Training frontline workers to recognize and reduce anemia in Madhya Pradesh

Neera Soni picks her way down a muddy road and out of the village, back to her motorbike. She still has two more stops to make, both miles apart. When she arrives at the next village, a group of adolescent girls are waiting for her at the Anganwadi center, the local health and education hub and an integral part of the National Integrated Child Development Scheme. Neera settles into a chair at the head of the group and flips open a small book to a page with an illustration of a girl sticking out her tongue.

“Who can tell me all the signs of anemia?” she asks the girls. A number of hands shoot up.

Neera Soni, CHAI’s project coordinator, on her way to the Anganwadi Centre to train frontline workers. Photo credit: Sujata Khanna Photography

Anemia refers to a lack of iron in the blood. If not treated appropriately, it can cause serious health problems – especially in women. It significantly increases the risk of death due to hemorrhage during child birth, which is a leading cause of maternal deaths in India.

Over 50 percent of women across the country between the ages of 15 and 49 are anemic, according to the National Family Health Survey (NFHS-4; 2015-2016). The burden is even higher in the state of Madhya Pradesh, at an estimated 53 percent. To combat the illness, the Indian Government launched a comprehensive and multipronged program called ‘Anemia Mukt Bharat’ (Anemia Free India) in 2018. As part of this program, CHAI, with support from the IKEA Foundation, supports the Government of Madhya Pradesh to reduce anemia across the state by raising awareness about the condition and by increasing the availability and distribution of iron folic acid (IFA) tablets to girls and women. These tablets prevent anemia and if taken daily, can protect pregnant women from developing life-threatening complications related to the condition.

Adolescent girls checking each other for signs and symptoms of Anemia. Photo credit: Sujata Khanna Photography

Training frontline workers in Madhya Pradesh
Neera is one of 137 CHAI-trained project coordinators who train local Accredited Social Health Activists (ASHAs) across the state. ASHAs are selected from their own villages and are accountable to them, working as liaisons between the community and the public health system. CHAI has built the capacity of ASHAs in Madhya Pradesh to recognize signs and symptoms of anemia and then deliver appropriate treatment.

Neera’s next stop is the village of Garh in the district of Shivpuri. Here, along with the village ASHA Umarmila Dhakad, she checks in on a new mother named Jamuna and her healthy four-month-old. During Jamuna’s first trimester, the ASHA recognized the tell-tale signs of anemia and had her tested. The result was positive. Jamuna was severely anemic, which posed a serious risk to her and her expected child. She was referred to a larger Community Health Center so that she could receive an iron sucrose injection, the recommended treatment for her condition. Jamuna’s family did not initially recognize anemia as a health risk and preferred to try homemade remedies, but, with support from Neera, the ASHA was able to convince the family so that Jamuna could receive the treatment she needed for a healthy delivery.

Jamuna, left, and Umarmila, an ASHA worker, with Jamuna’s healthy son. Photo credit: Sujata Khanna Photography

Launching a national campaign

Raising awareness about this condition, the potential complications it poses, and the importance of getting the right treatment is critical to saving the lives of women like Jamuna and her son.

The ‘Anemia Mukt Bharat’ campaign aims to do just that. The campaign’s goal is to reduce anemia prevalence in the country by one-third by 2022. The campaign has intensified efforts with the existing National Iron-Plus Initiative, which ensures that 450 million people across the country, including infants, children, teenage boys and girls and women, have regular access to iron folic acid through public health facilities, like village Anganwadi centers, as well as schools.

Scaling up iron folic acid tablets
In Madhya Pradesh, the campaign is further buttressing the efforts that CHAI, in collaboration with the Government and support from the IKEA Foundation, is already making to train frontline workers and ensure distribution of IFA tablets.

Doorstep delivery of IFA to a local health and education facility. Photo credit: Sujata Khanna Photography

An uninterrupted supply of IFA tablets is critical to the success of anemia control efforts. CHAI has been working to scale-up a comprehensive supply chain strategy to ensure that frontline workers, health facilities and schools can consistently access IFA. Led by Madhya Pradesh, the strategy aims to eliminate the supply and demand gap by building a forecasting tool to streamline procurement and distribution. The forecasting tool also helps in monitoring procurement at individual district levels and implementing strong distribution mechanisms that ensures doorstep delivery of IFA at health and school facilities.

Neera’s last stop for the day is a nearby girls’ hostel that houses about 100 middle school children, some of whom would otherwise have to travel up to 35 kilometers every day to attend classes. Neera holds regular health assemblies for the girls, opening with a song to help them remember how to check for signs of anemia. Afterward, the girls line up to receive their weekly dose of folic acid.

Neera vistis a tribal hostel, leading adolescent girls in a song. Photo credit: Sujata Khanna Photography

Breaking the cycle of malnutrition

Anemia, combined with childhood malnutrition, which affects over 42 percent of children across Madhya Pradesh, form a deadly inter-generational cycle: a malnourished child is more likely to become anemic as a teenager and then as a pregnant woman, who is more likely to deliver an underweight infant who grows into a malnourished child.

This is the second of several joint initiatives with the government of Madhya Pradesh that CHAI, with support from the IKEA Foundation, is working on in order to break that cycle in the state.