shiree │

nutrition

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Bangladesh Demographic and

Health Survey – 2011

Summary Output

23rd April 20122

Fertility and Family Planning

Bangladesh Demographic and Health Survey – 2011

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Trends in FertilityTotal Fertility Rate(Births per woman)

2016 Aim: 2.0

4

Trends in Use of ContraceptionPercentages of married women age 15-49 currently using

a methods of family planning2016 Aim: 72

5

Unmet Need for Family PlanningPercentages

of married women age 15-49 who

wish to spare or limit births

but are not using

contraception

2016 Aim: 9%

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Maternal Health

Bangladesh Demographic and Health Survey – 20117

Trends in Maternal HealthAmong births three years before the survey

2016 Aim: 50% for all three indicators

8Source: BDHS 2011

Trends in Delivery in Health Facilities by WealthPercentages of births delivered in health facilities in

the three years before the survey

2016 Aim: <1:4 for

percentage of deliveries of deliveries in

health facilities among the poorest

and wealthiest women

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Child Survival and Health

Bangladesh Demographic and Health Survey – 2011

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Deaths per 1,000 live births

2016 Aim: 482016 Aim: 31

Trends in Child Mortality

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Source: BDHS 2011

Childhood CarePercent of children under age five

2016 Aim: 90% 2016 Aim: 90%2016 Aim: 50%

12Source: BDHS 2011

Nutrition

Bangladesh Demographic and Health Survey – 201113

Trends in Exclusive BreastfeedingPercent of children under 6 months who are

exclusively breastfeed

2016 Aim: 50%

14Source: BDHS 2011

Trends in Vitamin A SupplementationPercent of children age 9-59 months receiving Vitamin A supplementation in the six months preceding the survey

2016 Aim: 90%

15Source: BDHS 2011

Source: BDHS 201116

2016 Aim: 52%

IYCF PracticesPercent of children age 6-23 months

2016 Aim: 38%

Trends in Children’s Nutritional StatusPercent of children under age five

17Source: BDHS 2011

WHO threshold for 'very high‘ prevalence of

underweight (30%)

WHO threshold for 'very high‘ prevalence of

stunting (40%)

Nutrition Status at

shiree

shiree Change Monitoring System (CMS) - 3

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Stunting, wasting and underweight amongst under 5s (shiree BHH) with data CMS3 surveys

WHO threshold for 'very high‘ prevalence of

stunting (40%)

WHO threshold for 'very high‘ prevalence of

underweight (30%)

WHO threshold for 'very high‘ prevalence of

wasting (15%)

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Adult nutrition status of shiree beneficiaries

WHO threshold for 'very high‘ prevalence of CED (BMI<18.5 is 40%)

WHO threshold for 'high‘ prevalence of CED

(BMI<18.5 is 20%)

WHO threshold for Severe public health problem

(Adult anaemia = 40.0 %)

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Why Nutrition is important?

Foundation to development contributing to MDG’s

Economic benefit

Low Birth Weight (LBW) perpetuates intergenerational cycle of undernutrition and disease

Economic growth – unlikely to yield Nutrition results

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20% of the world’s deaths and disabilities are due to undernutrition.

Loss of GDP from undernutrition can be as high as 3% (year in, year out).

Better nutrition empowers people and communities through:

•improved intellectual capacity•income generation and access to assets•poverty reduction; and •rapid development

Nutrition’s Impact on Poverty

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Income Poverty

Low Food Intake

Frequent Infections

Hard physical labour

Frequent pregnancies

Malnutrition

Large families

Direct loss in productivity form poor physical status

Indirect loss in productivity from poor cognitive development and schooling

Loss in resources from increased health care costs of ill-health

Loss in resources from increased

health care costs of ill-health

Direct loss in productivity

from poor physical status

Indirect loss in productivity from poor cognitive development

and schooling

Modified from WB,2004

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MDG Nutrition is a foundation for MDGs. It help to achieve:

Goal 1: Eradicate extreme poverty and hunger.

Improved cognitive and physical development, and income earning potential

Goal 2: Achieve universal primary education.

Good nutrition improves school attendance and performance

Goal 3: Promote gender equality and empower women.

Empowering women in society improves their own and children’s nutrition.

Goal 4: Reduce child mortality. Prevention of child deaths caused directly or indirectly by undernutrition

Goal 5: Improve maternal health. Prevention of undernutrition will improve maternal health and lower the risk of maternal mortality.

Goal 6: Combat HIV/AIDS, malaria, and other diseases.

Reduced risk of HIV transmission, onset of full-blown AIDS and premature death. Reduced risk of TB infection resulting in disease, and improved malarial survival rates.

Nutrition contribution to MDGs

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2-3 % GDP lost as a result of undernutrition – most developing countries including Bangladesh

>10% reduction in life time earning of each malnourished individual

Bangladesh – loses over USD700 million in vitamin and mineral deficiencies

Scaling up core micronutrient interventions cost less than US$65 million per year

Economic Benefit

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Figure : GDP Loss Due To Iron Deficiency

Source: Horton 1999, web-link: http://www.unscn.org/files/Publications/Briefs_on_Nutrition/Brief8_EN.pdf

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What are the causes of Malnutrition then?

Social economic

and political context

Lack of capital: financial, human,

physical, social, and natural

Income poverty: employment, self-employment, dwelling, assets,

remittances, pensions, transfers etc.

Household food insecurity

Inadequate careUnhealthy household environment

and lack of health services

Inadequate dietary intake

Disease

Maternal and child undernutrition

Short-term consequences:Mortality, Morbidity, Disability

Long-term consequences:Adult size, Intellectual ability, Economic productivity, Reproductive performance, Metabolic and cardiovascular diseases

Basic Cause

Underlying Cause

Immediate Cause

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When should we intervene?

The “Window of Opportunity” for Improving Nutrition is very small …pregnancy until 18-24 months of age

Beyond two years stunting is largely irreversible

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-2.00

-1.75

-1.50

-1.25

-1.00

-0.75

-0.50

-0.25

0.00

0.25

0.50

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60

Age (months)

Weig

ht

for

ag

e Z

-sco

re (

NC

HS

)

Latin America and Caribbean

Africa

Asia

Window of Opportunity” for Improving Nutrition

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key interventions

- Infant and young child nutrition and treatment of severe undernutrition- Micronutrient supplementation & fortification - Hygiene practices

INSTITUTIONS

POLITICAL & IDEOLOGICAL FRAMEWORK

ECONOMIC STRUCTURE

RESOURCESENVIRONMENT, TECHNOLOGY, PEOPLE

Food/nutrientintake

Health

Water/Sanitation

Health services

Interventions

Immediate causes

Underlying causes

Basic causes

SHORT

ROUTES

LONG

ROUTES

- Agriculture & food security- Health Systems - Soc. Protection/safety nets- Water & sanitation- Gender & Development- Girls’ Education-Climate change

Maternal and child-

care practices

Access to food

Determinants of Child Nutrition and Interventions to Address them

Adapted from UNICEF 1990

- Poverty reduction & economic growth programs-Governance, stewardship capacities & management-Trade & patents (&role of private sector)- Conflict Resolution- Environmental Safeguards

Nutrition specific interventions

Nutrition sensitive interventions

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Shiree nutrition intervention

1. Scale up proven intervention

2. Innovation Fund

3. Research and Monitoring

4. Advocacy

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SF Target Groups:

1.Pregnant  women  2.Breastfeeding women 3.Children < 2 years 4.Children 2-5 years 5.Adolescent girls

6.All family members (deworming only !)

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Major Scale Fund Interventions:

Behavior change interventions (Individual counselling and group meetings)

1.Breastfeeding promotion and supporta. Early initiation of breastfeedingb. Exclusive breastfeeding for six months and continued

breastfeeding until two years of age2.Complementary feeding promotion

a. Behavior change promotion to follow international best practices Proven Interventions

3.Handwashing with soap and promotion of hygiene behaviorsa. Delivery of educational messages

Micronutrient and deworming interventionsa.Multiple micronutrient supplements (MNS - 5 components)b.Deworming (Albendazole Tablets and suspensions)c.Iron-folic acid supplements (IFA tablets)

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Expected results

1.An improvement in adolescent and maternal nutritional status as defined by changes in weight (and concomitant body mass index) and haemoglobin concentration

2.An improvement in child growth (i.e. reduction of stunting, wasting and underweight infants and young children) and improvement in haemoglobin concentration

3.Beneficiaries are better placed to sustainably transition out of extreme poverty

Counselling IFA MNP Deworming Social Mobilisation

Pregnant mothers

Through Group meeting and Social mobilisation sessons

1. All target groups

2. Adolescent girls

3. Religious leaders

4. Village doctors & TBAs

5. School teachers & Local Govt.

6. Local influentials

Breastfeeding mothers

Adolescent girls

Infants 6 to 23 mo’

Children 12 mo’ to 5 yrs

Others Only family members - At the beginning

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Activity Details – Individual counselling

Step 1: survey community and list eligible shiree beneficiary households

Step 2: Allocation of responsibility to community

volunteers

Step 3: Hands on training

Step 4: Supportive Supervision

Step 5: Monthly meetings

Step 6: Performance IncentivesStep 7: Accountability, Monitoring, Learning and Evaluation

Performance Improvement Cycle

Central Coordination,Management,

Exchange Lessons

Mass media CampaignVideo show; Tea stall

Social MobisationV Doc, Religious Leaders, Adolescents, TBAs, School

Teachers

SupplyIFA Tab; Deworming

drugs; MNS

7. Monitoring for data based

decision

1. Listing all PW to 24m in catchment

area

3. Basic Hands on Training

2. Allocate Staff, volunteers of 1

(CPKs/V): 20 and 1 (sup): 10 ratios

5. Monthly review, feedback, micro-

planning

6. Reward, recognition, or performance

based incentives

4. Observed supervisional

support

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Approved Drug Regimen by Target Group

Category of Clients De-wormingIron & Folic Acid

(IFA)

Micronutrient Supplément

(MNS)- 5 components.

Remarks

Pregnant women1 tablet of 400 mg per women/year after the

first trimester

180 tablets per woman/year (each

tablet contains 60 mg iron and 400

microgram folic acid)

 

Deworming will be given after first trimester. IFA will

be given as soon as pregnancy is detected maximum 180 tablets.

Breastfeeding women

 

90 tablets per woman/year (each

tablet contains 60 mg iron and 400

microgram folic acid)

  

For 3 months post partum.

Adolescent girls (10 - 16 years of age).

2 tablets of 400 mg per girls/year

2 tablets/week (each tablet contains 60 mg iron and 400 mcg folic

acid) total 104 tablets/year.

  

IFA once a week and deworming twice a year.

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Approved Drug Regimen by Target Group

Category of Clients De-worming (IFA)Micronutrient Supplément -5 components.

Remarks

Children aged between 7 - 12 months

   1 sachests / day

for 60 day 

Children aged between 13 - 18 months

2 vial (suspension) of 200 mgs per child/year

  

1 sachests / day for 60 day

12 months is the minimum age at which children can receive deworming treatment.

Children aged between 19 - 23 months

2 vial (suspension) of 200 mgs per child/year

  

1 sachests / day for 60 day

 

Children aged between 24-59 months

2 tablets of 400 mg per child/year

  

   

Other family members1 tablets of 400 mg per person/year

  

 

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Training Materials

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BCC Materials

1.Job aid 2.Training Manuals 3.Social Mobilisation Brochure 4.Social Mobilisation Manual, FlipChart5.Brochure for Adolescent Girls6.Advocacy brochure

7.Observation Checklist and Social Mobilization Guidelines8.Illustrated comic books on maternal and child nutrition for adolescent groups 9.DVDs on IYCF TVCs, RDCs and Meena film

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1. Technical support & consultation will be provided by A&T (Alive and Thrive)

2. Existing training materials developed by A&T on IYCF and micronutrient supplementation will be used

3. Modules for group meetings will be reviewed and adopted – shiree partners and A&T

4. Master trainers will be trained by A&T

Logistics

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Procurement & Supply

1.Procurement of IFA for pregnant women and adolescent girls

2.Procurement of MNPs for children under 2

3.Procurement of deworming drugs for children and other family members

will be centrally procured and distributed to the SF NGOs

Target group 2012-13(82850 BHHs)

2013-14(215500

BHHs)

2014-15(215500

BHHs)

Total

Pregnant  women (3% of total population) 8650 22500 22500 53,650

Breastfeeding women (7.33% of total population)

21000 55000 55000 131,000

Children < 2 years(6.67% of total population)

19,000 50,000 50,000 119,000

Children 2-5 years(15.33% of total population)

45,000 115,000 115,000 275,000

Adolescents (14.29% of total population)

41,000 107,135 107,135 255,270

All family members(assuming a family number of 3.48 /households)

331400 862000 862000 2,055,400

Total 466,050 1,211,635 1,211,635 2,889,320

Forecasted numbers of beneficiaries 2012-2015 47

Monitoring &

Evaluation

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Used for:

1. Reporting to Donor and GoB• Progress against log-frame• Achievements of quarterly/monthly targets

2. Programme Management• Track the changes• Feeding back to the implementing partners

3. Exchange and sharing with other stakeholders

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Impact Indicators

1. % point of targeted U-2 children:stuntedunderweight wasted anaemic.

2. % point of targeted pregnant and breastfeeding mothers and adolescent girls:

chronic energy deficient (CED)anaemic

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Outcome Indicators

1.% of targeted mothers of infants 0-6 months exclusively breastfeeding (as per WHO definition)2.% of targeted mothers of children 7-23 months practicing appropriate complementary feeding (as per WHO definition)3.% of targeted U-2 children (7-23 months) consuming Micronutrient Supplement (MNS) and 95% children 12-24 months consuming antehelmintics (deworming)4.% of targeted pregnant and breastfeeding women consuming iron and folic acid5.% of targeted pregnant women consuming antehelmintics (de-worming tablets)6.% of targeted adolescent girls consuming iron and folic acid and antehelmintics7.% reduction in diarrhoea among targeted children < 5 years of age over a 30 day period

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Reporting Frequency:

1.Monthly monitoring report2.Programme report3.Financial report

Tools :

1.Change Monitoring System2.Internal monitoring and MIS3.Community Pusti Karmi’s register4.Observation Checklist – visitors (?)

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1.Availability of suitably qualified people, especially in remote areas.

2.Getting community support and involvement for the intervention;

3.Target groups are not affected by significant shocks e.g. high food price inflation or disasters;

4. Identification of target groups- Pregnant

Key things to focus on:

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5. Behavioural Change Communication (BCC) provided by trained nutrition consellors

•Regular visit•Supportive supervision•Monthly meeting

6. Micronutrient supplements and deworming tables: •Logistical arrangements, •Timely distribution and •Consumption

Key things to focus on:

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Strengthening Indirect responses:

1. Social transfers and other social protection measures

2. Food security and agricultural interventions• Homestead food production

3. Primary and maternal and child health care – Linkages to existing health services

4. Clean and safe drinking water and improved sanitation and hygiene

5. Education, especially girls’ education6. Women’s empowerment

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1922

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Entire sample Poorest quintile Entire sample Poorest quintile Entire sample Poorest quintile Entire sample Poorest quintile

Food-for-Work Program Vulnerable Group Feeding Program

Vulnerable Group Development Program

Grameen Bank or BRAC

Rates of severe stunting, by availability or non-availability of public intervention in village of residence, 2000

Not available Available

Source: siteresources.worldbank.org/.../PA2+Child+Nutrition+-+Oct02.ppt

Project Inputs

Direct interventionsBreast feeding promotion and supportComplementary feeding promotionPromotion of hygienic behaviourMicronutrientsDeworming

Indirect interventionsAsset transfer (livestock, poultry etc.)Cash transferIncome generating activitiesHomestead gardeningCommunity mobilisation and activities to promote women empowerment

Linkage with health and education services and government safety next

programmes

Promoting innovationTesting mechanisms to increase access to high protein diet

shiree (EEP) internal monitoring and evaluationStrengthen Monitoring and Evaluation

1. Improved Infant and child feeding practices

2. Improved hygiene

3. Improved parasite control

Improved diet and increased food diversity

Increased understanding on importance of animal protein dietIncreased demand of high protein diet

Baseline data collected/establishedData collection and analysis every monthUndertake operational research providing feedback on delivery service, systems and compliance

Reduced micronutrient deficiency

Reduced disease burden

Reduced anaemia

Increased animal protein dietEvidence of how to increase protein in the dietEvidence shared and rolled out in extreme poverty programmes

6 monthly reports publishedEvidence shared to Partners and DFID NutritionLessons learned informed programme amendmentsImproved delivery service

Reduced maternal and child

under-nutrition

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Theory of Change

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Additional Staff for implementation:

1.Technical Coordinator: Nutrition – 1/ SF NGO

2.Nutrition Officer – 1 / SF NGO

3.Master Trainer – 2 / SF NGO

4.Community Pusti Karmis – Female counsellors

(based on requirement)

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NEXT:

1.Shiree agreement with DFID2.Contract amendment with SF partners3.Recruitment of technical staff and female counsellors (CPKs)4.Finalising NGO operational plan, including logistics5.Training planning and conduction 6.Ensuring effective M&E and MIS – using existing M&E7.Roll out the intervention

THANKS

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