Background of Health, Population and Nutrition Sector Development program (HPNSDP)
During the past 2 decades, Bangladesh has made considerable progress in development, sustaining high rates of economic growth and reducing poverty rates by 9% between 2000 and 2005 (from 49% to 40 %). The country is also on track to meet some of the Millennium Development Goals (MDGs) related to human development such as child mortality and combating HIV/AIDS, where it has outperformed other countries in the region. However, all these improvements have not translated into positive effects on maternal and child nutrition. The prevalence of malnutrition in Bangladesh is still one of the highest among the developing countries.
Although there has been a decline in rate of underweight children over the years, the rates of underweight, stunting and wasting are still all above the WHO’s thresholds for very high levels, typically found in emergency situations. Around 7.8 million children suffer from under nutrtion, which contributes to at least one third of child deaths; Percentage of underweight children (underweight for age) declined to 41% in 2006 from 48% in 2003. The percentage of wasted children (underweight for height) fluctuates, with very high levels in the pre-harvest season (17% in 2007) and lower levels in other seasons. Percentage of stunted children (short for age) has not changed much over the years and was estimated at 43% in 2007 (BDHS). According to WHO health targets set in 1998, stunting rate in children should be less than 20% in all countries and in all specific sub-groups within the countries by the year 2020”. Stunting is an indicator of chronic malnutrition and unlike stunting, underweight status is influenced by short term changes in health or food security situation. It is also noteworthy that large disparities in nutritional status exist across the socio-economic groups. Nearly 51% of under-fives in the lowest quintile are undernourished, compared to 26% in the highest quintile (BDHS 2007). ). The causes of stunting are multifactorial and include among other factors, lack of exclusive breastfeeding, inappropriate complementary feeding, recurrent infections, etc.
Deficiencies in key micronutrients have been and still continue to be a public health challenge in Bangladesh. Vitamin A deficiency was identified as a public health problem since the 1960’s and has been the single most important preventable cause of night blindness in children. More importantly, subclinical vitamin A deficiency among pre-school aged children was classified as a public health problem in rural Bangladesh where almost 75% had vitamin A values below the WHO cut-off of <1.05 µmol/ for mild vitamin A deficiency. More than 20% had serum retinol concentrations less than 0.70 µmol/l, the benchmark for a public health problem. Such high levels of mild vitamin A deficiency are associated with increased risk of mortality in children. Since the past 25 years, vitamin A supplementation program targeting children 9 – 59 months of age has been implemented by the IPHN, health services and NGOs with coverage reaching over 80%. This has contributed to a reduction in night blindness in children 12-59 months of age living in rural areas reduced from 3.5% (1983) to 0.62% (1998)4. To sustainably eliminate vitamin A deficiency in the population, supplementation needs to be complemented with more effective and sustainable improvements in dietary vitamin A. Fortification of edible oil and other foods is one of the means of achieving this. However, the long term solution through dietary diversity needs to be promoted for sustainable reduction in Vitamin A and other micronutrient deficiencies.
Policy and Program Response
In 1975, the Bangladesh National Nutrition Council (BNNC) was established by order of the President of Bangladesh. Headed by the Prime Minister, the Council was constituted by concerned ministers, secretaries, senior administrators, policy makers, nutrition experts, journalists, heads of relevant organizations, and divisional women representatives. The management of the council was vested in an Executive Committee (EC), headed by the Minister for Health and Family Welfare. Secretaries of different ministries and heads of different agencies represent the other EC members. The BNNC also has a Standing Technical Committee consisting of technical experts on nutrition. The objectives of the BNNC are the formulation and updating of the National Food and Nutrition Policy; approval of nutrition programs for different ministries and institutes; and monitoring and evaluation of nutrition research programs. Other functions include- establishment of a nutrition information and documentation centre, preparation of a national plan for nutrition, organizing national and international conferences and training courses; publishing and disseminating technical and general information on nutrition; and providing financial support for nutrition related research projects. Although BNNC has been tasked with important responsibilities for nutrition in the country, it has unfortunately not been effective during the past decade.
National Nutrition Services (NNS): A Mainstreamed and Integrated Approach to Addressing Malnutrition
Under HNPSP, there were two OPs named National Nutrition Programme (NNP) and Micronutrient Supplementation (MNS). Facility based limited services were provided through MNS and community based services were undertaken through NNP-OP. There was evidence of lack of coordination and duplication activities among these two OPs. Moreover, the NNP interventions were contracted to several NGOs and had fragile or no links with the mainstream health system. Referral and intensive management for children with severe acute malnutrition was very inadequate. There are also several other nutrition related projects/ programme run by the different Ministries/Divisions supported by DPs but their activities were not well coordinated and monitored. Moreover, the total estimated cost of the NNP-OP (FY 2003 to 2011) for the interventions in 263 Upazila was Tk. 1,251 crore, whereas it was implemented in about 173 Upazilas in phases covering only 34% of the entire population. The Annual Program Review (APR) of HNPSP in 2009 recommended that to scale up the nutrition interventions the only option is to mainstream the critical nutrition interventions in the services provided through DGHS and DGFP. If the present model of NNP is continued country wide by contracting NGOs, the cost for NNS interventions will be about Tk. 5000.00 crore and it would not possible to achieve MDG target by 2015 with the implementation of the existing model.
In light of this situation, the Government of Bangladesh is planning to accelerate the progress in reducing the persistently high rates of maternal and child under nutrition by mainstreaming the implementation of nutrition interventions into health (DGHS) and family planning services (DGFP), scaling-up the provision area-based community nutrition, updating the National Plan of Action on Nutrition in the light of food and nutrition policies, amongst other important priority actions. To achieve this, nutrition has been made a priority for the proposed sector program and a variety of key strategies and actions will be pursued. The mainstreamed program will be guided by 2 main principles:
The program will focus on those activities within its mandate and where it has the capacity as well as the comparative advantage to act. The key activities that lie outside the mandate of the health sector, NNS will play a coordination as well as advocacy role and ensure active engagement with other the key sectors (for example, Ministries of Agriculture, Food and Disaster Management, Ministry of Industry, etc)
The nutrition program will seek to intervene at the different stages of the lifecycle –during pregnancy, at delivery/neonatal, post natal, childhood, adolescence, newly weds – but with a strong focus on the “window of opportunity”, that is, pregnancy through first two years of life.
Under the HPNSDP, the mainstreamed nutrition programme aims to deliver the nutrition services country wide through the existing DGHS and DGFP set up will costs only about 1490.00 crore TK, which will be cost-effective and more sustainable in future. Since MOHFW being implemented SWAp in a sustainable manner from 1998 which covers almost all HPN services, it will not be worthy to have a separate project for the nutrition services with only GOB resources, as because DPs will not fund for the parallel project outside the scope of HPNSDP.
National Nutrition Services(NNS)
Brief Narratives on priority activities of NNS is provided below:
- Behavior Change Communication (BCC)
- Behavior Change Communication to Promote Good Nutritional Practices:
- BCC is the core strategy for achieving NNS objectives. The objectives of BCC for NNS are –
- to bring positive changes in maternal, infant and child caring practices,
- to increase demand and utilization of health services,
- to help to develop the capacity of the community to understand and address the malnutrition problems,
- to strengthen the capacity of the health service providers to train and support the community workers to perform their BCC activities,
- advocacy for policy support to provide nutrition service by motivating policy makers and opinion leaders.
BCC under NNS includes policy communication, advocacy and social mobilization, interpersonal communication in the community level program. A BCC strategy is under developement for a national advocacy and policy development campaign with technical support from health education bureau and BCC unit of DGFP. NNS is providing support for material development, and production to strengthen social mobilization approach. Mass media campaigns, social mobilization and behavioral change and communication activities at health facility and community levels is being implemented to promote good health and nutrition practices. Consistent dissemination of key message to create social awareness will be ensured in mass media, printing media etc. Specific behaviors to be targeted will include: counseling pregnant women on adequate diet and care, promotion of exclusive breast feeding for 6 months and continued breastfeeding up to 2 years; introduction of complementary foods of adequate nutritional quality and quantity after the age of 6 months; improved hygiene practices including hand washing, and healthy practices among adolescents. Traditional methods as street theater, drama, jari-shari, courtyard drama etc. is also being considered. Other important strategies to implement BCC activities are –
- Regular communication program with general population and stakeholders in nutrition field
- Involvement of ministry of information in raising awareness about nutrition
- Awareness creation about healthy eating habit to prevent under and over nutrition
- Involving religious leaders on advocacy regarding nutrition issue.
- Organizing nationwide nutrition day/week annually on important nutrition themes through nutrition fair, festival, folksongs, film show, debate, essay competition etc. at different level
- Maximum utilization of mass media including television, radio, newspaper for nutrition advocacy and education
- BCC message should include information on production and consumption of safe food, healthy dietary practices, food security etc.
NNSis now flourishing as the national resource center for all nutrition related information. The standardized materials, messages on nutrition issue developed in NNS and approved by MoHFWis now being used by the stakeholders working in nutrition field. NNS website has been developed and relevant BCC materials are available in the existing website. Existing library of IPHN will be enriched and upgraded with latest information, books, journals, magazines etc. on health and nutrition. Media dissemination on NNS activities are regularly done. A media forum is now under process of formation that would include different media personnel and enrich BCC program of NNS with the Ideas of new dimension for disseminating nutrition messages.NNS would seek technical assistance from relevant Government agencies/ Development partners for BCC related procurement as deemed necessary.
- Human resource development (HRD) Training/Capacity Building:
- Capacity building and various forms of training and orientation is a major priority for NNS because of two main reasons: firstly, the weak capacity to sufficiently and effectively supervise and monitor the implementation of the NNS has been identified as a key hindrance to effectiveness of the nutrition program. Secondly, the mainstreaming process requires health and family planning service personnel (At all level of health/ Family Planning service delivery system) to perform duties and responsibilities for which they had not received any or sufficient training. Therefore, NNShas developed a Comprehensive Training Planfor five years and is now implementing training according to the approved training plan for the capacities (human as well as institutional) of NNS as well as that of other line directorates with the responsibilities for delivering nutrition service/intervention. Orientation training for government and non- government personnel at district level and below, which would help in facilitating and updating their knowledge, change of attitudes and help them in delivering and coordinating nutrition services.
- NNSis following the strategies mentioned below to achieve the training objectives:
- Capacity development of individuals- different focal personnel working for NNS at national and sub-national levels needs capacity enhancement in order to effectively implement the interventions.
- Job training- A pre service training for newly recruited or involved as nutrition service provider will be given to increase technical knowledge, communication and management skill etc.Threrefore, for the next two years, NNS would also focus on training the intern doctors on public health nutrition. Also, LD, PSE in collaboration with Center for Mediacl Education (CME) would insert Public Health Nutrition in relevant subjects in Under Graduate curriculum.
- In service training- Regular in service training for field functionaries will be arranged to re-enforce the skill developed in job training and providing continuous community interaction and feedback.
- Orientation- Due tomultisectoral involvement in nutrition services, a number of personnel from various departments of GOB, NGOs and relevant stakeholders would be oriented on nutrition program.
- Specific program and theme based training:Cascade training on IYCF, management of severe malnutrition, CMAM, Food Safety problems etc would be given to the program managers and the field staffs.
- Workshop/ seminars/conferences-Advocacy workshop, program related seminars and conferences is regularly arranged for strengthening program related orientation among policy and decision makers and field functionaries of not only health but also personnel working in Multi-stakeholder Platform. Dissemination of Program Status, technical evidences and Survey findings to the policy planners and decision makers are regularly organized.
- Overseas training for doctors and nurses- To strengthen capacity and update knowledge on modern technology of the service providers, opportunity for overseas training or courses in the field of nutrition is incorporated in the OP.
- Control of Vitamin-A deficiency disorder Vitamin A supplementation
Bangladesh has had much success in attaining as well as sustaining high coverage of Vitamin A supplementation. This high coverage has been attained through bi-annual Vitamin A campaigns for children 6-59 months. High dose (200000 IU/100,000 IU) vitamin A capsule are distributed among 6-59 months children during the national vitamin A campaign. Children aged 6-11 months is being provided with Vitamin A capsules (100000 IU) during National Vitamin A Plus campaign. Vitamin A capsule is also given therapeutically to the children suffering from vitamin A deficiency (night blindness). Vitamin A is also being provided to all <5 years children in emergency situations (flood or cyclone) and to the children suffering from measles, diarrhea, severe malnutrition.NNS is working on National Micronutrient Deficiency Control Strategy based on the findings of National Micronutrient Survey- 2011-12 (Jointly conducted by NNS, UNICEF, ICDDR,B) to increase coverage further. NNS is also conducting special activities to reach population groups living in HTR areas.
- Control & prevention of Anaemia Iron folate supplementation
Bangladesh has one of the highest prevalence of maternal anemia in the world. The country has a policy of providing iron-folic acid supplements to pregnant women (during ANC) in order to reduce the incidence and prevalence of anemia. Three high risk groups have been identified for intervention name as children aged 6-23 months, Pregnant and lactating women, Adolescent girls and newlywed women. Groups at high risk of aneamiais being provided with iron supplements to prevent anaemia. NNSis supporting the coordinated nationwide effort for iron folate supplementation. NNS is developing a National Micronutrient Deficiency Control Strategy based on the findings of National Micronutrient Survey- 2011-12 (Jointly conducted by NNS, UNICEF, ICDDR’B) which is focusing on Iron deficiency too.
Iron folate supplementation / multiple micronutrient supplements are being provided to the children aged 6-23 months, pregnant women, lactating mothers for first three months after delivery, adolescent girls and newlywed women in the recommended doses. NNS has issued a national Circular on dosing regimen for the targeted groups. Pregnant women and lactating women are being counseled on importance of taking iron folate regularly, so that increased compliance can be achieved. However, poor coverage, compliance and stock-outs have affected the effectiveness of this intervention. Therefore the program is trying to set up systems to ensure adequate procurement and supply of IFA tablets at all levels of the health system and; skill transfer, Orientation & training of health service providers (MO, nurses etc) including SACMOs, HAs, CHCPs and FWAs to develop their skills to counsel women as well as effective monitoring to enable full compliance.
For sustainable improvements, food based dietary approach to increase consumption of iron rich food is important. NNS is promoting food based approach through BCCto not only control anemiabut also to improve nutritional status in general. Breast feeding, appropriate complementary feeding, increased intake of animal food, green leafy vegetables etc. is being encouraged. Worm infestation, diarrhea, malaria are important causes of anemia. Routinely, Anti helminthes are being procured and disbursed by nation wide by NNS to control worm Infestation.
- Control of Iodine deficiency Disorder Control of Iodine Deficiency Disorder (IDD) and Salt Iodization Program
BSCIC of Ministry of Industry is responsible for iodization of salt. NNSis facilitating and cooperating activities relating to salt iodization, including production, quality control. NNSis supporting BSCIC to undertake initiative for introduction of appropriate technology for salt production, improving salt iodization plants and enforcing salt iodization laws. The salt iodization programmeis continued to be strengthened and expanded through advocacy at household and national level. The BCCcomponent of the program, for example, is promoting awareness of and increased use of iodized salt by households and help sustain consumer demand of the product.NNS is working on National Micronutrient Deficiency Control Strategy based on the findings of National Micronutrient Survey- 2011-12 (Jointly conducted by NNS, UNICEF, ICDDR’B) that incorporates strategy on controlling Iodine Deficiency.
- Other Micronutrient problems of Public Health importance (zinc, vitamin ‘D,’ calcium etc.)
- Zinc Supplementation during Treatment of Diarrhea
The incidence of diarrhea among Bangladeshi children is amongst the highest in the sub-continent, hence contributing to infant and young child malnutrition. Zinc supplementation during treatment of diarrhoea has been shown to have both curative (reduction in the severity of diarrhoea) as well as preventive (few future episodes). Therefore, NNSis promoting and strengtheningservice delivery system for zinc supplementation along with ORS as part of the protocol for the management of diarrhea. The BCC component of the program is focusing on educating caregivers and other household decision makers on the importance and benefits of full compliance with taking zinc supplements for the full 10 days during treatment/ management of diarrhea
- Vitamin D, Calcium Supplementation
Calcium is essential for pregnant women for development of growing foetus. Thus promotional program is now being designed to advocate for consumption of calcium rich food and calcium supplementation during pregnancy. Disability among children due to deficiency of calcium and/or vitamin D is also identified in some pocket areas of Bangladesh which are suspected as Rickets cases. Special programs for Calcium and Vitamin D supplementation for specific cases will be undertaken.
- Community & facility based management of severe acute malnutrition (SAM & CMAM)
Management of Severe Acute Malnutrition (SAM) and Community Management of Acute Malnutrition (CMAM)
Mainstreaming the implementation of nutrition interventions into health and family planning services will ensure more coordination in the treatment of moderate and severe acute malnutrition at the health facility as well as community level. At the health facility level, children having severe acute malnutrition with medical complications is now being treated according to national guidelines based on internationally recommended protocols. NNS is providing training to relevant service providers on management of severe acute malnutrition cases and also establishing SAM management centres in all hospitals, so that severely malnourished children referred from the community can be successfully treated. At the community level, the GOB is addressing community-based management of acute malnutrition through providing training and logistics to CC level facilities and also working on establishing referral linkages to higher facilities.National guidelines for the management of severely malnourished children as well as Community Management of Acute Malnutrition (CMAM) in Bangladesh is now in use.
- Institutional Capacity Development Institutional Development
NNS would work on identifying and selecting core institutions and provide support for institutional capacity development, viz. curriculum review and/or update to include nutrition for Medical College, MATS, Nursing Colleges/ Training Institutes, Institute of Health Technology , etc., strengthening linkages between tertiary facilities and outreach services, strengthening IPHN and relevant institutions, collaboration with other ministries, and support to IPH for food safety & quality (including laboratory) activities. Tertiary Institutes (ICMH and Medical Colleges) are already implementing NNS training like SAM, IYCF. Short term Certificate course on Nutrition would be introduced at IPHN through NNS.
Orientation / Advocacy of Division, District, Upazila managers.
Coordination of other program and sectors is essential for multi sectoral program like nutrition. NNS requires to havenutrition implementation plansintegrate in the different OP level activities andalso in national and local level development plans. NNS is also focusing on orientation and training on nutrition to political leaders, religious leaders, policy makers, field level service providers of working in nutrion sensitive sectors etc. Volunteers are regularly orientated during on NVAC. Memebrs of Community groups and community Support Groups are also now provided with orientation on nutrition activities. Private and Business sectors are also neededto brought in the same platform for promoting ethical and rational nutrition related food based dieary approach and nutrition care practices. Existing Bangladesh laws and Acts related to nutrition would be promoted among the relevant stakeholders.
- Protection, Promotion & Support of Breastfeeding/ Infant and Young Child Feeding (IYCF) including BFHI &BMS Code
Under IYCF activity, counseling of all women with children on exclusive breast feeding until 6 months of age including positioning and attachment, supporting for trouble-shooting for any breastfeeding problem, proper complementary foods and advice on adequate nutrition after six months of age, weight and height measurements. In addition, BCC messages on IYCF nutrition education and counseling is now being provided to adolescents, pregnant and lactating women on topics such as, personal hygiene and cleanliness especially during preparation of food and feeding of infants and young children, general nutrition, health and nutritional importance of deworming and consumption of micronutrient supplements. In order to achieve and continue IYCF practices successfully, NNS isproviding training to relevant service providers. BCC materials on IYCF are developed and disseminated and Job aid for the Service Providers is regularly distributed at the field level. NNS has developed a National Strategy for IYCF and has developed a training module on the basis of the strategy. This module is widely used by National NGOs and other stakeholders.
- Technical Support on Food fortification (Salt Iodization, fortification of oil/other food with Vitamin ‘A’, iron etc.) Food fortification
NNS is providing technical support for food fortification, which entails adding nutrients to universally consumed foods to serve as vehicle or carrier for certain minerals or nutrients. Salt Iodization to prevent IDD in Bangladesh is a successful program in reducing IDD. Addition of Vitamin A other vitamins (eg. Vitamin D), Iron, Zinc, Calcium etc to oil, flour, sugar, fruit juice etc may be considered. NNS is foolwoing the Newly Enacted Food Fortification Act 2013 and promote it to relevant stakeholders
- School Nutritional Education Program School nutrition education Program:
NNS is providing children and adult of all age with nutrition education materials on how to improve their diets and their lives. NNS would also provide training and technical assistance for nutrition education, nutrition club formation including school gardening for school children including adolescent and their caregivers and school and community support for healthy eating and physical activities. NNS is developing nutrition messages and supporting contents and guideline for healthy diets for children.Obesity is an emerging problem in Bangladesh. Many children in urban school are overweight. NNSis working to formulate diets which with exercise can keep a person’s weight under control allowing them to enjoy healthy and active lifestyle.
- Food Quality and Food Safety
Assurance of safe and quality is one of the important determinants of public health. Food contamination and adulteration are significant problems in Bangladesh. This is due to the absence of a satisfactory food regulatory and control system and the lack of education and awareness among food producers, food handlers and consumers. The real impact of the unsafe and adulterated food in Bangladesh could not be assessed as there are no data available on both outbreak investigations and rates of contamination on food. Generally there are widespread non-compliance with hygienic/food safety practices along the food chain. In particular, practices by the informal food sector such as street sellers and home production businesses require significant improvements. Moreover, in Bangladesh there is a business culture by to improve profitability by using easy solutions and there is widespread evidence of food adulteration, and the chronic effects of such events are unlikely to be observed or reported. Food contamination and consumers’ exposure to food safety hazards have major implications on public health in Bangladesh.
The food inspection and control activities across Bangladesh are still fragmented with inadequate coordination, so they fail to adequately cover the entire food production and distribution chains. The responsibilities are divided between local Government inspectors, city corporation inspectors, Ministry of Health and Family Welfare (MOHFW) inspectors, Bangladesh Standards and Testing Institution inspectors and agriculture inspectors, with no common procedures for food safety inspections and little coordination between them. Likewise, analytical laboratories that are essential tools in the assurance of food safety have low capacity in terms of both equipment and manpower.
Other issues of concern with regard to the food control system in Bangladesh are: the low level of awareness about food safety among consumers, food handlers and food producers; outdated food laws and regulations that do not embody recent developments in international standards and agreements including Codex; financial resource constraints, including costs of assessing compliance with national and international requirements; an absence of proper enforcement mechanisms; and limited knowledge about food laws, regulations and standards, especially among small- and medium-scale food producers.
With regard to the situation and while some standards are in place, these concentrate more on the quality parameters such as size, weight, colour and adulteration aspects but not on food safety parameters. Further, the standards are not based on risk assessments. The lack of food safety parameters in the standards also does not give consumers the confidence that the products consumed are safe.
To overcome the situation a European Commission-funded project “Improving Food Safety, Quality and Food Control in Bangladesh” was completed on 30 June 2012 with a number of activities in relation to strengthening food control systems such development of a comprehensive draft Food Safety and Quality Policy document; development of guidelines and sampling requirements for inspectors as well as a draft food safety emergency response plan covering a coordination mechanism between related departments and ministries; establishment of a new National Food Safety Laboratory (NFSL); establishment of a food safety documentation centre, etc. The new laboratory set up under the Directorate General of Health Services (DGHS) however requires further inputs before it is able to serve as a functional food safety tool for the Government of Bangladesh. In addition, a major food safety awareness campaign directed at food handlers has been developed along with television and radio exposure and videos, brochures and billboards and implemented the Bangladesh Food Safety Network has been established with civil society organizations (CSOs) for the advocacy of food safety.
Considering the food safety and quality situation in the country as well as for a sustainability of the achieved targets during the EC supported project, the Food Safety Programme has been initiated with the technical support of the FAO of UN and financial support Government of the Kingdom of Netherlands for a period of three years (2012-15) with an estimated cost of US $ 12.5 million. From FY 2013-14, this project would run under the NNS OP (Detail of the Food Safety project is in described in Annexure -VII).
- Monitoring, Evaluation, Operations Research, Survey
- Monitoring and Evaluation:
Monitoring involves the process of assessing the operational aspects of project implementation, particularly, the assessment of delivery, coverage, and the use of project resources. Evaluation covers the assessment of inputs into process, output, outcome, effects and impact of project intervention based on information gathered during the course of monitoring. This will be carried out by an independent entity. Further, impact evaluations on nutrition will be obtained from the national sector wide surveys.
The monitoring and evaluation component of the program would provide important data on the cope, coverage and effectiveness on the nutrition program’s activities. The M&E data would be used to monitor progress in key nutritional outcomes (anthropometric indicators) as well as provide data on inputs, outputs (coverage). NNS already incorporated indicator and monitoring system with Community Clinic register and checklist, IMCI & nutrition corner monitoring system & checklists and as well as DGFP monitoring system. NNS is working closely with relevant stakeholders like development partners (UNICEF, WHO, DFID, GIZ) and International NGOs like Save the Children International and Micronutrient Initiative (MI) for developing & integrating Nutrition components within existing M&E system of DGHS & DGFP.
- Operational Research & survey:
Coverage and quality of nutrition intervention would also be measured through operation research, survey, nutrition surveillance etc.
- Nutrition Information System including surveillance Program
- Nutrition Information System (NIS) – integrated within HMIS-DGHS & FPMIS-DGFP and MIS of other stakeholders:
A nutrition information system (NIS) based on service records and reports at the community level would enable to monitor the progress of activities undertaken according to target. NNS has undertaken activities leading to mainstreaming of nutrition system within MIS of both DGHS & DGFP, capacity development of personnel, networking and linkage with MIS of other relevant stakeholders. NNS has already integrated DNI indicators with routine information system of DGHS & DGFP rather developing a parallel system and is encouraging other stakeholders working in urban area like UPHCSDP & NHSDP to use similar platform. So that a countrywide information system network is established to capture data on nutrition service delivery through different stakeholders. The data generated from field through DGHS MIS & DGFP MIS are analyzed, processed and synthesized to transform it into information, to provide management with appropriate information at the appropriate time for their decision making needs. Monitoring of nutritional status also provide feedback to the communities, program manager and policy makers.
- Nutrition Surveillance:
Surveillance of nutritional status of the population should go hand in hand with the formulation and execution of plicy. It is a continuous process and provides on-going information about nutritional condition of the population and factors that influence them. This information would serve as the basis for decision related to policy making, planning and management of nutrition program. Continuous monitoring of nutritional status will be undertaken through nutrition surveillance with technical and financial cooperation with other government organization, development partners, research and academic organizations and non-government organizations.
National Nutrition Services (NNS) and BBS would institutionalize the national surveillance system through ‘Food Security and Nutrition Surveillance Project (FSNSP)’–a project of BBS, James P Grant School of Public Health of BRAC University, and Hellen Keller International.
- Establishment of IMCI-Nutrition Corner and strengthening of existing NU
The main activities at Nutrition Units at facilities of DGHS and DGFP include:
- IYCF: counseling to all women with under two children who come to OPD (for example for Immunization, FP methods and at the ORT corner and IMCI Corner) on exclusive breast feeding until 6 (180 days) months of age, proper complementary foods and advice on adequate nutrition after six months of age, weight and height measurements.
- Screening for malnutrition (MUAC, growth monitoring), nutrition counseling for all under -5-children , classification and categorization of referred children by level of malnutrition, treatment of SAM & MAM , follow-up of referrals from the community , monitor & follow-up visits to children under treatment.
- Behavior Change Communication (BCC): In addition to BCC messages on IYCF, nutrition education and counseling are being provided to adolescents, pregnant and lactating women on personal hygiene and cleanliness especially during preparation of food and feeding of infants &young children, , health and nutritional importance of deworming and consumption of micronutrient supplements (Vit. A, Iron, Folate etc)
- Micronutrients: Provide advice to households on iodine, iron, and vitamin A & zinc advocacy and monitor follow-up and compliance of use of iron-folic acid by pregnant& lactating women, provision of zinc in addition to ORS during treatment of diarrhea, provision of de-worming medication and post-partum vitamin A supplementation.
IMCI-Nutrition corners of the Health and Family Planning facilities (UHCs, MCWC,USCs etc) and NNS is arranging training for the relevant and required health personnel, also supply logistics, and facilitate maintenance of MIS system with HMIS and FP-MIS and monitor the field level activities jointly with directorates of DGHS (MNCAH, ESD, HSM) and DGFP (MCRAH, FSDP).
- Community based Nutrition (CBN) in selected area Community based nutrition services
Each community clinics are gradually being equipped sufficiently to provide adequate nutrition services along with other health and family planning services. HA, FWA & CHCP are being trained on nutrition, thus they are able to bring about changes in the nutritional situation of the area.
Community based nutrition activities would be pursued in Hard-to-reach areas and where health and family planning care providers are scarce in number. This service provision would involve community volunteers and would be rolled out on the basis of requirement. The CBN services under NNS, when rolled out in selected areas would include –
- Regular growth monitoring for children under 2 years of age.
- Nutrition education for mothers, adolescent girls, newlywed women
- Individual counseling of parents for concerning child growth & development, child care, immunization etc.
- Pregnant women counseling for self care, well-being and healthy factors, food etc.
- Micronutrient supplementation (Vit. A, Iron Folate)
- Deworming for children and adolescent girl,
- Referral for SAM and other illness of children and pregnant women ANC, PNC.
Nutrition interventions in hard to reach areas, chars, hill-tracts:
NNS is building up partnership with national and international NGOs for catering nutrition service delivery in hard to reach areas, chars, hill tracts.Delivery of Direct Nutrition Intervention of NNS is facilitated by partners in the health & family planning facilities in the partnership area.Flexible & diversified program design to accommodate with realities in these areas.
- Multi sectoral collaboration Coordination of Nutrition Activities across Different Sectors
Malnutrition is intrinsically multi-sectoral, and hence achieving sustainable nutrition security is fundamentally a multi-sectoral cross-cutting challenge requiring a coordination of policies and strategies of different sectors/ministries on a sustained basis. Therefore, the NNSis working to develop mechanisms for effective coordination of nutrition and nutrition-related activities in other relevant sector and that are capable of synergistic impact on nutrition; for example, food security, food safety, fortification of staple foods, livelihoods programs, women empowerment, education, social protection and BCC etc.
The multi-sectoral Steering Committee headed by the Secretary, MOHFW is entrusted with overall guidance, policy direction, stock-taking and coordination of nutrition activities. The committee has representation from all relevant ministries at appropriate level (not below the level of Joint Secretary), development partners, technical organizations, civil society organizations and others. Line Director–NNS is the Member Secretary of the Committee.
Further, a Nutrition Implementation Coordination Committee headed by the DGHS and with membership from relevant LDs (ESD, MNCAH, NNS, CBHC, NCD, MIS, MCRAH-DGFP and others) is working to supervise and monitor NNS progress. The LD-NNS is the Member-Secretary of the Committee.
NNS is coordinating with development partners and other stakeholders including NGOs to develop a comprehensive framework for regular mapping of nutrition interventions.
Moreover, in collaboration with ministry of information, nutrition key messages will be disseminated by using all possible channels of information. To prevent illness and diseases and environmental sustainability, linkage will be established with development program, sanitation program, and appropriate technology for improving sources and forms of food etc. Establish linkage with agricultural programs which can assists small farming household in producing their food requirements. On the other hand NNS will provide health education and orientation to the workers of agriculture sectors to promote nutritious food production, safe food production with minimum use of insecticides. For increased availability and access to protein rich food, promotion for fish culture, poultry rearing and dairy among beneficiaries will be encouraged along with the relevant program under ministry of fisheries and live stock. On the assumption that malnutrition is caused by lack of knowledge about food needs at various stages of life, the nutrition value of different foods etc. introduction of nutrition into the curriculum of formal and non-formal education is essential. NNS will work in this issue along with ministry of education. LGED is responsible for implementing the urban health projects in the city and municipality areas. Keeping liaison with Ministry of LGED, NNS will ensure and provide technical support to implement nutrition activities in urban areas. NNS will also assist to find out the way for improving nutrition services in urban areas.
- Mainstreaming Gender into Nutrition Programming
Gender and nutrition are closely associated in Bangladesh, and there are strong linkages between a woman’s status and both her health and her children’s nutritional outcomes. Therefore, both the health facility and the community-based nutrition interventions will involve all community and household members who are responsible for decision making and those who can influence maternal, infant and young child feeding practices as well as other nutrition behaviors. Such an approach will ensure that the concerns of men and women, when it comes to household food and nutrition security, are considered as the joint responsibilities for the nutritional well-being of all household members of men, women and the community as a whole, with an emphasis on nutritional status of adolescent girls in the country.
- Nutrition in emergency
- Nutrition during Emergencies/disasters
Bangladesh is the most vulnerable to natural disasters and every year natural calamities upset people’s lives in some part of country. The major disaster are flood, cyclone, storm, drought, tornado, land slide etc, The extreme natural disasters adversely affect the whole environment including human being, their shelters & resources essential for livelihoods following a disaster impacts on human and generally manifested in the form of injuries, deaths and diseases. Effect on nutritional status comes out as delayed impacts of disaster. Nutritional blindness and other deficiency diseases are common.
Health professional have precise responsibilities and opportunities in post disaster disease prevention and emergency management. Pregnant women, children, people with illness, persons over 60 years are the most nutritionally vulnerable during disaster. Health workers should be trained sufficiently to take care of these vulnerable groups during and after disaster to prevent malnutrition. NNS will provide technical support and work with other relevant ministries to ensure that nutrition situation is monitored and the most vulnerable groups are properly targeted. Relief distributing agencies should be careful in selecting food as relief particularly for the infants and young children. It must correspond to the nutritional need and food habit, legislation (BMS code), sufficient in quality and quantities, ready to eat. Ration should be given to the high risk groups on a priority basis. Include supplementation of micronutrients particularly iron, vitamin-A, zinc should be in ration. NNS will have a functional coordination system with MOA and MOF&DM to remain prepared for emergency situations and mobilize its workforce specifically to provide essential nutrition services (e.g. food and micronutrient supplementation in the affected areas, management of severe and acute malnutrition among women and children, etc.) in the affected areas.
In collaboration with the Ministry of Food & Disaster management, a guideline for disaster preparedness to prevent malnutrition after disaster will be developed and all health workers will be trained, so that they will be able to respond to the nutritional needs of the population during any emergency condition. Health Workers must promote, protect and support breastfeeding among under two children.
- Climate change:
Climate change is likely to alter the geographical locations from food source which may affect nutritional status. Agriculture adaption to climate change will lead to the development of new crop breeds to survive in difficult climatic conditions or in new geographic areas. It is important to ensure that crop breeding should focus on maintenance of nutrient content. Changes in how foods are grown, processed, stored, prepared and cooked may affect nutritional content of the food.
The safety of food varies by food type and where it is produced. Climate change may also lead to alter chemical and pathogenic characteristic of food. Climate change may increase the demand for irrigation of water, increasing pathogen risks. Flooding is one way for transporting pathogens and chemicals on to agricultural land. Elevated temperature may increase food borne pathogen. Food transport, storage and processing affect food safety risks, but there is insufficient information on how these will alter under climate change
Through coordination with relevant ministries (agriculture, disaster management, water resources, environment etc.) following measures can be undertaken to reduce the effects of climate change:
- Consumption of healthy diets e.g. reducing intake of meat, sugary food and drinks and take more seasonal and locally produced fruit and vegetable. Ensuring adequate years-round consumption of a variety of fruit and vegetable is important.
- Enhance monitoring of food source.
- Provide dietary guidelines to individuals.
- Mechanisms that may be effective in some circumstances include legislation, mass media campaign, social marketing, and community programs.
- Train stuff to help people change their behavior.
- Imposing rules, regulations and market structure supporting the provision of safe and nutrition food.
- Policy to support pro-environmental behavior and provision of information to modify attitudes and knowledge.
- Nutrition related chronic diseases
- Non-Communicable Disease (NCD):
Diet related NCDs like obesity, diabetes mellitus, hypertension, and coronary heart diseases are becoming common due to epidemiologic transition and have been emerged as double burden of disease in the developing countries. Obesity in childhood is shifted to adult obesity in almost 70% cases. Dietary modification can play strong role in the prevention of NCDs and NNS will assist relevant line directorates in promoting healthy lifestyle as well as nutrition during the sector program.
- Geriatric nutrition:
Changes associated with normal aging increases nutritional risks for old and adults. Nutritional needs of the older individuals are determined by multiple factors, including specific health problem, level of activity, energy expenditure, caloric requirement and personal food preference. Micronutrient deficiency is common problem in elderly people due to number of factors: reduced food intake, lack of variety of foods they eat, medications that interfere nutrient(s) absorption and create side-effect, food choices. They may suffer from anorexia due to aging leading suppressed hunger, which may cause caloric deficit and malnutrition. A number of changes may occur in the aging person’s social and psychological status, potentially affecting appetite of nutrition status, depression, memory impairment, social isolation. Efforts will be undertaken to create a nutrient guideline to address the nutritional need of increasing elderly population.
- Establishment of nutrition Service in CC & GMP
- Growth Monitoring and Promotion (GMP):
GMP, the regular measurement, recording and interpretation of a child’s growth change in order to counsel act and follow-up on results, are being implemented to detect growth faltering of infants and young children early and enhance the transfer of nutrition information in order to take the preventive and curative actions needed.
GMP is an important process of assessing the nutritional state of a child. This process also includes the analysis of the cause of malnutrition or illness and action to be taken for improvement of the situation. There is also opportunity to re-assess the child during follow up and take necessary steps.
GMP is being done in both facility and community levels. All facilities are gradually being equipped with weighing machine, height/length board and growth charts and the capacity of health & family planning workers are developed gradually as they can manage the GMP session efficiently. The child’s well-being are assessed by weighing the child, plotting the weight against his/her age on the growth chart indicating standard growth patterns for age.
All children aged 0-24months living in the catchment area of a community clinic would be weighed once every 3 months up to the age of 2 years. Counseling of mothers would also focus on the appropriate message about child care, child nutrition etc. during GMP session.
The GMP session represent the most important regular contact between the health worker and the mother when an effective interpersonal communication can be achieved. The children not attending the required weight for successive two months or growth faltered or have any illness will be referred to the physician.
- Coordination with C-IMCI Program:
NNS will ensure maternal and child’s health through necessary support to implement IMCI program. NNS will participate in the planning, review and sharing meetings at various levels and carry out monitoring and supervision of activities along with their own responsibilities. NNS personnel will undertake relevant CMAM, C-IMCI, and MNCH/IMCI training and provide technical support for conducting TOT and oversight the technical interventions under IMCI. Necessary maternal and child nutrition related issues, messages will be incorporated in the training module of IMCI. Exclusive breast feeding, early initiation of breast feeding, immunization, zinc therapy during diarrhea, vitamin A supplementation, deworming of children, control of anaemia, consumption of iodized salt, referral for ANC and PNC under NNS program will be considered as priority activities to facilitate IMCI activities.
- Early Childhood Development (ECD)
Early Childhood Development refers to the many skills and milestones that children are expected to reach by the time they reach the age of five. The development of a child starts from the mother’s womb and it includes both physical and mental development of the child. Thus it is important to take necessary steps for healthy development of the child within the age 0-5 years. NNSwould disseminate important messages related to ECD to the families and community, campaign for awareness, ensure ANC and nutrition for pregnant women. Health worker will also give technical support and nutrition related information to school management committee for early childhood development of school children. ECD is to be integrated with different relevant programs of NNS including IYCF.
An effective referral system is being established for malnourished children with complications and children who fail to gain desired weight. These children are referred to appropriate health facility. Each hospital from primary to tertiary level will be equipped and trained so they will be able to manage the severe acute malnutrition cases.
- Procurement of equipments, micronutrients, and deworming tablets:
Whilst the nutrition services will be provided at the facility and community levels by a number of line directorates, NNS will be ensuring the supply of vitamin A supplements (for mothers and children), iron/folic acid supplements, calcium, deworming tablets, and measuring equipments to establish SAM/nutrition corners at the Upazila Health Complex level and GMP/nutrition education corner at the Community Clinics. NNS will also be procuring equipments and re-agents to functionalize the Food Safety Laboratory at IPHN.