by Julie Wang’ombe & Diksha Radhakrishnan, Evidence Action
For several years, Evidence Action has partnered with the Government of India to deliver mass school-based deworming as part of our Deworm the World Initiative. What began as a one-state effort in 2011 evolved into a national initiative in 2015, reaching roughly 89 million children across 11 states. India’s National Deworming Day now reaches nearly 270 million children annually for as low as 0.05 USD per treatment. [1] 
The ongoing success of this partnership has allowed us to explore opportunities to extend our impact in India. Last year, we began a conversation with the Ministry of Health and Family Welfare about expanding our collaboration to deliver additional evidence-based, cost-effective, life-changing health programs at massive scale. We identified a few high-potential areas for collaboration, focusing especially on child health interventions that could be delivered through a school-based model, given our in-depth experience with that distribution channel. Ultimately, we settled on one promising area for further exploration through our Beta incubator: India’s national Weekly Iron and Folic Acid Supplementation (WIFS) program, which is designed to address the pressing challenge of anemia among school-age children.
Globally, anemia affects over 1.6 billion people. In India, it is the leading cause of disability and is particularly prevalent among women, adolescent youth, and young children. Prolonged anemia in childhood can have deleterious and potentially irreversible effects on children’s physical and cognitive development, jeopardizing their ability to succeed both in education and later-life. Although a number of factors can drive anemia, the single largest cause is iron deficiency, which contributes to over 50 percent of anemia cases in India.
In 2013, the government launched the National Iron Plus Initiative under which the school-based Weekly Iron and Folic Acid Supplementation (WIFS) program now exists to reach children and teenagers aged 5 to 19. The WIFS program grew out of a UNICEF-led pilot that was highly successful, achieving a 24 percent reduction in anemia prevalence after one year at an average cost of just 0.58 USD per girl treated. Similar initiatives outside India have also been high impact, leading to dramatic reductions in the prevalence of anemia and iron deficiency, and in some cases resulting in improvements in the physical and cognitive development and educational attainment of targeted children.
WIFS has since been rolled out in all states across the country, targeting out-of-school children through government-run health centers (known as anganwadi centers). However, the program – a complex, multi-faceted initiative – has faced challenges that have impeded its reach, effectiveness, and impact. A government-approved survey that we conducted in February 2018 in over 4,000 schools across 10 states [2] where we support school-based deworming, shed light on some of these challenges. For example, we found that WIFS was reportedly implemented (regularly or irregularly) in just 31 percent of schools, with a significant number of these schools indicating they lacked a regular supply of tablets. Meanwhile, 61 percent of schools indicated they were unaware of the program and, consequently, were not implementing it. Some schools also indicated that they struggled to store tablets, manage inventory, and administer tablets to children. Similar issues were observed in a parallel survey we conducted of more than 5,000 anganwadi centers involved in WIFS implementation.
External observers have also noted implementation challenges. For example, a working paper by a group of development economists who studied WIFS implementation in Odisha state found that the program had limited effect. The researchers concluded this was due to disruptions stemming from inconsistent tablet distribution and breaks in the school calendar. 
Based on our initial assessment, and drawing on our experience meeting similar logistical and public advocacy needs for India’s National Deworming Day, we have identified several areas where we think Evidence Action can offer targeted support to improve program delivery, coverage, and monitoring. These include supply chain management (from procurement to the distribution of tablets), teacher and community worker training on effective drug administration, community sensitization on the existence, need for, and benefits of the WIFS program, and program monitoring systems.
We expect that there will be opportunities to leverage not just our experience with National Deworming Day, but also the National Deworming Day platform itself, including existing inter-ministerial planning committees and teacher training tools. If it is possible to achieve this kind of overlap in planning and delivery platforms and program cost-sharing, it could drive up cost-effectiveness for India’s National Deworming Day as well as the WIFS program.
With the government’s guidance and the support of charity evaluator GiveWell, we spent 2018 conducting a light-touch assessment of the potential of this intervention and identifying key questions for further exploration as part of phase 1 of our Beta incubation process. In 2019-2020, with the continued support of GiveWell (we’ll share a link to their assessment soon), we are launching phase 2 of the incubation process, centered on “prototyping” our proposed technical assistance model, which we plan to test in two states in India over the next two years. The goals of this work will be to:
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Create a more robust understanding of the program’s current cost-effectiveness;
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Develop and iteratively improve our technical assistance model before potentially scaling up; and
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Understand the extent to which our technical assistance is able to lead to significant program delivery and coverage improvements and track how cost-effectiveness improves through our support.
We are excited about this promising opportunity to build on a strong government partnership that already benefits hundreds of millions of children every year, and we look forward to sharing lessons as this new work progresses.
Photos Stephanie Skinner/Evidence Action
[1] Average cost per child, per treatment round in 2017.
[2] Bihar, Chattisgarh, Jharkhand, Karnataka, Madhya Pradesh, Rajasthan, Telangana, Tripura, Uttarakhand, Uttar Pradesh
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