Situation Analysis for Nutrition at the Center CARE Bangladesh October 2013 Compiled by: Dr Farzana Ishrat 1 CONTENTS Acronyms 3 Preamble 5 Methodology 5 Bangladesh: brief history on Nutrition 6 Population statistics 7 National Initiatives or Programs Addressing Nutrition 8 UN supported activities 13 USAID supported initiatives on Nutrition: 15 National Initiatives or Programs Addressing WASH 16 National Initiatives /Programs Addressing Food Security & Agriculture 17 USAID funded projects/ initiatives on Agriculture 18 National level coordination or initiative on integrating nutrition with food security/agriculture or WASH Target area: Sunamganj district 19 List of agencies working on Nutrition in Bangladesh: 22 DONORs for Nutrition services in Bangladesh: 22 Persons met/ communicated with 23 References: 24 20 Annex 2 ACRONYMS/ABBREVIATIONS ARI Acute respiratory infection ASPS Agriculture Sector Program Support BCC Behaviuor Change communication BF Breastfeeding BFHI Baby Friendly Hospital Initiative BINP Bangladesh Integrated Nutrition Project BMS Breastmilk substitute BNNC Bangladesh National Nutrition Council CBN Community based Nutrition CBNC Community Based Nutrition Componenet CC Community Clinics CDD Control of Diarrheal Diseases CED chronic energy deficiency CG Community group CHCP Community Health Care Provider CIP Country Investment Plan (CIP) CSA Civil Society Alliance (CSA) DAE Department of Agriculture Extension DGFP Directorate general of Family Planning DGHS Directorate General of Health Services DP Development Partner DPHE Department of Public Health Engineering EPI Expanded program on Immuniation FANTA Food& Nutrition Technical Asssistance FAO Food & Agriculture Organisation FFS Farmers Field School FP Family Planning FSNSP Food security & Nutrition Surveillance project GMP Growth monitoring & Promotion GOB Government of Bangladesh ICDDRB International Centre for Diarrheal Diseases, Bangladesh IMCI Integrated Management of Childhood Illness IYCF Infant & Young Child Feeding LGRDC Local Government, Rural Development & Cooperatives MCWC Mother & Child Welfare Centre MDG Millenium Development Goal MIS Management Information System MO Medical Officer 3 MOHFW Ministry of health & Family Welfare MPTF Multi-Partner Trust Fund MYCNSIA Mother & Young Child Nutrition Security in Asia NCD Non communicable diseases NGO Non Government Organisation PHC Primary Health Care PHN Public Health Nutrition PoA Plan of Action RCHCIB Revitalization of Community Health Care Initiatives in Bangladesh (RCHCIB) SAM Severe Acute Malnutrition SPRING SPRING Strengthening partnership, results and Innovation in Nutrition Globally SUN Scaling up Nutrition SWAp Sector Wide Approach UHC Upazila Health Complex UHFWC Union Health & Family Welfare Centre (UHFWC) UNDAF United Nations Development Assistance Framework (UNDAF) UNICEF United nations' Children’s Fund USAID VAD United States Agency for International Development Vitamin A deficiency WASH Water, Sanitation & Hygiene WHO World Health Organisation UNDAF Bangladesh United Nations Development Assistance Framework 4 Preamble: With the highest population density in the world, at 1142per sq km1 excluding a handful of city states of and small countries with populations under less than 10 million) Bangladesh has one of the highest rates of peace-time undernutrition in the world. Again, within the country there are pockets of very high prevalence of under-nutrition. To improve the situation in remote parts of Bangladesh, CARE is planning to serve the people in two subdistricts or upazilas (Derai and Bishwambarpur) in Sunamganj district situated in the north eastern haor* area of Bangladesh, bordering the Assam province of India. Prior to designing the project CARE has commissioned this situation analysis to help in designing the appropriate interventions. Methodology: This report has been prepared primarily from information collected from secondary sources including document reviews and the internet. Face to face meeting some personnel in the Government of Bangladesh and the Development Partners have added value to the report. Where face to face meetings were not possible information were collected over telephone. For the quantitative data several data sources were consulted In addition support of a statistician experienced in demographic surveys was also obtained. Limitations: The planned face-to face interview with some key personnel could not be conducted for various reasons including. One of them was away on sick leave following cardiac surgery and another was out of the country. Attempt was made for meeting before finalizing this report but could not be done due to unavoidable circumstances. ______________________________________________________ *A haor is a wetland ecosystem in the north eastern part of Bangladesh which physically is a bowl or saucer shaped shallow depression, also known as a backswamp 5 Bangladesh Brief History: The poor nutritional status of the people of Bangladesh first came to notice following the National Nutrition Survey conducted in 1962-64,2 This was perhaps instrumental in including the nutrition issue in the constitution of the country soon after independence in 1972. Article 18(1) of the constitution states: “The State shall regard the raising of the level of nutrition and the improvement of public health as among its primary duties, and in particular shall adopt effective measures to prevent the consumption, except for medical purposes or for such other purposes as may be prescribed by law, of alcoholic and other intoxicating drinks and of drugs which are injurious to health”.. Following this the Institute of Public Health Nutrition was established in 1974 and the Bangladesh National Nutrition Council (BNNC) in 1975, chaired by the head of Government (Prime Minister)2. Both the bodies are housed in the Ministry of Health & Family Welfare (MOHFW). However, in the early days the most important and large scale program was the Vitamin A supplementation project as the incidence of night blindness due to Vitamin A deficiency (VAD) in children 12-59 months was much above the World Health Organization (WHO) criteria for Public Health problem (3.5% in 1983)3. The plan was to immediately address the problem with Vitamin A supplementation while promoting long term solution through dietary diversity to increase the intake of vitamin A and best carotene rich food by the household as a whole. Nevertheless, while the Vitamin A supplementation project continued for years successfully keeping the night blindness incidence in children under 5-year old at 0.62%, well below the WHO threshold of 1.0% for clinical VAD, the subclinical deficiency remained pretty high with 22% pre-school children having low retinol level (,0.70μmol/L). Furthermore, high incidence of night-blindness in pregnant women surfaced. This indicated lack of or non-effective promotion of dietary diversity to reduce VAD as well as deficiency of other nutrients. The fight against iodine deficiency was later included alongside the fight against VAD. However, these piecemeal projects left the greater nutrition problems of mass scale under-nutrition in children and chronic energy deficiency (CED) in adults unsolved and unaddressed. In the early 1990s the World Bank, UNICEF and a few other development partners supported the Government to design and implement Under 5year children the first large scale integrated nutrition project, the Stunted 41% Bangladesh Integrated Nutrition Project (BINP)4. It Wasted 16% had a core component called Community based Underweight 36% nutrition component (CBNC) and subcomponents involving the food production units – Poultry for Nutrition (PFN) and Household Food Security through Home Gardening (HFSNG)5. The BINP was implemented during 1995-2002. Encouraged by the mid-term review findings of BINP, expansion of nutrition services was designed taking into consideration the lessons learnt from BINP.The National Nutrition Program (NNP) came into being in 2000 and was 6 implemented till mid 2011 ( in two phases 2000-2006 and 2006-2011). From 2006 NNP was included in the Health SWAp and from mid 2011 being implemented as National Nutrition Services (NNS) under the Health Population Nutrition Sector Development Program(HPNSDP). Nutrition has been identified as a priority area in the HPNSDP3,7. This mainstreaming of nutrition services was done primarily because of the annual program review (APR) of Health Nutrition & Population Sector Program (HPNSP) 2009 recommendation as “DPs will not fund for the parallel project outside the scope of HPNSDP.”3 However, no transition plan was drawn nor any transition period was allowed for this shift in the implementation policy.. As such field implementation is suffering as identified by the recent Annual program review (APR) mission in September 2013 led by the World Bank6. Population statistics: Total population Population of women of reproductive age [give age range used in country (a) 15-49) or (b) 14-49 (c) any other ________] And also expressed as a % of total population Population of children under 24 mos. And also expressed as a % of total population % of Rural Population % of population classified as “marginalized”, if any % of population below poverty line -“poor”. Use MGD definition*. Women’s literacy overall - For lowest poverty quintile - For rural areas National Data Data Source with Year Target Area Data (usually district level) Data Source with Year 142,319,000 Population and Household Census, 2011 (Socio-economic and Demographic Report), BBS DO 2,443,000 (Sunamgonj District) Population and Household Census, 2011, BBS 554656 DO 36,960,144 a) 53.1% of females b) 25.96% of total population 7794603 DO 5.60 of total population 112510154;(80.8%) (Sunamgonj District) - 45.50 % of female - 22.70% of Total Population 605691 (Sylhet Division) DO 6.60 87.98 (Sylhet Division) DO - DO DO 31.5** -- 53.44 - 50.20 49.8 DO (Sunamgonj District) *The MGD definition is “living on less than $1.25 per day”. ** http://data.worldbank.org/country/bangladesh ( Accessed on 29.10.13) 7 National Initiatives or Programs Addressing Nutrition National Nutrition Services (NNS)4 The prevalence of under-nutrition is still one of the highest in the world, (highest peace time). The Government of Bangladesh as well as its development partners (DPs) have identified nutrition as a priority area for development. The MOHFW has a separate operational plan (OP) for nutrition -the National Nutrition Services (NNS) out of the 32 OPs in the HPNSDP. The Directorate General of Health Services (DGHS) is primarily responsible for the implementation of NNS. Both the DGHS and DGFP (Directorate General of Family Planning) are given the responsibility of streamlining and strengthening the nutrition services by using their regular manpower from their respective directorates, thus doing away with the need of having nutrition staff/workers in different tiers including the grassroot level. The OP states that at “the community level, nutrition services will be delivered by Health Assistant, Family Welfare Assistant and CHCP (Community health care providers) in addition to their usual duties” . However, how this will be done is not clearly mentioned in the operational plan. Already 482 medical officers (MO) in the Upazila Health Complexes (UHC) have been designated as MO (Public Health Nutrition)7. The MO (PHN) is responsible for coordinating all activities of NNS at the upazila level and below. The MO (PHN) will oversee the delivery of health centre-based nutrition services in the UHC as well as monitor health centre-based nutrition interventions in all unions and Community Clinics (CC) as a whole.” The objectives of NNS4: General Objective: To reduce the prevalence of malnutrition among the people of Bangladesh with special emphasis on the children, women, adolescents and underprivileged section of the society. Specific Objectives: 1. To implement a mainstreamed, comprehensive package of nutrition services to reduce maternal and child malnutrition and ensure universal access 2. To develop and strengthen coordination mechanisms with key relevant sectors (especially Ministry of Food and Disaster Management, Ministry of Agriculture, Ministry of Women and Children Affairs, Ministry of Information, Ministry of Education, Ministry of Livestock and Fisheries, Ministry of Local Government, Rural Development and Cooperative, etc.) to ensure a multi-sectoral response to malnutrition 3. To strengthen the human resource capacity to manage, supervise and deliver nutrition services at the different levels of the health &family planning services. 4. To strengthen nutrition management information systems and operations research to ensure an evidence-based response and establish linkages to MIS 8 Major Components of NNS OP Major Activity a) Behaviour Change Communication (BCC) b) c) d) e) f) g) h) i) j) k) l) Control of Vitamin-A deficiency disorder Control & prevention of Anaemia Control of Iodine Deficiency Disorder Other Micronutrient problem of Public Health importance (zinc, vitamin D, calcium etc) Community & facility based management of severe acute malnutrition(SAM) Protection, Promotion & Support of Breastfeeding/ Infant and Young Child Feeding (IYCF) including BFHI & BMS Code Food fortification (Salt Iodization, fortification of oil/other food with Vitamin A, iron etc.) School Nutritional Education Program Food Quality and Food Safety Monitoring, Evaluation, Operations research, survey Nutrition Surveillance Program m) Establishment of nutrition unit (NU) and strengthening of existing NU n) Community based Nutrition (CBN) in selected area o) Nutrition in emergency / NCD p) Establishment of nutrition Service in CC & GMP HPNSDP has been designed for functional integration and mainstreaming of nutrition However, it is yet to materialize. “The Health Directorate implements and supervises their own activities and FP Directorate does the same. The field staff is yet to learn, internalise and own nutrition services” laments an official of MOHFW 8. Even the MIS from many peripheral health care centres did not report any nutrition services. The staff could not describe the nutrition services at MCWC; very little attention is given to nutrition and few staff trained6. MYCNSIA (DGFP)8 The DGFP is implementing MYCNSIA project ( Mother and Young child nutrition security initiative in Asia) with support from UNICEF and Technical assistance from ICDDR,B in 17 upazilas (subdistrict) in 8 districts. The project started in Nov 2011 and expected to be completed in 2014. District 1 2 3 4 5 6 7 8 Bhola Cox’s Bazar Rangpur Comilla Jamalpur Sunamganj Narail Satkhira Upazila Lalmohon and Sadar upz Moheshkhali and Sadar Badraganj and Pirgachha Burichang Islampur and Sharishabari Derai and Duarabazar Kalia and Lohagara Kaliganj, Asasuni, Shyamnagar & Debhata 9 The 1,000 day nutrition services for the mothers and children under MYCNSIA 8 (translated from a leaflet collected from the project personnel) A. Pregnant Mothers: a. At least 4 ante-natal check-up in the health care centre b. Nutritional counseling for consuming more vegetables, meat, fish during pregnancy c. At least one Iron-Folate tab every day during pregnancy and 3 mo following child-birth B. Under 2yr Children: a. Early initiation of BF ( within 1 hr) b. Exclusive breastfeeding for the first 6 months (180 days) c. Introduction of home-made complementary food after completing 6 months (180 days) d. Feeding MNP ( multiple micronutrient powder) from 6 mo to 24 months e. After completing 6 months (180 days) children should be fed at least 4 types of food ( carbohydrates + pulses +protein (fish / meat / offal +vegetables and fruits) f. The child must be administered Vitamin A capsules as recommended g. Both hands must be washed well with soap and water before preparing food, before feeding the child and after cleaning the baby 10 Revitalization of Community Health Care Initiatives in Bangladesh (RCHCIB)9 The GOB has taken initiatives for revitalization of Community Clinics (CC) as the top-most priority project in the Health sector. The CC is basically meant for health education (on health, nutrition and family planning), health promotion and treatment of minor ailments, first aid and identification of emergency & complicated cases to establish a referral linkage with higher facilities like Union Health & Family Welfare Centre (UHFWC) and Upazila Health Center (UHC). The services to be provided at the CC are9: 1. 2. 3. 4. 5. Maternal and neonatal health care services Integrated Management of childhood Illness (IMCI) Reproductive Health & Family Planning Services EPI, ARI, CDD Registration of newly married couple, pregnant women, birth, death, prediction of EDD 6. Nutritional education and micronutrient supplements 7. Health & Family Planning Education & Counseling 8. Identification of other illnesses like TB, Malaria, Pneumonia, Life threatening influenza, Obstetric emergencies and refer to higher facilities 9. Identification of emerging and reemerging diseases & refer to higher facilities 10. Other services as identified by GOB to be provided 11. Treatment of minor ailments 12. Establishing effective referral linkage with higher facilities The CCs are the first point of contact for the rural people in the remotest areas of Bangladesh. It is a one-stop centre for PHC ( primary health care) services. There are 12,217 out of the planned 13,500 CC in operation currently (as of Jan 2013) These are open 6 days a week. It is staffed by one Community Health Care Provider (CHCP), who should be available all 6 days. So far approximately equal number of male and female CHCP have been recruited (as of Jan 20013) In addition, one Health Assistant (HA) (mostly men) from the DGHS and one Family Welfare Assistant (FWA) (all women) from DGFP is present on alternate days to serve the clients coming to the CC as per the above list of services. The CHCP is supposed to receive a three month foundation training. But all the CHCPs are yet to be trained. Community based nutrition services, growth monitoring & promotion and promotion of IYCF are not clearly mentioned in the list of services to be provided from the CCs. RCHCIB project has partnered with several NGOs including CARE Bangladesh (40 upzs from Brahmanbaria, Cox’s Bazar, Jhalokathi & Moulvibazar) for capacity development of the community group (CG), operational research . 11 Food Security & Nutrition Surveillance project (FSNSP)10 The Food Security & Nutrition Surveillance Project (FSNSP) is the only surveillance project in Bangladesh that provides nationally representative estimates of food security and nutrition The system provides up-to-date evidence on the food security, nutrition and health status of women and children to support the design, implementation and evaluation of national strategies and assess progress towards internationally agreed development targets such as those of the MDGs. Pockets of low dietary diversity is found to exist in the Haor basin (including Sunamganj) where women’s calorie intake is approximately 60-70% of the requirement resulting in 40% of women being are underweight. It is important to note that in the last 10 years the proportion of women with CED ( chronic energy deficiency) has halved while proportion of overweight women has more than doubled3 in the country. An important point for future planners. 12 UN supported activities The Bangladesh United Nations Development Assistance Framework (UNDAF) 2012-2016: 11 The UNDAF is the UN System’s coherent and collective response for addressing inequalities in Bangladesh. It elaborates what and how results will be achieved over the next five years for the people of Bangladesh, particularly for the most vulnerable, deprived and marginalized citizens. The seven UNDAF Pillars and the respective UN Lead Agencies are as follows: 1. Democratic Governance and Human Rights (UNDP) 2. Pro-poor Growth with Equity (UNDP) 3. Social Services for Human Development (UNICEF) 4. Food Security and Nutrition (WFP) 5. 6. Climate Change, Environment, Disaster Risk Reduction and Response (UNDP) Pro-poor Urban Development (UNDP) 7. Gender Equality and Women's Advancement (UNFPA) Some FAO projects in Bangladesh 18 : 1. National Food Policy Strengthening Program (NFPSP) 2. Food Safety project 3. Integrated Agriculture Productivity Project (IAPP) 4. Emergency center for Transboundary Animal diseases support 5. Prevent, Prepare, Respond to Food and agriculture threats and emergencies 6. Improving Surface Water Irrigation in Coastal Areas and Sylhet Division in Bangladesh 7. Food Security through enhanced agricultural production diversified sources of income, value addition and marketing in Bangladesh 13 The Country Investment Plan (CIP)12 The CIP is a roadmap towards investment in agriculture, food security and nutrition It has been jointly prepared by 13 ministries of the Government of Bangladesh coordinated by the Food Planning and Monitoring Unit (FPMU) of the ministry of Food. The CIP is a planning, fund mobilization and alignment tool. It is a 5yr comprehensive plan that aims at ensuring sustainable food security. It is the investment arm of the national Food Policy (NFP, 2006) and its plan of action (PoA 2008-2015) and reflects the food security content of the 6th 5yr plan (SFP) 20112015. It is an advocacy and financial tool for increased resource allocation from the budget (both GOB and DPs)12. The CIP provides a coherent set of 12 priority investment programmes to improve food security and nutrition in an integrated way. Component Program 1 Sustainable and diversified agriculture thru integrated research & extension Food availability 2 Improved water resource management and infrastructure for irrigation purposes Food access Food Utilisation 3 Improved quality of inputs and soil fertility 4 Fisheries & aquaculture development 5 Livestock development with a focus on poultry & dairy production 6 Improved access to market, value addition in agriculture & non-farm incomes 7 Strengthened capacities for implementation & monitoring of NFP & CIP actions 8 Enhanced public food management system 9 Institutional Development & capacity Development for more effective safety nets 10 Community based nutrition programs & services 11 Orient Food & Nutrition actions through data 12 Food safety & quality improvement The M/o Finance and several DPs have committed to use the CIP to allocate budget contributions, grants and loans.. 14 USAID supported initiatives on Nutrition: i) SUN (Scaling up Nutrition) 13 It is primarily a movement launched in 2010 to help countries reach MDG on nutrition targeting the first 1000days of life ( -9months to 24months after birth.) SUN supports both direct nutrition specific interventions and multi-sectoral nutrition sensitive approach. Bangladesh is one of the “early rising” SUN countries alongwith Nepal, Ethiopia, Ghana, Malawi, Mozambique, Peru, Senegal, Tanzania, Uganda and Zambia (12 countries). The Government has nominated Mr. Shafiqul Islam, Additional Secretary, MOHFW as the Country Focal person of SUN. However SUN is yet to be visible in the Government programs. The SUN Civil Society Alliance (CSA) , led by BRAC is more active. The CSA has received funds from the MultiPartner Trust Fund (MPTF)13 The major sponsors for SUN are the World Bank and USAID. CIDA, DfID /UKAid and the EU have also joined in. Other USAID supported initiatives on Nutrition and Food Security are a) SPRING b) FEED-the FUTURE, c)FANTA II 15 National Initiatives / Programs Addressing WASH Bangladesh is a country where annual flooding is a natural phenomena. In the densely populated low-lying areas rural sanitation is in very poor condition and the water sources are contaminated during the flood. About 45% of the population don’t have access to improved sanitation and over 25 million people lack access to safe water resulting in the death of 7,000 under 5yrs children annually. This vicious cycle is difficult to control but not impossible.14 The National WATSAN Policy (1998 ) was adopted with the goal of ensuring the installation of at least one sanitary latrine in each household in the rural areas of Bangladesh and improving public health standard through inculcating the habit of proper use of sanitary latrines. The National Sanitation strategy15 was formulated in 2005 in the backdrop of the MDGs set in 2005. The scope of the strategy is to address issues related to unhygienic defecation only. The goal was set to achieve 100% sanitation by the year 2010. The Department of Public Health Engineering (DPHE) and the Local Government Division of m/o Local Government, Rural Development & Cooperatives (LGRDC) are the lead agencies addressing WASH in the country. Efforts are underway for collaborative action to promote WASH services to enhance the achievements in the nutrition programs/ initiatives. The NNS OP emphasise the need for safe water, proper sanitation and hygiene4. However, the practical situation regarding service and awareness creation by NNS, DPHE, LGRD, in the community and household level needs to be assessed. UNICEF, WHO, World Bank , IDB, ADB, CIDA are important development partners in promoting WASH activities in the country. NGO Forum, WaterAid, BRAC, Plan Bangladesh, CARE Bangladesh are some of the lead agencies working in WASH. The WASH Alliance Bangladesh currently consists of 14 members16 Projects currently being implemented by DPHE in collaboration with different agencies: 1 Bangladesh Rural Water supply & sanitation project 2 Water supply, sanitation & Drainage project in Sylhet and Barisal city 3 Water supply & environmental sanitation project at thana sadar and growth centre pourashava 16 National Initiatives /Programs Addressing Food Security & Agriculture Agriculture Extension Service (DAE)17 Department of Agriculture Extension (DAE) is under the m/o Agriculture. The lowest level of staff members are the Sub Assistant Agriculture Officer (SAAO). They hold a diploma in Agriculture - a 4yr course taken after completing 10yrs of schooling (SSC). Regular Farmers Field School (FFS) are held with both men and women farmers. Usually one man and one woman from the same household attend these FFS. Topics related to human nutrition, homestead vegetable gardening, growing fruit trees, use of farmyard manure and making energy saving stove are specifically addressed to women farmers They also receive information to bring about changes in consumption pattern to improve the population below poverty nutritional status of the household members. line dropped from above They are also taught how to cook vegetables 58% to 29% preserving their nutritional values5. This is done under the Agriculture Sector Program Support (ASPS). The ASPS works in the percentage of ultra-poor Haor areas of Sylhet division which includes dropped to 16 from 37 Sunamganj Bangladesh has been awarded a diploma by the FAO in June this year (2013) for its progress in fighting hunger and reaching MDG 1. This is in recognition of halving the people below the poverty line. NATP National Agriculture Technology Project Livestock extension support component19 The role of Fisheries and Livestock sectors in the development of agro-based economy of Bangladesh is very important and promising. They contribute around 8% to national income, which also is 32% of the total agricultural income. About 90% of animal protein in our diet comes from fish and livestock. Hence, the Bangladesh Government has identified livestock as one of the key player of poverty reduction strategy and achieving the MDGs. It has set strategic targets for meeting protein demand, employment generation thru livestock sub-sector20 The main functions of the Ministry of Fisheries and Livestock are to preserve fisheries resources, fulfill the requirement of animal protein through proper management and planned development, increase socio-economic conditions of fishermen, create employment opportunities for rural unemployed and landless people19 The DLS is currently implementing about a dozen projects to this effect. 17 Ekti Bari ekti khamar (one house , one farm) EBEK21 A project implemented in selected unions of all the upazilas in the country. Every house in the village has unutilized land, home yard, pond/ditch, canal, etc. It also has unskilled manpower, unemployed youths and women. EBEK project aims at tapping these unutilised resources to increase the family income by offering training on agriculture, home gardening, fish culture, poultry and livestock, seed money and encouragement.. EBEK is being implemented by the Rural Development & Cooperative Division, Ministry of Local Government, Rural Development and Cooperatives. USAID funded projects/ initiatives on Agriculture SPRING (Strengthening partnership, results and Innovation in Nutrition Globally)22 : SPRING is a nutrition sensitive intervention in agriculture and works with NNS, RCHCIB and other partners across health and agriculture sectors to improve nutritional status of pregnant women and children in order to decrease the prevalence of stunting among children. SPRING’s work in Bangladesh centers around the use of 1000 days approach across different sectors, including health and agriculture to facilitate social and behavior change with the goal of preventing stunting in young children. SPRING is currently working in15 upz in the Barisal and Khulna divisions Bangladesh. It plans to expand to another 25 upazilas in the south. 18 National level coordination or initiative on integrating nutrition with food security/agriculture or WASH. WaterAid is engaging with BRAC & ICDDRB on collaboration to reduce infection and worm infestation to improve child nutritional status In the recent years the mortality from diarrhoea is greatly reduced because of ORS and Zn supplementation following bouts of diarrhea in children, However, morbidity incidence is still high because of poor hygiene and lack of proper sanitation holding back the improvements in indicators like stunting and wasting. The incidence of diarrhea including Cholera has increased disproportionately this year Experts attribute lack of hygiene practices, lack of safe water and proper sanitation as some of the major reasons for this23. The SUN movement could be a perfect platform for collaboration and coordination between WASH and Nutrition services. Sir Abed (BRAC) and the Prime Mister of the Government of Bangladesh had breakfast meeting in New York in September 2013 of with Chief Executive of WaterAid Barbara Frost to discuss collaboration to effectively address the link between stunting & wasting and WASH24. RCHCIB, NNS and SPRING have recently set up collaboration to increase capacity for over 5,300 key MOHFW personnel on nutrition and hygiene counseling25 19 Target area: Sunamganj district Situated in the north eastern haor area of Bangladesh Consists of 11 upazila i) Bishwamberpur,ii) Chhatak, iii) Dakhin Sunamganj ,iv) Derai v), Dharmapasha, vi) Dowarabazar vii) Jagannathpur viii) Jamalganj ix) Sunamganj Sadar x) Sulla xi) Tahirpur Literacy rate of 35% in the district is much lower against national 51.8% There are many wetlands (haors and beels) in Sunamganj. For reaching remote areas mostly boats are used. There are several ethnic groups (Khasia,Manipuri, Garo etc) living in this border district.. The district is known for the stone and sand business, River Sand. It has been supplying river sand, natural sand, crushed stone, gravel and shingle. Several thousand workers are directly dependent on these for their livelihood. Demography: (census 2011); Sunamganj dist Bishwamberpur Derai Total popn 24,67,968 1,56,381 2,43,690 Household 4,40,332 29,336 45,040 Density 659/sq km HH size 5.58 Housing & electricity Sunamganj dist Bishwamberpur Derai Pucca 6.6 0.8 4.3 Semi pucca 11.7 5.4 11.4 Kutcha 77.5 77.9 81.7 Jhupri 4.2 14.9 2.5 Electricity 34.0 21.0 34.0 Drinking Water supply Sunamganj dist Bishwamberpur Derai Tap % 1.0 0.1 0.2 Tubewell % 88 85 93.4 Other % 11 15 6.5 Toilet facilties: Sunamganj dist Bishwamberpur Derai Sanitary (water sealed) % 7.4 3.1 6.4 Sanitary (non water sealed) % 25.3 19.3 30.0 Non sanitary % 55.2 62.6 51.9 None % 12.1 15.0 11.7 20 Map of Bangladesh Map of Sunamganj 21 List of agencies working on Nutrition in Bangladesh: 1. National a. BRAC b. DSK (Dustho Shastho Kendra) c. Bangladesh Breastfeeding Foundation d. TAHN (Training & Assistance for Health & Nutrition) e. Eminence Bangladesh f. VARD g. VOSD 2. International a. CARE Bangladesh b. Save the children c. Plan International d. HKI e. Micronutrient Initiative f. CONCERN g. World Vision h. Alive & Thrive i. MSF j. TDH k. ACF 3. UN agencies: a. UNICEF b. WHO (World Health Organisation) c. World Food Programme d. FAO e. IFAD 4. Academic /Research agencies a. ICDDR,B b. INFS ( Institute of Nutrition & Food Science) c. College of Home Economics 5. Others: a. USAID funded i. World Fish ii. Global Health Initiative iii. Feed the Future iv. FANTA v. SPRING b. GAIN DONORs for Nutrition services in Bangladesh: 1. 2. 3. 4. 5. World Bank JICA USAID DFID CIDA 22 Persons met/ communicated with: 1. Prof Fatima Parveen Chowdhury Secretary BNNC and Director, CME (former Director IPHN and Line Director NNS) Ministry of Health & Family Welfare (MOHFW) Government of Bangladesh 2. Prof Soofia Khatoon Professor of Pediatrics Shaheed Suhrawardy Medical College and Secretary, Bangladesh breastfeeding Foundation,& Chairperson, BFHI Committee, BBF 3. Dr Mary Manandhar International REACH Facilitator, UN REACH 4. Dr Iftekhar Rashid National REACH Facilitator , UNREACH 5. Dr Lalita Bhattacharjee Nutritionist, NFPCSP-FAO National Food Policy Capacity Strengthening Program, FPMU, Ministry of Food & Disaster Management, Govt. of Bangladesh , 6. Dr Tahmina Hossain Talukder Assistant Director & Deputy Program Manager, DGFP 7. Dr Shamsul Karim Assistant Director, MCH Services & Program Manager Directorate of Family Planning, Government of Bangladesh 8. Dr Alamgir T Azad Member, Annual Program Review (APR) team HPNSDP-World Bank 9. Mr Shamim Ahmed Program Manager, WaterAid Bangladesh 23 References: 1. http://www.tradingeconomics.com/bangladesh/population-density-people-per-sq-km-wbdata.html 2. IPHN website: http://iphn.gov.bd/english/ 3. Program Implementation Plan, HPNSDP, MOHFW, July 2011 4. Operational Plan(OP) for National Nutrition Services, DGHS, MOHFW July 2011 5. Implementation completion report. Report no 25183, World Bank, Dec 2002 6. Personal communication with Review Mission member 7. Health Bulletin, DGHS, June 2012 8. Personal communication with PM, DGFP 9. http://www.communityclinic.gov.bd/about.php 10. State of Food Security & Nutrition in Bangladesh, FSNSP 2010 11. Bangladesh United Nations Development Assistance Framework 2012-2016 12. Bangladesh Country Investment Plan, Government of Bangladesh, June 2011 13. http://scalingupnutrition.org/news/funding-approved-to-support-civil-society-coordinationon-sun-in-bangladesh 14. http://www.wateraid.org/where-we-work/page/bangladesh 15. National Sanitation strategy 2005 m/o Local Government, Rural Development & Cooperatives, 2005 16. http://www.washbd.org/ 17. http://www.dae.gov.bd 18. http://www.fao.org/asiapacific/bangladesh/fao-projects/en/ 19. http://www.mofl.gov.bd/ 20. http://natpdls.org. 21. http://www.ebek-rdcd.gov.bd/ 22. http://www.spring-nutrition.org/news/spring-expands-partnership-governmentbangladesh-improve-nutrition 23. http://www.wateraid.org/where-we-work/page/bangladesh 24. Project Manager, WaterAid, personal communication 25. http://www.spring-nutrition.org/news/spring-expands-partnership-governmentbangladesh-improve-nutrition 24