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Evaluation report

2014 Bhutan: Evaluation of the Weekly Iron and Folic Acid Supplementation (WIFS) Program-2004-2014



Executive summary

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Background:

Anaemia has been recognized as a major public health problem in Bhutan. The first anaemia survey done in 1986 showed a high prevalence of anaemia among pregnant women (60 per cent), preschool children (58 per cent) and among school children (36 per cent). In addition the iron survey conducted in 2001 and 2002 showed high prevalence of anaemia among children 6-60 months of age at 81 per cent. Among non-pregnant women the prevalence was reported at 55 per cent while among men it was 28 per cent. Following these studies, the government prioritized anaemia control in the 9th Five Year Plan and developed a multi-pronged national strategy with introduction of a weekly Iron Folic Acid supplementation (WIFS) as the main intervention. The Ministry of Health, Ministry of Education, Ministry of Agriculture and UNICEF partnered together to develop the strategy and to implement the programme. It was implemented in all schools throughout the country with weekly supplementation of IFA tablets for both girls and boys administered till Class VIII and for only girls in higher secondary schools. The programme implemented since 2004 still continues in all schools. The programme was supported by UNICEF till 2008, the Government took full responsibility for the programme beginning 2009, demonstrating the importance of this initiative.

Purpose/Objective:

The main objective of the study was to evaluate the effectiveness, efficiency and relevancy of the weekly Iron Folic Acid supplementation in schools. The impact of the programme was not assessed since it is a well-known fact that providing iron supplements has a direct positive impact on reducing anaemia. There was also no baseline data.

Methodology:

The methodology employed a mixed method consisting of desk reviews of all programme documents including reports of both the term and sentinel reports; a qualitative component consisting of key informant interviews and focus group discussions; and a quantitative component based on a survey from a representative sample of schools and students. A three stage cluster sampling method was used to select districts (two districts from each of the three regions), schools (17 in total) and students (sample size of 500). A pre-tested questionnaire was used to collect information on demography, knowledge on anaemia and practice of WIFS among students. In-depth interviews were conducted among teachers (school health coordinators, teachers, and principals), health workers (doctors and health assistants) and district education and health officers. In addition, both the term and sentinel data collected was analysed to assess impact and effectiveness of the WIFS.

Findings and Conclusions:

Some of the main findings are:

1) The national strategy document developed in 2004 did not set any specific goals, objectives and the absence of a formal memorandum of understanding between the agencies led to weak accountability and responsibility by respective agencies. 

2) The analysis of the supply and procurement data revealed that quantities of supplements procured were not be sufficient to meet the total requirements of the country.

3) Implementation at the school level was constrained by teachers who had not received training or information on WIFS implementation. As a result, requisition of Iron Folic Acid (IFA) tablet was not made correctly resulting in unavailability of supplements during certain weeks. Coordination between schools and health centre was also weak in implementing WIFS.

4) 33 per cent of students reported that they did not ingest the tablet. This was higher among girls (40 per cent) compared to boys (24 per cent). Side effects were experienced by nearly all students with vomiting reported as the most common symptom (66 per cent).

5) 52 per cent of students reported knew why they needed to take IFA tablets with a higher percentage among girls (62 per cent) and 61 per cent students said that anaemia was not discussed or taught in their schools.

6) The coverage of WIFS was quite good with only one out of the 17 represented schools in the survey having stopped implementation.

7) An analysis of sentinel data showed that the impact on anaemia control was good in the first two years (2004 and 2005) of the programme implementation. Thereafter the prevalence of anaemia increased slightly in the selected schools indicating that either compliance was poor or that there were other underlying causes resulting in anaemia.

Recommendations:

Some of the main Recommendations:

1) A national level anaemia prevalence study should be conducted to decide on the continuation of the WIFS programme in the schools and whether to expand the programme to out-of-school settings and in different age groups. Since it has been more than a decade after the last anaemia survey, it is not only timely but critical for decisions to be made regarding relevancy of WIFS and future control of anaemia.

2) The National Strategy and the Monitoring/Reporting protocol for teachers needs to be revised  and updated by incorporating eligibility criteria for WIFS, reporting channels, reporting formats and monitoring and evaluation mechanisms including frequency, timelines and compliance.

3) A training plan needs to be developed and implemented to enable all school health coordinators and school health committee members to be trained and well-informed on the importance of controlling anaemia with iron and nutrition supplementation. Monitoring of side effects is an important task for teachers.

4) Communicating and raising awareness on anaemia and iron deficiency should be improved and revived as part of the school curriculum and at the national level.

5) An efficient and reliable data management system must be established that will have the capacity to review and analyse reports sent from schools. This can be part of the overall Bhutan Health Management Information System. However there is a need for a dedicated personnel to receive and enter data on WIFS reports into the database. The data should inform the program on future strategies.



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Report information

Year:
2014

Country:
Bhutan

Region:
ROSA

Theme:
Nutrition

Type:
Evaluation

Language:
English

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