ASSESSMENT REPORT Bottlenecks in Anemia Prevention and Control in the West Bank and Gaza Strip © 2022 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy, completeness, or currency of the data included in this work and does not assume responsibility for any errors, omissions, or discrepancies in the information, or liability with respect to the use of or failure to use the information, methods, processes, or conclusions set forth. 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Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | ii Acknowledgements A team formed by members of the Swiss Tropical and Public Health Institute and the An-Najah National University implemented an assessment of the bottlenecks of anemia prevention and control in the Palestinian Territory. This document contains a description of the methodological approach and main findings. The Swiss TPH team included Dr. J. Luis Segura (lead) and Dr. Salvador Camacho (technical expert). The An-Najah National University team led by Dr. Abdulsalam Alkaiyat consisted of 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. We are especially 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. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | iii ABBREVIATIONS ANC Antenatal care APC Anemia prevention and control CWS Cold water-soluble CWS/A Cold water-soluble based on gum acacia EMRO Eastern Mediterranean Regional Office (World Health Organization) FFMC Food Fortification Monitoring Committee GDP Gross domestic product HAR Health Annual Report (Ministry of Health) IFA Iron and folic acid INGO International non-governmental organization GS Gaza Strip KII Key informant interviews MCNNP Maternal and Child National Nutrition Protocol MICS Multiple Indicator Cluster Surveys MoH Ministry of Health MoH-EHD Ministry of Health-Environmental Health Department MoH-CHD Ministry of Health-Community Health Department MoH-CPHL Ministry of Health-Central Public Health Laboratory MoH-MCH Ministry of Health-Maternal Child Health MoH-ND Ministry of Health-Nutrition Department MoNE Ministry of National Economy MoNE-CPD Ministry of National Economy-Consumer Protection Department MT Metric ton (1,000 kilograms) NGO Non-governmental organization NNPSAP National Nutrition Policy, Strategies & Action Plan NNSS National Nutritional Surveillance System OR Odds ratio PCBS Palestinian Central Bureau of Statistics PHC Primary health care PHIC Palestinian Health Information Center (Ministry of Health) PMRS Palestinian Medical Relief Society PMS Palestine Micronutrient Survey PRCS Palestine Red Crescent Society PSI Palestinian Standards Institution UN United Nations UNFPA United Nations Fund for Population Activities UNICEF United Nations Children's Fund UNRWA United Nations Relief and Works Agency US$ United States of America dollar WASH Water, sanitation, and hygiene WB West Bank WB & GS West Bank and Gaza Strip WFP United Nations World Food Program WHO World Health Organization WS Water-soluble Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | iv TABLE OF CONTENTS Abbreviations .................................................................................................................................. iv Table of Contents............................................................................................................................. v Table of Figures.............................................................................................................................. vii List of Tables ................................................................................................................................. viii Executive summary......................................................................................................................... 1 1 Background .............................................................................................................................. 4 2 Methods .................................................................................................................................. 6 2.1 Targeting ........................................................................................................................ 6 2.2 Key interventions ........................................................................................................... 9 2.2.1 Collection of relevant contextual information ..................................................... 9 2.2.2 Interviews with key informants ............................................................................ 9 2.2.3 Fortification: supply of wheat flour in retail shops .............................................. 9 2.2.4 Supplementation: supply of iron supplements .................................................. 10 2.2.5 Barriers to demand ............................................................................................. 10 2.3 Assessment limitations ................................................................................................ 11 3 Findings .................................................................................................................................. 13 3.1 Targeting ...................................................................................................................... 14 3.1.1 The burden of anemia ........................................................................................ 15 3.1.2 Factors associated with anemia ......................................................................... 17 3.1.3 Additional analyses ............................................................................................. 21 3.1.4 Main general conclusions ................................................................................... 22 3.2 Key interventions ......................................................................................................... 23 3.2.1 Fortification program.......................................................................................... 25 3.2.2 Supplementation program ................................................................................. 32 3.2.3 Promotion of an increased dietary intake of micronutrients ............................ 46 3.2.4 Other anemia prevention and control interventions ......................................... 47 4 Main conclusions ................................................................................................................... 48 5 Appendixes ............................................................................................................................ 53 5.1 Documents included in the desk review conducted for the mapping......................... 53 5.2 Questionnaire for mapping of fortification program................................................... 55 5.3 Questionnaire for mapping of supplementation program .......................................... 58 5.4 Informants interviewed ............................................................................................... 61 5.5 Complementary questionnaire for mapping of anemia prevention programs ........... 62 Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | v 5.6 Types of barriers and their corresponding determinants............................................ 78 5.7 Results of the multivariable analyses .......................................................................... 80 5.8 Estimation of normative needs of supplements versus operational estimation and amount distributed. ..................................................................................................... 87 Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | vi TABLE OF FIGURES Figure 1: The prevalence of anemia at the national level ............................................................ 16 Figure 2: Flowchart of the food fortification monitoring system................................................. 28 Figure 3: Wheat flour compliance with national standards for fortification ............................... 29 Figure 4: MoH logo of the fortification program .......................................................................... 31 Figure 5: Distribution of PHC clinics by region and management organization. ......................... 36 Figure 6: Ratio of inhabitants to PHC clinics by governorate and region ..................................... 37 Figure 7: Supply chain of iron supplements in the MoH .............................................................. 39 Figure 8: Percentage of National Protocol-based needs for IFA tablets ...................................... 41 Figure 9: The prevalence of anemia among the most vulnerable groups in ............................... 48 Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | vii LIST OF TABLES Table 1: Availability of data on the anemia status of the subpopulations in the Palestinian Territory .............................................................................................................................. 7 Table 2: The WHO’s classification of anemia as a problem of public health significance 6 .......... 15 Table 3: Classification of high-risk populations in the WB & GS according to the WHO’s categories of anemia significance as a public health problem .......................................................... 16 Table 4: Factors associated with hemoglobin levels and anemia prevalence among pregnant women in bivariate analyses ............................................................................................ 17 Table 5: Factors associated with hemoglobin levels and anemia prevalence among postnatal women in bivariate analyses ............................................................................................ 18 Table 6: Factors associated with hemoglobin levels and anemia prevalence among children of ages 6–59 months in bivariate analyses ........................................................................... 20 Table 7: Factors associated with hemoglobin levels and anemia prevalence among adolescents in bivariate analyses ............................................................................................................. 20 Table 8: Key characteristics of APC interventions in the WB & GS .............................................. 25 Table 9: The PSI and MoH-ND standards for flour fortification ................................................... 26 Table 10: Wheat flour available in the WB and GS ...................................................................... 27 Table 11: Iron supplementation scheme recommended by the WHO and in the guidelines of the MoH and UNRWA ............................................................................................................. 34 Table 12: Summary of findings from the literature review .......................................................... 43 Table 13: Number of interviews and the type of barriers explored for each stakeholder group 44 Table 14: Regressions of Hemoglobin and Anemia for Pregnant Women (n=1,200) .................. 82 Table 15: Regressions of Hemoglobin and Anemia for Postnatal Women (n=1,200) .................. 83 Table 16: Regressions of Hemoglobin and Anemia for Children (n =1,200) ................................ 84 Table 17: Regressions of Hemoglobin and Anemia for Adolescents (n=2,400) ........................... 86 Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | viii EXECUTIVE SUMMARY According to the information available1,2,3,4,5 and the thresholds established by World Health Organization (WHO)6, anemia is a public health problem among the most vulnerable groups in the Palestinian Territory, namely pregnant and postpartum women, children aged between 6– 59 months, and adolescents aged 15–18 years. The burden of anemia has remained static during the last decade, suggesting that the anemia prevention and control (APC) interventions in place have not produced their expected outcomes. This assessment, therefore, identifies and analyzes bottlenecks in the ongoing interventions to provide insights to strengthen APC in the West Bank and Gaza Strip (WB & GS). The three main APC activities identified in the Palestinian Territory were the universal fortification of wheat flour with micronutrients, iron supplementation to pregnant and postnatal women and children aged between 6–23 months, and the promotion of an increased dietary intake of micronutrients. Methods The collection of information was organized in five modules: targeting, mapping of service delivery, supply of iron supplements, supply of wheat flour in retail stores, and barriers to demand. The targeting module was designed to identify the prevalence and severity of anemia among high-risk groups by location and socioeconomic and physiological statuses. The mapping of the service delivery module consisted of mapping and reviewing available anemia-related prevention and control programs. The supply of iron supplements module consisted of a review of the supply chain of iron supplements, including stocks at the facilities and governorates. The supply of wheat flour module investigated the availability of fortified and non-fortified flour in retail shops. The barriers to demand module aimed to identify reported or observed barriers to complying with the recommended APC programs. Targeting Since anemia is a condition caused by a broad range of concurrent factors, this assessment aimed to identify the most relevant ones. The results indicate that residing in the Gaza Strip (GS) is associated with an increased prevalence of anemia across all vulnerable groups. In addition, iron deficiency was associated with anemia across all groups, whereas some other factors were specific only to some subpopulation groups. The most relevant factors across all groups were vitamin A and folic acid deficiencies, diarrhea, fever, not taking iron and folic acid (IFA) during and after pregnancy, infrequent consumption of iron-rich food, and socioeconomic disadvantages. Some factors were found to be associated with anemia in some subpopulation 1 Palestinian Health Information Center (PHIC) - Ministry of Health, Health Annual Report - Palestine 2018 (2019). 2 Palestinian Health Information Center (PHIC)- Ministry of Health, "Health Annual Report - Palestine 2019," (2019). 3 Palestinian Health Information Center (PHIC) - Ministry of Health, "Health Annual Report - Palestine 2020," (2020). 4 Nutrition Department - Directorate General of Primary Health Care and Public Health - Ministry of Health - State of Palestine, Palestinian Micronutrient Survey 2013 (2014). 5 Nutrition Department - Directorate General of Primary Health Care and Public Health - Ministry of Health - State of Palestine, "National Nutrition Surveillance System Report 2018," (2018). 6 World Health Organization, Nutritional anaemias: tools for effective prevention and control (Geneva, 2017). Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 1 groups only, due to an increased physiological need for iron. Specifically children of ages 6–11 months, female adolescents, and pregnant women in their second and third trimesters. These findings support the continued implementation of the universal fortification of wheat flour, aiming to increase the intake of iron and other micronutrients, including vitamin A and folic acid, among the general population. These findings also provide support to target the supplementation program toward pregnant and postnatal women and children of ages 6–23 months. The evidence available indicates the need to strengthen efforts in the GS, particularly for the population with socioeconomic disadvantages and female adolescents. Fortification program The fortification of wheat flour with a variety of micronutrients, including iron, zinc, folic acid, vitamin A, and vitamin B12, has been mandatory by law since 2006 in the Palestinian Territory. Wheat flour producers and importers bear the costs of adding micronutrients. Food fortification monitoring is carried out only in the West Bank (WB). Results indicate that only between three to five percent of wheat flour samples collected between 2016 to 2020 contained adequate iron in accordance with the national standards. In addition, in the WB & GS, wheat flour and wheat flour-based products are sold without any certifications or reliable identification of their fortification status. Consequently, bakeries and consumers can neither identify products that are adequately fortified nor make informed decisions about which products to buy. Currently, promotion of consuming fortified flour and its products by the Ministry of Health (MoH) and its partners is limited. Based on these findings, this assessment concludes that food fortification approaches to date may not have resulted in the expected increase in iron intake. Supplementation program Iron supplementation in the Palestinian Territory is guided by the Maternal and Child National Nutrition Protocol (MCNNP) and currently targets pregnant and postnatal women and children of ages 6–23 months. The inclusion of these groups in the target population of the supplementation program is appropriate and consistent with the WHO’s recommendations. The MCNNP also provides guidance for health care providers on counseling patients to improve their adherence to IFA supplementation regimens and on monitoring the compliance. The MoH procures and distributes iron supplements (IFA tablets as well as iron drops) based on the past consumption reported by primary health care (PHC) clinics. The volume of IFA tablets distributed to pregnant and postnatal women registered as users of the MoH’s clinics was estimated to be equivalent to 61 percent of the necessary amount to comply with the supplementation schedule established in the MCNNP. This assessment concludes that the target population is consuming substantially fewer iron supplements than indicated by the MCNNP. The gap may be explained by a combination of the late initiation of antenatal care (ANC), noncompliance with the schedule of ANC visits, and noncompliance with the iron supplementation regimen. The monitoring process of iron supplementation activities registers the volume of supplements dispensed but not the individual patients’ compliance with the supplementation schedule. The monitoring process does not collect information about the elements of care associated with the success of supplementation initiatives, such as the delivery of counseling. Stocks available at the Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 2 MoH-PHC clinics are not reported to the MoH, so the MoH Nutrition Department (MoH-ND) and directorates cannot monitor the availability of supplements in its network of clinics. Activities to promote iron supplementation have been limited and sporadic and do not follow an overall communication plan. ANC and childcare service beneficiaries find the information they receive about nutrition to be inadequate. The health care service providers also expressed concerns that the technical guidance available to them is not comprehensive enough for anemia prevention. Few of the patients who reported to have suffered undesired side effects of iron supplementation discussed it with the medical staff. However, health care providers consider the beneficiaries’ compliance with iron supplementation satisfactory. These findings reveal multiple and connected shortfalls relating to the guidance and support of the clinical staff and in the monitoring of compliance. The promotion of increased dietary intake of micronutrients The MCNNP provides guidance to all stakeholders and caregivers on the promotion of breastfeeding, dietary counseling during pregnancy and lactation, and complementary feeding of children of ages 6–23 months. The MoH-ND collaborates with the MoH Education and Promotion Department to produce information, education, and communication materials with the technical and financial support of the United Nations Children’s Fund (UNICEF) and WHO. The MoH-ND implements occasional training events for clinical staff and sends the governorates reminders about nutrition-specific messages to distribute to health care providers. To establish the progress achieved by these efforts, the only source available is household- based surveys. They show that between 20147 and 20208, exclusive breastfeeding of children (newborn to five months) increased from 39 to 43 percent, while the proportion of children aged 6–23 months who are breastfeeding and receiving semisolid or solid meals decreased from 45 to 41 percent. This assessment concludes that the promotion of exclusive breastfeeding and appropriate complementary feeding requires further strengthening. Other anemia prevention and control interventions Poor access to clean water as well as sanitation and hygiene are related to anemia. The assessment noted several initiatives, including the rehabilitation and expansion of infrastructure to increase access to water and sanitation, a deworming program in schools, and the surveillance of water quality. However, despite these efforts, the prevalence of diarrhea among children under five years increased from 11.3 to 14.5 percent between 20147 and 20208, suggesting that these efforts are unlikely to have a positive impact on anemia prevention. As iron requirements rise during pregnancy, delaying the first birth and spacing births further are effective in contributing to anemia prevention among women of reproductive age. The MoH and its partners provide family planning services. However, the percentage of married women with unmet family planning needs increased from 11 to 13 percent between 20147 and 20208, indicating that there has been no increase in the contribution of this approach to anemia prevention in the WB & GS. 7 UNICEF Palestinian Central Bureau of Statistics, UNFPA, Palestinian Multiple Indicator Cluster Survey 2014 - Final Report (Ramallah, Palestine, 2015). 8 UNICEF Palestinian Central Bureau of Statistics, Palestinian Multiple Indicator Cluster Survey 2019-2020 - Survey Findings Report (Ramallah, Palestine, 2021). Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 3 1 BACKGROUND The Palestinian Territory has been characterized by instability and warfare and continues to remain a volatile region, causing adverse determinants of health, including widespread poverty, a high prevalence of lifestyle risk factors, vulnerability to man-made and natural hazards, weaknesses in health and food systems, and difficult access to health care9. Additionally, sanctions, such as the import restrictions set by the Paris Agreement, have resulted in publicly procured medicines costing almost seven times that of the global market9. The differences between the two regions are considerable. The gross domestic product (GDP) per capita of the GS is equivalent to one-third of the GDP in the WB10. In addition, there are also substantial economic variations in household income and expenditures; the percentage of food-secure households in the GS is approximately one-half of that in the WB10. For decades, a number of assessments have indicated a deterioration in the indicators of nutritional status of pregnant and postnatal women and children of ages 6–23 months in the WB & GS, including iodine and vitamin A deficiencies, and anemia 4,11,12. 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 in children, causes fatigue and low productivity, and, in pregnancies, is associated with poor birth outcomes (including low birth weight and prematurity) as well as maternal and perinatal mortality13. Iron deficiency without anemia can be also associated with adverse clinical and functional consequences14 due to the reduction in the body’s iron stores. APC interventions targeting the most relevant contributing factors in a particular setting can effectively address anemia and contribute to preserve productivity, child development and learning capacities, and maternal health15. In response to the micronutrient status of its population, the country has been implementing APC interventions recommended by the WHO, including food fortification, iron supplementation, and the promotion of breastfeeding and consumption of iron-rich food. United Nations (UN) agencies and other partners have supported these initiatives. The food fortification program includes the mandatory addition of ten micronutrients to wheat flour, including iron. To target vulnerable groups, iron supplementation is distributed via PHC clinics to pregnant and postnatal women and children aged 6–23 months. The program also incorporates the promotion of iron-rich foods, including fortified wheat flour, to increase the dietary intake of iron. Most of these promotion efforts are through health services, schools, and mass media. Although the effectiveness of such interventions in addressing anemia is well-recognized, global experience indicates that the implementation and coverage of interventions is hindered by 9 World Health Organization - Regional Office for the Eastern Mediterranean, Country cooperation strategy for WHO and occupied Palestinian territory 2017 – 2020: Palestine (Cairo, 2017). 10 Palestine Economic Policy Research Institute (MAS), "Socio-economic and food security survey 2018 - State of Palestine," (2018). 11 Nutrition Department - Directorate General of Primary Health Care and Public Health - 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, Ministry of Health (June 2005 2005). 12 Nutrition Department - Directorate General of Primary Health Care and Public Health - Ministry of Health - State of Palestine, "National Nutrition Surveillance System - Report 2017," (2017). 13 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. 14 Sant-Rayn Pasricha et al., "Iron deficiency," The Lancet 397, no. 10270 (2021/01/16/ 2021), https://doi.org/https://doi.org/10.1016/S0140- 6736(20)32594-0. 15 The Population Health and Nutrition Information Project, Anemia Prevention and Control: what works (2003). https://bit.ly/3DA1Yy8. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 4 various factors. Those factors include the lack of government ownership, low capacity of the national industry to produce high-quality fortified food, poor access to health services, ineffective procurement and distribution systems, dietary preferences, and limited or ineffective efforts to create demand16,17. A preliminary analysis in the WB & GS suggested that anemia remains a public health problem18. Using anemia as indicator, the assessment concludes that the APC interventions have not achieved the intended impact as articulated in the National Health Strategy 2017 –202219 and in the National Nutrition Policy, Strategies and Action Plan (NNPSAP) 2017 –202220. The purpose of this assessment is, therefore, to identify the bottlenecks impeding the success of the APC interventions21 implemented by the MoH and the ways to overcome them. The assessment focuses on the following areas and research questions: • Targeting: Are the programs targeting the right populations? • Service delivery: Is the high-risk population receiving adequate and necessary prevention? Are the control measures as planned? • Supply: Are the iron supplements at facilities and iron-fortified flour and food products at retail shops available and distributed to the beneficiaries? • Demand: Are there incentives and barriers to the right implementation of prevention and control interventions? How will barriers be managed with the existing resources and programs? 16 S. J. M. Osendarp et al., "Large-Scale Food Fortification and Biofortification in Low- and Middle-Income Countries: A Review of Programs, Trends, Challenges, and Evidence Gaps," Food Nutr Bull 39, no. 2 (Jun 2018), https://doi.org/10.1177/0379572118774229, https://www.ncbi.nlm.nih.gov/pubmed/29793357. 17 J. McGuire J Galloway R, "Determinants of compliance with iron supplementation: supplies,side effects, or psychology?," Soc Sci Med 39, no. 3 (1994). 18 Rae Galloway R., "Brief: The Prevalence of Anemia in the West Bank and Gaza," (2019). 19 The National Health Strategy 2017–2022 set as expected results of the fortification and micronutrient supplementation: “90 percent of effectiveness of the fortification program (compliance with established standards)” and a “reduction of 30–40 percent in the prevalence of micronutrient deficiencies (iron and Vitamin A)”. 20 The NNPSAP 2017–2022 set as expected results “flour fortification process covered 90% of available flour in the markets” and “reduction by 20% the micronutrient deficiency among the vulnerable groups”. The document does not include specific goals for the supplementation program. 21 This assessment covers the APC interventions included in the document World Health Organization, Nutritional anaemias: tools for effective prevention and control (Geneva, 2017). Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 5 2 METHODS The collection of information was designed to follow the modules defined in the scope of work of this assessment: targeting, mapping of service delivery, supply of iron supplements, supply of wheat flour in retail stores, and barriers to demand. The targeting module was designed to identify the prevalence and severity of anemia among high-risk groups by location and socioeconomic and physiological statuses. The mapping of the service delivery module consisted of mapping and reviewing available anemia-related prevention and control programs. The supply of iron supplements module consisted of a review of the supply chain of iron supplements, including stocks at the facilities and governorates. The supply of wheat flour module investigated the availability of fortified and non-fortified flour in retail shops. The barriers to demand module aimed to identify reported or observed barriers to complying with the recommended APC programs. The approach to collecting the information relating to each module is described below. 2.1 Targeting In addition to consultations with the MoH-ND and nutrition focal points of the WHO and UNICEF, a systematic search on Medline, Scopus, WHO-Vitamin, and Mineral Nutrition Information System and Google Scholar databases was conducted to identify the relevant studies reporting the prevalence of anemia and/or iron deficiency in the WB & GS22. The search process identified four data sources: • The Palestinian Micronutrient Survey (PMS) 2013 is a cross-sectional survey that administered a series of tailored questionnaires to pregnant women, postnatal women, and children of ages 6–59 months attending MoH or UNRWA clinics and adolescents attending public and private schools. The sample was recruited from MoH and UNRWA health clinics and schools, therefore it is not necessarily representative of the total population. The PMS collected a wide range of data, including biomarkers of micronutrient status, factors potentially associated with nutritional anemia (e.g., access to and use of fortified food and micronutrient supplements, behaviors, breastfeeding, food consumption, smoking, and anthropometric measurements). The datasets and questionnaires were available for the assessment. However, a manual for the enumerator describing the methods and rules used to ask questions was not available. • The National Nutrition Surveillance System (NNSS) is an ongoing monitoring system that collects nutritional information from children of ages 12–15 months, pregnant women, and schoolchildren attending one of the 71 maternal and child health care clinics. These are all high-volume service centers that are regarded to be “sentinel centers”12. • The Health Annual Report (HAR) that is produced by the MoH’s Palestinian Health Information Center (PHIC) contains information about maternal and child health, including anemia and micronutrient supplementation. The HAR is a summary of data collected in all health services of the MoH, including services for pregnant and postnatal women and children of ages 6–59 months. Only the tables included in the annual report were available for the assessment. 22 Acombination of the following terms was used to search for abstracts and titles: anaemia, anemia, iron, deficiency, intake, status, prevalence, Palestine, WB, GS, women, adult, adolescent, pregnant, children. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 6 • The UNRWA monitoring system collects data from the population, namely pregnant and postnatal women and children under five years old, receiving health care in its clinics located in both the WB & GS. The data includes the results of 78 laboratory tests, including the determination of hemoglobin levels and indicators related to preconception, antenatal care, delivery, and postnatal care. These health services target the refugee population and are in refugee camps. Considering that the NNSS, HAR, and the UNRWA collect data continuously, the researchers used the data corresponding to the last five years (2016–2020). Among these three data sources, only the NNSS provides a dataset containing individual-based data. To better understand the information available, it is necessary to mention that in the WB, the MoH manages most of the clinics (71 percent), whereas in the GS, non-governmental organizations (NGOs) manage half of the clinics (50 percent), followed by the MoH (33 percent). A more detailed description is in the findings section. A summary of the physiological and age groups whose anemia status is available in each of these four data sources is shown in Table 1. Table 1: Availability of data on the anemia status of the subpopulations in the Palestinian Territory Subpopulation PMS 2013 NNSS 2018 MoH HAR UNRWA monitoring 2018 & 2019 2019 Preconception23 Not available Not available Not available Women 15–49 years n=37,991 (2019) Pregnant women First, second, and First, second, and third 36 weeks gestational At first ANC visit and third trimester trimester age at 24 weeks n=1,200 n=19,874 (2018) n=26,610 (2019) n=47,224 (2019) Postnatal women Available Not available Six weeks Six weeks postpartum n=1,200 postpartum24 n=24,744 (2019) n=53,023 (WB only, 2018) Children 6–59 months 12 months 12 months 12 months n=1,200 n=25,365 (2018) n=62,748 (WB only, n=52,688 (2019) 2019) Adolescent 15–18 years Not available Not available Not available Male and female n=2,400 The PMS 2013, NNSS 2018 and the UNRWA monitoring 2019 data sources and the assessment used the hemoglobin level cutoff points set by the WHO6 to identify cases of anemia. Only the HAR used a cutoff of ≤ 11 g/dL instead of the WHO recommended <11 g/dL for pregnant women and 12-month-old children, which overestimates the anemia prevalence in these groups. An explanation for this discrepancy was not provided to the researchers. The data obtained from the NNSS, the HAR, and the UNRWA were analyzed to estimate the prevalence of anemia among 23 Preconception care is provided during visits for other health problems or as a part of regular preventive care. 24 Only for the WB. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 7 the population groups at high risk of anemia. Despite potential variations in quality, coverage, and availability, the analysis of these three sources was considered highly relevant, taking into consideration that the most recent micronutrient survey was conducted seven years ago. To identify factors associated with anemia that should inform the targeting of APC interventions and might affect their design and implementation, the assessment included bivariate and multivariable analyses in the PMS 2013 dataset. The selection of factors to be tested as independent variables was guided by the WHO’sError! Bookmark not defined. determinants of anemia. This includes a broad range of factors, including nutritional deficiencies, physiological status, gender, age, disease and inflammation, and social, behavioral, and environmental factors. The bivariate analysis aimed to identify the factors associated with two outcomes: hemoglobin concentration (g/dL) and anemia among each group included in the PMS 2013: pregnant and postnatal women, children of ages 6–59 months, and adolescents. Given the high number of assessed factors in the bivariate analysis, the Bonferroni adjustment was applied to mitigate the multiple testing issue25. The cutoff of p<0.001 was adopted as the result of dividing 0.1 by the number of variables included in the analysis of each group (96 for pregnant, 137 for postnatal, 93 for children of ages 6–59, and 79 for adolescents). The association with hemoglobin concentration was measured using the slope and p-value obtained from a linear regression for those factors registered as continuous variables: the Kruskal–Wallis test for categorical variables, the Wilcoxon test for binary variables, and Cuzick’s nonparametric test for trend (nptrend) for ordinal variables. The strength of the association with anemia was measured using an odds ratio (OR) obtained from a logistic regression for the factors registered as continuous or binary variables. The association with categorical predictors was evaluated with the chi-square test for categorical variables and the nptrend for ordinal variables. The assessment used nonparametric tests because some of the categorical factors lead to groups small enough that parametric methods may be inappropriate. It was not practical to select the most appropriate test on a factor-by-factor basis. Having identified factors to be considered in the design of APC interventions in the bivariate analysis, the assessment conducted a multivariable analysis aiming to provide criteria for a simple screening tool to identify individuals at an increased risk of anemia. The multivariable analysis, with its focus on simplifying targeting, included only data collected routinely by health services or those that require minimal effort for screening. The collection of biological samples, the assessment of the individuals’ knowledge of health and nutrition, and the elements of care associated with iron supplementation were excluded because of their high cost and time- consuming data collection. Given the limitations of the PMS 2013, the bivariate analysis aimed to identify the characteristics that are associated with a higher prevalence of anemia. The multivariable analysis, however, aimed to identify those at a higher prevalence with an efficient and robust identification of factors associated with outcomes, even after adjusting for all other factors. The multivariable models can also be used to predict the prevalence of anemia by taking several factors into account simultaneously. In this way, they can serve as a starting point for further research into the causes of anemia in the WB & GS. The factors associated with the outcomes in the bivariate analyses, subsequently confirmed by the multivariable analyses, were considered to be robust, 25 Observing at least one significant result strictly due to chance due to testing simultaneously a set of hypotheses. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 8 independent predictors of the outcomes and thus promising candidates as indicators for targeting current or new APC interventions to reach groups at a high risk of anemia. For each of the four populations included in the PMS 2013, a linear regression for the outcome hemoglobin and binary logistic regressions for the outcome anemia were carried out. The breadth of the multivariable analysis was limited by the dataset sizes and prevalence of binary outcomes. To improve the interpretability of the results, some continuous variables were categorized. In some categorical variables, levels were merged to avoid overfitting. 2.2 Key interventions 2.2.1 Collection of relevant contextual information A desk review was carried out to find the available documents describing the health system structure and resources, epidemiological profile, and demographic characteristics, as well as those including policies, strategies, and operational guidance. Additional documents were identified through discussions with key informants. These included documents setting the strategic approach of the country regarding health in general, particularly nutrition and anemia (see Appendix 5.1). 2.2.2 Interviews with key informants The head of the MoH-ND identified the informants and made the formal introductions. Subsequently, additional informants were contacted as the assessment evolved. Tailored guides for semi-structured interviews were developed for different types of respondents (Appendixes 5.2 and 5.3). After the research team explained the objectives of the research, the process of data handling, and the participants’ rights to withdraw at any time, all participants provided verbal consent before starting their interviews. The assessment protocol and tools were not submitted to the Institution Review Board and Ethics Committee because this mandate did not involve access to or a collection of private or sensitive data. A list of the interviewed informants is included in Appendix 5.4. In order to fill in some remaining gaps in the information available about the programs, a written questionnaire was submitted to the MoH in June 2021 (Appendix 5.5). Since then, the information has been collected through in-depth interviews with representatives of the MoH- ND, the Central Warehouse Department, and officers at the governorate level of the Community Health Department (MoH-CHD) and the Maternal Child Health Department (MoH-MCH). 2.2.3 Fortification: supply of wheat flour in retail shops The availability of iron-fortified flour was assessed based on the reports of domestic production and importations26. Compliance with the national standards of mandatory fortification was 26 M. Al-Halaika (personal communication, 15 July 2021) Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 9 assessed by summarizing the test results of wheat flour samples collected by food fortification monitoring. To assess the availability of fortified and non-fortified wheat flour in retail shops, according to technical consultation with the MoH, 15 bakeries were visited. These bakeries were in the governorates with the highest prevalence of anemia among pregnant women (Gaza and Rafah in the GS and Hebron and Jericho in the WB). A questionnaire was administered to the proprietor of each establishment to explore the factors associated with the preferences of bread producers and final consumers. 2.2.4 Supplementation: supply of iron supplements The estimation of needs for iron supplements was based on the MoH-MCNNP 202127, the HAR 20192, and the UNRWA monitoring system. The MoH Central Warehouse Manager and the UNRWA Deputy Head of Field Logistics office for the Palestinian Territory refugees provided the quantification of needs and/or amounts distributed. As no documentation was available, the mapping of the iron supplement supply chain was exclusively based on the information provided by the informants, including the Head of the MoH- ND, the pharmacy manager at Balata Primary Care Center in Nablus, and the Central Warehouse Manager. According to our informants, the clinics and governorates do not report information about the stocks available, so a quantification of stocks was not possible. Information regarding the logistics system was collected through visits to a total of eight PHC clinics, four per region (two managed by the MoH and two by the UNRWA). The clinics were chosen from the governorates28 with the highest prevalence of anemia among 12-month-old children, according to the most recent information available from the NNSS5 and HAR2. The visits were done in March 2021 with authorization from the MoH. Additionally, three regional warehouses were visited: two belonging to the MoH (one in the WB and one in the GS) and one belonging to the UNRWA in the GS. 2.2.5 Barriers to demand To assess the barriers to an effective implementation of APC interventions and the management of barriers with existing resources and programs, this assessment selected and adapted elements from the Barrier Analysis Method from the Designing for Behavior Change Framework29. This framework is a practical behavioral framework tested in a field that strategically supports planning for maximum effectiveness in interventions that have a behavioral component, such as nutrition, turning it relevant for anemia prevention programs. This framework was used to implement an analysis as tailored to the studied settings as possible. Taking the assessment’s characteristics and limitations into consideration, the framework was adapted to cover the most relevant behavioral determinants. A behavioral determinant refers to any factor that strongly influences and affects a given behavior producing a behavioral effect that may be desirable or undesirable. For example, culture exerts a major influence on how people behave and is therefore a major behavioral determinant. When the determinant produces a 27 Nutrition Department - Directorate General of Primary Health Care and Public Health - Ministry of Health - State of Palestine, "Maternal and Child National Nutrition Protocol," (06 July 2021 2021). 28 Gaza and Rafah in the GS and Hebron and Jericho in the WB. 29 Bonnie Kittle, "A practical guide to conducting a barrier analysis," New York: Helen Keller International (2013). Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 10 behavior that blocks a desired effect, it is considered a barrier. For this assessment, the selected behavioral determinants were perceived to be self‐efficacy/skills, perceived social norms, perceived positive consequences, perceived negative consequences, access, cues for action/reminders, perceived susceptibility, perceived severity, perceived divine will, policy, and culture. The assessment considered barriers with an immediate influence on a given behavior (e.g., lack of reminders) and policies that indirectly affect service utilization and compliance. Demand was mainly focused on supplementation, but several aspects of fortification were also explored (Appendix 5.6). Using this framework, the assessment was able to identify not only the specific bottlenecks affecting the anemia prevention program but also actors that might influence change in these areas. This overview also enables the identification of possible solutions that might be feasibly implemented. The process developed to identify the barriers is described as follows: • Review of: - White literature (leading journals and peer-reviewed publications) and - Gray literature (policies, frameworks, guidelines, and studies on the subject) • Key Informant Interviews (KII) with: - Program managers within the MoH, UNRWA, UNICEF, WHO, World Food Program (WFP), and the Ministry of National Economy (MoNE) - Service delivery providers: doctors and nurses for pregnant women from the MoH and UNRWA - Key logistics elements: officers in charge of warehouses and central pharmacies from the MoH and UNRWA and staff from bakeries - Final users of health services (target population): mothers of 6–11-month children and pregnant women 2.3 Assessment limitations The key staff of the MoH in the WB & GS, MoNE, and their partners provided support for the implementation of this assessment. However, here are some salient limitations: • There is no centralized repository for the MoH’s monitoring data (e.g., anemia status of pregnant women attending ANC visits), and documentation of the data flow is not available. Despite the collaboration of multiple stakeholders, health services data from both regions (the WB & GS) for the last five years were not always available. • The only micronutrient survey available (PMS 2013) recruited participants from MoH and UNRWA health clinics and schools, so the sample included is not necessarily representative of the total population. • In the absence of documents containing the planning, technical, or monitoring procedures, the description of the APC programs relied exclusively on interviews with key informants. • The scope of this assessment did not include direct observation or exit interviews to assess the health care worker’s clinical behavior related to iron supplementation, Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 11 including counseling women about why, how, and when to take iron supplements and how to manage side effects. • In addition to the usual restrictions for mobility, the assessment team’s visits to clinics, central pharmacies, central warehouses, and bakeries were challenged by the restrictions imposed by the country’s response to the COVID-19 pandemic. • The data collection activities of the assessment were delayed by the violent incidents of May 2021. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 12 3 FINDINGS The only structure committed to addressing nutritional issues in the government is the MoH-ND, which acts as the overall coordinating body for nutrition-related issues. The MoH-ND includes six staff members and is under the Public Health General Directorate of the MoH. Additionally, a Nutrition Thematic Group composed of high-profile representatives of technical and academic organizations provides technical advice to the MoH30. The NNPSAP 2017–202231 defined the prevention and treatment of micronutrient deficiencies as a priority and set three objectives: implement a food fortification policy, increase compliance with micronutrient supplementation, and promote nutritional and dietary diversification. The NNPSAP 2017–2022 defined the activities, indicators, responsible bodies, timeline, and costs of nutritional interventions, providing a solid roadmap for their implementation. Section 3.2 describes in detail the fortification and supplementation interventions. However, it is worth mentioning that the food fortification policy requires adding a total of ten micronutrients, including iron, vitamin A, and folic acid, to wheat flour to help reduce the prevalence of anemia by addressing the micronutrient deficiencies that cause it. Adding folic acid to wheat flour also contributes to a higher intake of folic acid among pregnant women which in turn reduces the risk of neural tube defects that occur in the first 20 days after conception. The National Health Strategy 2017–202232, currently in force, includes policy interventions related to the micronutrient status of the population. Expected outputs for the fortification and micronutrient supplementation were set at “90 percent of effectiveness of the fortification program (compliance with established standards)” and a “reduction of 30–40 percent in the prevalence of micronutrient deficiencies (iron and vitamin A)”. 30 Members of the committee include the MoH, WHO, UNRWA, UNICEF, FAO, Care International, and USAID. 31 Nutrition Department - Public Health General Directorate - Ministry of Health - State of Palestine, National Nutrition Policy Strategies and Action Plan 2017 - 2022. 32 General Directorate of Health Policies and Planning - Ministry of Health - State of Palestine, National Health Strategy 2017-2022, (2016). Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 13 3.1 Targeting Key points • Due to increased iron needs related to growth, fetal development, and losses during childbirth or menstruation, the population groups most vulnerable to anemia are children under 5 years of age, adolescents, women of reproductive age (15 –49 years), and pregnant women. • In the WB and GS, the high prevalence of anemia in the most vulnerable population groups is a public health problem1,2,3,4,5. o Those with the highest prevalence of anemia are pregnant and postnatal women and children of ages 6–23 months. o The national prevalence of anemia remained static during 2012 –2018. o The prevalence of anemia is higher in the GS than in the WB across all groups most vulnerable to anemia (pregnant women, children of ages 6–23 months, children of ages 2–5 years, postnatal women, and adolescents). • The analysis of data from the PMS 2013 provided evidence that certain conditions are associated with lower hemoglobin levels or a higher prevalence of anemia in the WB and GS. The most salient were: - Iron deficiency - Residing in the GS - Deficiency of vitamin A and folic acid among pregnant and postnatal women and adolescents - Infection (fever or diarrhea) among postnatal women and children - Not taking IFA tablets regularly for pregnant and postnatal women - Not taking IFA tablets during or after pregnancy for postnatal women - Lack of awareness about fortified flour among postnatal women - Lower consumption of iron-rich food among pregnant women, adolescents, and children - Second or third trimester of pregnancy - Age group of 6–11 months - Female of age group 15–18 years The assessment reviewed the most recent available information on the burden of anemia in the WB & GS to assess whether the supplementation program’s targeting of pregnant and lactating women and children of ages 6–23 months is consistent with the epidemiological profile of these populations and current international recommendations. Additionally, an analysis of the PMS 2013 was conducted to identify the factors associated with low hemoglobin levels and a higher prevalence of anemia. Using these data, this section also provides an overview of the existing infrastructure and access to key supplementation services. Even though none of these data sources capture a random sample of their total population and each of them collects data from different subpopulations33, the analyses of these data sources have provided a meaningful and 33 The MoH-Annual Health Report (MoH-AHR) provides information about all users of 466 MoH’s PHC clinics, the MoH-NNSS about users of 132 MoH’s clinics and 86 schools included as sentinel sites in the NNSS, and the UNRWA monitoring system about users of 65 cl inics. In 2013, the PMS collected data of individuals recruited in clinics managed by the MoH, the UNRWA, and schools. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 14 complementary body of information to support the targeting of current or future APC interventions. 3.1.1 The burden of anemia The WHO provides a classification of anemia as a problem of public health significance (Table 2). This provides a reference for the inclusion of a population group as a target of iron supplementation programs. Table 2: The WHO’s classification of anemia as a problem of public health significance6 Prevalence of Category of public health anemia (%) significance ≤ 4.9 No public health problem 5.0–19.9 Mild public health problem 20.0–39.9 Moderate public health problem ≥ 40 Severe public health problem Using the most recent and comprehensive sources available, for each high-risk group in the WB & GS, Table 3 presents the prevalence of anemia, its corresponding category as a public health problem, and its eligibility for being included as a target population of a supplementation program. This assessment concludes that the inclusion of pregnant and postnatal women and children ages 6–23 months as target groups of the iron supplementation program in the WB & GS is aligned with the WHO’s recommendations. The prevalence of anemia among children of ages 6–23 months in the WB was found to be slightly lower (39 percent) than the threshold established by the WHO’s recommendations (40 percent). The assessment considers that the borderline anemia status of the children in this age group in the WB is sufficient to justify their inclusion in the supplementation program. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 15 Table 3: Classification of high-risk populations in the WB & GS according to the WHO’s categories of anemia significance as a public health problem Population group Region Prevalence of Data source Public health Is supplementation anemia problem recommended?6 Pregnant GS 57 % HAR 2020 Severe Yes women WB 27 % HAR 2019 Moderate Yes Children 6–23 GS 55 % NNSS 2018 Severe Yes months34 WB 39 % HAR 2019 Moderate Yes35 Children 2–5 GS 21 % PMS 2013 Moderate No years WB 15 % PMS 2013 Mild No Postnatal GS 35 % PMS 2013 Moderate Yes women WB 25% HAR 2018 Moderate Yes Adolescents 15– GS 12 % PMS 2013 Mild No 18 years male WB 9% PMS 2013 Mild No Adolescents 15– GS 22 % PMS 2013 Moderate No 18 years female WB 19 % PMS 2013 Mild No Additionally, according to the MoH-NNSS, the burden of anemia at the national level has remained mainly static among pregnant women (between 27 and 32 percent during 2012–2018) and experienced a slight decrease among 12-month-old children (from 54 percent in 2012 to 48 percent in 2018) (see Figure 1). Figure 1: The prevalence of anemia at the national level among 12-month-old children and pregnant women from 2012 to 2018 Source: NNSS 34 The prevalence reported for this age group by the HAR and NNSS corresponds to anemia testing at 12 months of age. 35 The prevalence of anemia was estimated as 39%, and the recommendation is to include populations with a prevalence of 40% or higher. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 16 3.1.2 Factors associated with anemia The bivariate analysis identified the factors associated with hemoglobin levels and anemia among the four vulnerable population groups included in the PMS 2013: pregnant women, postnatal women, children of ages 6–59 months, and adolescents. As explained in Section 2.1, an association was considered statistically significant if its p-value was below the Bonferroni- corrected threshold. The threshold was calculated independently for each group, using the number of variables included in the analysis. The associated factors identified using the criteria above are presented below for each group. Tables identify each association with “+++”. 3.1.2.1 Among pregnant women Hemoglobin levels were lower, and the prevalence of anemia was higher (p<0.001) among those: • Who have lower ferritin and serum iron levels and higher levels of transferrin. • Who have lower folate levels. • Who live in the GS, in comparison to the WB. • In the second or third trimester of pregnancy, as opposed to those in the first trimester. • Who do not take IFA tablets regularly. Hemoglobin levels were lower (p<0.001) among those: • Who have lower vitamin B12 levels. • Who consume chicken or white bread less than once per week. Table 4: Factors associated with hemoglobin levels and anemia prevalence among pregnant women in bivariate analyses Outcome Lower Higher Factors hemoglobin prevalence levels of anemia Lower ferritin level +++ +++ Higher transferrin level +++ +++ Lower serum iron level +++ +++ Lower vitamin B12 level +++ ns Lower folic acid level +++ +++ Second and third trimester of pregnancy +++ +++ Residing in the GS +++ +++ Consumes white bread less than once per week +++ ns Consumes chicken less than once per week +++ ns Not taking IFA tablets regularly +++ +++ ns = not statistically significant 3.1.2.2 Among postnatal women Hemoglobin levels were lower, and the prevalence of anemia was higher (p<0.001) among those: • Who have lower ferritin and serum iron levels and higher levels of transferrin. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 17 • Who have lower levels of vitamin A. • Who have fever today or within the previous week. • Who reside in the GS. • Who reside in a city or camp (as opposed to those who reside in villages or Bedouin communities). • Who were recruited for the survey in UNRWA clinics (as opposed to those recruited in MoH clinics). • Who have not taken IFA tablets after delivery. The prevalence of anemia was higher (p<0.001) among those: • Who do not know what foods increase breast milk supply. • Who during the last pregnancy did not receive education on good nutrition for lactating mothers. • Who during the last pregnancy did receive health education on preparation for breastfeeding. • Who during the last pregnancy did receive health education on exclusive breastfeeding. • Who during the last pregnancy did receive health education on complementary feeding. • Who have not heard of fortified flour. • Who know the importance of vitamin A. • Who have not taken folic acid tablets prior to their last pregnancy. • Who have not taken IFA tablets during their last pregnancy. • Who received vitamin A after giving birth in the clinic. Hemoglobin levels were lower (p<0.001) among those: • Who have three or more children under five years old (compared to those with fewer children). • Who after delivery have not taken IFA tablets at least once per week. • Whose counselor who emphasized the need to take IFA tablets the most was not a nurse. • Whose first prescriber of IFA tablets was not a nurse. The counterintuitive association between knowledge or access to nutritional education with a higher prevalence of anemia could be due to the content of the education messages. Here the education would probably be on the benefits of exclusive breastfeeding and complementary feeding to the child with less focus on the maternal diet and its relation to maternal health. Table 5: Factors associated with hemoglobin levels and anemia prevalence among postnatal women in bivariate analyses Outcome Lower Higher Factors hemoglobin prevalence levels of anemia Lower ferritin level +++ +++ Higher transferrin level +++ +++ Lower serum iron level +++ +++ Lower vitamin A level +++ +++ Having fever today or during the past week +++ +++ Residing in the GS +++ +++ Residing in a city or camp +++ +++ Recruited in UNRWA clinics +++ +++ Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 18 Outcome Lower Higher Factors hemoglobin prevalence levels of anemia Have three or more children under five years old +++ ns Do not know what foods increase breast milk supply ns +++ Never heard of fortified flour ns +++ During their last pregnancy did not receive health education on good ns +++ nutrition for lactating mothers During their last pregnancy received health education on preparation ns +++ for breastfeeding During their last pregnancy received health education on exclusive ns +++ breastfeeding During their last pregnancy received health education on ns +++ complementary feeding Know the importance of vitamin A ns +++ Received vitamin A after giving birth in the clinic ns +++ Did not take folic acid tablets prior to the last pregnancy ns +++ Did not take IFA tablets during their last pregnancy ns +++ Did not take IFA tablets after delivery +++ +++ First prescriber of IFA tablets was not a nurse +++ ns Have not taken IFA tablets at least once per week after delivery +++ ns The counselor who emphasized the need to take IFA tablets the most +++ ns was not a nurse. ns = not statistically significant 3.1.2.3 Among children 6-59 months Hemoglobin levels were lower, and the prevalence of anemia was higher (p<0.001) among those: • Who have lower ferritin and serum iron levels. • Who have lower beta-carotene levels. • Who are ages 6–11 (compared to those ages 12–59 months). • Who had diarrhea in the previous two weeks. • Who reside in the GS. • Who consume chicken less than once per week. • Who were not taking iron drops for at least three or four weeks from the day of the survey. Hemoglobin levels were lower (p<0.001) among those: • Who have higher levels of transferrin. • Who have not taken vitamin A and D drops for at least six months. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 19 Table 6: Factors associated with hemoglobin levels and anemia prevalence among children of ages 6–59 months in bivariate analyses Outcome Lower Higher Factors hemoglobin prevalence levels of anemia Lower ferritin level +++ +++ Higher transferrin level +++ ns Lower serum iron level +++ +++ Lower beta-carotene level +++ +++ Ages 6–11 months (among children of ages 6–59 months) +++ +++ Diarrhea over the past two weeks +++ +++ Residing in the GS +++ +++ Consumes chicken less than once per week +++ +++ Not taken vitamin A and D drops for six months or more +++ ns Not currently taking iron drops (for at least three or four +++ +++ weeks) ns = not statistically significant 3.1.2.4 Among adolescents Hemoglobin levels were lower, and the prevalence of anemia was higher (p<0.001) among those: • Who have lower ferritin and serum iron levels and higher levels of transferrin. • Who have lower levels of vitamin A. • Who are female (as opposed to male). • Who do not eat dinner regularly. Hemoglobin levels were lower (p<0.001) among those: • Who have lower levels of vitamin E. • Who reside in the GS. • Who have six or more siblings. • Who attend a public school (as opposed to those attending a private school). • Who consume red meat, sausages, eggs, or nuts less than once per week. • Who do not eat a light snack after dinner regularly. Table 7: Factors associated with hemoglobin levels and anemia prevalence among adolescents in bivariate analyses Outcome Factors Lower Higher hemoglobin prevalence levels of anemia Lower ferritin level +++ +++ Higher transferrin level +++ +++ Lower serum iron level +++ +++ Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 20 Outcome Factors Lower Higher hemoglobin prevalence levels of anemia Lower vitamin A level +++ +++ Lower vitamin E level +++ ns Female +++ +++ Residing in the GS +++ ns Having six or more siblings +++ ns Attending a public school +++ ns Do not eat dinner regularly +++ +++ Do not eat a light snack after dinner regularly +++ ns Consumes red meat less than once per week +++ ns Consumes sausages less than once per week +++ ns Consumes eggs less than once per week +++ ns Consumes nuts less than once per week +++ ns ns = not statistically significant Below the main findings of the bivariate analysis: • Low levels of iron and residing in the GS were associated with lower hemoglobin levels and/or a higher prevalence of anemia across all four demographic groups. • Physiological statuses leading to increased iron requirements (women in their second or third trimester of pregnancy, children aged 6–11 months) or losses of iron (female adolescents) were associated with lower hemoglobin levels and/or a higher prevalence of anemia among their respective demographic groups. • Additional conditions related to socioeconomic factors (e.g., postnatal women residing in cities or camps, receiving health care from the UNRWA, or having three or more children under five years old; adolescents having six or more siblings or attending a public school) were associated with lower hemoglobin levels and/or a higher prevalence of anemia across all groups. • A lower intake of some iron-rich foods, was associated with lower hemoglobin levels among pregnant women, children of ages 6–59 months, and adolescents. • Signs of infection (fever among lactating women, diarrhea among children of ages 6–59 months) were associated with lower hemoglobin levels and a higher prevalence of anemia. • The use of iron supplements was associated with higher hemoglobin levels and a lower prevalence of anemia among pregnant women, lactating women, and children of ages 6– 59 months. • Receiving counseling from a nurse, when compared to any other professional profile, was associated with higher hemoglobin levels, suggesting that the quality of counseling is not homogeneous across different cadres. 3.1.3 Additional analyses Multivariable analyses were conducted to identify the factors associated with anemia and hemoglobin levels while adjusting for each other. These findings are meant to generate hypotheses regarding independent predictors of anemia and hemoglobin levels to add another Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 21 layer of targeting among the most vulnerable groups. As such, the multivariable analyses included only those factors that are collected routinely by health services or require a minimal effort for screening. By identifying the factors that remain associated with the outcomes, even after adjusting for all other factors, the multivariable models can also be used to correctly quantify the risk of anemia when several factors can be considered simultaneously. The results can be used as the basis for further research into the causes of anemia in the WB & GS. The results of the multivariable analyses are presented in Appendix 5.7. 3.1.4 Main general conclusions The evidence described in this section provides robust support for: • Universal fortification of wheat flour with micronutrients by aiming to increase the intake of iron and other micronutrients, such as vitamin A and folic acid. • Targeting the iron supplementation program at pregnant and postnatal women and children of ages 6–23 months. • Ensuring that residents of the GS and those in lower socioeconomic levels have adequate access to APC interventions, including fortification and supplementation programs. • Increasing efforts to reduce infections, particularly among children under five years old. • Strengthening communication efforts to increase the dietary intake of iron, including iron-fortified flour, among the most vulnerable groups. • Implementing APC interventions targeting female adolescents. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 22 3.2 Key interventions KEY POINTS Fortification program • The fortification of wheat flour with ten micronutrients, including iron, has been mandatory in the Palestinian Territory since 2006. Producers and importers of flour are responsible for complying with the national standards of fortification without any subsidies or compensation. Fines of up to 9,000 Israeli shekels can be imposed to those producing, importing, or selling products not complying with the fortification standards. • The MoH leads a food fortification monitoring system with the participation of the MoNE, the Ministry of Security, and the Federation of Food Industries. The system is not active in the GS. • Only between three and five percent of the wheat flour samples collected in the WB comply with the iron fortification standards. Thus, the availability of adequately fortified wheat flour is estimated to be low. Therefore, this assessment concludes that the objective of increasing the dietary intake of iron and other micronutrients by the general population has not been achieved. • The MoH and its partners have promoted actively the consumption of fortified wheat flour in previous years through communicational efforts, such as the design of a fortification logo and mass media campaigns. However, those efforts have not been maintained because the flour available to consumers is frequently not fortified, and the resources available for communicational activities are limited. • Bakery owners and final consumers do not have the means for identifying micronutrient- fortified wheat flour or wheat flour-based products. The use of the fortification logo is not regulated, so its presence does not necessarily identify fortified products. Bakeries do not make any differentiation in the labelling of products offered to the final users. Supplementation program • The iron supplementation program targets three groups: pregnant women, postnatal women, and children of ages 6–23 months. This is consistent with the WHO’s recommendations. • The MoH procures iron supplements with its own resources, and the amount of iron supplements procured and distributed by the MoH is based on past distribution at clinics. • The assessment identified a substantial gap between the annual amount of IFA tablets distributed and the amount required to cover the supplementation scheme of pregnant and postnatal women registered in the MoH services. • The MoH clinics keep a register of stocks, but these are not reported to the higher administrative levels. Moreover, the delivery of counseling to improve compliance with the IFA/iron supplementation and the tracking of the actual compliance are not registered. • NGOs and the private sector do not report their health services to the MoH’s information system. • Users of ANC and childcare services stated that they received inadequate information about the management of iron supplement side effects. • Health care providers reported that they consider the available protocols and technical guidance to be not adequately comprehensive for effective anemia prevention and treatment. • The efforts of the MoH and its partners to provide training to health care staff are sporadic Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 23 and usually associated with the launching of new protocols or initiatives. • Access to clinics (the ratio of the population to PHC clinics) is more limited in the GS than in the WB, and the commencement of ANC visits is later in pregnancy in the GS than in the WB. The promotion of an increased dietary intake of micronutrients • The promotion of breastfeeding, adequate food intake during pregnancy, and complementary feeding for children aged 6–23 months is included in the MCNNP. Although the implementation of these activities is not monitored, the available evidence indicated progress during exclusive breastfeeding but not in complementary feeding. Other APC interventions • Multiple efforts are in place to improve access to safe water and sanitation and to provide family planning services, which positively affect APC. However, these efforts have not achieved an adequate impact, particularly among GS residents and those in the lower socioeconomic strata. Under the overall objective of reducing the micronutrient deficiencies among vulnerable groups, the NNPSAP 2017–2022 set three objectives: implement a food fortification policy, increase compliance with micronutrient supplementation, and promote dietary diversification. The clusters of activities with the explicit objective of reducing anemia, currently implemented by the MoH and its partners, are listed in Table 8. This assessment refers to those clusters of activities with a clear definition of operational outputs as “programs.” Other interventions that may contribute to preventing anemia are described at the end of this section. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 24 Table 8: Key characteristics of APC interventions in the WB & GS Cluster of Service Purpose Main output Target population activities providers Food Increase intake of iron Wheat flour General Bakeries and fortification with and other fortified with population retail shops micronutrients micronutrients, micronutrients including folic acid, that reduce the risk of neural tube defects36 Iron Increase the intake of Iron supplements Pregnant women, PHC clinics supplementation iron among those at available in PHC postnatal women, managed by high risk for anemia clinics children aged 6– the MoH and 23 months UNRWA Promotion of Increase the dietary Communicational General Health breastfeeding, intake of interventions population, with facilities complementary micronutrient-rich food emphasis on managed by feeding, and those at high risk the MoH and increased access for anemia UNRWA to iron 3.2.1 Fortification program 3.2.1.1 Policy framework Following on the results of the nutrition situation in 200611, the Palestinian Territory implemented a nationwide fortification program by adopting mandatory standards (shown in Table 9) for the content of micronutrients in all wheat flours, imported or produced domestically37. The Palestinian Standards Institution (PSI) Mandatory Technical Instructions37 set the minimum permissible level of micronutrients per kilogram of flour, and the MoH-ND complemented these standards with the expected average and the maximum tolerance level38. The Palestinian Standards and Metrology Law No. (6), the Public Health Law, and the Economy Law provided the legal framework to the enforcement of the fortification standards. 36 Z. O. Amarin and A. Z. Obeidat, "Effect of folic acid fortification on the incidence of neural tube defects," Paediatr Perinat Epidemiol 24, no. 4 (Jul 1 2010), https://doi.org/10.1111/j.1365-3016.2010.01123.x. 37 Palestinian Standard Institution - Palestinian Authority, Mandatory Technical Instructions 9-2005 Wheat Flour, (2005). 38 Nutrition Department - Public Health General Directorate - Ministry of Health - State of Palestine, Palestinian Flour Fortification Formula, PN118019 (2010). Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 25 Table 9: The PSI and MoH-ND standards for flour fortification Nutritional Fortificant compound Minimum Average Maximum component addition level addition tolerance level (mg/kg flour) level (mg/kg) (mg/kg) Folic acid Folic acid 1 1.5 2.5 Iron Ferrous sulphate 25 34.4 60 Cyanocobalamin Vitamin B12 0.1% WS39 0.0025 0.0040 Not available Thiamine (B1) Thiamine mononitrate 2 2.9 Not available Riboflavin (B2) Riboflavin 2.5 3.6 Not available Pyridoxine (B6) Pyridoxine hydrochloride 2.5 3.6 Not available Niacin (B3) Niacinamide 25 35 Not available Zinc Zinc oxide 15 20.6 40 Vitamin A Vitamin A (retinol 1 1.5 2.5 palmitate) CWS40-250 Cholecalciferol Vitamin D3 (cholecalciferol) 0.015 0.0023 0.050 (D3) 100 CWS/A41 The fortification program targets the general population of the WB & GS. Fortified products are accessible through commercial outlets for the general population and through humanitarian food baskets for the poor and vulnerable. The MoH-ND leads the fortification program. 3.2.1.2 Financial resources Producers and importers of flour are responsible for complying with the national standards of fortification without any subsidies or compensation42. New producers starting operations receive technical information from the MoH and have a few months to comply with the national fortification standards. The testing of flour samples (at an estimated cost per test of US$300–400 by the MoH) is funded and conducted by the government, and there are no charges for producers or importers. When the program started, UNICEF provided training for mill workers, the premix for the first year of implementation, premix feeders (three in the WB and seven in the GS), and printed communication materials for producers and the general population. The WFP also provided technical support through international and national experts, which became sporadic over time. More recently, the MoH-ND received financial support for program activities from the WHO (which provides support for trainings, workshops, and forms for inspectors) and UNICEF (which provides trainings and tools to collect flour samples). 39 Water-soluble. 40 Cold water-soluble. 41 Cold water-soluble based on gum acacia. 42 According to the MoH-ND “the local price of premix is US$15/kilo, so a big mill requires around US$300,000/year”. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 26 The MoH and MoNE staff who monitor the fortification program consider their participation to be part of their routine work, and they execute these activities without specific planning or budgeting. Only the periodical training of the MoH-EHD and MoNE Consumer Protection Department (MoNE-CPD) inspectors requires specific funding support. The budget of the MoH laboratory includes a special item for the assessment of flour samples, but the MoH-ND contributes the reagents. 3.2.1.3 Activities and results: supply Availability of iron-fortified flour As Table 10 illustrates, the total amount of wheat flour available in the country for 2019 and 2020 was estimated at 376,650 and 428,053 metric tons (MT), respectively43. Based on the total population of the WB & GS for those years44, the assessment estimates that 200–220 grams of wheat flour per capita per day were available during that period. However, the available amount of wheat flour complying with the national standards for micronutrient fortification is unknown. The collection of these data is challenging because the producers are not obliged to declare the amount of premix used or fortified flour produced. Furthermore, 65 percent of the flour available is imported (see Table 10), and there is a considerable limitation for the authorities to exert border control for imported goods. Table 10: Wheat flour available in the WB and GS Year Imported (MT)45 Local production (MT) Total (MT) 2019 247,300 129,350 376,650 2020 277,753 150,300 428,053 Fortified food monitoring system The Fortified Food Control and Monitoring Guide (2009)46 describes monitoring activities and their implementers. These include the MoH-Environmental Health Department (MoH-EHD), which is responsible for collecting samples in mills; the MoNE-CPD, which is responsible for collecting samples in markets, bakeries, and border controls; and the customs police, which are responsible for collecting the samples at borders. The guide also identifies the MoH-Central Public Health Laboratory (MoH-CPHL) for running tests to assess the content of micronutrients in the samples collected, the Federation of Food Industries for linking the MoH with producers, and the Preventive Security Service for providing security for inspectors. Inspectors from the MoH-EHD and MoNE-CPD collect samples with the support of the Public Safety Committee at the governorate level. The program does not produce a general plan to be implemented by inspectors defining a timeline and source of samples. Each team of inspectors independently produces a weekly plan to collect samples of fortified flour to assess the levels of fortificants and to perform other purposes, including detecting potentially harmful substances 43 M. Al-Halaika (personal communication, 15 July 2021) 44 "Palestinian Central Bureau of Statistics, Estimated Population in Palestine Mid-Year by Governorate,1997-2021," 2018, accessed 30.05.2021, https://bit.ly/3ltWX3Y. 45 MT for metric ton (1,000 kilograms). 46 Ministry of Health - Palestinian National Authority Fortified Food Control and Monitoring Guide, (2009). Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 27 (e.g., aflatoxins). There are neither sampling frameworks nor documented procedures for the selection of flour samples, and each team of inspectors decides which sites to visit based on their working knowledge of outlets such as bakeries and markets. According to the MoH-ND, during 2018 and 2019, samples were obtained from 20 importers and four local mills. Both the MoNE-CPD and MoH-EHD teams send samples to the MoH Laboratory, which in turn sends the results to the MoH-ND and the organization that sent the samples (either the MoNE- CPD or MoH-EHD). The MoH-ND compiles the MoH-CPHL’s test results in an electronic worksheet and produces an annual report with recommendations that are submitted to MoH authorities47 (Figure 2). Figure 2: Flowchart of the food fortification monitoring system In the GS, the staff was initially trained and received laboratory equipment, kits, and reagents to implement the same procedure as in Ramallah. Nevertheless, monitoring in the GS is currently not active due to a lack of essential supplies for the determination of the micronutrient content. Currently, the MoH-Ramallah receives only flour and premix samples from the GS sent by producers interested in certification for commercial purposes (bidding) or samples of flour donated by the WFP or UNRWA. Results of the monitoring of food fortification According to the data provided by the MoH, during 2016 –2020, the monitoring of the fortification program collected an average of 114 samples each year, all of them from the WB. As shown in Table 10, in 2020, only 35 percent of the flour available was produced in the Palestinian Territory, whereas in the same year, 67 percent of the samples collected by the monitoring system corresponded to domestically produced flour. This discrepancy indicates that the monitoring is not collecting representative samples of the flour available in country. As Figure 3 illustrates, during 2016–2020, between three and five percent of the samples complied with the national standards of fortification 48. Therefore, we can conclude that the objective of increasing the general population’s iron intake as set by the national standards has not been achieved. The dataset with the results of the flour sample assessments was well-organized. However, the lack of some details does not allow further analysis. These include the identification of the inspecting team, the unique identifying codes for producers and bakeries, and the categorization of sources for producers, importers, and bakeries. 47 Includes a table with annual results and recommendations. 48 24–47% were assessed as negative by the qualitative test, and 51–74% were assessed as low (<25mg/kg) by the laboratory test. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 28 100% 150 Percentage of iron adequacy 80% among samples tested Number of samples 60% 100 40% 50 20% 0% 0 2016 2017 2018 2019 2020 Negative (Qualitative) Low (<25mg/kg) Adequate (25–60mg/kg) Number of samples Figure 3: Wheat flour compliance with national standards for fortification Source: Data collected by the Food Fortification Monitoring System As a precedent, in 2013, the PMS4 reported that only 30 percent of the wheat flour samples collected at the national level were adequately fortified with iron. Follow-up of laboratory assessment results According to the Palestinian Standards and Metrology Law No. (6) (2020), Public Health Law, and the Economy Law, when the MoH-CPHL declares that a sample does not comply with the standards, the producer, shop, or bakery receives a warning from the MoNE-CPD, the MoH-EHD, or the Custom Police. In the case of a second offense, the situation is presented directly to a Ministry of Justice judge who manages the case and is empowered to impose fines (maximum of 9,000 Israeli shekels49) and even jail sentences of up to one year. However, according to the MoH- ND, nobody has ever been prosecuted for not complying with the fortification program standards. In the case of imported flour that does not meet the standards, it can be taken to national mills for fortification. The MoH-EHD and the MoNE-CPD do not make recommendations about corrective actions. It is the judge who decides whether a fine should be imposed. There are no differentiated fines for bakeries and wheat flour producers. The Food Fortification Monitoring Committee (FFMC), which is chaired by the MoH-ND, also follows up on the collecting and testing of samples50. Before the 2020 coronavirus pandemic, the FFMC had quarterly meetings to discuss the collection of samples, laboratory analysis, and results. The agenda of those meetings also included actions in response to noncompliance (e.g., the involvement of the Food Industry Association to address noncomplying producers). The 2018 WHO Eastern Mediterranean Regional Office’s (EMRO)51 report about the status of food fortification in the region and the main challenges in the WB & GS emphasized the 49 Equivalent to US$2000. 50 Composed of representatives of various government bodies (Custom Police, Ministry of Social Affairs, PSI, MoH-CPHL, and MoNE-CPD). Other members of the committee include the Food Industries Association and international agencies such as UNICEF, WFP, and WHO. The constitution and members’ roles of the committee are also described in the Food Fortified Control and Monitoring Guide. 51 World Health Organization - Regional Office for the Eastern Mediterranean, Wheat flour fortification in the Eastern Mediterranean Region (Cairo, 2018). Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 29 “difficulties for border controls, weak monitoring, a lack of funding, and incomplete application of the law”. Assessment of availability of wheat flour in bakeries As described in Section 2.4, this assessment included visits to 15 bakeries (seven in the WB and eight in the GS). The key findings of those visits are presented in this section and should be considered within the context that the producers and/or importers do not provide fortification quality control certificates. However, it is also important to consider that the presence of the MoH food fortification logo, any other fortification label, or a perceived change in color52 does not ensure that a product has been fortified. Because of these circumstances, the bakery managers cannot be certain whether the flour they receive is fortified. This assessment found that wheat flour products were available for purchase and consumption in every bakery visited in the Palestinian Territory, namely in governorates with a high prevalence of anemia. All bakeries visited in this assessment reported to have ordered flour during the previous six months, and the amount received varied between 2,000 and 10,000 kilograms. Two-thirds of the bakeries visited reported they had changed suppliers at least once during the previous six months. Almost all those who changed suppliers explained that this decision was related to the “quality of the product.” Most commonly, they reported the presence of gluten, which they regarded as an undesirable element. In the WB, the seven bakeries visited reported that they were able to identify whether the wheat flour was fortified. Of these seven, five bakeries regarded the fortification logo on the packaging to be the key identifier of fortified flour. Only two of the seven bakeries that reported they were able to identify fortified flour claimed that they could do so based on the color of the product. However, the bakeries have no access to a reliable method to differentiate between fortified flour and unfortified flour. In the GS, none of the eight bakeries visited reported any kind of ability to identify fortified flour. Seven of the 15 informants reported that fortified flour has disadvantages, with a higher price and a change in color (to a yellowish color) as the most common ones. A third of the informants (five) commented that fortified flour has advantages, but only one out of the 15 visited reported a health-related advantage. Almost half the informants (seven) stated that balancing advantages and disadvantages, they preferred to buy fortified flour, and the other half had no preference. All bakeries in the WB and a half of those in the GS reported that they had been informed that adding iron to wheat flour is the producers’ legal responsibility. In the GS, the most frequent source of information was the MoNE, whereas in the WB, the main source was the MoH. Only three of the 15 combined WB & GS informants reported that they were aware of the national efforts to promote the consumption of iron-fortified flour. According to all informants, their customers do not have a preference for iron-fortified flour. 52Fortified flour may cause changes in color and taste. However, small changes are not visually noticeable. Visual inspection is not included among the quality control procedures of fortified flour. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 30 Vulnerable groups’ access to fortified food There are no national policies to ensure the vulnerable groups’ access to fortified food. However, the WFP and UNRWA provide fortified flour to refugees53 as part of essential food items. The WFP uses a global fortification formula, but in the WB & GS, it applies the national standards. Additionally, the WFP hires third parties to inspect mills and send flour samples to both the MoH- CPHL and laboratories abroad. The monitoring process occurs once in each distribution cycle, and if the samples fail to meet the standards, the batch is immediately rejected and sent back to the supplier. Even though all flour imported by the WFP and UNRWA is fortified, its distribution fluctuates with donations and does not cover all families’ needs. Additionally, the Ministry of Social Development distributes food, including flour imported by the WFP, to poor people to mitigate their food insecurity. On occasion, local donors distribute flour when implementing temporary programs, and the MoH ensures the distribution of fortified flour. 3.2.1.4 Activities and results: demand Behavior-change communication According to the MoH-ND, various efforts have been implemented to raise awareness of the importance of fortified foods. These include the production and dissemination of fortification information stickers at local bakeries and schools, brochures on fortified foods, ongoing educational seminars on food fortification, and educational advertisements on radio and TV. Another effort has been the design of the fortification program logo shown in Figure 4. Figure 4: MoH logo of Although not mandatory, the MoH-ND encourages the use of the logo both the fortification in fortified products for final consumers and bulk packaging. program The use of the logo or any other signal to identify fortified flour either in bulk packaging or in final products is not universal. Therefore, the identification of fortified flour at the point of delivery or from final consumers was not feasible. A communication strategy and action plan with objectives related to the promotion of the fortification program was not made available to this assessment. According to the MoH-ND, since the flour is not fortified, the MoH does not plan to promote the consumption of the flour. In addition, the MoH-ND does not have sufficient financial resources to implement advocacy or communication activities. The PMS 20134 is the most recent source of information regarding knowledge about the fortification program among the general population. The survey reported that only one-third of pregnant and postnatal women heard of fortified flour. The main sources of information cited were friends, media (e.g., TV, radio, newspapers), and educational tools (e.g., leaflets, information sessions). 53 According to the 2017 census, 40% of the national population are refugees, and in the GS, this percentage can reach up to 70%. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 31 3.2.2 Supplementation program 3.2.2.1 Policy framework Micronutrient supplementation in the WB & GS is guided by the MCNNP 201754, which was updated in July 202127. These protocols were developed with the support of UNICEF and other technical partners and are based on the national adapted guidelines for health care, such as the integrated management of childhood illness, and ongoing national programs, including ANC. They are also based on the internationally accepted guidelines and protocols for maternal and child care. The MCNNP sets the technical specifications for the prevention of iron deficiency anemia and is aligned with the most recent WHO guidelines for pregnant women55, postpartum women56, and children of ages 6–23 months, as well as with the MoH’s guidelines for antenatal, postpartum, newborn, and child care. Table 11 provides a summary of international iron supplementation guidelines and the National Protocols for the population most vulnerable to anemia. For each target population, the MCNNP includes additional guidance for care providers regarding other elements of care, such as counseling on dietary practices to increase iron and acid folic intake and on counseling to improve continuance and compliance57 with IFA supplementation and compliance monitoring58. The program managers interviewed for this assessment stated that the implementation of the activities and actions of the iron supplementation program is adequately informed by the guidelines and protocols. In the absence of the documented guidelines about the opportunities to provide iron supplements to children of ages 6–23 months, the MCNNP does not indicate the duration of supplementation, whereas the WHO recommends three consecutive months per year. The MoH- ND has verbally indicated that the most common practice is integrating the dispensation of iron supplements within visits to the PHC clinics for immunization and given that the immunization schedule ends at 18 months, in practice, the iron supplementation program does not continue beyond that age. The MoH-ND stated that it is reviewing evidence from the vitamin A supplementation program59 to assess the possibility of extending the supplementation program to children up to 23 months. Whereas children of ages 24–59 months were included within the target population in the protocols of 2017 and 2021, the MoH has not distributed iron supplements to them. The prevalence of anemia in this group has been estimated at 15 percent in the WB and 21 percent in the GS4, whereas the WHO’s recommendations set a minimum of 40 percent prevalence to include them as a target group for the supplementation program. 54 Nutrition Department - Directorate General of Primary Health Care and Public Health - Ministry of Health - State of Palestine, "Maternal and Child National Nutrition Protocol," (2017). 55 World Health Organization, WHO recommendations on antenatal care for a positive pregnancy experience (Geneva, 2016). 56 World Health Organization, Guideline daily iron supplementation in adult women and adolescent girls (Geneva, 2016). 57 Messages included in the protocol: When and how to take supplements, how to store supplements (keeping supplements out of reach of children), when to return for more tablets, how to give supplements to children, the importance of taking all supplements, side effects (what they are and that they are not serious and should subside in a few days), managing side effects if they do not subside, reinforce there are no negative effects from taking IFAS. 58 The protocol indicates that during the follow-up, patients should be asked about their stool color and side effects. 59 According to the MCNNP, children 12–59 months of age receive vitamin A supplements every four to six months. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 32 The supplementation program does not target adolescents as a group because according to the PMS 20134, the prevalence of anemia in this group was 15 percent and thus below the WHO’s minimum prevalence of 40 percent. Furthermore, the MCNNP, updated in July 2021, includes a chapter with supplementation guidelines for children of ages 5–12 years and adolescent girls in locations with an anemia prevalence of at least 40 percent in alignment with the WHO’s guidelines. Although the supplementation program does not target specific subgroups, the UNRWA’s health care services target refugee camps, providing antenatal, postnatal, and childcare services, including iron supplementation. Other organizations, including Juzoor for Health and Social Development, the Palestinian Medical Relief Society (PMRS), Health Work Committees, and the Palestine Red Crescent Society (PRCS), also deliver iron supplements as part of their services. However, as these organizations do not have a national-level presence, they were not included in this review. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 33 Table 11: Iron supplementation scheme recommended by the WHO and in the guidelines of the MoH and UNRWA Group WHO UNRWA MoH PREGNANT • At least eight ANC visits. • At least eight ANC visits. • At least four ANC visits. WOMEN • 30–60 mg of elemental iron plus 0.4 mg (400 • 30–60 mg of elemental iron plus 0.4 mg of folic • 60 mg of elemental iron plus 0.4 mg of folic μg) of folic acid daily throughout pregnancy60. acid61 daily throughout pregnancy62. acid61 daily at least six months into pregnancy • In settings where anemia in pregnant women • 60 mg in settings where the prevalence of and continuing to three months postpartum is a severe public health problem (40 percent anemia is higher than 40 percent. (or a total duration of nine months). among pregnant women), a daily dose of 60 • In settings with >40 percent of anemia54,27. mg of elemental iron is preferred at a lower dose. POSTNATAL • Oral iron supplementation, either alone or in • 60 mg of elemental iron and 2.8 mg of folic acid. • See aboveError! Bookmark not defined.,Error! Bookmark not WOMEN combination with folic acid, may be provided • One supplement per week until three months defined. . to postpartum women for 6–12 weeks after delivery. following delivery. • Following scheme used during pregnancy (daily or weekly). • In settings where gestational anemia is ≥20 percent63. CHILDREN 6–23 • 10–12.5 mg of elemental iron, in form of • Settings with ≥40 percent prevalence of • 12.5 mg of elemental iron, in form of drops or MONTHS drops or syrup, daily, one supplement per day anemia: syrup daily, one supplement per day. for three consecutive months per year. o 10–12.5 mg of elemental iron, daily, one • In settings with a prevalence of anemia of <40 • Low-birthweight infants should be given iron supplement per day, three consecutive percent, for children 6–12 months of age with supplements from two to 23 months of age. months per year. normal birthweight. • Populations where the prevalence of anemia • Settings with ≥20 percent prevalence of • In settings with a prevalence of anemia of >40 is ≥40 percent64. anemia: percent, for children 6–24 months of age with o 12.5 mg of elemental iron, twice a week normal birthweight. for three months, followed by three • For children 2–24 months of age with low months without supplementation. birthweightError! Bookmark not defined.. 60 World Health Organization, WHO recommendations on antenatal care for a positive pregnancy experience (Geneva, 2016). 61 The MoH and UNRWA distribute combined tablets of iron plus folic acid for pregnant and lactating women. 62 UNRWA, UNRWA - Technical Instructions Review (2020). 63 World Health Organization, Guideline Iron Supplementation in postpartum women (Geneva, 2016). 64 World Health Organization, Guideline: Daily iron supplementation in infants and children (Geneva, 2016). Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 34 Group WHO UNRWA MoH CHILDREN 24–59 • 30 mg of elemental iron daily, one • Settings with ≥40 percent prevalence of • 20–30 mg of elemental iron daily. MONTHS supplement per day, three consecutive anemia: • Note: Included in the National Protocol 2017 months per year. o 30 mg of elemental iron, daily, one and 2021 but not implementedError! Bookmark not • Where the prevalence of anemia is ≥40 supplement per day, three consecutive defined. . percent60. months per year. • Settings with ≥20 percent prevalence of anemia: o 25 mg of elemental iron, twice a week for three months, followed by three months without supplementation. CHILDREN 5–12 • 30–60 mg of elemental iron daily, one • Not included in the UNRWA’s Technical • 30–60 mg of elemental iron daily, one YEARS supplement per day, three consecutive Instructions. supplement per day, three consecutive months months per year. per year. • Where the prevalence of anemia is ≥40 • Where the prevalence of anemia is ≥40 percent60. percent. • Note: Included in the National Protocol published in July 2021Error! Bookmark not defined.. MENSTRUATING • 30–60 mg of elemental iron daily, one • 0.4 mg of folic acid daily for at least three • 30–60 mg of elemental iron daily, one WOMEN AND supplement per day, three consecutive months before pregnancy. supplement per day, three consecutive ADOLESCENT months per year. months per year. GIRLS • Where the prevalence of anemia is ≥40 • Where the prevalence of anemia is ≥40 percent65. percent. • Note: Included in the National Protocol published in July 2021Error! Bookmark not defined.. 65 World Health Organization, Guideline daily iron supplementation in adult women and adolescent girls (Geneva, 2016). Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 35 3.2.2.2 Financial resources Until 2018, the MoH procured iron supplements for all service providers with the financial support of UNICEF and the UNRWA, which were distributed by NGO clinics. Since 2019, the MoH procures iron supplements by means of public funding for distribution at its clinics, whereas the UNRWA and NGOs procure the iron supplements to be delivered to their own clinics with their own funds. Iron supplements are included in the MoH budget, approved by the Ministry of Finance, under the budget line for the procurement of essential medicines. The budget for the procurement of IFA and iron supplements was not made available to this assessment. According to the users of the MoH and UNRWA clinics, the delivery of IFA tablets to pregnant and postnatal women and iron supplements to children of ages 6–23 months is free of charge. 3.2.2.3 Program structure and contribution from partners The head of the MoH-ND is the main focal point of the supplementation program. The Central Warehouse Department is responsible for the procurement and distribution of iron supplements, and the MoH-CHD provides technical support and monitors implementation by clinics. The supplementation program receives technical advice from the WHO Regional Office, WHO country office, and UNICEF. 3.2.2.4 Activities: supply Infrastructure and access to relevant health services Given that access to clinics and the quality of services may affect the effectiveness of iron supplementation, this section provides an overview of the infrastructure and coverage of key services in the Palestinian Territory. In 2017, the MoH’s information system registered 743 PHC clinics with 583 of them located in the WB and 160 in the GS. As shown in Figure 5, in the WB, the MoH is the predominant health care provider, managing 71 percent of the PHC clinics in that region. In the GS, however, the main providers are NGOs that manage 50 percent of the clinics, followed by the MoH that manages 33 percent. However, the exact nature of other providers is unknown, as the MoH’s information system does not disaggregate clinics managed by specific NGOs or the private sector. Figure 5: Distribution of PHC clinics by region and management organization 66. Source: HAR 2017 66 PMMS stands for Palestinian Medical Military Services. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 36 The number of inhabitants to PHC clinics registered by the MoH was three times higher in the GS (11,725) than in the WB (4,408)1, illustrating that access to clinics may be more limited in the GS. As Figure 6 illustrates, the variation was considerable between the governorates inside each province: in the GS, this ranged from 9,304 in Deir al-Balah to 13,758 in Rafah, and in the WB, this ranged from 3,026 in Jerusalem to 5,780 in Nablus. Figure 6: Ratio of inhabitants to PHC clinics by governorate and region Source: HAR 2017 Access to ANC The reported number of pregnant women with at least one ANC visit registered by the MoH- HAR has experienced a steady annual increase from three percent in 2018 to four percent in 2019, a rate slightly higher than the projected population growth of 2.5 percent estimated by the Palestinian Central Bureau of Statistics (PCBS)67. The MoH-HAR 20192 included the ratio of women who made at least one ANC visit to the MoH clinics to the number of live births registered in the same year, which is 0.46. This ratio varied across governorates, ranging from 0.2 in Bethlehem to 0.98 in Salfit. According to the UNRWA monitoring system, the ratio for pregnant women attending UNRWA clinics to the number of live births registered in UNRWA clinics was around one. The MoH-HAR reported that in 2019, the average number of ANC visits among users of MoH clinics was 4.2 visits, and this figure varied across governorates from 3.8 to 5.1 ANC visits. In the same year, the UNRWA monitoring system registered that 97 percent of pregnant women attended four or more ANC visits in the GS, compared with 87 percent in the WB. A household-based survey implemented in 2019–20208 reported that 87 percent of pregnant women make their first ANC visit with a gestational age of four or fewer months. This percentage was lower in the GS (81 percent) than in the WB (91 percent), also indicating disparity in the access to timely ANC services between these two regions. 67Palestinian Central Bureau of Statistics, "Palestinian Central Bureau of Statistics, Estimated Population in Palestine Mid-Year by Governorate,1997-2021." Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 37 Access to anemia testing The coverage of anemia testing among pregnant women who attend MoH clinics68 was 41 percent in the WB, while among users of UNRWA’s clinics69, it reached 90 percent in the GS and 82 percent in the WB. The total number of pregnant women tested for anemia in UNRWA’s services (47,224)70 was almost twice as those tested in MoH services (26,610)2. Quantification of needs A written description of the procedures to estimate the annual needs was not made available to this assessment. In the assessment, the officers of the Central Warehouse Department at the central level and the MoH-CHD at the governorate level informed that the amount of iron supplements to be procured is based on the annual requirements of each governorate of the WB & GS71. Each governorate estimates its requirements based on the annual requests made from its network of clinics, which in turn is based on their annual amount distributed as the process illustrates in Figure 7. The aggregated estimation of needs is submitted to the MoH bidding committee, which launches the procurement following the established process for the acquisition of pharmaceuticals. A document or verbal statement describing the procedure to confirm the needs estimated by the governorates was not made available to this assessment. The procurement and distribution of iron supplements The bidding committee of the MoH includes representatives from the Procurement Unit, the Department of Drug Registration, the Department of Pharmacy, the Central Warehouse Department, the General Administration of Primary Health and Hospitals, and the MoNE. Once selected, the provider delivers the order to the central medicine store in the WB that dispatches the supplies to the governorates’ warehouses (central pharmacies) as shown in Figure 7. The governorates distribute the supplies of iron supplements and other pharmaceutical products in response to the bimonthly requests submitted by primary and antenatal health care clinics. The amount requested by the clinics is based on the consumption during the previous period and the stock on hand. In turn, the governorates submit the clinics’ requests to the central medical warehouse every two months. In case of a shortage of stocks, the Central Warehouse Department is authorized to order the procurement of additional supplements for up to 15 percent of the annual amount without a new bidding process. 68 Tested at 36 weeks of gestational age, pregnant women with at least one ANC visit registered in 2019. The MoH Guidelines for Standard Antenatal Care indicate hemoglobin control at the first visit and the 24–28th and 36th weeks of pregnancy, but the HAR includes test results at the 36th week of pregnancy. 69 Tested at 24 weeks of gestational age, pregnant women with at least one ANC visit registered. The UNRWA Health Department Technical Instructions Review (January 2020) indicates anemia testing at 24 weeks of gestational age. 70 UNRWA, "UNRWA Collective Reports," (2019). 71 The head of the MoH-ND indicated that in 2017, the ND provided a quantification of needs based on the number of live births. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 38 Ministry of Health -supply chain of iron supplements Central Level Governorate Clinics Yearly order Bids Committee Annual quantification Annual Annual of needs consumption consumption MoH - Primary Health Care Provider MoH Central Clinics Governorate Warehouse and Authority Department Supply Request Supply Request Antenatal Clinics every second every second month month Shipment every Shipment every Annual second month second month shipment (if required) (if required) Figure 7: Supply chain of iron supplements in the MoH Monitoring of stocks (logistics information) The MoH Central Warehouse Department runs a routine quality control when it receives iron supplements. This includes physical counting, the identification of damaged products, and the verification of shelf life. Each clinic verifies the visible characteristics of the products received (including the integrity of packaging and color of products). According to the Central Warehouse Department, the clinics and governorate warehouses do not submit reports of stocks, so this information is not available for monitoring at the central level. However, the head of the Central Warehouse Department, who is responsible for governorate warehouses and clinics, mentioned that the program has rarely experienced stockouts at the main warehouse in the WB, governorate warehouses, or clinics, and when this happened, it lasted only for a few days. The stockouts were due to delays in supplying the products or clinics missing the submission of supply requests for more than two cycles. The amounts of supplements estimated to be needed and/or distributed to each PHC clinic or governorate by the MoH and the occurrence and duration of stockouts at any level were not available for this assessment. Multiple informants involved in the management of the supplementation program confirmed a lack of access to logistics information. Stock management (spot check of warehouses and clinics) Eight PHC clinics managed by the MoH and UNRWA (four per region, including two from MoH and two from UNRWA), plus three central pharmacies (MoH-WB, MoH-GS, and UNRWA-GS, total n=11 facilities), were visited during this assessment. During these visits, we found that the managers of all central pharmacies are qualified pharmacists. In addition, four of the eight clinic managers were also pharmacists, and the assistant pharmacists manage the remaining four clinics. Almost all (10 out of 11) heads of clinics and central pharmacies reported that they had occupied their current position for at least 10 years. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 39 The staff of all UNRWA facilities and the MoH central pharmacy in the GS reported that they have learned to use logistic forms in a workshop. The staff of MoH clinics and the central pharmacy in the WB reported to have learned the use of logistic management forms through on-the-job training and self-learning. Apart from the MoH central pharmacies, which are the highest technical authority in their regions, all other facilities visited by this assessment reported to have received supervision, including verification of the proper use of logistic forms, in the previous month from governorate-level staff. Supply of iron supplements According to their head, the MoH central pharmacy of the WB and all UNRWA facilities submit monthly reports, which include the stock on hand and the quantities dispensed. The MoH’s clinics, on the other hand, do not report the stocks available, which was confirmed by the staff responsible for the stocks in clinics, staff of the MoH’s central pharmacies, and the MoH-ND. The head of the UNRWA central pharmacy reported receiving monthly reports from their network of clinics. This assessment did not have access to the amount of iron supplements distributed to each clinic or governorate. Although the amount distributed by each clinic to the target population is reported monthly, this assessment only had access to the annual national consolidated data reported in the 2019 HAR72. The heads of the MoH central pharmacies informed that they receive bimonthly requests of supplies from the governorates. For the MoH, the quantities to be resupplied are determined by the facility itself, whereas for the UNRWA, the quantification involves a higher-level facility. The calculation of the amount to be requested was clearly explained in all UNRWA facilities, MoH central pharmacies, and one of the four MoH clinics visited based on the consumption during the previous period, the stock on hand, and the need for a buffer stock. The time between ordering and receiving products was reported as under one month, apart from the MoH central pharmacy in the GS (more than two months) and one MoH clinic in the WB (between one and two months). These reports were verified in the six establishments that made available the necessary documentation to this assessment: the iron supplements were received after 3–31 days in the five verified clinics and after 184 days in the UNRWA central pharmacy of the GS. The assessment also verified that among those six establishments, only one MoH clinic received less than the amount ordered (44 percent of the total). Availability of stocks In none of the facilities, an emergency order was necessary during the previous three months. However, among all the facility heads interviewed, there were reports of previous experience with a) stockouts (the MoH central pharmacy in the GS, one UNRWA clinic, and one MoH clinic) and b) no surplus of stocks before the resupply was received (two UNRWA clinics). Only in the UNRWA central pharmacy was possible to verify the amounts ordered versus the amounts supplied, and these were found to be identical during the year 2021 for iron drops and IFA tablets. All facilities reported the use of registers in the management of health products. The MoH central pharmacy in the WB and all UNWRA facilities have adopted a system based on digital 72 Annex 51 in the Palestinian Health Information Center (PHIC)- Ministry of Health, "Health Annual Report - Palestine 2019." Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 40 registers only. In fact, out of the 11 facilities visited, two UNRWA clinics did not have the availability of stock registers verified due to the informants’ limited access to the digital information system. In the remaining nine facilities (six clinics and three central pharmacies), the registers indicated that the stocks were available on the day of the assessment visit, and during the previous six months, only one UNRWA clinic experienced a stockout of iron tablets for nine days. In those five facilities that made the documentation required by the assessment available, the assessment verified that the stock was adequate to cover between four to six months of the average monthly consumption. A physical verification of stocks, however, was not possible at the time. Programmatic quantification of needs versus National Protocol-based estimation of needs To estimate the number of supplies required to cover the needs of pregnant and postnatal women based on the National Protocol, this assessment assumed that 270 IFA tablets (nine months × 30 tablets/month) should be available for each pregnant woman who received at least one ANC service. The amounts of National Protocol-based IFA needs of pregnant and postnatal women in 2019 were compared against the amounts estimated to be needed or distributed per region by the MoH or UNRWA. These are set out in Figure 8. For MoH, GS was excluded because the annual number of new pregnant women registered is not available73; and for UNRWA, the estimated needs for GS and the amount distributed to WB were not available for the assessment. The MoH’s estimation of needs for the WB was equivalent to 77 percent of the protocol-based needs, and the actual amount distributed was equivalent to 61 percent of the protocol-based needs. With a similar approach, the UNRWA’s estimation of needs was equivalent to the 84 percent of the protocol-based needs in the WB, and the amount distributed in the GS was equivalent to 77 percent of the protocol-based needs. The details of these estimations are set out in Appendix 0. 84% 77% 77% 61% West Bank West Bank Gaza Strip MOH UNRWA Estimated needs Distributed Figure 8: Percentage of National Protocol-based needs for IFA tablets for pregnant and postnatal women covered by the amount estimated and the amount distributed by the MoH and UNRWA 2019 73For GS, the annual number of registered pregnant women includes those registered in the previous year and still attend the clinics, and those registered in the year reported. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 41 Monitoring of iron supplementation services The staff members of the MoH-CHD supervise clinics providing antenatal, maternal, and child health care. This includes reviewing all health care services, including the delivery of IFA and iron supplements. A supervision plan, schedule for supervisory visits, and standard supervision guides were not made available for this assessment. The PHC clinics submit monthly reports to their governorate, including the quantity of supplements distributed to children, pregnant, and postnatal women. At the governorate level, the staff of the MoH-CHD enter the data from the monthly report into an online information system. At the central level, the staff of the MoH-CHD review and approve the reports, and then the data are shared with the MoH-Health Information Center. The indicators regarding supplementation that are included in the HAR are based on the clinic’s monthly reports. The reports received by the MoH-CHD are accessible to the MoH-ND upon request. Written guidance about the preparation of these monthly reports was not made available to this assessment. The MoH-CHD can follow up with the governorates in cases where it identifies issues, such as the case of the MoH-CHD requesting the governorate’s intervention when it detected that some clinics were delivering supplements for more than 24 months. The MoH clinics do not register information about the elements of care associated with the supplementation program, such as counseling or following up on compliance. Regarding the delivery of supplements to the target population, the only indicator is the number of units of IFA tablets distributed against the registered number of pregnant women and bottles of iron drops against the registered number of children aged 12 months. These data are set out in the HAR2. In the case of children, the number of bottles reported include those distributed to children older than 12 months74; therefore, the rate reported (bottles/children aged 12 months) is overestimated. In both cases, the rates do not inform about the percentage of users not receiving adequate iron supplementation. The program managers interviewed by the assessment highlighted that the private providers of antenatal, postnatal, and child care do not report to the MoH information system. In addition, the clinics in the GS do not report information to the MoH-CHD in Ramallah either. Training The MoH-ND organizes occasional training to the PHC clinical staff about the implementation of iron supplementation, sometimes in collaboration with the MoH-CHD or at the request of the governorates. The training is channeled through meetings, workshops, and training-of- trainers, which are implemented at the central and peripheral levels. The MoH does not produce training plans, and trainings have typically been associated with the launching of new guidelines or protocols. During 2020, there were no trainings because of the COVID-19 pandemic. 74Written guidelines to fill the monthly report, including the number of iron supplements distributed, are not available. This statement is based on a verbal description provided by the staff of a PHC clinic. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 42 3.2.2.5 Activities: Demand Behavior-change communication The MoH Education and Promotion Department, in collaboration with the MoH-ND, has occasionally produced information, education, and communication materials. However, they reported that due to limitations in staff and transport, they distribute them only to governorates and MoH partners, such as UNRWA, but do not generally train staff to use them. On occasion, UNICEF has provided technical and financial support to produce and broadcast educational material on nutrition but not specifically on anemia prevention. Although the MoH does not have a communication plan for the prevention and control of iron deficiency, some of its nutrition experts appear occasionally on TV and radio to promote positive nutrition practices, including compliance with the supplementation program. The staff of the Education and Promotion Department at the governorate level conduct monthly educational presentations for mothers attending the clinics. These cover various topics such as nutrition and anemia. The outcomes of these meetings are reported to the Education and Promotion Department. While the HAR includes a variety of tables reporting the health education activities implemented by the MoH, it does not identify those with nutrition- related content. Barriers for demand The barriers to the implementation of APC activities relevant to the WB & GS and the proposed solutions were identified by this assessment through the review of 28 peer-reviewed papers published between 2014 and 2020 and four reports from the gray literature published between 2005 and 2020. The results from this review are set out in Table 12 below. Table 12: Summary of findings from the literature review Behavioral barriers Proposed solutions to overcome barriers Access • Free services and other supporting measures to increase accessibility. • Policies and guidelines for medical or ANC staff to provide information for patients to educate them about the benefits of supplementation and nutritional advice, showing Policy a clear health education strategy. • Deworming and information about the relationship between parasites and anemia in health centers. Cues for action/ • Follow-up measures from health centers to increase the compliance of visits (e.g., SMS reminders reminders, paper-based reminders). Perceived susceptibility/ • Actions to enhance the patients’ general knowledge of pregnancy or children’s risk development and anemia (e.g., videos and slides in ANC show good evidence). Perceived severity • Providing information to increase knowledge of iron supplementation in pregnancy or Perceived positive infancy, aiming to enhance compliance (e.g., management of side effects). consequences • Information on how to breastfeed, benefits of exclusive breastfeeding, and the Perceived action efficacy weaning process starting point. • Providing information to educate health care providers and users about the benefits Culture of supplementation and nutritional advice, showing a clear health education strategy that is culturally appropriate. Perceived self- • Receiving information to increase knowledge of the benefits of supplementation and efficacy/skills nutritional advice and the management of side effects. • None identified. It appears that there are no perceived social norms affecting Perceived social norms supplementation or fortification in a detectable way. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 43 The presence or absence of the identified barriers and their solutions were confirmed through 97 KIIs with stakeholders, according to the area of expertise and influence, namely policymakers and program managers, service delivery providers, and final users. The types of barriers explored for each stakeholder group are shown in Table 13 below. Table 13: Number of interviews and the type of barriers explored for each stakeholder group Group of stakeholders Barriers Explored Policymakers and program • Access and policies managers (n=17) • Cues for action/reminders Service delivery providers • Perceived self-efficacy (n=16 service providers for • Perceived risks pregnant women and n=16 • Perceived positive consequences service providers for mothers • Perceived action efficacy and children) • Culture • Perceived social norms • Cues for action/reminders Final users • Perceived self-efficacy • Perceived risks (n=24 mothers of children of • Perceived positive consequences ages 6–11 months and n=24 • Perceived action efficacy pregnant women) • Culture • Perceived social norms The findings from the interviews helped to confirm the perceived absence or presence of the barriers identified in the literature review and to explore the possibility of detecting additional barriers unique to the explored settings. The main findings grouped by the type of barrier are discussed below. Policies The policymakers and program managers mentioned that the promotion of the adequate intake of iron is not sufficient. They mentioned that if the MoH and its partners could assign more resources to improve the awareness of anemia and the available preventive services, a consequent seeking behavior for APC services would follow. Access Iron supplements are delivered free of charge. Free services and supplementation, including IFA and iron, decrease the financial barrier to health care access. Independent from the fact that it is possible that there is an underestimation of needs, none of the program managers or service delivery providers interviewed mentioned stockouts, shortages of iron supplements, or health services as access barriers. There are policies in place to monitor quality control of service provision. However, pregnant women and mothers of 6–11-month-old children who participated in this assessment reported that they had sought additional services in the private sector, and almost half of those interviewed reported that they do this because of quality concerns. This assessment did not register specifics regarding those quality concerns. Cues for action/reminders According to the data from the patients and service providers, health units implement an effective reminder system of appointments for preventive services (e.g., ANC). Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 44 Perceptions and culture Patients can identify anemia as a “nutrition-related issue linked to iron” and recognize that it may have negative consequences for health, such as affecting wellbeing and children’s development, and they seem to be open to receiving iron supplements, which are free of charge and obtained directly from the health centers. The service providers informed the assessment that they commonly use protocols and guidelines as technical guidance for providing health care to their patients. However, most of the providers interviewed do not consider their protocols comprehensive enough for anemia prevention and treatment. When the providers were asked about the changes needed in the protocols, there was no elaboration. Therefore, this assessment cannot remark any specific points to attend to this matter. In the same tenor, patients consider the information they receive about nutrition to be inadequate, but they did not elaborate about it either. Importantly, the patients do not consider that they receive enough information about the expected and undesired side effects of iron supplementation or how to manage them. This could be one of the points of concern regarding the quality of the services. Almost none of the patients who reported to have suffered the undesired side effects of iron supplementation discussed it with the medical staff and reported to have interrupted the intake of the supplementation for this reason. However, the medical staff manifested that they think that the patients comply well with the supplementation. This discrepancy may be due to the insufficient monitoring of the undesired effects of supplementation by service providers. This assessment did not use probes to explore the subjacent reasons for noncompliance, so the actual reason for noncompliance may have not be reported by the patients. The discrepancy identified between the health staff’s perception and the patient’s answers about compliance is relevant because if the patients could discuss this problem with the medical staff, together, they could identify the real problem for noncompliance and find alternatives to solve it, hence avoiding the treatment interruption. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 45 3.2.3 Promotion of an increased dietary intake of micronutrients The current National Nutritional Policy75 includes other interventions that the WHO6 considers to be effective in preventing anemia, such as raising “awareness regarding foods rich in micronutrients, foods that improve micronutrient absorption and those that interfere negatively micronutrient absorption”. In compliance with this policy, the MCNNP provides guidance to all stakeholders and caregivers regarding the promotion of breastfeeding and dietary counseling during pregnancy and lactation76 and complementary feeding of children of ages 6–23 months. The counseling protocol indicates the use of a nutritional checklist and the anthropometric assessment of nutritional status, to identify the specific areas for counseling to the pregnant and postnatal women, her husband or other family members. The MoH-ND collaborates with the Education and Promotion Department to produce educational materials, including brochures, pamphlets, and radio and TV messages. The MoH Department of Education and Promotion distributes the material mainly to the MoH’s PHC and antenatal clinics, and if available, to other partners providing health care services. For specific campaigns, the MoH-ND prepares communication material with the technical and financial support of agencies such as UNICEF and the WHO. The MoH-ND also organized and implemented occasional trainings to MoH health care providers until 2019, when these were interrupted due to the COVID-19 pandemic. Depending on the number of trainees and travel conditions, these trainings were decentralized or located in Ramallah. On occasion, the MoH-ND has trained staff at the directorate level, which then replicates the contents using the training of their modality. According to the MoH-ND, these training events were implemented to support the launching of new programs, protocols, or guidelines or upon the identification of a large group of new staff but did not follow an overall training plan. The MoH-ND can produce communication materials and organize trainings in response to requests from subnational authorities of the MoH; however, the MoH-ND has no resources to cover transportation costs. The MoH-ND has the capacity to send reminders and nutrition-related messages to clinic users and sends updated protocols to the Directors of Governorates Department, which in turn forwards those documents to the governorates. Additionally, there is a National Committee for Breastfeeding, led by the MoH-MCH Department, whose activities mainly include the development of guidelines and training materials. A Baby-friendly program is operating in all MoH hospitals and clinics as well as in some private hospitals and is under the supervision of the MoH-ND. The monitoring of the implementation of activities promoting exclusive breastfeeding and complementary feeding through periodic supervision is the responsibility of each directorate. This assessment did not identify the availability of that information at the governorate or central level. UNICEF’s Multiple Indicator Cluster Surveys (MICS)7,8 identified that between 2014 and 2020, there was an increase in exclusive breastfeeding of children of ages 0–5 months from 39 to 43 75 Nutrition Department - Public Health General Directorate - Ministry of Health - State of Palestine, National Nutrition Policy Strategies and Action Plan 2017 - 2022, (2017). 76 Objectives of counseling for pregnant and lactating women: increase food quantity and/or variety; use fortified foods (flour and salt); eat more iron-rich food; avoid drinking tea, coffee, or cocoa during meals or within two hours of a meal; eat more foods high in natural vitamin A; and practice hygienic food preparation. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 46 percent and a slight decrease in breastfeeding and receiving semi-solid or solid meals from 45 to 41 percent for children of ages 6–23 months. These results demonstrate the progress achieved in the promotion of breastfeeding but not in the promotion of adequate complementary feeding. However, in both cases, there is a considerable room for improvement. 3.2.4 Other anemia prevention and control interventions 3.2.4.1 Water, sanitation, and hygiene (WASH) The deworming program of the MoH is currently inactive; however, the MoH-EHD implements the surveillance of the quality of water and distributes chlorine to the population. In addition, in response to the restricted access to safe drinking water and poor sanitation77, initiatives by organizations such as the Palestinian Water Authority; the water, sanitation and hygiene (WASH) cluster78; and UNICEF provide support to the rehabilitation and construction of the WASH infrastructure. Considering that the presence of hookworms has been reported in the GS79, it is relevant that the albendazole distribution in schools is managed by the UNRWA (single dose for three successive years) with the support of the WHO. The increase in the percentage of children under five years old who had an episode of diarrhea in the previous two weeks from 11.3 percent in 20147 to 14.5 percent in 20208 is indicative of the status in sanitation among the population of the WB & GS during that period. In 2020, this percentage was higher in the GS (17 percent) than in the WB (13 percent) and higher in the poorest quintile (17 percent) than in the richest quintile (13 percent)8, illustrating differentials across the regions and socioeconomic levels. 3.2.4.2 Reproductive health Physiological factors such as menstruation and pregnancy increase iron needs and the risk of anemia. Because of those factors, some reproductive health practices have a role in the prevention of anemia among women, including the delay of the age of first pregnancy, optimal birth spacing, access to adequate ANC, and optimal timing of umbilical cord clamping. The MoH and its partners offer family planning services that promote the use of modern contraceptives and birth spacing. However, during the last five years, there has been no progress in the coverage of family planning, and there are differentials across regions: the percentage of married women ages 15–49 years with unmet needs for family planning was estimated in 2020 as 13 percent8, which was slightly higher than the 11 percent estimated in 20147. In 2020, the percentage of unmet needs was 14 percent in the WB and 12 percent in the GS. Although delayed cord clamping is recommended in the obstetric guidelines of the MoH80, its implementation is not monitored by the MoH. The MoH-ND does not collect or receive information about the monitoring of interventions with objectives related to WASH and reproductive health. 77 In the GS, only 10 percent of households have direct access to clean and safe drinking water. In the WB, a significant majority of the population has direct access to a water source but in insufficient quantities. Only 38 percent of the people in the WB and 82 percent of the people in the GS are connected to sewage lines (UNICEF, Children in the State of Palestine 2018). 78 Partners operating in various humanitarian sectors such as food security, protection, education, health, and shelter. 79 Sami Bdir and Ghaleb Adwan, "Prevalence of intestinal parasitic infections in Jenin Governorate, Palestine: a 10 –year retrospective study," Asian Pacific Journal of Tropical Medicine 3, no. 9 (2010), https://doi.org/10.1016/s1995-7645(10)60179-4. 80 State of Palestine - Ministry of Health - Women's Health and Development Directorate, "Obstetric Guidelines and Labour Ward Protocols," ed. Ministry of Health (2016). Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 47 4 MAIN CONCLUSIONS TARGETING: Are the programs targeting the right populations? Anemia is a public health problem among pregnant and lactating women, children of ages 6– 59 months, and adolescents (Figure 9Error! Reference source not found.), and its prevalence has remained static during the last decade in the WB & GS. The results of this assessment confirm that the APC programs that follow the National Protocols adequately target the populations most vulnerable to anemia in the WB & GS. Figure 9: The prevalence of anemia among the most vulnerable groups in the WB & GS, according to the WHO’s classification of anemia as a public health problem81 The prevalence and distribution of anemia is affected simultaneously by a broad range of factors. This assessment identified that residing in the GS is associated with a higher prevalence of anemia across all the four groups: pregnant women, lactating women, children of ages 6–59 months, and adolescents. Iron deficiency was also associated with anemia across all groups, whereas other associated factors were specific to some of the population groups. The most relevant factors were the deficiency of vitamin A or folate, diarrhea, fever, failure to take IFA supplements during and after pregnancy, failure to take IFA supplements regularly during and after pregnancy, infrequent consumption of iron-rich foods, and socioeconomic disadvantages. The food fortification program aims to increase the intake of iron and other micronutrients of the entire population by adding 10 micronutrients to wheat flour, including iron, vitamins A and B12, and folic acid. The MoH and UNRWA are the main implementers of the iron supplementation program and distribute iron supplements to pregnant and postnatal women and children of ages 6–23 months in the Palestinian Territory. This is aligned with the WHO’s supplementation program inclusion criteria and has been designed to respond to the high prevalence of anemia among the high-risk groups shown in Figure 9. All health care providers are expected to follow the guidance set out in the MCNNP on nutritional counseling to increase the intake of micronutrient-rich foods among pregnant and 81 Data sources are detailed in section 3.2. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 48 postnatal women and children aged up to 59 months82. The guidance includes the promotion of breastfeeding and complementary feeding. The updated version of the protocol published in July 2021 includes adolescents and school-aged children. SERVICE DELIVERY: Are high-risk populations receiving adequate and necessary services? The food fortification program is not contributing to the increase in the intake of iron as expected. Only three to five percent of the flour samples collected complied with the national standards. While a monitoring system in the WB can identify producers, wheat flour importers, and bakeries selling non-fortified flour, the enforcement mechanisms have not been effective. The promotion of the consumption of fortified flour has been reduced, and the bakeries and final users cannot differentiate what products are adequately fortified. Further strengthening of the legal framework and a dialogue with the commercial sector to identify proper incentives are required. The amount of IFA tablets distributed by the MoH to PHC clinics was substantially lower (61 percent) than the amount needed to meet the iron supplementation needs as defined by the National Nutrition Protocol for the number of pregnant women registered at ANC services. This result indicates that the target population is consuming fewer iron supplements than recommended by the National Protocol. This shortfall results from a combination of factors, including a late start of ANC visits and the noncompliance of patients with the iron supplementation regime. The iron supplementation program partially covers the requirements of the target population by distributing supplies based on previous consumption instead of the actual needs. The MoH and UNRWA are the main providers of PHC services in the two provinces. However, analysis of the information available to this assessment revealed variation across regions and governorates in access to health services and iron supplementation. Additionally, while a high percentage of pregnant women have access to ANCs, there is no information available about the quality of the services received from private providers and NGOs or if they include iron supplementation. For vulnerable and disadvantaged segments of the population, the lack of adequate access to health services hampers their ability to benefit from iron supplementation initiatives. Nutritional counseling and following up There was a lack of information available about the elements of care associated with iron supplementation (e.g., counseling to improve continuance and compliance, and compliance monitoring). However, the substantial unmet supplementation needs suggest the presence of a combination of circumstances that may be hindering the effectiveness of the supplementation program. These would include a late start of ANC, and an ineffective counseling and following up to address issues related to the compliance of iron supplements. A multilevel effort aiming to improve the services associated with the delivery of iron supplements is required, namely counseling and compliance monitoring. Are the supplies available? 82 Counseling protocol is described in section 3.2.3 Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 49 This assessment found that wheat flour products were available for purchase and consumption in all the bakeries visited in the Palestinian Territory, including governorates with a high prevalence of anemia. However, these products were not necessarily fortified, and their fortification status could not be established. The proportion of the population with an adequate iron intake is, therefore, unknown, and there are insufficient data to make a calculation. However, based on the MoH monitoring results, we can infer that is extremely low. IFA tablets and iron drops were found to be available in all the clinics and pharmacies visited, both in the WB & GS. Information about the frequency of stockouts of iron supplements at MoH clinics and the governorates’ central pharmacies was not available for this assessment. However, according to the staff interviewed from central, governorate, and clinical levels, the occurrence of stockouts of iron supplements is rare and short. In facilities that made registers available for verification, stocks were found to be sufficient for four to six months, according to previous consumption patterns. All the patients interviewed reported to have received supplements during consultations and not to have paid for their iron supplements. Incentives and barriers to APC This assessment did not identify significant cultural barriers impeding APC strategies, and no beliefs or cultural practices were found to hamper patients engaging in APC activities. However, several other implementation barriers were identified. The incentives for the MoH to promote the consumption of fortified food are limited. The population cannot make informed decisions at the points of purchase because in practice, the availability of non-fortified flour is substantial, and the consumer cannot rely on any brand or, indeed, the food fortification logo to differentiate between wheat products that contain fortified flour and those that do not. Regarding APC services, some patients interviewed expressed dissatisfaction with the services they received. This included the lack of information they received about the side effects of iron supplementation and the best way to manage them. Some were dissatisfied with the communication style from the clinic’s staff overall, which was reported to be a top-down transmission of information with few or no opportunities for questions and answers. This weak information flow and support of the patients’ health literacy regarding APC are not supporting effective counseling and may be hindering the resolution of the compliance with supplementation regimes. 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Nutrition Department - Directorate General of Primary Health Care and Public Health - Ministry of Health - State of Palestine. "National Nutrition Surveillance System Report 2018." 2018. Nutrition Department - Directorate General of Primary Health Care and Public Health - Ministry of Health - State of Palestine. Palestinian Micronutrient Survey 2013. (2014). Nutrition Department - Public Health General Directorate - Ministry of Health - State of Palestine. National Nutrition Policy Strategies and Action Plan 2017 - 2022, 2017. Nutrition Department - Public Health General Directorate - Ministry of Health - State of Palestine. Palestinian Flour Fortification Formula, 2010. Osendarp, SJM, Martinez, H, Garrett, GS, Neufeld, LM, De-Regil, LM, Vossenaar, M, and Darnton-Hill, I. "Large-Scale Food Fortification and Biofortification in Low- and Middle-Income Countries: A Review of Programs, Trends, Challenges, and Evidence Gaps." Food Nutr Bull 39, no. 2 (Jun 2018): 315-31. https://doi.org/10.1177/0379572118774229. https://www.ncbi.nlm.nih.gov/pubmed/29793357. Palestine Economic Policy Research Institute (Mas). "Socio-economic and food security survey 2018 - State of Palestine." (2018). Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 51 "Palestinian Central Bureau of Statistics, Estimated Population in Palestine Mid-Year by Governorate,1997-2021." 2018, accessed 30.05.2021, https://bit.ly/3ltWX3Y. Palestinian Central Bureau of Statistics, SOP. "Palestine in Figures, 2019." (March, 2020). Palestinian Central Bureau of Statistics, U. Palestinian Multiple Indicator Cluster Survey 2019-2020 - Survey Findings Report. (Ramallah, Palestine: 2021). Palestinian Central Bureau of Statistics, U, Unfpa. Palestinian Multiple Indicator Cluster Survey 2014 - Final Report. (Ramallah, Palestine: 2015). Palestinian Health Information Center (Phic)- Ministry of Health. "Health Annual Report - Palestine 2019." 2019. Palestinian Health Information Center (Phic) - Ministry of Health. Health Annual Report - Palestine 2018. (2019). Palestinian Health Information Center (Phic) - Ministry of Health. "Health Annual Report - Palestine 2020." 2020. Palestinian Standard Institution - Palestinian Authority. Mandatory Technical Instructions 9-2005 Wheat Flour, 2005. Pasricha, S-R, Tye-Din, J, Muckenthaler, MU, and Swinkels, DW. "Iron deficiency." The Lancet 397, no. 10270 (2021/01/16/ 2021): 233-48. https://doi.org/https://doi.org/10.1016/S0140-6736(20)32594-0. State of Palestine - Ministry of Health - Women's Health and Development Directorate. "Obstetric Guidelines and Labour Ward Protocols." edited by Ministry of Health, 2016. The Population Health and Nutrition Information Project. Anemia Prevention and Control: what works. 2003. https://bit.ly/3DA1Yy8. Unrwa. UNRWA - Technical Instructions Review. (2020). Unrwa. "UNRWA Collective Reports." 2019. Valente, C. "Civil conflict, gender-specific fetal loss, and selection: a new test of the Trivers-Willard hypothesis." J Health Econ 39 (Jan 2015): 31-50. https://doi.org/10.1016/j.jhealeco.2014.10.005. https://www.ncbi.nlm.nih.gov/pubmed/25461897. World Health Organization - Regional Office for the Eastern Mediterranean. Country cooperation strategy for WHO and occupied Palestinian territory 2017 – 2020: Palestine. Cairo, 2017. World Health Organization - Regional Office for the Eastern Mediterranean. Wheat flour fortification in the Eastern Mediterranean Region. (Cairo: 2018). World Health Organization -Nutrition for Health and Development. Guideline. Daily Iron Supplementation in infants and children. 2016, 2016. World Health Organization. Guideline daily iron supplementation in adult women and adolescent girls. Geneva, 2016. World Health Organization. Guideline Iron Supplementation in postpartum women. (Geneva: 2016). World Health Organization. Guideline: Daily iron supplementation in infants and children. Geneva, 2016. World Health Organization. Nutritional anaemias: tools for effective prevention and control. Geneva, 2017. World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. Geneva, 2016. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 52 5 APPENDIXES 5.1 Documents included in the desk review conducted for the mapping 1. Nutrition Department - Directorate General of Primary Health Care and Public Health - Ministry of Health - State of Palestine. Maternal and Child National Nutrition Protocol, 2021. 2021. 2. Maternal and Child National Nutrition Protocol. March 2017, (2017). 3. Palestinian Health Information Center - Ministry of Health. Health Annual Report - Palestine 2017. 2018. 4. Palestinian Health Information Center (PHIC) - Ministry of Health. Health Annual Report - Palestine 2018. Nablus, Palestine; 2019. 5. Palestinian National Authority - Ministry of Health. Fortified Food Control and Monitoring guide. 2009. 6. General Directorate of Health Policies and Planning - Ministry of Health - State of Palestine. National Health Strategy 2017-2022. 2016. 7. Nutrition Department - Ministry of Health - Palestinian National Authority. National Nutrition Policy and Strategy - 2008. 2008. 8. Nutrition Department - Public Health General Directorate - Ministry of Health - State of Palestine. National Nutrition Policy Strategies and Action Plan 2017 - 2022. 9. Ministry of Health Palestine U. National Nutrition Surveillance Report Highlights, January- June 2011. 2011. 10. Nutrition Department - Directorate General of Primary Health Care and Public Health - Ministry of Health - State of Palestine. National Nutrition Surveillance System - Report 2017. 2017. 11. Nutrition Department - Ministry of Health - Palestinian National Authority. Operational Plan of Action for Nutrition 2008-2010. 2008. 12. Department of Nutrition - Ministry of Health - State of Palestine. National Strategy for Infant and Young Child Feeding PSE 2008. 2008. 13. Nutrition Department - Directorate General of Primary Health Care and Public Health - Ministry of Health - State of Palestine. Palestinian Micronutrient Survey 2013. 2014. 14. 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. 15. Nutrition Department - Public Health General Directorate - Ministry of Health - State of Palestine. Palestinian Flour Fortification Formula. 16. Palestine PCBoS-So. The Palestinian Expenditure and Consumption Survey. 2018. 17. UNICEF. Children in the State of Palestine 2018. 18. Bottcher B, Abu-El-Noor M, Abu-El-Noor N. Choices and services related to contraception in the Gaza strip, Palestine: perceptions of service users and providers. BMC Womens Health. 2019;19(1):165. 19. Technical specifications for Fortified Wheat Flour for Palestine, (2013). 20. Palestinian Central Bureau of Statistics. Population, Housing and Establishments - Census 2017. 2019. 21. Track 20. Projected Trends in Modern Contraceptive Prevalence 2021 [Available from: http://track20.org/State_of_Palestine. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 53 22. Palestinian Central Bureau of Statistics. Sustainable Development Goals-SDGs 2021 [Available from: https://www.pcbs.gov.ps/mainsdgs.aspx. 23. Palestinian Central Bureau of Statistics, UNFPA. Palestinian Multiple Indicator Cluster Survey 2014 - Final Report. 2015. 24. World Health Organization Regional Office for the Eastern Mediterranean. Country cooperation strategy for WHO and occupied Palestinian territory 2017 – 2020: Palestine. Cairo; 2017. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 54 5.2 Questionnaire for mapping of fortification program 1. What interventions consisting on iron fortification of food exist in West Bank & Gaza Strip? 2. INPUTS 2.1. What is the legal framework of the iron fortification program? Please provide a copy of the corresponding law/decree 2.2. What is the structure of the iron fortification program? If available, please provide an organogram or documentation describing it. 2.3. Regarding the body with the main responsibility for the iron fortification program, please describes its staff and to whom reports? 2.4. Please describe the coalition supporting the iron fortification program. • What national and international organizations are represented? • What is the policy framework for this coalition? • What are the terms of reference or mandate for this coalition? • What are the contributions of the coalition members to the program? 2.5. What are the financial resources (e.g. annual budget) of the program? 2.6. What is the contribution of the government? 2.7. What infrastructure is available to the program (offices, mills, transport, warehouses, etc.)? 3. ACTIVITIES 3.1. POLICIES • Please provide the national anemia control strategic plan in force • What are the domestic financial commitments towards prevention and control of anemia? • Please describe the engagement of multisectoral stakeholders in the prevention and control of anemia, if any. • Please describe the engagement of international partners (technical and financial partners), private sector, civil society and academic organizations in the prevention and control of anemia, if any. 3.2. PRODUCTION AND SUPPLY • Who is responsible for the procurement of the nutrient premix (fortificant)? • What is the source of the financial resources used to procure the premix? • What is the regulatory framework for the procurement, and what authority is responsible to ensure its compliance? • Who is responsible for the fortification process, it is the mix of fortificant with the food used as vehicle (e.g. flour)? Where is/are this/these organization(s) located? What is the annual volume produced by each one of them? 3.3. DELIVERY • What are the channels of distribution of the food fortified? Please describe the supply chain. • Does the label of the fortified product allow the consumer to identify that the product is fortified? • Do the national authorities, producers, distributors, or retail shops promote the consumption of fortified products? Is branding used for that purpose? Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 55 • Do the national authorities, producers or distributors promote the selling in retail shops (e.g. discounted prices, tax reduction) 3.4. QUALITY • Please provide the regulatory framework for fortification (law, decree, normative) • Who is overall responsible for monitoring the quality of the fortified product? • An external and/or internal monitoring plan is available? • Please describe what monitoring activities are implemented, in particular the outputs of these activities • Please provide an example of the reports produced 3.5. BEHAVIOUR CHANGE COMMUNICATION • What efforts are in place to engage stakeholders on interventions aiming to anemia prevention and control (including communicational interventions). Who is leading those efforts and what resources are available? • Is there an IEC strategy for behavior change around anemia awareness and prevention? • What IEC efforts are in place regarding iron fortification of food? 4. OUTPUTS 4.1. AVAILABILITY OF THE IRON FORTIFIED PRODUCT • What is the amount of iron fortified product available in the country (produced in-country or imported; commercial or donated) 4.2. COMPLIANCE WITH QUALITY STANDARDS & SPECIFICATIONS • Do you have access to reports produced by the monitoring activities, in particular but not limited to those assessing the compliance with quality standards at the retail shop level? If so, please share it • Could you share key results about the compliance of iron fortified products with quality standards? 4.3. KNOWLEDGE AND MOTIVATION OF DISTRIBUTORS, RETAILERS AND GENERAL PUBLIC ABOUT IRON FORTIFIED PRODUCTS. • What information about the knowledge and motivations of distributors and retailers regarding iron fortified products does exist in the country? Please share what is immediately available • What information about the knowledge and motivations of general public (target population in particular) regarding iron fortified products does exist in the country? Please share what is immediately available • What information about the knowledge, motivations and practices of health providers and opinion leaders regarding iron fortified products does exist in the country? Please share what is immediately available 4.4. ACCESS • Is there any data source about the distribution of the population according to the category of retail shops where they obtain food (e.g. supermarket, traditional market, point of delivery of humanitarian organizations)? • Is there any data source about the availability of iron fortified products in retail shops? Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 56 • What is the exposure of general population to BCC interventions regarding iron fortified products? 4.5. USE • What information exist in the country about the preferences and actual consumption of iron fortified products? Does this information disaggregate the target groups? Please share what is immediately available. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 57 5.3 Questionnaire for mapping of supplementation program 1. What interventions consisting on iron supplementation exist in West Bank & Gaza Strip? 2. CONTEXTUAL INFORMATION 2.1. Please provide tables with • Health services providers of antenatal care • Providers of maternal and child care to mothers with children belonging to the age groups: < 60 months, 5-9 years, 10-14 years and 15-18 years. Distributed by • Organization (MoH-Ramallah, MoH-Gaza, UNRWA, etc.) • Status of iron supplementation provider (yes/no) 2.2. Please provide information about access to Antenatal Care (number of ANC visits during the pregnancy) and child care services, ideally disaggregated by region, trimester of pregnancy/age groups and socioeconomic level. 3. INPUTS 3.1. What is the legal framework of the iron supplementation program? Please provide a copy of the corresponding law/decree 3.2. What is the structure of the iron supplementation program? If available, please provide an organogram or documentation describing it. 3.3. Regarding the body with the main responsibility for the iron supplementation program, please describes its staff and to whom reports? 3.4. Please describe the coalition supporting the iron supplementation program (if any). • What national and international organizations are represented? • What is the policy framework for this coalition? • What are the terms of reference or mandate for this coalition? • What are the contributions of the coalition members to the program? 3.5. What are the financial resources (e.g. annual budget) of the program? 3.6. What is the contribution of the government? 3.7. What infrastructure is available to the program (offices, mills, transport, warehouses, etc.)? 4. ACTIVITIES 4.1. POLICIES • Please provide the national anemia control strategic plan in force • What are the domestic financial commitments towards prevention and control of anemia? • Please describe the engagement of multisectoral stakeholders in the prevention and control of anemia, if any. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 58 • Please describe the engagement of international partners (technical and financial partners), private sector, civil society and academic organizations in the prevention and control of anemia, if any. 4.2. PRODUCTION AND SUPPLY • Who is responsible for the procurement of iron/folic acid supplements? • What is the source of the financial resources used to procure the p iron/folic acid supplements? • What is the regulatory framework for the procurement, and what authority is responsible to ensure its compliance? • What has been the annual volume procured during the last 5 years? 4.3. DELIVERY • What are the channels of distribution of the iron supplement? Please describe the supply chain (main warehouse, intermediate warehouses, service delivery points). • Do the products procured for the iron supplementation program are differentiable based in their labels or any physical characteristics? • What efforts are in place to promote the adequate use of iron supplements? Who provide the resources and who implement those efforts? • Who provide training and/or educative material to providers of iron supplements at the health service delivery points? 4.4. QUALITY • Please provide the regulatory framework for iron supplementation (law, decree, normative) • Who is overall responsible for monitoring the quality of the iron supplements at all levels (importation/production, warehouses, service delivery points)? • An external and/or internal monitoring plan is available? • Please describe what monitoring activities are implemented, in particular the outputs of these activities • Please provide an example of the reports produced 4.5. BEHAVIOUR CHANGE COMMUNICATION • What efforts are in place to engage stakeholders on interventions aiming to anemia prevention and control (including communicational interventions). Who is leading those efforts and what resources are available? • Is there an IEC strategy for behavior change around anemia awareness and prevention? • What IEC efforts are in place regarding iron supplements? 5. OUTPUTS 5.1. AVAILABILITY OF THE IRON SUPPLEMENTS • What is the amount of iron supplements available for the program (produced in-country or imported)? 5.2. COMPLIANCE WITH QUALITY STANDARDS & SPECIFICATIONS • Do you have access to reports produced by the monitoring activities? Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 59 • Could you share key results about the compliance of iron supplements with quality standards? 5.3. KNOWLEDGE AND MOTIVATION OF DISTRIBUTORS, RETAILERS AND GENERAL PUBLIC ABOUT IRON SUPPLEMENTS. • What information about the knowledge and motivations of iron supplementation providers does exist in the country? Please share what is immediately available • What information about the knowledge and motivations of general public (target population in particular) regarding iron supplements does exist in the country? Please share what is immediately available • What information about the knowledge, motivations and practices of health providers and opinion leaders regarding iron supplementation does exist in the country? Please share what is immediately available 5.4. ACCESS • Is there any data source about the access to antenatal care and maternal-child care? Ideally disaggregated by region, age, and socioeconomic group • Is there any data source about the availability of iron supplements in health facilities? • What is the exposure of general population to BCC interventions regarding iron supplements? 5.5. USE a. What information exist in the country about the preferences and actual consumption of iron supplements provided by the program? Is this information disaggregated by target groups? Please share what is immediately available. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 60 5.4 Informants interviewed Organization Position 1. Director of Nutrition Department-West Bank 2. Head of Nutrition Department-Gaza 3. Director of drug warehouse- West Bank Ministry of 4. Director of drug warehouse- Gaza Strip Health (MoH) 5. Director of Palestinian Health Information Center (PHIC) 6. Director of Community Health Department 7. Head of Maternal Child Health Sub-Department 8. Director of Consumer Protection directorate- Gaza Strip Ministry of 9. Director of chemical and products laboratory- Gaza Strip National Economy 10. Head of Consumer Protection MoNE- West Bank (MoNE) 11. General Director of Consumer Protection- West Bank 12. Director of technical regulations in PSI (Palestinian Standards Institution) 13. Technical Training and Management Support staff- West Bank 14. Field Family Health officer – West Bank UNRWA 15. Deputy Field Pharmaceutical Services Officer –West Bank 16. Field Family Health Officer 17. Deputy head field logistics office. UNICEF 18. Health and Nutrition Specialist- West Bank WHO 19. Research Manager- WHO Palestinian national Institute of Public Health 20. Nutritionist and Food Technologist/Local Procurement- West Bank WFP 21. General operation in WFP Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 61 5.5 Complementary questionnaire for mapping of anemia prevention programs 1) PREVENTION OF MICRONUTRIENT DEFICIENCIES PURPOSE of the information The assessment requires Information requested Information currently available (confirmation or information still collected/provided and (assessment missing): corresponding answers questions) What are the The document "National Nutrition Please confirm if this target remains valid. Targets were confirmed national goals and Policy, Strategies & Action Plan If not, please provide the document with the current targets regarding (NNPSAP) 2017 – 2022" included national indicators and targets for the prevention of micronutrients the Prevention and treatment of micronutrient deficiencies. micronutrient deficiencies as a priority, with the Overall Objective: To reduce micronutrients deficiencies among vulnerable group, and the target of "Reduce by 20% the micronutrient deficiency among key vulnerable group by 2018". Sources available to National Nutrition Surveillance Please identify if any other source of information is No additional source was evaluate System 2017 available to establish if the interventions to prevent identified interventions to Annual Health Report 2018 anemia have achieved the expected goals. prevent micronutrient deficiencies Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 62 FORTIFICATION PROGRAM PURPOSE of the information Information Information currently requested The assessment needs to collect collected/provided and available (assessment corresponding answers questions) What is the target "National Nutrition Policy, • Please confirm the general population of both West Bank • General population was population of the Strategies & Action Plan and Gaza as the target population of the fortification confirmed as target program (NNPSAP) 2017 – 2022" program. population of fortification • Is there any policy to ensure the access to fortified food program to specific groups of the population (e.g. refugees)? • There are no policies • Please provide the document with the policies described related to specific groups above. To identify the The document "National • Could you please confirm if the indicators and targets set • Indicators of NNPSAP were goals and targets Nutrition Policy, Strategies & by the NNPSAP 2017 are still valid? confirmed as still valid of the program Action Plan (NNPSAP) 2017 – If not, please provide the document with the current 2022" set targets for the food indicators and targets of the fortification program. fortification program that included: -Flour fortification process covered 90% of available flour in the markets. -All flour available in the Palestinian market are fortified and all table salt is iodized. -Needed materials (for education and promotion) are produced and disseminated Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 63 To identify the We have received the • Is there any other document describing the roles and • No additional documents roles and documents: responsibilities of the fortification program's were provided responsibilities of • Mandatory Technical implementers? If so, please provide a copy. • According to the MoH-ND the implementers Instructions 9-2005 Wheat • Please provide the current organogram of the Nutrition all stakeholders comply of the fortification Flour. 2005. Department, and the Ministry of Health. with their roles and program • Fortified Food Control and • Please indicate if in your opinion, all stakeholders comply responsibilities Monitoring guide-2009. adequately with the roles and responsibilities described We understand the Food in the Food Fortification Control and Monitoring Guide Fortification Monitoring (or the document currently in force). In case the Committee includes expected activities are not implemented as expected, representatives of all please elaborate about the subjacent reasons (e.g. stakeholders and have periodic budget, staff, technical capacity) meetings. To establish what Fortified Food Control and Please provide the planning document that periodically A planning document was are the activities Monitoring guide-2009. set the key activities to be implemented, as well as its not made available implemented by implementers, costs, timeline, and monitoring indicators. the fortification Please make sure that the document includes those program activities not directly linked with the fortification or quality control of wheat flour, such as promotion, behavior change communication and trainings To establish the If not included in the planning document, please provide Costs of activities were not costs associated the total and unit costs for the activities included in the made available with the operational plan of the fortification program. implementation Please include the level of absorption of the budget during of the fortification the last period. program To identify the We understand that producers Are there any positive incentives available for the No incentives for incentives for and importers of wheat flour producers and importers of wheat flour, aside of producers/importers are producers and/or do not receive financial complying with the national standards and avoiding fines available compensation from the or any other penalty? For instance, does the MoH or any Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 64 importers of program in compensation for other organization assign resources for the promotion of wheat flour the addition of the fortified wheat flour? micronutrient premix. If any incentive were available, please describe in detail According to our observations the nature of the incentive, the source of resources and in bakeries and shops, there the budget assigned. are no differentiated prices for fortified products. To establish the We understand that the Please provide the The total annual amount access to iron amount of flour fortified 1. Number of mills producing wheat flour per governorate produced in the country, fortified food available in the country 2. Annual amount of wheat flour produced in the country, and the total annual (including local production, disaggregated by province amount imported were importation, and donations) is 3. Annual amount of wheat flour imported for commercial made available. unknown. purposes, disaggregated by province Dataset with results of food 4. Annual amount of wheat flour imported as donations, fortification monitoring Annual reports (2018-2020) of disaggregated by donor and province were made available the food fortification 5. Annual reports of the food fortification monitoring, monitoring, including only the including the absolute numbers of samples collected and percentages of samples that the results of the laboratory assessments; disaggregated complied with the national by province and source (commercially imported, standards. donations imported, local mills, bakeries/shops). To establish the Please provide the most recent estimation available of This information is not consumption of dietary intake of fortified flour or wheat flour, available. iron fortified food disaggregated by province, and key socio-economic characteristics (e.g. education, location, poverty, refugee status, and employment status), age and physiological status. To identify Please provide the monitoring results of all the activities Results of wheat flour lab potential related to the fortification program, corresponding to the testing were made bottlenecks in the period 2018-2020. Please include disaggregated results by available. implementation province and any other relevant characteristics of the Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 65 of fortification target population (socio-economic attributes, gender, Monitoring results related program’s refugee status, etc.). Please include the information you to communicational activities receive from UNRWA, WFP and any other relevant MoH activities or training, or partners. Please make sure to include the results of the related to activities of monitoring of those activities not directly linked with the MoH’s partners were not fortification or quality control of wheat flour, such as available. promotion, behavior change communication and trainings. If not included in the document(s) described above, please provide a rationale for those key activities that were not implemented as expected. For instance: “In 2019, we planned to test 1200 samples of wheat flour collected in mills, but only 600 tests were implemented due to the lack of adequate financial resources for the transport of the staff collecting samples”. To identify If not included in the documents requested above, please Answers were collected bottlenecks in the provide a detailed description of the methodological through interviews, and monitoring and approach used to collect and report the monitoring included in the report. evaluation of the indicators of the program. Please describe briefly how the fortification results of the monitoring are used in the management of program the fortification program. Provide examples of what actions have been taken in response to issues identified in the implementation of the program. Do you consider that the monitoring and evaluation of the fortification program is adequate? If not please describe the limitations as detailed as possible and the subjacent reasons (e.g. lack of resources to collect samples of flour, or to verify if the promotion of fortified food is included in the counseling to pregnant women) Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 66 2) SUPPLEMENTATION PROGRAM PURPOSE of the information The assessment needs to Information collected/provided requested Information currently available collect and corresponding answers (assessment questions) What is the target As per the Maternal and Child • Please provide the rationale for not Answers were collected through population of the National Nutrition Protocol 2017, adhering to the WHO recommendations interviews, and included in the program we understand that the target regarding the inclusion of children 5-12 report. groups of the supplementation years as target population of the program are: supplementation program. Pregnant women • We understand that the MoH does not Postnatal women distribute iron supplements for the Children 6-23 m prevention of anemia to children 24-59 Children 24-59 months months. Please explain this divergence with respect the National Protocol • Is there any policy to target the access to iron supplementation to specific groups of the population? If so, please provide the document setting that policy. We are referring to groups identified by their socio- economic characteristics (e.g. urban, refugees, poor), prevalence of anemia/micronutrient deficiency, physiological status, geographical location, or age group considerations. • Please provide the information available regarding what percentage of the population receive antenatal, post-partum Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 67 and child care from each provider (MoH, UNRWA, NGOs and private providers). We are interested in identifying the expected coverage of each provider, disaggregated by province, governorate or socioeconomic level. To identify the The document "National Nutrition Could you please confirm if those targets Targets in NNPSAP were confirmed goals and targets Policy, Strategies & Action Plan remain valid?. If not, please provide the as still valid of the program (NNPSAP) 2017 – 2022" included as document with the current indicators and targets of the micronutrient targets of the supplementation program. supplementation for pregnant women, children up to 2 years, postnatal mothers and school children: • All micronutrient supplements are available in all health centers. • Micronutrient supplements are distributed to all health centers and targeted schools • Micronutrient supplements reached all target groups • Monitoring reports are produced regularly • Leaflets posters, radio spots and presentations on micronutrient supplements are produced and disseminated. • Awareness raising campaigns are conducted. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 68 To identify the Maternal and Child National Please provide the document that describes MoH guidelines for newborn and roles and Nutrition Protocol 2017, the roles and responsibilities of those MoH child care were provided responsibilities of MoH guidelines for antenatal and units at the central, and decentralized level, the implementers post-partum care. involved in the implementation of the iron supplementation program Please provide the MoH guidelines for newborn and child care To establish what Please provide the planning document that The planning of activities related to are the activities periodically set the key activities to be the supplementation program is implemented by implemented, as well as its implementers, not documented the costs, timeline, and monitoring indicators. supplementation Please make sure that the document program includes those activities not directly linked with the distribution of supplies, such as training and counseling, and quality control. To establish the If not included in the planning document, This information was not made costs associated please provide the total and unit costs for available for the assessment with the the activities included in the operational plan implementation of the supplementation program. of the Please include the level of absorption of the supplementation budget during the last period. program activities To establish the Please provide the documents related to the This information was not made access to iron quantification of iron supplementation needs available for the assessment supplements for 2018, 2019 and 2020 as specific as possible. These documents should include 1) the data and calculations used for annual procurement, 2) the data and calculation used to establish the amount to be distributed to governorates and clinics. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 69 Please includes a clear description about the time that each individual receives iron supplement as anemia prevention (number of daily doses per each individual of the target population). Please provide the amount of iron supplements distributed to each clinic, governorate, and province in 2018, 2019 and 2020. Please identify the target group for each presentation of iron supplements, if possible disaggregated by socio-economic, epidemiological characteristics or any other attribute of the target population. In case the amounts distributed diverge more than 20% of the estimation of needs (quantification), please provide the rationale for the difference. We are interested in documenting the frequency and duration of stockouts at different levels of the supply chain: please provide the monthly reports of central drug warehouses in West Bank and Gaza for 2018- 2020 to the central level, and the bimonthly reports from Governorates to central drug warehouses. To establish the The annual average number of Could you please confirm that the iron Availability of iron supplements compliance with tablets prescribed per pregnant supplements are absolutely free of charge free of charge was confirmed. iron supplements women, and bottles prescribed per for the patient? (i.e., that no payments of schemes child (Annual Health Report) any kind are made by the patient, such as The Health Annual Report was the (consumption) solidarity fees or similar) only source made available Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 70 Could you please provide the MoH's containing information regarding assessment of the amount of supplements the dispensation of supplements. prescribed reported in the Annual Health Report, and how those indicators are used in Additional answers were collected the management of the supplementation through interviews, and included in program? e.g. “re-distributing supplies to the report. governorates with the lowest number of bottles prescribed”. Please provide the annual reports produced by the Community Health Department for the period 2018-2020. We understand that the MoH-Community Health Department compiles annually the monthly reports submitted by the MoH Directorates containing information collected during supervisions such as the number of children, pregnant and postnatal women receiving supplements, the amount of stocks available by each clinic, and observation about the quality of services. Please provide any additional information regarding the prescription and/or dispensation of iron supplements to pregnant women, postnatal women and children, as well as about their compliance with the supplementation schemes. Please provide this information disaggregated by geographical location, socio-economic characteristics, or any other attribute of the population. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 71 Please provide any additional information regarding the prescription and/or dispensation of iron as treatment to pregnant women, postnatal women and children, as well as about their compliance with the supplementation schemes. Please provide this information disaggregated by geographical location, socio-economic characteristics, or any other attribute of the population. To identify Please provide any additional information The Health Annual Report was the potential about the monitoring results of all the only source made available. This bottlenecks in the activities of the supplementation program, source does not include implementation including but not limited to: information about quality of of + quality of the service (iron service or training. supplementation supplementation), including aspects related program’s to the counseling to increase dietary intake activities of iron rich food, counseling to improve compliance with the supplementation, and the follow up and referral of anemia cases. +training of providers +communicational interventions to promote the compliance with the supplementation Please provide this information as disaggregated as available, by geographical location (province, governorates), socio- economic characteristics, any other relevant characteristics. Please also include the information (also disaggregated) you receive from MoH partners such as UNRWA, NGOs and other Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 72 relevant providers of health care. In case you do not receive this information, please provide a reason why this is the case. To identify If not included in the documents requested Answers were collected through bottlenecks in the above, please provide a detailed description interviews, and included in the monitoring and of the methodological approach used to report. evaluation of the collect and report the monitoring indicators of supplementation the program. program Please describe briefly how the results of the monitoring are used in the management of the supplementation program. Provide examples of what actions have been taken in response to issues identified in the implementation of the program. Do you consider that the monitoring and evaluation of the supplementation program is adequate? If not please describe the limitations as detailed as possible and the subjacent reasons (e.g. disruptions in the logistics management information system, staff not available for supervisions the quality of counseling during antenatal care, partners do not share information about their activities) Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 73 3) ADDITIONAL INTERVENTIONS TO PREVENT ANEMIA PURPOSE of the information Information collected/provided requested Information currently available The assessment needs to collect and corresponding answers (assessment questions) To what The document "National Could you please confirm if the objectives, Activities and targets in NNPSAP additional Nutrition Policy, Strategies & activities and targets described in the NNPSAP were confirmed as still valid. interventions to Action Plan (NNPSAP) 2017 – remain valid?. If not, please provide the Additional answers were collected prevent and 2022" included as priorities to document currently in force. through interviews, and included in control anemia, the Is the Government committed with additional the report. in particular “Protection, promotion and interventions to prevent and control anemia? If those support for exclusive so, please provide the documents containing the recommended by breastfeeding (up to 6 national policies or strategies related to those WHO. months), appropriate, safely commitments. and timely complementary We are interested in identifying commitments feeding of infants and diet related to any of the interventions recommended diversity for children.”, and by WHO such as: “Improvement and protection Food-based strategies (Dietary diversification and of food security” enhancing the bioavailability of micronutrients, breastfeeding, complementary, targeted fortification, point-of-use fortification, social and behavior-change communication strategies). Nutrition-sensitive solutions to anemia (control of parasitic infections; water, sanitation and hygiene; reproductive health practices such as delaying the age of first pregnancy, birth spacing, and perinatal care; intersectoral actions such as supporting educational and income generating Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 74 opportunities for girls and women, raise awareness among policy-makers and communities). What are the Is there any policy to target the access to those There is no policies regarding target additional interventions identified above to specific groups of the population population/sub- specific groups of the population? If so, please population of provide the document setting that policy. We are those referring to groups identified by their socio- interventions economic characteristics (e.g. urban, refugees, poor), prevalence of anemia/micronutrient deficiency, physiological status, geographical location or age group considerations. To identify the Please provide the documents describing the The National Maternal Child roles and roles and responsibilities in the implementation Nutrition Protocol was made responsibilities of of the additional interventions to prevent and available. the control anemia, of MoH units at the central, and implementers of decentralized level, as well as of other the additional Government’s bodies and country partners. interventions To establish what Please provide the planning document that The planning of these activities is are the activities periodically set the key activities to be not documented. implemented by implemented, as well as its implementers, costs, the additional timeline, and monitoring indicators. interventions To establish the If not included in the planning document, please Costs of activities were not made costs associated provide the total and unit costs for the activities available included in the operational plan of the additional interventions. Please include the level of absorption of the budget during the last period. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 75 To establish the Please provide the information available about This information was not made access to the the delivery of services or goods related to the available. additional additional information, if possible disaggregated interventions by socio-economic, geographical, and epidemiological characteristics or any other attribute of the target population. To establish the Please provide the information available about This information was obtained from results of the adoption of those behavior/practices national surveys. behavior change promoted by the additional interventions, if interventions possible disaggregated by socio-economic, geographical, and epidemiological characteristics or any other attribute of the target population. To identify Please provide any additional information about There is no monitoring of potential the monitoring results of the additional additional interventions to prevent bottlenecks in the interventions, including but not limited to: anemia implementation + quality of the services of the additional + training of providers interventions + communicational interventions Please provide this information as disaggregated as available, by geographical location (province, governorates), socio-economic characteristics, any other relevant characteristics. Please also include the information (also disaggregated) you receive from UNRWA, NGOs and other relevant partners of the MoH. In case you do not receive this information, please provide a reason why this is the case. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 76 To identify If not included in the documents requested above, There is no monitoring of additional bottlenecks in the please provide a detailed description of the interventions to prevent anemia monitoring and methodological approach used to collect and evaluation of the report the monitoring indicators of the additional additional activities. activities Please describe briefly how the results of the monitoring are used in the management/decision making of the country response to anemia. Provide examples of what actions have been taken in response to issues identified. Do you consider that the monitoring and evaluation of the supplementation program is adequate? If not please describe the limitations as detailed as possible and the subjacent reasons (e.g., lack of adequate mechanisms of coordination across MoH departments, Ministries, government bodies in West Bank and Gaza, partners) Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 77 5.6 Types of barriers and their corresponding determinants Type of Determinants Examples of these barriers barriers The degree of availability to the program’s target population of the needed products (e.g., tablets) or services (e.g., primary health care) required to Access adopting supplementation and/or fortification. It includes barriers related to Indirect barriers cost, geography, distance, linguistics, cultural issues, and gender Laws and regulations (local, regional, or national) that affect behaviors and access to products and services (e.g., the presence of fortified food and its Policy regulations) To determine if iron supplements formulas with less side effects could increase adherence (ER or sustained-release IFA tablets or soft-gelatin iron capsule). The presence of reminders that help a person remember to do a particular Cues for action/ behavior, the presence of reminders that help a person remember the steps involved in doing the behavior (such as memory aids), key powerful events that reminders triggered a behavior change in a person (e.g., “my brother-in law died of cholera” so I decided to wash my hands regularly). Perceived susceptibility/ A person's perception of how vulnerable or at risk he/she feels to the problem risk (e.g., is it possible that I have anemia?). The belief that the anemia is serious (e.g., a person may be more likely to take Perceived severity steps to take supplementation if she thinks anemia is a serious problem to be avoided). What positive things a person thinks will happen as a result of performing a Perceived positive behavior, responses to questions related to positive consequences may reveal consequences advantages (benefits) of the behavior, attitudes about the behavior, and Direct barriers perceived positive attributes of the action. The belief that by practicing the behavior one will avoid the problem, that the Perceived action efficacy behavior is effective in avoiding the problem (e.g., if I eat fortified products, I will not develop anemia). A person’s belief that it is God’s will (or the gods’ wills) for him/her to have the problem and/or to overcome it. It includes the priority group’s perception of what their religion accepts or rejects and perceptions about the spirit world or Perceived divine will magic (e.g., spells, curses). Numerous unpublished Barrier Analysis studies have found this determinant to be important for many behaviors (particularly for health and nutrition behaviors). The set of history, customs, lifestyles, values, and practices within a self-defined group, associated with ethnicity or lifestyle, such as gay or youth culture, often Culture influences perceived social norms. In this case, particular emphasis on the acceptance of eating fortified foods or taking supplements will be made. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 78 Type of Determinants Examples of these barriers barriers Factors that have been found to motivate most people, irrespective of other variables, usually used in mass media activities (e.g., billboards, posters, public Universal Motivators service announcements), include love, security, comfort, recognition, success, freedom, positive self- image, social acceptance, peace of mind, status, pleasure, and power. An individual's belief that he/she can do a particular behavior given his/her Perceived self-efficacy/skills current knowledge and skills. The set of knowledge, skills, or abilities necessary to perform a particular behavior. The perception that people important to an individual think that he/she should do the behavior. Norms have two parts: who matters most to the person on a Perceived social norms particular issue and what the person perceives those people think he/she should do. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 79 5.7 Results of the multivariable analyses In this section, the results of the multivariable analyses are presented, starting with those factors that emerged as associated with the outcomes hemoglobin or anemia, in two or more of the population groups studied. The regression models including the coefficients, odds ratios and confidence intervals from multivariable regression models are shown in Table 14 for pregnant women, Table 15 for postnatal women, Table 16 for children aged 6-59 months and Table 17 for adolescents. The results highlighted in this section indicate associations after adjustment for all the factors included in the respective models. Place of residence: Residing in Gaza Strip was found to be associated with lower hemoglobin levels and higher prevalence of anemia among all four groups included in the PMS 2013, and these associations were statistically significant with the exception of anemia prevalence among adolescents. Socioeconomic status: The PMS 2013 captured limited information about socio-economic status, however, the multivariable analysis provided the following insights: - Among pregnant women, “working outside the home” was statistically significantly associated (p<0.05) with lower hemoglobin levels and higher prevalence of anemia, and “husband not working for a private company or NGO” was statistically significantly associated (p<0.05) with higher prevalence of anemia. -Among postnatal women, “having three or more children under five years” was statistically significantly associated with lower hemoglobin levels with respect to those with one child under five years, and “having a diploma, bachelor’s degree or post-degree” education level was associated with higher hemoglobin levels with respect to those with an education level “up to preparatory”. Working for a private company or an NGO was associated with lower hemoglobin levels and higher prevalence of anemia, compared to those working in the public sector. This unexpected association was driven by a group of postnatal women working for an NGO (n=15), whose hemoglobin levels were particularly low in comparison to those with any other employment status. - Among children aged 6-59 months, “having a mother working for the public sector” and “living with at least one additional child aged 6-59 months” was statistically significantly associated with lower hemoglobin levels, compared to those with their mother with any other employment status, and those living with only one child aged 6-59 months. - Among adolescents, “attending schools managed by the government” was statistically significantly associated with lower hemoglobin compared to attending a private school. “Living in cities” was associated with a higher prevalence of anemia and lower hemoglobin levels compared to those living in camps. All these associations suggest that those affected by anemia and/or have lower hemoglobin levels are disadvantaged, larger families, on low income, with parents with lower educational level, and relying on the public schools system for their children’s education. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 80 Provider of iron and folic acid supplements: Among pregnant women, receiving IFA supplements “from any combination of providers” was statistically significantly associated with lower hemoglobin levels and higher prevalence of anemia, compared to those receiving these supplements “only from the MoH”. Similarly, among postnatal women, receiving IFA supplements “only from UNRWA” was associated with lower hemoglobin levels when compared with those receiving supplements “only from the MoH”. Infection: the reporting of fever during the days before the survey was statistically significantly associated with lower hemoglobin levels among pregnant women, and children aged 6-59 months: and with higher prevalence of anemia among pregnant women. In addition, the reporting of diarrhea in the previous two weeks was statistically associated with lower hemoglobin levels and higher prevalence of anemia among children aged 6-59 months. Anthropometric indicators of nutritional status: Reported pre-gestational overweight or obesity was statistically significantly associated with higher hemoglobin levels and lower prevalence of anemia among pregnant women. Among adolescents, having a normal or higher height-for-age was statistically significantly associated with higher hemoglobin levels. Gestational age and age group Among pregnant women: Women in the second and third trimester of pregnancy had statistically significant lower hemoglobin levels and higher anemia prevalence when compared to those in the first trimester. Among postnatal women: Those younger than 25 years had higher hemoglobin levels and lower prevalence of anemia when compared to the group aged 25-29 years, and this association was statistically significant. Among children aged 6-59 months: Hemoglobin levels tended to increase and the prevalence of anemia to decrease along with the age of the children. This association was statistically significant for those in the group of 2-5 years old when compared to the group 6-11 months old. Among adolescents: The age of 13-15 years was statistically significantly associated with lower hemoglobin levels but with a coefficient positive, leading to the conclusion of no differences between these groups. Sex: Among children, being female was statistically significantly associated with higher hemoglobin levels and lower prevalence of anemia; and conversely among adolescents, with lower hemoglobin levels and higher prevalence of anemia. Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 81 Table 14: Regressions of Hemoglobin and Anemia for Pregnant Women (n=1,200) Linear regression for Logistic regression Hemo- hemoglobin for anemia globin Anemia levels [95% Conf. preva- Odds [95% Conf. ( mean Coef. lence Interval] Ratio Interval] Variables N g/dl) (%) Province West Bank 589 11.7 Ref. 24.1 Ref. Gaza Strip 599 11.2 0.56 ** -0.71 -0.41 37.4 2.18 ** 1.55 3.05 Type of community City 527 11.4 Ref. 32.3 Ref. Village & Bedouin 367 11.6 0.07 -0.07 0.22 26.7 0.90 0.64 1.26 Camp 294 11.3 -0.01 -0.20 0.19 33.3 0.91 0.59 1.41 Supervising body of place of recruitment MOH 788 11.5 Ref. 28.9 Ref. UNRWA 399 11.3 0.06 -0.13 0.25 34.6 0.94 0.61 1.44 Pregnant women age Less than 20y 111 11.4 Ref. 28.8 Ref. 20-29 years 700 11.5 0.02 -0.20 0.23 30.4 1.07 0.66 1.74 30 or more years 377 11.3 -0.22 -0.45 0.01 32.1 1.36 0.81 2.29 Pregnant women's educational level Up to preparatory 303 11.4 Ref. 30.0 Ref. Secondary or Vocational 489 11.5 0.06 -0.10 0.21 29.0 0.95 0.67 1.36 Diploma, BA or Postgraduate 396 11.4 0.05 -0.13 0.23 33.6 0.99 0.66 1.50 Pregnant women work out of home No 1,067 11.4 Ref. 30.0 Ref. Yes 113 11.2 -0.26 * -0.49 -0.04 37.2 1.65 * 1.01 2.71 Husband's educational level Up to preparatory 402 11.5 Ref. 28.4 Ref. Secondary or Vocational 450 11.4 -0.08 -0.23 0.06 31.1 1.20 0.86 1.67 Diploma, BA or Postgraduate 330 11.3 -0.14 -0.32 0.04 33.3 1.16 0.78 1.73 Husband's employer Public sector employee 297 11.3 Ref. 35.4 Ref. Private, NGO, International NGO 78 11.6 0.25 -0.01 0.52 23.1 0.52 * 0.28 0.98 Self-employed, Temporary, Unemployed 812 11.4 -0.02 -0.17 0.13 29.8 0.94 0.67 1.32 Gestational age First trimester 285 11.8 Ref. 16.5 Ref. Second trimester 442 11.3 -0.51 ** -0.67 -0.35 31.2 2.40 ** 1.58 3.63 Third trimester 455 11.3 -0.55 ** -0.72 -0.38 39.6 3.33 ** 2.16 5.14 Years since last delivery Less than 2 412 11.5 0 30.6 Ref. 2 or more years 776 11.4 -0.05 -0.17 0.08 30.9 1.01 0.76 1.35 Fever during last week No 1,127 11.4 Ref. 30.0 Ref. Yes 51 11.2 -0.32 * -0.61 -0.04 43.1 2.05 * 1.11 3.80 Pre-pregnancy BMI Normal or Underweight 667 11.4 Ref. 33.1 Ref. Overweight or Obesity 521 11.5 0.27 ** 0.11 0.42 27.8 0.65 * 0.46 0.91 Current BMI Normal or Underweight 382 11.4 Ref. 30.4 Ref. Overweight or Obesity 805 11.4 0.00 -0.16 0.17 31.1 1.03 0.72 1.49 Source of IRON AND FOLIC ACID pills Only from MoH 416 11.6 Ref. 25.5 Ref. Only from UNRWA 388 11.3 0.03 -0.17 0.23 36.3 1.17 0.74 1.85 Only from Privates 68 11.1 -0.27 -0.53 0.00 44.1 2.10 * 1.18 3.71 Any other combination 85 11.2 -0.25 * -0.50 -0.01 43.5 2.02 ** 1.19 3.40 Not receive 220 11.6 0.01 -0.18 0.21 22.7 1.00 0.62 1.60 (*) for p <0.05 and (**) for p <0.01 Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 82 Table 15: Regressions of Hemoglobin and Anemia for Postnatal Women (n=1,200) Hemog Linear regression for lobin Anemia Logistic regression for levels hemoglobin preva- anemia ( mean Coef. [95% Conf. lence Odds [95% Conf. Variables N g/dl) Interval] (%) Ratio Interval] Province West Bank 591 12.7 Ref. 20.4 Ref. Gaza Strip 600 12.2 -0.52 ** -0.68 -0.36 35.3 2.33 ** 1.62 3.34 Type of community City 542 12.4 Ref. 30.6 Ref. Village & Bedouin 366 12.7 0.12 -0.04 0.27 21.5 0.74 0.52 1.07 Camp 283 12.4 -0.05 -0.25 0.15 31.1 0.95 0.62 1.47 Supervising body of place of recruitment MOH 796 12.5 Ref. 25.5 Ref. UNRWA 395 12.3 -0.07 -0.27 0.12 33.4 1.19 0.77 1.83 Lactating women's age Less than 25 years 429 12.6 Ref. 24.4 Ref. 25-29 years 323 12.4 -0.22 * -0.39 -0.04 29.7 1.61 * 1.09 2.37 30 or more years 431 12.5 -0.13 -0.32 0.05 29.7 1.37 0.91 2.07 Lactating women’s educational level Up to preparatory 310 12.4 Ref. 29.0 Ref. Secondary or Vocational 472 12.4 0.04 -0.13 0.21 28.4 0.88 0.61 1.27 Diploma, BA or Postgrad. 409 12.6 0.21 * 0.00 0.41 26.7 0.81 0.51 1.28 Lactating women's employer Public sector 45 12.7 Ref. 17.8 Ref. Private, NGO, INGO 48 12.2 -0.53 * -0.96 -0.09 43.8 4.49 ** 1.59 12.66 Self-employed, Temporal, Unemployed 1098 12.5 -0.20 -0.54 0.14 27.7 2.20 0.91 5.33 Husband’s educational level Up to preparatory 345 12.4 Ref. 29.2 Ref. Secondary or Vocational 424 12.5 -0.04 -0.20 0.11 28.7 1.01 0.71 1.44 Diploma, BA or Postgrad. 316 12.6 0.13 -0.07 0.33 26.9 0.74 0.47 1.16 Husband's employer Public sector 327 12.4 Ref. 30.2 Ref. Private, NGO, INGO 90 12.3 -0.18 -0.44 0.09 35.5 1.53 0.86 2.72 Self-employed, Temporal, Unemployed 773 12.5 0.14 -0.02 0.30 26.0 0.79 0.55 1.14 Number of household members 1-5 members 525 12.6 Ref. 26.2 Ref. 6-8 members 422 12.5 0.01 -0.15 0.18 27.4 0.89 0.61 1.29 9 or more members 241 12.3 -0.02 -0.22 0.17 32.7 1.09 0.71 1.68 Number of children under five 1 child 397 12.6 Ref. 23.9 Ref. 2 children 508 12.5 -0.08 -0.23 0.07 28.1 1.07 0.76 1.51 3 or more children 279 12.3 -0.19 * -0.37 0.00 33.3 1.12 0.74 1.67 Age of last child <6 months 643 12.5 Ref. 27.5 Ref. 6-11 months 434 12.5 0.05 -0.09 0.19 27.4 0.98 0.72 1.33 12 or more months 113 12.3 -0.10 -0.33 0.12 31.8 1.11 0.69 1.81 Fever during last week No 1130 12.5 Ref. 27.6 Ref. Yes 49 12.3 -0.28 -0.59 0.03 34.7 1.67 0.87 3.20 Pre-pregnancy BMI Normal or Underweight 645 12.5 Ref. 25.7 Ref. Overweight or Obesity 542 12.4 -0.13 -0.30 0.04 30.4 1.47 0.99 2.16 Current BMI Normal or Underweight 476 12.5 Ref. 27.7 Ref. Overweight or Obesity 711 12.5 0.07 -0.11 0.24 28.1 0.80 0.54 1.21 Where do you get IRON and FOLIC ACID pills from Only from MoH 309 12.6 Ref. 23.9 Ref. Only from UNRWA 427 12.5 0.31 ** 0.09 0.52 29.2 0.67 0.41 1.09 Only from Privates 192 12.5 -0.01 -0.22 0.20 26.5 0.96 0.59 1.56 Any other combination 197 12.4 -0.09 -0.30 0.11 32.9 1.33 0.83 2.13 Not receive 64 12.5 0.28 -0.03 0.60 26.5 0.63 0.31 1.30 (*) for p <0.05 and (**) for p <0.01 Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 83 Table 16: Regressions of Hemoglobin and Anemia for Children (n =1,200) Hemo- globin Linear regression for Logistic regression levels hemoglobin Anemia for anemia ( mean [95% Conf. prevale Odds [95% Conf. Coef. N g/dl) Interval] nce (%) Ratio Interval] Province West Bank 518 11.8 Ref. 21.6 Ref. Gaza Strip 582 11.4 -0.36 ** -0.56 -0.17 30.7 1.67 * 1.07 2.61 Type of community City 492 11.5 Ref. 28.1 Ref. Village & Bedouin 313 11.7 0.05 -0.13 0.23 23.0 0.93 0.61 1.42 Camp 295 11.5 -0.01 -0.25 0.24 27.5 1.12 0.64 1.94 Supervising body of place of recruitment MOH 713 11.6 Ref. 25.6 Ref. UNRWA 387 11.5 0.09 -0.16 0.33 27.9 0.80 0.46 1.39 Gender Male 587 11.5 Ref. 28.3 Ref. Female 513 11.6 0.16 * 0.01 0.31 24.4 0.75 0.53 1.05 Child's age 6-11 months 133 11.0 Ref. 47.4 Ref. 1-2 Years 287 11.3 0.16 -0.11 0.43 35.2 0.73 0.42 1.26 2-5 Years 680 11.8 0.62 ** 0.34 0.90 18.7 0.28 ** 0.16 0.50 Mother’s age Less than 25 years 310 11.5 Ref. 27.7 Ref. 25-29 years 323 11.6 -0.07 -0.26 0.13 27.6 1.16 0.74 1.82 30 or more years 460 11.6 -0.15 -0.35 0.06 25.2 1.34 0.84 2.15 Mother’s educational level Up to preparatory 286 11.5 Ref. 24.8 Ref. Secondary or Vocational 466 11.5 -0.02 -0.21 0.17 27.9 1.23 0.79 1.89 Diploma, BA or Postgrad. 348 11.6 0.05 -0.18 0.27 25.9 1.01 0.60 1.69 Mother’s employer Public sector 42 11.3 Ref. 35.7 Ref. Private, NGO, INGO 25 12.2 0.78 * 0.17 1.38 12.0 0.21 0.04 1.01 Self-employed, Temporal, Unemployed 1,033 11.6 0.40 * 0.00 0.81 26.4 0.55 0.23 1.31 Father’s educational level Up to preparatory 383 11.5 Ref. 27.2 Ref. Secondary or Vocational 446 11.6 0.04 -0.14 0.21 27.4 1.07 0.73 1.59 Diploma, BA or Postgrad. 268 11.6 0.02 -0.21 0.24 24.3 0.84 0.50 1.41 Father’s employer Public sector 267 11.4 Ref. 28.1 Ref. Private, NGO, INGO 76 11.7 0.00 -0.33 0.33 26.3 1.10 0.53 2.31 Self-employed, Temporal, Unemployed 754 11.6 0.05 -0.15 0.25 26.0 0.85 0.54 1.33 Number of household members 1-5 members 448 11.6 Ref. 26.6 Ref. 2 6-8 members 652 11.5 -0.01 -0.18 0.16 26.4 0.85 0.57 1.26 Number of children 6-59 months 1 child 389 11.7 Ref. 23.7 Ref. 2 children 489 11.5 -0.21 * -0.38 -0.05 26.6 1.17 0.80 1.72 3 or more children 218 11.5 -0.21 * -0.43 0.00 31.2 1.42 0.88 2.28 Length/Height for age Stunted 292 11.6 Ref. 26.4 Ref. Normal/Tall 805 11.6 0.00 -0.17 0.16 26.6 0.91 0.62 1.32 Weight for age Normal/Wasted 857 11.5 Ref. 27.1 Ref. Overweight/Obese 235 11.6 0.13 -0.05 0.31 24.7 0.80 0.53 1.21 Fever over the past two weeks Yes 406 11.4 Ref. 30.3 Ref. No 691 11.6 0.22 ** 0.06 0.38 24.3 0.84 0.58 1.20 Cough over the past two weeks Yes 342 11.6 Ref. 24.6 Ref. No 757 11.5 -0.14 -0.31 0.03 27.3 1.43 0.97 2.10 Diarrhea over the past two weeks Yes 190 11.3 Ref. 37.4 Ref. No 909 11.6 0.20 * 0.01 0.39 24.2 0.63 * 0.41 0.95 Breastfeeding Breastfed less than 6 mos. 98 11.5 Ref. 24.5 Ref. Breastfed 6 or more mos. 780 11.7 0.04 -0.21 0.30 23.4 1.28 0.71 2.33 Still breastfeeding 150 11.0 -0.24 -0.6 0.08 44.7 1.74 0.87 3.46 Where do you get vitamin A & D Only from MoH 413 11.7 Ref. 23.7 Ref. Only from UNRWA 344 11.5 -0.03 -0.36 0.30 27.9 1.19 0.56 2.52 Only from Private 59 11.3 -0.17 -0.56 0.22 38.9 1.40 0.60 3.27 Any other combination 101 11.6 0.05 -0.25 0.36 24.7 0.80 0.40 1.61 Where do you get the iron drops from? Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 84 Hemo- globin Linear regression for Logistic regression levels hemoglobin Anemia for anemia ( mean [95% Conf. prevale Odds [95% Conf. Coef. N g/dl) Interval] nce (%) Ratio Interval] Only from MoH 433 11.7 Ref. 24.5 Ref. Only from UNRWA 451 11.5 -0.07 -0.42 0.28 27.3 1.02 0.46 2.24 Only from Private 16 11.4 -0.18 -0.81 0.44 31.3 2.10 0.56 7.83 Any other combination 78 11.5 -0.23 -0.58 0.12 32.1 1.81 0.83 3.94 Not receive 108 11.4 -0.27 -0.61 0.07 26.9 1.34 0.64 2.82 (*) for p <0.05 and (**) for p <0.01 Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 85 Table 17: Regressions of Hemoglobin and Anemia for Adolescents (n=2,400) Linear regression for Logistic regression for Hemogl hemoglobine anemia obin levels [95% Conf. Anemia [95% Conf. ( mean Coef. Interval] prevale Odds Interval] N g/dl) nce (%) Ratio Province West Bank 1,177 13.7 Ref. 9.9 Ref. Gaza Strip 1,185 13.4 -0.36 ** -0.52 -0.21 12.5 1.52 0.96 2.41 Type of community City 1,286 13.5 Ref. 12.7 Ref. Village & Bedouin 750 13.6 0.09 -0.04 0.21 9.5 0.65 * 0.45 0.94 Camp 326 13.5 0.21 ** 0.07 0.35 9.5 0.56 * 0.36 0.87 Supervising body of place of recruitment Government 2,317 13.5 Ref. 11.4 Ref. Private 45 14.4 0.45 * 0.08 0.83 4.4 0.35 0.07 1.71 School gender Boys 1,134 14.3 Ref. 2.4 Ref. Girls 1,095 12.7 0.20 -0.16 0.56 20.3 2.14 0.51 8.92 Co-ed 133 13.7 0.08 -0.23 0.39 12.0 2.73 0.69 10.88 Grade 1 1,365 13.6 Ref. 10.9 Ref. 2 997 13.5 0.14 -0.02 0.29 11.6 0.61 * 0.38 0.97 Student’s gender Male 1,198 14.4 Ref. 2.4 Ref. Female 1,164 12.7 -1.82 ** -2.17 -1.47 20.3 5.33 * 1.35 21.09 Did you have fever today or during the past week? Yes 137 13.6 Ref. 12.4 Ref. No 2,206 13.5 -0.06 -0.25 0.14 11.1 0.85 0.48 1.51 Student's age 13-15 years 912 13.6 Ref. 10.2 Ref. 16 -18 years 1,450 13.5 0.15 * 0.02 0.27 11.8 1.22 0.84 1.77 Height for age Stunted 506 13.5 Ref. 11.7 Ref. Normal/Tall 1,855 13.6 0.13 * 0.02 0.24 11.1 0.90 0.65 1.26 BMI for age Normal or Underweight 1,826 13.5 Ref. 11.0 Ref. Overweight or Obesity 532 13.6 0.03 -0.08 0.14 12.2 1.07 0.77 1.48 Number of siblings 1 to 5 970 13.7 Ref. 10.2 Ref. 6 or more 1,388 13.5 0.01 -0.09 0.12 12.0 0.94 0.68 1.30 Student’s order in the family 1st-2nd 909 13.6 Ref. 11.0 Ref. 3rd or more 1,448 13.5 -0.08 -0.18 0.02 11.4 1.06 0.78 1.44 Father’s educational level Up to preparatory 730 13.5 Ref. 10.1 Ref. Secondary or Vocational 875 13.5 -0.02 -0.13 0.10 12.5 1.33 0.94 1.88 Diploma, BA or Postgrad. 710 13.6 -0.05 -0.18 0.09 11.3 1.25 0.82 1.89 Father's employer Public sector 578 13.5 Ref. 12.6 Ref. Private, NGO, INGO 256 13.6 0.04 -0.13 0.20 10.2 0.75 0.45 1.25 Self-employed, Temporal, Unemployed 1,481 13.5 0.06 -0.07 0.18 11.1 0.81 0.57 1.16 Mother’s educational level Up to preparatory 825 13.5 Ref. 11.4 Ref. Secondary or Vocational 1,029 13.5 -0.01 -0.12 0.09 11.2 0.93 0.67 1.28 Diploma, BA or Postgrad. 508 13.7 0.07 -0.08 0.23 11.0 0.98 0.62 1.56 Mother’s employer Public sector 162 13.8 Ref. 9.3 Ref. Private, NGO, INGO 93 13.7 -0.06 -0.35 0.23 9.7 1.02 0.40 2.62 Self-employed, Temporal, Unemployed 2107 13.5 -0.05 -0.26 0.16 11.4 1.13 0.58 2.20 (*) for p <0.05 and (**) for p <0.01 Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 86 5.8 Estimation of normative needs of supplements versus operational estimation and amount distributed. Normative needs Pregnant Operational for pregnant and Distributed Year Region Provider women Presentation estimation of lactating women (units) registered needs (units) (units) 2019 West Bank MOH 36,048 50 mg elemental iron per 9,732,960 7,464,000 5,931,000 tablet (160mg ferrous sulphate & 0.4mg folic acid) 2019 West Bank UNRWA 15,129 100mg elemental 2,450,898 2,063,800 Not available iron/coated tablet (Ferrous Fumarate BP 310mg) 2019 Gaza Strip UNRWA 38,244 100mg elemental 6,195,528 Not available 4,793,200 iron/coated tablet (Ferrous Fumarate BP 310mg) Assessment Report – Bottlenecks of Anemia Prevention and Control in the West Bank & Gaza Strip | 87