Administrative and Operational Issues in Iron Sucrose therapy

Procurement of Resources Field Level – Availability of functional Sahli’s Haemoglobinometer /Hemocheck scale in the field Demand of IFA is not as per need Facility Level – Facility store incharge is not demanding IFA as per the need of facility and field. Facility store incharge is not distributing IFA judiciously to DDC and ANM of the sector. Demand of IV iron sucrose and 100ml NS are inadequate or not as per requirement Lack of IEC material related to IV Iron Sucrose District Level – DDW demand as per demand from field, which is already inadequate

Training Gaps Field Level – Field staff is not competent to correctly estimate haemoglobin level by using Sahlis Hemoglobinometer Gap in real demand assessment of IFA and Albendazole in the area according to the beneficiaries load ANM not Distributing IFA and Albendazole as per norms Lack of counselling by the provider regarding IFA, albendazole and Iron Sucrose

Training Gaps Facility Level – Gap in real demand assessment of IFA, Albendazole, iron Sucrose and 100 ml NS in the area according to the beneficiaries load IFA provided for only 5 or 10 days after ANC Check-up Iron Sucrose not administered as per guidelines (Hb = 7-10 gm%) Emergency protocol not being followed during administration of Iron Sucrose (Availability of Emergency tray)

Training Gaps Lack of counselling by the provider regarding intake of IFA and follow-up of Iron Sucrose Lab technician do not regularly calibrate sahlis Hemoglobinometer System Level – No specific training package on Anemia Management in pregnancy has been developed for Doctors and nursing staff

Recording and Reporting Facility Level – Recording mechanism of Iron Sucrose available (KMK Register) Lack of reporting mechanism of Iron Sucrose (Except only for KMK portal) System Level – No report on Iron Sucrose except PMSMA is collected from the facility Reporting only on PMSMA and SMD on KMK Portal, we are not getting data of 1st 2nd 3rd and forth dose from portal

Other challenges Ideal method for estimation of Hb is Digital Haemoglobinometer (Hemoque), which is not available in the field and at facility level. After referral from field women do not turn up at the facility for Iron Sucrose. Lack of Follow up mechanism for 2nd, 3rd and 4th dose of Iron Sucrose Distribution of albendazole to beneficiary not as per the guidelines (DOTS method) Community not willing to get blood transfuse, primary reason donors are not available/ready

RCHOs/DLOs Responsibilities To ensure the availability of KMK (HRP) register at every CHC/PHC in every block of districts To provide suggestions and feedback about program in every monthly meeting To check KMK (HRP) register for complete line listing maintained by medical officer in charge during monthly inspection To make special efforts for PHC/CHC showing unsatisfactory progress To ensure entries in PCTS from every PHC/CHCs HRP register on every Monday To ensure availability and adequacy of resources like Tab. FA, IFA, Albendazole, Iron Sucrose and POC kits used by ANM

Important responsibilities of Health worker MOs responsibilities in KMK Program Important responsibilities of Health worker Every pregnancy should be registered before 12 weeks & proper identification of HRP In an area of 2500 population 5-6 PW may be HRP Call every HRP weekly and pay a visit every fortnight During the 8th & 9th month pay weekly visits to the PW with HRP During the 9th month of pregnancy identify the 104 Janani express, 108 Ambulance and the phone number of ambulance driver should be identified. After the start of labour pain before referring the PW for delivery to the identified facility, availability of the concerned doctor should be established beforehand

MOs Responsibilities As a clinician: Ensure/perform clinical assessment of all pregnant women coming to ANC OPD and identify anemia as early as possible. Ensure all pregnant women are tested for Hb levels at all ANC visited. Ensure prescription and distribution of prophylactics iron folic acid (IFA) tablets, therapeutic iron (IFA + Iron Sucrose) as per protocols Ensure need based referral of anemic pregnant women to higher centers for specialist care and refer back to health sub-centres (HSC) for continuum of care

Responsibilities As a manager: Oversee and ensure smooth running of ANC services daily at the facility and during PMSMA day Ensure availability of sufficient resources/logistics Ensure respectful care of all pregnant women visiting the facility and outreach sessions Ensure ANC register/RCH register/KMK Register/PCTS/MCTS/iron sucrose reporting form/iron sucrose summary sheet are maintained

Responsibilities As a supervisor: Conduct supportive supervision visits to outreach facilities during MCHN/VHNDs and other ANC service platforms like Prasuti Niyojan Diwas (PND) at HSC Conduct and chair monthly meetings with ANMs and ASHAs to review the status of ANC services, Hb testing, identification, management and timely referral of HRP cases in the catchment area of the facility and prepare review action plan for improvement Acknowledge and recognize the good performing staff during monthly meetings.

ANMs Responsibilities Ensure proper counselling is given to all pregnant women regarding ANC services Proper follow up of every pregnant women who is taking iron sucrose in field so that they can come for further dosage and complete the treatment Update KMK register/RCH register/PCTS/iron sucrose summary sheet for recording information of all pregnant women visiting the facility

Responsibilities of Community Health Officers Support the team of ANMs and ASHAs on their MCHN day, including on the job mentoring, support and supervision. Support and supervise the collection of ANC and HRP data by ANMs and ASHAs, collate and analyse data for planning and report the data to the sector level in an accurate and timely fashion. He/she also responsible for follow up of HRP Cases. Coordinate with community platforms such as the MCHN/PMSMA/SMD/PND and work closely with PRI to address social determinants of Anemia and promote behaviour change for improved health outcomes.

Summary: Administrative & operational issues Condition Need Dosage Issues Roles & Resp. Conception & First trimester Folic acid before two months of conception & in first trimester Tab FA 0.5 gm OD 1. Gap in real demand assessment 2. Distribution of tablets is not judicious to facilities 3. Lack of IEC material 4. Lack of ANM knowledge 5. Lack of counselling to the beneficiaries for adherence purpose 6. Lack of reporting mechanism for iron sucrose 7. Poor recording 1.Proper follow up from state for logistics requirement 2. Regular monitoring from district and state level 3. Ensure ANMs are updated regularly as per new guidelines 4.IEC material availability Second & third trimester IFA, Calcium, Albendazole, Iron sucrose IFA: Therapeutic- IFA (100 mg Iron & 0.5 gm FA) OD Prophylactic- IFA (100 mg Iron & 0.5 gm FA) BD Calcium- 500 mg Ca+ 250 IU Vit D3 BD Albendazole- 400 mg once in second trimester(5-6 Month) Delivery & PNC IFA, Calcium, newborn immunization according to the schedule IFA, Calcium-Same as described above Newborn Immunization as per schedule

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