A pregnant woman in Uganda receives iron-folic acid supplements to prevent anemia. Photo credit: URC

Uganda Anemia Implementation Science Initiative (ISI)

The Challenge

Anemia among pregnant women in Uganda contributes to its high maternal mortality ratio (375 per 100,000 live births). Iron–folic acid supplementation (IFAS) has been found to be effective in reducing anemia among women and their unborn babies. However, in Uganda less than 25% of pregnant women take the recommended supplements. And in the Busoga region – which has some of the highest levels of anemia and nutritional deficiencies among pregnant women in the country – this rate is even lower, with less than 12% of pregnant women taking the recommended supplementation.

Overview and Objectives

To identify the priority challenges in poor IFAS supplementation rates, URC and the Ugandan Ministry of Health (MOH) engaged with stakeholders at national, regional, and local levels to identify the major bottlenecks to IFAS uptake. The conclusion: IFAS stockouts due to poor quantification procedures and inadequate health education for pregnant women during antenatal care (ANC).

To address these issues, the Uganda Anemia Implementation Science Initiative (ISI) – with support from the USAID Regional Health Integration to Enhance Services in East Central Uganda Activity (RHITES-EC) Activity – designed interventions to improve IFAS provision at ANC clinics using quality improvement (QI) methods and processes, including Plan-Do-Study-Act cycles. These interventions included the following:

  • Regular monthly IFAS performance review meetings;
  • District mentors providing onsite mentorships and reminder to health workers about IFAS standard protocols;
  • Integrated IFAS messages in health education sessions conducted at ANC clinics;
  • District medicine management supervisors conducting monthly onsite mentorships for logistics personnel on stock management; and
  • Weekly facility data reviews to assess percentage of pregnant women attending ANC and receiving IFAS to monitor performance.


Anemia ISI conducted a mixed method, difference-in-differences effectiveness study to assess whether the intervention increased availability of IFAS. The study used longitudinal, facility-level data from two treatment and one comparison district for the quantitative results. Researchers conducted exit interviews with clients and in-depth interviews with providers and district managers for greater insight into the implementation process.

The study found the intervention significantly increased the probability of pregnant women receiving IFAS during ANC. Women in the intervention group were twice as likely as the control group to receive IFAS supplements after adjusting for other factors. According to interviewees, Anemia ISI’s implementation science approach and QI methods improved stakeholder engagement and buy-in at national, district, and facility levels. Health providers better understood the importance of IFAS and were able to communicate the importance more clearly to clients.

Said one health care provider at an ANC clinic: “Pregnant women actually take (the supplements) because they now know the reason as to why they should take the IFAS.”

Engaging national stakeholders and supply chain managers helped address the barriers around stockouts, which were difficult to resolve at the facility or even district levels. This improvement in IFAS availability and uptake happened without additional funds for IFAS procurement and despite the implementation challenges related to the COVID-19 pandemic.




Health Service Delivery, Implementation Science, Quality Health Systems

International Initiative for Impact Evaluation (3ie)

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