Child Nutrition: Multisectoral Approach For Investing In The Future
The Daily Star and BRAC organised a roundtable on ' Child Nutrition: Multisectoral approach for investing in the future' on December 21,2013. We publish a summary of the discussion --Editor
Dr. Kaosar Afsana, Director, Health, Nutrition and Population Programme, BRAC
Bangladesh has achieved laudable success in various areas of health, particularly in health related MDGs. Although we have made few achievements in nutrition, we are still lagging behind compared to many other countries. For example, African countries with less GDP per capita are making far better improvement in terms of nutrition compared to Bangladesh. BDHS, 2011 data clearly reflects this uncomfortable situation of our nutrition status. According to United Nations, Bangladesh is one of the 36 countries with high malnutrition in the world. Moreover, World Health Organisation (WHO) has stated that Bangladesh is in an alarming situation with 16% of acute malnutrition.
Evidence has shown that multisectoral approach contributes significantly in reducing malnutrition. For example in Mali under-five mortality has reduced dramatically. Although it is easy to talk about multisectoral approach, it is difficult to implement in reality. Many of us are working in our respective fields but are quite oblivious of the linkage with nutrition. For example, after so many attempts from nutrition sector; now water, sanitation and hygiene (WaSH) sector is linking up their works with nutrition. Therefore, incorporating nutrition sensitive component by each relevant sector will collaboratively contribute in reducing the prevalence of malnutrition in Bangladesh.
We need strong leadership from the Prime Minister's Office in accelerating our efforts in nutrition and all stakeholders including UN agencies, donor partners, NGO sector, private sector, civil societies and media will provide utmost support in pushing forward the national nutrition agenda.
Dr. Raisul Haque, Programme Coordinator, Health, Nutrition and Population Programme, BRAC
If we look at data of health sector we will see that Bangladesh has achieved tremendous progress in different health indicators like MMR, IMR, EPI Coverage and so on except nutrition. Bangladesh is one of the 34 countries in the world who are suffering from heavy burden of malnutrition. Alone in Asia, there are 85 million children suffering from malnutrition. It is an alarming situation.
Lancet series 2008 recommended some nutrition specific interventions like breast feeding, complementary feeding and some other interventions that could have reduced the high number of child mortality in our country had those been followed accordingly. We could have reduced 22% child mortality by optimal breastfeeding and 17% stunting i.e, height -for- age by providing breastfeeding support. A lot more could have been achieved by working on the 1000 Days Approach, which is a window of opportunity between the time a mother conceives her baby to the child's second birthday. The proper nutrition during these 1000 days can greatly affect both the mental and physical growth of a child over time. An ICDDR,B study shows that there is a reduction in exclusive breastfeeding after the child reaches three months. Mothers want to exclusively breastfeed their children but after three months the mothers perceive that they do not have enough breast milk to carry on with exclusive breastfeeding. So mothers opt for supplementary foods and that eventually hampers exclusive breast feeding. Initiation of complementary foods at the beginning of seven month also does not happen properly. These initial setbacks cause malnutrition and stunting among children.
In our country, we have an enabling environment for doing extensive work on nutrition. We have a national strategy, a national plan of action for feeding practices, strategic framework for communication, national nutrition policy, BMS Code and maternal leave for six months.
Initially, BRAC launched a nutrition programme in Muktagachi. Based on the experience of this programme we prepared an integrated nutrition programme in 1995. Later we launched National Nutrition Programme (NNP). Following the NNP, the government has launched a mainstream programme called National Nutrition Service. Our government is well aware about nutrition programmes and they are doing a lot in this regard. Besides government, we are also getting effective support from different stakeholders.
If we take the MDG 4 and MDG 5 track we will find that stunting has come down to 41%, wasting 36%, acute malnutrition 16% and chronic malnutrition among women 24%. Exclusive breast feeding has increased to 64% from 43%. These numbers indicate that we are heading forward, albeit in a slow pace.
We can mention here the outcomes of a project run by Alive&Thrive in 50 Upazilas that started in 2009. It focused on exclusive breastfeeding, reducing stunting and reducing anemia among children under 5. Along with the main programme we included home fortification programme with micro nutrient powder, emphasizing on sanitation and hygienic activities like hand washing, the lack of which causes diarrhea and Acute Respiratory Infection among children. These diseases also hamper expected improvement of nutrition among children. After five years of close monitoring we find this programme really works. We need to scale up this programme.
We are all currently involved in the Scaling Up Nutrition (SUN) movement. This is a global movement that is happening across 43 countries and was initiated by UN Secretary General Ban Ki-moon. Our government and civil society alliance are actively involved here.
Lancet Series 2013 recommends a life cycle approach that includes children, adolescents and women. The 2013 Series also suggests conducting nutrition sensitive intervention along with nutrition specific intervention. And it estimates that we have to spend US $ 9.6 billion to improve the global scenario of under-nutrition. In Lancet Series 2011 we got a framework that suggested incorporating socio-economic development, improvement in school performance, food security and other related activities to improve the overall nutrition status.
UNICEF has adopted a conceptual framework in 2013. In this framework we find that inadequate dietary intake is interlinked with diseases. When a child suffers from disease it hampers her nutrition absorption. It stunts her childhood development. When she becomes an adolescent the impact lingers on. When she becomes a mother she gives birth to an under-nourished child. This is the vicious cycle of nutrition. To come out of this we need to adopt the multi-sectoral approach. We need to incorporate WaSH (water, sanitation and hygiene) and integrated management of acute malnutrition along with initiation of breast feeding, complementary feeding and micro-nutrient feeding practices.
The agriculture sector can play a very important role here. If farmers engage in energy densed and nutrient densed production they can themselves come out of the nutrition vicious cycle and help consumers out of the vicious cycle as well.
Education is also an important area to work on. An undernourished child lags behind in school attendance and performance because her mental capacity has been negatively affected by malnutrition. Her poor performance in school will impact on her career. These children do not get good jobs and consequently do not live up to their potential. Furthermore, their children suffer from the same vicious cycle. Social protection programmes can bring people out of this cycle. Brazil, Ethiopia, Djibouti have achieved remarkable success by strengthening their social protection programmes.
BRAC has started working in a multi-sectoral approach. We have involved different stakeholders like agriculture and food, education, hand washing and WASH, maternal health and so on.
Different stakeholders have different goals but we have to make them understand through advocacy that nutrition is a cross-cutting issue and the multi-sectoral approach has a synergistic impact upon it. We have to also share our knowledge about multi-sectoral approach with stake holders. Finally, the government has to lead the multi-sectoral effort and play a stewardship role.
Dr. Tahmeed Ahmed, Director, Centre for Nutrition & Food Security, ICDDR,B
Only nutrition specific interventions cannot eradicate malnutrition to a greater extent. Even if we scale up our nutrition specific interventions to 100%, it would only reduce child mortality by 15%. So we need nutrition sensitive interventions along with nutrition specific interventions. Nutrition sensitive interventions are food security, water sanitation and hygiene, employment generation, women empowerment and so on. For example, village people rush to Dhaka in search of a better livelihood but they end up in the dire living conditions of slums. In our slums, 60% of all the children are zinc deficient. So without improvement of employment opportunity you cannot ensure better health and nutrition for these internal migrants and their children,
The Ministry of Health and Family Welfare alone cannot take the responsibilities of nutrition sensitive intervention. Other ministries like Ministry of Agriculture, Ministry of Women and Children Affairs and so on should work in tandem with the MoHFW. Bangladesh is now self sufficient in rice production. With proper incentives we can also become self sufficient in production of nutrient foods like lentils, wheat, corn etc. This is an example of the multisectoral approach.
Multisectoral activities should be coordinated from the highest level of government. In Brazil, President Lula led the multisectoral programme on nutrition and achieved remarkable success within few years. We also need a leader to take our nutrition programmes further. Active participation from private sector will further strengthen it.
We lag behind in human resources. According to WHO, there is a need of 23 health workers for every 10,000 people. India has 14.6, Sri Lanka has 22. In Bangladesh the number is only 7.7. We need more community health workers who will implement nutrition programmes at the grass root level.
Bangladesh has the highest population density in the world. Overpopulation creates an unbearable stress on the ecosystem and pollutes the environment. For example, about 2 crore people live in Dhaka city. Every day, 70% of the biological waste produced by this huge population goes to surrounding rivers without any processing mechanism. It seriously pollutes the water of those rivers. Children get infected because they consume water from these rivers. It hampers their digestive systems and causes malnutrition. This is the effect of environmental enteropathy. In our study we have found that 30-40% stunting occurs due to environmental enteropathy. Health ministry cannot solve the problem alone. It needs support from local government ministry. It needs multisectoral approach.
Low birth rate is a major risk factor of child malnutrition. In our country low birth rate is more than 30%. It mostly happens to adolescent mothers. They themselves are malnourished. So we need to start from adolescent girls, then pregnancy, pregnancy nutrition, infant and childhood.
Finally we have to find innovative ways of eradicating malnutrition.
Ganesh Chandra Sarkar (Joint Secretary), Director (IEM) and Line Director (IEC), Director General of Family Planning
The most important task is to make our programmes sustainable. Many efforts start with vigour but cannot be sustained for a long time and therefore end haphazardly. We have to come out of it. Our monitoring and supervision should be scientific and adequate.
Early pregnancy and its poor outcome is the major reason of malnutrition. Awareness to prevent adolescent and early pregnancy can be more effective than use of medicines We have to make people aware about the poor outcomes of early pregnancy.
Dr. Selina Amin, Director-Country Projects, Plan International Bangladesh
To prevent early pregnancy we need to prevent child marriage. To realize this goal we have formed many adolescent peer groups and provided them life skill training. They are really working for this cause. In many cases we have found that peers step forward to stop child marriage. Adolescent boys are particularly playing an extraordinary role. Some of our adolescent boys have won UN awards for their extraordinary role in prevention of child marriage.
We often talk about women empowerment. But we should also focus on equal participation of boys and girls. Our society is still male dominated. We cannot afford keeping men and boys away. Parents should also be made aware about ill effects of child marriage.
Most of our unmarried adolescent girls do not get iron capsules. We do not take the issue seriously. We have to remember that adolescent nutrition is equally important.
We have been talking about multisectoral approach for many years but we never talk about what the sectors should do. We need to prepare specific indicator and accountability mechanism for each sector. Only then we would be able to implement multisectoral programmes for eradication of malnutrition. At the local level, we have found multisectoral approaches, but it is absent at the top level. So these local level efforts cannot go further. We have to consider this issue seriously.
Dr. Jahangir Hossain, Program Director-Health, CARE Bangladesh
Union Parishads should be the local operating units of multisectoral programme. The Union Parishad Chairman has the constitutional rights to facilitate such programmes. S/he can take the leadership and make the programme effective.
Nutrition indicators should be incorporated in every level of health administration and our health workers should be made accountable for their role in improving the nutrition status.
Special care should given to WaSH activities particularly hand wash.
Dr. Dibalok Singha, Executive Director, Dushtha Shasthya Kendra (DSK)
In our country, 47 million people live under the poverty line. Among them, 26 million are extreme poor. They do not have access to three meals a day, let alone nutritious food. We have to focus on this social inequality. Our poverty reduction rate is only 1%, which is very slow. If we cannot eradicate poverty we would not be able to eradicate malnutrition.
Now we are approaching towards Sustainable Development Goals (SDG). In SDG phase, we have to expedite our nutrition programmes.
Water and sanitation should be integrated with health care. We should emphasise on national WASH improvement activities. We should undertake a time-bound programme in this regard. Government should strengthen water treatment plants.
Sham El Arifeen, Director and Senior Scientist, Centre for Child and Adolescent Health, ICDDR,B
If we look at the correlation between stunting and feeding practices, we will find it is 21%. At the top 20% of well to do families it is 30%. So, malnutrition is not related with food insecurity; rather, it is the absence of good feeding practices that cause malnutrition in our country. That's why people have to be made aware about feeding practices.
There are some structural hindrances in coordinating activities of different ministries. This is true irrespective of any development activities. So we have to address this issue.
Dr. Nasrin Khan, Deputy Program Manager, NNS, IPHN
Most of the relevant ministries have nutrition sensitive programmes. For example, the Ministry of Women and Children's Affairs provides VGD for lactating mothers. The Agricultural ministry is focusing on non-cereal crop production like legumes, fruits, vegetables and so on. Fisheries department is focusing on promoting indigenous small fishes. These are nutrition indicators. Besides, 6th five-year action plan and Vision 2021 has given due importance to nutrition. In our MIS system we have already incorporated eight Direct Nutrition Indicators (DNIs). We all have to work together. Government should coordinate these activities.
Dr. Ferdousi Begum, Country Project Manager, FANTA, FHI360
We have to increase multi-sectoral investment for improvement of child nutrition.
We often do not count the presence of health workers from private sector. That's why the health worker-population ratio is so poor. We should also count them.
In every meeting we talk about different sectors but find only people from health sector. So how can we achieve the goal of multi-sectoral approach as we cannot even bring them to the discussion table.
Many nutritional interventions are cross cutting. We have found that nutrition sensitive interventions have been shared by different ministries. They have separate budget for these activities. If we can coordinate these activities then there will be no resource shortage. I will urge CSA SUN for stock taking different activities of our stakeholders and distribute duties to different stakeholders to monitors different parts of the multisectoral programme.
Dr. Morseda Chowdhury, Programme Coordinator, HNPP, BRAC
Malnutrition is inter-generational; a malnourished mother gives birth to a baby weighing less than normal. If this baby failed to make up this by gaining adequate weight, it becomes stunted. This is one of the immediate effects. But there are some long term effects too. Stunted children have more chances of suffering from cardiovascular diseases, diabetes, osteoporosis and so on in adult life, which not only reduce individual quality of life but also burdens health system.
In BRAC, we focus on nutrition of pregnant mothers. We found that only advice regarding nutritious foods is not adequate. Now we provide them practical knowledge of diversified food, we make them understand of its importance, health workers teach them how to measure adequate amount of food with special attention to animal protein. This technique has created lots of interest among mothers and gradually bringing change in dietary behaviour.
I think we should speak in same language to work multisectorally. Everyone understands the term 'return' from each unit of investment. If we can show every sector how much return one could expect from their investment, then it would be easier to motivate relevant sectors to bring policy change towards more investment in nutrition specific and sensitive interventions.
Shamim Ahmed, Program Manager, Water Aid
From Water Aid we have done two important projects: community led total sanitation and access to water. Only 4% of our total population use open toilets. Previously the rate was 50%. Initially we ask people to use sanitary latrines in order to eliminate diarrhoea. The result was obvious, and so people got interested in using sanitary latrines. In our country the rate of diarrhoea contamination hasreduced. Now parents ask us why their children are still suffering from malnourishment even though they use sanitary latrines. Now we have to tell them about the impact of WASH on nutrition. So we are working on nutrition. I think this a good example of multisectoral approach where every stakeholder finds his return. We should share such case studies with each other so that the outcome of multi-sectoral approach becomes evident.
Mahbubul Huda, Deputy Executive Director, Unnayan Sangha, Jamalpur
Local volunteers can play a great role in implementing nutrition programmes. They continue their activities even after the end of the project. They live in the targeted communities so they spread their knowledge among community members. We should create a linkage between these volunteers and donors and implementing agencies including government. We should also avoid duplication of programmes.
Shishir Morol, Special Correspondent, Prothom Alo
Media can play a big role in creating awareness about nutrition. I think the media should be included in multisectoral approach. Nutrition gets very little attention in our media. Our reporting on nutrition is as weak as our nutrition status.
There is a national nutrition council. We do not want what is its status , what it does or why is it so inactive? Our national nutrition institute IPHN is also very weak. It suffers from rampant corruption by the officials. We should strengthen this institution.
Dr. S. M. Mostafizur Rahman, Program Manager, NNS, IPHN
Bangladesh has come a long way. We have some remarkable achievements in nutrition. A good example is the Vitamin A capsule campaign. But we have to do more. We have to emphasise on nutrition sensitive interventions along with nutrition specific interventions. Government has been providing leadership in this nutrition movement and will continue to do so.
Food safety is also very important, as contaminated food is very bad for children's health.
Dr Salauddin Ahmed, Managing Editor, The Daily Star
In our country, coordination is a difficult task. But once we can make it happen it would work like a miracle. In development sector Bangladesh has many world class achievements. All of these are results of coordinated efforts.
We have also a crisis in leadership. All of our institutions, be it government, be it private, make thesame mistakes. First, everyone thinks they themselves are the best. It is completely wrong because there are smarter people outside than you are. Second one is working for money. Third one is not letting the managers go. Leaders intervene into managers' work. Fourth one is recruiting people with whom you are most comfortable. Organisations cannot be a social club. They must be professional.
We sometimes create very complex programme which is beyond comprehension of the general people. Programmes should be easily comprehensible. Simple is beautiful.
Recommendation
1. Forming a high level body
* Help PMO to make an action plan tasking all relevant sectors
* Clearly define the role of all sectors
* Separate out the investment on nutrition sensitive and specific interventions of all relevant sectors
* All stakeholders will regularly share the bottlenecks in terms of policy, implementation and outcome and together come up with solutions
2. Forming a working group
* Make a plan to revisit nutrition sensitive and specific indicators of relevant sectors
* Develop homogenous messages for the community and use different pathways e.g., media, CHW, local government bodies and all relevant platforms and different sectors and ministries
* Develop monitoring indicators for different sectors
3. Communication and advocacy
with media
* Form an action group with all media (electronic and print) under leadership of SUN, BD
* Conduct sensitization workshop and let the media come with their potential to contribute to improve nutrition of Bangladesh
* Clearly define the area of reporting including knowledge sharing, case study and policy issues
4. Inclusion of Private Sector
* Establish functional linkage with private sector, ministry of industries and the working group
* Formulate and amend policies to incorporate production, distribution and create demand of nutrient dense products
* Develop incentive based policies for the private sector and SMEs, for example, tax rebate, production subsidy, etc.
* Control quality of dense nutrient products and ensure that the products are cost effective
5. Behaviorial Change Approach
* Disseminate nutrition specific and sensitive messages across community people
* Sensitize and educate community people regarding nutrition
* Use of national, sub-national and community-based communication to change behavior
6. Accountability
* The working group will track progress of the nutrition sensitive and specific interventions and make recommendations to the PMO and the lobby group
* An accountability framework will be developed which will be used as a tool to lobby to increase or decrease investment based on effectiveness
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