1. Anemia as a public health problem Adolescent Girls’ Anemia Control Program Baroda Experience and Scaling up For Nutrition Workshop Prakash V Kotecha Department of Preventive Social Medicine Medical College Vadodara, Gujarat, India Technical Support : UNICEF Gujarat

2. 13th May 2005 Kotecha 2 Iron Deficiency « Iron deficiency is the most common nutritional disorder in the world. 4-5 billion people (66-80%) of the global population is iron deficit. « 2 Billion anemic people (30% of global population) in the world are anemic « ID affects more people than any other condition in the world.. And remains silent despite severe consequences than other common conditions…

3. 13th May 2005 Kotecha 3 Population, anemia prevalence in risk groups, and death and disability attributable to iron-deficiency anemia in the world and in selected developing regions of the world Source: Stoltzfus et al i.DALY = disability-adjusted life year ii.Excluding Egypt, Morocco, Somalia, Sudan and Tunisia iii.Excluding Cuba iv.Afghanistan, Djibouti, Egypt,Iraq,Morocco, Pakistan, Somalia, Sudan, Yemen RegionPopulation (Thousands) Anemia PrevalenceBurden attributable to iron deficiency (thousands) WomenMenChildrenDeathsDALYs(i) Africa(ii)639,59341%28%60% 27110,140 Latin America (iii)502,16223%11%46% 331,249 Eastern Mediterranean (iv) 481,63544%17%63% 80 3,195 Southeast Asia – I (v)293,81949%32%49% 341,528 Southeast Asia – II (vi)1,241,80660%36%66% 324 12,497 North America (vii) 325,1838%5%7% 5478 World6,045,183-- 841 35,057 GBD 2000 WHO estimates: Southeast Asia contributes 1/5 th of the population; But contributes to more than 40% of the deaths due to anaemia and almost 1/3 rd of the DALY lost due to anaemia! v.Indonesia, Srilanka, Thailand (I) vi.Bandladesh, Bhutan, Democratic People’s Republic of Korea, India, Maldives, Myanmar, Nepal (II) vii.Including Cuba viii.Because anemia cutoffs are defined as the 5 th percentile of normative distribution, this represents the theoretical minimum population prevalence of anemia

4. 13th May 2005 Kotecha 4 Prevalence of Anemia in Children NFHS II Large proportion anemia More than 2/3 of them are moderate to severe

5. 13th May 2005 Kotecha 5 Prevalence of Anemia in Women ICMR Mutli Centric Districts Study Large proportion anemia More than 5/6 of them are moderate to severe

6. 13th May 2005 Kotecha 6 Anemia Control strategy Position « Magnitude of the problem and its effects are well appreciated in the programs…..! « #Tenth five year plan 2002-2007 goal  To reduce prevalence of anemia by 25% and moderate and severe anemia by 50% in children, pregnant and lactating women and adolescents!  Screening of children for anemia whenever required and appropriate treatment of those found anemic!  Universal screening of pregnant women for anemia and appropriate treatment! #Tenth Five Year Plan: Volume II Sectoral policies and Programs: Nutrition

7. 13th May 2005 Kotecha 7 So what should we do? « Not just know anemia but UNDERSTAND anemia, its wide spread consequences in the field much beyond health « Effectively communicate that to those who DECIDE POLICY AND ALLOCATE RESOURCES « Come with technically sound, practically feasible and realistically targeted program

8. 13th May 2005 Kotecha 8 Why Anemia Control? Reduction of anemia means « More School attendance « Better Learning « More capacity to work and increased productivity « More income for individual and country « Less expenses and need for health care « Ability for care for self and others improved « Quality of life improves….

9. 13th May 2005 Kotecha 9 Why Anemia Control? The World Health Organizations (WHO) 2002 Report titled “Preventing Risk, Promoting Healthy Life”, mentioned iron deficiency as the 9 th of 26 preventable risks to disease disability and death in the world today It is social and economic scourge and not a medical problem…

10. 13th May 2005 Kotecha 10 Gujarat Experience

11. 13th May 2005 Kotecha 11 Why Adolescent Girls? « Anemia in pregnancy has not been controlled ever….and anywhere…. « Quality of life matters…. « Adolescent age group is 1/6 th of the total population and important one… « Half of them adolescent girls: « 40% marriage by age of 18 years among all married women including young women (MICS 1999, 2001)

12. 13th May 2005 Kotecha 12 Background for the Project « Baseline prevalence of anemia 75% in adolescent school girls « Similar among rural, tribal and urban areas « Readiness to take IFA tablets to 98% level « Technical and Administrative Assistance available « All 426 schools covered under the program

13. Department of Education Department of Health & Family Welfare UNICEF Gujarat (Technical & Financial Help ) Medical College Vadodara Project Support unit (Technical Guidance and Documentation) Vadodara District District Education officer Regional Deputy Director Health & Chief District Health Officer Medical Officer of Health V. M.Corporation 193 Rural Schools 177 Urban Schools 56 Tribal Schools 426 Total Schools Education Inspectors MOs PHCs MOs VMC More than 4000 Teachers Beneficiaries in the schools More than 65000 Adolescent Girls Adolescent Anemia Control Program Indian Medical Association Association Of Teachers and Principal

14. 13th May 2005 Kotecha 14 State Ministers Health, Education & UNICEF Chief Inaugurating

15. 13th May 2005 Kotecha 15 Project Inputs « Once a week supervised IFA tablet « IEC for girls, teachers and parents « Training & Logistics – « Monitoring-  Individual,  Class (weekly),  School  SVS  District level

16. 13th May 2005 Kotecha 16 Prevalence of Anemia at Different Hb. Cut off Points Before and After Intervention

17. 13th May 2005 Kotecha 17 Positive Lessons «Easy, doable and successful program. Replicable and effective to control anemia «Effective in reducing anemia by 20% with improvement in hemoglobin for 82% of girls in 17 months of the intervention period «Compliance for the schoolgirls to went up to 90%.... In 2003 in Vadodara district. Kotecha

18. 13th May 2005 Kotecha 18 Progress based on Vadodara Project lessons « Program extended to ALL 25 districts, owned by education and health department of Government of Gujarat jointly and supported by UNICEF (16 districts) and MI (9 districts) « Currently covers over one million adolescent girls in the schools « Internalized with education and health program with minimum extra input

19. 13th May 2005 Kotecha 19 Monitoring Education « Schools to « QDC and SVS « DEO « State Health « Schools « PHC/SC « CDHO/RCHO « State Beneficiaries want and ask for this program: We need to ensure that implementers to implement…

20. 13th May 2005 Kotecha 20 Vital Keys for Future «Key for success is commitment and monitoring by District and State authorities (DDO can help tremendously here with their team members DEO and CDHO) «State Offices for Education and Health need to emphasize the importance of monitoring and request regular reports and a discussion and follow up on the monitoring

21. 13th May 2005 Kotecha 21 Key to success are District Authorities « Please ensure monitoring « Please ensure joint review of monitoring reports and corrective actions for regularity and necessary feed back…. « Health and education and WCD need to be partners at district level with strong linkages… « These linkages will come from whole hearted commitment and follow up at state level authorities…GO & NGO

22. 13th May 2005 Kotecha 22 Out of school girls… « Out of school girls are about 70% of adolescent girls and they are not effectively covered… « Reach “Out of school girls” through ICDS, Panchayat, NGO etc.  Through ICDS AWW by involving them in urban area.  Over 10,000 girls covered under urban areas…staring in rural areas too..  KSY is ensuring larger coverage…

23. 13th May 2005 Kotecha 23 Thank You..