This presentation by Masum Billah, iccdr,b was shown at the Transform Nutrition - Evidence for Action regional meeting in Kathmandu, Nepal on 8 July 2017. This one-day event shared Transform Nutrition evidence on key issues related to nutrition policy in Nepal, Bangladesh and India, lessons on strategies for change from other contexts and discuss the relevance and applicability of the research findings to policies/programmes that aim to address nutrition in South Asia.

1. Using the health system to deliver
nutrition interventions in
Bangladesh
International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b)
International Food Policy Research Institute (IFPRI)

2. Heady et. al (2015)
NEPAL
Stunting reduction: Sources
Health 16%!
Can health
do more?

3. Why does the NNS matter?
Delivery of direct nutrition interventions  key to meet the development targets
47
64
67
20.9
83
60
37
81
34
52
55
65
23
78
62
44
84
38
0
20
40
60
80
100
Early initiation
of BF
Exclusive BF
(0-6 mo)
Introduction of
CF at 6-9 mo
3 expected
IYCF practices
All basic
immunizations
Vitamin A
suppl (<3s)
Women - > 3
ANC visits
ORT for
diarrhea
ORT + zinc
Percent
2011 2014
Source: BDHS

4. History of NNS
In 2009, Annual Program
Review (APR) of the
Health, Nutrition and
Population Sector Program
(HNPSP) recommended
scale up critical nutrition
interventions by
mainstreaming nutrition
services provided through
the DGHS and DGFP
In 2011,
Operational
Plan (OP) of
National
Nutrition
Services (NNS)
was approved
by the GoB
The OP suggests
mainstreamed
NNS
interventions will
be implemented
through existing
health systems
(DGHS and DGFP)
between July 2011
and 2016
NNS is supposed
to pursue a
variety of key
strategies and
actions targeted
towards
mainstreaming
critical nutrition
interventions
Several aspects
of
mainstreaming
process have
been
undertaken
since 2012
National Nutrition
Policy 2015
National Plan
of Action for
Nutrition
(DRAFT) 2016
4th Sector
programme
(NNS OP)

5. Assessment of Implementation of NNS in
Bangladesh
International Food Policy Research Institute (IFPRI)
International Centre For Diarrhoeal Disease Research,
Bangladesh (icddr,b)
Identified “what’s working”; “what needs more
work”
 Management and support services
 Training and capacity development
 Service delivery
 Monitoring and evaluation
 Exposure to Interventions (from DNSO evaluation)

6. What ‘New’ is being done?
• NNS along with UNICEF and CIFF as implementing and funding
partners is attempting demonstration components to addresses
the NNS challenges
• Provide a temporary dedicated human resource, the District Nutrition
Support Officers (DNSOs)
• Demonstrate and prove the feasibility and impact of Competency based
training for managers, supervisors and service providers to deliver
nutrition interventions

7. Methods
Major domains Data sources to address research questions
1. Management and support services - Content review of NNS documents
- National-level in-depth interviews
2. Training and capacity development - Content review of NNS documents
- National-level in-depth interviews
- Service provider surveys
3. Service delivery - Healthcare provider surveys
- Facility assessments
- Structured observations
- In-depth interviews, FGDs with healthcare providers
4. Monitoring and evaluation - National-level in-depth interviews
- Healthcare provider surveys
- Facility assessments (record review)
- FGDs & in-depth interviews with healthcare providers
5. Exposure to interventions - Household coverage survey (DNSO evaluation)

8. Management and Support
Services

9. What’s working?
NNS operational plans (OP) & progress in subnational coordination
• Operational plans
 OP outlines all components of NNS
 Institutional arrangements for delivery of NNS interventions using existing health and
family planning infrastructure are described in specific detail
 New sector programme reemphasizes the direct interventions and community clinics
• Progress in subnational coordination
 Good progress in coordination of nutrition services and with levels of communication
between staff managed by DGHS and DGFP at the upazila level and below
Source: Saha et al, 2015, implementation assessment done in 2014

10. What needs more work?
Governance and institutional arrangements
Capacity and workload related challenges within NNS/IPHN
 Capacity to developing feasible and specific implementation plans for intervention
delivery
 Ability to develop training approaches, to maintain and manage records on training
roll-out and to manage a large budget
Retention challenges for the Directorship of IPHN
Lack of bureaucratic authority limits monitoring/coordination of NNS activities
Source: Saha et al, 2015, implementation assessment done in 2014

11. What needs more work?
Program design and intervention platforms
Choice of delivery platforms
 IMCI-Nutrition corners and Community Clinics are primarily visited by sick
children
 Key NNS components, especially IYCF counseling, micronutrient
supplementation, and screening for SAM/MAM are targeted towards all
children & current platforms not designed to reach all, no CMAM
Source: Saha et al, 2015, implementation assessment done in 2014

12. What needs more work?
Program design and intervention platforms
Percentage of Mother-newborn pairs (care continuum) had contacts
with the routine health services
26.1
13.5
9.8
5.1 4.9
ANC Delivery PNC ANC and PNC ANC and Delivery and
PNC
BDHS 2014
*Physicians are the predominant provider

13. What needs more work?
Coordination and communication
 Horizontal coordination at national level:
• Lack of communication and coordination – particularly at senior levels.
• Coordination across DGHS and DGFP are also reported to be challenging
 Vertical coordination/communication:
Local providers described how communications with NNS staff based in Dhaka
were challenging, different line supervisors
Source: Saha et al, 2015, implementation assessment done in 2014

14. Training and Capacity
Development

15. What’s working?
Training and capacity building roll-out
 Training manuals are in place – Basic Nutrition, IYCF, SAM/CMAM,
Competency Based Training (CBT), Supportive Supervision
 Overall NNS training is ongoing and UNICEF supported CBT have started,
covered 30,000+ service providers in 26 districts

16. What needs more work?
Coverage of Nutrition trainings
Percentage of service providers receiving trainings in nutrition (N= 364)
0
10
20
30
40
50
60
70
80
90
100
Physician Nurse SACMO FWV FWA CHCP
Basic nutrition training IYCF training Any other nutrition training
Initial Assessment (DNSO Evaluation), 2016* CBT coverage is not presented here
*

17. Service Delivery

18. What’s being done?
Integration with IMCI-N
• Nation-wide establishment of IMCI-N corners is completed
 All facilities include IMCI-Nutrition Corners
 Basic Nutrition Training adds some value to IMCI for screening of
SAM/MAM; elaborates on nutrition knowledge and includes more detail on
IYCF training
 NNS-trained providers appeared to offer more nutritional advice during
sick child care
Source: Saha et al, 2015, implementation assessment done in 2014

19. Availability of equipments and job aids
43
35
22
35
27
5
Weighing scale
Height scale
Length scale
MUAC Tape
GMP Card (both girls and boys)
IYCF manual
% of health facilities with key equipment in
Sick child management area[N=37]
89% sick child management area had <50%
essential equipment/guidelines
~70% ANC rooms had at least 7 of the 11 essential
equipment/supplement/guidelines
95
54
41
54
95
46
16
Weighing scales
Height Scale
MUAC tape
Picture cards with maternal
danger signs
Iron Folic Acid (IFA) tablet
Calcium tablet
Basic National Nutrition
Services nutrition training…
% of health facilities with key equipment
in ANC room [N=37]
Source: Saha et al, 2015, implementation assessment done in 2014

20. Delivery of Nutrition services during ANC
94
39
78
66
62
56
60
63
33
46
39
78
35
30 30
0
20
40
60
80
100
%
Advice/service provided to women
Weighed and recorded weight
Measured and recorded height
Examined anemia in eyes
take more food
take balanced diet
take seasonal/available food
take green/colored vegetables
drink more water
take iodized salt
take rest at least for two hours/day
maintain personal hygiene
take routine iron and folic acid
told about importnace of breast feeding
told about breastfeeding within an hour
told about danger signs to neonate
Examinatio
n
Advice provided
N=381 ANC observations
Source: Saha et al, 2015, implementation assessment done in 2014

21. 0
10
20
30
40
50
%
Advice/services provided to children
Weighed and recorded weight
Measured and recorded height
Clinically screen the child for SAM
Demonstrate IYCF practices using visual job aids
Checked child's weight against a growth chart
Nutritional
Assessment
Nutrition
Counselling
N=826 sick child case management observations
Delivery of Nutrition services during sick U5 child management
Source: Saha et al, 2015, implementation assessment done in 2014

22. Monitoring and Evaluation

23. What’s working?
Indicators, performance review visits are coming together
 Nutrition Information System
 Considerable progress in institutionalizing the reporting of nutrition indicators in
the routine RHMIS through:
 Monthly IMCI-Nutrition Corner reporting format
 Monthly community clinic reporting format for newborn and child health
 Program Performance
 Some supervisory visits are taking place at the level of the health facilities
at limited scale
Source: Saha et al, 2015, implementation assessment done in 2014

24.  Record-keeping within the NNS should be focused
 information on implementation roll-out, performance/outputs, and
development partner support to geographic and technical areas is
currently not easily available to all key stakeholders
 A system for technical monitoring of service quality by National Level
experts and Managers
What needs more work?
Record-keeping on training, roll-out and service delivery monitoring
Source: Saha et al, 2015, implementation assessment done in 2014

25. Recommendations
• Strengthen the leadership authority of the NNS
• Ensure regular technical supervision visits/support to field
• Develop very specific implementation plans with rational delivery platforms
• Invest in developing a cadre of workforce for delivering core nutrition messages beyond the
curative platforms
• Exploring other potential high coverage outreach platforms like some NGO platforms
• Strengthen nutrition counseling and screening within IMCI, but invest more in an outreach-
based platform for delivering core preventive NNS services
• Coordination of activities among Development Partners
• Emphasize rapid growing urban population and completely different health service
structure
• A system for technical monitoring of service quality by experts
• Carefully review of the current set of NNS indicators