Wrap-up: Next Steps for Program Implementation and for Measuring Success for Anemia Prevention and Control

(APC) and Calcium Supplementation April 14, 2013

Dr. Justine A. Kavle, Senior Program Officer for Nutrition, MCHIP

What have we learned about anemia control program implementation?

Demand side: Interplay between product, how it is provided, and how it is used
Continue to use
Sociocultural Context

Users needs and desires

Willing and able to use

Demand
IFA

Correct

use

Product: Acceptability, packaging Service: Practical counseling from provider on what to expect Personal/Cultural: Motivation
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Supply side: Balance between push and pull

Respond to demand community and/or facilitybased needs

- Ensure on essential drugs list, correct formulations, budget allocated - Clear coordination + roles for procurement - Accurate forecasting at local level - Inventory control to monitor expiration dates of supplies
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Harmonization is needed to achieve integration of IFA and IPTp 5 mg dose of folic acid should be removed
Combined IFA supplement with 0.4 mg of folic acid is recommended and should be given with IPTp for malaria in pregnancy

Anemia Prevention and Control (APC) Components for integration at various levels
KENYA Strategic integration Government leadership Multiple strategies

Integrate: Key plans, policies, guidelines Stakeholder commitment: Capacity building, BCC

Multisectoral Micronutrient Deficiency Council

Partner with Private sector Budget allocated

IFA - focused ANC and adolescents

Home fortification ITNs - Malaria Deworming

What have we learned about measuring success for anemia prevention and control?

Components of successful iron folic-acid supplementation programs

Stoltzfus & Dreyfuss, INACG, 2001, World Bank, 2004

Ensure supply

M&E

Evaluation

-Establish policy - Know problem

Choose Effective Delivery system

Generate demand

Coverage

Measure Impact reduction in IDA

Compliance

Implementation barriers to APC Potential challenges to scale-up

Klemm, Harvey, Wainwright, Faillace 2009

Inadequate political support

Low priority for IFA Insufficient bundling of interventions IFA, deworming, antimalarial (IPTp with SP), delayed cord clamping Inadequate supplies - low utilization - weak demand Lack of evidence for effective program implementation Lack of community-based programs -- complement ANC
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APC: What is needed for Scale-up

NEPAL

Communitybased distribution Training Situation analysis Awareness activities Ensuring supplies Recording, reporting

Integrated monitoring supervision Integrated package

Strengthen M & E: integrate, monitor, and supervise to achieve scale-up

A2z project 2011

ANC FP Malaria Deworming Integrate indicators HMIS

Monitor program implementation

Address gaps
Establish supervisionclinic & community level

Complement survey data

How does APC inform on calcium supplementation? What research is underway?

We can build on the experience of APC: Iron folic-acid (IFA) & calcium share common elements

Formative research to generate demand

Behaviors adherence to supplements

Forecasting for supplies

Same Delivery Platform

Cost Differs: IFA -$0.48 for 90 pills, ferrous fumarate Calcium carbonate - $13.44 per pregnancy

Calcium Acceptability and Preference Pilot in Nepal

Preference for Pills vs. Sprinkles

- High compliance to Ca - Bulky- storage space

- Reason for missing IFA and calcium dose was forgetfulness, taking extra Ca pills and GI effects did not affect adherence to IFA - Acceptable to take at IFA and calcium at different times
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- Cost for scale-up - Different platform than IFA - More reported GI symptoms w/ sprinkles

- Ingestion of large pills difficult

Operations research underway to address challenges in program design

Challenge 1: Address low uptake, low ANC coverage and late and infrequent contact with health care system Determine optimum delivery platform for calcium and IFA Challenge 2: Address compliance to IFA and calcium Collect perspectives of health care providers and users to design effective behaviour change communication Design models for delivery and promotion of calcium and IFA supplements in pregnancy.

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Next steps for Calcium Research

Evidence supports effectiveness of lower dose of calcium (500 mg 1 pill) - which could be feasible and address some of the challenges presented today. More research is needed.
Research interactions between calcium and iron, currently testing pill with both calcium and iron Research on supplementation in early pregnancy (before 20 weeks) and before pregnancy

Thank you!

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