Anemia Implementation Science Initiative


The Uganda Anemia Implementation Science Initiative (ISI)  improved the implementation of iron-folic acid (IFA) supplementation through undertaking an implementation science (IS) approach. Anemia ISI activities are nested within the URC USAID Regional Health Integration to Enhance Services in East Central Uganda Activity (RHITES-EC) Project.


The Challenge

Anemia among pregnant women is on the raise in Uganda and contributes to the unacceptably high maternal mortality ratio (336 per 100,000 live births) in the country. Busoga region, where the implementation research (IR) is being undertaken, has one of the highest levels of anemia and nutritional deficiencies among pregnant women and their children in Uganda. Improving the nutritional status of women plays a critical role in fighting against pregnancy-related anemia. IFA supplementation has been found to be effective in reducing the prevalence of anemia among women and their unborn babies. In Uganda, less than 25% of the women take the recommended 90+ IFA supplements, the situation is worse in the Busoga region (11.8%). An assessment conducted by URC and the Ugandan MOH revealed two major bottlenecks to uptake of IFA: uncoordinated health education and frequent drug stock out. To address this, Anemia ISI, with support from USAID RHITES-EC, designed an intervention to improve IFA-related health education and quantification using enhanced support for Quality Improvement (QI). Using an IR approach, the project will investigate the implementation and the effectiveness of QI.



  • Assess national- and district-level bottlenecks to effective IFAS. Stakeholders in the IFAS service delivery and supply chain systems came together at a national-level bottleneck analysis workshop in October 2018 to prioritize bottlenecks in each system. Priority bottlenecks in the service delivery system included poor health education in antenatal care and low rates of male involvement in ANC. In the supply chain systems, bottlenecks revolve around recurrent stock-outs of IFAS due to poor quantification procedures.
  • Conduct two implementation research studies based on the priority bottlenecks. Research questions will focus on the current implementation of antenatal health education and quantification and assessing how the use of QI approaches changes health education and stock-outs and hopefully uptake and utilization of IFA. Implementation research studies commenced in mid-2019.
  • Conduct a third Focused Ethnographic Study to investigate the barriers of early initiation of ANC services and use the findings to identify potential interventions that are appropriate for the local population.
  • Integrate the evidence from the implementation research studies into anemia prevention programs and policy. Evidence uptake activities will occur throughout the project with key members of the core team communicating important findings to policymakers and program managers. At the end of the project, an evidence-sharing meeting will be held to ensure that all information from the two implementation research studies, as well as the bottleneck assessments, are widely shared and utilized.



  • Established a Core team with representatives from the Ugandan Ministry of Health, bilateral agencies, implementing partners and researches from the Makerere University School of Public Health to provide strategic and technical guidance to the Initiative and share experiences in addressing IFAS implementation challenges.
  • Conducted a Bottleneck Assessment Workshop with key stakeholders to map the IFAS delivery system. From the workshop, Anemia ISI developed a Bottleneck and Solutions Inventory Tool that is routinely updated with identified IFAS bottlenecks and possible solutions.
  • Presented a poster on “Stakeholder Engagement in Identifying and Addressing Implementation Bottlenecks in Iron-Folic Acid Supplementation Programs in East Central Uganda” at the 4th annual Federation of African Nutrition Society (FANUS) conference
  • Hosted global webinars to highlight the Effectiveness-Implementation Hybrid design of the IFAS IR work in Uganda
  • Developed a Baseline Assessment Report on Quality Improvement Approaches to Enhance Iron and Folic Acid Supplementation in Antenatal Care in Iganga and Buyende Districts, Uganda


Mothers and their children wait outside a clinic in Uganda. © 2017 Cynthia Ayeza Mutabaazi, Courtesy of Photoshare
Mothers and their children wait outside a clinic in Uganda. © 2017 Cynthia Ayeza Mutabaazi, Courtesy of Photoshare
2018 to 2021
International Initiative for Impact Evaluation (3ie)
Society for Implementation Science in Nutrition (SISN)
Regions/ Countries