Identifying bottlenecks in the iron and folic acid supply chain in Bihar, India: a mixed-methods study

Amanda S Wendt,Amy Webb-Girard,Usha Ramakrishnan,Pankaj Verma,Melissa F Young,Carol J Hogue,Sridhar Srikantiah,Rob Stephenson,Reynaldo Martorell

doi:10.1186/s12913-018-3017-x

Abstract

BackgroundMaternal anaemia prevalence in Bihar, India remains high despite government mandated iron supplementation targeting pregnant women. Inadequate supply has been identified as a potential barrier to iron and folic acid (IFA) receipt. Our study objective was to examine the government health system’s IFA supply and distribution system and identify bottlenecks contributing to insufficient IFA supply.MethodsPrimary data collection was conducted in November 2011 and July 2012 across 8 districts in Bihar, India. A cross-sectional, observational, mixed methods approach was utilized. Auxiliary Nurse Midwives were surveyed on current IFA supply and practices. In-depth interviews (n = 59) were conducted with health workers at state, district, block, health sub-centre, and village levels.ResultsOverall, 44% of Auxiliary Nurse Midwives were out of IFA stock. Stock levels and supply chain practices varied greatly across districts. Qualitative data revealed specific bottlenecks impacting IFA forecasting, procurement, storage, disposal, lack of personnel, and few training opportunities for key players in the supply chain.ConclusionsInadequate IFA supply is a major constraint to the IFA supplementation program, the extent of which varies widely across districts. Improvements at all levels of infrastructure, practices, and effective monitoring will be critical to strengthen the IFA supply chain in Bihar.

Highlights

Maternal anaemia prevalence in Bihar, India remains high despite government mandated iron supplementation targeting pregnant women
Our study included qualitative in-depth interviews with key players in the iron and folic acid (IFA) supply chain and surveys distributed to Auxiliary Nurse Midwives (ANMs)
From both qualitative and quantitative data collection, we developed a description of the IFA supply chain and ANM receipt and distribution

Summary

Introduction

Maternal anaemia prevalence in Bihar, India remains high despite government mandated iron supplementation targeting pregnant women. In Bihar, India, even greater proportions of ever-married (60%) and pregnant women (58%) are anaemic, higher than national prevalence estimates (53% and 50%, respectively) [3, 4]. Current recommendations include a daily dose of 100 mg elemental iron for 100 or more days from 14 to 16 weeks of pregnancy until the 3rd month post-partum [9]. Despite these guidelines, high anaemia prevalence persists [5]. In Bihar, only 10% of women reported consuming IFA for at least 100 days during their last pregnancy, despite

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