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MINISTRY OF HEALTH

DIVISION OF NUTRITION

ACCELERATING REDUCTION OF IRON DEFICIENCY ANAEMIA AMONG

PREGNANT WOMEN IN KENYA

PLAN OF ACTION

2012-2017

GOVERNMENT OF KENYA

MINISTRY OF HEALTH


ACCELERATING REDUCTION OF IRON DEFICIENCY ANAEMIA AMONG PREGNANT WOMEN IN KENYA

PLAN OF ACTION

2012-2017

GOVERNMENT OF KENYA

PLAN FOR ACCELERATING ANAEMIA REDUCTION THROUGH IRON AND FOLIC ACID SUPPLEMENTATION OF PREGNANT AND LACTATING WOMEN IN KENYA2

ACKNOWLEDGEMENTSThe Division of Nutrition appreciates the tireless efforts of members of the task force through the supplementation sub-committee for their valuable inputs in development of this Plan of Action. The task force was comprised of members from Division of Nutrition (DoN), Division of Child and Adolescent Health, Division of Reproductive Health, in the Ministry of Health (MoH), USAID-MCHIP, Kenyatta University, UNICEF (KCO), and Micronutrient Initiative (MI).

We would like to express our gratitude to USAID-MCHIP for their Technical and Financial support. Special thanks go to Evelyn Kikechi (DON), Evelyn Matiri (USAID-MCHIP), Marjorie Volege (UNICEF –KCO), Ruth Situma (UNICEF KCO) and Esther Wamae (MI) for their contributions and support for technical processes in developing this strategy. The ministry also acknowledges the support and contributions of all national staff of the Division of Nutrition for their contributions.

Last but not least, appreciations go to the Permanent secretary Mr. Mark Bor, the Director of Public Health and Sanitation, Dr, Sharif, Head, Department of Family Health, Dr. Wamae for their invaluable support and contributions that enabled us to accomplish this task.

Terrie Wefwafwa HSC

Head, Division of Nutrition

3

FOREWORDWith three years left to the Millennium Development Goals (MDG) deadline, many countries, Kenya included, are far from achieving the targets set almost ten years ago. Kenya has made insufficient progress towards achieving these goals especially MDG 4 and 5 with a slow decline in child mortalities and stagnation of maternal mortality (KDHS, 2008-09). At the current rates, the under 5 mortality and maternal mortality are respectively 2.3 and 3.3 times higher than the MDG targets.

Iron and Folic acid (IFA) supplementation for pregnant women has been shown to reduce maternal anaemia and consequently maternal mortality and LBW while folic acid if taken from the time of pre-conception and throughout the early months of pregnancy is critical in preventing neural-tube birth defects. Whereas these high impact interventions are known, their uptake is low and therefore children and women do not optimally benefit from them. Various factors contribute to these low uptake levels and hence to Kenya’s slow progress in addressing MDG 4 and 5. These factors need to be well addressed effectively to help achieve the MDG targets.

IFA deficiency control is prioritized in the National Food and Nutrition Security Policy and the draft National Health Sector Strategic Plan (NHSSP III). The National Nutrition Action plan 2012 - 2017 identifies four main strategies to successfully address iron and folic acid deficiencies among pregnant women. These are 1) dietary diversification and modification 2) food fortification and bio-fortification, 3) iron and folic acid supplementation and 4) public health measures including malaria control and helminthes control. Other public health strategies to control iron and folic acid deficiencies are also highlighted in the Food and Nutrition Security Policy which takes cognizance of other sectors that contribute to reducing micronutrient deficiencies.

While the main focus of this document is on iron and folic acid supplementation programs, this plan of action acknowledges the beneficial role parasite control, food fortification and dietary diversification and malaria control programs can have in controlling iron deficiency anemia.

Addressing iron and folic acid deficiency requires clear policies, strategies, actions and investment. While the policies are in place, this plan of action seeks to provide the practical implementation plan with clear actions and costing for the next five years. The plan of action document has been developed by the Division of Nutrition within the Ministry of Health to coordinate all relevant stakeholder efforts on the priority actions that the country will focus on, for the next 5 years, to strengthen the IFA programme to improve coverage and utilization of iron and folic acid supplements thereby preventing and controlling the iron deficiency anemia among pregnant women. The plan of action will be useful for stakeholders who are involved in designing, implementing and evaluating IFA programs at national, county and community levels.

Dr. Annah Wamae OGW

Head, Department of Family Health


TAbLE OF CONTENTS

LIST OF ACRONyMS .............................................................................................................5

ExECUTIVE SUMMARy ........................................................................................................6

1.1 SITUATION ANALySIS OF MATERNAL ANAEMIA IN KENyA ................................7

1.2 INTERVENTIONS TO ADDRESS ANAEMIA AMONG PREGNANT WOMEN .......7

1.3 CHALLENGES CURRENTLy FACED IN IFA SUPPLEMENTATION ..........................7

2.0 PROPOSED PLAN TO ADDRESS BARRIERS OF IFA SUPPLEMENTATION .........10

2.1 PURPOSE AND OBjECTIVES OF PLAN .....................................................................10

2.2 PROCESS OF DEVELOPING PLAN ..............................................................................10

Table 1: IFA Supplementation Plan: Focus Areas and Expected Outcomes ......................11

Table 2: IFA Supplementation Plan: Implementation Framework and Summary Budget .... for the period 2012-2017 .................................................................................................12

ANNEx 1: DETAILED BUDGET .........................................................................................17

ANNEx 2: LIST OF CONTRIBUTORS ...............................................................................25

REFERENCES ........................................................................................................................26

5

LIST OF ACRONyMS

ACSM Advocacy, Communication and Social MobilizationANC Ante Natal CareCHW Community Health WorkersCME Continuous Medical EducationDCHS Division of Child Health ServicesF&Q Forecasting and QuantificationFANC Focused Ante Natal CareFAO Food and Agriculture OrganizationFSNP Food Security and Nutrition PolicyHIS Health Information SystemHIV Human Immuno VirusHMIS Health Management Information SystemHW Health WorkersIDA Iron Deficiency AnaemiaIEC Information, Education and CommunicationIFA Iron and Folic Acid IRCK Inter Religious Council of KenyaKAP Knowledge, Attitude and PracticesKDHS Kenya Demographic Health SurveyKEMSA Kenya Medical Supplies AgencyKSPA Kenya Service Provision AssessmentLBW Low Birth WeightM&E Monitoring and EvaluationMCH Maternal and Child HealthMCHIP Maternal and Child Health Integrated ProgramMI Micronutrient InitiativeMIYCN Maternal, Infant and young Child NutritionMOA Ministry of AgricultureMOMS Ministry of Medical ServicesMOPHS Ministry of Public Health and SanitationMTEF Mid Term Expenditure FrameworkNMDCC National Micronutrient Deficiency Control CouncilOJT On job TrainingPNC Post Natal CarePS Permanent SecretarySCUK Save the Children UKSUN Scaling Up Nutrition TBD To Be DoneTOR Terms of ReferenceUNICEF United Nations Children’s FundsWFP World Food ProgrammeWHO World Health Organization


ExECUTIVE SUMMARyThe National IFA Supplementation Plan of Action 2012-2017 was formulated and developed through extensive participatory collaborations and consultations between the Ministry of Public Health and Sanitation, NGOs, partners and other relevant stakeholders. The process was coordinated by the Division of Nutrition though the National Supplementation Sub-Committee, the National Micronutrient Deficiency Control Council and the Nutrition Interagency Coordinating Committee. The main objective of this document is to provide a framework for coordination of stakeholder efforts towards strengthening the IFA programme implementation to improve the coverage and utilization of iron and folic acid supplements among pregnant women, thereby contributing to the reduction of iron deficiency anaemia.

Implementing the costed Plan of Action will require increased political will, donor investment, stakeholder involvement, public investment and a heightened awareness of the critical importance of IFA supplementation among health workers, pregnant women and community based care providers. Involvement of the national and county government, families, communities, community based organizations (CBOs), in collaboration with international organizations and other concerned parties will ultimately ensure that necessary action is taken.

The Costed Plan of Action is divided into eight broad areas as follows:

• Chapter One: This section provides an insight into the status of maternal anaemia in Kenya, the interventions in place to address anaemia among pregnant women and the challenges currently faced in IFA supplementation,

• Chapter Two: Proposed Plan to Address Barriers of IFA Supplementation - this section provides the objectives of the Plan of Action 2012-2017 and also a 5 year costed IFA Supplementation Plan with 5 key Focus Areas and their expected outcomes.

7

CHAPTER 1

1.1 Situation Analysis of Maternal Anaemia in Kenya

The prevalence of anaemia among pregnant and lactating women in Kenya is worrying. The Kenya Micronutrient Survey, 1999 indicated the prevalence of iron-deficiency anaemia among pregnant women to be high at 55.1% and 46.4% among non-pregnant women. Anaemia, resulting from iron deficiency, referred to as iron deficiency anaemia, is the most common type of anaemia globally. The risk factors of iron deficiency anaemia (IDA) include: inadequate consumption or low intake of haeme iron, consumption of staples with low bio available iron, inadequate intake of foods that enhance iron absorption from diet such as vitamin C, consumption of foods high in inhibitors of iron absorption, parasitic infection, malaria, chronic infections, heavy blood loss and restricted food intake.

The consequences of anaemia are major. Maternal anaemia contributes to maternal and peri-natal mortality, pre-term delivery, low birth weight (LBW) and fetal impairment. Anaemia is associated with an increased risk of morbidity and mortality, especially in pregnant women and young children. Maternal deaths in Kenya have been on the increase as evidenced in the last two demographic health surveys; 488 maternal deaths per 100,000 live births were recorded in 2008-09 compared with 414 deaths per 100,000 live births in 2003. Neonatal deaths were at 31 per 1,000 live births in 2008-09 and they accounted for approximately 60 percent of under-five mortality.

1.2 Interventions to address Anaemia among Pregnant Women

Globally and in Kenya, one of the key strategies that has been used for years to address anaemia among pregnant women is iron and folic acid (IFA) supplementation. IFA supplementation is critical as it has been shown to reduce maternal anaemia and consequently maternal mortality and LBW while folic acid is critical in preventing neural-tube birth defects. IFA supplementation for pregnant women in the country is one of the routine services provided within Focused Antenatal Care [FANC].

It is important to note that the IFA supplementation is only one of the maternal anaemia control strategies. It is clear from experience that implementation of a package of proven interventions are much more likely to succeed in improving maternal anaemia than implementing any one single intervention. Other interventions critical in dealing with maternal anaemia include fortification of food with iron, malaria control, HIV management, hookworm control and optimal birth spacing as appropriate. For the coordinated integration of all these strategies, there is need for strong collaboration with key divisions including Divisions of Nutrition (DON), Reproductive Health (DRH), Malaria and Environmental Health.

1.3 Challenges currently faced in IFA supplementation

1.3.1 Compliance

As indicated in the Kenya Demographic Health Survey (KDHS) 2008-09, IFA compliance is poor with only 2.5% of women taking supplements for ≥90 days. Over 30% women do not take any iron supplements during pregnancy. A comparison with 2003 KDHS data indicates that the proportion of women who took iron supplements increased from 41% to 60% in 2008-09. Although this is a sizeable increase, almost all of the women who took iron supplements took them for less than 60 days during pregnancy.


1.3.2 Counselling skills and Awareness

The KSPA indicated that there were limited pre- and in-service training on FANC and this compromised quality of counselling at the Ante Natal Care (ANC) and Postnatal Care (PNC).

1.3.3 Late start of antenatal care by pregnant women

IFA supplementation is dependent on client adherence to recommended number and timing of ANC visits. The KDHS 2008-09 currently indicates that 47% of all pregnant women meet the recommended four or more ANC visits. Provider capability to provide the range of services required for focused ANC remains weak in some aspects and most providers have limited knowledge of which routine services are expected for FANC, including critical aspects like the timing of visits, and many aspects of education and counseling. It is worth noting that the training curricula for ANC in pre-service training institutions have remained unchanged, a situation that gravely affects the quality and sustainability of focused ANC services, including IFA supplementation.

1.3.4 Supply Chain

IFA tablets are part of the essential drugs list procured and distributed by government to all health facilities. The procured iron supplements are used both for treatment and supplementation in the health facility, a situation which sometimes results in shortages of IFA supplements for use during the pregnancy period. Iron supplementation program for pregnant women through public health system had many challenges amongst them poor stock control management leading to breakage of supply chain and collapse of the program during the last decade. Data from the Kenya Service Provision Assessment (KSPA) 2012 showed that only 41% of health facilities had iron tablets, while 74% had folic acid supplements. A thorough analysis of the FANC supply chain system is necessary to understand all other factors affecting availability of stocks within health facilities.

Figure 1: Distribution of women who took iron tablets or syrup during pregnancy of last birth by number of days (KDHS 2008)Pe

rcen

tage

wom

en

30.9%

None < 60 days 60-89 days >90 days

54.2%

3.1%

Number of days

2.5%

9

1.3.5 Formulation

The current IFA supplementation recommendations for pregnant women are detailed in the Kenya National Technical Guidelines for Micronutrient Deficiency. The recommended dosage per day is 60mg iron and 400µg folic acid, and the period for supplementation is from the first month of pregnancy for a period of 6 months.

The Ministry of Health (MOH) has recently introduced enteric coated and combined formulations (60mg Fe and 400µg FA). This formulation is recommended to replace the high dose iron supplements (200mg that are currently being used which have been associated with side effects such as constipation and other gastrointestinal effects including nausea, vomiting and diarrhoea. The new formulations will reduce the side effects experienced by women and will be important to the country because they are likely to be more acceptable resulting in increased compliance levels. The combined formulations will also be easier to take than separate iron and folic supplements.

1.3.6 Weak implementation strategy

National guidelines indicate that iron tablets and folic acid tablets are to be provided to all pregnant women attending ANC at the Maternal and Child Health (MCH) clinics in all health facilities (levels 2-5). Due to lack of clarity, it has been found that health workers insist on first screening pregnant women for anaemia before prescribing IFA tablets.

For IFA supplementation to have the desired impact on the iron and health status of pregnant women and newborns, it is necessary to strengthen the implementation of the intervention.


CHAPTER 2

2.0 Proposed Plan to Address barriers of IFA Supplementation

2.1 Purpose and Objectives of Plan

The Ministry of Health (MOH), Division of Nutrition with support from partners has embarked on a robust five year plan aimed at accelerating reduction of anaemia among pregnant women through strengthening IFA supplementation.

The main objective of this plan is to coordinate stakeholder efforts towards strengthening the IFA programme to improve the coverage and utilization of iron and folic acid supplements among pregnant women, thereby contributing to the reduction of iron deficiency anaemia.

The specific objectives of the plan are:

1. To improve the knowledge, attitudes and practices on IFA supplementation among pregnant women, health workers and other key influencers

2. To ensure quality and timely implementation of evidence-based IFA interventions

3. Increase coverage of IFA supplementation for pregnant women from 68.7% to 80% by the year 2017

4. Increase compliance to IFA supplementation (for more than 90 days) from 2.5% to 30% by 2017

5. To develop an effective and efficient supply chain management system of IFA commodities

6. To strengthen the coordination of IFA interventions among key stakeholders

7. Improve monitoring and support for IFA supplementation at all levels

2.2 Process of Developing Plan

The process of developing the IFA supplementation plan included:

(1) An initial IFA supplementation meeting among key stakeholders who are members of the supplementation committee under the National Micronutrient Deficiency Control Council (NMDCC). The main purpose of the meeting was to share the challenges currently faced in the IFA intervention and to forge a way forward. From the meeting, consensus was drawn regarding the need to have an elaborate plan to unlock the barriers in the intervention and;

(2) A IFA supplementation stakeholder workshop was held in February 2012 to develop a comprehensive costed plan of action (2012-2017) to be implemented under the leadership of the Division of Nutrition;

(3) the Plan of Action 2012-2017 was reviewed and adopted by the National Micronutrient Deficiency Control Council (NMDCC) and the Nutrition Inter-agency Coordinating Committee (NICC); and

(5) A national dissemination meeting with key stakeholders was held where partners committed resources for the implementation of the 5 year plan.

11

2.3 The Action Plan

The plan is based on five focus areas outlined below together with the expected outcomes.

Table 1: iFa Supplementation Plan: Focus areas and expected Outcomes

FOCUS AREAS ISSUE ADDRESSED EXPECTED OUTCOME

1. Policies and legislation Need for heightened advocacy among key policy makers to ensure prioritization of nutrition

National Food Security and Nutrition Policy enacted, Micronutrient Strategy and Technical Guidelines reviewed

2. Capacity development and service delivery strengthening

Health workers knowledge, attitudes and practices on IFA interventions, including supplementation

Improved quality of IFA supplementation service delivery at all levels

3. Advocacy, partnership and communication

BCC needed to address barriers and facilitating factors for increasing IFA uptake, utilization and compliance among pregnant women

Increased awareness and support for IFA interventions

4. IFA commodities and supply chain management

The entire supply chain system including forecasting, quantification, procurement, distribution and storage mechanisms

Effective and efficient supply chain management system

5. Monitoring, evaluation and research

Need to strengthen M&E at all levels from health facility to national level. This includes data reporting tools, sensitization of health workers on importance of appropriate and timely reporting

Quality and timely implementation of evidence-based IFA interventions

The proposed budget for the 6-year IFA supplementation plan is approximately Kes 1 billion (~$12 million). The implementation framework and summary budget for the plan is indicated in Table 2.


Tabl

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e as

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men

t

Prop

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ach

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d

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OH

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ON

DR

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elop

men

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plan

Stra

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D

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tion

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t nat

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and

im

plem

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for

supp

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enta

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Prop

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f the

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ach

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RH

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ICEF

, M

I, M

CH

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ly

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eetin

gs

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000

Advo

cate

incl

usio

n of

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age

nda

in

all n

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rela

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coor

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ms

Prop

ortio

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nut

ritio

n co

ordi

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rum

s su

ppor

ting

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in

terv

entio

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OH

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ON

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OH

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ICEF

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0

15

OU

TP

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OR

SB

ASE

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EN

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PAR

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S

Impr

oved

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P am

ong

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th

wor

kers

and

co

mm

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n IF

A

Rev

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mon

ize

and

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lop

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m

ater

ials

to in

clud

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A m

essa

ges

Prop

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ceiv

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en

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um o

f 90

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ets

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for I

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80%

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H –

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Util

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tiple

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ls fo

r co

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unic

atio

n in

clud

ing

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s, m

edia

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nd

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, UN

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, M

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CH

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ly

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Dev

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OU

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UT

SA

CT

IVIT

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IND

ICAT

OR

SB

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LIN

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anag

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H -

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, UN

ICEF

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I, M

CH

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ans

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finan

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hro

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175,

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/= co

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NIT

ORI

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AN

D R

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PEC

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OU

TCO

ME:

QUA

LITY

AN

D T

IMEL

Y IM

PLEM

ENTA

TIO

N O

F EV

IDEN

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BASE

D IF

A IN

TERV

ENTI

ON

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prov

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agem

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ter-

vent

ions

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en

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cus

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2


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nica

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t for

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and

men

torsh

ip

part

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cus

area

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rterly

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tive

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rvisi

on

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000

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000

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0,00

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30

0 di

strict

s * (

8 D

HM

T * 4

000/

= D

SA)+

3000

fu

el/da

y) *

10

days

* 4

times

pe

r yea

r = 4

20M

- o

ur co

ntrib

u-tio

n to

IFA

= 2%

of

420

M=

8.4M

Revie

w ex

istin

g IFA

in

dica

tors

in th

e HIS

&

per

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c su

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20,0

00

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0,00

0

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uctio

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rt of

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mal

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ram

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plem

entat

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ewor

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tiona

l nut

ri-tio

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&E

strate

gy

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e don

e as

part

of M

&E

strate

gy d

evelo

p -m

ent w

ork

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000

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00,0

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TAL

BUD

GET

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GET

(USD

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7,89

1.57

25

ANNEx 2: LIST OF CONTRIBUTORS

NAME ORGANIZATION

Terry Wefwafwa DON - MOPHS

Evelyn Kikechi DON - MOPHS

Valerie Wambani DON – MOPHS

james Njiru DON – MOPHS

john Mwai DON - MOPHS

Sarah Onsase DON-MOPHS

Samuel Murage DON - MOPHS

Evelyn Matiri USAID - MCHIP

Herbert Kere USAID - MCHIP

Crispin Ndedda DCAH - MOPHS

Alex Mutua DCAH - MOPHS

josephat Mutua DCAH-MOPHS

Patrick Warutere HMIS

Charity Tauta DCHS - MOPHS

Samuel Muchiri Kamau MI/DON

Cosmas Mutunga DRH - MOPHS

Esther Kariuki MI

Ruth Situma UNICEF

Marjorie Volege UNICEF

Lucy Maina-Gathigi DON - MOPHS

Rae Galloway USAID - MCHIP

judith Kimiywe USAID - MCHIP

Kiersten Israel USAID - MCHIP


REFERENCES1. Mwaniki, D. L., Omwega, A. M., Muniu, E. M., Mutunga, j. N., Akelola, R., Shako, B., Gotink, M. H. and Pertet, A. M. (1999). Anaemia and Micronutrient Status of Iron, Vitamin A and Zinc in Kenya; National Micronutrient Survey Report.

2. jane, B., Michael, B. and Klaus, K. (2007). The guidebook. Nutritional Anemia. Sight and Life Press. pp 1-11.

3. Ross, j. and Horton, S. “Economic Consequences of Iron deficiency.” The Micronutrient Initiative, 1998: Pp 26.

4. Kenya National Bureau of Statistics (KNBS) and ICF Macro, 2010. Kenya Demographic and Health Survey 2008-09. Calverton, Maryland: KNBS and ICF Macro: 113-118.

5. Central Bureau of Statistics (CBS) [Kenya], Ministry of Health (MOH)[Kenya], and ORC Macro. (2004). Kenya Demographic and Health Survey 2003. Calverton, Maryland: CBS, MOH, and ORC Macro: 163-167.

6. National Coordinating Agency for Population Development (NCAP) [Kenya], Ministry of Medical Services (MOMS) [Kenya], Ministry of Public Health and Sanitation (MOPHS) [Kenya], Kenya National Bereau of Statistics (KNBS) [Kenya], ICF Macro. 2011. Kenya Service Provision Assessment Survey 2010. Nairobi, Kenya.

7. MOPHS. (2008). The Kenya National Technical Guidelines for Micronutrient Deficiency Control. Government of Kenya. pp 49-71.

MINISTRY OF HEALTH


ACCELERATING REDUCTION OF IRON DEFICIENCY ANAEMIA AMONG

PREGNANT WOMEN IN KENYA

PLAN OF ACTION

2012-2017

GOVERNMENT OF KENYA

ministry of health - home | k4health · ifa supplementation for pregnant women in the country is...

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