Supporting policy action to reduce adolescent anaemia in South Asia

Evidence generation and use to influence decision making

Vision and commitment from the highest political office are essential prerequisites for formulating well designed government funded programmes for reducing anaemia across South Asia. Even the most committed and experienced public administrators often struggle to work out how best to advance policy decisions discussions with elected policy makers,8 and it is here that rigorous evidence provides a strong basis on which to convince and influence decisions in the highest political office. Championing an evidence based approach with public administrators has been a cornerstone of scaling up anaemia programmes for adolescent girls in South Asia. Key strategies include analysing and presenting country specific data on the burden, causes, and risk factors of anaemia in adolescent girls; highlighting cost effective and scalable interventions from within the region and beyond; and engaging a wide range of stakeholders, such as scientific bodies, academia, professional associations, local implementers, clinicians, and community and advocacy groups, to build a consensus on advocacy messages that will guide techno-bureaucratic and political decisions.

To help inform and consolidate countries’ policy and programme visions, Unicef supported national micronutrient surveys in Bhutan, India, Nepal, and Sri Lanka to fill critical knowledge gaps on anaemia. These surveys showed that in these contexts anaemia was often linked to concurrent micronutrient deficiencies, such as vitamin B₁₂, folate, and vitamin D.9101112 The surveys provided insights which helped trigger policy conversations on broadening the focus of anaemia control programmes beyond iron deficiency and for using global standardised methodologies for measuring micronutrient deficiencies to allow comparison over time and between countries. For example, in 2022, the Government of India launched the diet and biomarker survey to estimate the prevalence of anaemia among urban and rural populations using state-of-the-art techniques. The survey started using venous blood samples to estimate anaemia, instead of the capillary method,13 as recommended by a comprehensive national nutrition survey, commissioned by Unicef in collaboration with the national government.10

Furthermore, our experiences in the region have taught us that packaging evidence into formats like investment cases, which detail costs, scale, performance targets, and impacts, can be key to gaining commitment from decision makers for new programmes.14 Making the most of political opportunities, such as pre-election periods, may offer opportunities for alignment with political visions. Until recently, Pakistan had been one of the last countries with a high prevalence of soil transmitted helminth infections but without a deworming programme among school age children. Evidence Action, an international non-profit organisation, and its local partners launched Pakistan’s first nationwide survey of soil transmitted helminth prevalence in 2016, which found a need for annual deworming in 17 million school age children and identified 45 at-risk districts in which to focus programming. The survey results combined with a compelling cost-benefit impact of deworming on health, education, and economic outcomes for an estimated average cost of less than $0.50 (£0.40; €0.48) per child per treatment provided the basis for a strong advocacy.

These efforts succeeded in gaining government buy-in for launching a school based annual programme, and by 2020 over 3 million children were receiving treatment as more provincial governments of Pakistan joined the initiative.15

In national scale-up efforts, demonstrating programme effectiveness through embedded monitoring, evaluation, and innovation across programme cycles has been important for expanding schemes to different sub-regions, building momentum for change, and gaining credibility among policymakers. Piloting anaemia prevention programmes with in-built evaluation provides an opportunity to test approaches and refine technical protocols and tool kits to inform replication and future scale-up.16 One example of an iterative scale-up is India’s Adolescent Anaemia Control Programme, which launched as a pilot programme in 2000 and delivered weekly iron and folic acid supplementation (WIFS) through 2000 public schools in five states. The pilot study showed that adherence to taking supplements was high (>88% in all states), programme cost was less than $1 per girl per year, and the prevalence of anaemia among girls fell on average by an impressive 24 percentage points during the first year of implementation.17 On this basis, and after another decade of expansion, replication of success in different states, and further evidence evaluation, in 2018 the programme became universal and was renamed Anaemia Mukt Bharat (Anaemia Free India). Under this flagship, programmes were expanded to reach more target groups, and the platform now includes improved fiscal outlay, the establishment of state and national centres of excellence in medical colleges for continued technical and programme support, strengthened reporting and monitoring mechanisms, and implementation of research and special strategies for increasing public awareness such as test, treat, and talk anaemia camps.18

These experiences highlight the need for strong vision and long term commitment in programme design and implementation informed by evidence. In particular, the sheer scale of national programmes in Bangladesh, India, and Pakistan and the decentralised governance and delegation of programme funding and implementation to sub-national administrative levels mean that expansion from pilot studies to nationwide programmes can take time. However, compelling evidence of cost effectiveness and intentional, iterative scale-up support efficient geographic expansion.

To improve programme quality at all stages of scale-up, monitoring and reporting of data should be streamlined into routine management information systems to ensure corrective actions are taken promptly. Developing mechanisms for regular and systematic reviews of programme data can ensure ongoing feedback loops for programme optimisation. In India, third party external supply monitoring assessments and harmonised monitoring methods among implementing partners provided critical feedback for dealing with gaps in its adolescent anaemia services.19 Engaging external institutions, especially local academia, in fact finding rather than fault finding exercises can support validation of programme data and build on capacities to improve programme coverage and quality and strengthen accountability. Securing the resources needed for programme scale-up can be challenging, but partnerships with academic or training institutes and development partners have been critical for supporting monitoring and evaluation of pilot studies and scale-up, which can be difficult for governments to do given high staff vacancies and lengthy hiring procedures in several South Asian countries.

Capacity building for efficient programming at scale

Building programme managers’ capacity to improve fiscal allocative, disbursement, and expenditure efficiency for anaemia programmes is critical for enhancing programme quality and coverage. Decision makers need to ensure sustained funding for scale-up building on the resources already invested for the programme expansion process while ensuring longer term sustainability. Most South Asian countries (except Afghanistan) finance adolescent anaemia control programmes through domestic health and social sector budgets. India and Bangladesh have done intensive work to understand the budgetary mechanisms entailed in their anaemia programmes and have worked systematically to track budgetary allocations and expenditures.20 They have used tools such as simplified costing spreadsheets, budget trackers, and partnerships for capacity building. Technical assistance strategies include deploying programme planning specialists and collaborating with organisations like the World Bank for joint advocacy and technical support to enhance programme efficiencies.21 Using this approach, the Anaemia Free India Program budget increased from $75m in the financial year 2019-2020 to $90m in 2021-2022.22 Despite these advancements, challenges remain in these and other aspects of financial management. Delays in fund transfers between local governments and service providers are a common complaint. In both Sri Lanka and India, delays in providing funds to food procurers for school meal programmes seem to be common, and the lack of flexibility of disbursements to food price fluctuations and inflation are a persistent concern, which could threaten the nutritional quality of school meals.623 Investments in the fiscal management capacity of programme managers must occur alongside allocation of sufficient resources for implementation.

Expanding the range of services delivered through established platforms is another critical component of capacity building, and can be used to bundle strategies that may positively reinforce each other. Adding nutrition education alongside supplementation has proved helpful across many WIFS programmes in the region, particularly for generating demand for supplements from adolescents themselves and for encouraging adherence when encountering manageable side effects.1724 Providing school meals together with supplementation can also be beneficial, with initial WIFS trials in Haryana state in India showing that older adolescent girls, who were not included in the government school meal programme, were likely to come to school and take supplements on an empty stomach, which was associated with a higher chance of having adverse side effects.25 In some contexts, combining interventions may also help improve equity in delivery given the multiple deprivations that adolescent girls face. Evidence from a major trial programme in Nepal suggests that while more socioeconomically advantaged women had positive outcomes after engaging with only one of a bundle of four interventions for changing nutrition behaviour, those from disadvantaged backgrounds required interaction with two or more interventions to achieve the same outcomes.26 While bundling delivery of a package of interventions together through the same platform has distinct benefits, efforts to expand nutrition and health packages must recognise and tackle the additional demands this places on core workers, such as schoolteachers and community health workers.27 Training, appropriate social incentives, and clear communication strategies are credited as agents of social change that contribute to the common good, with community appreciation and social recognition that motivates teachers to consider provision of nutrition and health interventions as part of the mission of education and schools. Prioritising a limited number of evidence based interventions and focusing on achieving scale in their delivery have all been considered important, while bundling interventions.1727

Engaging communities and diverse stakeholders to reach all girls

Effective community engagement is critical for improving programme uptake and ensuring equitable coverage, particularly in diverse and challenging contexts. Engaging key stakeholders, such as adolescent girls, parents, community leaders, educators, district level programme managers, policy makers, and national or local media during programme scale-up, can ensure programmes remain context appropriate and impactful in reducing anaemia, misunderstandings, and difficulty in accessing the supplements. For example, in Bangladesh, engagement with health workers found that the iron and folic acid supplements delivered to pregnant women were uncoated and disintegrated in humid conditions. To tackle this, a more appropriate product was procured when the programme was expanded to adolescents.28 Additionally, theatre groups and adolescent girl power groups were encouraged to spread awareness of nutrition and gender equality.29 Adolescent girls can be articulate about the benefits of the programme; thus involving girls in “girl-to-girl” information and counselling approaches has been effective in reaching out-of-school girls in India17 and Bangladesh.2930 Simple monitoring tools and aids such as individual self-compliance cards facilitate adherence to the programme as it diminishes girls’ “forgetfulness” (most frequently reported cause of low adherence by girls), improves programme implementation and monitoring, and allows for timely corrective action.17 In India, as part of a response to poor compliance with WIFS programmes, an evaluation in Haryana state found that a lack of proactive communication on how to manage side effects to both girls in schools and families via media channels had led to an environment of strongly negative media, peer pressure between girls not to take supplements, and low motivation among teachers to administer it. Recommendations based on success in other states suggested that multi-channel communication with teachers, families, media, and girls would be important for shifting the narrative, generating demand and increasing compliance.25

Further adapting programmes to reach their target remains a considerable challenge, particularly in conflict affected or remote areas, and requires innovative and context responsive models of care. In Afghanistan, the WIFS programme initially relied on schools as the primary delivery platform, but school based delivery became unfeasible in August 2021 after the restrictions on girls’ education imposed by the de facto authorities. To ensure continuity, a community based programme was piloted in five districts, with supplements delivered directly to girls’ homes by female community health workers, tackling both logistical challenges and political constraints. Costing just $3 per girl annually, the initiative has been expanded to all 34 provinces.31 While the programme has shown that doorstep delivery of services is possible and affordable, shifting from schools based delivery has entailed developing strong partnerships with community based local organisations and substantial investments in community volunteers and workers. Many other adolescent health programmes in Afghanistan have not yet successfully overcome these hurdles to transition to reaching girls outside schools.

With schools as the major platform for most anaemia prevention packages in the region, all countries must also consider how to reach out-of-school adolescent girls. In the Indian state of Bihar, state-wide school deworming days were followed by “mop-up” days a few days later, when girls’ younger siblings, pre-school children, and out-of-school adolescents were encouraged through public broadcast messaging to attend. Through this mechanism a total of 1 million non-enrolled children received treatment in the programme’s first round.32 Other innovative strategies include using in-school adolescent girls as peer-to-peer nutrition trainers in Nepal33 and Bangladesh,32 and WHO specialists have suggested such methods could be extended to encourage in-school girls to share information with out-of-school girls in their communities.25 In areas with high school non-attendance or high enrolment in non-government schools, achieving the same coverage and cost effectiveness in non-school based programmes is challenging, but using community health workers has been particularly successful where these platforms are well embedded within communities and anaemia interventions can be integrated into other routine health packages.34

These lessons learnt over the years underscore the importance of evidence generation, capacity building, and community engagement in scaling up anaemia programmes across South Asia. While the stage of implementation and coverage of programmes differ across the region, these experiences of working at scale offer valuable insights into tackling systemic barriers to improve anaemia among adolescent girls. By using a mix of complementary strategies such as strengthening data systems to inform policies, building the capacity of programme managers to optimise resources, and engaging girls themselves for peer-to-peer awareness, communities and grassroots coalitions, countries can enhance the reach and impact of their efforts. These approaches, although varied in the extent to which progress has been measured and documented, provide a foundation for learning and adaptation, highlighting the potential to overcome challenges and accelerate progress in tackling anaemia among adolescent girls.