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Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 10-15

Operational issues and lessons learned during National Iron Plus Initiative documentation in Eastern India

1 Department of Community Medicine and Family Medicine, AIIMS, Bhubaneswar, Odisha, India
2 Department of Community Medicine, Pondicherry Institute of Medical Sciences, Pondicherry, India

Date of Web Publication4-Jul-2019

Correspondence Address:
Sasmita Pradhan
Department of Community Medicine and Family Medicine, AIIMS, Bhubaneswar, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJCFM.IJCFM_2_19

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Anaemia 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. Nutritional anaemia is a major public health problem in India and is primarily due to iron deficiency. Symptoms of iron deficiency anaemia are primarily non specific and become apparent when there is severe anaemia. The National Iron Plus Initiative (NIPI) is the most ambitious and comprehensive anaemia control programme in the world. 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 in Odisha. To achieve variation in responses and to get full set of information on how NIPI was being implemented, process documentation and survey data were collected in four districts of Odisha– Keonjhar, Jagatsinghpur, Bhadrak and Kalahandi. This review will give an overview about the operational issues encountered during the National Iron Plus Initiative documentation in Odisha.

Keywords: Anemia, iron and folic acid supplementation, National Iron Plus Initiative documentation

How to cite this article:
Bhatia V, Parida SP, Mahajan PB, Pradhan S. Operational issues and lessons learned during National Iron Plus Initiative documentation in Eastern India. Indian J Community Fam Med 2019;5:10-5

How to cite this URL:
Bhatia V, Parida SP, Mahajan PB, Pradhan S. Operational issues and lessons learned during National Iron Plus Initiative documentation in Eastern India. Indian J Community Fam Med [serial online] 2019 [cited 2021 Oct 25];5:10-5. Available from: https://www.ijcfm.org/text.asp?2019/5/1/10/262117

  Introduction Top

Anemia 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.[1] It is a condition in which red blood cells have fewer hemoglobin (HB) molecules than normal, or fewer red blood cells overall, and thus have less ability to carry oxygen to tissues in the body. The word anemia derived from the ancient Greek word meaning “lack of blood.”[2]

Iron deficiency, due to diets poor in iron, accounts for around 50% of anemia.[3] A study estimated that 25% of all anemia among children under 5 years and 37% among nonpregnant WRA were due to iron deficiency.[4],[5] Others estimated that 42% of anemia in children would be amenable to iron supplementation and 50% anemia in women could be eliminated with iron supplementation.

Among the 24 countries in the global review, the prevalence of anemia in the mid-2000s among pregnant women was >50% in 13 developing countries, including India, was 30%–49% in 10 countries, and was <30% in only one country (Haiti).

India is one of the countries with a very high prevalence of anemia in the world. Nutritional anemia is a major public health problem in India and is primarily due to iron deficiency.

The National Iron Plus Initiative (NIPI) is the most ambitious and comprehensive anemia control program in the world. Its beneficiaries are from adult women to infants – pregnant and lactating women, adolescent girls and boys in secondary school and adolescent girls out-of-school, preadolescent school-going girls and boys in primary school, and young children 6 months to 5 years. NIPI was inaugurated in 2013. After 2 years of program experience, the Government of Odisha wanted to investigate how the program was progressing and chose to conduct a process documentation in the state. Therefore, the Department of Health and Family Welfare, Government of Odisha, in partnership with the UNICEF aimed to review the current implementation status of childhood, adolescents, and pregnant and lactating mothers' anemia components of NIPI in the state, with the purpose of documenting the successes, challenges, bottlenecks, and lessons learned and making concrete recommendations for future actions.

  Methodology Top

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 and to get full set of information on how NIPI was being implemented, hence a process documentation and survey data were collected in four districts of Odisha–Keonjhar, Jagatsinghpur, Bhadrak and Kalahandi. The quantitative survey team conducted 4809 survey interviews from April to July 2016 in the same four districts.

Selection of districts

To understand the scenario of Odisha as a whole, it was decided to take one district from each revenue division. As per the Annual Health Survey (AHS) 2012–13, districts of Odisha were ranked by taking the average percentage of consumption of iron and folic acid (IFA) by mothers (who consumed IFA for 100 days or more) and children (aged 6–35 months, who received IFA tablets/syrup during the past 3 months). Taking above mentioned indicators the district having poorest performance from each revenue division was selected for the process documentation. To understand the variations among good-performing and poor-performing districts, the best-performing district as per the AHS 2012–13 was selected as the fourth district under the study. The four districts selected were Bhadrak, Keonjhar, Kalahandi, and Jagatsinghpur.

Selection of blocks

Within the selected districts, one good-performing block and one poor-performing block were purposively selected based on the inputs from district collectors, Chief District Medical Officer/Assistant District Medical Officer, and district officials from other line departments.

To achieve variations during the process documentation the data were collected from 2 blocks from each districts of keonjhar & jagatsinghpur district (Harichandanpur March 10–18, 2016, and Banspal April 26–29, 2016, in Keonjhar district and Raghunathpur April 7–12, 2016, and Kujang April 18–21, 2016, in Jagatsinghpur district). The documentation in Bhadrak and Kalahandi was limited to one block because no new information was being gleaned from interviews (Bhandari Pokhari Block in Bhadrak district and Lanjigarh Block in Kalahandi district).

Officials at state and district and many at block level were interviewed individually during in-depth interviews. Groups of sector/cluster officials, field workers, and beneficiaries were interviewed during focus group discussions. In addition, observations were made of records of IFA distribution at Village Health and Nutrition Day, Anganwadi Centre, and schools, as well as the actual distribution of IFA at VHNDs and schools.

  Sampling Top

Qualitative survey

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 such as fathers, and beneficiaries. There were 170 respondents – 12 state officials, 27 districts, 32 blocks, 16 sectors/cluster, 49 field workers, and 34 beneficiaries – with district officials chosen evenly across the four districts and with block and sector officials, field workers, and beneficiaries chosen evenly across the six blocks.

According to three departments jointly implementing NIPI, the most respondents were associated with the Health Department's implementation (70), the second largest group associated with the Education Department (55), and the smallest group from the Integrated Child Development Services (ICDS) Department (35), as well as 10 others.

Quantitative survey

A line list of all the subcenters from within the selected eight blocks in four districts was prepared. From this were selected 50 subcenters using probability proportionate to size sampling method. [Figure 1] shows the process of sample selection and size for the quantitative survey.
Figure 1: Sample selection and size for the quantitative study

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Ethica approval and informed consent

The process documentation protocol was approved by the Ethical Committee of AIIMS Bhubaneswar. Informed consent was obtained from all the study participants. Confidentiality was maintained. All those detected with anemia were advised to visit the nearest health center or AIIMS for further management.

  Operational Issues in National Iron Plus Initiative Documentation in Odisha Top

Political commitment

There was lack of political commitment to increase coverage and strong service delivery of the NIPI.

Teachers are apprehensive and also have poor clarity regarding the program. Hence, the program is not running well in schools. Active involvement of teachers should be there for the smooth running of the programme. However, they do not want to take the risk.

Coordination and convergence among government departments

  1. District level – Leadership at the district level is less apparent and a number of issues have emerged
  2. Block level – At the block level, there were lack of co-ordination between Education department and Health Department.

Logistics management

Indenting of iron and folic acid and albendazole

For the health department

  • Lady Health Visitor are not involved in the practice of indenting as per the guidelines, rather ANMs pass their indent to the MO I/C
  • The block pharmacist assists the MO I/C to prepare the indent, and the district pharmacist assists the CDMO.

For the Integrated Child Development Services

  • The Child Development Project Officer (CDPO) compiles the indent for the MO I/C in practice, instead of the opposite, the CDPO should compile it for the District Social Welfare Office as per the guidelines.

  • For the education department

    • The Block Education Officer (BEO) compiles the indent for the Border Personnel Meeting (BPM) in practice, instead of the opposite, the BEO should compile it for the Department of Economic Opportunity (DEO) as per the guidelines
    • 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 meals and being sent to the Health Department at the state Director of Family Welfare level as per the guidelines.

    At field and sector levels, the indent is prepared by hand. Starting at the block level, the indent is entered online.

    Warehouse maintenance

    The conditions of the State Drug Management Unit warehouses were typically inadequate – not enough space, racks, ventilation, or refrigeration. Odisha State Medical Corporation Limited is gradually upgrading them, including a refrigerator for those drugs that require cold storage condition; however, currently, space is still severely limited.

    Timeline in the flow of supply

    At the district level, every new installment of supply takes a minimum of 2 months, in most cases 3–4 months, before it gets distributed to block community health centers. This was found to be the case for all formulations of IFA tablets and IFA syrup. The main reason for this time lag was the wait for quarantine clearance for new batches of supply.

    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 situ ations where officials were aware of the low stock availability of a particular IFA formulation at field level.


    Most district, block, sector, and frontline workers described receiving training at the beginning of NIPI and getting updated NIPI information through regular meetings. For the most part, any gaps in information or shortfalls in performance could be filled through additional supportive supervision at all levels. A budget for refresher training should also be considered.

    Administration of iron and folic acid supplements

    • More clarity on guidelines and implementation of IFA consumption during the school holidays is recommended
    • 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, or cause black stools or that the tablets may reach their expiry date and then may be dangerous.

    Diagnosis, treatment, referral, and follow-up

    HB concentration is not tested among young children, schoolchildren, or adolescents out-of-school. Instead, the visual pallor technique is used, which detects only severe anemia.

    Without assessing HB concentration, it is difficult for RBSK teams and anganwadi workers (AWWs) to follow the GOI NIPI guidelines for the treatment of mild and moderate anemia.

    Monitoring and supervision

    Despite the number of visits and meetings for monitoring and supervision, little was mentioned about the actions taken during and after these occasions. A robust monitoring system is needed to assess further acceptance of IFA consumption, albendazole consumption, and behavior change related to hygiene and dietary diversity.

    Recording and reporting mechanisms

    Those who will be recording and reporting the data they should have knowledge regarding the purpose of collection and use of data. At minimum, data are recorded to show accountability for having distributed the IFA tablets and syrup. Ideally, the data recorded at all levels will be reported back to those who compiled it in a summary form so that it can inform the work at each level.

    Inadequate reporting

    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, and numerous BEOs did not report to the DEO.

    Social mobilization and community awareness for anemia and National Iron Plus Initiative

    The NIPI Program has largely overcome initial resistance and is performing reasonably well, but to increase program participation further, the program needs ways of increasing relevance (NIPI beneficiaries except pregnant women do not understand that they are likely anemic) and enthusiasm (for example, giving awards, staging competitions, and initiating other information, education, and communication [IEC]).

    Hard-to-reach National Iron Plus Initiative 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. Although all four might exist together, especially among tribal people, separating the components of being hard to reach is important for making recommendations to reduce programmatic constraints related to their geographic, cultural, and educational circumstances.

      Discussion Top

    In the present study, the IFA and albendazole supply chain is managed well and consistently. The visual pallor technique is used, which detects only severe anemia in young children, schoolchildren, or adolescents out-of-school. In a qualitative study by Shet et al., they found that at the health system level, lack of streamlining of Lady Health Worker duties, inability of LHWs to diagnose anemia, and temporary shortfalls in the availability of iron supplements constituted potentially modifiable barriers.[6]

    Resistance to NIPI has decreased significantly due to social mobilization. Similarly, in a study by Chakma et al. regarding IFA supplementation among tribal adolescent girls of Bijadandi block, Mandla district, Madhya Pradesh, social mobilization, timely supply of tablets, quality of tablets (blister pack), and availability of teachers and AWWs were also associated with the compliance and feasibility.[7]

    In this study, little emphasis was given to raise awareness among beneficiaries, community members, field-level workers, and so on to build demand for reducing anemia. However, a study by Vir et al. showed that counseling has very much positive effects on the regular weekly IFA intake that contributed to a high compliance rate.[8]

    A study by Aguayo et al. found that knowledge-centered approach can successfully guide the scaling up of public health nutrition interventions and facilitate intersectoral convergence among different government departments and development partners to break the intergenerational cycle of undernutrition and deprivation.[9]

    In a study by by Kotecha et al. observed that supervised, once a week IFA supplementation to adolescent girls through institutions, especially schools, was found to be an effective intervention to reduce anemia and was scalable within the system. The experience to educate the girls on dietary behavior has not been satisfactory, and covering all out-of-school girls is still a challenge to the success of anemia control.[10]

      Conclusion and Recommendations Top

    There is a coordination among the Health, ICDS, and Education Departments for the provision of IFA supplements, successful biannual provision of deworming medicine to all beneficiaries, and a well-functioning supply chain of IFA supplements – but coverage of IFA supplementation lags behind. Other components such as to promote iron-rich diets and hygiene practices ultimately reduce the prevalence of anemia.

    For further betterment of the program, some recommendations are needed at particular levels as mentioned below.

    For enhanced social mobilization

    To prioritize social mobilization and develop an enhanced NIPI communication (IEC) strategy, IFA should universally be referred to as a “supplement” to food, not as a tablet, to avoid fear of medicines and their side effects. IEC material should be translated into several of the major tribal languages. Leaflets should be developed with pictorial messages for nonliterate beneficiaries.

    For administering the intervention

    For pregnant and lactating women, frontline workers (ANMs, ASHAs, and AWWs) should ensure that they get 360 IFA tablets, if anemic, and 180 if not.

    Pregnant women should be encouraged to take their Mother and Child Protection (MCP) Card with antenatal care records with them when they move to their natal home for the end of their pregnancy and 1st month or so postpartum. For administration of IFA syrup to children 6 months to 3 years, 3–5 years encourage the mother to give on Tuesdays and Fridays and self-record it in MCP card. 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.

    For logistics management

    For proper storage of IFA and albendazole along with other essential drugs more racks should be included in the pharmacies of district, block and primary health center level. Local storage conditions in AWCs, schools, and subcenters should be checked.

    Recommendations for increased diagnosis, treatment, referral, and follow-up

    All health centers should have functioning hemoglobinometers. Hemoglobinometers should be available to RBSK teams to assess students' anemia status and should develop a strategy to monitor whether hemoglobin levels are improving over time.

    For monitoring and supervising the National Iron Plus Initiative Program

  • Provide copies of supply and consumption reports to align reporting and supervision processes. The purpose of reporting should be clear, widely available, and summary of results comparing districts, blocks, even sectors, and clusters

  • Review whether the purpose, participants, and frequency of meetings in which NIPI is discussed are adequate for its monitoring implementation review and problem-solving and for updating participants.

  • For strategic training

    Audio–video training tools on anemia could be made widely available and shown at regular or project meetings, functioning as refresher training.

    For reaching the hard-to-reach

    Resources by state and district governments need to be increased for more remote hilly areas, including roads and health services. Involvement of local village tribal heads in the program should be encouraged to minimize local resistance and arrange for their sensitization, budgeting accordingly.

    Financial support and sponsorship

    We acknowledge the Financial and project support of UNICEF and express the contribution made by Nutrition Section, UNICEF Odisha and Deptt of Health and Family Welfare, Govt of Odisha.

    Conflicts of interest

    There are no conflicts of interest.

      References Top

    World Health Organization. The Global Prevalence of Anaemia in 2011. Geneva: World Health Organization; 2015.  Back to cited text no. 1
    Klemm R, Sommerfelt AE, Boyo A, Barba C, Kotecha P, Steffen M,et al. Are We Making Progress on Reducing Anemia in Women? Cross-country Comparison of Anemia Prevalence, Reach, and Use of Antenatal Care and Anemia Reduction Interventions. AED; June 2011.  Back to cited text no. 2
    DeMaeyer E, Adiels-Tegman M. The prevalence of anaemia in the world. World Health Stat Q 1985;38:302-16.  Back to cited text no. 3
    Petry N, Olofin I, Hurrell RF, Boy E, Wirth JP, Moursi M, et al. The proportion of anemia associated with iron deficiency in low, medium, and high human development index countries: A systematic analysis of national surveys. Nutrients 2016;8. pii: E693.  Back to cited text no. 4
    Ozkasap S, Yarali N, Isik P, Bay A, Kara A, Tunc B, et al. The role of prohepcidin in anemia due to helicobacter pylori infection. Pediatr Hematol Oncol 2013;30:425-31.  Back to cited text no. 5
    Shet AS, Rao A, Jebaraj P, Mascarenhas M, Zwarenstein M, Galanti MR, et al. Lay health workers perceptions of an anemia control intervention in Karnataka, India: A qualitative study. BMC Public Health 2017;17:720.  Back to cited text no. 6
    Chakma T, Vinay Rao P, Meshram PK. Factors associated with high compliance/feasibility during iron and folic acid supplementation in a tribal area of Madhya Pradesh, India. Public Health Nutr 2013;16:377-80.  Back to cited text no. 7
    Vir SC, Singh N, Nigam AK, Jain R. Weekly iron and folic acid supplementation with counseling reduces anemia in adolescent girls: A large-scale effectiveness study in Uttar Pradesh, India. Food Nutr Bull 2008;29:186-94.  Back to cited text no. 8
    Aguayo VM, Paintal K, Singh G. The adolescent girls' anaemia control programme: A decade of programming experience to break the inter-generational cycle of malnutrition in India. Public Health Nutr 2013;16:1667-76.  Back to cited text no. 9
    Kotecha PV, Nirupam S, Karkar PD. Adolescent girls' anaemia control programme, Gujarat, India. Indian J Med Res 2009;130:584-9.  Back to cited text no. 10
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