RECOMMENDATIONS
TO IMPROVE THE IMPLEMENTATION
OF ANEMIA PREVENTION AND
CONTROL INTERVENTIONS
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RECOMMENDATIONS TO IMPROVE APC INTERVENTIONS | ii
Acknowledgements
A team formed by members from Swiss Tropical and Public Health Institute and the An-Najah
National University implemented an assessment of bottlenecks in anemia prevention and
control in the Palestinian Territory.
The Swiss TPH team included Dr. J. Luis Segura (lead) and Dr. Salvador Camacho (technical
expert).
The An-Najah National University team included Dr. Abdulsalam Alkaiyat (lead), as well as
Marah Sameh Shakhshir, Dr. Marwan Jalambo, Dr. Nagham Osama Joudeh, Dr. Nesma Ghanim,
and Dr. Ola Jamal Anabtawi (technical experts).
The authors of this report extend their sincere gratitude and appreciation to all those who
contributed to the production of this report. In particular, we are grateful for the guidance and
support received from Dr. Yaser Bozeyya, MoH Director General of Public Health, Eng. Mousa
R. Al-Halaika, MoH Director of Nutrition Department, Ms. Lina Bahar, MoH Head of Nutrition
Surveillance and Studies Division-Nutrition Department and Ms. Maria Yousef Al Aqra, MoH
Head of International Cooperation.
Financial support for this work was provided by the Government of Japan through the Japan
Trust Fund for Scaling Up Nutrition.
RECOMMENDATIONS TO IMPROVE APC INTERVENTIONS | iii
ABBREVIATIONS
APC Anemia prevention and control
FFMC Food Fortification Monitoring Committee
GS Gaza Strip
IFA Iron and folic acid
MCNNP Maternal and Child National Nutritional Protocol
MoH Ministry of Health
MoH-CHD Ministry of Health Community Health Department
MoH-ND Nutrition Department of the Ministry of Health
MoNE Ministry of National Economy
SMS Short Message Service
UNRWA United Nations Relief and Works Agency
WB West Bank
WHO World Health Organization
RECOMMENDATIONS TO IMPROVE APC INTERVENTIONS | iv
TABLE OF CONTENTS
Abbreviations........................................................................................................................... iv
Table of contents ...................................................................................................................... v
1. Introduction ....................................................................................................................... 1
1.1 Definition of anemia and its consequences and causes .......................................... 1
1.2 Anemia prevalence in the West Bank and Gaza Strip ............................................. 1
1.3 Interventions to address anemia ............................................................................. 2
1.4 Assessment and its findings ..................................................................................... 3
2. Recommendations for the wheat flour fortification program .......................................... 5
3. Recommendations for the iron supplementation program.............................................. 8
RECOMMENDATIONS TO IMPROVE APC INTERVENTIONS | v
1. INTRODUCTION
1.1 Definition of anemia and its consequences and causes
Anemia is a condition in which the hemoglobin concentration in the blood is lower
than normal. It is associated with poor cognitive and motor development outcomes
in children. It causes fatigue and low productivity in all people affected. When anemia
occurs during pregnancy, it is associated with poor birth outcomes (including low
birth weight and prematurity) as well as maternal and perinatal mortality1.
Iron deficiency is the overall dominant cause of anemia. However, there is an
interplay between biological and socio-economic factors, and not all anemia cases
can be corrected by providing additional iron alone. Anemia is also caused by
deficiencies in other nutrients (e.g., folate, vitamin A), increased physiologic
requirements for iron during growth (young children, pregnancy), or blood loss
(menstruation, helminth infections). The underlying causes of anemia include
poverty, lack of access to services providing anemia prevention and control (APC)
interventions, among others.
1.2 Anemia prevalence in the West Bank and Gaza Strip
The historical situation of instability in the West Bank (WB) and the Gaza Strip (GS)
has multiple adverse impacts on the population2. In this context, several assessments
have documented a deterioration in the nutritional status of the population of the
WB and GS including static or increasing prevalence of anemia, caused by iron
deficiency, and other nutrition deficiencies (e.g., iodine and vitamin A)3,4,5.
According to the most recent information available3,6,7,8,9, anemia is a public health
problem among pregnant and postnatal women, children aged 6–59 months, and
adolescents (Figure 1). In these four groups, the prevalence of anemia is higher in the
GS compared to the WB. The fact that children aged 6–59 months are affected by
anemia makes it probable that children aged 0–5 months are also affected. However,
this may not be reflected in the data because this age group is not normally sampled
1 N. J. Kassebaum and G. B. D. Anemia Collaborators, "The Global Burden of Anemia," Hematol Oncol Clin North Am 30, no. 2
(Apr 2016), https://doi.org/10.1016/j.hoc.2015.11.002, https://www.ncbi.nlm.nih.gov/pubmed/27040955.
2 World Health Organization - Regional Office for the Eastern Mediterranean, Country cooperation strategy for WHO and
occupied Palestinian territory 2017 – 2020: Palestine (Cairo, 2017).
3
Nutrition Department - Directorate General of Primary Health Care and Public Health - Ministry of Health - State of Palestine,
Palestinian Micronutrient Survey 2013 (2014).
4
Nutrition Department - Ministry of Health - Palestinian National Authority, The State of Nutrition: West Bank and Gaza Strip -
A comprehensive review of nutrition situation of West Bank and Gaza Strip (2005).
5
Nutrition Department - Directorate General of Primary Health Care and Public Health - Ministry of Health - State of Palestine,
"National Nutrition Surveillance System - Report 2017," (2017).
6 Palestinian Health Information Center (PHIC) - Ministry of Health, Health Annual Report - Palestine 2018 (2019).
7
Palestinian Health Information Center (PHIC)- Ministry of Health, "Health Annual Report - Palestine 2019," (2019).
8 Palestinian Health Information Center (PHIC) - Ministry of Health, "Health Annual Report - Palestine 2020," (2020).
9 Nutrition Department - Directorate General of Primary Health Care and Public Health - Ministry of Health - State of Palestine,
"National Nutrition Surveillance System Report 2018," (2018).
RECOMMENDATIONS TO IMPROVE APC INTERVENTIONS |1
due to the procedure involving taking a blood sample from babies. Babies aged 0 –5
months are particularly vulnerable if they are born with inadequate iron stores, e.g.,
if their mothers are anemic, babies are not exclusively breastfed or suffer from
episodes of diarrhea.
In the GS, anemia is a severe public health problem10,11, among pregnant women and
children aged 6–23 months. In the remaining groups of both the WB and GS, anemia
is a mild-moderate public health problem. Among children aged 6–23 months of the
WB, anemia is virtually a severe problem.
Figure 1 Prevalence of anemia in high-risk groups of the West Bank (WB) and Gaza Strip
(GS)3,6,7,8,9 according to the WHO’s classification of anemia as a public health problem10.
1.3 Interventions to address anemia
The two main APC activities in the Palestinian Territory are the universal fortification
of wheat flour with micronutrients and iron supplementation to pregnant and
postnatal women, and children aged 6–23 months. Despite these efforts, the
prevalence of anemia has remained static during the last decade9 (see Figure 2),
indicating possible poor coverage and quality of these interventions considering this
type of intervention has proven effective in other parts of the world.
10
World Health Organization, Nutritional anaemias: tools for effective prevention and control (Geneva, 2017).
11
The WHO categories of anemia prevalence as public health problems are: Severe, for prevalences 40 percent or higher;
Moderate, for prevalences 20–39.9 percent; and Mild, for prevalences 5–19.9 percent.
RECOMMENDATIONS TO IMPROVE APC INTERVENTIONS | 2
Figure 2 Prevalence of anemia at the national level among children at 12 months
and pregnant women from 2012 to 2018. Source: National Nutrition Surveillance System
1.4 Assessment and its findings
An assessment was implemented to identify bottlenecks in the APC interventions in
the WB and GS. The methodology of the assessment included reviewing all available
data regarding the population’s anemia status; policy and technical documentation;
interviewing key program implementers at central, regional, and local levels, with
users of maternal and childcare services; and visiting warehouses of iron supplements
and points of sale of fortified foods. The assessment identified demand-and-supply-
side bottlenecks for the two major interventions: flour fortification and iron
supplementation.
This assessment identified that residing in the GS is associated with a higher
prevalence of anemia across all the four groups of pregnant and lactating women,
children aged 6–59 months and adolescents. Iron deficiency was also associated with
anemia across all groups, whereas other factors associated were specific to certain
population groups. The most relevant factors were vitamin A or folate deficiency,
diarrhea, fever, not taking iron and folic acid (IFA) supplements at all during and after
pregnancy, not taking IFA supplements regularly during and after pregnancy,
infrequent consumption of iron-rich foods and socio-economic factors. Conditions
related to an increased need for iron due to physiological state (2nd and 3rd trimester
of pregnancy), age (children aged 6–11 months) and gender (females among
adolescents) were also found to be associated with anemia.
The flour fortification program aims to increase the intake of iron and other
micronutrients for the whole population, by adding 10 micronutrients to wheat flour,
including iron, vitamin A, and folic acid. Currently, the Ministry of Health (MoH) and
partners implement limited activities to promote the consumption of fortified flour.
The monitoring of flour fortification indicated that only 3–5 percent of the wheat
flour samples collected from 2016 to 2020 contained iron levels that complied with
RECOMMENDATIONS TO IMPROVE APC INTERVENTIONS | 3
national standards12. Due to the low iron fortification of wheat flour, this assessment
concludes that the fortification program has a poor implementation, causing it to
have a limited contribution to the general population’s iron intake.
This assessment verified the availability of wheat flour and wheat flour-based
products in the WB and GS. However, these products are sold without any
certification or reliable identification of their fortification status. Consequently,
bakeries and consumers cannot make informed decisions regarding which products
to buy because they cannot identify products that are adequately fortified.
The Maternal and Child National Nutritional Protocol (MCNNP) guides the iron
supplementation program. The MCNNP includes pregnant and postnatal women, and
children aged 6–23 months as the target populations of the supplementation
program, which is appropriate and consistent with the recommendations of the
World Health Organization (WHO). The monitoring of iron supplementation activities
registers the volume of supplements dispensed but not the delivery of counselling or
individual patients’ compliance with the supplementation schedule. Activities to
promote iron supplementation have been limited and sporadic and do not follow an
overall communication plan. The iron supplementation program partially provides for
the target population’s requirements by distributing supplies based on previous
consumption instead of on actual needs. The volume of IFA tablets distributed to
pregnant and postnatal women who are registered as users of the MoH clinics was
estimated to be equivalent to 61 percent of the amount necessary to comply with
the supplementation schedule established in the MCNNP.
Iron supplementation supplies were found to be available in all the clinics and
pharmacies visited, both in the WB and GS. However, users of antenatal care and
childcare services perceive the educational information about iron
supplementation—intended to aid in compliance—to be inadequate. Conversely,
health care providers consider the compliance of patients to be satisfactory. The
assessment concluded that the target population consumes substantially fewer iron
supplements than indicated by the MCNNP.
This document provides recommendations to address demand-and-supply-side
bottlenecks for wheat flour fortification and iron supplementation. The following
recommendations can be taken independently to improve these two interventions.
12 Source: Dataset of the MoH-Food Fortification Monitoring System 2016–2020.
RECOMMENDATIONS TO IMPROVE APC INTERVENTIONS | 4
2. RECOMMENDATIONS FOR THE WHEAT
FLOUR FORTIFICATION PROGRAM
The wheat flour fortification and iron supplementation interventions have been a
priority in the national strategic agenda for almost 20 years4. In addition to the
policies, strategies and regulations in place, the Nutrition Department of the Ministry
of Health (MoH-ND) has been appointed as the national coordination office. The
addition of micronutrients to all wheat flour, including iron, was made mandatory in
2006. However, the outcomes of this program and its impact have not been as
effective as expected. The assessment hypothesizes that this is due to poor
implementation. Some actions and policies could help enhance implementation to
increase the effectiveness of the strategies and actions in place. A multi-sectoral
partnership in fortification programs is known to be successful in diverse contexts13,14
and in the Eastern Mediterranean region15. The multi-sectoral approach provides an
opportunity to coordinate agendas and identify synergies among various
stakeholders.
First identified problem
During the period 2016–2020, only 3–5 percent of wheat flour samples complied with
national fortification standards, according to data collected by the flour fortification
monitoring system16. This suggests poor implementation and enforcement of the
fortification program17,18.
Recommendation
The MoH, in partnership with the Ministry of National Economy (MoNE), should
commence a field investigation to identify the underlying reasons for non-compliance
with the national fortification standards among flour producers and importers. The
investigation should consult representatives of the private sector (including millers,
pre-mix suppliers, importers, bakeries, and retail shops), government authorities
responsible for food safety (MoH, Public Safety Committee) and those responsible
for law enforcement (Ministry of Justice and Ministry of National Security). Inclusive
stakeholder consultation will foster their support towards defined actions and their
effective implementation.
13 Bechoff A. Lalani B., Bennett B., "Which choice of delivery model(s) works best to deliver fortified foods?," Nutrients 11, no.
1595 (2019), https://doi.org/10.3390/nu11071594.
14 Greg S. Garrett, Caroline Manus, and Andreas Bleuthner, "Chapter 11 - The Importance of Public–Private Collaboration in
Food Fortification Programs," in Food Fortification in a Globalized World, ed. M. G. Venkatesh Mannar and Richard F. Hurrell
(Academic Press, 2018).
15
World Health Organization - Regional Office for the Eastern Mediterranean, Wheat flour fortification in the Eastern
Mediterranean Region (Cairo, 2018).
16 24–47 percent were assessed as negative by the qualitative test and 51–74 percent were assessed as low (< 25 mg/kg) by the
MoH lab test. Source: Dataset of the MoH-Food Fortification Monitoring System 2016–2020.
17
Greg S. Garrett, "Chapter 5 - National Mandated Food Fortification Programs," in Food Fortification in a Globalized World, ed.
M. G. Venkatesh Mannar and Richard F. Hurrell (Academic Press, 2018).
18 I. Darnton-Hill, "Overview: Rationale and elements of a successful food-fortification programme," Food Nutr Bull 19, no. 2
(1998).
RECOMMENDATIONS TO IMPROVE APC INTERVENTIONS |5
With the results from this assessment, the MoH and the MoNE should determine and
agree on short- and medium-term actions towards improving the compliance and
enforcement of flour fortification. The participation of MoNE in this investigation is
relevant due to its regulatory role in food production and importation. The MoH
should continue leading its efforts on quality control of the flour fortification
program, namely sample collection and assessment.
Second identified problem
There are very limited efforts to promote fortified flour consumption. The MoH
considers that promotion is unnecessary given that fortification is mandatory, but
also due the not sufficient presence of fortified flour.
Recommendation
The MoH should establish a communication campaign to raise awareness regarding
the importance of reducing the prevalence of anemia and highlighting the
consequences for improved health and productivity. In addition, the communication
campaign should include information regarding prevention and available resources
in place. Though the campaign should target the general population, it should include
tailored and extensive efforts to target at-risk sub-groups with the highest
prevalence. These groups include pregnant and postnatal women, adolescents, and
children aged 6–59 months and their caregivers. Bakeries, as a place frequently
visited by consumers, should be targeted to disseminate information regarding
wheat flour fortification and iron supplementation, as well as clinics, homes,
supermarkets, traditional markets, and other relevant places. The communication
campaign should also consider the use of digital channels (e.g., via social media) if
this is relevant to the targeted populations.
The communication campaign should be accompanied by nutrition education and
behavior change actions at health facilities, for example, promoting the consumption
of foods containing iron and the avoidance of tobacco consumption in addition to
iron supplementation. The contents of nutrition education and behavior change
actions should be tailored to the specific needs of patients attending health facility
services. Increasing awareness will increase the demand for fortified wheat and APC
services, which will ultimately have a positive result in the effectiveness of APC
services.
Third identified problem
The following weaknesses were identified in the food fortification monitoring system
operating in the WB19:
• The sampling of monitored actions is not systematic (each team decides
independently what sources are included and why).
• There is no tracking of previous non-compliers (no unique identification).
• There is no categorization of sources (e.g., mills, importers, bakeries).
19
The assessment could not evaluate details in the GS.
RECOMMENDATIONS TO IMPROVE APC INTERVENTIONS | 6
Recommendation
The Food Fortification Monitoring Committee (FFMC) should update its guidelines by
including a random-based procedure for sample collections to ensure
representativeness and transparency. The revised FFMC guidelines should include
criteria to define the minimum number of samples by source (producers, importers,
bakeries) in each governorate. Clear classification and coding of each source should
be included in the system to allow for the tracking of each collected sample with
additional information, such as stages of testing, results, and actions taken according
to a test result.
RECOMMENDATIONS TO IMPROVE APC INTERVENTIONS | 7
3. RECOMMENDATIONS FOR THE IRON
SUPPLEMENTATION PROGRAM
The MoH and the United Nations Relief and Works Agency (UNRWA) distribute iron
supplements to pregnant and postnatal women, and children aged 6 –23 months in
the WB and GS20. The table below summarizes the schedules of supplementation
recommended by WHO and compares them to the schedules of the MCNNP for each
population group.
National Nutrition
Population WHO’s recommendations
Protocol
Pregnant 30–60 mg of elemental iron plus 400 μg 60 mg of elemental iron
women (0.4 mg) of folic acid daily throughout plus 400 μg of folic acid
pregnancy21. daily for at least six
Postnatal In settings where gestational anemia is months of pregnancy, plus
women ≥20 percent24 oral iron alone or with folic continuing to three
acid, may be provided to postpartum months postpartum (or a
women for 6–12 weeks following total duration of nine
delivery. months)22, 23.
Scheme used during pregnancy (daily or
weekly).
Children In populations where the prevalence of 12.5 mg elemental iron,
aged 6–23 anemia is ≥40 percent25. drops or syrup daily, one
months 10–12.5 mg elemental iron, drops or supplement per day.
syrup daily, one supplement per day,
three consecutive months per year.
First identified problem
There is a gap between the required quantity of supplements to cover the normative
needs of the registered pregnant women and how much is actually distributed. This
indicates that the target population is consuming fewer iron supplements than
recommended by the MCNNP. The gap comes from the calculation of supplements
quantity; it is based on past consumption and not on the actual needs of the
population receiving maternal childcare from MoH clinics, including pregnant and
postnatal women, and children aged 6–23 months.
20
UNRWA also distributes iron supplements to children 24–59 months.
21 World Health Organization, WHO recommendations on antenatal care for a positive pregnancy experience (Geneva, 2016).
22 Nutrition Department - Directorate General of Primary Health Care and Public Health - Ministry of Health - State of Palestine,
"Maternal and Child National Nutrition Protocol," (2017).
23
Nutrition Department - Directorate General of Primary Health Care and Public Health - Ministry of Health - State of Palestine,
"Maternal and Child National Nutrition Protocol," (2021).
24 World Health Organization, Guideline Iron Supplementation in postpartum women (Geneva, 2016).
25 World Health Organization, Guideline: Daily iron supplementation in infants and children (Geneva, 2016).
RECOMMENDATIONS TO IMPROVE APC INTERVENTIONS | 8
Recommendation
To ensure the adequate availability of iron supplements in clinics to supply the
normative needs of the target population, iron supplement needs should be
calculated for each specific target group by using the number of registered users and
the schedule established in the MCNNP.
Based on the results of an estimation of needs guided by the MCNNP, the MoH
budget for essential medicines should include sufficient financial resources to cover
the target populations’ needs for IFA and iron supplements. The MoH Central
Warehouse Department should be ready to order additional amounts of iron
supplements in between annual orders in preparation for an eventual increase in
demand.
In order to increase the service delivery of iron supplementation and contact with the
target population, MoH clinics can expand current experiences that use a "child's
unified file" system (where children receive multiple preventive health services
during the same visit to clinics) or deliver iron supplements during home visits.
Additionally, the MoH should consider providing non-financial incentives for
collecting the supplements, e.g., foods or plates26 to women.
The MoH and organizations providing healthcare services should track attendance as
a standard procedure for monitoring the delivery of antenatal, postnatal and
childcare services. With adequate data on the beneficiaries, varied communication
and community engagement (e.g., SMS reminders, phone calls, community-based
networks) should be sought to encourage compliance with the supplementation
schedule.
The MoH Community Health Department (MoH-CHD) should include an indicator to
monitor the amount of iron supplements distributed to each registered user, as a
proxy of compliance with the iron supplementation protocol. This indicator will
provide the percentage of users who received the amount established in the
protocol.
Second identified problem
Iron supplement delivery for children aged 6–23 months is linked to the
immunization schedule. However, the last immunization dose is scheduled at 18
months; hence, children aged 19–23 months could miss an opportunity to receive the
supplements.
Recommendation
The MoH-ND, jointly with the MoH-CHD, should establish a standard calendar of
contacts for iron supplement delivery to children aged 6–23 months. These could be
26
See for example: Banerjee A V, Duflo E, Glennerster R, Kothari D. Improving immunisation coverage in rural India: clustered
randomised controlled evaluation of immunisation campaigns with and without incentives BMJ 2010; 340 :c2220
doi:10.1136/bmj.c2220.
RECOMMENDATIONS TO IMPROVE APC INTERVENTIONS | 9
linked with the six visits for growth monitoring as per the MOH guidelines for child
health services.
Third identified problem
Most of the providers interviewed do not consider their protocols comprehensive for
APC. In addition, patients consider nutrition counseling to be inadequate; they
receive insufficient information regarding the potential undesired side effects of iron
supplementation and how to manage them.
Recommendation
The MoH should strengthen health staff capacity to provide APC services through pre-
service and in-service training and supportive supervision. The training should include
how to provide counseling regarding iron supplementation (antenatal, postnatal, and
childcare). The supportive supervision should include monitoring compliance with
iron supplementation per individual and the associated quality of services
(counseling).
A campaign to educate women and mothers on the importance of iron
supplementation should take place in the health services, especially at the
pharmacies where patients collect their supplements. For example, pamphlets on the
importance of taking IFA supplements daily, early on and throughout pregnancy,
could be distributed. In addition, pamphlets should include information on possible
side effects and how to manage them, and a supplementation schedule. This
campaign is not, however, a replacement for one-on-one counseling by doctors,
nurses, and relevant health staff, and it would benefit from reminder systems already
in place (e.g., SMS) that prompt women to attend the clinic and take their
supplements.
Moreover, a communication campaign through schools and/or mass media (including
digital channels and social media) could target female adolescents to provide
information regarding anemia and its consequences, effective preventive
interventions available, and promote pre-conception care.
Fourth identified problem
The following weaknesses were identified in the supplementation monitoring
system:
• MoH clinics do not report stocks.
• Monitoring does not collect data about counseling or follow up on
compliance.
• Monitoring does not report the percentage of individuals who have received
the amount established in the MCNNP.
Recommendation
MoH clinics should submit monthly reports on the available stocks of iron
supplements to the MoH Central Warehouse Department. The dataset should be
RECOMMENDATIONS TO IMPROVE APC INTERVENTIONS | 10
available to MoH-ND, MoH-CHD and MoH staff at the governorate level for them to
identify risks of stockouts and act accordingly.
In addition, the PHC clinics should collect and include the following indicators related
to the iron supplementation program in their routine monthly report: the numbers
of the individuals who received iron supplementation counseling and those who
received the recommended number of IFA supplement tablets or iron droplet bottles.
The MoH-CHD should summarize and share these indicators with the MoH-Health
Information Center for its dissemination (e.g., in the section -maternal and child
health- of the Health Annual Report).
The MoH staff at the governorate level, to compile and analyze the information
available each quarter. The analysis should include information from the supportive
supervision, the clinics’ monthly reports, and the logistic information system. This
analysis should guide further efforts of training and supervision.
RECOMMENDATIONS TO IMPROVE APC INTERVENTIONS | 11
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RECOMMENDATIONS TO IMPROVE APC INTERVENTIONS | 13