MAKING MULTISECTORAL COLLABORATION WORK

Adolescent girls’ nutrition and prevention

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of anaemia: a school based multisectoral
collaboration in Indonesia
Marion Roche and colleagues highlight lessons from a multisectoral project implementing
weekly iron supplementation for adolescent girls in West Java, Indonesia, which provides a scalable
model for reducing anaemia

I
ron deficiency anaemia is estimated anaemia among females aged 15-24 years review of the findings of the working report
to be the single largest cause glob- is 18.4%3; other surveys suggest a preva- (supplement 1).
ally of morbidity and mortality in lence of 30% in adolescent girls.4 Screen-
adolescent girls; it is expressed as ing data from junior high school students Design of the demonstration project intervention
disability adjusted life years.1 Dis- in West Java, the most populous province The adolescent nutrition WIFAS demonstra-
advantages linked to iron deficiency anae- with 47 million inhabitants,5 indicated a tion project was conducted between 2015
mia include reduced academic potential; prevalence of >50%.6 and 2018. It aimed to show how the revised
decreased wellbeing and productivity at Indonesia’s Ministry of Health updated national WIFAS policy could be intro-
home or in the community; and increased its national programme for anaemia duced through the UKS/M school health
maternal and infant morbidity and mor- prevention and control in adolescent programme, supported by four ministries:
tality for adolescents who become preg- girls and women of reproductive age Ministry of Health, Ministry of Education
nant. 2 The World Health Organization (WIFAS policy) in 2016 to align more and Culture, Ministry of Religious Affairs,
recommends weekly iron folic acid supple- closely with WHO guidance (box 1). As and Ministry of Home Affairs (box 3). The
mentation (WIFAS) to reduce anaemia in part of the revision, it was suggested that Ministry of Health selected the peri-urban
adolescents aged 10-19 years and women an existing school health programme, and rural districts of Cimahi and Purwa-
of reproductive age, in regions where anae- Usaha Kesehatan Sekolah/Madrasah karta, respectively, in West Java (fig 1), as
mia is a public health concern, affecting (UKS/M), should deliver the service7 (box implementation sites. The districts reported
>20% of females aged 15-49 years.2 In 2). In Indonesia, adolescents rarely access high rates of anaemia (>50%) and had also
Indonesia, the national prevalence of preventive health services, but over 86% shown leadership in championing adoles-
are enrolled in secondary school. Thus cent nutrition.
school based interventions are seen as The demonstration project involved three
KEY MESSAGES ideal to reach adolescent girls, and are cost key strategic components based on broader
•   A school-based iron supplementation effective in other settings.9 Although the adolescent nutrition programme work by
project for adolescent girls in West WIFAS policy had been revised, it had not Nutrition International. This includes
Java, Indonesia provides a scalable been implemented, and practical guidance both WIFAS and nutrition education for
model for anaemia reduction from the Ministry of Health was limited. adolescents11; see also, project timeline
•   Existing platforms and policy frame- To overcome this challenge, the ministry (supplement 2).
works for action help to catalyse mul- received technical and financial support
from an international non-governmental (1) Increasing awareness of, and securing
tisectoral collaboration
organisation—Nutrition International— government commitment to, the
•   Political commitment from the high- WIFAS project and adolescent health,
est policymaker of each sector or in 2015, to introduce a demonstration
project for adolescent nutrition. This in general. This to be achieved through
ministry is key, but local and institu-
project worked through the school health implementation of policies, ensuring
tional commitment, such as from each
programme to understand the roles, budget allocation for procurement and
school principal, is also needed
challenges, and opportunities inherent in supply of IFA supplements, training,
•   Capacity building is needed at all lev- supportive supervision, and providing
this multisectoral approach, with the aim
els, but investments in strengthening resources through joint advocacy
of designing a scalable programme.
individual and institutional relation- meetings at national, provincial, and
This case study was developed in
ships across sectors help to foster col- district levels.
response to a global call for proposals by
laboration (2) Improvement of the supply of
the Partnership for Maternal, Newborn, and
•   Data drive decisions and accountabil- Child Health. It aimed to identify factors commodities through skills building
ity, so harmonisation and collabora- of Ministry of Health staff in
for successful multisectoral collaboration
tion on data collection, monitoring forecasting, procuring, and supplying
for women’s, children’s, and adolescents’
systems, and joint responsibility for, IFA for district health offices, and
health. 10 The methods used included
and ownership of, shared results, out- by strengthening supply chain
document review and interviews with key
comes, and goals are key to engage- management systems. Programme
informants to provide information for a
ment by all stakeholders work also included provision of joint
working report, and a multistakeholder

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MAKING MULTISECTORAL COLLABORATION WORK

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Box 1: Evolution of weekly iron folic acid supplementation (WIFAS) policies in Indonesia Enabling environment, political commitment, and
local context
•   Since 1997, the government of Indonesia has had a mandate to introduce iron folic acid sup- The multisectoral collaboration was driven
plementation for adolescent girls, in order to reduce future maternal health complications.
by a change in policy. It was also enabled
The original 1997 guideline recommended one supplement, once weekly for 16 weeks, and
by an existing mandate for collaboration,
an additional supplement every day for 10 days of menstruation each month7
political commitment at all levels, and by
•   This guidance was not aligned with the updated 2011 WHO guidelines for iron folic acid
overall coordination across sectors by a
supplementation.2 These guidelines recommend one supplement weekly for 3 months and
non-governmental organisation (Nutrition
then 3 months without supplements (6 months total/year), or the option to implement the
International).
programme once weekly during the school semester, as aligned with the school calendar2
The Ministry of Health sent a letter to
•    2015, academics and nutritional experts, including Nutrition International, participated
In
all heads of provincial and district health
in technical consultations led by the Ministry of Health, to align national guidelines with
offices in Indonesia providing details of
theWHO recommendations. The revised Indonesian guideline recommends WIFAS of
the WIFAS policy change.7 The updated
•   60 mg elemental iron +400 µg folic acid, once weekly for every week of the year.7 The for-
anaemia prevention and control guideline
mula recommended by WHO (60 mg elemental iron + 2800 µg folic acid) was not affordable
globally
suggested that IFA supplements should be
delivered to schools through the existing
UKS/M school health programme (box 2).
and on the job training for teachers and The behaviour change intervention The letter clearly prioritised this initiative
primary health facility (puskesmas) strategy aimed to show that WIFAS by provincial and district staff in the health
staff, and district officials from the and anaemia reduction would improve sector. However, three other ministries
health, education, and religious school performance and wellbeing of (religious affairs, education and culture,
sectors. This aimed to improve adolescent girls, rather than linking it and home affairs) needed to be involved
knowledge of, and skills to prevent, to reproductive health (supplement 3). when the Ministry of Health mandated
anaemia, WIFAS consumption and delivery through the UKS/M programme.
counselling, and forecasting and Findings from the demonstration They had not yet received guidance from
reporting. Teachers distributed WIFAS project could help to scale up the policy their own leadership (box 2).
to adolescent girls, supervised, and beyond these two districts. We estimate Political commitment from these
recorded consumption, and provided that the demonstration project might have three sectors was generated through
instructions on the prevention and contributed to preventing 4071 cases of joint national, provincial, and district
management of side effects. Following anaemia, by reaching 52 000 adolescent level meetings, facilitated by Nutrition
best practice elsewhere, a fixed day girls with the WIFAS scheme in the two International. The meetings aimed to raise
approach was followed—for example, districts. These figures are based on awareness among all four sectors of the
every Friday at assembly.12 estimates from Nutrition International’s burden of anaemia for adolescent girls and
(3) Increasing demand, and acceptability Outcome Modelling for Nutrition Impact the benefits of anaemia reduction. After
of the project to different stakeholders, Tool13; modelling based on the national these meetings, the district planning and
t h r o ug h a b e h av i o u r c h a n ge prevalence of anaemia for women of development agency (Bappeda) agreed
intervention strategy, including reproductive age; and 27% cases of to contribute funds to train additional
a branded campaign “Healthy, anaemia averted by WIFAS. 14 Details of UKS/M teachers, beyond those covered
beautiful, and smart without anaemia” additional achievements provided by the by the Nutrition International project. In
(fig 2). Campaign messages were endline evaluation measurements are Indonesia, the importance of government
based on formative research with shown in supplement 4. Below, we examine endorsement of a project, including
adolescent girls, parents, health the different components of collaboration issuing circulars to national, provincial,
staff, teachers, and religious leaders.6 that contributed to this success. and district/municipal areas, cannot
be overestimated. In schools, better
commitment from the staff to implement
Box 2: Usaha Kesehatan Sekolah/Madrasah (UKS/M): national school health programme WIFAS activities was achieved when the
The UKS/M programme, established in 1976, aims to improve students’ educational head teacher issued an official letter.
achievement by encouraging a healthy lifestyle and creating a healthy environment for “A key factor in the success of
students8 collaboration was the support from
the head of the district and the legal
The programme was updated in 1984, and endorsed by a joint regulation of four ministries:
standing of the project. Therefore,
the Ministry of Education and Culture, Ministry of Health, Ministry of Religious Affairs, and
it can be merged into the district
Ministry of Home Affairs. Each sector has its own role and responsibilities for supporting
programme and consequently the
UKS/M activities. These guidelines were updated in 2014. They provided a comprehensive list
budget will be secured.” Key informant
of activities for schools to adopt those most needed
interview, district social welfare officer
The programme promotes intersectoral collaboration for school health among ministries with (May, 2018)
national, provincial, district, and subdistrict coordination teams. In schools, the head teacher Although a programme and a written
and one or more teachers oversee UKS/M actions. Each school is expected to work with primary mandate for collaboration existed,
health facility (puskesmas) staff to carry out certain programme activities. In 2016 the national assessment showed that the effectiveness
Ministry of Health requested that weekly iron folic acid supplementation should be one of the of the UKS/M programme in schools was
UKS/M activities limited, with few activities taking place.

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 MAKING MULTISECTORAL COLLABORATION WORK

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Box 3: The roles of key partners and stakeholders in the weekly iron folic acid supplementation demonstration project

Ministry of Heath
•   Develop programme planning and national coordination within the directorate general of public nutrition
•   Facilitate coordination through UKS/M programme
•   Ensure timely and adequate procurement of iron folic acid (IFA) supplements, in consultation with the district health offices, to ensure
the availability of stocks at schools
•   Support health staff and frontline health workers, through regular meetings and on the job training
•   Strengthen monitoring and supervision of personnel; and review stocks and coverage of the IFA supplements
Ministry of Education and Culture and Ministry of Religious Affairs
•   Support the programme by providing school and madrasah resources and infrastructure, including school staff and personnel
•   Facilitate inclusion of health and nutrition education in the curriculum and activities for adolescents
•   Include education sessions on a healthy school environment
•   Encourage local government to improve the UKS/M infrastructure
Ministry of Home Affairs
•   Facilitate implementation of the school health programme, including encouraging the district to develop local regulation for improving
the UKS/M programme (including budget allocation)
•   Support districts in establishing or strengthening the UKS/M secretariat
Nutrition International
•   Technical support for procurement of IFA supplements and financial resources to fill any supply gaps
•   Technical assistance through the provision of provincial and district coordinators
•   Technical and financial support for advocacy meetings and training at provincial and district level; on the job training; development of
training modules and behaviour change intervention materials; and evaluating the demonstration project with academic and research
agency partners

Adolescent girls
•   Participation in focus group discussions for the project’s formative research
•   Participation in the design, revision, and testing of behaviour change materials and nutrition education
•   Peer leaders to support the focal point teachers
•   Provide feedback on the programme during supportive supervision visits

This proved to be a key challenge with using facilities and district health offices now trainers” course for district facilitators was
UKS/M to deliver WIFAS, and collaboration coordinated with schools. Secondary school the key entry point to collaboration.
with schools needed to be strengthened. management was moved to the provincial The main lesson from workshops was
District coordinators, supported by Nutrition level in 2017 soon after the WIFAS project that building relationships and trust among
International, were crucial for revitalising the was implemented. This resulted in changes stakeholders was essential for improving
UKS/M programme and involving each sector, in leadership for the demonstration project collaboration. Such working relationships
through extensive communication (box 3). in the education sector. and communication across sectors were
Project stakeholders emphasised that this Although misalignment between the previously absent. Improving personal
initial investment in the coordinators was health and education system reporting relationships was recognised by all as
essential for bringing together the relevant lines was a challenge, decentralisation also one of the main benefits of involvement
personnel across the multiple ministries. had the benefit of fostering innovation by in the project, in addition to improving
Defined roles and responsibilities local champions. Under the decentralised knowledge of health and nutrition and
were described in the UKS/M. However, system, primary and secondary schools identifying goals for the collaboration. Most
challenges emerged from the different have autonomy to prioritise which UKS/M informants used the term “silaturahmi” or
structures in management, communication, activities to implement in their schools “extending ties of friendships, fellowships,
and reporting between health and education and school principals played a vital role in or fraternity” to describe their personal
sectors. This was due to different levels and leadership of WIFAS activities.8 The district gain from the project (box 4). It was
timing of decentralisation across sectors, coordinators built relationships with school suggested that formal joint training and
and to changes of structures in the education principals to create and maintain their meetings should be followed up by informal
system during the project (supplement 5). interest in the project. networking, to improve collaboration
The demonstration project worked with 244 and build trust across sectors. This was
schools that were accustomed to reporting Building capacity and relationships especially important at the district level,
to the provincial office. On the other hand, Joint capacity building succeeded in its and revived the UKS/M programme in both
health services, including nutrition, were original goals, but also had the unintended districts, after a period of limited activities.
coordinated by, and reported to, their benefit of fostering relationships and com- However, one challenge to sustaining
respective district/municipal health office. munication. This proved invaluable for the relationships was to reduce the turnover
The project moved the expected lines collaboration. Project stakeholders across of staff, especially in schools, as it was
of reporting, and the network of health sectors agreed that the four day “training of teachers who delivered the IFA tablets and

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MAKING MULTISECTORAL COLLABORATION WORK

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Jakarta

Purwakarta
Banten

West Java
Cimahi
Aceh

East North
North Kalimantan Gorontalo Maluku
Sumatra Riau Riau West North West
Islands Kalimantan Central Sulawesi Papua
West Bangka Central Sulawesi
Sumatra Jambi Belitung Kalimantan West
South Sulawesi
Sumatra
Bengkulu South Maluku Papua
Kalimantan South East
Lampung South Sulawesi
Central Java Sulawesi
Banten
West Java Bali
Yogyakarta East Java
West Nusa East Nusa
Tenggara Tenggara

Fig 1 | Map of project demonstration sites

education to adolescent girls. Teachers adolescent girls, such as those in junior Red were essential for estimating commodity
could be easily transferred to other regions Cross/Red Crescent groups, in distribution procurement by the district health offices.
by the district or provincial education and reporting of WIFAS take up also helped After initial resistance, data sharing became
and religious affairs office. To reduce this the teachers. smoother when relationships were built:
problem the district health offices and “At the very beginning it was very
Nutrition International conducted on Strengthening supply chain management and difficult even to get a database of
the job training of teachers in schools, monitoring systems to mobilise resources students to estimate the IFA stock for
providing support and supervision. Some Providing local data to show the need for, West Java… Now our head (provincial
schools also used the WIFAS training and potential of, the project was necessary health office) is able to contact by
manual to provide pretraining information for the engagement of participants. School phone her good friend at the provincial
for newly appointed teachers. Involving enrolment data from the education office education office to get the data.” Key
informant interview, provincial health
officer (May, 2018)
District budget constraints were also cited
as a challenge to implementing the UKS/M
programme. Little information about UKS/M
financing at the various administrative
levels is available; and without a monitoring
and evaluation system, data are limited on
the impact of the programme’s activities.8
Participants outside the health sector
considered that monitoring and evaluation
should be carried out by the health sector.
However, there was no mechanism for
schools to share data about WIFAS activities
before the demonstration project. The
district coordinators helped to support
harmonisation and reporting across systems
and sectors and shared health data with
all sectors involved. This helped to build
interest in the progress being made, and
accountability for implementation across
sectors.
Use of evidence and local data involved
Fig 2 | Campaign image participants and drove the decisions made.

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 MAKING MULTISECTORAL COLLABORATION WORK

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Box 4: The concept of silaturahmi and the importance of extending personal relations for Path to sustainability
collaboration Although it is too early to confirm the sus-
tainability of the project in the demonstra-
The Islamic-Indonesian term and concept of silaturahmi is very important in Indonesia for tion districts, some promising signs have
building personal relationships. It is based on the Islamic value of goodwill and fellowship, and been seen. These include establishment of
the ability to extend personal ties of friendships to strengthen fraternity and mutual solidarity. the WIFAS project within UKS/M, revitalisa-
To have a wide network of contacts is thought to provide many personal benefits. Thus, it is tion of the UKS/M, support from policymak-
an important aspect of building relationships, contributing to successful collaboration across ers, and emergence of champions at every
sectors for the WIFAS programme. This was expressed by one district stakeholder: level. For example, project stakeholders
“Previously before the training of trainers we hardly knew each other, although we were all at the district level have agreed to jointly
working under the district government. We very rarely had coordination meetings with other pursue school operations grants and also
sectors, but after the training of trainers, we have been getting along very well …it extends funding from the universal health insur-
silaturahmi.” Key informant interview, district religious affairs officer (May, 2018) ance programme. In Cimahi district, the
collaboration has also expanded to include
Budgeting for procurement of WIFAS International’s principle: “Nothing about the district development planning agency
commodities needed to align with district her, without her.” Nutrition education (Bappeda), in support of implementation
funding cycles. Thus support was needed informed adolescent girls about their sex- and to extend potential financial invest-
for forecasting, with inputs required from specific nutritional needs, including iron, ments beyond the health sector.
both the health and education sectors. From and the benefits of healthier diet and lifestyle Data from the project can stimulate
2015, the Ministry of Health planned to cover choices. Teachers sought support from health interest, but it is still necessary to
20% of the cost of IFA tablets, increasing this staff to counsel girls who were rejecting strengthen the internal monitoring
to 30% by 2019. Districts were expected to supplements, but non-adherence was largely system of the UKS/M programme, which
provide the rest. During the demonstration due to absence from school. Overcoming currently depends on external support.
project Nutrition International covered the barriers to school attendance of girls, such Project participants were keen to improve
gap in supplements. Timely evidence based as menstrual hygiene management facilities coordination across sectors using mobile
advocacy for WIFAS, use of resources, and a and early marriage, were challenges that communication channels and to increase
specific government budget will be required remained. Furthermore, adolescent girls the quality of monitoring and evaluation.
to sustain and scale up the WIFAS project. who did not attend school were beyond the In Cimahi, the district health office and
reach of the UKS/M programme. Additional UKS/M are holding regular meetings on
approaches to reaching vulnerable girls monitoring as a way to improve data quality
Engaging stakeholders at all levels
require further consideration. and use. This is still in an early stage.
The prevalence of anaemia was high in
Teachers were essential to success, as they Importantly, scaling up of the WIFAS
adolescent girls at the start of the project.
distributed the supplements and counselled project is underway, based on the lessons
Nevertheless, awareness of the risk and
adolescent girls. Understanding anaemia and learnt from the demonstration project.
consequences of anaemia was low. This
its effect on school performance and overall Expansion of external resources is taking
resulted in little demand for iron supple-
wellbeing, motivated teachers. However, with place, with interest from both Canadian
mentation and little commitment among
already high workloads, teachers needed to and Australian governments; while
parents, teachers, and religious leaders.
feel that the additional time required was increasing financial commitments from
Iron supplements were generally perceived
worthwhile and recognised. Endorsement district governments are being made. This
as being primarily for pregnant women.6
and acknowledgment by school principals case study shows that targeted investments
Evidence of the local burden of anaemia
and district health leadership was critical. in multisectoral collaboration will be
and the effectiveness of WIFAS, with
This was achieved by sharing data showing critical for success.
appropriate description of the problem and
progress in implementation in schools by The next steps should also focus on
benefits of WIFAS, was critical in securing
assemblies and newsletters. This required the 14% of adolescent girls who do not
support from all involved, including
project and district level results, compiled by attend school in Indonesia, with gender
adolescents. The project highlighted the
the Ministry of Health, to be reported back to inequalities, social norms, early marriage,
potential benefit of WIFAS and anaemia
schools. and early childbearing making them all the
prevention for school performance:
Parents may feel sceptical about more vulnerable to anaemia. Overcoming the
“The district education office’s
interventions delivered outside the health limitations of this project to reach many of the
mission is to educate children and
system. They need to feel confident that vulnerable girls would be of interest to many
young people… therefore we commit
products are safe and that the teachers district sectors. Given the many consequences
to working together and continue the
delivering them are competent. For of anaemia and gender inequality, concerted
[WIFAS] programme… if the children
reassurance, parents were invited to meetings efforts for anaemia reduction are necessary to
are not healthy, they will not be
and sent letters stating the Ministry of Health achieve the sustainable development goals.
educated.” Key informant interview,
district education officer (June, 2018) endorsement of teachers, and details of the
Adolescent girls have been underserved UKS/M programme. These were jointly Conclusions
by the health system in Indonesia, so their produced by the Ministry of Health and the This study of the WIFAS demonstration
cooperation is essential for the development Ministry of Education and Culture. Schools project in Indonesia highlights several
of youth health services.15 Involving girls that informed the parent school committee key elements for successful collaboration:
in developing the intervention was vital or met parents had better coverage and political commitment, enabling policy,
to the collaboration, following Nutrition adherence to IFA consumption. shared goals, joint training and advocacy,

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MAKING MULTISECTORAL COLLABORATION WORK

building relationships and informal com- guidance; DI provided advice and direction. All 3 National Institute of Health Research and

BMJ: first published as 10.1136/bmj.k4541 on 7 December 2018. Downloaded from http://www.bmj.com/ on 10 January 2019 by guest. Protected by copyright.
authors contributed intellectual content and Development. Ministry of Health, Republic of
munication, and sharing data. The suc- approved the final version of this article for Indonesia. RISKESDAS. Ministry of Health, 2013.
cess in reaching adolescent girls in school submission. MLR is the guarantor for this article. 4 World Health Organization. Prevention of iron
and the estimated anaemia reduction, are deficiency anaemia in adolescents: role of weekly
Competing interests: We have read and understood iron and folic acid supplementation. World Health
greater than possible by any sector work- BMJ policy on declaration of interests and declare Organization – Regional Office for South-East Asia,
ing alone. This article, describing the the following interests: funding from the Partnership 2011. http://www.searo.who.int/entity/child_
perspectives and experiences of multiple for Maternal, Newborn, and Child Health (PMNCH) adolescent/documents/sea_cah_2/en/
secretariat (LB) and from Nutrition International (INY) 5 West Java Bureau of Statistics. West Java Province in
stakeholders, has illustrated challenges for consultancy fees and related costs for undertaking figures, 2016. https://jabar.bps.go.id/publication/20
and opportunities that should inform the case study; employees of Nutrition International 16/07/15/2297a52073f5f32eca26eb8a/provinsi-
scale up in Indonesia. It provides help- for implementing the project that is the focus of the jawa-barat-dalam-angka-2016.html
ful insights for other countries aiming to case study (EKA, TSP, SK); and attendance at the 6 Agustina  R, Prafiantini  E. Formative research for an
forthcoming PMNCH partners’ forum in December improved iron folic acid supplementation program
reduce anaemia and improve nutrition for 2018 (MLR, LB, EKA, TSP, SK, DI, AB). The views for school going adolescents in selected districts
adolescent girls. expressed in this article are the authors and do not of West Java province in Indonesia. Department of
Multisectoral collaborations require necessarily represent the views, decisions, or policies Nutrition, Human Nutrition Research Cluster, Faculty
of the institutions with which the authors are affiliated. of Medicine, Directorate of Research and Community
resources and coordination. To further
Services, Universitas Indonesia & Nutrition
reach adolescents, it will be critical to Provenance and peer review: Commissioned;
International, 2016.
externally peer reviewed.
build such collaborations that respond to 7 Ministry of Health. Anaemia prevention and
the unique needs of countries. This article is part of a series proposed by the control program in adolescent girls and women of
WHO Partnership for Maternal, Newborn and Child reproductive age. Ministry of Health, Republic of
Health (WHO PMNCH) and commissioned by The BMJ, Indonesia, 2016.
The authors thank the many people who supported which peer reviewed, edited, and made the decision
the preparation of this article, especially during the 8 Seameo Innotech. Analysis of the interface between
to publish the article. Open access fees for the series Usaha Kesehatan Sekolah (UKS) programme and
development of the case study working paper. At the are funded by WHO PMNCH.
national level, these include representatives from the school based management (SBM). Bonn: Deutsche
Ministry of Health, Ministry of Education and Culture, Marion Leslie Roche, senior technical adviser1 Gesellschaft für Internationale Zusammenarbeit (GIZ);
Ministry of Religious Affairs, Ministry of Home Affairs, 2016. http://www.fitforschool.international/wp-
and the UKS/M secretariat, who we thank for their Louise Bury, independent consultant2 content/ezdocs/SEAMEO_INNOTECH-GIZ_Analysis_
invaluable advice and direction for the WIFAS project of_UKS-SBM_Interface_in_Bandung_2017.pdf
Isma Novitasari Yusadiredja, consultant3 9 Bundy  D. School health and nutrition: policy and
and implementation, and support for developing the
case study. We are also grateful to Elvina Karyadi Eriana Kartika Asri, programme officer4 programs. Food Nutr Bull 2005;26(Suppl 2):S186-
in her former role as country director who worked 92. 10.1177/15648265050262S209 
Tutut Sri Purwanti, senior programme officer4 10 Partnership for Maternal, Newborn & Child Health.
with the Ministry of Health to establish and provide
strategic leadership for the demonstration project. At Sri Kusyuniati, country director4 Success factors case studies from 12 countries
the provincial level, we are grateful for the support announced. New Delhi, India, 2018. http://www.who.
Anjali Bhardwaj, regional manager1 int/pmnch/media/news/2018/success-factors-case-
of many people from the province health office,
province education office, province religion office, studies/en/
Doddy Izwardy, director of public nutrition5
province secretariat, and the UKS/M secretariat of 11 Nutrition International. Women and girls’ nutrition.
1
Adolescents’ and Women’s Health and Nutrition, https://www.nutritionintl.org/what-we-do/by-
West Java Province; and also the key staff from the
district health office, district education office, district Nutrition International, Ottawa, Canada programs/women-girls-nutrition
religion office, and district secretariat of Cimahi and 2
12 World Health Organization. Weekly iron and folic
Global Research Consultancy, Ipswich, UK acid supplementation programmes for women of
Purwakarta districts for their valued cooperation 3
during implementation of the demonstration project Isma Novitasari Yusadiredjai, Bandung, Indonesia reproductive age: an analysis of best programme
in those districts (2015-2018) and for providing 4
Nutrition International, Jakarta, Indonesia practices. World Health Organization, 2011. http://
information for the case study. For support during 5 apps.who.int/iris/handle/10665/207489
Directorate General of Public Health, Ministry of
fieldwork the authors would like to thank staff from 13 Nutrition International. Outcome modelling for
Health, Jakarta, Indonesia nutrition impact tool. https://www.nutritionintl.org/
the Jatiluhur health facility (puskesmas) and staff
and adolescent girls from Jatiluhur high school SMP1 Correspondence to: M L Roche knowledge-centre/omni
in Purwakarta district, who willingly shared their [email protected] 14 Fernández-Gaxiola  AC, De-Regil  LM. Intermittent
experiences of the demonstration project. We also iron supplementation for reducing anaemia
appreciate all the organisations that attended the and its associated impairments in menstruating
case study multistakeholder dialogue workshop on women. Cochrane, 201110.1002/14651858.
4 July 2018; and the research team led by Dr Rina CD009218
Agustina, Dr Erfi Prafiantini, and Dr Budi Wiweko, from This is an Open Access article distributed under 15 Marcus R, Gupta-Archer N, Darcy M, Page E. Rigorous
the Human Nutrition Research Cluster, Department of the terms of the Creative Commons Attribution IGO review. Girls’ clubs, life skills programmes and girls’
Nutrition, Faculty of Medicine University of Indonesia, License (https://creativecommons.org/licenses/by- wellbeing outcomes. GAGE: 2017. https://www.
for management of the baseline survey, formative nc/3.0/igo/), which permits use, distribution, and gage.odi.org/sites/default/files/2017-10/GAGE%20
research, and endline survey of the demonstration reproduction for non-commercial purposes in any Girls%20Club%20Report%20FINAL.pdf
project. medium, provided the original work is properly cited.
Supplement 1: Methods for the WIFAS pro-
Contributors and sources: MLR and LB conceived ject case study
the outline of this paper; MLR drafted the first
version, and revised it in consultation with LB. All Supplement 2: The project timeline
authors reviewed and provided comments on the Supplement 3: Behaviour change inter-
final draft. For the case study review supporting the 1 World Health Organization. Global accelerated vention strategy and campaign
findings of this article, INY wrote the draft working action for the health of adolescents -AA-HA!):
paper with inputs and final review from other
Supplement 4: Endline achievements
guidance to support country implementation.
authors; INY undertook key informant interviews; World Health Organization, 2017. http://www. Supplement 5: Decentralisation in the
and LB drafted an initial summary of findings used who.int/maternal_child_adolescent/documents/ health and education sectors
for consultation with stakeholders. TSP and EKA adolescents-health/en/
provided technical supervision and support to 2 World Health Organization. Guideline: See www.bmj.com/multisectoral-collabora-
the demonstration project, implementation and Intermittent iron and folic acid supplementation tion for other articles in the series.
assessments, and the case study multistakeholder in menstruating women. World Health
meeting. For the project and case study, SK provided Organization, 2011. whqlibdoc.who.int/ Cite this as: BMJ 2018;363:k4541
overall strategic guidance and AB technical publications/2011/9789241502023_eng.pdf http://dx.doi.org/10.1136/bmj.k4541

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