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EVALUATION OF THE WEEKLY IRON AND FOLIC ACID SUPPLEMENTATION
PROGRAM
Ministry of Health and UNICEF
FINAL REPORT
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Name of Evaluation Project:
Evaluation of the Weekly Iron and Folic Acid Supplementation (WIFS)
Program-2004-2014
Time period when Evaluation conducted:
April – July 2014
Evaluator:
Centre for Research Initiatives
Name of the Organization commissioning Evaluation:
Ministry of Healthand UNICEF
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Table of Contents
1. Executive Summary ..................................................................................................................... 5
2. BACKGROUND ............................................................................................................................. 9
3. RATIONALE FOR EVALUATION .................................................................................................. 11
4. OBJECTIVES OF THE STUDY ....................................................................................................... 11
5. METHODOLOGY ........................................................................................................................ 11
Step 1: Desktop review of related literature and analysis of secondary data ........................................ 11
Step 2: Qualitative data collection through interviews and FGDs ......................................................... 12
Step 3: Quantitative data collection through cross sectional study to explore the awareness level of
school children on WIFS and iron nutrition. ............................................................................. 12
5.1 Sample size calculation ..................................................................................................................... 12
5.2 Sampling methodology ..................................................................................................................... 13
5.3 Sample Weights: ............................................................................................................................... 14
5.4 Data Processing and Analysis: ........................................................................................................... 15
a. Ethical considerations ............................................................................................................... 15
b. Limitations of the evaluation .................................................................................................... 15
6. FINDINGS ................................................................................................................................... 15
6.1 General: Program implementation ................................................................................................... 15
6.2 National strategy ............................................................................................................................... 16
6.3Training of teachers and medical personnel on implementation including communication ............ 18
6.4 Supply and distribution of iron: ........................................................................................................ 20
6.5Implementation at the school level ................................................................................................... 21
6.6Knowledge of WIFS among teachers and students ........................................................................... 24
6.7Coverage of target population ........................................................................................................... 25
6.8Program level ..................................................................................................................................... 26
6.9Reporting, Monitoring and evaluation .............................................................................................. 26
6.10Coordination among stakeholders................................................................................................... 28
6.11 Impact of WIFS from secondary data ............................................................................................. 30
6.12Other strategies to control anemia ................................................................................................. 32
7. CONCLUSION AND LESSONS LEARNT ........................................................................................ 32
7.1 Conclusion ......................................................................................................................................... 32
7.2 Lessons Learnt ................................................................................................................................... 33
8. RECOMMENDATIONS................................................................................................................ 34
Bibliography ................................................................................................................................................ 37
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ANNEX 1: Conceptual framework of the methodology .......................................................................... 39
ANNEX 2: Evaluation questions .............................................................................................................. 40
ANNEX 3: Evaluation Matrix ................................................................................................................... 42
ANNEX 4: People Met ............................................................................................................................. 45
ANNEX 5: Case study of a school that has stopped implementing WIFS. ............................................... 47
ANNEX 6: Ministry of Health clearance Certificate ................................................................................. 48
ANNEX 7: Ministry of Education clearance Certificate ........................................................................... 49
ANNEX 8: Ministry of Home and Cultural Affairs clearance Certificate .................................................. 50
ANNEX 9: National Statistical Bureau clearance Certificate ................................................................... 51
ANNEX 10: Supplementary tables from data analysis. ........................................................................... 52
Terms of Reference………………………………………………………………………………………………………………………… 77
List of Acronyms
DEFF Design Effect
DEO District Education Officer
DHO District Health Officer
DMO District Medical Officer
DoPH Department of Public Health
DVED Drugs Vaccine Equipment Division
ECR Extended Classroom
FGD Focus Group Discussion
FYP Five Year Plan
HSS Higher Secondary School
IDA Iron Deficiency Anemia
IEC Information, Education and Communication
IFA Iron and Folic Acid
LSS Lower Secondary School
MI Micronutrient Initiative
MoAF Ministry of Agriculture and Forestry
MoH Ministry of Health
MoU Memorandum of Understanding
MSD Medical Supply Depot
MSS Middle Secondary School
PP Pre Primary
PS Primary School
RGoB Royal Government of Bhutan
SPSS Statistical Package for Social Sciences
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UNICEF United Nations Children's Fund
WHO World Health Organization
WIFS Weekly Iron and Folic Acid Supplementation
List of Tables
Table 1: Selected districts and schools using the above mentioned methods. .......................................... 14
Table 2: Timing of providing IFA supplement in the school........................................................................ 22
Table 3: Number of students (PP-XII) reporting supervised IFA supplementation .................................... 22
Table 4: Number and percent of students reporting not ingesting IFA tablet ........................................... 23
Table 5: Student opinion on whether most students ingested or throw IFA tablet ................................... 23
Table 6: Number and percent of students experiencing common side effects after taking IFA tablet ..... 23
Table 7: Knowledge on reason for taking WIFS among school children (PP-XII) ........................................ 24
Table 8: Students learning about anemia and IFA tablet in the school ...................................................... 24
Table 9: Students knowledge on side effects of IFA tablet ......................................................................... 25
Table 10: Knowledge among students on food that inhibit iron absorption ............................................. 25
Table 11: Districts and schools selected for sentinel reporting .................................................................. 30
List of Figures
Figure 1: National strategy for control of anemia ...................................................................................... 17
Figure 2: National strategy outlining activities and responsibility.............................................................. 18
Figure 3: Total number of IFA tablet procured annually (DVED) ................................................................ 20
Figure 4: Budget for procuring IFA tablet annually ..................................................................................... 21
Figure 5: Total number of students eligible for IFA tablet annually ........................................................... 21
Figure 6: Channel of reporting as per the national strategy ....................................................................... 27
Figure 7: Current reporting channel ........................................................................................................... 28
Figure 8: Anemia control approach with sector specific roles.................................................................... 29
Figure 9: Prevalence of anemia at sentinel sites from 2005-2007 ............................................................. 30
Figure 10: Number of missing data from sentinel sites from 2005-2007 ................................................... 31
Figure 11: Number of students reporting with very low hemoglobin levels .............................................. 31
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1. Executive Summary
BACKGROUND AND RATIONALE
1 Anemia has been recognized as a major public health problem in Bhutan since 1986 following the first
anemia survey which showed a high prevalence of 60 % among pregnant women, 58% among
preschool children and 36% among school children. The response to this high level of anemia was
however limited to pregnant women with the implementation of daily iron folic acid supplementation
throughout pregnancy. Without any program for other population groups, it was not surprising that
the next two iron surveys in 2001 and 2002 confirmed extremely high prevalence of anemia – 81 %
among children 6-60 months of age. Among non-pregnant women the prevalence was 55% while
among men it was 28%. The cause for this high prevalence of anemia among women and children was
attributed to iron deficiency as both the population groups have high demand for iron compared to
men. The government prioritized anemia control in the ninth five year plan and developed a multi-
pronged national strategywith weekly supplementation of IFA tablet 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 program. Preparation was done in 2003 with the
development of several documents (information pamphlets for schools, training manuals for teachers
and Monitoring and evaluation booklets) and training of school health coordinators, principals and
DEO’s.
2. The program was implemented throughout the country in all schools with WIFS for both girls and boys
till the VIII standard and for girls only in higher secondary schools. The main stakeholders were MoH
and MoE. Every Thursday during the school calendar year was declared as “Iron day”, and every
student would be provided with IFA supplement and schools would practice supervised consumption
of the tablet. The health centres were to support the schools with supply of tablets and to treat any
side effects if reported. The schools were to send in term reports twice a year to the Nutrition Program
in the department of Public Health. Four districts, one in each region of the country including the
south were selected as sentinel sites and 796 students were followed up twice a year with
haemoglobin estimations. A program review was planned in 2007.
3. The program was implemented from 2004 and continues to be implemented in all schools. The
government has always considered anemia as a major public health concern and the WIFS continues
to benefit Bhutanese children in schools. While the program was supported by UNICEF till 2008, the
government took full responsibility from 2009 onwards demonstrating the importance for the
government of this initiative. The program in the department of public health recognized several
implementation problems over the years and decided to evaluate the program in 2013. A decision
was made to assess the effectiveness, efficiency and relevancy of the WIFS in schools. The impact of
WIFS was not considered since this is already well known and besides there was no baseline or control
groups to compare with.
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METHODOLOGY
4. The methodology employed a mixed method consisting of desk reviews of all program documents
including reports of both the term and sentinel report; a qualitative component consisting of key
informant interviews and Focus group discussion; 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) respectively. A pre tested questionnaire was used to collect information on
demography, knowledge on anemia 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. The data was
analysed using STATA 12.
5. Clearance was received from the Research Ethics Board of Health, National Statistics Bureau, the
Ministry of Education and the Ministry of Home and Cultural Affairs. Consent was taken from the
teacher as well as from students for all the survey questionnaires and information collected was
maintained in full confidentiality. The limitation of the study was that sampled schools were only 17
in number and conducting the survey in one district during the school examination period.
FINDINGS
6. The general findings from the evaluation are that program implementation over the ten year period
was not supported with regular reports and evidences from sentinel reporting. The program review
planned in 2007 was not conducted and so the national strategy could not be revised or updated.
Term and sentinel reporting became less frequent with many schools not reporting from second half
of 2007. BY the end of the 9th FYP, government priority had also shifted to other public health concerns
such as rubella and influenza. High attrition among trained teachers and program personnel also
impacted program implementation.
7. The national strategy document developed in 2004 did not set any specific goals, objectives or
timelines and therefore the program was deprived of a clear direction or mission. National anemia
prevalence has also not been assessed since 2002 and therefore the relevancy and effectiveness of
the program was difficult to assess in the absence of these indicators. The implementation process
was evaluated and its effectiveness and relevancy has been reported serially. The absence of a formal
MoU between the agencies (which was earlier drafted to be signed) led to weak accountability and
responsibility to carry out specific functions by respective agencies.
8. Training of teachers was limited to only two batches of teachers in 2004 with no further training for
teachers. Principals of all schools were informed of the program and information pamphlets were
distributed to all schools. The absence of further training and refresher training over the long period,
compounded by attrition of trained teachers reduced the efficiency and effectiveness of the
programat the school level. Implementation of the WIFS program was left to the individual interest of
principals and school health coordinators of individual schools. During the survey there were only two
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teachers out of the 26 interviewed who were trained in the first cohort. Only one school had a poster
on nutrition whereas none of the other schools had any posters or IEC materials for public display.
9. The supply and distribution of IFA tablets was good until 2008 when the program was supported by
UNICEF. After the government took over in 2009, there was a brief period of stock out after which
regular supply was ensured. An analysis of the supply and procurement data however reveals that
quantities procured may not be sufficient to meet the total requirements of the country. Records
from the term reports and from DVED show that many schools missed several weeks of implementing
WIFS and that the total amounts required by the schools was not met by the total amounts procured
by the DVED. Annually the schools alone require 7 million tablets of IFA, and pregnant women require
3.7 million while the total procurement is only 10 million. The estimated total requirement for IFA
tablet in the country is approximately 13 million indicating a shortage of 3 million tablets.
10. Implementation at the school level is constrained by teachers who have not received training or
information on WIFS implementation. As a result requisition of IFA tablet was not made correctly
resulting in unavailability of supplements on certain weeks. Coordination between schools and health
centre was also weak in implementing WIFS. Most schools provide supplements during the morning
assembly, however the most important component of practicing supervised ingestion was not
implemented uniformly with supervision being provided mostly in primary schools. Nearly one third
of students surveyed (31.5%) said that no supervision was done by teachers. Without supervision
compliance by students was affected as revealed by 33% of students who reported that they did not
ingest the supplement. The percentage was higher among girls (40%) compared to boys (24%). A
higher percentage of students said that they knew other students who threw the tablet. Side effects
were experienced by nearly all studentswith vomiting reported as the most common symptom (66%
of students reporting this). The second most common complaint was the bad taste and smell of the
tablet which led to many students not ingesting the tablet. Side effects such as severe vomiting have
impacted the program with one school deciding to completely stop the program in 2012 following
students’ complaints of severe vomiting.
11. Regarding knowledge ofWIFS, 52 % of students reported correctly the reason for taking IFA tablet
with a higher percentage among girls (62%). However 32% of students did not know the reason why
they had to take WIFS. The reason for this could be due to students not learning about anemia and
WIFS as reported by 61% students who said that these were not discussed or taught in school. This is
in contradiction to the requirement of all schools to include at least one session on anemia and iron
supplement as outlined in the strategy document. Majority of students (77%) also reported correctly
that girls required more iron because of blood loss, however not many knew that growing children
also required more. 92 % of students knew that lethargy and weakness were signs of anemia and that
they needed to go the health centre. However only 3 % of students reported ever being diagnosed as
anemia and taking IFA on a daily basis.
12. The coverage of the WIFS is quite good with only one school out of the 17 represented schools in the
survey having stopped implementation. This means that approximately 30 schools in the country
could have stopped implementation. Another school encounteredduring travel was also found to
have stopped implementing the program. The main concern is that schools are arbitrarily deciding to
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stop implementing a national program without reporting or seeking advice. This is indicative of weak
coordination and monitoring. Reporting from school has also been irregular with no uniform channel
and. Besides receiving only 12 reports in 2012, schools were sending reports to programs in both the
MoH and MoE. A meeting to streamline reporting with the national school committee has improved
reporting with more than 70% of reports having received by the School health program in the MoH
till date.
13. Sentinel data was collected from 12 schools in four districts, one from each geographical region
between 2005 and 2007. A total of 796 students had their haemoglobin levels measured twice
annually. An analysis of this data showed that the impact on anemia control was good in the first two
years of the program implementation in 2004 and 2005. Thereafter the prevalence of anemia
increased slightly in the selected schools indicating that either compliance was poor or that anemia
was due to other causes. However another problem identified was poor quality of data with many
incorrect reports and missing data. The sentinel data is a rich source of information given that similar
programs of such duration has not been implemented elsewhere.
14. The findings from the evaluation show that the processes in program implementation has not been
efficient and effective. Awareness on the importance of WIFS is poor compounded by absence of IEC
materials and teaching programs in schools. Teachers have not been trained and are not supported
with information packages. Coordination is weak at the national and district level especially between
the main implementing partners albeit the meeting of the national school health committee has seen
some improvement. IFA tablet quantification, procurement and supply needs improvement to ensure
adequate supply. The relevancy of the program will depend on the prevalence of anemia especially
IDA which needs to be confirmed by a national survey. Several lessons have been learnt among which
the most important component is that for WIFS to succeed, supervision must be ensured.
RECOMMENDATIONS
15. Several recommendations have been proposed among which the critical ones are to conduct a
national anemia survey to study prevalence and to decide on the further continuation of the program.
Until such time, the program needs to be continued with better coordination among stakeholders,
revise the national strategy and strengthen monitoring and reporting. Training needs to be imparted
to teachers and logistics should be improved with better estimation of IFA quantities and more
efficient supply. Information pamphlets and posters must be designed and distributed to increase
awareness. Most importantly the WIFS program must be supervised to ensure that all students ingest
the tablet and side effects should be monitored and reported diligently.
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2. BACKGROUND
Anemia is one of the commonest nutritional disorder globally with an estimated 2 billion people or 30 %
of the world’s population being anaemic.1If affects people in all walks of life, in developing as well as
developed countries however its prevalence is much higher in developing counties and among pregnant
women and children. International organizations such as the WHO, UNICEF and Micronutrient
Initiativeestimate that 50 % of all anemia cases is due to iron deficiency.2
The earliest study on anemia done in 1986 by Sood and Sharma indicated a prevalence of anemia in
pregnant women to an extent of 60%, in preschool children 58% and in school children 36% based on a
survey of 561 pregnant women, 540 preschool children and 266 school children.3 The study had certain
limitations and besides strengthening iron supplementation for pregnant women and enhancing
advocacy, no specific intervention was designed. In 2001-2002 a sub national survey was conducted which
revealed the prevalence of anaemia among 6-14 years as 64%.4To corroborate this and to develop a
comprehensive strategy to control anemia, a systematically planned survey, with well design sampling
involving the community was conducted in 2002 covering 1800 women, 1800 men and 1800 children from
10 districts and two urban areas.5 The study pointed to a high prevalence of 81% anemia in children of 6-
60 months of age, 55% anemia in non-pregnant women and 28% anemia among men. The study used
World Health Organization (1968) criteria for defining anemia for children below 11gd/dl as anemic, for
non-pregnant women at less than 12 g/dl hemoglobin as anemic and for men as 13.0 g/dl to define as
anemic after correcting for altitude. One key finding of high concern was that among young children below
two year of age, the prevalence was as high as 89%. In addition the problem of anemia was not uniform
in the country with the central, east and south zones being more affected than west zone and urban areas.
The cause for this high prevalence of anemia in Bhutan was attributed to iron deficiency based on the
research findings and from the high prevalence among children and women who have the highest demand
for iron. In addition the dietary pattern, food consumption practices and prevalence of worm infestations
provides further evidence for iron deficiency being the main cause of anemia. It is well known that iron
deficiency results from sustained negative iron balance, which is caused by inadequate dietary intake,
decreased absorption or utilization of iron, increased iron requirements during the growth period, or
blood loss due to parasitic infections such as malaria, soil-transmitted helminthic infestations and other
infections. It is only in the later stages of iron depletion that the haemoglobin concentration decreases,
resulting in anaemia. In addition to iron deficiency, other micronutrient deficiencies (e.g. folate, vitamin
B12 and vitamin A), chronic inflammation and inherited disorders of haemoglobin structure can also cause
anaemia.
Children are particularly vulnerable to iron deficiency anaemia because of their increased iron
requirements in the periods of rapid growth, especially in the first 5 years of life, poor dietary intake of
iron and high rate of infection and worm infestation. Among adolescents, early marriage, menstrual loss
1 WHO. Website 2 WHO. Prevention of iron deficiency anaemia in adolescents. Role of weekly iron and folic acid supplementation. Regional Office for South East Asia, 2011, p2 3Sood S.K. and Sharma S. Occurrence and cause of nutritional anemia in Bhutan. Survey carried out by RGoB and UNICEF, 1986 4 Nutrition Program. Strategy for control of anemia in Bhutan, Department of Public Health, Ministry of Health, 2004 5 Ministry of Health. National Anemia survey report. Nutrition program and UNICEF, 2003
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and teenage pregnancy contribute to high burden of anemia among this population group. Iron deficiency
anaemia in children has been linked to increased childhood morbidity and impaired cognitive
development and school performance. Significantly when these impairments occur at an early age, they
may be irreversible, even after repletion of iron stores, thus reinforcing the importance of preventing this
condition.6
These findings suggested that iron deficiency anemia was a major public health problem in Bhutan. To
respond to this, the RGoB developed a multi-pronged strategy in consultation with UNICEF shortly after
the anemia survey results were published in 2003. The Ministry of Health as the lead agency formulated
the national strategy for control of IDA and one of the key prophylaxis components was to provide
supervised weekly iron folic supplementation to school children throughout the academic year. Daily iron
supplementation was not considered given the difficulty in logistics, insufficient tablet distribution,
prolonged duration of the intervention and the associated side-effects such as gastrointestinal discomfort,
constipation and staining of teeth with drops or syrups, which would limit adherence to the intervention,
especially in young children.7 Intermittent consumption of oral iron supplements was proven to be
effective and was being successfully implemented in several countries.8,9The proposed rationale behind
this intervention was that intestinal cells turn over every 5–6 days which have limited iron absorptive
capacity.10 Thus intermittent provision of iron would expose only the new epithelial cells to this nutrient,
which should, in theory, improve the efficiency of absorption. Intermittent supplementation is also
thought to minimize blockage of absorption of other minerals due to the high iron levels in the gut lumen
and in the intestinal epithelium. Experience in different populations has furthermore shown that
intermittent regimens reduce the frequency of other side-effects associated with daily iron
supplementation and are more acceptable to recipients, thus increasing compliance with
supplementation programmes.11
6Lozoff B. Iron deficiency and child development. Food and Nutrition Bulletin, 2007, 28:S560–571. 7Gillespie SR, Kevany J, Mason JB. Controlling Iron Deficiency. Administrative Committee on Coordination/Subcommittee on Nutrition State-of-the-Art Series. Geneva, UN Standing Committee on Nutrition, 1991 (Nutrition Policy Discussion Paper No. 9; http://www.unscn.org/layout/modules/resources/files/Policy_paper_No_9.pdf, accessed 18 June 2014). 8 Berger J et al. Weekly iron supplementation is as effective as 5 day per week iron supplementation in Bolivian school children living at high altitude. European Journal of Clinical Nutrition, 1997, 6:381–386. 9 Wright AJ, Southon S. The effectiveness of various iron supplementation regimens in improving the Fe status of anemic rats. British Journal of Nutrition, 1990, 63:579–585. 10Viteri FE et al. True absorption and retention of supplemental iron is more efficient when iron is administered every three days rather than daily to iron-normal and iron-deficient rats. Journal of Nutrition, 1995, 125:82–91. 11De-Regil LM et al. Intermittent iron supplementation for improving nutrition and developmental outcomes in children under 12 years of age. Cochrane Database of Systematic Reviews, 2011 (12): CD009085 (http:// onlinelibrary.wiley.com/doi/10.1002/14651858.CD009085.pub2/abstract, accessed 15 December 2011).
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3. RATIONALE FOR EVALUATION
The National iron folic supplementation program was launched in September 2004 with the MoH and
MoE as implementers. While the iron tablets were procured and distributed by the MoH, the schools were
responsible for actually supervising and ensuring that students ingested the supplement. All boys and girls
in class eight and below are given once a week supervised iron folic acid tablets (60mg iron and 400
microgram folic acid) while only girls in the secondary, higher & college students are given once a week
supervised iron folic acid tablets12. After ten years of implementation, the number of schools covered by
the program is reported as 501.13Despite a strategy and reporting mechanisms in place, the program has
never been evaluated and the effectiveness or impact of the program has been documented. This
evaluation is thus being undertaken by the MoH with technical and financial support from UNICEF to
provide information on the efficiency, effectiveness and relevancy of the program.
The efficacy of WIFS in preventing IDA is well established provided that the target population consumes
the supplement.14 The impact of the program is therefore assured as long as the program process such
as procurement, supply, distribution, supervision and compliance is efficient and effective. Therefore
the present evaluation of the WIFS program focuses on the relevancy, efficiency and effectiveness of
WIFS. The impact and sustainability parts are omitted from this evaluation upon mutual agreement
between the stakeholders and the consultants owing to the above reason, as well as for lack of time and
limited financial resources. Therefore, this will be a process evaluation of the program that will inform on
the need of an outcome/impact evaluation.15
4. OBJECTIVES OF THE STUDY
I. To determine whether the intervention is still valid or relevant.
II. To assess the effectiveness of the programme for school children.
III. To assess the efficiency of the WIFS program
5. METHODOLOGY
A conceptual framework for the methodology as well as a list of evaluation questions were drawn up
(Annex) and this was then presented in an evaluation matrix (Annex). The methodology for the evaluation
consisted of answering a number of evaluation questions through a mixed method using both quantitative
and qualitative method. A three step process was adopted to complete the evaluation as follows:
Step 1: Desktop review of related literature and analysis of secondary data
(i) Desktop review of all existing program documents& publications (Listed in Annex)
12 MOH and UNICEF. National Strategy for control of IDA in Bhutan, 2004 13MoE. Annual Education Statistic, 2012 14 Beaton GH, McCabe GP. Efficacy of intermittent iron supplementation in the control of IDA in developing countries. Micronutrient Initiative, Canada, 1999. 15UNICEF/RFP. Terms of Reference, dated 25.10.2013
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(ii) Secondary Data Analysis: The reporting system adopted by the WIFS program since its
inception consisted of collecting two types of reports, the term report and the sentinel report
on a regular basis.
Term report: This is a quarterly report submitted by the schools through the DHO to the program. It
provides the number of students provided with WIFS and quantity of tablets distributed. This was put in
place to ensure and assess all schools in their implementation of the program. In addition the robustness
of the program in terms of timeliness and completeness of reporting could also be assessed. The
evaluation aimed to review the data to assess both the effectiveness and efficiency of the
supplementation.
Sentinel Reports: There are foursentinel sites identified by the program from where regular data on
hemoglobin status of the students were to be assessed by the health center and reported to the program.
The analysis of this data would enable us to assess the effectiveness of the WIFS and also indicate the
impact on control of anemia.
Step 2: Qualitative data collection through interviews and FGDs
The qualitative data of the evaluation was collected through interviews and focus groups discussion with
relevant stakeholders (Annex). The main interviewees consisted of the DEO and DHO for each of the
selected districts, the School health coordinator and Principal of each selected school and health in-charge
of the closest health centre. These stakeholders were selected as they are the main implementers in the
schools and districts and are responsible for ensuring the success of the program.During Focus group
discussion some parent were also included to get their perspective as they also have a stake in maintaining
good nutrition of the child. An interview guide (Annex) was used to collect relevant information. An
observation checklist was also used to observe storage of tablets, presence of posters on WIFS and
maintenance of records on iron supplementation.
Five focus group discussions (FGD)were conducted using a FGD guide. Three were conducted among
teachers, health workers, managers and parent while two were among students.
Step 3: Quantitative data collection through cross sectional study to explore the awareness level of
school children on WIFS and iron nutrition.
5.1Sample size calculation
Since such a study was conducted in the country for the first time, information regarding the proportion
of awareness level was not available,therefore an assumption of 50% awareness level among school
children was assumed (to get the maximum sample size).Considering a confidence interval of 95% i.e.
allowing 5% margin of error andusing the formula below, sample size was fixed at n =500 spread over 17
schools.
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𝒏 =𝒁𝜶
𝟐 ∗𝒑(𝟏−𝒑)
ϵ2∗ 𝐷𝐸𝐹𝐹
Where 𝒏 = Sample size required
Zα = 1.96 (95% confidence interval)
p = proportion of awareness level (0.5)
ϵ = Margin of Error (0. 05)
𝐷𝐸𝐹𝐹 = Design effect 1.2
Allowing for 5% refusal rate: 𝒏= 462 + (462*.05) ≈ 500
5.2 Sampling methodology
The total numbers of students in 501 schools where the WIFS program was implemented was used as a
sampling frame for selecting the sampling units. Using the Three-Stage Cluster Sampling Methodology
along with the PPS (Probability Proportional to Size) Method districts, schools, and students were selected
in the following manner: i) The first stage of sampling was conducted to select total of 6 districts i.e. 2
districts each (15% of districts from each region) from each of the three regions (Western, Central and
Eastern), (ii) In the second stage, number of schools to be sampled was determined based on the available
fund for the study and assuming that the school where the program has been implemented will have
homogenous behavior regarding the awareness level of students, it was calculated that 30 students per
school will be selected from each school to obtainthe possible maximum number of school for the
study.Therefore, dividing n=500 by 30 approximately 17 schools were selected for the survey. Then using
Proportional Allocation Method the numbers of schools to be selected from each selected district were
determined i.e. 6 schools were selected from east, 6 from west, and 5 from the central region. iii) The
third stage involved selecting the students from the selected schools. The number of boys and girls to be
selected from each school were determined using proportional allocation method. The students were
then selected at each school using circular systematic sampling method. The samples are therefore
representative at the school and student level.
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Table 1: Selected districts and schools using the above mentioned methods.
Region District Schools level
West
Thimphu
Jemina PS
Lungtenzampa MSS
Zilukha LSS
Wangdue
Bajo HSS
Wangdi LSS
Rinchengang PS
East
T/Yangtse
Ramjar MSS
Thragom LSS
Pangtokha PS
S/Jongkhar
Garpawoong MSS
Orong LSS
Reshore ECR
Central
Sarpang Pelrithang MSS
Samtenling PS
Zhemgang
Yebilaptsa MSS
Bjokha PS
Tshaidang PS
5.3 Sample Weights:
To account for differential probabilities of selection due to type of sampling methodology employed and
to ensure accurate survey estimates, student-levelsampling weights were calculated and assigned to the
dataset. The calculation of the sampling weights for students sampled were calculated using the formula
given below:
Say, probability of selection of district in region (stage 1) is 𝜌1𝑖, probability of selection of school in district
(stage 2) is 𝜌2𝑖, and probability of selection of students in school (stage 3) is 𝜌3𝑖, then raw weights for
student is:
𝑾𝒊 =𝟏
𝝆𝟏𝒊 ∗ 𝝆𝟑𝒊 ∗ 𝝆𝟒𝒊
However, using raw weights can give correct estimates of means and proportion, but the test statistics
will have too much power, therefore these raw weights were normalized 𝑾𝒏 (standardized). The method
of normalizing these raw weights involved dividing the raw weights 𝑾𝒊 by the mean of the raw weights
�̅�. Since, study didn’t have any non-response the weighting process didn’t have to adjust for it.
𝑾𝒏 =𝑾𝒊
�̅�
15 | P a g e
5.4 Data Processing and Analysis:
Once the data entry was competed, it was validated manually for data entry error and completeness. The
data was then cleaned and analysed using STATA 12. Since, this study employed a complex study design
(multi-stage sampling method) the standard errors - for the purpose of calculating confidence intervals -
were calculated using Taylor Series Linearization Method for variance estimation. All the estimates are
weighted at student level. Where relevant data is disaggregated by gender and level of school.
Furthermore although not representative, rural and urban disparities have been analyzed and presented
in tables which are annexed.
a. Ethical considerations
The inception note including the evaluation design were approved by both National Statistical Bureau
(NSB) and Research Ethics Board of Health (REBH) after careful consideration. All interviews were
conducted with due consent from teacher and individual student and the information collected were
maintained with full confidentially.
b. Limitations of the evaluation
Limited time and funds allowed for the selection of 17 schools in the whole country. One of the
schools had stopped implementing WIFS because of non-receipt of IFA tablets. Another school (not
listed in the survey) which stopped the program was identified during field visit and reason was due
to severe side effects experienced by students. Identifying more such schools would have offered
varied reasons for stopping and more information for this evaluation.
The survey component for the schools in Thimphu district were done during the examination period
and with exam stress among students, it may have impacted the response to some of the questions.
6. FINDINGS
6.1 General: Program implementation
The alarming high prevalence of anemia revealed by the 2002 national anemia survey led to the
implementation of the WIFS program in 2004. There was serious commitment from all stakeholders in
particular the MoE and MoH and international agencies such as UNICEF and WHO. Considering the
problems associated with WIFS such as compliance and monitoring, the technical committee established
for the purpose, recommended implementing the program in the schools only where close supervision
and monitoring could be provided by teachers. The strategy set in place term reporting by all schools and
sentinel reporting on a quarterly basis from schools located in 4 districts with one from east, west, north
and southern parts of the country. The Program decided to conduct this vigorously over the next three
years and to review all the reports and to evaluate the program at the end of 2007.
Reporting and monitoring of the program took place systematically and effectively over the next two years
as revealed by the timeliness and completeness of reporting between 2004 and 2006. Thereafter there
was only one sentinel report in 2007 and many of the schools defaulted in sending term reports. Anemia
received less priority as other conditions such as rubella and pandemic influenza emerged as major public
health program. Funding for the WIFS also decreased substantially with UNICEF handing over the
procurement to the RGoB in 2008. As a result the review of the term and sentinel reports and the
16 | P a g e
evaluation of the program did not take place as planned. The program continued to be implemented with
less monitoring and without any supervision. Attrition among teachers who were trained and without any
training for replacements, implementation at the school level became less efficient. The quality of the
program was largely dependent on the capability and interest of individual principals and school health
coordinators.
At the program level, there were changes in the management with the senior Program Manager having
resigned in 2007 followed by the transfer of the Program Officer in 2011. With limited training for new
replacements, there was loss of institutional knowledge and processes.Although the program continued
to be implemented in the schools, there was very little interaction between implementers in the schools
and the Program. The same changes in the MoE and in particular the school health and feeding program
also led to infrequent supervision and monitoring.
6.2 National strategy
A national strategy for control of iron deficiency anaemia in Bhutan was developed to implement the WIFS
by three Ministries of Health, Education and Agriculture and UNICEF. Although comprehensive in
describing the burden of anemia, the strategic document is weak in that no specific objectives were
defined for the WIFS. Several interventions, targeting different population groups were developed
however no timelines or specific activities were detailed.
Figure 1: National strategy for control of anemia16
16 MoH, MoE, MoA, UNICEF. National Strategy for control of iron deficiency anemia in Bhutan. 2004
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There was no action plan and as a result delineation of responsibilities was not specified. Time bound
activities were also not specified and as a result implementation was not uniform with immense delay in
implementation. Groups such as girls not attending school, non-pregnant womenand children 4 months
to pre-school age group could not be reached.
Figure 2: National strategy outlining activities and responsibility17
17 MoH, MoE, MoA, UNICEF. National Strategy for control of iron deficiency anemia in Bhutan. 2004
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Many of the important activities also could not be realized making the program ineffective such as signing
the MoU between the three Ministries, implementing the Monitoring system, developing and mass
distribution of IEC materials including pamphlets and most importantly ensuring compliance. The biggest
weakness of the program was not following the recommendation in the strategy that “independent
process evaluation and impact evaluation after one/two year of implementation of the program” be
conducted.
Although a national strategy document is relevant and required to make the program effective and
efficient, the existing document needs to be updated with clear objectives and time bound strategies and
activities. In addition a formal MoU needs to be signed between all stakeholders for accountability and
delegating responsibilities.
6.3Training of teachers and medical personnel on implementation including communication
At the start of the program in 2003, the program planned to train two teachers (health coordinator + one lady teacher preferably with science background) from every school and one school where total teacher numbers was less than nine. The training was to be conducted for one day and in batches of 30-50 in all districts with program and district medical officers as resource person. The training materials consisted of the following documents:
Strategy to control iron deficiency anemia in schools, MoH
Micronutrient supplement in school, Resource booklet, MoH
Nutrition information booklet for schools
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Instruction Pamphlet for Teachers:Micronutrient Supplementation in Schools
Reporting and Recording forms
The focus of the training was on the strategy of iron supplementation for schools, importance of anemia, logistic of the supply, part of IEC and the format of monitoring. The trained teachers on returning to their respective schools were expected to train and orient other teachers about the program objectives, activities and orientation and also how to implement and monitor the actual program. The District Education officers in turn were expected to monitor implementation of the program and to ensure that all educational institutes were complying with the strategy.
BY June 2004, two batches of School health coordinators were trained and the program was rolled out in September 2004. All DEO’s and few principals were also sensitized during a one day workshop. No further training was conducted after rolling out the program in 2004.
From the interviews with education and health officers, only two teachers in two schoolsout of the total 28 teachers interviewed had received training in 2004 on WIFS. Teachers in four schools reported attending training in first aid and three school health coordinators said that they had received training in basic health. Anemia and iron supplementation were a small component of the training, however it was inadequate to address issues around WIFS. Majority of teachers interviewed had taken the initiative to learn from the World Wide Web however the information differed from the weekly supplementation of the program. They also had difficulty filtering information and understanding technical details. Most teachers during the FGD raised the problem of excessive work burden on teachers and enquired if health workers might come to school to teach about anemia and iron to students. Some of the school health coordinators said that going to the health center to collect IFA tablets and maintaining records took a lot of time. Allof them however agreed unanimously on the need to implement targeted training on IFA supplementation especially for the school health coordinators.
Absence of training or refresher programs has led to general lack of awareness and apathy among teachers and school health coordinators. Most of the teachers interviewed said that there was no system of keeping records and supervision by DEOs. Nearly half of teachers interviewed did not know that there were guidelines for providing IFA tablet in the school including timing and need to supervise ingestion. Only five schools reported having the guidelines in the school although none could provide a copy of it. There is also complete absence of IEC (information, education and communication) materials including program documents, manuals or posters. Only one out of the 17 schools had any poster on anemia on display in the school premises. Many of the older school health coordinators have also been replaced and new in charges tend to implement the program mechanically without interest and ownership. Almost all principals said that they left the implementation of the program to the school health coordinator despite knowing that the teacher had not received training. One teacher commented that her job was just to collect the IFA tablet and give to the individual call teacher for distribution. She did not know when and how the program had begun and said that there was no follow up, record keeping or reporting. It is imperative that for programs such as IFA supplementation to be successful, teachers must be trained and committed to ensuring compliance. A well planned training program and refresher training at regular intervals is not only relevant but will enable more effectiveness of the program.
6.4 Supply and distribution of iron:
The iron supplement chosen by the program is iron folic acid (IFA) tablet containing 60 mg of elemental iron and 400 mcg of folic acid. The amount of IFA tablet required as per the program document was to calculate 60 tablets for every eligible student (one tablet every week for 52 weeks and considering 8 tablets as wastage/extra). Each school was asked to submit its requirement to the health center who
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would then prepare an annual requirement based on a list of all the schools under its catchment along with their requirements. This was sent directly to the DVED who would then compile the requirement at the national level, procure and supply it through its supply chain. Once the supplies reached the health center, they are expected to supply to each of the schools on a 6 monthly basis and to maintain records.
UNICEF funded the procurement of IFA tablets until 2008, after which the RGoB took it up. During the changeover in 2009, there was a drop in the number of tablets procured and many schools did not receive supplies for a period of 6 months. This can be seen as a reduction in procurement in 2009 in figure 3. It is also seen that post 2010, the government has been procuring on average 10 million IFA tablets annually. The number of eligible students for iron supplementation annually in figure 5 shows that there are 135,000 students from pre-primary to high school and taking an annual need of 52 tablet per student, the total requirement is close to 7 million. This is for the IFA supplementation in schools only. With 14,000 pregnancies on average annually, the requirement for IFA tablets in this group is 3.7 million tablets. Therefore the total requirement for these two groups already exceeds 10 million.
It can be concluded that the current annual procurement of IFA tablets is inadequate to meet the total requirements. Taking the last figure of 2008 supplied by UNICEF it can be seen that current quantities are short by approximately 2-3 million tablets. This is further corroborated from the stock outs reported in a number of schools.
Figure 3: Total number of IFA tablet procured annually (DVED)
Figure 4: Budget for procuring IFA tablet annually
10,000,000
13,758,000
1,526,000
12,873,000
10,138,000
10,138,000
10,531,000
10,204,000
0
2,000,000
4,000,000
6,000,000
8,000,000
10,000,000
12,000,000
14,000,000
16,000,000
2007 2008 2009 2010 2011 2012 2013 2014Total IFA procured
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Figure 5: Total number of students eligible for IFA tablet annually
The WIFS is sustainable as demonstrated by the investment made by the government on the program in
the last 6 years, from 2009 onwards. The RGoB funded the procurement and distribution of IFA tablets to
the schools. Although more investment is required for training, communication, and coordination, the
investment will be cost effective given that the negative impacts of anemia, visible and hidden can be
immense. The decision of the government to utilize the resources generated from the health trust fund
to procure all essential medicines including IFA also demonstrates the political will of the government.
6.5Implementation at the school level
According to the strategy, either the Principal or the school health coordinator is expected to be the
coordinator and to receive the IFA tablet supplies from the health center and to maintain records. The
iron tablets are then distributed to the classes through respective class teachers or appointed students.
Each school is expected to make a requisition to the health center based on the number of eligible
students and available stock positions in the school. However only eight schools had made any requisition
based on number of students, while the others based it on past experience and often on whatever supplies
the health center provided. As a result there were either stock outs or excess stocks reported in most of
993,475
1,584,219.88
412,020
901,110506,900
506,900
684,515
663,260
0
500,000
1,000,000
1,500,000
2,000,000
2007 2008 2009 2010 2011 2012 2013 2014
Budget in Ngultrum
Budget
77434 81300 85443 86094 88458 84181
52206 52567 52006 51042 49248 47250
129640 133867 137449 137136 137706131431
0
20000
40000
60000
80000
100000
120000
140000
160000
2 0 0 8 2 0 0 9 2 0 1 0 2 0 1 1 2 0 1 2 2 0 1 3
Girls (Cl PP-12) Boys (Cl PP-8) Total
22 | P a g e
the schools. There was also no fixed schedule for sending in requisition with most schools requesting for
supplies on an ad hoc basis, at times on a weekly basis.Interviews with health workers said that this was
inconvenient to the health center especially when there were delays in supplies from Medical supply
depot (MSD) or towards the end of the annual indent year. They said that they did not provide the tablet
if the stock situation was low in the health center.
In seven schools, shortages were not addressed immediately resulting in students not receiving IFA
supplementation for several weeks. The term reports submitted by the schools reveal that in almost all
the schools, students were not provided with supplementation over several weeks. During shortages,
some schools did not give IFA tablets to certain groups based on teachers’ knowledge, such as not giving
to younger students or boys, believing that girls who were menstruating were the ones most in need.
In majority of the schools (63%), IFA tablets are provided to the students during the first period while in
14 %, they were provided after lunch(table 2). A few schools chose to provide during morning assembly
and during last period. It can be concluded that while majority are following the recommendation, there
is still uncertainty among schools on the most appropriate time to give the supplementation.
Table 2: Timing of providing IFA supplement in the school
When is IFA given in school? Boys Girls Both
During assembly 26 28 54 (11%)
First period 128 184 312 (63%)
After lunch 30 37 67 (14%)
Last period before going home
10 1 11 (2%)
No fixed time 29 18 47 (10%)
Supervised supplementation of IFA tablets is the most important aspect for the success of the program.
While 13 school health coordinators out of 16 interviewed reported that they were supervising the intake
of tablets by the students, 31.5 % of students reported not being supervised(table 3).
Table 3: Number of students (PP-XII) reporting supervised IFA supplementation
Boys Girls Both
Yes No Yes No Yes No
138 (58%) 99 (42%) 210 (77%) 61 (33%) 348 (68.5%) 160 (31.5 %)
In most instances, mere distribution of the tablets by the teacher and asking students to swallow was
deemed adequate supervision. Teachers from the seven primary schools reported that for the smaller
children, supervision was insured by providing water and making sure they ingested the supplement.
Many schools, especially in higher classes allocated the supervisory responsibility to the class captain who
often was the one distributing the tablet as well. The national strategic document also does not provide
clarity on what constitutes supervision. Some of the teachers expressed difficulty and time constraints in
having to observe each student ingest the tablet individually. Suggestions were given on increasing
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awareness and knowledge among students who would then see the benefits and would be committed to
taking the supplement.
In the absence of supervised ingestion of iron supplements it was not surprising to find that significant
number (33%) or one third of students did not ingest the tablet(table 4).Comparing this by gender, 108
(40%) of girls ever did not ingest IFA tablet compared to 58 (24%) of boys.
Table 4: Number and percent of students reporting not ingesting IFA tablet
Description
Boys Girls Both
Number Percent Number Percent Number Percent
Ever not ingest IFA tablet 58 24% 108 40% 164 33%
Always ingested 180 76% 163 60% 343 67%
Since there was a possibility of students not being truthful about answering question directly, they were
also asked if they knew other students who did not ingest. The responses were similaras shown in table
5, with 29 % of boys and 39% of girls saying they knew other students who did not take the tablet. However
when asked their opinion on whether most students ingested or threw the tablet, more numbers, 118
(44%) of girls said that most threw the tablet.
Table 5: Student opinion on whether most students ingested or throw IFA tablet
Description
Boys Girls Both
Number Percent Number Percent Number Percent
Ingest 127 54% 114 42% 241 47%
Throw 71 30% 118 44% 189 37%
Don’t know 39 16% 39 14% 78 15%
One concern with IFA supplementation in general is with minor side effects which may be severe enough
for students not to take the tablet. Student compliance is often compromised because of the frequency
of side effects. In the current survey majority of students reported experiencing side effects and the most
common reported was vomiting (69%)followed by bad taste and stomach ache (table 6).
Table 6: Number and percent of students experiencing common side effects after taking IFA tablet
Description
Boys Girls Both
Number Percent Number Percent Number Percent
Vomiting 152 64% 199 73% 351 69%
Bad taste 80 34% 82 30% 162 32%
Stomach pain 22 9% 30 11% 52 10%
Constipation and dark stool 5 2% 6 2% 11 2% *Absolute numbers reported with more than one answer, therefore the total number and percent does not equal 100%
24 | P a g e
Only seven out of the 17 schools reported ever having a coordination meeting among teachers and
sometimes with health workers on WIFS. This was evidenced by minutes of the meeting and list of
participants. The meetings however were not regular and were usually arranged to address issues such as
supply of tablets, side effects and inviting health workers to speak on anemia.
6.6Knowledge of WIFS among teachers and students
One of the important impacts of the WIFS envisioned was to instill knowledge on iron deficiency anemia
(IDA) among the students who would then serve as agents of change for improving nutritional outcomes
in the family. The nutritional information booklet for schools incorporated knowledge on IDA and
recommended that this be included in the curriculum and that teachers discuss enquire about the
program during school health activities. These received significant attention in the first few years but over
the passage of time, the booklets have disappeared from the schools and very few teachers discuss about
anemia and iron with the students. Only one school had a poster on IDA and the importance of WIFS in
the school. It is therefore not surprising to find that the level of knowledge among students was quite
poor.
Among the samples students, nearly 32% of the students did not know the reason why iron was given in
the school. Only 52% of the students knew the correct reason and of these knowledge was higher among
girls (62 %) boys compared to boys (40 %).
Table 7: Knowledge on reason for taking WIFS among school children (PP-XII)
Why is iron given in school? Boys Girls Both
To reduce anemia 91 (40%) 165 (62%) 256 (52%)
To give strength 36 (16%) 44 (16%) 80 (16%)
Don’t know 98 (44%) 58 (22%) 156 (32%)
The reason for poor knowledge among students is apparent with 61% of the students saying that topics
on anemia and iron were not discussed in school.
Table 8: Students learning about anemia and IFA tablet in the school
Do you learn about anemia and IFA tablet in school? Boys Girls Both
Yes 67 (28%) 131 (48%) 198 (39%)
No 170 (72%) 140 (52%) 310 (61%)
Majority (77%) of the students said that girls required iron more than boys and attributed this to
menstruation and blood loss. 13 % felt that both sexes required equally while 7 % did not know who
required more. Many did not know that iron was required for growing children. Majority of the students
responded to the cause of anemia as menstruation, blood loss and poor diet. Almost 88 % of the students
also said that IFA tablet should be taken after food.
Of concern was the lack of knowledge among students on the side effects of IFA tablet, with 71% stating
that they did not know the side effects and only 29 % responded correctly with stomach ache (gastritis),
25 | P a g e
vomiting, headache and black stool as the most frequent answers sequentially. Girls (35%) had better
knowledge on side effects compared to boys (23 %). Three teachers also said that they did not know the
side effects.
Table 9: Students knowledge on side effects of IFA tablet
Knowledge on side effects of IFA tablet Boys Girls Both
Know side effects 54 (23%) 95 (35%) 249 (29%)
Don’t know 182 (76%) 176 (65%) 358 (71%)
Only 3% of the students responded affirmatively to having been diagnosed as anemic and receiving
treatment from the health center. Majority (92%) of the students identified weakness and lethargy as
symptoms of anemia although few also thought that body ache, diarrhea and cough were symptoms of
anemia. Majority of students identified green leafy vegetables and meat as good source of iron. As shown
in table 10, more than half (59%) of the students knew that tea was to be avoided when taking IFA tablet.
A small number of students (18%) mostly from lower classes thought that even water was to be avoided
which is incorrect.
Table 10: Knowledge among students on food that inhibit iron absorption
Food items to avoid when taking IFA tablet Boys Girls Both
Tea 118 (50%) 180 (66%) 298 (59%)
Milk 67 (28%) 48 (18%) 115 (23%)
Water 41 (17%) 54 (20%) 95 (18%)
All the health workers intervieweddid not have any work plan in their calendar regarding WIFS and
anemia. They were not monitoring the program and did not follow up on any side effects experienced by
the students. Of the 12 health workers interviewed, ten of themdid not know the age category and
eligibility criteria of providing IFA supplementation. Similarly in schools, 14teachers did not know the
eligibility criteria. As a result schools were providing IFA tablet inappropriately such as giving boys who
were not eligible (in higher classes) or giving to only girls.
6.7Coverage of target population
The coverage of the WIFS has not been studied however in the present survey, one school (Ramjar Middle
Secondary School) out of the 17 schools did not implement the program. The school had stopped
implementing the program in 2012 after it stopped receiving IFA tablet supplies from the health center.
The health in-charge said that there were no program since his arrival in 2012 and he presumed that it
had been stopped.
Another school which was not part of the survey had similarly stopped implementing WIFS. (case study in
box) It is apparent that the coverage of WIFS among schools is not 100 % with some schools having
dropped the program completely. Even where it is being implemented WIFS is not being implemented
26 | P a g e
regularly with almost all schools skipping some weeks without WIFSas reflected from the term reports.
Respondents from the FGD revealed that schools stop providing WIFS when school schedules are busy
such as before events and examination period.
WIFS was also not being provided to all the eligible students. As per the national strategy, all students
(both girls and boys) upto standard VIII/lower secondary school were eligible, while only girls from
standard IX-XII were eligible. During the surveyit was found that 76 % of class IX students reported
receiving IFA tablet within last one month at school while 15 % of class VIII students reported not receiving
IFA tablet. This discrepancy was noticed in almost all the schools and there was no uniformity. The reason
for this is the unawareness among teachers on the eligibility criteria outlined in the strategy. While there
is no harm in supplementing boys in higher classes, this finding reveals the inefficiency of the program
and ineffectiveness in informing implementers on the national strategy.
6.8Program level
There were two program officers at the start of the WIFS program and with both leaving the program,
there was loss of institutional knowledge and experience. Successive program managers/officers have not
received any training or provided with opportunity to update on anemia and IFA supplementation. While
there is regular documentation and evidence of activity in the first two years, there is very little
documentation thereafter including reports received. After UNICEF support ended in 2008, many of the
activities such as training for teachers, monitoring, supervision, distribution of IEC materials, field visits,
program reviews and regular reporting by majority of school hadcompletely stopped.
In the ninth five year plan, anemia was one of the priority public health issues with the MoH setting a
target “To reduce iron deficiency anemia among pregnant women, children under five and adolescent
girls.”18Thereafter in the next two FYPs,despiteanemia continuing to be recognized as a public health
problem, no specific targets or major interventions were planned. The implementation of the WIFS was
left entirely to the regular machinery of the MoH and MoE and to the commitment of the field workers.
Recognizing the need to review the WIFS, the program included this activity in its 2012-2013 work plan.
Subsequently in November 2013, the program deliberated on reporting issues with MoE officials during
the National school health committee meeting. The program raised its concerns on the erratic reporting
from the school and poor state of implementation in the schools. From the discussions, the lack of
coordination, monitoring and poor supervision became apparent. It was thus decided that the WIFS
needed to be thoroughly reviewed and to see whether it was efficient and effective.
6.9Reporting, Monitoring and evaluation
When the program was started in 2004, a booklet titled “Monitoring and Reporting protocol for teachers”
was developed by the Food and Nutrition Program MoH and the Program Division of the MoE to enable
proper monitoring. The role of the class teacher, the head of the institution, the DEO, the school health
committee and the DMO were clearly stated. The channel of reporting was as shown in figure6. The Class
teacher was to prepare report and submit to the Principal who would in turn report to the Food and
Nutrition Program with a copy to the DEO. Over the course of implementation, there is little
understanding among implementers on the correct channel of reporting. Most schools had completely
stopped reporting while those that did sent their reports to several places. Figure 7 shows the current
18 GNHC. Nineth Five Year Plan, Main document, RGoB, 2003.
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scenario of reporting where some reportswere sent to Comprehensive School health Division in the MoE,
some remained at the DEO or the DHO office in the districts and very few were spent to the Food and
Nutrition Program. In 2013 the program received only 12 reports.
Figure 6: Channel of reporting as per the national strategy
The Monitoring and Evaluation system was designed only for the initial three years when term and
sentinel data were being collected. The implementation was weak as reflected by the number of term
reports received from the school data after the first year. Only the sentinel data continued to be collected
for the first two years after which even this was stopped. There was also limited capacity within the
program to utilize the reports and conduct thorough data analysis. All this led to a breakdown in reporting
and carrying our effective monitoring. Since there was no wide dissemination of any M&E system, many
of the he schools were not aware and did not submit reports. Even when they did, there was no clear
channel for reporting.
In the beginning of 2014 all the schools were informed through the MoE, on the need to send in regular
reports. This improved reporting with the nearly 70% of all schools having sent in reports at the time of
this evaluation. In addition, the school health program in the DoPH, has been entrusted to receive and
manage all reports pertaining to the WIFS.
Figure 7: Current reporting channel
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Furthermore the national school health committee comprising of members from both the MoH and MoE
have agreed to meet bi-annually to strengthen school health issues. While these measures are expected
to improve uniform and regular reporting, monitoring and feedback could potentially still be a problem,
because administratively the schools are not answerable to the MoH and there is no MoU established
towards this effect. The School health Program in the MoH will therefore not be able to take action in case
of non-reporting. As in the past, the only action that could be taken is to send out reminders and requests
for report submission which may or may not be honored. Therefore to formalize and strengthen this
system and to ensure regular reporting, a MoU should be signed between the MoH and MoE to this effect.
The CSHP in the MoE should be closely involved and joint monitoring should be conducted. The monitoring
and reporting protocol needs to be revised to include clear responsibilities at all levels and timelines for
reporting. The data collected should be compiled and analyzed on an annual basis and presented to the
National school health committee for deliberation.
6.10Coordination among stakeholders
The main implementing partners for the WIFS are the MoE, MoH and MoAF as reflected by the joint
development of the National Strategy for control of IDA in Bhutan. The role of each of the sectors was
outlined in the national strategy as shown in figure below.
Figure 8: Anemia control approach with sector specific roles
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The MoE and MoH were expected to work closely together and towards this a “memorandum of
Understanding to Control and prevent Iron Deficiency Anemia in School children” was drawn up in March
2004.19 A working committee with representation from all three ministries and partners was to be set up,
with the Joint Director of the Program Division, MoE as Chair and Program Officer, Food and Nutrition
Program as co-chair. However in June 2004, both the Ministries did not feel the need to sign the MoU
because they felt that they “always worked together towards improving the physical and intellectual
health of the children of the country”. Therefore, based on mutual understanding, both the ministries
agreed to execute the program according to the strategy developed.
The working committee was never formed and there has been no formal meeting between partners on
the WIFS program. Each sector has been working independently of each other, without any formal
working mechanism. The lack of coordination has resulted in ineffective and inefficient implementation.
There was no ownership with each sector expecting the other to conduct, monitor and supervise the
program. Some improvement has taken in 2013 with discussion and agreement on joint coordination and
closer monitoring between the sectors. There is genuine concern on controlling anemia from all
19 Draft Memorandum of Understanding to Control and prevent Iron Deficiency Anemia in School children between MoH and MoE. Food and Nutritional Program, Department of Public Health, MoH, 2004.
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individuals’ right from the program to the field level and strong commitment. What is urgently required
for the success of the program is better coordination and consultation.
6.11 Impact of WIFS from secondary data
The relevancy of WIFS is dependent upon the availability of prevalence of anemia and without this critical
data it is difficult to comment. At the start of the WIFS program in 2004, sentinel data was collected from
four districts, one in each geographical region. A total of 796 students in 12 schools (table 11) were
enrolled and hemoglobin levels were assessed twice a year from 2005 to 2007.
Table 11: Districts and schools selected for sentinel reporting
Trongsa Paro Mongar Sarpang
Trongsa PS Isuna CPS Kilikhar PS Sarpang PS
Kingarabten LSS Lango LSS Mongar LSS Gelephug LSS
BjeZam CPS Shari CPS Redaza CPS Jigmeling CS
Data collected from 2004 to 2007, the prevalence of anemia among the students at the sentinel sites did
not change significantly annually or over the two and half year period as shown in the graph below.
Figure 9: Prevalence of anemia at sentinel sites from 2005-2007
As shown in figure 9, in the first two years of the WIFS program, implementation was good and prevalence
of anemia decreased uniformly among both females (from 20 % at baseline to 10% at end of 2005) and
males (from 48% at baseline to 34 % at end of 2005). From 2006 onwards the prevalence of anemiaamong
girls increased to 22% which is higher than pre-intervention level and around 35% for males. Since the
impact of iron supplementation in improving and preventing IDA is established, this finding suggests that
continuing prevalence of anemia in the sentinel sites is either due to poor compliance or that anemia is
0
10
20
30
40
50
60
2005Baseline
2005 1st 2005 2nd 2006 1st 2006 2nd 2007 1st
Pe
rce
nta
ge
Girls % Boys %
31 | P a g e
due to causes other than iron deficiency. The sentinel data however is also compounded by data issues
which raises questions on the method used to measure hemoglobin and on data management including
data review and data entry. Analysis shows progressively high number of missing data and incorrect entry
of hemoglobin values as shown in the two graphs below.
Figure 10: Number of missing data from sentinel sites from 2005-2007
Figure 11: Number of students reporting with very low hemoglobin levels
It can be seen that the 24 % of the data was missing from second year and another 14% of the data had
incorrect values of hemoglobin (below 3 g/dl). Together the total percentage of data that could not be
186
186
200
796
796
796
796
610
610
596
0 100 200 300 400 500 600 700 800 900
2005 Baseline
2005 1st
2005 2nd
2006 1st
2006 2nd
2007 1st
2007 2nd
Number of students
Total number of missing hemoglobin vaules per reporting without including hemoglobin
level below 3Not Missing Missing
3 22 54102 109 117
796793 774 742694 687 679
0
0
100
200
300
400
500
600
700
800
900
2005Baseline
2005 1st 2005 2nd 2006 1st 2006 2nd 2007 1st 2007 2nd
Nu
mb
er
of
stu
de
nts
< 3g/dl > 3g/dl
32 | P a g e
used for analysis amounted to 38%. With more than one third of the data either missing or incorrect,
there were no enquiries made to the health center or the school. This points to inefficiency of reporting
from the school/health center and lack of monitoring from the program. The fact that this data was never
analyzed and reviewed to make decision on the continuation of the WIFS raises several questions on
capacity of program to analyze data, decreased interest and priority for anemia control or oversight of
the program. The sentinel data is a rich source of information for a WIFS program implemented over the
whole calendar year. The program could benefit with more information from further analysis of this data
as there are very few examples from other countries of such a prolong intermittent supplementation
program.
Despite these findings there isgeneral consensus among all teachers and health workers interviewed and
participants from the FGD on the need to continue the program for the benefit of growing children as well
as for adolescent girls. The decision to continue will however depend on evidence of high anemia
prevalence among adolescents and non-pregnant women which can only be generated from a national
anemia survey.
6.12Other strategies to control anemia
One of the important outcomes expected from the WIFS program was to increase the level of knowledge
on anemia among students and who would then go out to “mobilize awareness in the community and to
their mothers and peers not attending schools”. From the current poor level of knowledge among
students, this objective is unlikely to have been achieved. This is a result of poor knowledge among
teachers and the absence of any discussion or teaching on anemia and iron supplementation. Teachers in
turn have not been provided any training and neither have they been provided with any updates.
Frequent reports of outbreaks of peripheral neuropathy in the schools has led to the government in
initiating a study on this and more importantly in revising the diet given to students who reside as borders.
The MoE has initiated discussion with the Food Corporation of Bhutan who are the suppliers of rations for
the schools in seeking a long term solution to addressing micronutrients. The plan is to begin fortification
of certain food products starting with fortification of oil although the details on what or how much has
not yet been made. The Ministry of health has not been involved at this early stage. It is important that
all stakeholders consider the evidence and prioritize which micronutrients to be fortified in what food
product without compromising on the taste or smell. This long term solution if done well could bring
immense benefits and prevent many nutritional deficiency disorders.
7. CONCLUSION AND LESSONS LEARNT
7.1 Conclusion
This evaluation of the WIFS, for its efficacy, effectiveness and relevance clearly demonstrates that while
the program is still relevant, implementation is not effective or efficient. The long time period - over ten
years before any review or evaluation of the program resulted in not identifying the problems earlier and
taking corrective measures.
While the program was implemented appropriately to respond to the high prevalence of anemia, the
target chosen were school children, given the ease of implementation especially considering that
compliance needed to be assured through supervised ingestion of WIFS. The program was implemented
nationwide in all schools without any exclusion criteria. Both boys and girls were given the supplement
33 | P a g e
except for boys above standard VIII who were excluded based on their decreased requirement for iron.
All girls were given IFA supplement up to class XII.
In the first two years of the WIFS, the program went smoothly as evidenced by good reporting from both
term and sentinel sites. The Food and Nutrition Program had intended to review the program after three
years -in 2007 or within one or two years of implementation, however this was not done. Problems in
reporting and monitoring started from the third year with only one complete reporting in the first quarter.
Thereafter there were no reports and no systematic reporting. Over the years with attrition and changes
among teachers and program officers, there was loss of institutional knowledge and experience. Those
who were trained left and replacements were not trained or updated on the program requirements. Some
of the schools have stopped implementing the program citing non receipt of the IFA tablets from the
health centers and severe side effects among students. Knowledge on anemia, iron and WIFS is poor
among students, teachers and administrators. At the national level, there is poor coordination and near
absence of monitoring and reporting. The total IFA requirements are also potentially unmet leading to
frequent stock outs at school level. In almost all the schools supplements are not provided regularly with
students missing several weeks in a year. Many schools are also not aware of the eligibility criteria
resulting in provision of IFA tablets to those that are not eligible while denying those that require them.
One of the most important weaknesses of the program is not being able to provide adequate supervision
during distribution of IFA tablet. As a result, compliance is poor and nearly half of the students surveyed
threw the tablet or knew someone who threw it.
The M&E system was designed only for the first three years when term and sentinel data was collected.
Thereafter there was a complete breakdown in the system with little (no standard reporting channel) or
no reporting. Although there has been some resurrection in 2013, the M&E system needs to be redesigned
and strengthened.
UNICEF provided financial and technical support to the program from 2004-2008, after which it was
handed over to the government. IFA supplies were adequate and well distributed in these years, however
post 2009 the total amount of tablets procured and distributed fall short of the actual requirements. There
is therefore a need to reevaluate the requirements and strengthen the procurement and supply chain so
as to provide adequate stocks of IFA tablets.
7.2 Lessons Learnt
WIFS in the schools is efficacious in preventing IDA, however to make it effective proper
coordination, monitoring and above all, ensuring strict compliance through dedicated supervision
during distribution is critical.
When several sectors are involved in implementing a program, there needs to be a MoU that
outlines the objectives, goals and the responsibilities of each sector. This is important to ensure
accountability and commitment.
A National strategy that is developed jointly by partner agencies to implement the program must
be meticulously followed. A performance framework with outcome, impact targets and timelines
should be developed and regular reporting and monitoring the progress should be developed and
followed up.
34 | P a g e
Program review and performance assessment must be done continuously according to a plan. An
M&E plan that incorporates all key aspects of the program including reporting channels and
frequency must be part of any program. Monitoring should be an important component of the
program and must be implemented as planned.
Public health program such as the WIFS must be supported with adequate IEC materials which is
widely distributed. Information should be widely disseminated and all stakeholders should know
where and how to access relevant information. In the school setting, the same information should
be incorporated and adapted into the health activities of the school. This is especially relevant
when providing health product for public health intervention. Correct information about the
health product including potential side effects must be informed to both implementers and
recipients and strategies to deal with them must be instituted. Mechanisms to report adverse
effects and related events should also be in place and must be aligned to the national adverse
reaction reporting mechanism.
When a program continuous indefinitely for such long periods, there must be opportunity for
more training including refresher training for all implementers from program personnel to school
health teachers. Implementers must be regularly updated on the program and feedback sought
on the progress at the field level. Those at the program level should take every opportunity during
field visits to enquire on the program and identify issues such as need for training.
All school based health programs should have the support from parents by engaging them by
including them in the decision making. Schools should ensure that school health is one of the
discussion points at the annual Parent - Teacher meeting (PTM). Awareness among parent will
ensure better implementation and in the long run, sustainability of the program.
Proper documentation and recording is important for managing the program. Future programs
should decide and plan in advance on the type of reports and documents that need to be
documented and preserved. At the central level, a documentation library both in soft and hard
copy will greatly improve this and will be beneficial for all programs.
Capacity of program managers to manage data including analysis and interpretation is important.
Appropriate training and skills development must be on going.
8. RECOMMENDATIONS
The following recommendations are listed on priority basis and they should be addressed with
relevant partners and donors.
1. A national level anaemia prevalence study should be conducted to decide on the continuation of
the WIFS program in the school and whether to expand the program to out of school setting and
in different age groups. Since it has been more than a decade after the last anemia survey, it is
not only timely but critical for decisions to be made regarding relevancy if WIFS and future control
of anemia.
2. To continue the WIFS program, coordination needs to be improved and strengthened. The
following mechanisms are recommended.
35 | P a g e
a. A new and updated memorandum of understanding to be drafted and signed between
the MoH and MoE.
b. The working committee as described in the first draft to be instituted and to meet
biannually.
c. The school health programs in the MoH and MoE to coordinate closely through regular
meetings on a quarterly basis.
3. The national strategy and the Monitoring and reporting protocol for teachers needs to be revised
and updated by incorporating eligibility criteria for WIFS, reporting channels, reporting formats
and M&E mechanisms including frequency and timelines. All reports need to be reviewed and
feedback provided to the school on identified issues. A performance framework that outlines
goals, objectives and targets of the WIFS needs to be developed which would improve monitoring
and reporting.
4. One of the most important component in the WIFS is ensuring compliance through supervision of
IFA tablet ingestion. This needs to be strengthened through uniform implementation as
recommended in the national strategy. It should be given every Thursday during assembly and
students should be advised to come after eating a good breakfast.
5. The quantities of IFA tablets required needs to be reviewed in depth through consultation with
District health Officers, Drugs Vaccine Equipment Division (DVED) and Program at the earliest.
Emphasis must be placed on the number of schools with eligible students and quantities required
calculated accordingly. Reporting forms should ensure that stock levels of IFA at the school and
health centre level are reported each term.
6. The capacity of the Program personnel must be strengthened through appropriate training,
workshop or updates. Such capacity building programs should include topics on prevention and
control of anemia and be based on “a guide for program managers” developed by WHO. In
addition capacity to manage data including data analysis will be helpful and make them less reliant
on technical assistance.
7. Communicating and raising awareness on anemia and iron should be improved and revived.
Appropriate and updated messages on anemia (such as from the Facts of Life 4th Edition) must be
developed and disseminated through both print and audio-visual media. The 2004 Nutrition
information booklet for schools needs to be revised and updated. Important messages on anemia
and other micronutrients from this booklet needs to be incorporated into the “Guidebook for
teachers on adolescent health” and other guides used by the MoE.
8. A training plan needs to be developed and implemented to enable all school health coordinators
and school health committee members to be trained and informed on importance controlling
anemia with iron and nutrition supplementation. The longer term goal of enhancing knowledge
of students, and through them the knowledge of the community leading to behavioural change
must be incorporated in the training program. In addition an information package consisting of
posters, pamphlets and messages maybe developed for distribution to all schools.
9. Improve and strengthen documentation system including building a central archive to store
important documents. This will include all communications, reports and data. This will benefit all
programs and assist in reviewing and evaluating programs.
36 | P a g e
10. Ensure availability of adequate funds for procurement of medicines and for monitoring activities.
Both process and impact evaluation at regular intervals should also be planned and budgeted. The
findings from these should be used to inform the program.
11. The most common reason for non-compliance is attributed to the bad smell and taste. While there
is an option to consider procuring iron capsules instead of tablet to minimize the taste and smell
and also side effects, the disadvantages are cost and reduced bioavailability. One consideration is
to supply a combination of iron folic acid with Vitamin C tablet. The Program could however
explore this further with experts and in consultation with technical bodies such as WHO,
Micronutrient Initiative and CDC.
12. Monitoring of side effects is an important task for teachers. Both teachers and students must be
made aware on the common side effect which can be managed in the school such as gastritis
(taken after food although it may hamper absorption), dark stools, nausea etc. Rarely will side
effects be severe enough to warrant a hospital visit. Despite the minor side effects, there must be
complete recording of all side effects and this must be reported to the health centre who in turn
will inform regularly to the Program and Pharmaco-vigilance unit of the pharmacy department at
JDWNRH.
13. An efficient and reliable data management system must be established that will have capacity to
review and analyse reports sent from the school. This can be part of the overall Bhutan health
management and information system however there needs to be a dedicated officer that will
receive and enter data on WIFS reports into the database. The data should inform the program
on future strategies.
14. The data from the sentinel data is valuable in that it is the only data of WIFS implemented for two
years. No country has implemented WIFS for such long periods. It is therefore recommended that
the data be further analysed to derive new findings that could help programming elsewhere.
Bibliography
UNICEF, MoE, MoH and MoA. National strategy for control of iron deficiency anaemia in Bhutan, 2004
37 | P a g e
MoH. Micronutrient supplement in school, Resource booklet. Food and nutrition Program, MoH &
Program Division, MoE, 2004
Memorandum of understanding on anemia control (draft) between Ministry of Health and Ministry of
Education
MoH. Nutrition information booklet for schools, Public Health Department, Ministry of Health, 2004
MoH. Instruction Pamphlet for Teachers: Micronutrient Supplementation in Schools, Ministry of Health,
2003
MoH. Monitoring and Reporting Protocol for teachers, Food and Nutrition Progam, MoH & Program
Division, MoE, 2004.
WHO. Iron deficiency anaemia: Assessment, Prevention and Control. A guide for Programmer Managers;
WHO/NHD/01.3, Geneva, World Health Organization, 2001
UNICEF. Anameia prevention and control programmer evaluation in Uzbekistan, 2005
WHO. Prevention of iron deficiency anaemia in adolescents; Role of weekly iron and folic acid
supplementation. SEA-CAH-02, Delhi, World Health Organization, 2011
Beaton GH and McCabe GP. Efficacy of intermittent iron supplementation in the control of iron deficiency
anaemia in developing countries;Micronutrient Initiative, 1999.
Sood SK & Sharma S. Occurrence and causes of nutritional anaemia in Bhutan. Survey carried out by RGoB
and UNICEF, 1985
Appleton J. Better Nutrition in Bhutan. A review of the Nutrition Program and its role among Bhutan’s
nutrition stakeholders, MoH, 2009
WFP. Food and Nutrition Handbook, Strategy and Policy Division, Technical Unit (Nutrition), Rome Italy.
Food and Nutrition Program. Public Health Nutrition for RIHS, DoPH, MoH Thimphu Bhutan
Flay BR, Biglan A, Boruch RB et al. Standards of Evidence: Criteria for Efficacy,Effectiveness and Dissemination. Prevention Science, Vol. 6, No. 3, September 2005 WHO. Guideline: Intermittent iron supplementation in preschool and school-age children. Geneva, World Health Organization, 2011.
Nestle P. Adjusting hemoglobin values in program survey. International Nutritional Anemia Consultative
Group, 2002
Zariwala MG, Somavarapu S, Farnaud S et al. Comparison Study of Oral Iron Preparations Using a Human
Intestinal Model. Sci Pharm, 81; 2013; p 1123–1139
WHO/UNICEF/UNU. Iron deficiency anaemia: assessment,prevention, and control. Geneva, World HealthOrganization, 2001 (WHO/NHD/01.3). (http://www.who.int/nut/documents/ida_assessment_prevention_control.pdf, accessed 12 July 2014)
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International Nutritional Anemia Consultative Group (INACG). Integrating programs to move iron deficiency and anaemia control forward. Report of the 2003 International Nutritional Anemia Consultative Group Symposium 6 February 2003, Marrakech, Morocco. Washington DC, ILSI Press, 2003. (http://inacg.ilsi.org/file/INACGfinal.pdf, accessed 17 July 2014)
WHO & UNICEF. Focusing on anaemia:Towards an integrated approach for effective anaemia control. Joint statement; 2004
School Feeding program. Presentation to the Cabinet on review of nutritional level of food given to
students in boarding schools. Ministry of Education, 2013
United Nations. ACC/SCN statement on the control of iron deficiency. New York, 1991
Moschovis PP, Banajeh S, MacLeod WB et al. Childhood Anemia at High Altitude: Risk Factors for PoorOutcomes in Severe Pneumonia. Pediatrics 2013;132;e1156
ANNEX 1: Conceptual framework of the methodology
Objectives Methodology & Tools Indicators criteria
To determine whether the WIFS
Literature review of current evidence supporting WIFS
WIFS strategy Target Groups Coverage
39 | P a g e
program is still relevant?
Secondary data analysis of anaemia, nutrition and worms infestation Survey questionnaire and interview
Effectiveness of WIFS Sustainability of WIFS Prevalence of anaemia from
secondary data
Relevancy
To assess efficiency of the WIFS program.
Secondary data analysis of past 8 years (annual/quarterly term reports) Trend Analysis Indebt interview and stake holders meeting. Meet with DVED/UNICEF/Budget Officer/ DHO/DEO/Program Officers
Budget allocated and amount of money spent
Number of children covered Year wise
Number of schools covered year wise Number of schools not implementing
WIFS Number of schools dropping out
WIFS Total number of boys & girls
supplemented (year wise) age wise Age and gender disaggregated
number of children reached. Number and type of schools reached.
Efficiency
To assess the effectiveness of WIFS program on iron nutrition.
Field study using stratified cluster sampling methodology. Interview Guides Survey Questionnaires Stake holder’s interview & consultation.
Number of student aware WIFS & Iron Nutrition.
Regularity of supervised supplementation.
Compliance of school children to WIFS.
Sub clinical data (if available) from sentinel sites.
Number of Schools with supervised WIFS.
Anemia prevalence from sentinel data analysis.
Effectiveness
ANNEX 2: Evaluation questions
Relevance
1. Is WIFS an efficient way of addressing anaemia in school children and is it the most appropriate public health strategy?
2. How relevant is school-based iron supplementation programme to the overall national anaemia prevention and control effort?
40 | P a g e
3. Are the activities and output of the programme consistent with the overall national anaemia reduction goal?
4. Is the supplementation in line with needs of the schools, students and parents? 5. How do the school children, teachers and health workers view the importance of the
programme? 6. What is the magnitude of IDA among school children 7. How important is WIFS for school children and to what extent does it address their
nutritional status? 8. Was an assessment of IDA and prevalence carried out followed by the requirement of
WIFS as the strategy? 9. To what extent were the perspectives of different stakeholders, including the Ministries
of Health and Education taken into account in the design of the initiative? Were the schools involved in the design of the WIFS programme?
Efficiency
10. What is estimated cost for implementing WIFS in schools and source of funds? 11. Were the supplements delivered to all the schools in a timely manner? 12. How many schools were covered by the program for WIFS? 13. How many students have been effectively reached with WIFS 14. How are the fefo supplements quantified, purchased and delivered by the program? 15. What type of supplement used and what is the basis for quantifying requirements? 16. Are there reports on the supply and distribution of iron tablets? 17. Has there been an assessment on WIFS at the school, district, region or national level? 18. Is there a M&E plan in place for WIFS? How frequently is the program monitored and
what is the reporting mechanism? 19. Have the focal teachers received training and are there aware of the importance of
WIFS? 20. Was fefo supplements provided as per guideline and were any problems reported? 21. Is there a potential to make better use of the resources than previously?
22. Is there a potential for optimizing planning, procurement and logistics?
Effectiveness
23. Were the objectives clearly defined and to what extent have the objectives of the WIFS been achieved?
24. Did the WIFS reach all school children? 25. How do the students respond to the method of administration of iron tablets? 26. How is it ensured that the iron tablets are swallowed? 27. Have side effects been reported and what are the side effects? 28. What are the key factors that have influenced the achievement/failure of WIFS on IDA
prevalence? 29. To what extent were the originally defined objectives of the development intervention
realistic?
41 | P a g e
30. Which agencies were involved in implementing WIFS and are there clear roles for each?
31. What coordination mechanism was in place? 32. What is the level of knowledge among students and teachers on IDA and WIFS 33. Are there updated standards and guidelines for iron supplementation in school and are
they used? 34. Is there a policy on iron supplementation in schools and how are additional costs if any
taken care of? 35. What kind of intended and unintended changes has the programme achieved over its
implementation period?
Logical framework for school based Iron supplementation evaluation
Inputs Activities Output Outcome
Hard components:
Iron tablets,
guidelines, standard.
Iron
supplementation
programme
Improved school
enrolment,
particularly for girls
through improved
school feeding and
targeted advocacy,
Improved diet and
health, nutrition
and learning.
Soft components:
Training, awareness
education, effective
coordination,
monitoring prompt
and timely support
services
42 | P a g e
ANNEX 3: Evaluation Matrix
Evaluation criteria & question Indicator Data source
Relevancy
Is WIFS an efficient way of addressing anaemia in school children and is it the most appropriate public health strategy?
Evidence of WIFS as a strategy for IDA Number of recommendations from WHO/CDC
Literature review of evidence
How relevant is school-based iron supplementation programme to the overall national anaemia prevention and control effort? Are the activities and output of the programme consistent with the overall national anaemia reduction goal?
Evidence of WIFS as a strategy for IDA
Literature review of evidence
Is the supplementation in line with needs of the schools, students and parents?
Prevalence of IDA in schools Effectiveness
Sentinel site data analysis Secondary data analysis
How do the school children, teachers and health workers view the importance of the programme?
Percentage of teachers/health workers in support of WIFS
Survey and interview
What is the magnitude of IDA among school children Prevalence of IDA Nutritional status
Sentinel site data analysis Secondary data analysis
How important is WIFS for school children and to what extent does it address their nutritional status?
Dietary pattern of school children Prevalence of anaemia
Interview school children & teachers Secondary data analysis
Was an assessment of IDA and prevalence carried out followed by the requirement of WIFS as the strategy?
National report Literature review Interview
To what extent were the perspectives of different stakeholders, including the Ministries of Health and Education taken into account in the design of the initiative? Were the schools involved in the design of the WIFS programme?
Strategy development report Minutes of the meeting
Literature review Interviews
Efficiency
What is estimated cost for implementing WIFS in schools and source of funds?
Costs for fefo tablets Budget for WIFS
Program budget, procurement bills
43 | P a g e
Evaluation criteria & question Indicator Data source
Were the supplements delivered to all the schools in a timely manner?
Number of tablets delivered Schedule of delivery by Program and requisition by school
Supply and receipt documents
How many schools were covered by the program for WIFS? Number of schools covered Program document Interview
How many students have been effectively reached with WIFS Number of students reached Secondary data analysis
How are the fefo supplements quantified, purchased and delivered by the program?
Number of fefo tablets procured and distributed Procurement and Supply systems
Program quantification and indent documents Interview with ley informants
What type of supplement used and what is the basis for quantifying requirements?
Quantification of tablets On site review Key informant interview
Are there reports on the supply and distribution of iron tablets? PSM report On site review
Has there been an assessment on WIFS at the school, district, region or national level?
Number of assessment reports Interview
Is there a M&E plan in place for WIFS? How frequently is the program monitored and what is the reporting mechanism?
Presence of M&E plan Number of schools submitting reports Number of monitoring and supervision visits and reports
Survey Secondary data Interview
Have the focal teachers received training and are there aware of the importance of WIFS?
Number of teachers trained Number of training conducted
Survey results from schools Interview
Was fefo supplements provided as per guideline and were any problems reported?
Availability of guideline in school Report/data of WIFS in school
National Guideline on WIFS Secondary data Interview
Is there a potential to make better use of the resources than previously?
Number of recommendations Literature review
Is there a potential for optimizing planning, procurement and logistics?
Number of stock outs at school level Stock registers Interviews
Effectiveness
Were the objectives clearly defined and to what extent have the objectives of the WIFS been achieved?
Verifiable objectives of WIFS Percent reduction in ODA
National guideline and strategy Secondary data analysis
Did the WIFS reach all school children? Number of schools reached Secondary data analysis
44 | P a g e
Evaluation criteria & question Indicator Data source
Number of students on WIFS
How do the students respond to the method of administration of iron tablets?
Percent of students reporting supervised WIFS
Survey
How is it ensured that the iron tablets are swallowed? Number of schools practicing supervised WIFS
Survey
Have side effects been reported and what are the side effects? Percentage of students reporting side effects List of side effects reported
Survey
What are the key factors that have influenced the achievement/failure of WIFS on IDA prevalence?
List of factors influencing delivery of WIFS
Interview FGD
To what extent were the originally defined objectives of the development intervention realistic?
Targets for WIFS Guideline and program documents
Which agencies were involved in implementing WIFS and are there clear roles for each?
Number of agencies involved Roles identified
Coordination
What coordination mechanism was in place? Number of coordination meetings Interviews Minutes of meeting
What is the level of knowledge among students and teachers on IDA and WIFS
Percentage of students/teachers with good knowledge on IDA & WIFS
School survey
Are there updated standards and guidelines for iron supplementation in school and are they used?
Percent of schools with guidelines Survey Interview
Is there a policy on iron supplementation in schools and how are additional costs if any taken care of?
Policy on WIFS Budget
Literature review Interview
What kind of intended and unintended changes has the programme achieved over its implementation period?
Measurable changes brought by WIFS
Interview
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ANNEX 4: People Met
Name Designation Place District
Chorten Health Coordinator Thragom LSS TrashiYangtse
PhuntshoWangchuk Vice Principal Thragom LSS TrashiYangtse
RinchenPhuntsho Senior DEO TrashiYangtse
Gang Dorji DHO TrashiYangtse
SonamTshewang HA Ramjar BHU TrashiYangtse
NetenDorji BHW Thragom BHU TrashiYangtse
SonamLhendup HA Thragom BHU TrashiYangtse
NimGyeltshen Principal Ramjar MSS TrashiYangtse
Tenzin Wangmo School Health Coordinator Ramjar MSS TrashiYangtse
Nima Principal Pangtokha PS TrashiYangtse
SonamWangchuk Health Coordinator Pangtokha PS TrashiYangtse
KelzangLoday Vice Principal Garpawoong MSS S/Jongkhar
BhimBhadur School Health Coordinator Garpawoong MSS S/Jongkhar
PemaNorbu Principal Orong LSS S/Jongkhar
Durga Maya Health Incharge Orong LSS S/Jongkhar
Jamba Teacher Reshore ECR S/Jongkhar
PemaTshewang DHO S/Jongkhar
ChunglaDorji ADEO S/Jongkhar
SK Rai BHW Orong BHU S/Jongkhar
ThinleyTharchen ADHO WangdiPhodrang
Karma Tshering DEO WangdiPhodrang
RadaWangmo Pharmacist Bajo hospital WangdiPhodrang
Melam VP Bajothang HSS WangdiPhodrang
LobzangChoden School Health Coordinator Bajothang HSS WangdiPhodrang
PemaTshering Principal Wangdue LSS WangdiPhodrang
Tashimo School Health Coordinator Wangdue LSS WangdiPhodrang
NamgayDorji Principal Rinchengang WangdiPhodrang
NamgayWangmo School Health Coordinator Rinchengang WangdiPhodrang
Lemo School Health Coordinator Zilukha MSS Thimphu
DorjiTshewang DHO Thimphu
LhamTshering ADEO Thimphu
BM Subbha ACO Hejo Satellite Clinic Thimphu
SonamPhuntsho Pharmacist Gidakom hospital Thimphu
BirkhaBdrMongar Pharmacy technician DVED Thimphu
UgenJinpa Principal Bjemina PS Thimphu
TsheringYangzom School Health Coordinator Bjemina PS Thimphu
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Name Designation Place District
KuenzangDorji Vice Principal Lungtenzampa MSS Thimphu
ShardaKoirala School Health Coordinator Lungtenzampa MSS Thimphu
DawaTshering Principal Zilukha MSS Thimphu
YangchenDema School Health Coordinator Zilukha MSS Thimphu
PemaTshering DEO Sarpang
LokBdrGhalley DHO Sarpang
TsheringTashi Store incharge Gelephu Hospital Sarpang
RinzinDorjji Principal Samtenling PS Sarpang
DupthoZangmo School Health Coordinator Samtenling PS Sarpang
DekiPelden Vice Principal Pelrithang MSS Sarpang
PemaChoden School Health Coordinator Pelrithang MSS Sarpang
SonamTshering DEO Zhemgang
Sangay Tenzin DHO Zhemgang
Tshelthrim HA Bjokha BHU Zhemgang
TashiGyeltshen HA Tshaidang BHU Zhemgang
Mani Kumar GNM Yebileptsha hospital Zhemgang
Khendrup Principal Tshaidang School Zhemgang
SonamJigme Principal Bjokha PS Zhemgang
ThuktenSingye School Health Coordinator Bjokha PS Zhemgang
LekiTshering Vice Principal Yebileptsha MSS Zhemgang
Phuba School Health Coordinator Yebileptsha MSS Zhemgang
SangayThinley Program Manager School Health Program MoH, Thimphu
Ugen Program Officer Food and Nutrition MoH, Thimphu
Kinley Wangmo Program Officer Food and Nutrition MoH, Thimphu
Pema Program Officer Food and Nutrition MoH, Thimphu
Ms Karma
Comprehensive School Health Division MoE, Thimphu
Dr Chandra Health and Nutrition UNICEF Thimphu
MsDechen M&E UNICEF THimphu
MrGyamboSithey
Consultant/Ex Program Manager Food and Nutrition Program
MsUgenZam Ex Program Officer Food and Nutrition MoH, Thimphu
Pema Procurement Officer DVED MoH, Thimphu
47 | P a g e
Name Designation Place District
Karma Yeshey Director Department of School MoE, Thimphu
Program Officer School Feeding Program MoE, Thimphu
If feasible, intermittent supplements could be given throughout the school or calendar year20
ANNEX 5: Case study of a school that has stopped implementing WIFS.
Case study of a School in not implementing WIFS
This Higher Secondary School located in central Bhutan is connected by a motorable road. There are 509
students of which 283 are girls. The current principal joined the school in 2012 while the school health
coordinator joined in 2010. The WIFS was stopped in the school since 2010 presumably from a verbal
order given by the previous principal. The school health coordinator narrated an incidence of a student
becoming seriously ill with severe vomiting and stomach ache. This was attributed to the side effect of
iron and following this, there were several other complaints from concerned parents. As a result the
principal passed a verbal order to stop the WIFS. Since then for anemia control, students are assessed on
a monthly basis for pallor at the BHU and those who are detected are treated with daily IFA tablet. He
also felt that the school agriculture program was an effective way of providing nutritional requirements
including iron. His conclusion was that these two strategies were adequate to control IDA in the schools.
He cited problems with WIFS such as the difficulty of compliance and monitoring especially the timing of
providing supplements. Interviews and FGD with the students corroborated the absence of WIFS in the
school. Although all of the students had taken IFA tablet in their previous school, they cited experiencing
side effects such as giddiness, stomach pain and vomiting. The bad smell and taste of the tablet was cited
as the worst part of taking IFA tablet and it was for this reason that many students did not take them.
20World Health Organization 2011. Guideline: Intermittent iron supplementation in preschool and school-age children
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ANNEX 6: Ministry of Health clearance Certificate
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ANNEX 7: Ministry of Education clearance Certificate
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ANNEX 8: Ministry of Home and Cultural Affairs clearance Certificate
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ANNEX 9: National Statistical Bureau clearance Certificate
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ANNEX 10: Supplementary tables from data analysis.
Demographic Profile
Demographic characteristics Total no. of students interviewed for the survey
Percentage
Gender Male 243 48.3 Female 260 51.7
Age Under 10 years 145 28.8 10 to 15 years 256 50.9 Above 15 years 102 20.3
School Type Community Primary School 53 10.5 Primary School 150 29.8 Lower Secondary School 90 17.9 Middle Lower Secondary School 180 35.8 Higher Secondary School 30 6
Location Urban 179 35.7 Rural 323 64.3 missing 1 -
District SJongkhar 83 16.5 Sarpang 60 11.9 TYangtse 90 17.9 Thimphu 90 17.9 Wangdue 90 17.9 Zhemgang 90 17.9
Region East 173 34.4 West 180 35.8 Central 150 29.8
Parents able to read/write
Yes 303 60.4
No 199 39.6 missing 1 -
Total 503
53 | P a g e
Iron day in schoolspercent within schools
School type
Number of students aware of iron supplementation day (once a week)
Boys % Girls % Total %
HSS 25 12.0 27 10.7 52 11.3
MSS 103 49.1 132 52.6 236 51.0
LSS 56 26.6 66 26.3 122 26.4
PS 24 11.3 25 9.7 48 10.5
CPS 2 1.0 2 0.7 4 0.8
Total 211 100 252 100 462 100
Iron day in schools by gender
School type
Boys Girls Both
Once a week
% Don't know
% Once a week
% Don't know
% Once a week
% Don't know
%
HSS 25 93.3 2 6.7 27 100.0 0 0.0 52 96.7 2 3.3
MSS 103 83.5 20 16.5 132 88.0 18 12.0 236 86.0 39 14.0
LSS 56 94.7 3 5.3 66 100.0 0 0.0 122 97.5 3 2.5
PS 24 95.5 1 4.5 25 98.5 0 1.5 48 97.0 1 3.0
CPS 2 100.0 0 0.0 2 80.0 0 20.0 4 90.0 0 10.0
Total 211 26 252 19 462 45
Number of students aware of importance of iron tablets
School type
Number of students aware of importance of iron tablets (iron deficiency)
Boys % Girls % Total %
HSS 7 7.9 22 13.1 29 11.2
MSS 57 62.7 94 57.1 151 59.1
LSS 21 23.0 46 28.2 67 26.3
PS 5 5.7 2 1.4 8 2.9
CPS 0 0.3 0 0.2 1 0.2
Total 91 100 165 100 256 100
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Number of students aware of importance of iron tablets by gender
School type Boys Girls Both
Yes % No % Yes % No % Yes % No %
HSS 7 26.7 20 73.3 22 80.0 5 20.0 29 53.3 25 46.7
MSS 57 46.1 67 53.9 94 62.6 56 37.4 151 55.2 123 44.8
LSS 21 35.4 38 64.6 46 70.1 20 29.9 67 53.7 58 46.3
PS 5 20.8 20 79.2 2 9.5 23 90.6 8 15.1 42 84.9
CPS 0 13.3 2 86.7 0 13.3 2 86.7 1 13.3 4 86.7
Total 91 146 165 106 256 252
Number of students who had side effect from iron tablets
School
type
Number of students who had side effect from iron tablets(Stomach pain, constipation, dark stool, vomiting)
Boys % Girls % Total %
HSS 16 9.8 23 10.9 40 10.4
MSS 82 49.7 117 54.8 200 52.5
LSS 46 27.8 52 24.1 98 25.7
PS 20 11.9 20 9.2 40 10.4
CPS 1 0.9 2 0.9 3 0.9
Total 166 100 214 100 380 100
Number of students who threw iron tablets
School type Number of students who threw iron tablets
Boys % Girls % Total %
HSS 9 15.5 16 14.94 25 15.13
MSS 26 45.3 66 60.57 92 55.24
LSS 16 27.8 20 18.67 36 21.85
PS 5 9.2 5 4.62 10 6.23
CPS 1 2.2 1 1.20 3 1.56
Total 58 100.0 108 100.0 166 100.0
Number of students who threw iron tablets
School type
Boys Girls Both
Yes % No % Yes % No % Yes % No %
HSS 9 33.33 18 66.67 16 60.00 11 40.00 25 46.67 29 53.33
MSS 26 21.23 97 78.77 66 43.58 85 56.42 92 33.49 182 66.51
LSS 16 27.29 43 72.71 20 30.50 46 69.5 36 28.99 89 71.01
PS 5 21.44 20 78.56 5 20.08 20 79.92 10 20.76 40 79.24
CPS 1 60.00 1 40.00 1 50.00 1 50.00 2 60.00 2 40.00
Total 57 179 108 163 165 341
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Number of students who knew someone who threw iron tablets
School type
Number of students who knew someone who threw iron tablets
Boys % Girls % Total %
HSS 11 15.5 5 5.1 16 9.2
MSS 33 46.9 52 49.5 85 48.4
LSS 18 25.7 39 36.9 57 32.4
PS 8 11.3 8 7.8 16 9.1
CPS 0 0.6 1 0.7 2 0.9
Total 70 100 106 100 176 100
Number of students reporting supervised ingestion of iron supplements
School type
Number of students reporting supervised ingestion of iron supplements
Boys % Girls % Total %
HSS 16 11.7 23 11.1 40 11.4
MSS 56 40.7 100 47.5 156 44.8
LSS 42 30.4 61 29.0 103 29.6
PS 23 16.3 24 11.6 47 13.5
CPS 1 0.8 2 0.8 3 0.8
Total 138 100 210 100 348 100
Number of students reporting supervised ingestion of iron supplements by gender
School type Boys Girls Both
Yes % No % Yes % No % Yes % No %
HSS 16 60.0 11 40.0 23 86.7 4 13.3 40 73.3 14 26.7
MSS 56 45.3 68 54.7 100 66.3 51 33.7 156 56.8 118 43.2
LSS 42 71.1 17 28.9 61 91.8 5 8.2 103 82.0 23 18.0
PS 23 90.1 2 9.9 24 97.5 1 2.5 47 93.8 3 6.2
CPS 1 53.3 1 46.7 2 73.3 1 26.7 3 63.3 2 36.7
Total 138 99 210 61 348 160
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Do you receive some medicine from school?
Boys Girls Both
Yes % No % Yes % No % Yes % No %
Type of School
CPS 3 100 0 0.0 3 100 0 0 6 100 0 0.0
PS 25 100 0 0.0 25 100 0 0 50 100 0 0.0
LSS 59 100 0 0.0 66 100 0 0 125 100 0 0.0
MLSS 121 97 3 2.6 151 100 0 0 271 99 3 1.2
HSS 27 100 0 0.0 27 100 0 0 54 100 0 0.0
Region
West 138 100 0 0.0 151 100 0 0 289 100 0 0.0
East 35 100 0 0.0 37 100 0 0 72 100 0 0.0
Central 62 95 3 4.9 83 100 0 0 145 98 3 2.1
Age
<12 years 68 100 0 0 87 100 0 0 155 100 0 0
>12 years 166 98 3 1.9 185 100 0 0 351 99 3 0.9
Total 234 99 3 1.3 272 100 0 0 506 99 3 0.6
What medicine do you receive?
Boys Girls Both
Iron % Dewo rming % Both % Iron %
Dewo rming % Both % Iron %
Dewo rming % Both %
Type of School
CPS 2 54 0 - 1 46 1 50 0 - 1 50 3 52 0 - 3 48
PS 4 18 1 2 20 80 3 13 1 2 21 84 8 16 1 2 41 82
LSS 39 66 2 3 19 32 51 77 0 - 15 23 90 72 2 1 34 27
MLSS 27 22 45 37 49 40 54 36 12 8 84 56 81 30 57 21 133 49
HSS 14 53 0 - 13 47 23 87 0 - 4 13 38 70 0 - 16 30
Region
East 5 15 18 51 12 34 12 31 9 24 17 45 17 23 27 37 29 40
West 67 48 8 6 63 46 88 58 0 - 63 42 155 54 8 3 126 44
Central 14 23 21 34 27 43 34 41 4 5 45 55 48 33 25 17 72 50
Age
< 12 years 32 47 3 5 33 48 48 55 3 3 36 42 80 51 6 4 69 45
>12 years 54 33 43 26 68 41 86 46 10 5 89 48 140 40 53 15 158 45
Total 86 37 47 20 101 43 134 49 13 5 125 46 220 43 59 12 227 45
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How often do you receive it?
Boys Girls Both
Once a week %
Once a Month %
Don't know % M %
Once a week %
Once a Month %
Don't know %
Once a week %
Once a Month %
Don't know % M %
Type of School
CPS 3 100 0 - 0 - 0 - 2 85 0 - 0 15 5 92 0 - 0 8 0 -
PS 24 96 0 - 1 4 1 - 25 99 0 - 0 1 48 95 0 - 1 3 1 2
LSS 56 95 0 - 3 5 3 - 66 100 0 - 0 - 122 95 0 - 3 2 3 2
MLSS 103 86 0 - 8 6 8 8 132 88 4 3 14 10 236 88 4 1 22 8 8 3
HSS 25 93 2 7 0 - 0 27 100 0 - 0 - 52 97 2 3 0 - 0 -
Region
East 28 81 0 - 7 19 0 - 37 98 1 2 0 - 65 90 1 1 7 9 0 -
West 131 95 2 1 5 4 0 - 149 99 0 - 2 1 280 97 2 1 7 2 0 -
Central 52 85 0 - 0 - 10 15 66 80 3 4 13 16 119 82 3 2 13 9 10 7
Age
<12 years 65 95 0 - 4 5 0 - 84 97 0 - 2 3 149 96 0 - 6 4 0 -
>12 years 147 88 2 1 8 5 10 6 168 91 4 2 13 7 315 90 6 2 21 6 10 3
Total 211 183 2 1 12 10 10 6 253 188 4 2 15 10 464 92 6 1 27 5 10 2
Is there a specific day you receive?
Boys Girls Both
Yes % No % Don't know % missing % Yes % No %
Don't know % missing % Yes % No %
Don't know % missing %
Type of School
CPS 3 100 0 - 0 - 0 - 3 95 0 - 0 5 0 - 6 97 0 - 0 3 0 -
PS 24 96 0 - 1 4 0 - 25 99 0 1 0 - 0 48 97 0 1 1 2 0 -
LSS 54 92 5 8 0 - 0 - 66 100 0 - 0 - 0 - 121 96 5 4 0 0 -
MLSS 98 81 2 2 11 9 10 8 129 86 3 2 15 10 3 2 227 88 6 2 26 10 13 5
HSS 25 93 0 - 2 7 0 - 27 100 0 - 0 - 0 - 52 97 0 - 2 3 0 -
Region
East 28 80 4 11 3 9 0 - 37 98 0 - 1 2 0 - 65 89 4 5 4 5 0 -
West 130 94 3 2 5 3 0 - 149 99 0 0 2 1 0 - 279 97 3 1 6 2 0 -
Central 46 74 0 - 6 10 10 15 64 77 3 4 13 16 3 4 110 83 3 2 19 15 13 10
Age
< 12 years 65 96 0 - 3 4 0 - 81 93 0 0 6 6 0 - 146 94 0 0 8 5 0 -
>12 years 138 83 7 4 11 7 10 6 169 91 3 2 10 5 3 307 91 10 3 21 6 13 4
Total 204 87 7 3 14 6 10 4 250 92 4 1 15 6 3 1 454 92 11 2 29 6 13 3
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Name the day in which you receive the medicine tablet?
Boys Girls Both
Thur sday %
Any Other day %
Miss ing %
Thur sday %
Any Other day %
Miss ing %
Thur sday %
Any Other day %
Miss ing %
Type of school
CPS 3 100 0 - 0 - 3 100 0 - 0 - 6 100 0 - 0 -
PS 24 96 1 3 0 1 25 100 0 - 0 - 48 98 1 2 0 1
LSS 54 100 0 - 0 - 65 99 0 - 1 1 120 99 0 - 1 1
MLSS 105 89 0 - 13 11 141 96 3 2 3 2 246 93 3 1 16 6
HSS 25 93 2 7 0 - 27 100 0 - 0 - 52 97 2 3 0 -
Region
East 31 100 0 - 0 - 37 98 0 - 1 2 68 99 0 - 1 1
West 132 98 3 2 0 0 151 100 0 - 0 - 283 99 3 1 0 0
Central 49 79 0 - 13 21 73 92 3 4 3 4 122 87 3 2 16 11
Age
<12 years 67 98 1 1 0 1 86 100 0 - 0 - 153 99 1 0 0 0
>12 years 145 91 2 1 13 8 174 96 3 2 4 2 319 94 5 1 17 5
Total 212 93 3 1 13 6 261 97 3 1 4 1 473 95 6 1 17 3
Who gives you the medicine? - Class teacher
Boys Girls Both
No % Yes % No % Yes % No % Yes %
Type of school
CPS 0 13 2 87 0 13 2 87 1 13 5 87
PS 13 50 12 50 13 50 12 50 25 50 25 50
LSS 29 49 30 51 29 49 30 51 58 49 61 51
MLSS 104 86 17 14 104 86 17 14 207 86 34 14
HSS 23 87 4 13 23 87 4 13 47 87 7 13
Region
East 17 49 18 51 19 50 19 50 36 50 37 50
West 106 77 32 23 110 73 41 27 216 75 73 25
Central 46 74 16 26 67 81 16 19 112 78 32 22
Age
<12 years 27 40 41 60 44 51 42 49 72 46 83 54
>12 years 141 85 25 15 151 82 33 18 293 83 58 17
Total 169 72 66 28 196 72 76 28 364 72 142 28
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Who gives you the medicine? - Principal
Boys Girls Both
No % Yes % No % Yes % No % Yes %
Type of school
CPS 2 87 0 13 2 87 0 13 5 87 1 13
PS 25 100 0 - 25 100 0 - 50 100 0 -
LSS 58 99 1 1 58 99 1 1 117 99 2 1
MLSS 121 100 0 - 121 100 0 - 241 100 0 -
HSS 27 100 0 - 27 100 0 - 54 100 0 -
Region
East 34 97 1 3 36 95 2 5 69 96 3 4
West 138 100 0 - 151 100 0 - 289 100 0 -
Central 62 100 0 - 83 100 0 - 145 100 0 -
Age
<12 years 67 98 1 2 86 100 0 0 153 99 2 1
>12 years 166 100 0 - 183 99 1 1 350 100 1 0
Total 233 100 1 0 270 99 2 1 503 99 3 1
When is the medicine given? - School Health Coordinator
Boys Girls Both
Yes % No % Yes % No % Yes % No %
Type of school
CPS 3 100 0 - 3 100 0 - 6 100 0 -
PS 19 75 6 25 19 75 6 25 38 75 12 25
LSS 32 54 27 46 32 54 27 46 64 54 54 46
MLSS 69 57 52 43 69 57 52 43 138 57 103 43
HSS 5 20 22 80 5 20 22 80 11 20 43 80
Region
East 21 60 14 40 24 63 14 37 44 62 28 39
West 78 57 60 43 110 73 42 28 188 65 101 35
Central 29 47 33 53 20 24 63 76 49 34 96 67
Age
<12 years 56 82 12 18 63 72 24 28 119 77 36 24
>12 years 72 43 94 57 90 49 95 51 162 46 189 54
Total 128 55 107 46 153 56 119 44 281 56 225 45
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When is the medicine given? - Boys
Assembly % First period %
After lunch %
Before leaving school %
No Fixed time % missing %
Type of school
CPS 1 44 1 51 0 - 0 - 0 5 0 -
PS 7 27 13 52 5 19 0 - 0 2 0 -
LSS 0 - 33 57 7 12 3 5 16 26 0 -
MLSS 18 15 59 49 17 14 5 4 9 8 13 11
HSS 0 - 22 80 0 - 2 7 4 13 0 -
Region
East 2 7 32 91 1 2 0 - 0 - 0 -
West 3 2 68 49 28 21 10 7 29 21 0 -
Central 20 33 29 46 0 - 0 - 0 0 13 21
Age
< 12 years 8 12 37 54 16 23 3 5 4 5 0 -
>12 years 17 10 91 55 13 8 7 4 25 15 13 8
Total 26 11 128 55 29 12 10 4 29 12 13 5
When is the medicine given? - Girls
Assembly % First period % After lunch %
Before leaving school %
No fixed time % missing %
Type of school
CPS 1 40 2 60 0 - 0 - 0 - 0 -
PS 8 31 13 51 4 18 0 - 0 - 0 -
LSS 3 5 45 67 12 19 0 - 6 9 0 -
MLSS 14 10 100 66 20 14 1 0 12 8 3 2
HSS 2 7 25 93 0 - 0 - 0 - 0 -
Region
East 3 8 34 91 0 - 1 2 0 - 0 -
West 6 4 90 60 37 25 0 - 18 12 0 -
Central 20 24 60 72 0 - 0 - 0 - 3 4
Age
<12 years 11 13 58 66 17 20 1 1 0 - 0 -
>12 years 17 9 127 68 20 11 0 - 18 10 3 2
Total 28 10 184 68 37 14 1 0 18 7 3 1
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When is the medicine given? - Both
Assembly % First period % After lunch % Before leaving school % No fixed time % missing %
Type of school
CPS 2 42 3 56 0 - 0 - 0 3 0 -
PS 14 29 26 52 9 19 0 - 0 1 0 -
LSS 3 2 78 62 19 15 3 2 22 17 0 -
MLSS 32 12 159 59 38 14 5 2 21 8 16 6
HSS 2 3 47 87 0 - 2 3 4 7 0 -
Region
East 5 7 66 91 1 1 1 1 0 - 0 -
West 8 3 158 55 66 23 10 3 47 16 0 -
Central 40 28 89 61 0 - 0 - 0 0 16 11
Age
<12 years 20 13 95 61 33 22 4 2 4 2 0 -
>12 years 34 10 218 62 33 9 7 2 43 12 16 5
Total 54 11 312 62 67 13 10 2 47 9 16 3
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Does someone make sure that you have ingested the medicine?
Boys Girls Both
Yes % No % Don't know % missing % Yes % No %
Don't know % missing % Yes % No %
Don't know % missing %
Type of School
CPS 2 56 1 44 0 - 0 - 2 65 1 35 0 - 0 - 3 61 2 39 0 - 0 -
PS 23 90 2 10 0 - 0 - 24 97 0 1 0 1 0 - 47 94 3 5 0 1 0 -
LSS 42 71 17 29 0 - 0 - 61 92 2 2 3 5 1 1 103 82 19 15 3 2 1 1
MLSS 56 47 36 30 14 11 14 12 100 66 31 21 14 9 6 4 156 57 68 25 28 10 20 7
HSS 16 60 5 20 5 20 0 - 23 87 4 13 0 - 0 - 40 73 9 17 5 10 0 -
Region
East 19 55 14 42 1 3 0 - 33 69 12 24 4 5 13 2 52 54 27 28 5 5 13 13
West 86 63 36 26 14 10 2 1 26 78 9 14 2 6 1 1 112 64 45 26 16 9 2 1
Central 33 53 12 20 4 6 13 21 119 79 22 8 9 8 2 5 152 71 34 16 13 6 14 7
Age
<12 years 51 75 13 19 2 3 2 2 68 78 10 12 7 8 2 2 119 77 23 15 10 6 3 2
>12 years 87 52 50 30 17 10 13 8 143 77 28 15 10 5 5 3 230 65 77 22 27 8 17 5
Total 138 59 63 27 19 8 14 6 210 77 38 14 17 6 6 2 348 69 100 20 37 7 21 4
When was the last time you received the medicine?
Boys Girls Both
Thur sday %
Last month %
Don't know %
Miss ing %
Thur sday %
Last month %
Don't know %
Miss ing %
Thur sday %
Last month %
Don't know %
Miss ing %
Type of School
CPS 3 100 0 - 0 - 0 - 3 100 0 - 0 - 0 - 6 100 0 - 0 - 0 -
PS 24 96 0 - 1 4 0 - 23 94 1 2 1 4 0 - 47 95 1 1 2 4 0 -
LSS 54 92 5 8 0 - 0 - 62 94 1 1 3 5 0 - 117 93 5 4 3 2 0 -
MLSS 53 44 5 4 47 39 16 13 116 77 7 4 25 16 3 2 169 62 12 4 71 26 19 7
HSS 20 73 2 7 5 20 0 - 27 100 0 - 0 - 0 - 47 87 2 3 5 10 0 -
Region
East 16 47 3 8 13 36 3 9 41 54 0 20 8 26 13 - 58 60 3 3 20 21 16 16
West 96 70 9 6 33 24 0 - 20 94 7 - 10 6 0 - 116 67 16 9 42 24 0 -
Central 41 67 0 - 8 13 13 21 142 83 0 1 9 12 0 4 184 86 0 - 17 8 13 6
Age
< 12 years 58 85 2 2 8 12 1 1 73 84 1 1 13 16 0 - 131 84 2 1 21 14 1 0
> 12 years 96 58 10 6 45 27 15 9 159 86 7 4 15 8 3 2 255 73 18 5 61 17 18 5
Total 154 66 12 5 53 23 16 7 232 85 8 3 29 11 3 1 385 76 20 4 82 16 19 4
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Who ensures that you have taken the medicine? - Health Teacher
Boys Girls Both
No % Yes % No % Yes % No % Yes %
Type of school
CPS 3 100 0 - 3 100 0 - 6 100 0 -
PS 18 73 7 27 18 73 7 27 36 73 14 27
LSS 44 74 16 26 44 74 16 26 87 74 31 26
MLSS 99 82 21 18 99 82 21 18 198 82 43 18
HSS 16 60 11 40 16 60 11 40 32 60 22 40
Region
East 22 64 12 36 27 72 11 29 49 68 23 32
West 109 80 28 21 131 87 20 13 240 83 48 17
Central 48 77 14 23 48 58 35 42 96 66 49 34
Age
<12 years 49 72 19 28 71 82 16 18 120 78 35 22
>12 years 131 79 36 22 135 73 50 27 265 76 86 24
Total 180 77 55 23 206 76 66 24 386 76 120 24
Who ensures that you have taken the medicine? - Any teacher
Boys Girls Both
No % Yes % No % Yes % No % Yes %
Type of school
CPS 2 78 1 22 2 78 1 22 4 78 1 22
PS 12 48 13 52 12 48 13 52 24 48 26 52
LSS 48 82 11 18 48 82 11 18 96 82 22 18
MLSS 101 84 20 16 101 84 20 16 202 84 39 16
HSS 25 93 2 7 25 93 2 7 50 93 4 7
Region
East 29 82 6 18 19 52 18 48 48 66 24 34
West 119 87 18 13 142 94 10 6 261 90 28 10
Central 41 66 21 34 58 70 25 30 98 68 46 32
Age
<12 years 47 69 21 31 66 76 21 24 113 73 42 27
> 12 years 142 85 24 15 153 83 32 17 295 84 56 16
Total 189 81 46 20 219 81 53 19 407 81 99 20
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Who ensures that you have taken the medicine? - No one
Boys Girls Both
No % Yes % No % Yes % No % Yes %
Type of school
CPS 1 39 2 61 1 39 2 61 2 39 3 61
PS 23 94 2 6 23 94 2 6 47 94 3 6
LSS 54 92 5 8 54 92 5 8 109 92 9 8
MLSS 83 69 37 31 83 69 37 31 167 69 74 31
HSS 23 87 4 13 23 87 4 13 47 87 7 13
Region
East 21 60 14 40 30 80 7 20 51 71 21 29
West 115 84 23 16 136 90 15 10 251 87 38 13
Central 50 80 12 20 75 91 7 9 125 86 20 14
Age
<12 years 61 89 7 11 81 93 6 7 142 92 13 8
> 12 years 125 75 41 25 161 87 24 13 286 81 65 19
Total 186 79 49 21 242 89 30 11 427 84 79 16
Did you ever NOT ingest the medicine?
Boys Girls Both
Yes % No % Yes % No % Yes % No %
Type of School
CPS 1 46 2 54 1 45 2 55 3 46 3 54
PS 5 21 20 79 5 20 20 80 10 21 40 79
LSS 16 27 43 73 20 31 46 70 36 29 89 71
MLSS 26 21 97 79 66 44 85 56 92 33 182 67
HSS 9 33 18 67 16 60 11 40 25 47 29 53
Region
West 44 32 93 68 65 43 86 57 110 38 179 62
East 4 10 31 90 11 30 26 70 15 20 58 80
Central 10 16 55 84 32 38 51 62 42 28 106 72
Age
Below 12 years 16 23 53 77 29 33 58 67 44 29 111 71
Above 12 years 42 25 127 75 80 43 105 57 122 34 232 66
Total 58 24 180 76 108 40 163 60 166 33 343 67
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Do you know of other schools/students who take iron tablet?
Boys Girls Both
Yes % No % Don't Know % Yes % No %
Don't Know % Yes % No %
Don't Know %
Type of school
CPS 1 26 1 34 1 40 0 10 1 46 1 44 1 18 2 40 2 42
PS 9 34 8 34 8 32 7 26 9 36 9 38 15 30 17 35 17 35
LSS 32 54 12 20 16 26 29 44 19 28 19 28 61 49 30 24 34 27
MLSS 67 54 18 15 38 31 82 55 18 12 50 33 150 55 36 13 88 32
HSS 23 87 0 - 4 13 25 93 0 - 2 7 49 90 0 - 5 10
Region
East 23 65 10 27 3 7 21 57 13 35 3 8 44 61 23 31 6 8
West 82 59 18 13 38 28 92 61 14 9 45 30 174 60 31 11 84 29
Central 28 42 12 19 26 39 30 36 20 24 33 40 57 39 32 22 58 39
Age
<12 years 24 35 21 31 23 34 22.3 26 21 24 43 50 46 30 42 27 66 43
>12 years 108 64 18 11 43 26 12 65 26 14 37.7 20 229 65 44 13 81 23
Total 132 55 39 17 67 28 14 53 47 17 81 30 275 54 86 17 148 29
Do you know of other students who do not ingest the medicine?
Boys Girls Both
Yes % No % Don't Know % Yes % No %
Don't Know % Yes % No %
Don't know %
Type of school
CPS 0 15 1 19 2 66 1 25 1 40 1 35 1 20 2 30 3 50
PS 8 31 12 47 5 22 8 33 7 30 9 37 16 32 19 38 15 29
LSS 18 30 22 37 19 33 39 59 12 18 16 23 57 45 33 27 35 28
MLSS 33 26 46 37 45 36 52 35 59 39 39 26 85 31 106 38 84 31
HSS 11 40 2 7 14 53 5 20 11 40 11 40 16 30 13 23 25 47
Region
East 17 48 11 32 7 20 22 60 11 29 4 11 39 54 22 31 11 15
West 46 33 42 31 50 36 64 42 45 30 42 28 110 38 87 30 92 32
Central 7 11 29 44 29 45 20 24 34 41 29 35 27 18 63 42 59 40
Age
<12 years 24 35 26 38 18 27 39 45 16 19 31 36 63 41 42 27 49 32
>12 years 46 27 56 33 68 40 66 36 74 40 45 24 112 32 130 37 112 32
Total 70 29 82 35 86 36 106 39 90 33 76 28 175 34 172 34 162 32
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What do you or your friends complain about after taking the medicine? Bad taste
Boys Girls Both
No % Yes % No % Yes % No % Yes %
Type of school
CPS 2 66 1 34 2 66 1 34 4 66 2 34
PS 19 76 6 25 19 76 6 25 38 76 12 25
LSS 54 92 5 8 54 92 5 8 108 92 10 8
MLSS 70 57 54 44 70 57 54 44 140 57 108 44
HSS 13 47 14 53 13 47 14 53 25 47 29 53
Region
East 18 51 17 49 20 55 17 45 38 53 34 47
West 95 69 43 31 100 66 51 34 195 68 94 32
Central 45 69 21 32 69 83 14 17 113 77 34 23
Age
<12 years 59 87 9 14 68 79 19 22 127 82 28 18
>12 years 98 58 71 42 121 66 63 34 220 62 134 38
Total 157 66 80 34 190 70 82 30 347 68 162 32
What do you or your friends complain about after taking the medicine? Stomach pain
Boys Girls Both
No % Yes % No % Yes % No % Yes %
Type of school
CPS 3 96 0 4 3 96 0 4 5 96 0 4
PS 22 90 3 10 22 90 3 10 45 90 5 10
LSS 52 88 7 12 52 88 7 12 104 88 14 12
MLSS 112 90 12 10 112 90 12 10 224 90 24 10
HSS 27 100 0 - 27 100 0 - 54 100 0 -
Region
East 31 90 3 10 29 78 8 22 61 84 12 16
West 124 90 14 10 134 89 17 11 258 89 31 11
Central 61 93 4 7 78 95 4 5 139 94 9 6
Age
Below 12 years 58 85 10 15 77 88 10 12 134 87 21 13
Above 12 years 158 93 11 7 166 90 19 10 324 91 31 9
Total 216 91 22 9 242 89 30 11 458 90 51 10
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What do you or your friends complain about after taking the medicine? Constipation
Boys Girls Both
No % Yes % No % Yes % No % Yes %
Type of school
CPS 3 100 0 - 3 100 0 - 6 100 0 -
PS 25 100 0 - 25 100 0 - 50 100 0 -
LSS 59 100 0 1 59 100 0 1 118 100 1 0
MLSS 122 99 1 1 122 99 1 1 245 99 3 1
HSS 25 93 2 7 25 93 2 7 50 93 4 7
Region
East 34 97 1 3 36 97 1 3 70 97 2 3
West 136 99 2 1 148 98 3 2 284 98 5 2
Central 64 99 1 1 83 100 0 0 147 99 1 1
Age
Below 12 years 68 100 0 0 86 99 1 1 154 99 1 1
Above 12 years 166 98 3 2 181 98 4 2 347 98 7 2
Total 234 99 3 1 267 98 4 2 501 98 8 2
What do you or your friends complain about after taking the medicine? darkstool
Boys Girls Both
No % Yes % No % Yes % No % Yes %
Type of school
CPS 3 100 0 - 3 100 0 - 6 100 0 -
PS 25 100 0 - 25 100 0 - 50 100 0 -
LSS 59 100 0 - 59 100 0 - 118 100 0 -
MLSS 123 100 1 0 123 100 1 0 246 100 1 0
HSS 25 93 2 7 25 93 2 7 50 93 4 7
Region
East 34 98 1 2 37 98 1 2 71 98 1 2
West 136 99 2 1 150 99 2 1 286 99 3 1
Central 65 100 0 - 83 100 0 - 148 100 0 -
Age
Below 12 years 68 100 0 - 86 99 1 1 154 100 1 0
Above 12 years 167 99 2 1 183 99 2 1 350 99 4 1
Total 235 99 2 1 269 99 2 1 504 99 5 1
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What do you or your friends complain about after taking the medicine? Vomiting
Boys Girls Both
No % Yes % No % Yes % No % Yes %
Type of school
CPS 1 36 2 64 1 36 2 64 2 36 4 64
PS 7 29 18 71 7 29 18 71 14 29 35 71
LSS 16 27 43 73 16 27 43 73 32 27 86 73
MLSS 47 38 77 62 47 38 77 62 94 38 153 62
HSS 14 53 13 47 14 53 13 47 29 53 25 47
Region
East 9 25 26 75 10 26 28 74 18 26 54 74
West 65 48 72 52 48 32 103 68 114 39 175 61
Central 12 18 53 82 15 18 68 82 27 18 121 82
Age
Below 12 years 30 44 38 56 30 35 57 65 60 39 94 61
Above 12 years 56 33 114 67 43 23 142 77 99 28 256 72
Total 86 36 152 64 73 27 199 73 159 31 350 69
Do you know students who take others medicine and ingest more than one?
Boys Girls Both
Yes % No % Don't Know % Yes % No %
Don't Know % Yes % No %
Don't know %
Type of school
CPS 0 - 2 80 1 20 0 10 2 75 0 15 0 5 4 78 1 17
PS 2 9 19 76 4 16 2 6 17 30 7 27 4 8 35 71 11 22
LSS 15 26 24 40 20 34 12 18 30 45 25 38 27 22 53 43 45 36
MLSS 22 18 48 39 54 44 37 24 87 58 27 18 59 21 135 49 81 30
HSS 5 20 7 27 14 53 5 20 9 33 13 47 11 20 16 30 27 50
Region
East 10 28 17 49 8 23 13 35 20 52 5 13 23 31 37 51 13 18
West 29 21 53 39 55 40 35 23 45 41 54 36 64 24 98 36 109 40
Central 6 9 30 46 30 46 8 10 63 76 12 15 14 9 92 62 42 28
Age
<12 years 18 26 39 58 11 17 19 22 43 50 25 29 37 24 82 53 36 23
>12 years 27 16 61 36 81 48 37 20 101 55 47 25 64 18 162 46 128 36
Total 45 19 100 42 93 39 56 21 144 53 72 26 101 20 244 48 164 32
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In your opinion do you think most students swallow or throw the tablets?
Boys Girls Both
Swal low %
Thr ow %
Don't know %
Oth ers %
Swal low %
Thr ow %
Don't know %
Oth ers %
Swal low %
Thr ow %
Don't know %
Oth ers %
Type of School
CPS 1 20 0 8 2 72 0 - 1 33 0 2 2 65 0 - 1 26 0 5 4 68 0 -
PS 18 70 4 17 3 11 0 2 18 71 3 13 4 14 0 1 35 71 8 15 6 13 1 2
LSS 28 47 15 25 13 22 3 5 37 56 23 34 6 10 0 - 65 52 37 30 20 16 3 2
MLSS 66 54 41 33 16 13 1 1 53 35 74 49 23 15 0 - 119 44 115 42 39 14 1 0
HSS 14 53 7 27 5 20 0 - 5 20 18 67 4 13 0 - 20 37 25 47 9 17 0 -
Region
East 19 54 11 31 5 14 0 1 40 45 17 32 8 21 1 1 59 59 28 28 13 13 1 1
West 68 50 39 29 27 19 3 2 17 44 12 43 8 13 0 - 85 49 52 29 35 20 3 2
Central 40 61 17 26 8 12 1 2 66 38 65 49 20 13 0 - 106 49 82 38 27 13 1 0
Age
<12 years 43 62 18 26 4 6 3 5 54 62 14 16 19 22 0 0 96 62 32 21 23 15 4 2
>12 years 84 50 49 29 35 21 1 1 61 33 104 56 20 11 0 0 145 41 153 43 55 15 1 0
Total 127 67 39 4 114 118 39 0 241 47 185 36 78 15 5 1
Where do you normally ingest your medicine?
Boys Girls Both
At home % In front of teacher %
Any where % At home %
In front of teacher %
Any where % At home %
In front of teacher %
Any where %
Type of school
CPS 0 - 3 100 0 - 0 5 3 95 0 - 0 3 6 98 0 -
PS 0 2 25 99 0 - 0 - 24 30 1 2 0 1 49 98 1 1
LSS 3 5 35 60 20 35 7 11 56 85 3 5 10 8 92 73 24 19
MLSS 0 - 45 36 79 64 2 1 83 55 66 44 2 1 128 47 145 53
HSS 4 13 18 67 5 20 2 7 18 67 7 27 5 10 36 67 13 23
Region
East 0 - 21 61 13 39 1 2 28 75 9 23 1 1 49 68 22 31
West 7 5 65 47 65 48 10 6 45 58 54 36 17 7 110 45 119 49
Central 0 - 39 60 26 40 0 0 69 83 14 17 0 0 108 73 40 27
Age
<12 years 3 5 55 81 10 15 6 7 70 81 11 12 9 6 125 81 21 13
>12 years 4 2 71 42 95 56 5 3 114 62 66 36 9 2 185 52 161 46
Total 7 3 125 53 105 44 11 4 184 68 77 28 18 4 310 61 182 36
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Why is iron tablet given in the school? How does it help you?- Anemia
Boys Girls Both
No % Yes % No % Yes % No % Yes %
Type of school
CPS 3 89.8 0 10.2 3 89.8 0 10.2 5 89.8 1 10.2
PS 20 79.2 5 20.8 20 79.2 5 20.8 40 79.2 10 20.8
LSS 38 64.6 21 35.4 38 64.6 21 35.4 76 64.6 42 35.4
MLSS 67 53.9 57 46.1 67 53.9 57 46.1 133 53.9 114 46.1
HSS 20 73.3 7 26.7 20 73.3 7 26.7 40 73.3 14 26.7
Region
East 14 39.8 21 60.2 10 27.6 27 72.4 24 33.5 48 66.5
West 87 63.0 51 37.0 51 33.7 100 66.3 138 47.6 151 52.4
Central 46 71.2 19 28.8 45 54.8 37 45.2 92 62.0 56 38.0
Age
Below 12 years 50 73.8 18 26.2 57 65.7 30 34.4 107 69.2 48 30.8
Above 12 years 97 57.1 73 43.0 50 26.9 135 73.1 146 41.3 208 58.7
Total 147 61.9 91 38.1 107 39.3 165 60.7 254 49.8 256 50.2
Why is iron tablet given in the school? How does it help you?- Strength
Boys Girls Both
No % Yes % No % Yes % No % Yes %
Type of school
CPS 2 74.4 1 25.6 2 74.4 1 25.6 4 74.4 1 25.6
PS 18 72.5 7 27.5 18 72.5 7 27.5 36 72.5 14 27.5
LSS 50 84.2 9 15.8 50 84.2 9 15.8 100 84.2 19 15.8
MLSS 104 84.3 19 15.7 104 84.3 19 15.7 209 84.3 39 15.7
HSS 27 100.0 0 0.0 27 100.0 0 0.0 54 100.0 0 0.0
Region
East 33 94.3 2 5.7 35 92.6 3 7.5 68 93.4 5 6.6
West 120 87.1 18 12.9 135 89.2 16 10.8 255 88.2 34 11.8
Central 49 74.5 17 25.5 58 70.6 24 29.4 107 72.3 41 27.7
Age
Below 12 years 51 74.9 17 25.1 74 84.7 13 15.3 125 80.4 30 19.6
Above 12 years 150 88.6 19 11.4 155 83.6 30 16.4 305 86.0 50 14.0
Total 201 84.7 36 15.3 228 84.0 44 16.0 429 84.3 80 15.7
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Why is iron tablet given in the school? How does it help you?- Don't Know
Boys Girls Both
No % Yes % No % Yes % No % Yes %
Type of school
CPS 1 35.8 2 64.2 1 35.8 2 64.2 2 35.8 4 64.2
PS 13 51.2 12 48.8 13 51.2 12 48.8 26 51.2 24 48.8
LSS 30 51.2 29 48.8 30 51.2 29 48.8 60 51.2 58 48.8
MLSS 86 69.8 37 30.2 86 69.8 37 30.2 173 69.8 75 30.2
HSS 9 33.3 18 66.7 9 33.3 18 66.7 18 33.3 36 66.7
Region
East 25 70.3 10 29.7 31 82.5 7 17.5 55 76.6 17 23.4
West 73 53.2 64 46.8 117 77.2 35 22.8 190 65.8 99 34.2
Central 42 64.1 23 36.0 66 79.8 17 20.2 108 72.8 40 27.2
Age
Below 12 years 34 49.3 35 50.7 47 54.0 40 46.1 80 51.9 75 48.1
Above 12 years 106 62.5 64 37.6 167 90.3 18 9.7 273 77.0 81 23.0
Total 139 58.7 98 41.3 214 78.7 58 21.3 353 69.4 156 30.6
In your opinion, who needs the iron tablet more, boys or girls? - Boys
Boys
Boys % Girls % Both % Don't know % missing %
Type of school
CPS 0 10.24 2 56.93 0 15.36 0 17.47 0 0
PS 3 10.35 11 44.77 7 29.8 3 12.87 1 2.2
LSS 8 13.15 36 61.19 10 17.1 5 8.56 0 0.0
MLSS 1 0.48 94 76.18 17 13.84 12 9.51 0 0.0
HSS 0 0 27 100 0 0 0 0 0 0.0
Region
East 2 6.67 25 72.66 2 5.89 5 14.78 0 0
West 8 5.87 97 70.3 21 14.93 12 8.9 0 0
Central 1 1.29 48 73.88 13 19.18 3 4.81 1 0.84
Age
Below 12 years 5 8 38 56 13 19 11 17 1 1
Above 12 years 6 4 132 78 22 13 9 5 0 0
Total 11 4.7 170 71.6 35 14.8 21 8.6 1 0.2
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In your opinion, who needs the iron tablet more, boys or girls? - girls
Girls
Boys % Girls % Both % Don't know % missing %
Type of school
CPS 0 2.1 3 88 0 0.0 0 10 0 0.0
PS 0 1.5 15 61 5 18.2 4 17 1 2.2
LSS 3 4.7 42 63 16 23.9 6 8 0 0.0
MLSS 0 0.0 135 90 11 7.0 5 3 0 0.0
HSS 0 0.0 27 100 0 0.0 0 0 0 0.0
Region
East 0 0 33 87.58 0 0.78 4 11.48 0 0
West 3 2 111 73.05 29 19.46 8 5.2 0 0
Central 0 0 78 94.4 1 1 3 3.5 1 1
Age
Below 12 years 0 0.49 44 50.13 27 31.38 15 17.37 1 0.6
Above 12 years 3 1.68 178 96.32 4 2 0 0 0 0.0
Total 4 1.3 222 81.6 31 11.4 15 5.5 1 0.2
In your opinion, who needs the iron tablet more, boys or girls? - both
Both
Boys % Girls % Both % Don't know % missing %
Type of school
CPS 0 6.1 4 72.6 0 7.6 1 13.7 0 0.0
PS 3 5.9 26 53.0 12 24.0 7 14.8 1 2.2
LSS 11 8.7 78 62.2 26 20.7 11 8.5 0 0.0
MLSS 1 0.2 229 83.6 28 10.1 17 6.1 0 0.0
HSS 0 0.0 54 100.0 0 0.0 0 0.0 0 0.0
Region
East 2 3.3 58 80.4 2 3.2 9 13.1 0 0.0
West 12 4.0 207 71.7 50 17.3 20 7.0 0 0.0
Central 1 0.6 126 85.4 14 9.2 6 4.1 1 0.7
Age
Below 12 years 6 3.7 82 52.7 40 25.8 27 17.1 1 0.7
Above 12 years 9 2.6 310 87.5 26 7.4 9 2.6 0 0.0
Total 15 2.9 392 76.9 66 13.0 36 7.0 1 0.2
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What drink do you have to avoid with food to enable iron absorption? - Tea
Boys Girls Both
No % Yes % No % Yes % No % Yes %
Type of school
CPS 2 66.6 1 33.4 2 66.6 1 33.4 4 66.6 2 33.4
PS 9 35.7 16 64.3 9 35.7 16 64.3 18 35.7 32 64.3
LSS 34 58.4 25 41.6 34 58.4 25 41.6 69 58.4 49 41.6
MLSS 60 48.2 64 51.8 60 48.2 64 51.8 119 48.2 128 51.8
HSS 14 53.3 13 46.7 14 53.3 13 46.7 29 53.3 25 46.7
Region
East 11 31.2 24 68.8 10 27.3 27 72.7 21 29.2 51 70.8
West 73 53.1 65 47.0 41 27.1 110 72.9 114 39.5 175 60.5
Central 35 54.4 30 45.6 40 48.3 43 51.7 75 51.0 73 49.0
Age
Below 12 years 32 46.4 37 53.6 30 35.0 56 65.0 62 40.0 93 60.0
Above 12 years 88 51.8 82 48.2 61 32.9 124 67.1 149 41.9 206 58.1
Total 119 50.2 118 49.8 91 33.6 180 66.4 211 41.3 299 58.7
What drink do you have to avoid with food to enable iron absorption? - milk
Boys Girls Both
No % Yes % No % Yes % No % Yes %
Type of school
CPS 2 84.6 0 15.4 2 84.6 0 15.4 5 84.6 1 15.4
PS 20 78.9 5 21.1 20 78.9 5 21.1 39 78.9 11 21.1
LSS 40 67.9 19 32.1 40 67.9 19 32.1 80 67.9 38 32.1
MLSS 91 73.2 33 26.8 91 73.2 33 26.8 181 73.2 66 26.8
HSS 18 66.7 9 33.3 18 66.7 9 33.3 36 66.7 18 33.3
Region
East 30 86.8 5 13.2 35 94.7 2 5.3 66 90.9 7 9.1
West 92 67.1 45 32.9 112 74.3 39 25.7 205 70.8 84 29.2
Central 48 74.0 17 26.0 76 91.5 7 8.5 124 83.8 24 16.2
Age
Below 12 years 55 80.3 13 19.7 73 84.1 14 15.9 128 82.4 27 17.6
Above 12 years 116 68.5 53 31.5 151 81.5 34 18.5 267 75.3 88 24.7
Total 171 71.9 67 28.1 224 82.3 48 17.7 394 77.4 115 22.6
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What drink do you have to avoid with food to enable iron absorption? - water
Boys Girls Both
No % Yes % No % Yes % No % Yes %
Type of school
CPS 2 59.0 1 41.0 2 59.0 1 41.0 3 59.0 2 41.0
PS 21 84.3 4 15.7 21 84.3 4 15.7 42 84.3 8 15.7
LSS 52 88.2 7 11.8 52 88.2 7 11.8 104 88.2 14 11.8
MLSS 104 83.7 20 16.3 104 83.7 20 16.3 207 83.7 40 16.3
HSS 18 66.7 9 33.3 18 66.7 9 33.3 36 66.7 18 33.3
Region
East 30 87.0 5 13.0 34 90.3 4 9.7 64 88.7 8 11.3
West 113 82.2 25 17.8 137 90.2 15 9.8 250 86.4 39 13.6
Central 53 81.3 12 18.7 48 57.5 35 42.5 101 68.0 47 32.0
Age
Below 12 years 60 87.4 9 12.6 72 82.9 15 17.2 132 84.9 23 15.1
Above 12 years 137 80.7 33 19.3 146 79.1 39 20.9 283 79.9 71 20.1
Total 196 82.6 41 17.4 218 80.3 54 19.7 414 81.4 95 18.6
What drink do you have to avoid with food to enable iron absorption? - Others
Boys Girls Both
No % Yes % No % Yes % No % Yes %
Type of school
CPS 3 89.8 0 10.2 3 89.8 0 10.2 5 89.8 1 10.2
PS 21 83.8 4 16.2 21 83.8 4 16.2 42 83.8 8 16.2
LSS 51 85.5 9 14.5 51 85.5 9 14.5 101 85.5 17 14.5
MLSS 101 81.5 23 18.6 101 81.5 23 18.6 202 81.5 46 18.5
HSS 25 93.3 2 6.7 25 93.3 2 6.7 50 93.3 4 6.7
Region
East 32 91.6 3 8.5 33 87.8 5 12.3 65 89.6 8 10.4
West 112 81.2 26 18.8 125 82.6 26 17.4 237 82.0 52 18.0
Central 56 86.4 9 13.6 81 98.3 1 1.7 138 93.1 10 6.9
Age
Below 12 years 51 75.0 17 25.0 70 80.5 17 19.5 121 78.1 34 21.9
Above 12 years 149 87.8 21 12.2 169 91.7 15 8.3 318 89.9 36 10.1
Total 200 84.2 38 15.8 239 88.1 32 11.9 439 86.3 70 13.7
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What is the cause of goitre?Boys
Boys
Iodine Deficiency %
Less salt %
Don't know %
Others %
missing %
Type of school
CPS 1 20.5 0 5.1 2 74.4 0 0 0 0
PS 7 27.8 2 9.5 16 62.4 0 0.4 0 0
LSS 20 33.7 9 14.
5 28 46.6 3 5.3 0 0
MLSS 92 74.2 2 1.2 30 24.1 1 0.5 0 0
HSS 14 53.3 5 20 7 26.7 0 0 0 0
Region
East 18 50.3 2 6.7 14 41.1 1 2 0 0
West 72 52.1 13 9.5 50 36.1 3 2.3 0 0
Central 44 68.1 3 3.9 18 28 0 0 0 0
Age
Below 12 years 16 23 6 8.8 43 62.7 4 5.6 0 0
Above 12 years 118 69.6 12 7.1 39 23.3 0 0 0 0
Total 134 56.
2 18 7.6 82 34.
6 4 1.6 0 0
What is the cause of goitre? Girls
Girls
Iodine Deficiency % Less salt % Don't know % Others % missing %
Type of school
CPS 1 30.1 0 0.0 2 69.9 0 0.0 0 0.0
PS 5 18.2 3 11.5 16 65.9 1 2.2 1 2.2
LSS 36 55.0 5 7.0 19 28.6 6 9.4 0 0.0
MLSS 109 72.7 11 7.3 25 16.9 5 3.1 0 0.0
HSS 23 86.7 0 0.0 4 13.3 0 0.0 0 0.0
Region
East 21 56.7 5 13.2 10 28.0 1 2.1 0 0.0
West 104 68.6 5 3.6 31 20.8 11 7.0 0 0.0
Central 50 59.9 8 9.8 24 29.6 0 0.0 1 0.7
Age
Below 12 years 26 30.4 8 9.8 43 50.0 8 9.3 1 0.6
Above 12 years 148 80.3 10 5.5 23 12.5 3 1.8 0 0.0
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Total 175 64.3 19 6.8 66 24.5 11 4.2 1 0.2
What is the cause of goitre?- both
Both
Iodine Deficiency % Less salt % Don't know % Others % missing %
Type of school
CPS 1 25.3 0 2.5 4 72.1 0 0.0 0 0.0
PS 11 23.0 5 10.5 32 64.1 1 1.3 1 1.1
LSS 56 45.0 13 10.5 46 37.1 9 7.4 0 0.0
MLSS 201 73.4 13 4.6 55 20.2 5 1.9 0 0.0
HSS 38 70.0 5 10.0 11 20.0 0 0.0 0 0.0
Region
East 39 53.6 7 10.1 25 34.3 1 2.0 0 0.0
West 176 60.8 19 6.4 81 28.1 14 4.7 0 0.0
Central 94 63.5 11 7.2 43 28.9 0 0.0 1 0.4
Age
Below 12 years 42 27.1 14 9.3 86 55.6 12 7.6 1 0.4
Above 12 years 266 75.2 22 6.2 63 17.6 3 0.9 0 0.0
Total 308 60.5 37 7.2 149 29.2 15 3.0 1 0.1
How can we prevent goitre? - Taking iodized salt
Boys Girls Both
No % Yes % No % Yes % No % Yes %
Type of school
CPS 2 84.6 0 15.4 2 84.6 0 15.4 5 84.6 1 15.4
PS 16 64.8 9 35.2 16 64.8 9 35.2 32 64.8 18 35.2
LSS 27 45.6 32 54.4 27 45.6 32 54.4 54 45.6 64 54.4
MLSS 36 28.9 88 71.1 36 28.9 88 71.1 72 28.9 176 71.1
HSS 4 13.3 23 86.7 4 13.3 23 86.7 7 13.3 47 86.7
Region
East 15 43.0 20 57.0 13 33.6 25 66.4 28 38.1 45 61.9
West 48 34.9 90 65.1 45 29.7 106 70.3 93 32.2 196 67.8
Central 22 33.5 43 66.5 28 33.5 55 66.5 50 33.5 98 66.5
Age
Below 12 years 47 69.2 21 30.8 54 62.7 32 37.3 102 65.6 53 34.4
Above 12 years 38 22.3 132 77.8 31 16.7 154 83.3 69 19.4 286 80.6
Total 85 35.7 153 64.3 85 31.4 186 68.6 170 33.4 339 66.6
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How can we prevent goitre? -Don't know
Boys Girls Both
No % Yes % No % Yes % No % Yes %
Type of school
CPS 1 20.5 2 79.5 1 20.5 2 79.5 1 20.5 4 79.5
PS 10 40.7 15 59.3 10 40.7 15 59.3 20 40.7 30 59.3
LSS 32 54.4 27 45.6 32 54.4 27 45.6 64 54.4 54 45.6
MLSS 90 72.4 34 27.6 90 72.4 34 27.6 179 72.4 68 27.6
HSS 23 86.7 4 13.3 23 86.7 4 13.3 47 86.7 7 13.3
Region
East 20 57.2 15 42.8 25 67.1 12 32.9 45 62.3 27 37.7
West 92 66.8 46 33.2 111 73.5 40 26.5 203 70.3 86 29.7
Central 44 67.6 21 32.4 57 69.0 26 31.0 101 68.4 47 31.6
Age
Below 12 years 24 35.2 44 64.8 33 38.3 54 61.7 57 36.9 98 63.1
Above 12 years 132 77.8 38 22.2 160 86.8 24 13.2 292 82.5 62 17.5
Total 156 65.6 82 34.4 194 71.3 78 28.7 349 68.6 160 31.4
How can we prevent goitre? -Others
Boys Girls Both
No % Yes % No % Yes % No % Yes %
Type of school
CPS 3 94.9 0 5.1 3 94.9 0 5.1 5 94.9 0 5.1
PS 25 99.6 0 0.4 25 99.6 0 0.4 50 99.6 0 0.4
LSS 59 100.0 0 0.0 59 100.0 0 0.0 118 100.0 0 0.0
MLSS 121 98.1 2 1.9 121 98.1 2 1.9 243 98.1 5 1.9
HSS 27 100.0 0 0.0 27 100.0 0 0.0 54 100.0 0 0.0
Region
East 35 99.8 0 0.3 37 99.3 0 0.7 72 99.5 0 0.5
West 135 98.3 2 1.7 145 95.9 6 4.1 280 97.0 9 3.0
Central 65 99.8 0 0.2 81 98.2 2 1.8 146 98.9 2 1.1
Age
Below 12 years 68 99.9 0 0.1 87 99.7 0 0.3 155 99.8 0 0.2
Above 12 years 167 98.5 3 1.5 177 95.8 8 4.2 344 97.1 10 2.9
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Total 235 98.9 3 1.1 264 97.1 8 2.9 499 97.9 11 2.1
Number of Boy above class 9 who received iron tablets
When was the last time you received medicine? Number of students Percentage
Thursday 70 69.8
Last month 6 6.1
Don't know 22 22.3
missing 2 1.8
Total 100 100.0
Number of Boy above class 9 who received iron tablets -Stratified by type of school
MLSS % HSS % Total
Thursday 41 57.6 29 100.0 70
Last month 6 8.6 0 0.0 6
Don't know 22 31.2 0 0.0 22
missing 2 2.6 0 0.0 2
Total 71 100.0 29 100.0 100
Number of Boy below class 8 who did not received iron tablets
When was the last time you received medicine? Number of students Percentage
Thursday 316 77.7
Last month 14 3.4
Don't know 60 14.7
missing 17 4.2
Total 406 100.0
Number of Boy below class 8 who did not received iron tablets by level of class
When was the last time you received medicine? CPS % PS % LSS % MLSS % HSS % Total
Thursday 6 100.0 47 94.8 117 93.2 128 63.9 18 71.4 316
Last month 0 0.0 1 1.1 5 4.3 6 2.9 2 7.1 14
Don't know 0 0.0 2 4.1 3 2.5 49 24.6 5 21.4 60
missing 0 0.0 0 0.0 0 0.0 17 8.6 0 0.0 17
Total 6 100.0 50 100.0 125 100.0 200 100.0 25 100.0 406
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Terms of Reference
Evaluation of School-based Iron Supplementation Programme in Bhutan
1. BACKGROUND AND RATIONALE
Iron deficiency and anaemia are a public health problem in Bhutan. A survey conducted by the Royal Government of Bhutan (RGoB)
and UNICEF in 2002 revealed a high prevalence of anaemia in many vulnerable groups. The prevalence was 55% among non-pregnant
women, 81% among under-five children and 28% among men. Although there were no survey data for pregnant women, an analysis
of lab records from the national referral hospital in Thimphu in the same year indicated that 81% of pregnant women were anaemic
(Annual Health Bulletin, 2002). In addition, the prevalence of anaemia among 6-14 year old children in a 2001-02 sub-national survey
was 64%.
To respond to the public health problem, the RGoB developed a multi-pronged strategy in consultation with UNICEF shortly after the
survey results were published in 2003. The strategy combined iron supplementation with public health measures, targeting the following
vulnerable groups:
1. Pregnant women and lactating mothersPreschool age children( 4-59 months)
2. Adolescents girls and boys in school set up
3. Out–of-school adolescent girls
4. Pregnant women and lactating mothers
5. Women of reproductive age
The delivery strategies were as follows:
Target Delivery Channel Who Lead Ministry
Out–of-school adolescent girls
Women of reproductive age,
Preschool age children( 4-59 months)
Community, NFE VHWs, NFE, Volunteers
MoH with support from MoE
Adolescent school girls and boys
(10-19 years)
Schools Teachers, Boy
scouts
MoE with support
from MoH
Pregnant women and lactating mothers Health facilities,
communities
Health workers,
NFE, VHWs
MoH with support
from MoE
Routine iron supplementation to pregnant women and breastfeeding mothers is integrated with the pre-natal and post-natal health care
services and is also delivered to a limited extent by Village Health Workers (VHWs). Supplementation to out-of-school adolescent girls
and women of reproductive age and pre-school age children has not been implemented. School-based supplementation of iron was
initiated in 2006 and is currently implemented in total of 501 schools in the following categories.
The school-based iron supplementation programme provides weekly iron supplementation and 6 monthly de-worming to school-going
children. Through the programme, students receive 60 mg of iron and 0.4 mg folic acid once a week. Since the inception of the
programme in 2006, there has been no comprehensive evaluation of the implementation of the programme.
2. PURPOSE OF THE EVALUATION
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The purpose of evaluating the school-based iron supplementation programme is to examine the process, relevance, efficiency and
effectiveness of the programme for school children. The evaluation is aimed to identify the key challenges faced and lessons learned
during the implementation phase, and make practical recommendations especially to revise and improve the national anaemia
prevention and control strategy developed in 2003.
3. SCOPE
The evaluation will be focused on the iron supplementation programme implemented nationwide by the ministry of Health in
collaboration with the Ministry of Education. The evaluation will be conducted for the between the period 2006 to 2013. The
evaluation will also examine the roles of Ministries of Education and Health and other relevant stakeholders.
4. EVALUATION QUESTIONS
Sample representative of selected schools must be evaluated against listed form of OECD evaluation criteria21 below. The selected
methodology should answer the following evaluation questions using credible evidence.The below evaluation questions should not
be seen as exhaustive and the consultant must refine and add additional questions wherever relevant.
Relevance
How relevant is school-based iron supplementation programme to the overall national anaemia prevention and control
effort?
Is the supplementation in line with needs of the schools, students and parents?
How do the school children, teachers and health workers view the importance of the programme?
To what extent were the perspectives of different stakeholders, including the Ministries of Health and Education taken into
account in the design of the initiative?
Efficiency
How many students have been effectively reached with weekly supplementation (data to be disaggregated by age and sex
and location of school)?
From what source are the supplies obtained and how frequently is the requisition made and by whom? What is the requisition
process and who endorses the requisitions?
What type of iron preparation is used and what is the basis for determining the quantity of iron tablets required?
Are there report books (registers, charts, requisition forms etc.) on the supply and distribution of the stocks?
Are there stocks-out? How are stock-outs managed?
What other public health measures are in place for anaemia prevention and control?
To what extent did UNICEF’s engagement with national and international partners support the timely delivery of outputs?
Was there a baseline survey and analysis prior to design of the programme? To what extent does the programme address the
needs of different children, in particular boys and girls, as well as children from different geographical areas and communities
including children with special needs?
Have there been yearly reviews of the programme? If yes when was the last review?
Effectiveness
Were the school children, parents and teachers involved in the planning phase?
Were the programme objectives clearly defined?
21http://www.oecd.org/dac/evaluation/daccriteriaforevaluatingdevelopmentassistance.htm
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To what extent has the weekly supplementation programme made a difference in the lives of girl and boy students, taking into account different regional, ethnic and social circumstances?
How do students respond to the method of administration of the iron tablets? How is it ensured that the iron tablets are swallowed?
Have side effects been reported? What sorts of side effects have been reported? Have any of the side effects been serious?
Are there updated standards and guidelines for iron supplementation in schools? Are these standards and guidelines used in
all schools?
Is there a policy on iron supplementation in schools? How are the additional costs if any taken care of?
What kind of intended and unintended changes has the programme achieved over its implementation period
5. APPROACH AND METHODOLOGY
The consultant should propose the most appropriate methodology to answer the evaluation questions listed above. A mixed method of qualitative and quantitative methods including desk reviews and interviews with key informants that are not located in schools must be adopted.
The methodology, including the sample design and selection must allow unbiased generalization of all schools and provide precise
estimates of the distribution of sample characteristics and disaggregated by level of school, gender, age groups and location.The
evaluation will be guided by the OECD/DAC standard guidelines of relevance, efficiency, effectiveness, sustainability and impact.
Ethical clearance from MoE and MoH will be sought with particular attention for involving children in this evaluation.
6. COORDINATION AND MANAGEMENT ARRANGEMENT
The consultant will have to arrange for office equipment and car for field visits. The consultant will directly report to the Chief Programme Officer, Non-Communicable Disease Division (NCDD), Ministry of Health. Programme Officer, NCDD, Ministry of Healthwill be responsible for day-to-day management of the process with support of the PME and Health Specialist from UNICEF.
The Chief Programme Officer, Non-Communicable Disease, Ministry of Health will assist the consultant in arranging and coordinating meetings and visits to the respective stakeholders and will oversee the evaluation process from inception to dissemination of findings including managing the evaluation team, organizing meetings with relevant stakeholders, monitoring the work progress, organizing literature review and field visits to support data collection and coordinating reference group meetings. A reference group comprising of the Chief Programme Officer, Non-Communicable Disease Division (MOH), relevant officials from Ministry of Education, National Statistics Bureau and Research and Evaluation Division (Gross National Happiness Commission), M&E Officer(UNICEF), Health Specialist (UNICEF) will be formed for technical guidance.
7. DELIVERABLES AND TIME FRAME
The following will be submitted in line with the time frame.
An inception report-maximum of 5-10 pages must outline the consultants understanding of the evaluation and expectation
along with a detailed work plan for completing the evaluation as per the required template, to be provided by UNICEF. The
reports must contain detailed methodology and evaluation matrix.
A zero draft report of key findings with conclusions and recommendations based on evidence.
A second draft report that incorporates comments and feedback from the evaluation reference group and other relevant
stakeholders. For the sake of transparency, the consultants should prepare an ‘audit trail’ to account for how he/she has
addressed all comments.
A Final report comprehensive report.
Presentation on major findings and recommendations to the relevant stakeholders.
Table 1.0 The evaluation must be completed within the time frame of 40 working days,over the period of 2 months
Deliverables Time
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Sl. No 1 Deliver Draft Inception report and
draft data collection tool 5 working days
2 Stakeholder meeting 1 working day
2 Finalize data collection tool, questionnaires forms and train data collectors
5 working days
3 Pre-test and data collection 15 working days
4 Data analysis and draft report. Submission of first draft
8 working days
5 Presentation of first draft and incorporate comments. Submission of the second draft report
2 working days
6 Incorporate comments and prepare final report 2 working days
7 Present and submit the Final Report 2working day
40 working days
8. DESSIMINATION
The evaluation results should be presented in an accessible formatand should be reader friendly for publishing.
9. PROFILE OF THE CONSULTANTS
Masters in Social Sciences or Public Health
Prior experiences in carrying out assessment and evaluations related to similar work
Consultancy license
Proven skills and knowledge in data collection, analysis, reporting and presentation
Prior experience in applying an equity perspective in evaluation or similar analytical exercises would be preferred.
Strong communication skills in English; knowledge of additional languages spoken in Bhutan will be added advantage
10. PROPOSAL
Individual consultants/firms must submit a proposal of detailed methodology and work plan. The following must be submitted with the proposal.
Comprehensive curriculum vitae of the consultant
Relevant experience and proof of prior work in similar fields
Detailed work methodology and Work Plan
Consultancy fees with cost breakdown linked with number of working days.
Any other relevant information.
11. SELECTION CRITERIA
Candidates will be assessed using 30% weightage to the financial and 70% weightage to the technical.