shiree │ nutrition
1
Bangladesh
Demographic and
Health Survey – 2011
Summary Output
23rd April 2012
2
Fertility and Family Planning
Bangladesh Demographic and Health Survey – 2011
3
Trends in Fertility
Total Fertility Rate
(Births per woman)
2016 Aim: 2.0
7
6.3
6
5.1
5
4.3
4
3.4
3.3
3.3
3
3
2.7
2.3
2
1
0
BFS
1975
BFS
1989
CPS
1991
BDHS
93-94
BDHS
96-97
BDHS
99-00
BDHS
2004
BDHS
2007
BDHS
2011
4
Trends in Use of Contraception
Percentages of married women age 15-49 currently using
a methods of family planning
2016 Aim: 72
70
60
50
54
45
58
61
56
49
40
30
20
10
0
BDHS 93-94
BDHS 96-97
BDHS 99-00
BDHS 2004
BDHS 2007
BDHS 2011
5
Unmet Need for Family Planning
Percentages
of married
women age
15-49 who
wish to spare
or limit births
but are not
using
contraception
16
Sylhet
8
Rangpur
9
Rajshahi
8
Khulna
11
Dhaka
19
Chittagong
10
Barishal
0
5
10
2016 Aim: 9%
15
20
6
Maternal Health
Bangladesh Demographic and Health Survey – 2011
7
BDHS 2004
BDHS 2007
35
2016 Aim:
50% for all three indicators
32
30
27
26
25
20
BDHS 2011
22
17
21
20
16
16
15
10
5
0
Source: BDHS 2011
ANC at least 4 visits
Delivery attended by a
medically trained provider
PNC for mothers within 2
days of delivery from a
medically trained provider
Trends in Maternal Health
Among births three years before the survey
8
Trends in Delivery in Health Facilities by Wealth
Percentages of births delivered in health facilities in
the three years before the survey
Lowest Wealth Quintile
Highest Wealth Quintile
70
60
60
49
50
2016 Aim:
<1:4 for
percentage of
deliveries of
deliveries in health
facilities among
the poorest and
wealthiest women
38
40
30
20
10
3
0
6
10
9
Child Survival and Health
Bangladesh Demographic and Health Survey – 2011
10
Trends in Child Mortality
Neonatal Mortality
140
133
2016 Aim: 21
Infant Mortality
under-five Mortality
2016 Aim: 31
2016 Aim: 48
116
120
Deaths per 1,000 live births
94
100
87
88
82
80
66
60
52
65
65
52
48
42
41
40
37
53
42
32
20
0
1989-93
1992-96
1995-99
1999-2003
2002-06
2007-11
11
Childhood Care
Percent of children under age five
100
2016 Aim: 90%
2016 Aim: 50%
2016 Aim: 90%
90
80
88
70
71
60
62
50
40
30
20
10
0
Measles Vaccine
Source: BDHS 2011
ARI Treatment with
Antibiotics
Vitamin A
Supplemintation
12
Nutrition
Bangladesh Demographic and Health Survey – 2011
13
Trends in Exclusive Breastfeeding
Percent of children under 6 months who are
exclusively breastfeed
2016 Aim: 50%
70
64
60
50
46
45
46
BDHS 93-94
BDHS 96-97
BDHS 99-00
42
43
BDHS 2004
BDHS 2007
40
30
20
10
0
Source: BDHS 2011
BDHS 2011
14
Trends in Vitamin A Supplementation
Percent of children age 9-59 months receiving Vitamin A
supplementation in the six months preceding the survey
2016 Aim: 90%
90
80
82
88
80
62
70
60
50
40
30
20
10
0
BDHS 99-00
Source: BDHS 2011
BDHS 2004
BDHS 2007
BDHS 2011
15
IYCF Practices
Percent of children age 6-23 months
Fed with all 3 IYCF practices
Not fed with all IYCF practices
100
90
80
70
60
79
85
79
21
15
21
50
40
30
20
10
0
Breastfed
Source: BDHS 2011
Non-breastfed
All 6-23 months
2016 Aim:
52%
16
Trends in Children’s Nutritional Status
Percent of children under age five
BDHS 2004
2016 Aim: 38%
60
50
51
53
41
BDHS 2007
BDHS 2011
WHO threshold for
'very high‘ prevalence of
underweight (30%)
WHO threshold for
'very high‘ prevalence of
stunting (40%)
43
41
36
40
30
20
10
0
Stunting (height for age)
Source: BDHS 2011
Underweight (weight for age)
17
Nutrition
Status at
shiree
shiree Change Monitoring System (CMS) - 3
18
Stunting, wasting and underweight amongst under 5s (shiree BHH) with data
CMS3 surveys
Stunting
60
52.2
Underweight
WHO threshold for
'very high‘ prevalence of
stunting (40%)
WHO threshold for
'very high‘ prevalence of
underweight (30%)
50.8
48
50
Wasted
50
46.1
WHO threshold for
'very high‘ prevalence of
wasting (15%)
47.1
41
40
36
30
23.7
22.5
23.5
20
16
10
0
shiree 2009
shiree 2010
shiree 2011
BDHS 2011
19
Adult nutrition status of shiree beneficiaries
BMI <18.5
58.5
60
53.1
51.2
50
40
30
Anaemic
56.2
51.5
49
47
46.3
35
52.2
45.1
33.3
WHO threshold for
'very high‘ prevalence of
CED (BMI<18.5 is 40%)
WHO threshold for
Severe public health problem
(Adult anaemia = 40.0 %)
20
WHO threshold for
'high‘ prevalence of CED
(BMI<18.5 is 20%)
10
0
Mar-10
Mar-11
Male
Mar-10
Mar-11
Female
Mar-10
Mar-11
Total
20
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
21
Nutrition’s Impact on Poverty
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
22
Modified from WB,2004
Income Poverty
Low Food
Intake
Frequent
Infections
Hard physical
labour
Frequent
pregnancies
Large
families
Malnutrition
Direct
lossloss
in in
Direct
productivity
form
productivity
poorfrom
physical
poor
status
physical status
Indirect
Indirect
loss inloss in
productivityfrom
frompoor
poor
productivity
cognitive development
cognitive development
and schooling
and schooling
Loss
resources
Loss
inin
resources
from
increased
from
increased
healthcare
carecosts
costsof
of
health
ill-health
ill-health
23
Nutrition contribution to MDGs
MDG
Nutrition is a foundation for MDGs. It help to
achieve:
Goal 1: Eradicate extreme poverty and Improved cognitive and physical development, and
hunger.
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 fullblown AIDS and premature death. Reduced risk of
TB infection resulting in disease, and improved
malarial survival rates.
24
Economic Benefit
 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
25
Figure : GDP Loss Due To Iron Deficiency
Source: Horton 1999, web-link: http://www.unscn.org/files/Publications/Briefs_on_Nutrition/Brief8_EN.pdf
26
What are the causes of Malnutrition then?
27
Long-term consequences:
Adult size, Intellectual ability, Economic productivity,
Reproductive performance, Metabolic and
cardiovascular diseases
Short-term consequences:
Mortality, Morbidity, Disability
Maternal and child undernutrition
Inadequate
dietary intake
Household food
insecurity
Underlying Cause
Immediate Cause
Disease
Inadequate care
Unhealthy household environment
and lack of health services
Income poverty: employment,
self-employment, dwelling, assets,
remittances, pensions, transfers etc.
Lack of capital: financial, human,
physical, social, and natural
Basic Cause
Social economic
and political context
28
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
29
Window of Opportunity” for Improving Nutrition
0.50
Weight for age Z-score (NCHS)
0.25
Latin America and Caribbean
0.00
Africa
Asia
-0.25
-0.50
-0.75
-1.00
-1.25
-1.50
-1.75
-2.00
0
3
6
9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60
Age (m onths)
30
key interventions
31
Determinants of Child Nutrition and Interventions to Address them
Nutrition
specific
interventions
Interventions
- Infant and young child
nutrition and treatment of
severe undernutrition
- Micronutrient
supplementation &
fortification
- Hygiene practices
- Agriculture & food security
- Health Systems
- Soc. Protection/safety nets
- Water & sanitation
- Gender & Development
- Girls’ Education
-Climate change
- Poverty reduction &
economic growth programs
-Governance, stewardship
capacities & management
-Trade & patents (&role of
private sector)
- Conflict Resolution
Food/nutrient
intake
Access to
food
Health
Maternal
and childcare
practices
Water/
Sanitation
Health
services
Immediate
causes
R
O
U
T
E
S
Underlying
causes
L
O
N
G
INSTITUTIONS
POLITICAL & IDEOLOGICAL FRAMEWORK
S
H
O
R
T
Basic causes
ECONOMIC STRUCTURE
Nutrition 32
sensitive
R
O
U
T
E
S
Shiree nutrition intervention
1. Scale up proven intervention
2. Innovation Fund
3. Research and Monitoring
4. Advocacy
33
SF Target Groups:
1.
2.
3.
4.
5.
Pregnant women
Breastfeeding women
Children < 2 years
Children 2-5 years
Adolescent girls
6. All family members (deworming only !)
34
Major Scale Fund Interventions:
Behavior change interventions (Individual counselling and group meetings)
1. Breastfeeding promotion and support
a. Early initiation of breastfeeding
b. Exclusive breastfeeding for six months and continued
breastfeeding until two years of age
2. Complementary feeding promotion
a. Behavior change promotion to follow international best
practices Proven Interventions
3. Handwashing with soap and promotion of hygiene
behaviors
a. Delivery of educational messages
Micronutrient and deworming interventions
1. Multiple micronutrient supplements (MNS - 5 components)
2. Deworming (Albendazole Tablets and suspensions)
35
3. Iron-folic acid supplements (IFA tablets)
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
36
Counselling
Pregnant
mothers
Breastfeedi
ng mothers
Adolescent
girls
Infants 6 to
23 mo’
Children 12
mo’ to 5 yrs
Others
IFA
MNP
Deworming
Social Mobilisation
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.
Only family
members - At
the beginning 6. Local influentials
37
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 Incentives
Step 7: Accountability, Monitoring, Learning and
Evaluation
38
Social Mobisation
Mass media Campaign
Video show; Tea stall
1. Listing all PW to
24m in catchment
area
V Doc, Religious Leaders,
Adolescents, TBAs, School
Teachers
2. Allocate Staff,
volunteers of 1
(CPKs/V): 20
and 1 (sup): 10
ratios
7. Monitoring for
data based
decision
Central
Coordination,
Management,
Exchange
Lessons
6. Reward,
recognition, or
performance
based incentives
5. Monthly review,
feedback, microplanning
3. Basic Hands on
Training
4. Observed
supervisional
support
Supply
IFA Tab; Deworming
drugs; MNS
39
Approved Drug Regimen by Target Group
Category of Clients
Pregnant women
De-worming
Iron & Folic Acid
(IFA)
180 tablets per
1 tablet of 400 mg per woman/year (each
women/year after the tablet contains 60 mg
first trimester
iron and 400
microgram folic acid)
Micronutrient
Supplément
(MNS)- 5
components.
Remarks
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/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.
2 tablets of 400 mg
per girls/year
40
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
12 months is the
minimum age at
1 sachests / day
which children can
for 60 day
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
members
1 tablets of 400 mg per
person/year
41
Training Materials
42
BCC Materials
1.Job aid
2.Training Manuals
3.Social Mobilisation Brochure
4.Social Mobilisation Manual, FlipChart
5.Brochure for Adolescent Girls
6.Advocacy brochure
7.Observation Checklist and Social Mobilization
Guidelines
8.Illustrated comic books on maternal and child
nutrition for adolescent groups
9.DVDs on IYCF TVCs, RDCs and Meena film
43
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
44
Logistics
45
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
46
Target group
Pregnant women (3% of
total population)
Breastfeeding women (7.33
% of total population)
Children < 2 years(6.67% of
total population)
Children 2-5 years(15.33%
of total population)
Adolescents (14.29% of total
population)
All family
members(assuming a family
number of 3.48 /households)
Total
2012-13
2013-14
2014-15
Total
(82850 BHHs)
(215500
BHHs)
(215500
BHHs)
8650
22500
22500
53,650
21000
55000
55000
131,000
19,000
50,000
50,000
119,000
45,000
115,000
115,000
275,000
41,000
107,135
107,135
255,270
331400
862000
862000
2,055,400
466,050
1,211,635 1,211,635 2,889,320
Forecasted numbers of beneficiaries 2012-2015
47
Monitoring
&
Evaluation
48
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
49
Impact Indicators
1. % point of targeted U-2 children:
stunted
underweight
wasted
anaemic.
2. % point of targeted pregnant and breastfeeding
mothers and adolescent girls:
chronic energy deficient (CED)
anaemic
50
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 acid
5. % of targeted pregnant women consuming antehelmintics
(de-worming tablets)
6. % of targeted adolescent girls consuming iron and folic acid
and antehelmintics
7. % reduction in diarrhoea among targeted children < 5 years
51
of age over a 30 day period
Reporting Frequency:
1. Monthly monitoring report
2. Programme report
3. Financial report
Tools :
1.
2.
3.
4.
Change Monitoring System
Internal monitoring and MIS
Community Pusti Karmi’s register
Observation Checklist – visitors (?)
52
Key things to focus on:
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
53
Key things to focus on:
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
54
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’ education
6. Women’s empowerment
55
Rates of severe stunting, by availability or non-availability of public
intervention in village of residence, 2000
Not available
35
31
31
20
25
23
21
31
29
30
25
Available
19
19 19
22
23
19 20
20 20
15
10
5
0
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
56
Source: siteresources.worldbank.org/.../PA2+Child+Nutrition+-+Oct02.ppt
Theory of Change
Direct interventions
Breast feeding promotion and support
Complementary feeding promotion
Promotion of hygienic behaviour
Micronutrients
Deworming
Indirect interventions
Asset transfer (livestock, poultry etc.)
Cash transfer
Income generating activities
Homestead gardening
Community mobilisation and activities
to promote women empowerment
Project
Inputs
Linkage with health and
education services and
government safety next
programmes
shiree (EEP) internal monitoring
and evaluation
Strengthen Monitoring and Evaluation
Promoting innovation
Testing mechanisms to increase access
to high protein diet
1. Improved Infant and
child feeding practices
2. Improved hygiene
3. Improved parasite
control
Improved diet and
increased food diversity
Baseline data
collected/established
Data collection and analysis
every month
Undertake operational
research providing feedback
on delivery service, systems
and compliance
Increased understanding on
importance of animal
protein diet
Increased demand of high
protein diet
Reduced
micronutrient
deficiency
Reduced disease
burden
Reduced anaemia
6 monthly reports
published
Evidence shared to
Partners and DFID
Nutrition
Lessons learned
informed programme
amendments
Improved delivery
service
Reduced
maternal
and child
undernutrition
Increased animal
protein diet
Evidence of how to
increase protein in the
diet
Evidence shared and
rolled out in extreme
poverty programmes
57
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)
58
NEXT:
1. Shiree agreement with DFID
2. Contract amendment with SF partners
3. Recruitment of technical staff and female
counsellors (CPKs)
4. Finalising NGO operational plan, including
logistics
5. Training planning and conduction
6. Ensuring effective M&E and MIS – using
existing M&E
7. Roll out the intervention
59
THANKS
60
61