Iron Folate Supplementation

Although iron deficiency is the most widespread of nutritional problems, supplementation with iron has not proven to be a very successful intervention. Global policy recommendations to routinely provide iron/folate supplements for women during pregnancy and lactation have changed little in almost three decades, and all anemic pregnant women should receive such supplements in almost all contexts. Approximately half of the developing countries in the world are reported to have national iron supplementation policies. The World Summit for Children's goal to reduce anemia in women by one-third was given little or no priority by the principal actors involved such that no progress was made during the past decade. Anemia still affected 44% of nonpregnant women and 56% of pregnant women in developing countries at the end of the twenty first century.

Although there is ample evidence that iron deficiency and the anemia associated with it are a great burden on society, especially the poor, the advocacy base for pushing for program implementation is still weak. The link of iron deficiency to maternal and child survival has not been concretely proven. The effect of iron deficiency on cognitive deficits in children and on adults later in the life course has been established. The absolute losses in Southeast Asia are estimated to be approximately $5 billion annually, and for India the median value of productivity losses due to iron deficiency alone is approximately $4 per capita or 0.9% of gross domestic product. The efficacy of iron/folate supplements for controlling anemia is well documented, and there is a considerable amount of descriptive evidence linking maternal anemia to both low birth weight and maternal mortality.

Despite high cost-effectiveness, little or no priority has been given to iron deficiency anemia reduction programs. At $0.002 per tablet, the iron supplement is relatively cheap, and the cost per disability adjusted life year of $13 makes the supplementation of pregnant women with iron a very cost-effective intervention. At the national level, despite the existence of national policies, rarely is there a budget for the provision of supplements and/or supervision of iron deficiency anemia programs. Although UNICEF is a major supplier of iron/folate supplements to the developing world, the level of supply is far lower than that believed to be needed. In the period 19931996, 2.7 billion tablets were shipped to 122 countries at a cost of $7.5 million as part of UNICEF assistance to programs aimed at eliminating maternal anemia. This was less than 5% of that needed to cover all pregnancies in developing countries. There have been few, if any, attempts to gauge the coverage of iron/folate supplements at any level, be it district, national, or international. Neither has there been any effort put into creating political accountability to ensure high coverage.

Many meetings and publications during the past few decades that have examined the causes and solutions of iron deficiency anemia conclude that lack of effectiveness of iron supplementation programs for anemia control is largely related to problems with supply of the supplement. Although the side effects of iron pills are often cited as the reason why iron supplementation programs do not work, this rarely seems to be the case. One of the major causes of nonadherence seems to be lack of understanding of the benefits the supplements can bring among health staff that deliver the tablets. Most of the program reviews have concluded that where supportive community-level delivery mechanisms are put in place that encourage adherence, and the supply of supplements is ensured, high levels of coverage can be achieved and sustained. It is often the case, however, that in health systems in developing countries, nutrition is everybody's business and nobody's responsibility, and iron supplements have ended up low on the list of things to do.

Despite an international consensus that supplementation has a key role to play in the control of iron deficiency anemia, there are still those that question such programs. In 1998, a technical consensus meeting on what was needed to solve the problem of iron deficiency made the recommendation that although the interventions already existed for reducing both iron deficiency and iron deficiency anemia, more work was needed to develop large-

scale programs with packages of interventions delivered through multiple sectors. Despite the consensus, there are still those who question the advisability of iron supplementation programs, suggesting that hemoglobin cutoffs may be set too high and/or that receiving excessive amounts of iron is dangerous for those who are iron replete. Another complicating factor is undoubtedly related to the fact that adequate coverage of iron supplements alone will not ensure anemia control in many settings. A global review of anemia causality revealed that perhaps only half of anemia is solely due to iron deficiency, with other micronutrient deficiencies such as vitamin A contributing as well. Infections such as malaria and helminth are also important causes. Programs to eliminate anemia thus require packages of interventions, of which iron supplements are but a part.

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