup. An MOIC said that they check records at the subcentreandobserveactivitiesattheVHND,andthathealsoreceivesamonthlyreportfromANMs (detailsnotspecified). APHCMOsaidthathewasrequiredtomakefieldvisits6timespermonthonTuesdays,Wednesdays and Fridays. He monitors availability of essential equipment with the ANM like the blood pressure instrument and weighing machine. During visits toVHNDs, the MO PHC supervises whether ANMs are measuring BP, pulse and distributing IFA tablets and syrup. He is not aware of any kind of blood testbeingdoneatVHNDs. Also at the block level, RBSK Teams told that their supervisor is their MOIC, who conducts unannouncedspotchecksontheRBSKscreeningsatschoolsandAWCs.Inaddition,oneRBSKteam said they prepare a formatted monthly report which is then reviewed at a monthly meeting. BPMs also visit schools when an RBSK team is visiting:“In 2-3 months we are also visiting 1-2 schools. We enquirefromtheRBSKteam andtheyinformusiftheyfaceanyprobleminanyspecificschool,then wetalktotheconcernedCRCCs..” Health Department Visiting field sites andrecords
- 107. 95 At the district level, several district health officials expressed a similar sentiment to a DPM, who describedhistimeconstraints:“PracticallyIamnotabletovisitthe10timespermonthrequiredasa minimumforallNHMstaff,withallthemonthlymeetings,courtcases,allcomplaints.Iamonlyable to make field visits 4 days in a month, but I am happy with that.”One District Collector initiated a novel way to check – he asked BPMs and other block officials to post pictures of themselves at the places they were visiting on a WhatsApp group, as well as report the number of pregnant and lactatingwomenwhoreceivedservicesatVHNDs. Regarding monitoring by the state level officials, one state level official said that there are 10 State Integrated Monitoring Teams (SIMTs) to monitor programmes, three districts per each team. Anotherstateofficialrecommendedrevivingcompliancecardsfrom2012-2013foradolescentgirls thatthegirlskeptwiththemandtickedeachtimetheyconsumedIFAtablets. Much monitoring and supervision about NIPI occurs in regular meetings in which NIPI is one of numeroustopics.Healthstaffreportedthatthereare: ASHAreviewmeetingsinwhichANMsreviewASHAs'work Health sector meetings with ASHAs, ANMs, male and female health workers, MO PHC and others,monthly Blocklevelmeetings,monthly RMNCHAmeetingswiththeCollector,periodically Despite the number of visits and meetings for monitoring and supervision, little was mentioned about the content of what was learned by those who were monitoring and about any actions taken during and after these occasions. Hence, it is not clear how productive they are for identifying and solving the key issues that arise in the field, block, district, and state levels. As one state Health official said that the NIPI implementation system is in place but mechanisms for checks and monitoring ground reality are not:“Unless higher officials take interest in the programme, data is easily cooked and fed into reports from districts without them being able to monitor the actual situation.” IntheICDScontext,theAWWsatfieldleveldidnotreportanymonitoringofironsupplementintake bywomenorchildren,thisbeingtheroleoftheASHAs. AWWs from four of the six blocks, one set of ICDS Supervisors themselves, and one CDPO all describe the active visiting and supportive supervision schedule of the ICDS Supervisors. The SupervisorsthemselvessaidthattheyvisiteachAWWonceevery2-3months,orforthosethatneed Meetings Content and Quality of Monitoring and Supervision not Strong Visiting field sites andrecords â â â â ICDS
- 108. 96 more supervision, once each month.The ICDS Supervisors report always having access to a vehicle for visiting the AWWs, with 2-3 Supervisors travelling together. ICDS Supervisors report that they observe“…pre-school, SNP and registers, conduct home visits forVHND, and counsel mothers with malnourished children.” Importantly from a monitoring perspective, Supervisors arrive unannouncedfortheirvisits. At block level, CDPOs also visit the AWCs. Two groups of AWWs report being visited by the CDPO madam. We make the programme and submit it to sub-Collector and visit accordingly.” This includes supporting VHNDs. At district level, one DSWO described only that DSWOs should visit sites10dayspermonth,butdidnotconfirmherfrequency. In addition to supervision from within ICDS, AWWs report that ANMS also give them direction, and thattheMOICsvisittocheckonthem,andthatRBSKTeamsalsovisitregularly. Monitoring and review is also conducted in regular meetings, as with the Health Department, according to AWWs, ICDS Supervisors and CDPOs, and NIPI is discussed in these meetings some of thetime: Sector meeting of ICDS Supervisors, twice per month – AWWs report that IFA and anaemia arediscussedoccasionally ICDS review meetings, monthly – A CDPO reported regularly reviewing NIPI among adolescents including supply status, compliance, and any side effects observed, on priority basis Block meetings with the CDPO, BDO, BPM, other doctors, ICDS Supervisors and AWWs, monthly–AWWsreportedthatNIPIismentionedonlywhenabatchofIFAtabletsarrive Thenotionofmonitoringexistsstronglyamongstaffofthe ICDS, even if IFA consumption is not always among the variables being monitored. One district official said that every month someone from WCD state level visits district- wise, arriving unannounced to check on “all activity of anganawadi, IEC activity, and IFA supply and expiry date. Last month it was the Deputy Secretary WCD, and the monitoringofficialoftencomes.” Despite a strong notion of monitoring, a WCD official perceives the NIPI programme as the baby of the Health department as ICDS only reports on IFA consumption for out-of-school adolescent girls, a small portion of NIPI participants. Meetings Content and Quality of Monitoring and Supervision not Strong â â â
- 109. 97 EducationDepartment Visiting Field Sites and Records Meetings Content and Quality of Monitoring and Supervision not Strong At the sector level, many described the active role that CRCCs play visiting schools to supervise, assist and monitor teachers. Teachers, CRCCs themselves, a BEO and a DEO described that CRCCs visit about 4-25 schools per month in different districts, arriving unannounced. The DEO said that theCRCCsshouldbevisitingminimum15schoolspermonth.Respondentswerenotspecificabout thecontentofthesupervisionorthemonitoring,butrelatedtoNIPI,twoCRCCsdescribedthatthey reviewschoolrecordsontheamountofIFAreceived,consumedandremaining. At the block level, a BEO and DEO reported that visits to 10 schools per month were required for BEOs, 5 schools per month for ABEOs, and that the DEO also visits schools.. However, BEOs and ABEOs do so without provision for transportation, except bicycles, which can constrain how much they visit schools. BEOs and ABEOs check on the progress, reviewing the CRCCs' monitoring. Only one CRCC mentioned review specific to NIPI, saying that the BEO and ABEO check of the administrationofmedicinesattheschools. At the district level, DEOs and a DPC/SSA indicated that the monitoring system at the district level is not frequent. This is due to heavy workload of district officials, lack of data shared from the Health departmentandlackofinformationonIFAsupplementationalongsidetheregulardatasentupthe levels on the Samikshya format about MDMs (addressed further in the section on Content and QualityofMonitoringandSupervision). Supervision and monitoring is also conducted in Education regular meetings, as with the Health and ICDS Departments, according to CRCCs, BEOs, an ABEO, a DPC/SSA and a DEO. TheyreportthatNIPIisdiscussedinthesemeetingssomeofthetime: BEOs and ABEOs meet with CRCCs, monthly– a report from a district suggests that NIPI is not discussed, whereas one from another district suggests that BEOs review NIPI data collected bytheABEOs2-3timesperyear. District meeting of the DEO with BEOs and ABEOs, monthly – a report from one district suggests that NIPI is not discussed, whereas ones from two other districts suggest that the performanceofIFAsupplementationineachblockisreviewedasapartofMDMreview. DistrictmeetingofaDWOwiththeheadmasters,ANMspostedattheresidentialschoolsand lady matrons, as well as visits to residential schools – their health checklist is mostly about hygiene,notanaemiaandIFAsupplements. By2016,theEducationdepartmenthadbeguntoincreaseitslevelofmonitoringandsupervisionof NIPI activities, in contrast to the first years. A state level Education official said that the state level officials were watching more closely, and the district officials were taking more initiative.. A block â â â â
- 110. 98 official was particularly motivated to improve the rate of reporting: “Our district was a defaulter earlier.Butsincelastyearwehavegivenreports”. The notion of monitoring exists among those involved in education, even if IFA consumption has not yet become a monitoring priority. One set of teachers proudly told that their CRCC and block officials come to see the MDM and“whether our environment is good or not, whether teachers are teaching or not, what is the development in the students, how many children are migrated… and why there is migration.”IFA consumption is not mentioned, but the notion of monitoring exists. In addition,oneCRCCdescribesawayofalsofollowingupactionbasedonmonitoringinformation. In the residential secondary schools, there is a standard checklist for monitoring and reporting attendance,health,hygieneandotherschoolindicatorsoftheboarders,butIFAconsumptionisnot a part of the checklist, and there is no reporting on those children who attend the residential schools as day scholars instead of boarders. Monitoring in the residential schools could also be improved relatively easily. Also in need of improvement in the residential schools is that the ANMs assigned to the schools through the Education department, not the Health department, did not havesupervisorstodiscusstheirworkwith. An important issue when tracking reports of data and motivating those who will be recording it is for all concerned to know what the purpose of the data is and how the data will be used. At minimum, data is recorded to show accountability for having distributed the IFA tablets and syrup. Purposes beyond this minimum can help shape the format and frequency of how the data should be reported. Ideally, the data recorded at all levels will be reported back to those who compiled it in summaryformsothatitcaninformtheworkateachlevel. One DEO was not clear on the purpose of the reporting:“Actually we don't know what is happening with it later on because we don't receive any feedback. It is not being assessed or what we don't know as we have not received any feedback on the mistakes or whatever is there in it.”Whereas a BEO in another district knew that districts and blocks were ranked within the state based on the extentofreportingeachdidontheamountofIFAsupplementationconsumed.Consumptioncould behighinastate,butifthereportsonthatconsumptionwerenotcomplete,adistrictorblockcould notachieveahighrank. All respondents told of a similar flow of reporting across departments and districts, with the exception of Bhadrak Health and ICDS Departments, and the flow of reporting was consistent with theguidelines(Nov2015 ),withonlyafewexceptions. Health officials' reports are compiled across field level into sector and across sectors into block and districtanddescribedas: 44 RECORDING AND REPORTING MECHANISMS People Involved in the Flow of Reporting Ibid, NIPI Operational Guidelines Health, WCD, & School, 30 November 2015. 44
- 111. 99 IFAredtabletsforPLW: ANM(withhelpfromASHA) MOI/C CDMO,andsometimescopytoDSWO (InBhadrak,ASHA ANM AWW ICDSSup CDPO DSWO,andcopytoMOI/C) IFAsyrupforchildren6months-5years: ANM(withhelpfromASHA&AWW) MOI/C CDMO,andsometimescopytoDSWO (InBhadrak,ASHA ANM AWW ICDSSup CDPO DSWO,andcopytoMOI/C) ICDS officials' reports are compiled across field level into sector and across sectors into block, districtandstateanddescribedas: IFAlargebluetabletsforout-of-schooladolescentgirlsonly: AWW ICDSSup CDPO DSWO CDMOandWCDSecretary Education officials' reports are compiled across field level into sector and across sectors into block anddistrictanddescribedas: IFAlargebluetabletsforin-schooladolescentgirlsandboys: Headmaster CRCC ABEO/BEO/BRCC DEO& sometimesDPC(SSA) CDMOandSNOMDM Thereportedflowofreportingdifferedslightlyfromtheguidelinesforreporting: ANMs said they reported directly to MO I/Cs instead of through LHVs per the guidelines, a position that did not seem to be filled. Per the most recent guidelines , there was no mention of the Health Worker Male picking up the IFA consumption records from the headmasters and giving a copy to the MOI/C.Infact,HealthWorkersMalewerehardlymentionedbyrespondents. Reporting IFA consumption was cited as inadequate for many units under the Education Department – numerous schools did not report to a CRCC, numerous CRCCs did not report to an BEO,numerousBEOsdidnotreporttotheDEO.TeacherssaidthatnoCRCCeveraskedforreportsof IFA consumption. One headmaster and teacher said that they did not keep records of IFA consumption at their school. And one BEO said:“Some teachers are manipulating the data because their main job is to teach.They do not think these programs are part and parcel of their job. As long as they don't have a sense of ownership for these programs the success rate will remain low. We shouldmakethemrealisetheimportanceoftheseprogrammesforkids.” Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z 45 Inadequate Reporting 45 Directorate of Family Welfare letter, 7 December 2015, Subject: Involvement of HW(M) and RBSK MHTs in strengtheningNationalIronPlusInitiative(NIPI)interventioninOdisha.
- 112. 100 Formats and Mechanisms of Reporting Health ICDS Education For the IFA red tablets administered to pregnant women (but not lactating), ANMs report consumptionthroughtheHMISonamonthlybasis.Unfortunately,thetemplatestillaskedwhether a woman is taking 100 or 200 tablets instead of asking whether she is taking 180 or 360 tablets per thenewguidelines. Many respondents said that there is no format on which to report consumption of IFA syrup for childrenunder5,noraretherequestionsaboutIFAsyrupintheHMIS.ASHAsandAWWsrecordeach doseofsyrupconsumedoneachchild'sMCPcardandtheykeeptheirownregister(andASHAskeep their own diaries), and any compiling and reporting is tallied without the benefit of an established form. Also, when women take IFA tablets at home they mark on the MCP card. ASHAs noted that earlier cardshadnoprovisionformarkingcomplianceinconsumptionofIFAtablets,butinthecurrentcard there is a page with circles to be filled each time a woman consumes her tablet(s).Women bring the cardtotheVHND,andifregularconsumptionisnotindicated,theASHAsareremindingthewomen. Theyarealsocheckingtheircardswhenwemakehomevisits. IFA consumption is not recorded in the ICDS Monthly Progress Report (MPR), the AWWs main reporting mechanism, a monthly form for tallying other items to discuss in the monthly convergence meetings, and ICDS Supervisors suggest that it be added. According to a PO & consultant, anaemia is part of both the SABLA and Adolescent Anaemia Control Programme, but theyhavedifferentreportingmechanisms. The teachers typically keep two registers. One in which they tick off students who consumed an IFA tablet each week, and a stock register, where supply of IFA tablet is noted, including amount consumedeachMondayandtheamountofstockleft. The CRCCs report on IFA consumed in the Samikshya format and meals consumed in the MDM format. As one said: “There is no register from the government… [the teachers] do as per our instruction…. It would be better if the government would supply a register or format…. If they take seriously,itwouldbebetter.” An important finding is about a gap in the NIPI reporting format itself that could be relatively easily remedied. CRCCs describe that there is a place to record IFA consumption alongside MDM consumption in their Samikshya reporting form at the S&ME schools. However, there is no place to record IFA consumption on the Samikshya forms that are sent about MDM consumption to the block, district or state level. Many officials recommended that the IFA consumption data have a place to be recorded in the Samikshya MDM consumption format so that it can be more easily compiledandreportedtotheblock,districtandstatelevelsoftheEducationdepartment.
- 113. 101 7. DEWORMING Biannualdewormingtreatmentwithalbendazolewasreadilyacceptedacrosstheagerangesofthe NIPI programme, in schools, AWCs and VHND settings. Beneficiaries said that the medicine tasted good, and tablet distribution occurred twice per year.While deworming with albendazole is widely practiced,thepromotionofhygieneanddietarypracticesisacceptedbutnotfullyachievable. As one set of mothers described, worms make children weak, and they lose their appetites. While many beneficiaries understood that parasitic worms infected people by burrowing in through the skinandbyeatingsoil,anumberreportedthatwormswerecausedbyeatingtoomanysweets.They were clear, however, that the deworming medicine albendazole would treat the worm infestation and that using the latrine instead of the fields, wearing sandals in the latrine, and washing hands withsoapafterthelatrineandatotherkeytimescouldpreventit. Albendazole is a well-liked part of NIPI programme, especially by beneficiaries for its sweet taste. Fathers in Keonjhar knew their children were getting deworming medicine. They did not feel that theyknewmuchaboutthehealthinterventionsthroughtheschools,butthedewormingstoodout tothem. Regarding children in school, all respondents who were asked reported that albendazole tablets weregiventostudentsinschooltwiceeachyear,6monthsapart. Regarding pre-school aged children, all health personnel who were asked reported that children 1- 2 years old are given 5 ml of albendazole syrup twice each year, 6 months apart, and children 2-5 year olds are given 10 ml. One set of ASHAs confused the age groups for albendazole syrup with thoseforironsyrup. Most health and ICDS personnel reported that they have never seen any side effects from albendazole. An ICDS Supervisor said that they tell mothers what to expect from deworming, and if thereisanyadverseeffect,theyshouldgivethechildrestandinformtheAWW.Educationpersonnel expressedafewfearsaboutadverseeffectsfromthemedicine. Supply of albendazole tablets in schools was available for almost all distribution days. The stock arrives close to programme day, and no stock is kept during the 6 months in between. Two CRCCs toldofshortages:Onesaidthatin2015theygavethe1 dose,butnotthe2 ,whileanothersaidthat thetabletsdidnotreachintimeforNationalDewormingDaythatyearbuttheycollectedextrafrom sub-centresandcompletedthedistributionwithin10-15days.InAWCs,noshortageofalbendazole syrupwasreportedbyhealthandICDSpersonnel. Interviewees commented on other health programmes that could also contribute to reducing anaemia. One official commented that malaria is prevalent in Kalahandi. Another there told that they have Rapid Diagnostic Kits to test for malaria among pregnant women and medicine to treat them if they test positive. In Keonjhar, workers reported that malaria was prevalent, but has been reducingsincepeopleareusingmosquitonetsproperly. st nd KNOWLEDGEOFPARASITICWORMSWITHANAEMIA MALARIAANDFILARIASIS MECHANISMSOFTHEINTERVENTION
- 114. 102 8. SOCIAL MOBILIZATION AND COMMUNITY AWARENESS ON ANAEMIAANDNIPI Mobilization of the NIPI programme and consumption of IFA, from the state level to beneficiaries, has increased steadily over the 3 years since NIPI was started. IFA consumption was initially not well accepted, but after much effort has improved steadily. This is due to the diligence and persuasion across the Health, Women and Child Development, and Education Departments and coordinated from state, district, block, sector, field and beneficiary levels. Biannual deworming treatment with albendazole was readily accepted across the age ranges of the NIPI programme, in schools and AWC settings – most beneficiaries said that the medicine tasted good, and tablet distribution occurred twice per year as per government guidelines. Two set of behaviours are also related to the NIPI programme: increasing hygienic practices to prevent worms and dietary practices to enhance iron intake. Both behaviours were well- understood but not always practiced. Of these four programme elements , 1) awareness and IEC about IFA supplementation is discussed the most in this report, since it requires the most effort to implement; 2) deworming with albendazole is readily accepted, while the promotion of 3) hygiene and 4) dietary practices are accepted but not fully achievable. See Box 5 for key messagesfromthissection. A common theme of programme acceptance was expressed by respondents: “Initially there was huge resistance from parents, SMCs and teachers”to allow the distribution of IFA tablets, but “things have improved” said a high-ranking district official. “Earlier adolescent girls didn't like taking IFA, but now they ask for it”, said AWWs in another district.“In the beginning, they didn't wanttotake,butnowtheylineupnicelyonMondays”,reportedteachers. Success to date is largely due to two factors: setting up and improving the system of IFA procurement and distribution, and dissuading key officials and stakeholders of their resistance to IFA. Indeed, success is sometimes stated as lack of resistance instead of full support for NIPI: “No parents,guardians,SMC,students,orcommunityhaveopposedNIPI…sincethebeginning”saidan education official in Keonjhar. Positive and consistent awareness-raising about anaemia and NIPI programme,however,hasbeenonlyasmallpartoftheeffortstodate,and,accordingtomany,isthe 46 46 Guidelines for Control of Iron Deficiency Anaemia: NIPI, NRHM, 2013 Box5.KeyMessages l l l l l l Resistance to NIPI has decreased signifiantly due to social mobilization Full ownership of programme, however, is lacking, and IEC initiatives could build enthusiasm fortheprogramme Knowledge about anaemia is growinggradually Sources of information are mostly interpersonal, some radio (Meena), andlimitedTVandprint Largest gap is that anaemia is invisible – respondents do not think they are anaemic, nor do they know anyone who is, except severe anaemia. Health Department is the main messenger for anaemia and IFA because “everyone listens to doctors”.
- 115. 103 highest priority for programme improvement: Awareness raising is a must for programme success, suggested one high level official, and“Understanding of the anaemia situation is very less”said a high-rankingdistrictofficial. Anaemia was described by most respondents as weakness of the blood or shortage of blood (“bloodlessness”). This was common across beneficiaries and officials and health care providers alike. One group of adolescent school-going boys even elaborated correctly that anaemia was a condition of reduced haemoglobin in the blood, hence less oxygen circulating.. Occasionally, beneficiarieslikeonegroupofmotherswouldindicatethattheydidnotknowwhatanaemiawasor why they were taking IFA supplements or giving IFA syrup to their young children. Fathers often could not describe much about anaemia, too, but some knew to eat spinach and other green vegetables to combat it, that ASHAs gave their young children syrup, that their wives take IFA tabletsinbatchesof30throughoutpregnancy,andthatconsumingIFAcompensatedfortheblood lostindelivery. When asked about the common illnesses and conditions, neither officials, front-line workers nor beneficiaries mentioned anaemia, but talked of fever, diarrhoea and skin diseases among children, andbackpainandoedemaamongpregnantwomen. Beneficiaries and field level workers knew that tiredness -- weakness, feeling faint, doing less work, less concentration -- and pale colour (“bloodlessness”) of eyelids, tongue, nails and skin are symptoms of anaemia. Low appetite was also sometimes reported for both women and young children. Reflecting confusion of symptoms from other conditions, beneficiaries and field level workers also frequently reported swollenness as a symptom of anaemia – swollen face, feet, hands, andinthestomachsofpregnantwomen–tinglingofhandsandlegs,andhairfallingout. Respondents at all levels reported that anaemia in pregnant women could cause problems in child's development in utero, in delivery (prematurity, death or disability from haemorrhage) in young children could limit mental growth.Women and adolescent girls also reported that anaemia could cause irregular menstruation cycles. IFA supplements would prevent these negative consequences. In one group, an ICDS Supervisor said, “Children would be brainy and good”. Occasionally the benefits of IFA were oversold, e.g., telling pregnant women that IFA consumption would eliminate or reduce post-delivery abdominal pain. Mothers also credited the syrup given to theiryoungchildrenwithpreventingcolourblindness(confusingitwithvitaminAsyrup). KNOWLEDGE OF ANAEMIA IS INCREASING: RESPONDENTS DESCRIBE THECONDITION,CONSEQUENCES,SYMPTOMS,ANDCAUSES Describing the Condition Consequences of Anaemia and Benefits of IFA Supplementation
- 116. 104 Causes of Anaemia Causes of Inadequate Diet Sources of Information – Interpersonal Many respondents knew the causes of anaemia. The most common causes mentioned by beneficiaries and field level workers were inadequate diet and worm infestation (Perceived causes of worms are described in the Deworming section). Malaria was also mentioned sometimes (and usingbednetstopreventmalariawasknown),aswaslosingbloodduringmenstruationandduring delivery. Early marriage and early pregnancy were also cited as contributing to anaemia. Regarding delivery, one group of ASHAs persuaded pregnant women to take IFA, saying that with supplements women will have the required amount of blood that they would lose during delivery, otherwisetheycoulddie. Beneficiariesandfieldlevelworkerswereaskedwhattheyknewaboutfoodsthatpreventanaemia. Themostcommonlymentionedfoodsweregreenleafyvegetables,includingdrumstickleavesand spinach, pulses, milk and eggs. Also frequently mentioned was to drink tea at times other than meals.Insomecases,theyalsomentionedmuttonmeatandavarietyoffruitsandjiggery.Somealso mentioned foods that are not iron-rich or iron-absorption enhancing like starches/grains (rice, wheat,rootswithiron,pearlmillet),andsalt(possiblyconfusingironwithiodine). Ultimately though, said one district official, no matter how much we talk about balanced diet, in homes most people are not able to achieve it, and so IFA supplements are needed to improve the diet. Thus, the basic NIPI information about the IFA supplementation and deworming medicine to combat anaemia are known by most beneficiaries and field level staff. Supporting information on how to attain good hygiene to avoid worm infestation and malaria and to diversify diet is basically known as well, though neither is practiced consistently by those who know the information well. Themessagesneedtoberepeatedandre-enforced. Beneficiaries reported learning about anaemia, IFA supplements and deworming medicine from different sources. The field level workers (AWWs, ANMs, and sometimes ASHAs) inform out-of- school adolescent girls and women about their own iron status and that of their young children. Teachers and RBSK teams inform school-going adolescent girls and boys. The main way to spread informationaboutNIPIisverbal.RBSKteamsvisitedeachsecondaryschooleachyear(onceperyear in S&ME schools and four times per year in SC/ST residential schools) to conduct medical exams on all students, diagnose and refer any health problems, and conduct health education in the classrooms.They speak on a variety of health topics, including anaemia, and are the main source of healthinformationtostudents,teachersandheadmasters.AnRBSKteaminKeonjharreportedthat they do not have a checklist of topics to cover for each classroom, but themselves make a plan so SOURCES OF THE INFORMATION – MESSENGERS, MEDIA, IEC
- 117. 105 theycoveralltopicsovertimeateachschool.Onegroupofadolescentssaidtheyweretaughtabout anaemiabytheirteachersinStandards4-5,butoverallteacherswererarelymentionedassourcesof information. Students in one school in a district also learned about anaemia by listening to the Meena radio programmeweeklyduringschoolonSaturdays.Afewgroupsofadolescentsandmothersreported they had heard something about anaemia on TV, but gave no detail on the content, while others said they had never heard about anaemia from TV. Pregnant women reported that they learned fromANMsorASHAsduringVHNDs,butdidnotmentionanyhomevisits.Adolescentgirlsreported that “We watch on TV also, but we understand more from the AWW.” No beneficiaries reported seeingpostersorotherprintmaterialsonanaemia. The most common recommendation for enhancing NIPI success was to raise awareness on the profile of anaemia and on combatting it with IFA, diet, deworming and hygiene. While there is guidance on implementing other aspects of NIPI, e.g., procurement and reporting, there is much less on how to raise awareness among beneficiaries, community members, field level workers and others, and hence on to build demand for reducing anaemia. As one district-level education official explained, “There is no problem related to IFA tablets. Only awareness is required.” Awareness- raising efforts are much less for anaemia than for other health topics, like malaria, explained one groupofANMs.Thus,manyoftherecommendationscompiledbelowtoensurefurtherNIPIsuccess focus on raising awareness about anaemia and NIPI and creating demand improving iron status across thepopulation. Many respondents from all levels reported that they did not currently have or had not seen NIPI IEC materials. There had been materials earlier. Many said that some printed NIPI IEC materials were distributed at the beginning of NIPI (in 2013 or early 2014) – posters and booklets were most commonly mentioned – but none more recently. In one district, BPMs said that they are still making photocopies of the original booklets, and an AWW from there showed her only copy, which she says she consults and asks the adolescent girls to read from it during their Saturday sessions. In Keonjhar a senior health official said that posters are on the walls of health Sources of Information – Radio, TV and Print Little Emphasis on Raising Awareness IEC Materials Limited The blue coloured WIFS booklet developed by Department of Health and Family Welfare, GovernmentofOdisha
- 118. centres, AWCs, and secondary schools, though ICDS and Education officials there said they had no NIPI IEC materials. In one district, one team of RBSK said there were no materials on IFA but some for deworming, and one group of BPMs there said there were none for schools and none on IFA syrup but some on health during pregnancy and on deworming. All teachers had received booklets according to a CRCC and an RBSK team in another district. In the 9 districts in which the SABLA programme for adolescents at AWCs is running, there is a kit of materials on health and livelihoods, butbothAWWsandadolescentgirlsreportedthatitdoesnotcontaininformationonanaemia. Oneofthemajorconstraintstoraisingawarenessabouttheimportanceofreducinganaemiaisthat mostrespondents,fromstatelevelthroughtobeneficiaries,claimednottoknowmanypeoplewho were anaemic. This is despite Annual Health Survey 2014 results for Odisha results from 2014 indicating that 70-80 percent of women, adolescents, and young children are anaemic (seeTables in the Background section). The district-wide prevalence is even higher in Keonjhar and Jagatsinghpur, and similar to the state-wide proportion in Bhadrak and Kalahandi. Respondents who answered that they know someone who is anaemic describe persons with visible pallor, a blood transfusion, or cerebral malaria. Most respondents asked about this reported not knowing anyone who was anaemic. For example, mothers in one district said that their children were not weak or anaemic. Adolescent boys in the same district and adolescent girls in another district said that they don't know anyone suffering from anaemia. A matron in an SC/ST school said she had no anaemia case in her hostel. An ICDS official in another district said that he had not noticed any problems of iron deficiency, though children suffer from diarrhoea and minor illnesses. And an educationofficialsaidthatgirlswerenotanaemicbecausetheyareliterateandknewhowtocontrol it,includingtakingIFAsupplementsanddewormingmedicine. Even women who were taking double-dose of IFA supplements while pregnant or lactating were notreportedasanaemic,notbythemselvesorbyfield-levelhealthworkers.Thiswasthecaseevenif ANMs had assessed their haemoglobin during VHNDs and found them to be in the anaemic range andifthewomenthemselvesweretoldtotakeadoubledoseofIFA. This suggests that“anaemia”is interpreted as severe anaemia, which is indeed far less common (0- 8%, see Table from AHS in the Background) and that moderate and mild anaemia is virtually invisible. As an RBSK team said,“The reason anaemia doesn't get priority is that it is not seen.”Only one group of teachers, in another district, effectively acknowledged the invisible nature of anaemia – they requested IEC materials that included before-and-after pictures so that students could visualise how they would look with anaemia and without it, e.g., lacking concentration vs. feeling attentive to their studies. It is a major programme gap if beneficiaries and field level workers have knowledge about anaemia and are willing to go through the steps of implementing it, but do not think the beneficiaries are anaemic or in need of the NIPI programme. Participation in NIPI will not 47 INVISIBILITYOFANAEMIA 47 AnnualHealthSurvey(AHS).Clinical,AnthropometryandBiochemical(CAB)Factsheet,Odishasection,2014. 106
- 119. have much importance for them, and they will not take much “ownership” in it. Thus, a major emphasisoffutureawareness-raisingeffortsshouldbetoimpressonallNIPItargetgroupsandtheir families that they likely experience anaemia or are at risk of it (3 out of 4 chance), and that their participation in NIPI will benefit them. It is expected that this would be key for all those associated with the NIPI programme, especially the beneficiaries, to take a more personal interest in anaemia reduction. An important aspect of resistance to IFA at the beginning of NIPI was that many associated with the Education Department – teachers, headmasters, SMCs, CRCCs and others – were reluctant to implementamedicalintervention.Theyfearedbeingonthefrontlineandbeingperceivedasbeing responsible if students experienced side effects from the IFA, which they thought of as medicine. Earlyintheprogramme,themediaprintedastoryfromKalahandiDistrictinwhichastudentfainted after taking the IFA supplement.The student likely fainted due to dehydration or other reason, but many, especially the print media, associated the incident with IFA.This increased the teachers' fear and their resistance to distributing IFA supplementation to their students. There were reports of students or teachers throwing the supplement away, of parents and SMCs telling students not to takeit,andofCRCCsrefusingtotaketheIFAtabletstoschooltobedistributed. What emerged from the early resistance is that the Health Department officials, particularly the doctors, needed to be the main spokespersons promoting NIPI and handling the response to any perceived side effects. As a CRCC said, “A medical doctor has good status and position in the community and people could get convinced by doctors easily.” As an education official from another district said, “Suppose there is a local school where there is resistance against administration of IFA tablets. Teachers might be thinking it is not their duty. There should be instruction to the Health Department to organize a campaign by the health workers in school or community.That has to be done by the Health Department.”And indeed, it seemed that the Health Department was taking that responsibility, and that others involved in NIPI were able to count on their leadership. As the education official explained,“I talked to the MO of the area in which there wasresistance.Hetoldthathewillsendhealthworkerstocreateawareness.Inthatparticularschool hewillcallameetingoftheparentsandsensitisethematter.” Onegroupofteachersalsoadvocated forAIIMStoconducthealtheducationthroughoutOdisha,sayingthat“Villagerslistentodoctors”.It should be noted that respondents also suggested other important secondary messengers, to minimize local resistance, especially tribal leaders ( ) and influential people in villages because,asonesetofICDSworkerssaid,“Everyonelistenstothem”. mukhiya HANDLINGTHEEARLYRESISTANCE Health officials as the Main Messengers 107
- 120. How IFA was Promoted to Respond to Resistance Functionaries reported a number of special efforts they made to combat the resistance to IFA consumption at schools and among mothers, as well as regular features. In schools, an RBSK team and CRCCs told that two years earlier they had held a special meeting with headmasters and teacherswhodidnotwanttheschooltoreceiveIFA,andconvincedthem.Inonecasethisteamsaid they trained a health coordinator on how to convince the resistant parents. In another district with continued resistance in 2-3 clusters, the DEO met repeatedly with key people there so that the IFA could be distributed fully. While the parties still do not seem interested in the school children receivingIFA,theyarenolongerresistant. One element the team was listening for during the interviews was how much demand for IFA supplementationhadgrownovertheseveralyearssincetheNIPIprogrammestarted.Demandonly manifestedinacoupleofsmallways,butthesearehopeful.Teachersacrossthedistrictstoldusthat students would remind them of IFA distribution on Mondays, and notice if the supplements were not available at the usual time. Also, in one case, AWWs told that mothers-in-law accompany their daughters-in-law to make sure they receive IFA, and that they take them from the government, not theprivatedoctors. Even private doctors exhibited demand for the government's IFA supplementation. A number of government officials explained that beneficiaries regarded cost-free medicines as low quality. Indeed, ANC examinations during VHNDs were also regarded as low quality because there was no privacy afforded where they were conducted, typically on the veranda of the AWC. However, for the IFA supplementation, several groups of mothers and ANMs from several districts told us that women had returned to VHNDs after private doctors had told them to get their IFA there free of charge. Another way that nascent demand was expressed was through locally initiated innovations to promote the NIPI programme.While there were only a few examples, it seems that districts, blocks, sectors,schoolsandotherplatformscouldbeencouragedtoinnovatefurtherthroughoutOdisha: Atrainingfor270nodalteacherswasorganisedbythehealthteaminBhadrak A “campaign on NIPI” – getting MO I/Cs to speak on NIPI at schools was conducted in Jagatsinghpur Many frontline workers gathered together on National Deworming Day to promote deworming Readers club dedicated to health each 2 Saturday of each month initiated by teachers in Jagatsinghpur Schoolclubscompetingonhealth,initiatedinaclusterinJagatsinghpur. nd DEMANDFORNIPIANDNASCENTPROGRAMMINGINNOVATIONS â â â â â 108
- 121. 9. HARD TO REACH AREAS Discussed so far are numerous programmatic issues related to the NIPI programme. In this section a set of external factors concerning beneficiaries being hard to reach are discussed, which impose additional constraints on programme implementation. As expressed by the interviewees, “hard-to-reach” had four components – remoteness in terms of residing a far distance from main roads and from government attention, language in terms of beneficiaries not speaking Odia, tribal issues and customs, and low education level of beneficiaries. Though all four might exist together, especially among tribal people, separating out the components of being hard-to-reach is important for making recommendations to reduce programmatic constraints related to their geographic, cultural and educational circumstances.SeeBox6forkeymessages. Among the 6 blocks where interviews were conducted for this report, two are tribal-dominated – Keonjhar/Harichandanpur and Kalahandi/Lanjigarh. Most of the comments about being hard-to- reach came from these areas. There were also comments from two non-tribal areas– Keonjhar/Banspal and Bhadrak/Bhandari Pokhari.There were not comments about being hard-to- reachfromthetwoJagatsinghpurblocks,RaghunathpurandKujang. According to a health official in a largely tribal area, about 35% of the 472 villages are cut off from transportation during the rainy season, a few of which are cut off all year. Despite this, about 90% of VHNDs are conducted (more than 1500 of about 1700 sessions scheduled in the block). The ASHA andAWWliveinthevillages,andsoarethereallthetime.Sanitationfacilitiesarenotcommonthere, reportedanSMCmember–inonevillage90%ofhouseholdsdonothavelatrines. In one tribal-dominated village, fathers said that officials do not give much attention to their community.Theyalsodescribedthattheylivedfarfromamotorableroad,andduringanyflooding, which was very common, they would have to carry sick patients to the road on a bamboo carrier on their shoulders. They said that there are not many doctors in the tribal areas. According to village leaders, in recent years, non-trained doctors (“quacks”) have come into the area, selling ineffective medicinesathighprices. In another block, roads can also become impassable in the rainy season. An RBSK Team described that if they got to the village to do school screenings and it rained, they would not be able to come back. Some areas are remote because there is little phone connectivity, since there is only one REMOTENESS – DISTANCE FAR FROM MAIN ROADS, AND FROM GOVERNMENTATTENTION Box6.KeyMessages(HardtoReach) l l Four ways in which beneficiaries were hard-to-reach are: remoteness from main roads and government attention, language, tribal customs, andloweducationlevel NIPI-specific recommendations are to: engage tribal leaders to promote IFA and deworming, diet and hygiene; and prepare and use IEC materials in the major local tribal languages. 109
- 122. mobile tower in the block and the remote areas are not reached. In this case, people in the remote areaswouldalsonotbeabletoreachthetwohealthemergencynumbers(108and102).Inaddition, people fear the elephants who live there and sometimes do not seek health care out of fear, according to an ICDS official there. On the other hand, she said, in remote areas beneficiaries may attend services likeVHND more regularly because they do not have the private or other alternative healthservicesthatareavailableinmorecentralareas. In yet another block, some roads have been improved, but some still become covered in water during the rainy season and people need to get around in boats.This makes it difficult to deliver IFA supplements. A high level education official had not yet been to the remote areas in his district, but thought he should go. A health official said that some areas in the district are unreachable in the rainyseason,butcommunicationislessofaproblem–99%oftheareascanbereachedbyphone. In one district, in response to the remoteness, district health officials decided to take the health system to the distant villages in tribal areas. Regular health camps with doctors, gyanecologists, paramedics, nurses and ANMS were started in early 2016. Haemoglobin of pregnant women was tested, deworming medicine given, family planning methods promoted and provided, and many other services provided. Attendance was initially slow, but then the village headmen were contactedaboutaskingthewomentoparticipate,andattendanceincreased. In the tribal areas, the local tribal language, e.g., Juang, Munda, Ganda and others, is the mother tongueandOdiaisnotknownbyall.OnegroupoffathersexplainedthattheyspokeSantali,butnot Odia. This can be a problem if the beneficiary and the service provider cannot communicate, as described by an RBSK Team: “There are some people who cannot speak our language, and we cannot learn their symptoms or know how to send them for treatment”. However, it often is not a problem if translation is available, as reported by a health official:“We have no language problem. Peoplespeaktheirtriballanguage,buttheASHAandAWWfromthesameareatranslateforthoseof us who do not understand.” Whether translation is available or not, it is recommended that IEC materialsbeproducedinthemajortriballanguages,assuggestedbyhighlevelhealthofficials. A number of tribal beliefs and customs came to light during the interviews. The Juang in one area have a conviction that if they will have the tubal ligation operation for family planning, the ancestors will not receive offerings from them, though these ideas are reducing. Also, according to AWWs“Some mothers-in-law tell that due to iron tablet the child will grow more in the womb and the mother has to go for caesarian. We tell them the bleeding will be compensated with the iron tablet. Many in-laws now understand, and the anti-supplement ideas are reducing.”Furthermore, medical field workers explained that males in their tribal areas do not cooperate with AWW or allow LANGUAGE TRIBAL ISSUES AND CUSTOMS 110
- 123. family members to take services from VHND or AWC. However, they reported, this is starting to changebecausethetribalmenmixwithotherswhovalueandusetheservices. On a different note, fathers told that their ASHA does not come to their village, since she is of a different caste and does not speak their tribal language. By contrast, in a tribal neighborhood, adolescentgirlsreportedthatanASHAandanAWWgotogethertoprovidehealthservices,though theyliveinanon-tribalarea. As an ANM said,“As we work at the field level we feel that other people come to health centre for their health issue but the tribal people never come to health centre, they go for some home remediesfromwhichtheydonotgetanynutrition.Ifweforcethemtocometheysaywedon'thave moneyortimeforit. TheASHAandAWWforcefullydragthemtothehealthcentreforhealthcheck- up.”Shegoesontosaythatitisimprovinggradually,withwomencomingtotheVHNDs. In addition to the other components of beneficiaries being hard-to-reach, interviewees made a few comments about them being uneducated, whether tribal or living remotely or not. In one block, beneficiaries are mostly tribal and mostly illiterate, said a community leader. The uneducated women in hilly tribal areas, might hide their pregnancies from the ASHAs until the 9 month. In another block, one field health worker said that uneducated tribal people do not take the IFA supplements,despitetheircounseling,andthelocaldietismonotonous,mostlyricewithchillies. th LOW EDUCATION LEVELS 111
- 124. 112 Sectionsbelowarepresentedinorderofpriorityofthefindingsandrecommendations. The NIPI Programme has largely overcome initial resistance and is performing reasonably well, but to increase programme participation further, the programme needs ways of increasing relevance (NIPI beneficiaries except pregnant women do not understand that they are likely anaemic) and enthusiasm(forexample,givingawards,stagingcompetitions,initiatingotherIEC). The most common recommendation from all levels of respondents for how to make the NIPI programme more successful was to raise the priority of anaemia by raising awareness through all thestakeholdersaboutcombattingitwithIFA,diet,dewormingandhygiene. Enough background information was gleaned from respondents in the NIPI process documentation to inform an enhanced NIPI communication strategy. Though not designed specifically as formative research for a communication strategy, much information was gleaned (see Results). Once a communication strategy is designed and messages are drafted, additional informationcouldbecollectedabouthowthemessagesareunderstood(apre-testingphase). Much of the message about anaemia and the way that NIPI will reduce it is already being taught to NIPI audiences, and has begun to be understood and acted upon. However, the respondents revealed some specific gaps – 1) the main long-term consequences of anaemia – poor cognitive development and school performance, low work productivity, and poor delivery outcomes – were only related to severe anaemia, not moderate or mild; 2) most beneficiaries and many frontline workersthoughttheywerenotanaemic;and3)IFAisseenasamedicine,notasafoodsupplement. There are numerous audiences in NIPI -- the beneficiaries are the primary audience, and all agents involved in the programme are secondary audiences. Respondents at each level recommended that agents at other levels or beneficiaries were the ones that needed to apply themselves more to make the NIPI programme more successful. For example, IFA supplementation would be more successful if parents and teachers could be convinced, if “higher authorities” would see and appreciate the work of field level workers, if adolescent girls could be convinced to come to AWCs on Saturday mornings. This suggests that all persons in the existing system are recognized as importantforitssmoothfunctioning.OnlytwogroupsseemedtobeunderutilizedforNIPI–fathers andcommunityleaders. The health department personnel, particularly the doctors, are the main messengers of NIPI, and indeed play that role well. They quell resistance, lead trainings, and are ready to handle any emergencies that may arise. Education and WCD Department personnel are secondary SOCIAL MOBILISATION CONCLUSIONS, DISCUSSION AND RECOMMENDATIONS
- 125. 113 messengers, and are also ready to play their roles. Additional systematic efforts by the Health DepartmentarewarrantedtopromotefullerparticipationinNIPI. TheabilityofthecurrentNIPIprogrammetocommunicatethroughmultiplechannelstoeachsetof beneficiaries is limited, and therefore its ultimate success. Beneficiaries reported that they consistently heard about anaemia, IFA supplementation and other programme interventions through interpersonal communication (health workers, AWWs or teachers), and students and teachersheardfromtheRBSKTeamonceayear. The overall recommendation is to prioritise social mobilisation and develop an enhanced NIPI communication (IEC) strategy. Recommendations for some of the components of a strategy follow –NIPImessage,audiences,messengers,andchannels.ThepurposesofenhancedIECcouldbeto: RaisethedemandforIFA,iron-richdiet,dewormingandhygieneamongthebeneficiaries; Reducetheinvisibilityofanaemia;and Elevatethestatusoffieldlevelhealth,ICDSandeducationstaffasNIPIimplementers ForenhancingtheNIPI : Beneficiaries and their parents should know that anaemia can be invisible, but nonetheless cause harm such as poor school performance, low work productivity, or poor delivery outcomes Beneficiaryaudiencesshouldunderstandthattheyhavea3/4chanceofbeinganaemic IFA should universally be referred to as a“supplement”to food, not as a tablet, medicine, to avoidfearofmedicinesandtheirsideeffects IECmaterialshouldbetranslatedintoseveralofthemajortriballanguages Leaflets should be developed with pictorial messages for non-literate beneficiaries. In addition, it is recommended to sensitise and orient the media to reduce their tendency to over-react to any side effects of IFA experienced by students – as one state official said: “Thereisalwaysa'mediacrisis'. Inadditiontothemany alreadytargetedbyNIPIsocialmobilization,thefollowingshould beadded: Fathers, due to their influence within families, should be counselled on anaemia in addition tomotherssotheycansupportIFAconsumptionbytheirwivesandchildren message audiences Community leaders such as the , SHG and SMC, due to their influence in communities, should be persuaded about the importance of combatting anaemia so they canleadsupportofNIPIaswell sarpanch RecommendationsforEnhancedSocialMobilisation â â â â â â â â â â
- 126. 114 The key recommendation about an enhanced role from the Health Department is to bolstertheroleoftheRBSKTeaminschools: RBSK Teams are in the unique position of being doctors, therefore well-respected, and visitingeveryschoolintheirjurisdictiononceeachyear.Theirroleineducatingstudentsand teachers could be enlarged by allowing more time at each school to be used for educating. Alternatively a communication specialist could be added to each RBSK team to conduct a community or school information event during each visit, while the rest of the team are conducting health screenings. This recommendation is consistent with a recent directive letterfromtheDirectorateofFamilyWelfare,Odisha. Finally, for beneficiaries to hear about NIPI through is crucial for persuading aboutitsimportance,andthefollowingadditionalchannelsarerecommended: Awards, competitions and events to raise the status of the NIPI programme – as one District Education official said: “To generate interest there can be award or reward. We should motivatethemandenablethemtodo.” MediatoraisethestatusandincreasethereachoftheNIPIprogramme,includingsensitising mediaactorsonanaemia,andexpandingmessagesthroughradioshowsandpublicservice announcements, through scripts of existingTV serials andTV advertisements, through local drama as entertainment, or through a campaign (beneficiaries and officials frequently referredtothevisibilityofthepoliocampaign). New IEC materials such as updates for teachers; print materials with drawings of anaemic vs. non-anaemic young children, students, and women; section on anaemia for the science curriculum;andsectiononanaemiafortheSABLAkitforadolescents. Supplementation with IFA across the life cycle groups is being implemented relatively well, but therearegapsforeachgroupwhereIFAconsumptionfallsshortoftheguidelines. The intervention of supplementing the numerous groups with IFA (PLW, children under 5 years, male and female students 11-19 years, and adolescent girls out-of-school) is being conducted reasonably well, given that only two full years of start-up and implementation had occurred at the time of the interviews, that coordination is required among three departments, one of which has not coordinated on a large scale with the others before (Education vs Health and ICDS), and that 6 life cycle groups with their own considerations as are reviewed here and two more having more recently begun or soon to begin (children 5-10 years in school and WRA). The emphasis on the prevention side of the programme through supplementation over the therapeutic side is well- placed,giventhelargeproportionofmildandmoderatecases. There is an implementation gap for each life cycle group, however, in which each group systematicallyconsumeslessIFAthanintendedbytheguidelines: messenger multiple channels â â â â ADMINISTERING THE INTERVENTION
- 127. 115 â â â â â â â â â â â Pregnant women who are anaemic Lactating women Children 6 months-3 years Children3-5years Adolescentgirlsout-of-school Adolescent in Standards 6-10 , who receive the most focus of any of the life cycle groups, are not getting the full 360 IFA red tablets recommended for them, either because they are only given for 3-4 months instead of 6, are only given 200 total as per the earlier guidelinesinsteadof360,oraregivenanamountthatismiscalculatedinotherwaysandless thantheguidelines. as a group receive much less emphasis compared to pregnant women. Acknowledging that this group had only recently started receiving IFA red tablets to this group,andthatprogrammingforthemisatanascentstage,onlyasmallnumberoflactating womenwerereceivingtheirfullbatchesofIFAtabletstotakeduringtheirfirst6postpartum months. are supposed to receive syrup at home two times per week from theirASHA,butarelimitediftheASHAcannotreachallthehousesthisoften. aresupposedtoreceivesyruptwotimesperweekattheAWCduringdaily ICDSsessionswiththeAWW,butarelimitediftheircaretakerscannottakethemtwiceorthe AWWsdonotreceivetimelyadequatesupplies. . ,manyofwhomdonotattendtheAWCeverySaturdaydueto distance,workloadorinterest,andthereforearenottakingIFAtabletsweekly. are not receiving enough IFA in some school clusters where compliance with IFA is low and teachers, headmasters and/or CRCCs need more persuasion aboutNIPI'scontributiontotheirwell-being. Bylifecyclegroup: For pregnant women, frontline workers (ANMs, ASHAs and AWWs) should ensure that they get360IFAtablets,ifanaemic,and180ifnot. Encourage pregnant women to take their MCP card with ANC records with them if/when they move to their natal home for the end of their pregnancy and first month or so postpartumsotheirANCcanbeseamlessacrossthetwolocations. For lactating women, frontline workers should ensure that they get 360 IFA tablets, if anaemic,and180ifnot. For administration of IFA syrup to children 6 months-3years, encourage the mother to give the 1ml doses on Tuesdays and Fridays and self-record it in MCP card, and have the ASHA visitfrequentlytomonitorconsumptionandrecording. For administration of IFA syrup to children 3-5 years, allow the mother to keep the IFA syrup bottle at home and give the dose of IFA syrup to her child onTuesdays and Fridays and self- record it in MCP card, and have the AWW monitor IFA consumption and reporting during ICDSsessionsattheAWC(orduringhomevisitsbytheAWWorASHA). RecommendationsforAdministeringtheIntervention
- 128. 116 â â â â â â For adolescent girls out-of-school, make the session more informative focusing on their health, behavior and build in incentives for them to participate in Saturday sessions at the AWC, e.g., introduce /haemoglobin assessment and/or distribute eggs /take home ration (THR),/Mealsetc. For students in the 9 and 10 standards, extend the MDM programme to them to ensure higheruptakeofIFAanduniformityinprogrammeimplementationprotocol. Foradolescentgirlsandboysinjuniorcollege,distributeIFAtabletstothem. Inaddition: Given the low level of adverse effects of the IFA, and the robust systems in place for reaching medical assistance quickly, all the schools and AWCs should have the emergency contact numberwrittenonwallandIFAsupplementationregister. : Although incentive has been provisioned for IFA syrup administration by ASHAs at rate of Re.1 per 8 doses per month for each child, the utilization of this remains poor. One reason reported for poor utilization is that the current incentive is toolesstomotivateASHAs. : Multiple respondents from Education department expressed uncertainty over protocols and process of distributing IFA supplements during school holidays. Strengthening messaging and guidance around this is therefore recommended, so as to bringmoreclarityamongprogrammeimplementersonguidelinesandprotocols. Despite a strong supply chain, respondents did describe few instances of stock-outs of IFA tablets/syrup. At the time of study, two specific stock-outs in field were identified – for IFA Red tablets and IFA syrup. While the major reason for stock-out of IFA red tablets was inadequate procurement by state, in case of IFA syrup, the supply-chain below district level faced disruptions duetodelayed/inadequateindentingandsupply. The degree of sharing stocks and information to avoid shortages and stock outs is impressive at a localfieldlevelamongANMs,ASHAsandAWWs,andcouldbeencouragedfurtherwithinthestate- - among schools, among pharmacists, and at block and district levels using the electronic supply chain software. Regarding pharmacists, it was also noted that their knowledge of anaemia was limited, but their interest is high and their role among actors in the NIPI programme is central. Also relatedtopharmacists,storagespaceforIFAsyrupandtabletsandalbendazoleislimited. Mentioned countless times by teachers, headmasters, CRCCs as well as frontline workers was a fear of IFA tablets and syrup expiring. To be cautious, some even did not want to distribute tablets severalmonthsaheadoftheirexpirationdate. th th Provisioning higher incentives for ASHAs for IFA syrup administration and increasing utilization of the same Strengthen messaging around IFA administration among in-school adolescents during vacations LOGISTIC MANAGEMENT
- 129. 117 RecommendationsforLogisticsManagement RecommendationsforIncreasedDiagnosis,Treatment,ReferralandFollow-up Several key recommendations emerged from the analysis of interview data on logistics management: The way AWWs, ASHAs and ANMs share IFA information about IFA stock in the various local storage places and share the stock itself is useful for avoiding shortages and stock outs and should be conducted more widely across the state, including electronic sharing within OSMCL'se-Aushadiprocurementsoftwareatblockanddistrictlevels. Such supply disruptions could be identified and prevented if systems for tracking supply positionanddistributionuptoblocklevelareavailablethroughOSMCLsoftware. Inform pharmacists more about the NIPI programme so they can understand anaemia and morefullyengagewithcombatingit. Expand and improve storage space for IFA and albendazole among other essential drugs at district, block and PHC pharmacies, including adding racks such that boxes are not on the floor, and ventilation and temperature control that require adequate electricity. In addition, localstorageconditionsinAWCs,schoolsandsub-centresshouldbechecked. Consider softening the aspect of training and supervision of teachers, headmasters, CRCCs andfrontlineworkersaboutexpiredIFAtabletsandsyrup,lesttheydonotgivesupplements thatarestilleffectivefrombeingoverlyfearful. Hb concentration is not tested among young children, school children or adolescents out-of- school, only among pregnant and perhaps lactating women. Instead, the visual pallor technique is used,whichdetectsonlysevereanaemia.WithoutassessingHbconcentration,itisdifficultforRBSK TeamsandAWWstofollowGOINIPIGuidelinesfortreatmentofmildandmoderateanaemia. Several key recommendations emerged from the interviews related to anaemia diagnosis, referral, treatmentandfollow-up,allatthelevelofrevisionoftheguidelines: Allhealthcentresshouldhavefunctioninghaemoglobinometres. ThosewhoreviewanddeveloptheRBSKmechanismshouldconsiderbuildinginmoretime per school and developing more IEC material so that the RBSK Team can further educate students, parents, SMCs, teachers, headmasters, CRCCs and others can learn more about NIPI,gettheirquestionsanswered,andengagewiththeprogrammemore. The therapeutic side of NIPI in health centres is negligible, in large part because Hb concentrations in all except pregnant women are not tested, hence beneficiaries needing therapeuticIFAdosesarenotdetected. â â â â â â â DIAGNOSIS, TREATMENT, REFERRAL AND FOLLOW-UP
- 130. 118 â â â MakehaemoglobinometersavailabletoRBSKTeamstoassessstudents'anaemiastatus,and develop a strategy to monitor whether haemoglobin levels are improving over time. ModerateanaemiaisprevalentamongadolescentsinOdishaandthroughoutIndia,butitis difficulttodistinguishthosewithmoderatefromthosewithmildornoanaemiaunderNIPI– only severe anaemia can be distinguished and only with the skin pallor technique. Making haemoglobinometers available to RBSK Teams so they may determine the degree of anaemia is recommended. Once haemoglobin levels can be assessed, developing a mechanism to provide adequate doses to manage mild/moderate anaemia is recommended. Adolescent girls who are out-of-school should receive a health check-up, like the adolescents in school receive from the RBSK Team, and should have their haemoglobin checked, like PLW. The check-up could occur at the AWC when the RBSK Team screens the youngchildren. For adolescents, follow treatment protocols by Hb level for anaemic school children, includingIFAforchildrenwithmild/moderateanaemiaonadailyorneardailybasis. A robust monitoring system is needed to assess further acceptance of IFA consumption, albendazole consumption, and behaviour change related to hygiene and dietary diversity. The systemneednotassessNIPIprogresstomeasuringmanyparticipants,asinasurvey,ratherassessin small subsamples of beneficiaries and officials from state to field level. Monitoring techniques should also be applied to operational research situations, where different methods of improving programmeefficiencyandeffectivenessarecompared.Perhapscertainmonitoringtopicscouldbe fieldprojectsforAIIMSstudents. Though the ownership and supervision of NIPI within the ranks of the Education Department have increased greatly, there are some supervisors who do not receive IFA reports regarding IFA supply andconsumption,andthereforecannoteffectivelysuperviseandfeelownership. A number of recommendations are made toward a more robust and useful monitoring and supervisionsystem: Despite the number of visits and meetings for monitoring and supervision, little was mentioned about the actions taken during and after these occasions, so it is not clear how productive they are for identifying and solving the key issues that arise in the field, block, district,andstatelevels. MONITORING AND SUPERVISION RecommendationsforMonitoringandSupervisingtheNIPIprogramme
- 131. 119 â â â â â â â â â â Revise reporting forms – rationalise the reporting process to allow for the recording of NIPI results to be combined with the recording of related activities, e.g., IFA consumption per student to be on same form as consumption of MDMs in both S&ME and residential schools, andcollectinformationondayscholarsattendingresidentialschools. Enhance mechanisms whereby state officials supervise and hold accountable the district officialswhoreporttothem. Provide copies of supply and consumption reports to align reporting and supervision processes – ensure that all who supervise on NIPI have the reports that update them on the programme'sprogress. Motivate the reporting – make the purpose of reporting clear, make widely available a summaryofresultscomparingdistricts,blocks,evensectorsandclusters. Review whether the purpose, participants and frequency of meetings in which NIPI is discussed is adequate for its monitoring, implementation review and problem-solving, and forupdatingparticipants. Most district, block, sector and frontline workers described receiving training at the beginning of NIPI,andgettingupdatedNIPIinformationthroughregularmeetings.Forthemostpart,anygapsin information or shortfalls in performance could be filled through additional supportive supervision at all levels. A budget for refresher training should also be considered. There is currently no budgetaryprovisionfortrainingbelowblocklevel. Additionaltrainingcouldbeprovidedstrategicallyandintargetedfashioninthefollowingways: Additional training could be strategically used to the raise the status of the programme by giving opportunities for special training to teachers (for whom dispensing nutritional supplementsisanewresponsibility)andAWWs. Efforts are on-going according to state officials to incorporate technical health content, including NIPI-related information, into teachers' curriculum, and these should be supported. Audio-video training tools on anaemia could be made widely available and shown at regular or project meetings, functioning as refresher training, or as a spark to discussion on howtoimproveNIPIprogrammeimplementation. Acascadeoftrainingwithintheexistingsystemcouldbeconsideredfurther,makingsureto carveoutthetimeforanynewresponsibilities. A systematic check should be conducted to ensure that all workers who start working on NIPIsinceitsinceptiongettrainedadequatelyonNIPI. WorkersandofficialsatalllevelsreportedhavingbeeninstructedhowtoimplementtheNIPI programme. TRAINING RecommendationsforStrategicTraining
- 132. 120 HARD-TO-REACH NIPI BENEFICIARIES “Hard-to-reach”had four components – remoteness in terms of residing a far distance from main roads and from government attention, language in terms of beneficiaries not speaking Odia, tribal issues and customs, and low education level of beneficiaries. Though all four might exist together, especially among tribal people, separating out the components allowed for some practical recommendationstoreduceprogrammaticconstraints. Increaseresourcesbystateanddistrictgovernmentforthemoreremotehillyareasandtheir tribalpeoples,includingroadsandhealthservices Monitorandsupervisetomakesurejobsarebeingdone,andthegeographical,culturaland educationalconstraintsarebeingidentifiedandaddressed PrepareanddistributeIECmaterialsontheNIPIprogrammeinthemajortriballanguages Strengthen involvement of local village tribal heads ( ) in the programme to minimiselocalresistance,andarrangefortheirsensitisation,budgetingaccordingly. mukhiya RecommendationsforReachingtheHard-to-Reach â â â â
- 133. 121 The fund requirement for procurement of most of the formulations of IFA and Albendazole tablets/syrup/suspension were not requested to Govt. of India in the NHM PIP. Instead, the state bore this expenditure for procurement of drugs through the dedicated State Government funds. Followingisananalysisofthedifferenttypesofformulationsprocuredbythestate. IFABLUECOLOURTABLETS(FORADOLESCENTS) ANNEXURE1: ANALYSIS OF INDENTING, PROCUREMENT, SPECIFICATIONS OF IFA/ALBENDAZOLE FORMULATIONS OSMCL Drug Code D16029 OSMCL Drug Code D16030 Specifications of the tablets are as per Tab. Ferrous Sulphate + Folic Acid (Large) the Govt. of India specifications (Enteric Coated and blue coloured-Indigo caramine). IFA (Large) & IFA-WIFS name to be displayed prominently Estimated Adolescents (class 6 to 10 and 44,97,778 adolescents out of school adolescent girls) of state Estimated requirement of tablets for state 23,38,84,456 tablets Total number of tablets approved in NHM 16,37,19,116 tablets PIP (2015-16) (70% of total estimated requirement) Total number of tablets mentioned in the 16,37,19,116 tablets tender document (2015-16) Total number of tablets purchased 16,37,19,600 tablets (IFA tablets purchased in two instalments - through two Purchase Orders (POs) dated 16 September, 2015 and 31 December, 2015) Gap between estimated requirement of 7,01,64,856 tablets (30%) drug and actual purchase Specifications of the tablets are as per the Tab. Ferrous Sulphate + Folic Acid (Small) Govt. of India specifications (Sugar Coated and Pink coloured (The thickness of Aluminium foil: 40micron with LDPE 25 micron coating/ heat seal lacquer). IFA (Small) & WIFS Junior name to be displayed prominently Estimated Children (class 1 to 5) of state 38,36,492 children th st IFAPINKCOLOUREDTABLETFORWIFSJUNIOR(CHILDREN6–10YEARS)
- 134. 122 Estimated requirement of tablets for state 19,94,97,584 tablets Total number of tablets approved in NHM 13,96,48,308 tablets PIP (2015-16) (70% of total estimated requirement) Total number of tablets mentioned in the 13,96,48,308 tablets tender document (2015-16) (IFA tablets purchased in 2 instalments - through 2 purchase orders dated 16 September, 2015 and 31 December, 2015) Total number of tablets purchased 13,96,48,800 tablets Gap between estimated requirement of 5,98,48,784 tablets (30%) drug and actual purchase Remark EDL list indicates the Pink IFA tablet to have enteric coating. As per GoI recommendations, it should be mentioned as sugar coated. There are two types of IFA syrup being procured in Odisha mentioned as following: Specifications of the IFA Syrup are as per Each 1 ml containing 20mg of Elemental Iron the Govt. of India specifications and 0.1 mg of Folic Acid. It is put in an Amber colour Auto-dispensing bottle so that only 1ml can be dispensed at a time. Each bottle of 50 ml to be packed in a mono-cartoon and the instruction leaflet (as per GOI guideline) is to be placed inside the mono-cartoon. Estimated Children (6 months to 5 years age) 41,78,268 children of state Estimated requirement of syrup bottles 83,56,536 bottles (50 ml bottle) for state Total number of Syrup bottles (50 ml bottle) 58,49,576 bottles approved in NHM PIP (2015-16) (70% of the total estimated requirement) Total number of bottles (50 ml) mentioned 69,73,241 bottles in the tender document Total number of bottles (50 ml) purchased 58,49,600 bottles (Bottles purchased in 2 instalments -through 2 purchase orders dated 16 September, 2015 and 31 December, 2015) OSMCL Drug Code D16031 IFA SYRUP (CHILDREN 6 – 59 MONTHS) A. IFA Syrup (50 ml bottle, Auto-dispensable)
- 135. 123 Gap between estimated requirement of drug 25,06,936 bottles (30%) and actual purchase Remark Specifications are as per GoI but details mentioned in EDL sheet are inconsistent e.g. at one place it mentions 'dropper' and another place it mentions to have 'auto- dispenser' The EDL list mentions the bottle capacity as 100 ml instead of 50 ml. However, in the tender document, the capacity of auto- dispenser IFA is 50 ml which is as per GoI specifications. Specifications of the IFA Syrup Each 5ml contains 100mg of Elemental Iron and 0.5 mg of Folic Acid with measuring cap, dropper and plastic container as per I.P (This is NOT as per the Govt. of India specifications) Remark During field visits, it was found that this kind of dropper bottle is being given to health facilities to be prescribed if required in the OPDs of PHC/CHC/Hospital etc. Specifications of the IFA small tablet Tab. Ferrous Sulphate + Folic Acid (Enteric Coated, Red Colour) (Paediatric)(Aluminium foil/Blisterpack) - Each Enteric coated Tab. Contains 20mg Elemental Iron with 100 mcg Folic Acid (This is NOT as per the Govt. of India specifications). Total number of tablets mentioned in the 95,06,000 tablets tender document (2015-16) Specifications of the tablets are as per the Tab. Ferrous Sulphate + Folic Acid (Enteric Govt. of India specifications Coated, Red Colour) (Aluminium foil/Blister pack) Equivalent to 100 mg of Elemental Iron + Folic Acid 0.5mg (500mcg) / Enteric Coated Tablet OSMCL Drug Code D16011 OSMCL Drug Code D16037 OSMCL Drug Code D16038 B. IFA Syrup (100 ml bottle) IFA SMALL ENTERIC COATED IFA RED COLOURED TABLET FOR PREGNANT AND LACTATING WOMEN
- 136. 124 Estimated Pregnant Women (ANC) and 9,55,732 (ANC) + 8,93,225 (PNC) = 18,48,957 Lactating Mothers (PNC) of state Estimated requirement of tablets for Pregnant 27,52,50,816 tablets Women in state (180 tab for 40% PW + 360 tab for 60% PW) Estimated requirement of tablets for 16,07,80,500 tablets Lactating Mothers in state (180 tab per LM ) Estimated requirement of tablets for state 43,60,31,316 tablets Total number of tablets mentioned in the 3,61,15,300 tablets tender document (2015-16) Total number of tablets purchased 2,40,76,900 tablets Gap (between tender quantity and real 1,20,38,400 tablets purchase quantity (Only one PO for red IFA, dated 31 Dec 2015, could be traced as part of the study) Gap (between estimated requirement and 42,39,92,916 tablets (Based on the PO dated actual purchase quantity) 31 Dec, 2015) Remark Although NHM PIP 2015-16 mentions 'IFA large - Tab. Ferrous Sulphate + Folic Acid (Red color, Equivalent to 100 mg of Elemental Iron + Folic Acid 0.5 To be met out of JSSK drugs'; no specific document specifying the actual purchase could be traced under the study. The remark in JSSK head under NHM PIP (2015-16) is as follows: Specifications Inj. Iron Sucrose 50 mg/ 2.5 ml 5 ml/Amp (20 Ampules/Box) Total number of Ampules 93255 ampules (No PO could be traced for mentioned in the tender document any actual purchase) st st “Budgeted 10% & rest to be met out of State budget. This fund has to be utilised for meeting drugs & consumables, if not available at that point of time, with the respective facility from State supply. Procurement has to be done through local purchase, observing official procedure.” OSMCL Drug Code D16018 IRON SUCROSE
- 137. 125 TABLET IRON SYRUP IRON TABLET FOLIC ACID IRON DROP ALBENDAZOLE TABLETS FOR CHILDREN (CLASS 1 TO 5) AND ADOLESCENTS (ADOLESCENTS FROM CLASS 6 TO 10 + OUT-OF-SCHOOL ADOLESCENTGIRLS) OSMCL Drug Code D16020 OSMCL Drug Code D16021 OSMCL Drug Code D16002 OSMCL Drug Code D16019 OSMCL Drug Code D08004 Specifications Tab. Iron (Sugar Coated) (Aluminium foil/Blister pack) Equivalent to 100 mg of Elemental Iron 10 Tabs/Strip Total number of Tablets mentioned in the 9,84,000 tablets (No PO could be traced for tender document any actual purchase) Specifications Syrup Iron Each 5ml Contains 30mg of 100ml / Bottle Total number of bottles mentioned in the 1,68,400 bottles (No PO could be traced for tender document any actual purchase) Specifications Tab. Folic Acid (Aluminium foil/Blister pack) IP 5 mg/Tab Total number of Tablets mentioned in the 43,42,500 tablets (No PO could be traced for tender document any actual purchase) Specifications Palatable, with dropper and plastic container as per I.P) Elemental Iron 50 mg / ml. 15ml / Bottle Total number of bottles mentioned in the 78,250 (No PO could be traced for any tender document actual purchase) Specifications of the tablets are as per the Tablet Albendazole (Chewable, Aluminium Govt. of India specifications Foil/Blister Pack)
- 138. 126 Estimated children (class 1 to 5) + Adolescents 38,36,492 (children class 1 to 5) + (class 6 to 10 plus out of school adolescent 44,97,778 (adolescents 6 to 10 plus out girls) of state of school adolescent girls) = 83,34,270 Estimated requirement of tablets for children 76,72,984 tablets (class 1 to 5) in state Estimated requirement of tablets for 89,95,556 tablets Adolescents in state Estimated total requirement of tablets for 1,66,68,540 tablets state Total number of tablets approved in NHM 61,38,388 tablets (80% of requirement for PIP (2015-16) children class 1 to 5) + 62,96,886 tablets (70% of requirement for adolescents) = 1,24,35,274 tablets Total number of tablets mentioned in the Missing in tender tender document (2015-16) Total number of tablets purchased 61,38,440 tablets (for children class 1 to 5) + 62,96,960 tablets (for adolescents) = 1,24,35,400 tablets Gap between estimated requirement of 42,33,140 tablets (25%) drug and actual purchase
- 139. 127 Since its inception, the anaemia control programme has undergone multiple transitions. Since 2011,AdolescentAnaemiaControlProgramme(AACP)forout-of-schooladolescentgirlswasbeing implemented through the platform of Anganwadi centres. In 2013, the Weekly Iron Folic acid Supplementation (WIFS) programme was introduced, which also included school-going adolescent girls and boys. Bi-weekly IFA syrup supplementation to pre-schoolers was initiated in 2014 across all the districts through platform of Anganwadi centers (for 36–59 months children) and through home visits (6-35 months children). Since mid-2014, WIFS junior component in schools, for students in class I-V, has also been initiated. While IFA supplementation among pregnant women has been going on since decades, recently in 2016 lactating women were also broughtunderthefoldofNIPIprogramme. The process documentation on NIPI was conducted with the purpose of understanding the achievements, challenges, bottlenecks and promising practices in implementation of the programme in Odisha. The data collection for the documentation was conducted during 2015-16, and some time has elapsed before its release. During this period, various components of the NIPI programme have undergone structural changes. With the aim to make this document more comprehensiveandupdated,theserecentdevelopmentsunderNIPIhavebeenoutlinedbelow. State Level Coordination Meeting forWIFS has been subsumed to 'State Adolescent Health Committee' (SAHC). Inordertostrengtheninter-departmentalconvergenceandstreamlinereportingonWIFS,a letter was issued from Directorate of Family Welfare to all District Collectors requesting them to review the NIPI Programme during the monthly convergence meeting, in presence ofofficialsfromallconcerneddepartments Acknowledging the issue of expired tablets lying at various levels in the field, the DirectorateofFamilyWelfarealsoissuedanotherletter toallthedistrictshighlightingthe · · · (Adaptation of Order from Adolescent Division of Ministry of Health & FW, Govt.ofIndia) (DFWLetter) 48 49 50 . PlanningandCoordination LogisticsManagement ANNEXURE 2: RECENT DEVELOPMENTS IN IMPLEMENTATION DESIGN OF NIPI IN ODISHA BACKGROUND 48 49 50 Minutes of State Coordination Meeting on SAHC held on 17 Sept, 2016 th DFW Letter No. - 243 / Dt. 19-03-2016: Review of NIPI Programme in monthly RMNCH+A Review Meeting DFW Letter No. 164 / Dt. 21-02-2017: Revised Guideline for NIPI Programme focusing on supply chain, reporting and management of IFA Tablets
- 140. 128 importance of proper management and disposal of expired drugs.The letter stated that all expired drugs should be returned to central warehouse following the reverse pathway of the supply chain. The disposal of expired IFA Tablets / syrup will be done at district central warehousebyfollowingthestateguidelineforthesame. It was evident through routine programme monitoring and even during the data collection for this study, that there was further scope to improve the programme understanding and awareness among district/block officials, frontline workers and teachers. With the view to improve skills and capacities of functionaries at all levels, a capacity building programme is planned to be rolled-out during 2017-18. For this, the state-levelToTfordistrict-levelofficialsfromHealth,Education,WCDandSSDdepartments will be supported by UNICEF. The master trainers will further train the block officials and RBSK MHTs. Consequently, the AYUSH Doctors of RBSK MHTs will provide orientation and handholdingsupporttoteachers,AWWsandSMCmembers. As per the revised guideline on IFA Syrup supplementation (DFW Letter ASHA is responsible for administering IFA Syrup to all children from 6 months to 5 years age group. IFA Syrup bottles are to be handed over by ANM atVHND Session to respective mothers to keepattheirhomeandASHAisrequiredtoensuretheadministrationofIFASyrupthrough homevisits. Acknowledgingtheneedforprovidinghand-holdingandsupportivesupervisiontoAWWs and teachers, the Health department, with support from UNICEF has planned a pilot initiative for WIFS monitoring in three poor performing districts (one district from each revenue division). As part of this initiative, AYUSH doctors (posted at CHC/PHC and RBSK MHTs) will monitor WIFS implementation and make hand-holding visits to AWCs and schools. While RBSK doctors will do this during their routine visits to schools/AWCs, the AYUSH doctors posted at CHC/PHCs will be provided incentive (Rs.150/visit) which has beenapprovedunderNHMROP2017-18. · · · ) , 51 · Since 2016-17 the state has introduced deworming among pregnant women. All pregnant womennowreceiveoneAlbendazoletablet(400mg)during2nd trimester. Training AdministrationofIntervention MonitoringandSupervision 51 DFW Letter No. 346 / Dt. 17-05-2017: Revised Guideline for IFA Syrup Supplementation under NIPI Programme and strengthening NIPI in Urban Areas
- 141. 129 ReportingMechanism SocialMobilisation · · · · · GoIWIFSreportingformatsforschoolsandAWCshavebeentranslatedtoOdiaandprinted booklets have been supplied to districts by state NHM Office. Auto-carbon papers have beenusedinthesebookletstofacilitateeasyreportingandrecordmaintenance. WIFS reporting has been incorporated as part of DWCD department's e-pragati software. In coordination with Health department, DWCD has agreed to revise the e-pragati template,toalignitwiththemonthlyreportingformatforWIFS. FromApril2017onwards,GoIhasincorporatedWIFSreportingintoHMIS.Withreferenceto this decision, MD, NHM (Odisha) has issued one letter (NHM Letter) for incorporation of NIPIreportingintoHMIS. TheS&MEdepartmenthasdevelopedanSMSbasedmonitoringsystemtocapturedataon variouscomponentsofMid-DayMeal,includingIFAadministration. In order to build community demand for NIPI, the Health department has planned to develop (with support from UNICEF) and supply resource materials for Nutrition Health Education to be used at schools and AWCs.The department has also proposed in the NHM PIP(2017-18)fordevelopmentofpostersonWIFStobesuppliedtoallAWCsofthestate. 52 NHM Letter No.- 5596 / Dt. 17-05-2017: Strengthening of HMIS Reporting System in Odisha 52