Nepal's National Scale-up of The Iron Intensification Program Improved Iron Folic Acid Supplementation Coverage in Pregnancy and Showed Potential for Reducing Anemia.

Objectives: A national scale-up of an integrated facility and community-based delivery of iron and folic acid (IFA) supplements in Nepal spanned almost ten years through the Iron Intensification Program (IIP), over which time national coverage of IFA in pregnant women increased from 23% to 80%. The objective of this research was to estimate the potential effect of duration of district-level exposure to IIP on IFA coverage, and on anemia in mothers in Nepal. Methods: With data of the 2006 and 2011 Demographic Health Surveys (DHS), we used multiple regression modelling and controlled for IIP district exposure, age, pregnancy status, wealth, religion, parity in the last 5 years, weight, education, and ecological region (Terai, Hills & Mountain regions). Results: In 2006, women who had given birth during the intervention implementation period (n=5,110) exposed to the intervention for 1-3 years had a 7% reduced the odds of having anemia (OR: 0.93; 95CI 0.91, 0.95). In 2011, among women who had given birth in the previous 5 years in the Terai (n=864), intervention exposure for 3-5 years suggested a 45% reduction in the odds of having anemia (OR: 0.55; 95CI 0.31, 0.99). Intervention exposure also suggested benefits in likelihoods of mothers receiving IFA (6-11%), and de-worming (12-28%). Conclusions: These results suggest that the IIP had a role in increasing IFA and de-worming coverage and may have protected against anemia. Nepal's example suggests that large scale national programs with long term commitment can successfully impact IFA coverage and potentially impact anemia.

Lessons and Experiences from Implementing Small Scale Fortification in Asia.

Objectives: Small scale fortification remains an essential focus in many countries with the majority of flour milling and salt processing occurring in villages or on small holdings. Large-scale processing methods are not replicable in these environments. Two adapted methodologies were tested in Nepal (flour) and Indonesia (salt) to address these concerns. Methods: Nepal: MI through NGOs installed, trained and monitored the functioning of 100 small mills covering 3,000 households, including devising a revolving premix fund, extensive local monitoring and a final evaluation after two years of implementation. Indonesia: MI provided mobile iodization units for real time salt crushing/iodizing on salt farm sites. Mini mobile labs were equipped and government workers trained to test iodized salt while it was being harvested. This real-time and mobile approach was further supported by development of farmer's cooperatives, established to organize these disparate farmers into a single legal entity to empower members while enhancing their bargaining position among traders, buyers or agents. Results: Nepal: >160 metric tons of fortified flour produced and 75% of the premix costs were recovered. The evaluation found reductions in anemia among villagers (from 33% to 18%) with fortified flour in 80% of households and nearly 50% of women consuming this flour on a daily basis. Indonesia: Iodized salt production increased from 5800 metric tons in 2008 to 25,000MT (87% of all salt) and cooperatives continue to function well. Conclusions: Small scale fortification work requires tailored approaches based on country context. By thoughtful programming, success can be achieved using a variety of methods.