International Centre for Diarrhoeal Disease Research, Bangladesh

By Masum Billah and Shams El Arifeen, ICDDR,B

Despite important economic progress and reaching lower middle-income status in 2015, Bangladesh remains one of the high under nutrition burden countries. This is not due to a lack of political will. In 2009, the Annual Program Review of the Health, Nutrition, and Population Sector Program of the World Bank recommended scaling up nutrition interventions in Bangladesh through mainstreaming critical nutrition interventions in health and family planning services. To achieve this goal, the country made nutrition a priority.

The National Nutrition Services (NNS) has since been pursuing a variety of key strategies and actions. In 2011, the operational plan (OP) of NNS under the current Health, Population and Nutrition Sector Development Programme (2011-16) was approved by the Government of Bangladesh which meant mainstreamed nutrition interventions should be implemented through the existing health system from July 2011 onwards.

But how well is this program working? A new report  Bangladesh National Nutrition Services: Assessment of Implementation Status, published by the World Bank presents the findings of a research study done by IFPRI and icddr,b, partly supported by Transform Nutrition, to assess the implementation of the Government of Bangladesh’s National Nutrition Services Program (NNS). Importantly it also identifies the achievements, identifies key bottlenecks that adversely impact these achievements, and highlights potential solutions to ensure smooth delivery of the program in the future.

The study
The overall objective of this study was to assess the effectiveness of the delivery of the different components of NNS. The report was written by a team from IFPRI and ICDDR,B, including Drs. Shams El Arifeen and Purnima Menon, who lead Transform Nutrition’s work on making health systems more nutrition-sensitive.  The study focused on assessing issues related to management and support services; training and capacity development; service delivery; monitoring and evaluation, and; exposure to interventions.  A mix of quantitative and qualitative methods were used to assess the quality of  service provision related to integration of nutrition with antenatal care services and sick child care in health facilities: The research also focused on elements of the enabling environment to support the roll-out of the NNS interventions, examining institutional arrangements and the policy environment at the national level.

Key findings
The study indicated that NNS lacked specificity in choice of interventions and preventive service platforms resulting in attempts to deliver too many interventions with limited coverage and quality.  Frequent changes in leadership, coordination, capacity and workload-related challenges faced by the NNS have hampered the implementation of nutrition interventions.  The study also reported slow roll-out and poor coverage of training, especially among the frontline health workers. Although the quality of nutrition service during antenatal care, one of prioritized health service delivery contacts, was somewhat better; height and weight measurements, provision of appropriate nutrition counselling and screening for severe acute malnutrition during sick child management contacts were sub-optimal.  Critical challenges relating to service delivery at community and outreach level (preventive platforms), lack of systematic supportive supervision, poor recording and reporting of service statistics, and weak monitoring mechanisms have jeopardized the NNS’s ability to achieve adequate delivery of quality nutrition services.

Our recommendations
Our study found that the overall NNS effort is an ambitious, but valuable, approach to support nutrition actions through an existing health system with diverse platforms. The results indicate that although the maintenance of strong and stable leadership of NNS is an essential element to ensure integrated and well-coordinated service delivery, the current arrangement is unable to ensure effective implementation and coordination of NNS. So how can this be improved?

• Focusing on some of the critical challenges related to leadership and coordination and then embedding a smaller set of priority interventions into well-matched health system delivery platforms is most likely to help achieve scale and impact.
• Strategic investments in ensuring transparency, engaging available technical partners for monitoring and implementation support, and not shying away from other potential high coverage outreach platforms, such as some NGO platforms, also could prove fruitful.
• The Government of Bangladesh, and the health system in particular, must lead the effort to deliver nutrition and the NNS is an important start towards this goal. Nonetheless, it is clear that development partners who have expressed a commitment to nutrition must coordinate their own activities both among themselves and with the government and provide the support that can deliver nutrition’s potential for Bangladesh.

Bangladesh is ranked 142 of 187 countries on the 2014 Human Development Index and 57 among 120 developing and transitioning countries on the 2014 Global Hunger Index.  There is still some way to go to to ensure the population of Bangladesh is well nourished and able to make the most of economic progress. icddr,b, IFPRI and Transform Nutrition are working to generate evidence on effectiveness of different  nutrition-specific and nutrition-sensitive interventions in Bangladesh to support strategic policy and intervention choices that can improve nutrition in Bangladesh.