Report No. 4974-BD

BangladeshFood and Nutrition Sector Review

January 31, 1985

Population, Health and Nutrition Department

FOR OFFICIAL USE ONLY

Document of the World Bank

This document has a restricted distribution and may be used by recipientsonly in the performance of their official duties. Its contents may not otherwisebe disclosed without World Bank authorization.

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CURRENCY EQUIVALENTS

The external value of the Bangladesh Taka (Tk) is fixed inrelation to a basket of reference currencies, with the US Dollar serving asintervention currency. On October 12, 1983, the official exchange rate wasset at Tk 24.97 buying and Tk 25.03 selling per US Dollar.

US$ 1 = Tk 25.00Tk 1 = US$ 0.04Tk I million = US$ 40,000

FOR OMCAL USE ONLY

BANGLADESH

FOOD AND NUTRITION SECTOR REVIEW

Table of Contents

SUMMARY AND CONCLUSIONS .............................................. -i-

I* THE MALNUTRITION PROBLEM *..... ... * *............................. 1Nature and Exrent of Malnutrition ............. 6................. 1Food Cousumption and Malnutrition ............................. 3Health and Population Factors ....... ........................... 7Maim Causes of Malnutrition .... .......... ................... 8

II. INSTITUTIONAL ASPECTS ............. o ...... o ............ o 12

III. POLICIES AND PROGRAMS .................. .......... ........... 15Food Production Policy . *...... **.. ... .................... *... 15Food Procurement and Pricing Policy ............................ 17Agricultural Research and Crop Diversification ................. 18Rome Garde,ns ...............**....*****.**************,**...... 19Public Foodgrain Distribution System ................. ... ....... 20Health Programs ... ....................... ...... *.. * * ** ......... 30

IV. ISSUES AND CONSTRAINTS ....... ...... ... .. ...... .. ....... ..... 31National Nutrition Policy ...... ....... .. 0. . ... ... 0........O. ...... 32Institutional Aspects .................*........... .****.. 33Food Production Policy ... ...... *. ..*.*..o....o..... ...0-400* 34Food Procurement and Pricing Policy ............................. 36Agricultural Research and Crop Diversification ................. 36Home Garde-ns ....o.......... .......... o.................... 37Public Foodgrain Distribution System ....... 0.................... 38Health Programs o ............... **................ ... 42The Need for an Integrated Approach .....O_................. o... 46Role of Non-Government Organizations ........................... 48

V. RECOMMENDATIONS ...... .. .......................... .... 49

ANNEXES ....................... ............... o. ..............

1. STATISTICAL ANNEX .... .... oo ............. 552. TECHNICAL ASPECTS OF MALNUTRITION .......................... 71

Patterns of Food Consumption .......... ................ 71Nutritional Status of the Population ....................... 75Micro-Nutrient Deficiencies ...... ......................... 83The Etiology of MalnutritLon ............................... 88

Ibis document has a restricted distribution and may be used by recipients only in the performance of 1their official duties. Its contents may not otherwise be disclosed without World Bank authorization

TABLES

Page

1. Foodgrains and Caloric Intake by Socio-Economic Group,1976-77 4.... 4

2. Calorie Expenditure Elasticities by Socio-Economic Group ...... 103. Projected Trend of Net Production of Foodgraius

and Consumption Requirements, 1982-83 to 1987-88 164. Benefit-Cost Ratios for Maize 185. Distribution of the Public Foodgrain Distribution

by Socio-Economic Group, 1982-83 276. Beneficiaries of the Public Foodgrain Distribution

System by Socio-Economic Group, 1982-83 ...... 29

Annex 1

1.01 Summary of the Foodgrain Situation, 1978/79-1983/84 ........... 561.02 Trends in Agricultural Production and Value Added,

1978/79-1983/84 . *......... ..... 571.03 Estimated Foodgrain Stocks, 1972/73-1982/83 ........... s........ 581.04 Paddy Prices and Procurement, 1979/80-1983/84 ................. 591.05 Index of Minimum Market Price for Coarse Rice,

1979/80-1983/84 ............ ... 601.06 Average Minimum Retail Price for Paddy, Coarse Rice

and Wbeat in Bangladesh, 1980-83 ............................ 611.07 Public Foodgrain Distribution System .... 621.08 Weekly Cereal Quota per Adult Cardholder Under Statutory

Rationing, 1973-1983 ......... 63...................6. 631.09 Ration Issue and Sales Prices for Foodgrains, 1965-83 ......... 641.10 Food Intake by Nutrients, 1975-76 ............................. 651.11 Nutrient Intake Expressed as Percent of Requirements

for Different Age and Sex Groups, 1975-76 ................... 661.12 The Cost of Normative Minimum Dietary Pattern as Recommended

by FAO, 1963/64-1980/81 . ................... ................... 671.13 Daily Caloric Deficits Per Capita, 1976-77 .................... 681.14 Caloric Deficits of Socio-Economic Classes, 1976-77 ........... 691.15 Average Daily Real Wage Rates of Unskilled Agricultural

Labor by District, 1969/70-1981/82 .......................... 70

Annex 2

2.01 Daily Nutrient Intake Per Capita 722.02 Comparison of Nutrients from Daily Cereal Consumption

with Daily Requirements .................... *.*..*0.. -.** 732.03 Intake of Non-Cereal Foods Per Capita Per Day ................. 742.04 Comparison of PCM Prevalence by Weight-for-Height of

Children 0-4 Years 5......752.05 Second and Third Degree PCM by Age and Income Group ........... 762.06 Nutritional Status of Children 0-59 Months by Income

Levels of Households 772.07 Mid-Upper Arm Circumference of Children 12-59 Months by

Division and District ...... .......... ..... , 78

Page

2.08 Stunting by Age and Income Group, 1981/82 ....................... 792.09 Comparison of PCM Prevalence (Weight-for-Reight)

5-14 Years ........................ e****....... 802.10 Nutritional Status of Children 5-12 Years by Income

Levels of Households ........ ...... ... 009 ..099604 802.11 Weight and Height of Pregnant Women, 1983 ...... o...... 812.12 Mothers' Weights After Delivery ................................. 822.13 Birth Weight of New-Born Babies ................................. 822.14 Prevalence of Night Blindness, Conjunctival Xerosis,

and Bitot Spots by District and Division ........ 0. ............. 842.15 Prevalence of Goiter, Rural Districts, 1981-82 .................. 862.16 Distribution of Children, 0-4 Years, by Level

of Hemoglobin ................................................ 872.17 Growth Patterns of Infants, 0-11 Months ....... 6.................. 892.18 Duration of Breastfeeding ... oo ... .. ............ ..o ......... - ..... 902.19 Distribution of Acutely and Chronically Malnourished

Children by Age Group ............ ...... * * * ......... 912.20 Number of Acutely and Chronically Malnourished Children

by Age Group ..................... ........... *........ 922.21 Malnutrition in Bangladesh .0... ........ ......... .. .... .92

2.22 Criteria of Socio-Economic Groups ............................... 932.23 Seasonal Variation in Nutritional Status ........................ 952.24 Daily Caloric Intake by Region and Season ....................... 962.25 Causes of Death, Children 0-11 Months, 1979 ... ......... 4............ 972.26 Causes of Death, Children 1-4 Years, 1979 ....................... 98

2.27 Cause-Specific Death Rates per 100,000 Children, 1-4 Years ...... 982.28 Prevalence of Intestinal Parasites in Child Patients ............ 100

ABBREVIATIONS

BBS Bangladesh Bureau of StatisticsBRAC Bangladesh Rural Advancement CommitteeCARE Co-Operative for American Relief EverywhereFAO Food and Agriculture OrganizationFFWP Food-for-Work ProgramFPMS Food Planning and Monitoring SectionFREPD Foundation for Research in Educational Planning and DevelopmentFPC Food Policy CommitteeHES Household Expenditure Survey, 1976-77HYV High Yield VarietyICDDR,B International Center for Diarrheal Disease Research, BangladeshINFS Institute of Nutrition and Food Science, Dhaka UniversityIPHN Institute of Public Health NutritionMCH Maternal and Child HealthMOA Ministry of AgricultureMOE Ministry of EducationMOF Ministry of FoodMOHPC Ministry of Health and Population ControlmOSw Ministry of Social WelfareMR Modified RationingMTFPP Medium Term Food Production PlanNBPP National Blindness Prevention ProgramNGO Non-Governmental OrganizationNNC National Nutrition CouncilNORP National Oral Rehydration ProgramNSRB Nutrition Survey of Rural BangladeshOMS Open Market SalesORT Oral Rehydration TherapyPC Planning CommissionPCM Protein-Calorie MalnutritionPFDS Public Foodgrain Distribution SystemSCF Save the Children FederationSMH Social Marketing ProjectSR Statutory RationingTk TakaUNICEF United Nations' Children's FundUSA United States of AmericaVAC Vitamin A CapsulesVGFP Vulnerable Group Feeding ProjectWFP World Food ProgrammeWHO World Health Organization

This report is based on the findings of a food and nutrition sector missionwhich visited Bangladesh from April 20 to May 5, 1983. It consisted ofMr. Emmerich M. Schebeck (mission leader), Mr. Michael H. Mills (healtheconomist), Mr. R. Balasubramanian (consultant, food specialist), Mr. N.Koffsky (consultant, agricultural economist), and Mr. E. Thomson (con-sultant, nutritionist). The report also benefitted from contibutions fromMr. D. Pyle (consultant, nutrition planner) and Ms. S. Shochet (researchassistant). The findings were reviewed with the Government of Bangladeshduring a visit from April 26 to May 4, 1984.

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BANGLADESH

FOOD AND NUTRITION SECTOR REVIEW

Summary and Conclusions

1. Malnutrition is a widespread, persistent and apparently increas-ing problem in Bangladesh. Less than 5% of the population consume anadequate quantity and quality of food. Malnutrition most severely affectschildren under five years of age, and also pregnant and lactating women.Daily per capita caloric consumption has deteriorated significantly in thelast two decades-from an estimated 2,301 in 1962-66 to an estimated 1,943in 1981-82. These figures may be compared with an estimated minimum dailyrequirement of 2,020 calories per capita per day-showing that average con-sumption is 4Z below requirements, even ignoring unequal distributions offood between and within families.

2. Consumption of protein also fell from 1975-76 to 1981-82, from aper capita average of, 58.5g to 48g. This is attributed primarily to adecline in the consumption of pulses. By 1981-82, an estimated 77% ofhouseholds were deficient in protein consumption. Furthermore, due to thecaloric deficiencies, part of the protein consumed is converted for energypurposes, thus exacerbating the protein deficiencies. For dietary fat,average daily consumption was also severely deficient at about 9.8g percapita, representing only 25% of the recommended level.

3. Deficiencies in essential micronutrients also characterize thetypical Bangladesh diet. The high proportion of cereals in the diet (withfood grains comprising 90% of the caloric intake of the undernourished),the low amount of protein, and the absence of fruits and vegetables, allexacerbate the chroaic situation of caloric insufficiency. Indeed, thelatest survey results show that an increasing proportion of households con-sume significantly less than the minimum requirements of all the majormicronutrients, except for thiamine and iron. Even with the latter, how-ever, nutritional anemia is widespread throughout the population. Nutri-tional blindness due to vitamin A deficiency affects 30,000 children ayear; iodine deficiency results in a high prevalence of goiter particularlyin the northern section of the country; and lathyrism, a spastic andcrippling paralysis of the lower limbs which is caused by excessive con-sumption of khesari dhal, occurs principally in the north and west regionsof Bangladesh.

4. The major determinants of food consumption in Bangladesh arehousehold income and wealth, which depend primarily on land ownership,employment and the price of rice. Malnutrition is, therefore, essentiallya poverty and rural employment generation problem. The situation for thelandless and those in the informal labor market is particularly difficult--for example, reflecting the over-supply of labor, average daily real wage

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rates of agricultural labor declined 8X from 1976-77 to 1981-82. Improvingrural employment opportunities and increasing real incomes are of over-riding importance in significantly improving the nutritional status of thepoor.

5. The high incidence of diarrheal disease and intestinal parasitesfurther compromises nutritional status, particularly among children underfive, by limiting both the availability and absorption of food for meta-bolic use. Measles is also a major factor in precipitating severe orlife-threatening malnutrition.

6. Deleterious food beliefs and practices play a significant role inperpetuating malnutrition. Prolonged breastfeeding without supplementation,inadequate weaning foods, and avoidance of specific foods during illness,pregnancy and lactation tend to aggravate an existing state of ill health,which could have been rectified with proper care. Rapid population growthexacerbates the severity and magnitude of the problem.

7. Responsibility for the various dimensions of the malnutritionproblem falls under the aegis of a number of different government minis-tries and departments. Institutional problems range from the absence of anational nutritional strategy to the duplication and lack of coordinationof headquarters functions. There is a critical need for the development ofa national nutrition policy, based on an analysis of all the available foodand nutrition-related information. A start was made in early 1983 by theTechnical Committee of the National Nutrition Council with its workingdraft Nutrition Policy and Programme which was subsequently approved by theCouncil in 1984. However, the document still needs to be broadened toemphasize the link between food policies and improving nutrition, partic-ularly of the poor; the responsibilities for implementing and coordinatingpolicies and programs of various ministries; the role of non-governmentalorganizations and considering the scarcity of resources, the priorities andtiming of programs. Also, particular attention needs to be given to waysin which more rural employment could be generated in order to reduce thepoverty dimension of the malnutrition problem. Serious considerationshould also be given to the inclusion of a food and nutrition chapter, amatter presently under review, in the next national development plan; and anutrition data management plan should be developed to provide early warningof significant seasonal changes in national and regional nutritionalstatus. As part of the proposed national household survey, a module onnutrition should also be considered.

8. Some new approaches are now underway to improve both thecoordination of nutrition activities and also the clarification of theresponsibilities of the various institutions involved .n nutrition. Ofparticular importance is the recent establishment by the Minister of Foodof a ministerial-level Food Policy Committee. However, consideration needsto be given to expanding this Committee, particularly to include the Minis-ter of Industry and the Minister of Health and Population Control. Therole of the National Nutrition Council, which has been more or less

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dormant since its establishment in 1975, should also be re-defined to makeit primarily an advisory and advocacy (rather than a policy-making) body.It would then be responsible for the development and monitoring (but notexecution) of nutrition intervention programs. To do this, however, itwould need to be strengthened and expanded to include more private sectorrepresentation, especially from non-governmental organizations. In partic-ular this might help to improve the coordination of non-governmental nutri-tion activities.

9. The newly established Food Policy Committee needs a technicalunit to support its strategy and policy work. A number of different insti-tutional arrangements could be set up for this purpose, but particularconsideration should be given to the possible establishment of an interimfood and nutrition task force in the Ministry of Food. One of itsfunctions would be to coordinate the drafting of the proposed chapter onnutrition for the next national development plan. In addition, the FoodPlanning and Monitoring Section which is already located in the Ministry ofFood, should be fully staffed by filling existing vacancies especially inthe Economics Section. Previous recommendations made by the World Bank andthe FAO to strengthen the Department of Food should also be reconsidered.

10. At present there is an unfortunate overlap of the functions ofthe Institute of Nutrition and Food Science (at the University of Dhaka)and the Institute of Public Health and Nutrition (which is run by theMinistry of Health and Population Control). It is suggested that theserespective roles be clarified, with the former continuing to be responsiblefor university level teaching in nutrition related areas and associatedresearch, and with the latter focussing on the applied training of healthworkers in nutrition subjects.

II. Considerable attention has been paid in recent years to foodgrainproduction policies and programs, and particularly the medium-term food-grain production plan. Some significant progress has been made in recentyears in revising food procurement systems, and in raising incentive pricesfor producers. Agricultural research has also been made more appropriatein some ways, and some possibilities for crop diversification have begun tobe explored. It is estimated that foodgrain production could grow at about4% annually over the next few years; and that by the end of the 1980'sBangladesh could achieve the Government objective of providing an allowanceof 15.5oz of foodgrainsfperson/day, assuming population growth at 2 1/2%p.a. However, such a situation would not be adequate for two reasons:first, 15.5oz of foodgrains per day would only provide 80% of minimum dailycaloric requirements, the other 20% of which would have to come fromcomplementary foods, such as pulses and edible oils; and second, due topoverty and the lack of income-earning opportunities, many people wouldstill not have the effective demand to be able to acquire the foods whichare available.

12. Efforts should be focussed on increasing the domestic productionof alternative low-cost high-calorie crops and protein supplements thatwould be produced and/or consumed by the poor. Foodgrains oriented to the

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poor include maize, sorghum and pearl and finger millets. Of these, maizeis believed to offer the best production potential, but requires action todevelop consumer acceptance. This could be initiated by including somemaize and millets in the food aid supplied from abroad, and also by intro-ducing it into the public foodgrain distribution system (especially thefood-for-work program). In addition to these foodgrains, production ofsummer pulses as well as the development of inland fisheries should beencouraged in order to improve the availability of protein for consumption.

13. Home gardens are promoted by non-governmental organizations toincrease food production. Most rural families, even the "landless," dohave some land on the homestead available for a home garden. Yet, eventhough malnutrition is prevalent, home gardens are not generally in use.This is partly because women, who would be responsible for them, are un-familiar with vegetable and fruit growing and their nutritional importance.Cultural constraints may also be important. However, some pilot home gar-den projects have been encouragingly successful, and it is recommended thatthe Government considers carrying out a review of non-governmental projectsin order to identify feasible approaches for a national program. Homegarden production could be further promoted through a national educationalprogram along with the provision of necessary inputs (such as qualityseeds). In particular, home garden production schemes could be promotedthrough women's activities in the existing population program.

14. The ration system was originally conceived to provide cheap food-grain to the poorer classes. Experience has shown, however, that it pro-vides more subsidized grain per person to higher income groups than to thepoor. The Government is committed ultimately to give up the ration systemand depend on open market sales to assure the availability of adequate sup-plies of foodgrain at relatively stable prices. Indeed, in recent yearsthe Government has taken some steps in this direction: the reduction ofthe statutory ration quota; raising ration prices closer to market pricesto reduce the subsidy (though this seems to have been discontinued in1983-84); and increasing the use of open market sales. However, in1983-84, progress toward this objective has come to a halt. Market priceshave risen substantially above procurement and ration prices. Open marketsales operations have been negligible because stocks were deemed inadequateto effectively pursue price stability through open market sales. In addi-tion, there was uncertainty about the final foodgrain crop output. Theration system has therefore continued to dominate the public foodgrain dis-tribution system. To further the objective of open market sales, govern-ment stocks of foodgrains should be raised to about one million tons fromthe existing 600,000 tons at hand, the rice portion of the stockpile shouldbe eliminated, and the rice so designated should be made available for usein open merket sales. Further, management of the price relationships amongprocurement prices, ration prices and market prices were less effectivethan in 1982-83 in diluting the influence of the ration system and reducingthe subsidies involved. Despite the existence of some serious constraints,it is felt that more could be done to direct and target food distribution

towards the poor. For example, if programs for priority groups (e.g., de-fense, police, and civil servants) cannot be eliminated, the Governmentshould make every effort to assure that the maximum amount of foodgrainsdoes reach the poor. One way in which that could possibly be done would bethrough the establishment of "fair price" shops which distribute only lowerquality/cost grains (e.g., maize, sorghum, millets, lower quality rice,wheat and pulses). In this way market prices would be more stable and con-siderably more calories could be provided even for the same amount of moneynow spent. In particular, these foodgrains could be attractive to theindustrial labor force, which is particularly vulnerable to changes in themarket price and availability of food. The supplies of these grains couldeither come from a change in the existing import mix (as mentioned above),or from an increase in the import quantity, or from local production. Aspart of the testing of such a scheme, it would be necessary to mountcommunications efforts and a promotion campaign in order to gain acceptanceby consumers of the new foodgrains.

15. Employment opportunities are quite inadequate to accommodate theincreasing labor force, and the numbers of poor are likely to increase.The need for food aid will, therefore, also increase substantially in themedium-term. To provide the under-nourished population in 1987-88 with thegovernment standard of 15.5oz/person/day of foodgrain, an additional 1million tons more of food aid would be required. However, given theexisting administrative constraints, such an enlargement of distribution tothe targetted groups through the proposed programs, which include thef air price" shop food-for-work and vulnerable group feeding programs, doesnot appear to be realistic.

16. The food-for-work program is aimed at providing employment andpayment in the form of foodgrain to landless laborers in rural areas in thenon-agricultural season. This program provides more grain for the ruralpoor than does the ration system; and without it a large number of landlessand their families would be in great nutritional difficulty, especially inthe lean agricultural season when work is scarce. Because prospects forincreased employment elsewhere are insufficient, expansion of this programis very much needed. Some steps have been taken to alleviate certain limi-tations in the program. For example, although food is the program's onlyresource, part of the food aid is now being converted into cash payments towomen workers, and consideration is being given to extending partial cashpayments to others. This would obviate the need for workers to sell partof their wheat payment at low prices in order to buy other essentialitems. Also a significant part of food aid is converted into payment formaterials and equipment to improve infrastructure such as culverts,bridges, etc; and consideration is being given to extending the period forfood-for-work operations beyond the conventional 40 days. However, thereare still difficulties: there is inadequate provision for the subsequentmaintenance of projects; there is a shortage of technical staff andmanagerial manpower for the implementation of projects; and misappropri-ation of wheat is common, although some steps are now being taken to

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improve the situation. The food-for-work program which uses wheat donatedby the World Food Programme is now being evaluated, and the whole programshould be thoroughly re-examined in light of the study's results. The useof lower cost foodgrains (thereby increasing rations to those most inneed), upgrading of projects through more employment and more technicalsupport, and year-round employment for the poorest groups, should all beencouraged. Further consideration should also be given to ways in whichthe program could be better targetted, once data from the nationalsurveillance system are available.

17. The vulnerable group feeding program aims to provide food to cer-tain high-risk groups. In the report of an interim evaluation carried outin 1980, it was concluded that although the program contributed to increas-ing short term food consumption of many needy women and children, therewas no measurable improvement in the nutritional status of the benefici-aries. The program was also believed to have encouraged the take-up ofservices in the field of health, nutrition education and family plan-ning. It did not conclude whether this was due to problems with food dis-tribution, insufficiency of food rations, or compounding factors related tomorbidity etc. There are many issues yet to be resolved about the vulner-able group feeding program, such as improved targetting of beneficiariesand greater community involvement, and it is hoped that the evaluation car-ried out in 1983 will shed some light on them.

18. Poor health status and malnutrition are inexorably linked, andthere are several programs in the field of health which could have a signi-ficant impact on nutritional status. Approximately 250,000 children dieeach year in Bangladesh from the malnutrition and dehydration linked todiarrheal infections. Fortunately the Government has recently developed anoverall and agreed strategy for an oral rehydration program to deal withthis problem but there is still an urgent need for specific projects to bedesigned and implemented as soon as possible. The Government should alsosubstantially increase its production of packets of oral rehydration salts,and encourage other sources of supply too. The social marketing projectshould be allowed to supply and distribute such packets, though only withsafeguards to ensure that other supplies and also oral rehydration therapyprograms are not undermined unintentionally by any advertising campaigns.

19. The National Blindness Prevention Program distributes highpotency vitamin A capsules to about 45X rural pre-school aged children.Its mandate is to prevent nutritional blindness due to vitamin A deficiencywhich affects an estimated 30,000 pre-school age children each year. Thisis one of the better programs in health/nutrition in Bangladesh, and wereit not for this effort, many more children would go blind each year.However, while available data on the prevalence of xerophthalmia areconflicting, there is evidence that it has increased in rural areas by twoto three times over the last several years. Several concerns need to beaddressed regarding this program. First, the program does not addressother causes of blindness such as glaucoma, accidents or cataracts.Second, improved beneficiary targetting might facilitate the intensity

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needed to follow up with nutritional education, and with an evaluation ofthe effectiveness and efficacy of the capsules. Finally, and perhaps mostimportantly, capsule distribution should be linked to other maternal andchild health services.

20. Goiter is a nutritional deficiency which can be controlled effec-tively and relatively cheaply by iodizing salt. A salt fortification trialundertaken in Bangladesh indicated considerable improvement in reducing theincidence of goiter, with no problem of consumer acceptance of thefortified salt by the people. There has also been a preliminaryfeasibility study of the market structure for salt in the country, and this.has shown that the iodization of salt would provide a means of reaching 90%of the estimated 9 million people affected by goiter in Bangladesh.The cost-effectiveness of salt iodization in Bangladesh can hardly bequestioned--but rather the relevant issues concern the Government'sinterest in the problem, its commitment to do something about it, and howthe capital and operating costs could be financed. It is, therefore,recommended that the Government should legislate to eusure the iodizationof salt, and consider what monitoring activities would be needed to ensurecomplia-ace with the law. In addition, consideration should be given bothto the possibility of using an existing IDA credit for the purchase of thenecessary equipment, and to the possibility of UNICEF or another agencysupporting the operating costs for a limited period (probably on adeclining basis).

21. Although lathyrism affects only a very small percentage of thetotal population of the country, it is still a very serious probleiu as itcauses paralysis in humans. Until recently, no cure for this disease wasknown-but the Institute of Nutrition and Food Science has achieved a pos-sible breakthrough in its treatment by using vitamin C. Further researchis needed into this, as well as into ways of preventing the disease.

22. Nutrition education should be an integral part of each nutrition-related activity, from home-gardening to the distribution of vitamin Acapsules. Although mass media can assist in popularizing the specific mes-sages, attention should be directed towards training community-level work-ers, whether in health, agriculture or population, in basic communicationskills and in fostering behavioral change.

23. Given the multiple etiology of malnutrition in Bangladesh, atten-tion should be directed towards an integrated approach to improve nutri-tional status. Each activity or service provided should be related to thecause of the health/nutrition problem, its signs and symptoms, and itstreatment, in terms of both cure and prevention. Nutrition services shouldbe tied to basic maternal and child health services such as immunization,oral rehydration therapy, growth monitoring and family planning. Pilotprograms which encourage community involvement should be initiated topromote the most effective mix of services. Finally program planning andimplementation would benefit from coordination between the Government andnon-governmental organizations in light of the latter's many positive andunique experiences, as well as their credibility and acceptance at thecommunity level.

I. THE MALNUTRITION PROBLEM

Nature and Extent of Malnutrition

1.01 Hunger and malnutrition affect most of the people of Bangladesh.Less than 5Z of the population consume an adequate quantity and quality offood. 1/ The remainder suffer multiple nutritional deficiencies which in-duce and exacerbate disease, and increase the high risk of an early death.The severity of malnutrition is poignantly shown by the inordinate numbersof physically and -mentally stunted children characteristically seenthroughout the country.

1.02 Malnutrition most severely affects children under five years ofage, and pregnant and lactating women. Poor nutritional status is a majorfactor explaining why approximately 50% of all mortality in Bangladesh isin the preschool cohort.

1.03 Malnutritioa begins during fetal development. It is a conse-quence of the inadequate availability of nutrient stores of the pregnantwoman, who is, herself, malnourished. The additional nutritional demandsrequired during pregnancy and lactation aggravate the chronic nutritionaldeficit experienced by most Bangladeshi women. Even among high-incomeurban women, a third are below standard in height and almost half are sub-standard in weight. All rural mothers are classified as malnourished interms of weight-for-height. As a result, miscarriages and stillbirths arecommon and a high percentage of babies are born with low birth weights.The mean weight of babies born to rural women in Bangladesh, of both highand low income, is between 2.3 and 2.4 kg. A weight of 2.5 kg. at birth isthe accepted cut-off point, below which intensive care is required. Thus ahigh percentage of children are already malnourished from birth.

1.04 For many children, the situation never improves. A recent nutri-tion survey of rural Bangladeshi children, aged 0-59 months, 2, identifiedover 60% as having second or third degree malnutrition, based on the Gomez

1/ This assumes a standard of 1,620 calories from foodgrains and 400calories from other foods. Using the socio-economic classificationcontained in Annex 2 Table 2.22, it may be seen from Annex 1 Table1.13 that five socio-economic groups do not have a caloric deficitfrom foodgrains. However, all of these groups do have a caloric defi-cit from other foods. Only in the case of the urban formal group,which comprises about 4% of the total population, does the caloricsurplus from foodgrains compensate for the caloric deficit from non-foodgrains.

2/ Nutrition Survey of Rural Bangladesh, 1981-82. Institute of Nutritionand Food Science, Dhaka University.

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classification of low weight-for-age. This rate, which included bothchronic and acute cases of malnutrition, 3/ was found among all socio-economic groups, though it varied with income: 43% in the better-off groupcompared to 68% in the middle income group and 59% (possibly due to highermortality rates) in the lowest Income group. The greatest prevalence ofacute malnutrition was found among rural children, 12-23 months, at a rateof 61%; and the greatest prevalence of chronic malnutrition was also foundamong children, 48-59 months of age, at a rate of 75%. These findings werecorroborated by a survey based on measures of mid-upper arm circumference,4/ which showed that 1OZ of children, 12 to 59 months, were severely mal-nourished and another 40% were moderately malnourished. Prevalence variedconsiderably by district, as well as within districts, from 28% in Sylhetto 69% in Barisal and Patuakhali. Little data exist on the incidence ofkwashiorkor and marasmus, the most severe forms of protein-energy malnutri-tion. However, it is generally thought that marasmus and marasmic-kwashiorkor are more common in Bangladesh than kwashiorkor alone, due tothe degree of dietary insufficiency in both calories and protein.

1.05 Malnutrition persists throughout the childhood years. Data fromthe last several nutrition surveys 5/ reveal that acute malnutrition(based on weight-for-height) among children 5-14 years of age ranges from12-191. While this is less than half of that found among younger children,the prevalence of stunting persists among three-quarters of these children,due to the cumulative effects of long-term nutritional deprivation. Aswith the younger age group, females had greater rates of acute, chronic,and acute on chronic malnutrition.

1.06 The nutritional status of the poor may have deteriorated sincethe nutrition survey of 1975-76. 6/ In both 0-4 and 5-14 year age groups,the numbers of moderate to severely malnourished children have increased,and the numbers of mildly malnourished children have decreased. This isconsistent with the country's overall economic situation, in which thepoorest groups have been faced with an increasingly hostile economic envi-ronmnt, while the higher income groups have increased their share of thenational wealth (para. 1.21).

3/ Technical aspects of nutritional status are discussed in Annex 2.

4/ National Nutritional Blindness Study: Initial Data Report, May 1983.

5I Nutrition Survey of Rural Bangladesh, 1975-76; Nutrition Survey ofRural Bangladesh, 1981-82; UNICEF/FREPD Study, 1981.

6/ Such a deterioration is suggested by the results of the UNICEF/FREPDStudy, 1981, although the results of the Nutrition Survey of RuralBangladesh, 1981-82 do not appear to support this.

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Food Consumption and Malnutrition

1.07 Caloric Intake. Per capita caloric consumption has deterioratedsignificantly in the last two decades. In 1962-66, average daily per cap-ita caloric consumption was reported as 2,301; 7/ in 1975-76, it had fal-len to 2,094 calories per day; 8, and by 1981-82 it was a precarious lowof 1,943 calories. 9/ Using these food consumption data, and based on anestimated minimum daily requirement of 2,020 calories per capita, thefigure used by the Bangladesh Planning Commission, 10/ less than 40% ofthe population are adequately nourished in terms simply of quantity of foodconsumed. On the other hand, data from the 1976-77 HousehoLd ExpenditureSurvey indicate that only about 25% of the population purchase an adequatequantity of foodgrain. 1 1 Indeed, the average consumption of the lowerincome population groups ranges from 13% to 27% below estimated require-ments (Table 1). Both income levels and land ownership are stronglyassociated with the extent of low caloric consumption. The urban pooraccount for an estimated 10% of the malnourished, which approximates theproportion of urban to total population. The poorest, comprising 32% ofthe population, are the landless farm workers and the rural informal non-farmers. Their average per capita caloric intake of 1,500 calories perday, is considered to be the critical minimum level needed just to maintainbody weight without accounting for additional caloric expenditure, such asthat entailed in manual labor. As these figures represent average percapita caloric consumption of the various socio-economic classes, a

7_ Nutrition Survey of East Pakistan, 1962-66. US Dept. of Health,Education and Welfare.

8, Nutrition Survey of Rural Bangladesh, 1975-76. Institute of Nutritionand Food Science, University of Dhaka.

9/ Nutrition Survey of Rural Bangladesh, 1981-82; Institute for Nutritionand Food Science, Dhaka University.

10/ The 2,020 calorie standard is consistent with estimates based on theFAO/WHO energy requirements per kg of body weight, and the estimatedbody weights and age/sex breakdown of the Bangladeshi population. Thisstandard is considered to provide sufficient calories and protein formost of the population. The exceptions are infants and young childrenand pregnant and nursing mothers who require nutrient supplements. Itis also generally accepted that until the calorie requirements aresatisfied, the protein ingested is converted to energy (calories)rather than is able to perform its body building function.

11/ See Annex 2, Table 2.22 for criteria defining the 10 socio-economicgroups.

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substantial portion of these populations undoubtedly consume less than thecritical level. 12/

Table 1: FOODGRAINS AND CALORIE INTAKE BY SOCIO-ECONOMIC CLASS 1976-77

Average Annual Percent of CaloriesPercent of Income Food Grain From

Class Population per Month Costion Calories Foodgrains RiceTk Kg/Cap dayicap

Landless farm workers 21 897 142 1,519 92 84Small farmers 12 894 153 1,638 92 85Medium farmers (mainly tenants) 12 1,119 162 1,764 91 86

Medium farmers (mainly owners) 13 1,285 178 1,956 90 86Large farmers 10 1,659 194 2,150 89 86Very large farmers 4 2,789 184 2,087 87 84Rural informal non-farmers 11 850 138 1,482 91 84

Rural formal non-farmers 7 1,840 189 2,118 88 81Trban informal 6 1,039 157 1,708 90 74Urban formal 4 2,612 175 2,080 82 65

Average all classes 100 1,281 163 1,782 90 83

Source: 1976-77 Bangladesh Household Expenditure Survey, Bangladesh Bureau of Statistics andCenter for World Food Studies, Free University, Amsterdam.

Note: See Annex 2, Table 2.22 for description of socio-economic classes.

1.08 Foodgraims account for about 90% of the caloric intake of theundernourished. Rice alone accounts for 85% of the calories among the ru-ral poor, and for 75% among the urban poor. The higher income groups con-su more foodgrains per capita than the poor, and also upgrade their dietswith more meat, poultry and eggs, dairy products, vegetables, fruit andfish. The highest per capita income group - the urban formal category -consumes more wheat per person than any other group. Of the foodgrain con-sumed by the poor, a relatively high proportion is also wheat because it ischeaper than rice (paras. 3.06-3.09) and is also provided in various reliefoperations (paras. 3.32-3.33).

2/ The critical limit of calories is based on the requirement to sustain1.2 times the basic metabolic rate. The Fourth World Food Survey,1977 FAO Rome, Appendix H.

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1.09 Although foodgrains provide least cost calories, they do not con-tain an. the nutrients essential for an adequate diet (see Annex 1, Table1.12). Ideally, foodgrains should not make up more than 80% of the caloricintake. 13, Based on the 2,020 calorie standard, foodgrains should pro-vide about 1,620 calories, with 400 additional calories obtained from othernutritional sources. However, the landless laborers and rural informalnon-farmers obtain from rice about 1,400 and 1,350 foodgrana calories/perperson/per day, respectively, with only about 130 calories coming fromother foods. Although the small farmer and urban informal groups are some-what better fed, both the absolute amount of calories and the proportioncoming from other nutrient sources fall below recommended intake. Thus,while 25% of the population consume, on average, an adequate number of cal-ories, oaly the urban formal group, comprising 4% of the population, isable to consume a diet balanced in protein, calories, vitamins andminerals.

1.10 The overall foodgrain situation has improved since the 1976-77survey. This was due to a 22% increase in domestic production by 1981-82,and to an increase of 60% in food imports, accounting for 9% of total foodgrain availability. In 1976-77, foodgrain availability averaged 14.4ounces per person per day. In 1981-82, it averaged 15.9 ounces exceedingthe Government's objective of providing 15.5 ounces per day. 141 Despiteimprovements in aggregate food availability, however, data from the 1981-82Nutrition Survey suggest a deterioration in the average intake of caloriesand protein since 1975/76 among the poorest segments of the population.

1.11 Protein Intake. Available data on daily per capita protein con-sumption suggest severe deficiencies in both quality and quantity, partic-ularly among the poorest groups. From 1975-76 to 1981-82, average percapita consumption of protein fell-according to the officiaL figures-from58.5 g to 48 g. This is attributed primarily to a decline in theconsumption of pulses from 24 g per capita in 1975-76 to 8 g per capita in1981-82. While the reliability of these figures may be questioned, thereis widespread agreement about the trends. In 1981-82, 77% of all house-holds were deficient in protein consumption. Furthermore, the utilizationby the body of the available protein depends on caloric adequacy, proteinquality and the bio-availability of vitamins and minerals. Caloric defi-ciency will largely result in the conversion of protein into energy, untilcaloric needs are fulfilled. Low quality protein, such as that found Insome cereals, must be complemented with higher quality protein derived from

131 Energg and Protein Requirements, Joint FAO/WHO Ad Hoc Expert Committee,Rome 1971. Nutrition Value of Indian Foods, National Institute ofNutrition, Indian Council of Medical Research, Hyderabad, Reprinted1977.

14/ Availability of 15.5 ounces/day would provide about 1,600 calories/dayper person, if available supplies were equally distributed (which isnot the case). In 1981/82, foodgrain availability averaged 15.9ounces. The preliminary estimate for 1982/83 is about the same level.

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legumes or animal sources in order to ensure efficient metabolic consump-tion. Less than 50% of wheat protein, for example, is metabolized whenconsumed alone. As might be expected, consumption of higher quality pro-tein is related to income levels, with the urban high-income group consum-ing adequate quantities and the rural poor consuming less than 25% of esti-mated needs. Fish from the sea as well as from rivers and ponds is theimportant source of animal protein, but it makes only a small contributionto total dietary intake. Most dietary protein is derived from cereals andpulses.

1.12 Fat Intake. Average daily consumption of dietary fat (primarilyfrom vegetable oils, in 1981-82 was found to be severely deficient at 9.8 gper capita, representing only 25% of the FAO/WHO recommended level. Aver-age per capita consumption of fat has declined by 38% since 1966; and itsconsumption among the lower income groups is only 4.4 g per capita per day,just 10% of requirements. Fats are particularly important as they provide2.5 times the calories provided by foodgrains per gram, and as they areessential for the absorption of vitamins. Consumption of fats is stronglycorrelated with income levels.

1.13 Micronutrients. Deficiencies in essential micronutrients alsocharacterize the typical Bangladeshi diet. The high proportion of cereals,the low amount of protein, and the absence of fruits and vegetables, highin Vitamins A, B12 complex, and C, exacerbate the chronic situation of cal-oric insufficiency. The latest survey results show that an increasing pro-portion of households consume significantly less than the minimum require-ments of all the major micronutrients, except possibly for thiamine andiron. Despite the reported adequacy of iron intake, nutritional anemiastill afflicts an estimated 73% of children below 5 years of age; 74% ofboys and 75% of girls, aged 5-14 years; 60% of adult men; and 74% of non-pregnant, and non-lactating women. 15/ Factors such as malabsorption andlow bioavailability of iron contribute to anemia in the general population,while multiple, closely-spaced pregnancies and lengthy periods ofbreastfeeding are thought to compound the situation among women.

1.14 Average per capita intake of vitamin A is less than one-third ofthe recommended daily allowance and results, among other problems, in xero-phthalmia (an eye disease which may seriously impair vision and can resultin permanent blindness in early childhood). Current estimates of xero-phthalmia reveal a prevalence of 5% among rural children 6-59 months ofage, with an estimated annual incidence of active corneal lesions of 6 per1,000 pre-schoolers. 16/ The chance of surviving the blinding episode isprobably not better than 50%. All told, about 25,000-30,000 pre-schoolaged children are blinded each year due to vitamin A deficiency, of whomabout half survive.

1.15 Iodine deficiency results in a high prevalence of goiter in Bang-ladesh, particularly in the northern section of the country. Affected dis-tricts report rates of 30% among the general population and 80% among

15/ Nutrition Survey of Rural Bangladesh, 1975-76.

16/ Helen Keller International, personal communications, 1984.

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pregnant and lactating women. Although goiter itself is only of medicalconcern in extreme cases, it reflects the grave danger of cretinous babies,deaf-mutes or severely retarded children due to iodine deficiency inutero. Vitamin C consumption is also quite low, complicating the absorptionof iron as well as impairing general bodily functions. Lathyrism, a spas-tic and crippling paralysis of the lower limbs, is caused by the toxiceffect of excessive consumption of khesari dhal, a pulse eaten primarily bythe poor, especially when other foodgrains are scarce. This pulse occursprincipally in the north and west regions of Bangladesh, where scarcity ofrice has led to substitution of khesari-dhal for it. Riboflavin is alsoconsumed in insufficient quantities, (see Annex 1, Table 1.11) resulting inthe formation of sores at the corners of the mouth.

Health and Population Factors

1.16 Infection and malnutrition are inexorably linked, and in Bangla-desh it is difficult to discuss one without considering the other. Mostimportant when considering the susceptible under-five group is the highincidence of diarrheal disease and intestinal parasites, which limits boththe availability and absorption of food for metabolic use. Severe diar-rhea, plus the accompanying loss of appetite, frequent vomiting and fevercan result in nutrient loss of about 10% or even more of daily caloricintake. 17/ The dehydration associated with acute diarrhea can lead todeath. The danger increases dramatically when combined with severe malnu-trition. In Bangladesh, diarrheal disease is the leading cause of deathamong 1-4 year olds.

1.17 Intestinal parasites are also a common affliction. A study ofmDre than 600 children in a medical ward found that about half had para-sites, predominantly ascaris and hookworm. 18/ Heavy infestation ofascaris can lead to a food loss of 25% of ingested calories. 19/ Hookworminfestation can be a major cause of anemia resulting in a daly blood lossof 0.03 to 0.15 ml. 20_, though it is believed to be a significant problemonly in the north-west of the country. These high rates of infection aredue to inadequate sewage disposal, and adversely affects all levels ofBangladesh society.

1.18 In a marginally nourished population, measles may precipitatesevere or life-threatening malnutrition. Of all measles cases, 45% havebeen found to be suffering concurrently from malnutrition, with longer

17/ John Briscoe. ICDDR, B, Annual Report.

18/ Khan, Third Nutrition Seminar Series, Dhaka, 1979.

19/ L. Latham, M. Latham, S.S. Basta. The Nutritional and EconomicImplications of Ascaris Infection in Kenya. IBRD Staff Working Paper;1977.

20i Davidson and Passnore. Human Nutrition and Dietetics.

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recovery times as well as higher mortality rates. Child mortality attrib-uted to measles and respiratory infections is 3 to 7 times greater amongthe malnourished tian among the normal child population. 21/

1.19 Rapid population growth also adversely influences nutritionalstatus. Although Bangladesh has decreased its annual growth rate to 2.5%from a high of 3%, its population problem is still staggering. Factorssuch as parity, maternal age and birth interval have a significant impacton the nutritional status of children as well as mothers. Conversely, awell-nourished child in good health, with good chances of surviving, canmotivate a couple to accept family planning. The Government's efforts overthe past decade have led to widespread awareness about contraception. Fur-thermore, 60% of women who responded in the 1975 Fertility Survey said thatthey did not desire any more children, indicating that demand for contra-ception does exist. The proportion of eligible couples using family plan-ning has risen substantially in the last four yeares, but even now is esti-mated at only 20%.

1.20 The precarious situation can be summed up aq follows. About 4+million women now become pregnant in Bangladesh each year. At least half amillion of the pregnancies end in fetal wastage, through miscarriages andstillbirths. Of the 4 million live births, nearly 2 million Infants weighless than 2.5 kg. at birth. During the first year of life over half a mil-lion die. Of those who survive, 2.4 million are deprived of the essentialweaning foods to supplement mDthers' milk, at the most critical period oftheir development. They go on to be undernourished for the next two years,many of them severely. By the age of four years, three quarters will bephysically stunted and suffering from anemia. Around 20,000 will becomeblind; and of those living in endemic goiter areas, one third will sufferfrom goiter. Less than about 800,000 will become truly healthy, physicallyfit and fully productive citizens. All these figures refer to a cohort ofone year's pregnancies. If no improvements are forthcoming in the nutri-tion and related health and population situation, the statistics can onlygrow worse.

Main Causes of Malnutrition

1.21 The caloric defi.zit of most of the population is primarily due tothe inability of the poor to grow enough food or to purchase enough foodfor their families, according to the findings of the Household ExpenditureSurvey. The situation for the landless and those in the informal labormarket is particularly difficult. The rural labor force, predominantly inagriculture, has grown much faster than the labor requirements associated

21/ Sharhid Nigar. Complications of Measles in Rural Bangladesh.ICDDR, B., Report No. 3, Dhaka, June 1981.

with increasing crop production. 22/ Ref lecting the oversupply of labor,average daily real wage rates of unskilled agricultural labor declined 8%from 1976-77 to 1981-82, with reductions noted in two-thirds of the dis-tricts (Annex I, Table 1.15). A number of districts in each of the divi-sions show dramatic declines - in Rajshahi and Bogra, 24Z; Dinajpur, 22%;in Khulna and Patuakhali, 21%; Kushtia, 20%; in Faridpur, 19%, Mymensiugh,16%; in Chittagong and Sylhet, 21%; and in the Hill Tracts, 18X. On theother hand, in Dhaka District with the prlacipal city close by 3 the realwage rate for agricultural labor rose 21% in the 5-year period. _3/

'L.22 Small farmers with holdings of less than 1.5 acres are almost inthe same situation. Their plots are too small to provide food self-sufficiency and they also have to rely on outside work for half of thefamily income. This again emphasizes the crucial need to generate morerural employment. Although medium-sized farmers (1.5-5.0 acres) who areowners come close to meeting caloric requirements on the average, those whoare tenants consume 10% fewer calories per person because of high rentalspaid to landlords (usually 50% of the product on the land rented). Fur-ther, landlords rarely provide improved seeds and fertilizers to supportincreased output.

1.23 The economic disparity between the formal and the informal urbanpopulation is even more skewed than in the rural sector. The formal urbansector comprises 4% of the population. Average monthly income is greaterthan three times that of their urban counterparts, yet dietary adequacystill falls short of the 2,020 minimum caloric requirement. The informalurban sector comprises an estimated 5% of the total population; and averagemonthly income is low, approximating that of the small rural farmer.The 1981-82 Nutrition Survey revealed the severity of undernutrition amongthe industrial labor force. Average caloric intake was 1,688 calories,just 74% of minimum requirements. Greater than 90% of households had dietsdeficient in calories and in protein, magnified by significant deficienciesin vitamins A, C and riboflavin. Consumption of wheat and roots was signi-ficantly higher than the national average due primarily to the public dis-tribution of foodgraias, while that of pulses and milk was much lower.Anthropometric measures of the child population showed a greater prevalenceof stunting and wasting than found in the national sample. Without the in-cremental consumption from subsistence farming, this group is particularlyvulnerable to changes in the market price and availability of food.

22/ It is estimated that labor requirements increase about one-thirdof the percentage increase in foodgrain production. This does notmean a commensurate increase in employment since farm family membersare frequently underemployed. R. Ahmed. Agricultural Rice PoliciesUnder Complex Socio-economic and Natural Constraints: The Case ofBangladesh. IFPRI, October, 1981.

23/ Bangladesh: Selected Issues in Rural Employment. World Bank. March,1983.

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1.24 Improving employment opportunities and increasing real incomesare of overriding importance in significantly improving the nutritionalstatus of the poor. For the poorest one-quarter of the population, anincrease of 10% in real family income could bring about an increased intakeof about 100 calories per person per day. This would be especially impor-tant for those on the edge of starvation. Over the long run, it wouldrequire real income to rise approximately 50% to bring average intake tothe 2,020 calorie standard. By the same token, similar declines in foodprices could yield almost the same improvement in caloric intake.

1.25 The highest income group makes a relatively small response incaloric imtake either to income or price changes (Table 2). Furthermore,their participation in the subsidized ration schemes not only diverts foodsupplies from the rural poor, but also deprives the market of effective de-mand which could support agricultural production and increase agriculturalemployment and incomes. A significant proportion of increased expendituresgoes to nonfood items and preferred foods, although this does notnecessarily translate into an improvement in dietary balance. At thelowest levels, on the othier hand, any increases in expenditures are largelyon food to supply calories.

Table 2: CALORIE EXPENDITURE ELASTICITIES BY SOCIO-ECONOMIC GROUP

Landless 0.85Small Farmer 0.94Medium Farmer 0.83Large Farmer 0.40Informal Rural 0.94Formal Rural 0.53Informal Urban 0.74Formal Urban 0.59

Source: Center for World Food Studies, Amsterdam.

1.26 Fluctuations in food supplies severely affect the poor. Food-grain supplies declined in 4 of the past 10 years, bringing shortages most-ly felt by the poor since the higher income groups did not change theirconsumption much. Similarly, the seasonal patter: of foodgra-a harvestsaggravates insufficient food intake particularly in August-October prior tothe aman harvest, the main rice crop. During that period, food suppliesdwindle and prices normally rise substantially. The lack of purchasingpower among the rural poor in particular becomes more acute since there islittle agricultural work available, and the public foodgrain distributionsystem (PFDS) becomes an Important element in sustaining life for those whohave access to it. Even so, the Nutrition Survey of Rural Bangladesh,1975-76, indicated that for Dhaka and Rangpur Districts, per capita intake

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of calories was 14% and 19% lower, respectively, in the period prior to theaman harvest than following the harvest. In Chittagong, the seasonal pro-duction pattern is less pronounced, the seasonal reduction in caloricintake being about 6%. Seasonal variations in nutritional status reflectboth seasonal changes in food availability and the increased incidence ofdiarrheal and Infectious diseases which coincide with the monsoon rains.In fact, the period of poorest nutritional status begins with the height ofthe monsoon rains and continues until the time of the aman rice harvest24/.

1.27 The deficiency of quality protein in the diet has been aggravatedby the continued decline in the production of pulses by approximately 30%in the past decade. Both the acreage and yields of pulses have declined asa result of shifts to rice and wheat production, which are more profitablefor landowners. However, the development of short duration varieties ofsummer pulses now provides an opportunity to increase pulse productionsharply without competing with rice production.

1.28 Vulnerable Groups. Young children and pregnant and lactatingmothers are at greatest risk of falling into a malnourished state. Theetiology of malnutrition among these vulnerable groups is complex, involv-ing deleterious cultural practices, low income, the heavy physical workloadof women and a general lack of food. These factors are compounded by therelatively high metabolic requirements which accompany growth and develop-ment. A particularly vivid example of harmful food beliefs involves thediet of pregnant women. Fear of birthing an abnormally large baby resultsin an intentionally limited and insufficient dietary intake; eggs are noteaten for fear of destroying the fetus; meats of all kinds are avoided toprevent the child from inheriting 'an-iial-like" characteristics; and veget-ables are associated with edema, and thus are avoided. As a result of suchbeliefs, low birthweight babies, deficient in critical stores of vitamin Aand iron, tend to be the norm rather than the exception.

1.29 The vast majority of mothers regard milk as the most valuablefood for children, and believe that breastfeeding is essential. The cun-tribution of breastfeeding to maintaining the health of the infants iscritical. Furthermore, lactation results in post-partum amenorrhea, there-by acting as a natural contraceptive for an average of 30 months dura-tion. Unfortuaately, the practice of discarding the colostrum deprives thebaby of its natural immunities and renders it more liable to infection. Upto the age of four months breast milk provides all the nourishment most

24/ K. Brown, et al., "Seasonal Changes in Nutritional Status and thePrevalence of Malnutrition in a Longitudinal Study of Young Childrenin Bangladesh." American Journal of Clinical Nutrition 36. August1982, pgs. 303-313.

Nutrition Survey of Rural Bangladesh, 1981-82.

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infants require. However, food beliefs affect the quality of breast milk.For example, lactating mothers do not eat vegetables lest the baby suffersfrom stomach diseases, and they do not eat meat for fear that it may renderthe milk poisonous. Others avoid fruit and fish. Lacking these items inthe diet, the breast milk is likely to be low in its content of essentialvitamins.

1.30 Sometime between the age of four and six months, breast milk onits own is no longer sufficient to maintain normal growth; other foods arerequired in addition to breast milk. However, 75% of ilfants in the ruralareas receive no supplementary food in addition to breast milk until afterthe age of 10 months. A major reason is a legitimate fear of diarrhea.Unhygienic environmental conditions are closely related to poverty, and theintroduction of supplementary or weaning food carries a high risk ofinfecting the infant and causing diarrhea. During an episode of diarrhea,the traditional treatment is to withhold food and fluids including breastmilk. This practice aggravates malnutrition and may precipitate a moder-ately malnourished child to a very serious nutritional condition with lifethreatening dehydration. When supplementary food is given to the infant itis usually rice, wheat or barley mixed with water (which is also often con-taminated). Such a supplement has a low calorie content per uait ofvolume. The infant has a small stomach and such a supplement is too bulkyto provide adequate caloric intake. Among rural mothers and the urban poorweaning to a solid diet is normally deferred until the child is between 24and 27 months of age, a practice that is nutritionally disastrous. 25/

1.31 Compounding the difficulties of the vulnerable groups is the sex-biased distribution of the available food among family members. Pregnantand lactating women are severely deficient in nutrients at tse same timethat their condition requires more than the usual requirements. In themale-dominated Bangladeshi society, caloric intake is less for females thanfor males; for adult women 29% less (without allowing for needs of preg-nancy and lactat-on); for female children under 5, some 16% less; and forfemales 5-14, about 11% less. Female children have almost three times therate of malnutrition as males and a 45% higher mortality rate among theseverely malnourished. 26/

II. INSTITUTIONAL ASPECTS

2.01 Responsibility for the various dimensions of the malnutr'tionproblem falls under the aegis of a number of different governmentministries and departments. The Ministry of Agriculture 'MOA) isresponsible for research and extension activities to promote increased

25/ The Situation of Children in Bangladesh. UNICEF/FREPD, Dhaka, July1981.

26/ Chen, et al. 'Sex Bias in the Family Allocation of Food and HealthCare in Rural Bangladesh." Population and Development Review. Volume7, No. 1, 1981.

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production of food; the Ministry of Food (MOP) is responsible for assuringand managing food supplies and for the PFDS; the Ministry of Health andPopulation Control (MOHPC) is responsible for the technical aspects ofnutrition and health programs, and for implementation of health-relatedprograms in the field; the Ministry of Education (MOE) is responsible forthe introduction of basic concepts of nutrition In the schools, and for thefunding of activities at Dhaka University; the Ministry of Information isresponsible, via the Bangladesh Broadcasting System, for mass media cam-paigns on nutrition-related themes; and the Ministry of Social Welfare(HOSW) for providing the poor with a better quality of life which includesimproved nutrition. The Bangladesh Bureau of Statistics (BBS) and thePlanning Commission (PC) also have nutrition-related responsibilities, forcollection and analysis of statistics and planning activities respect-ively. The Food Planning and Monitoring Section (FPMS), which used to belocated in the PC, has also been transferred to the MOF, but its potentialeffectiveness is constrained by a number of unfilled vacancies. Institu-tional problems range from the absence of a national nutrition strategy foran improvement in nutrition and health to the duplication of activities andlack of coordi3ation at headquarters. As an example, nutrition comes underthe population control side of the MOHPC, whereas it is under health in thePC. The Technical Committee of the NNC has prepared a draft of a NutritionPolicy and Programme for Bangladesh. This may provide a point of departurefor formulating a broader food and nutrition policy, for considering theroles of the various institutions involved in implementing programs, andfor establishing an appropriate mechanism for coordinating activities.

2.02 Some new approaches are underway which may point the way toimproved coordination at the central level and implementation in thefield. The Minister of Food has established a Food Policy Committee (FPC)consisting of the Ministers of Agriculture, Local Government, and Financeand Planning, to coordinate the policies and activities of food productionand distribution. Moreover, the National Nutrition Council (NNC) which hasbeen more or less dormant since its establishment in 1975, is being re-formed to perform its functions of formulating a national nutrition strat-egy and of assisting in the development of corresponding programs. Unfor-tunately, however, important actors have been left out of each of thesebodies -- the Minister of Health and Population Control and the Minister ofIndustry from the FPC; and any representative from the MOF on the NNC.There is also unfortunate duplication of responsibilities between the FPCand the NNC.

2.03 The implementation of programs in the field is also made diffi-cult by five tiers of organization: division, district, sub-division,upazila and union. Lines of authority and responsibility are unclear, andno focal point exists for integrating nutricion-related programs. However,the Government's rural administration is being simplified to a three-tieredorganization -- district, upazila and union -- with decentralization ofauthority for implementation of all development programs given to theupazila officials. Departmental staff at the headquarters and districtlevels are to provide only technical and administrative guidance.

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2.04 In addition to the work of government departments, the Instituteof Public Health and Nutrition (IPHN) of the MOHPC provides technical sup-port for nutrition programs. For example, it prepares mass education ma-terial on nutrition for the community, develops field operations researchin nutrition for the health infrastructure, analyzes food, and provideslaboratory support to field services. One of the IPHN's most importantfunctions is training medical and paramedIcal personnel in nutrition. Ithas also conducted nutrition research and surveys, including one on theprevalence of goiter.

2.05 The Institute of Nutrition and Food Sciences (INFS) at Dhaka Uni-versity also conducts nutrition research and training. In addition, it hasdocumented the extent of nutritional deficiencies (protein-calorie malnu-trition, anemia, vitamin A and goiter) among the vulnerable groups. TheINFS's research has addressed several of the country's mDst serious nutri-tional issues: for example, the malabsorption of iron, the uutritionalbenefit from deworming, and the lodization of salt. The INFS also under-takes training activities, and has carried out a pilot project using highschool teachers and their students to improve village nutritional prac-tices. The Children's Nutrition Unit, Dhaka, is an excellent nutrition re-habilitation center. In addition to critical rehabilita:ive activities, itconducts research on a variety of autrition- related topics. Finally, men-tion should be made of the International Center for Diarrheal DiseaseResearch in Bangladesh (ICDDR, B), which conducts research on many nutri-tion related issues such as the interaction between nutrition and bealthstatus.

2.06 A large number of non-governmental organizations (NGOs) also en-gage in nutrition activities in Bangladesh. These agencies, as a group,have had remarkable success in reaching into villages and homes, and deliv-ering services to those most in need. In particular, NGOs have pioneeredinnovative approaches to improving nutritional awareness and nutritionalstatus. Some of these have developed into substantial activities admin-istered by both government agencies and NGOs at the local level. Partic-ular mention should be made of the community-based programs which have beendeveloped by the Bangladesh Rural Advancement Committee (BRAC), the Coop-erative for American Relief Everywhere (CARE), the Save the Children Feder-ation (SCF), and the United Nations' Children's Fund (UNICEF). For ex-ample, BRAC has undertaken integrated projects in ten districts, involviangprograms in agriculture, pisciculture, horticulture, poultry raising, nu-trition and health care, family planning and functional education. Theseprograms are initiated and controlled by cooperative groups of the targetpopulation; and in support of them, BRAC provides training, extension,credit and logistical assistance. BRAC has already undertaken a major oralrehydration therapy (ORT) program (see para. 3.33). CARE, on the otherhand, supports three different rural developmeat programs, while SCF hasdeveloped a community-based integrated rural development project In 17villages. UNICEF is supporting seven projects in Bangladesh aimed atproviding nutrition services to mothers and children: the ComprehensiveNutrition Project which aims to train trainers in applied nutritioneducation; weaning and supplementary feeding training project; support

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for the rural health and nutrition education and training project of BRAC;the development of village fish ponds; two projects for backyard poultry;and a village vegetable and fruit gardens project.

2.07 Other NGOs active in nutrition are Helen Keller International andthe Rangpur and Dinajpur Rehabilitation Service. The former provides con-siderable support to the National Blindness Prevention Program as well asto large-scale child feeding efforts on a national level. The latter pro-vides substantive nutrition outreach services through under-five clinics toa population of about 750,000 in three upazilas.

III. POLICIES AND PROGRAMS

3.01 Considerable attention has been paid in recent years to foodgrainproduction policies and programs, and particularly to the medium-term food-grain production plan (MTFPP). Some significant progress has been made inrevising food procurement systems, and in raising incentive prices for pro-ducers. Agricultural research has also been made More appropriate in someways, and possibilities for crop diversification have begun to be ex-plored. Some positive changes have been made in the operation of the PFDS,and even some home garden pilot projects have had some success. From thepoint of view of nutrition, however, the main problems have been the lackof an overall policy and strategy, and inadequate co-ordination of thesedifferent programs.

Food Production Policy

3.02 In 1982-83, about 15 million tons of foodgrains were consumed:85X from domestic production and the remaiader from imports, most of whichwere on a grant or concessional basis. Since the mid-1970s, foodgrain pro-duction has been rising close to 3.5% a year. This has been largely due toincreases in the boro rice crop and in wheat, reflecting the response ofhigh-yielding varieties (HYVs) to irrigation, fertilizers and pesticides.However, rice yields, particularly in the main aman crop and the aus crop,are only about half of those in other countries of the South Asia region.Practically all of the productive land in Bangladesh is being cultivated ata cropping intensity of about 155%; and with little cultivable land not inuse, it is necessary to increase further land use intensity and produc-tivity to raise food output. This was recognized in the MTFPP adopted in1981. The program involves heavy in:restment in irrigation, drainage andflood control; a sharp expansion in the use of HYV seeds, fertilizers andpesticides; and strengthening the supporting services and infrastructure.

3.03 Unfortunately, the MTFPP goal of 20 million tons of foodgrainsfrom domestic production by 1985 is not likely to be met because of short-falls in resources committed to the program and administrative difficultiesin implementation. However, the trend in foodgrain production is likely toincrease to perhaps 4% a year over the next few years, unless a prolongedstretch of bad weather intervenes. The irrigated area under modern methodsis expanding sharply, about 650,000 acres in the past two years, and now

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totals 3.6 million acres; and the potential irrigated area is almost 4times the present total. Fertilizer availabilitry and use have increasedsharply to a total of 968,000 tons in 1982-83; 2I/ and the HYVs that havespurred boro rice and wheat are now making some contribution to the amanand aus rice crops. In contrast to practically all of the wheat areas andtwo-thirds of the boro areas which are already under HYVs, only about one-sixth of the aus and aman areas have HYVs. Since flooding is not a factorfor the aus crop as it is for the aman crop, further significant increasesmay be expected for the aus crop from greater use of HYVs.

3.04 If the trend growth rate of foodgrain production turns out to be4% per year, the: more than 4 million additional tons of foodgrain, mostlyrice, would be available in about 7 years' time (Table 3). On the basis ofthe Government objective of providing 15.5 oz./person/day and allowing forannual population growth of 2.5%, the nation would at least theoreticallybe able to achieve this staadard. However, it is uarealistic to perceivethis situation as adequate for two reasons: first, as only 80% of minimumdaily caloric requirements would be fulfilled, the additional 20% will beneeded from complementary foods, such as pulses and edible oils; andsecond, because many people will still not have the effective demand to beable to acquire the necessary foods.

Table 3: PROJECTED TREND OF NET PRODUCTION OF FOODGRAINS AND CONSUMPTIONREQUIREMENTS, 1982-83 TO 1987-88

Net Production Consumption Requirement Deficitat 15.5 oz./day Net Production

Growth Rate Growth Rate4% 3.5% Population Growth 2.5% 4% 3.5%

Mil. Nil. Million Tons Nil. Mil.Year Tons Tons Tons Tons

1982-83 13.6 13.6 14.8 1.2 1.21983-84 14.1 14.1 15.2 1.1 1.11984-85 14.6 14.6 15.6 1.0 1.01985-86 15.2 15.1 15.9 0.7 0.81986-97 15.9 15.6 16.3 0.4 0.71987-88 16.5 16.2 16.7 0.2 0.51988-89 17.1 16.7 17.2 0.1 0.51989-90 17.9 17.3 17.6 (0.3) 0.3

Note: Net production is gross production minus 10% for seed, feed andwaste.

27/ B.E. Wennergren, An Assessment of the Agricultural Sector inBangladesh. Bangladesh: USAID, 1983.

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3.05 A 4% growth rate of foodgrain production would translate intohigher labor requirements of nearly 1 1/2% a year. Considering the highdegree of unemployment, estimated to be equivalent to about one-third ofthe agricultural labor force 28/, this would be quite inadequate to absorbthe increase in the rural labor force of about 3% a year. Thus, the antic-ipated growth rate of foodgrain production is not likely to have a suffi-cient effect on agricultural wages and on the purchasing power of the ruralpoor. Even though both migration of the rural poor to urban centers andurban poverty are likely to accelerate, the number of poor in rural areasis still likely to increase in the next five years.

Food Procurement Pricing Policy

3.06 Followlng independence, the Covernment viewed procurement as ameans to accumulate foodgrain supplies for the PFDS. Now, foodgrains areprocured to maintain producer prices and to encourage producers to increaseoutput by adopting HYVs and the associated technology. Procurement pricesrepresent a floor price to producers, and these are effective as long asthe Government is in a position to absorb any excess quantity available atthose prices. Some improvements have recently been made in the implement-ation of the program, strengthening the capability of the Government to beeffective in this respect. These include: announcing procurement pricesin advance of the planting seasons for the several rice crops and forwheat; maintaining procurement prices throughout the season; accepting forprocurement all grain of suitable quality, regardless of lot size; a moreresponsive payment system; increasing the number of procurement centers;and expanding government storage capacity to over 1.7 million tons. Someof these changes are not yet fully effective, and remote areas would bebetter served if government procurement centers were established there in-stead of relying on the private intermediaries. However, there has been asignificant improvement in overall performance.

3.07 In 1980-81 when over 1 million tons were procured, it amounted to6.4% of total foodgrain production, including 2.7% of aus, 6.4% of aman,and 7.5% of boro rice production, and 15.2% of wheat production. In1981/82, procurement amounted to only 298,000 tons, the lowest since thedrought year of 1974/75, and in 1982/83, procurement was about 192,000 tonsbecause market prices were generally higher than the procurement prices.

3.08 With procurement prices as a floor, current market prices appearto provide appropriate incentives to producers to exploit opportunities toincrease output via HYVs and associated technology. The ratio of rice pro-curement prices to fertilizer prices is clearly much more favorable than inPakistan or India, resulting in the rapid growth in production of boro riceand wheat under controlled irrigation and HYVs. As subsidies on fertil-izers have been significantly reduced, procurement prices have been raised,most recently in April 1983 when boro paddy was increased from TkI20/md toTk135, boro rice from Tk190 to Tk210, and wheat from Tk120 to Tk135. Theratio of procurement rice prices to urea remained at 1.4, about the same asin 1981-82 (when the ratio in India was 0.6).

28/ Bangladesh: Selected Issues in Rural Employment. World Bank No.4292-BD, March 11, 1983.

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3.09 Supplies to meet the PFDS requirements during the August-Octoberlean season depend on the availability of foodgrain stocks at the start ofthe fiscal year (July lst), and on foodgrain imports scheduled for the fol-lowing 3-4 months. The consensus of several analyses in the past fiveyears is that approximately 1.5 million tous of foodgrain are needed in themiddle of the year to ensure foodgrain security. This means that, for ex-ample, stocks on July 1 should be about I million tons and that importsduring the ensuing 3-4 months should total 500,000 tons in order to meetPFDS offtake requirements (including open market sales to contain pricerises during the months prior to the aman harvest). Government stocks offoodgrains on July 1, 1983 totalled only about 630,000 tons.

Agricultural Research and Crop Diversification

3.10 Crop diversification offers the potential to provide foodgrainsoriented to the needs of the poor, as well as complementary sources of nu-trients for a more balanced diet. Although the MTFPP focusses mainly onrice and wheat, the agricultural research establishment in Bangladesh hasdeveloped HYVs for several crops that have the potential to outyield pre-sent varieties and make use of land normally idle during certain periods ofthe crop year. These could, therefore: increase crop intensity; improveincomes of farmers, small as well as large; and provide some additional em-ployment opportunities for landless farm laborers.

3.11 Improved technologies are currently available for three non-food-grain crops, in particular maize, summer pulses, and mustard seed (foroil). The Government is formulating programs to exploit the latter two.However, maize also deserves attention. Yields of new maize varietiestested under farm conditions are double or more yields of boro and wheat,and almost five times the yields of local broadcast aus rice thus havingthe potentLal to increase substantially calorie supply. Further, on-farmdata, although quite limited, suggest that the benefit/cost ratios formaize are relatively favorable. The major constraint for maize is the lackof market and consumer acceptance, and its viability as a major element onthe food supply depends on overcoming that constraint. Tobacco also has afavorable ratio, but it is constrained by problems of quality and lack ofexport markets.

Table 4: BENEFIT/COST RATIOS FOR MAIZE

Crop Benefit/cost ratioFull cost basis

Sugarcane 1.5Groundnut 1.8Vegetables (average) 2.0Gram 0.7Lentil 0.9Mustard 1.4Potato 1.7Tobacco 2.6Maize:grain 2.5

1:1 grain/cobs 2.8cobs 3.2

Summer pulse (60 day crop only) 1.5

Source: A Strategy for Crop Diversification in Bangladesh. BARC. Nov.1982. Table A.2.3, Annex 2.

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3.12 The market for summer pulses is inadequately supplied and anyadditional production could be easily absorbed. Sixty-day maturing summermung and mashkalai meet the need for a cash crop between two main ricecrops, and also serve as intercrops and as post-disaster relief if, for ex-ample, the aus rice crop fails. These summer pulses, which have been suc-cessfully used in the Districts of Kushtia and Pabna since 1981, yield dou-ble those of other pulses, require mainly labor as an input, and at thesame time provide 40 lbs. of fixed nitrogen to the acre, which is utilizedby subsequent crops. The Bangladesh Agricultural Research Council esti-mates that more than one million acres could be profitably covered withsummer pulses, yielding no less than 0.5 to 0.6 million tons, and mDre thana million tons of cattle feed and fodder. If this crop could be exploitedover the next five years, it would triple the availability of pulses, add-ing about 15 g per person to current levels for the population at thattime, and thus adding 50 calories and 1.5 g of high-quality protein to theaverage daily diet. Nearly all income groups would benefit from anincrease in supply and somewhat lower prices for pulses, if the potentialsuggested from research work could in fact be obtained in practice. 29/

3.13 Consumption of fats is very low (para. 1.12). However, new vari-eties of mustard seed give 30-40X higher yields than traditional varieties,and the shift to the HYVs is under way. Since domestic production accountsfor only one-quarter of consumption and mustard oil accounts for about one-half of this domestic production, an increase of 30-40% in the mustard cropon present land would have only a minor effect on available supplies.Although domestic oil production would increase from some 35,000 tons toabout 41,000 tons, the amount needed to maintain per capita consumption atcurrent unsatisfactory levels five years' hence would be 155,000 tons or20,000 toas more than the present level. Thus, imports would still need tocontinue increasing. At present, imports consist largely of soybean oilobtained under concessional sales; they are cheaper than mustard oil, andare subsidized heavily (about 45%) in the PFDS. These imports at presenthave a serious disincentive effect on local production.

Rome Gardens

3.14 Home gardens are a means used particularly by NGOs to Increasefood production. Most rural families, including the landless, have someland on the homestead available for a home garden. Yet, even though malnu-trition is prevalent, home gardens are not generally in use. This Is part-ly because women, who would be responsible for them, are unfamiliar withvegetable growing and their nutritional importance. Cultural constraintsmay also be important.

3.15 CARE appears to have established an institutional paradigm withelements leading to a fairly successful experience. The project began inJuly 1980 as part of the larger Women's Development Program that integrateshealth and family planning with home gardening activities (indigenousvegetables) for groups of village women. Women are formed into informal

29/ M. M. Pitt. Food Preferences and Nutrition in Rural Bangladesh.-Review of Economics and Statistics. February 1983.

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cooperatives to receive instruction, and to buy seeds and other supplies.The project now covers 120 villages (about 120,000 people) in six upa-zilas. A survey of the winter vegetable program in early 1981 found pro-duction of over 11,00u mds (about 450 tons) of various vegetables by 2,815village women. This averages about 160 kg per participating family, andprovides some 60-70 cal/day/ person as well as essential nutrients, partic-ularly vitamins A and C. Gardening throughout the year where water is nota constraInt would likely double the contribution. The gross value perparticipant was Tk 313 and net after cash expenses about Tk 250. Highquality seeds and seedlings for carrots, cabbages, radishes, tomatoes,cauliflower and two types of local leafy vegetables, lal shak and palongshak, were distributed by CARE, which also provided field staff supervi-sion. Most produce was consumed at home with only a little sold. Comparedwith the average daily wage of agricultural labor (without food) of aboutTk 14-15 at that time, the extra value of the vegetables represents a sig-nificant increase in family income provided by the women of the household.It is hoped soon to expand the project to 150-160 villages, provided thatthe Government agrees.

3.16 Home gardening is also pursued in a number of government pro-grams, usually in conjunction with health programs, family planning, orhandicrafts. The Rural Development Board has formed some 400 women's co-operatives in villages primarily to promote family planning, but also toencourage the development of home gardens. Special attention is now beinggiven to the formation of cooperatives consisting of the rural poor. Underthe Department of Social Welfare, there are about 800 women's clubs thathave some home gardening activities, but these touch only a relativelysmall fraction of the villages. Poultry and fish enterprises have tendedto be less successful. Poultry stock suffer from disease, and fish pondstend to be underutilized because most people do not know how to use them.

3.17 The Agricultural Extension Service has established a program forpromoting the production of vegetables and poultry in home gardens. Some250-300 young women using a modified training and visit system contactclient families every 10 days. The extension agents are given I day oftraining each fortaight. However, their effectiveness is limited becauseof lack of transportation, inadequate training and the traditional diffi-culties of young women operating in a male-dominated society. As yet,their operations tend to be restricted to families on the fringes of towns,mostly bypassing the landless. The program does not provide inputs whichmany of the landless can ill-afford. The program is only just beginningbut, about 50 women are added to the extension force each year providingthe potential to expand it gradually to a nationwide program. As yet, itis not as effective as the NGO home garden programs which have a narrow fo-cus and better trained and motivated agents. The Government is also con-sidering a plan to lease government owned fish ponds to groups oflandless.

The Public Foodgrain Distribution System

3.18 The public distribution system mostly involves foodgrains, al-though other commodities (such as edible oil, sugar and salt) are also inc-luded. It takes place under six broad heads: statutory rationing

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(SR); distribution to priority categories; modified rationing (MR); openmarket sales (OMS); food for work program (FFWP); vulnerable group feedingprogram (VGFP), and gratuitous relief.

3.19 Statutory Rationing covers six cities -- Dhaka, Chittagong,Khulna, Narayanganj, Rajshahi and Rangamati. The consumers living in thesecities are provided ration cards on which they are entitled to draw rationsat stated periodic intervals from the ration shops. In theory, every per-son living in the cities used to be entitled to a ration card. However,this is no longer true, since from 1974 issue of fresh ration cards in theSR areas has been discontinued except for government employees moving intothese areas on transfer. The SR system covers more than four million peo-ple. Perhaps half as many are excluded, generally those who migrated fromrural areas to the cities since 1974. The quantity of ration made avail-able under these cards has been progressively reduced over the years andstands at present at two seers per adult. The mix of foodgrains under theration has also been progressively changed over the years. The rationwhich used to consist predominantly of rice is now mainly wheat. Of thepresent ration entitlement of two seers (equal to about four pounds orabout 1.8 kg), half a seer is rice and the balance is wheat. Originallythe issue price under the ration used to be highly subsidized, but fol-lowing the present policy of encouraging domestic producers, issue priceshave gradually risen almost to market levels. It is believed that -uch ofthe ration entitlement is given or sold to servants.

3.20 Distribution to Priority Categories covers the supply of rationsto defense personnel, employees in large industries, government servantsoutside the six SR urban areas, and other groups such as jail and hospitalinmates, students' hostels, etc. These priority categories are guaranteedsupplies at the same prescribed rate as card holders in SR areas. Em-ployees of large establishments outside of SR areas are usually entitled tobuy 35 seers of wheat per sonth (occasionally part is l-n rice) regardlessof family size. In addition, flour mills receive wheat for milling anddistribution to bakers as a matter of priority. Probably more than sixmillion people are covered in the priority categories.

3.21 Modified Rationing covers the rest of the country not covered bystatutory rationing. The recipients are classified Into four categoriesA to "D" based on the amount of tax paid by each f amily. This is meantto reflect the income level of the family. The quantity of ration and theproportion of rice and wheat in the ration depend upon the Government'savailability of grains and on its assessment of the needs in the MRareas. Supplies of foodgrain through the MR system to the rural areashave, therefore, not been regular. In theory, except when supplies are am-ple and large quantities can be made available through the MR system, onlythe lowest income categories are expected to receive supplies. But sincethe classification and control of supplies are by the elected local author-ities, it is generally accepted that the supplies do not always go to thepoorer groups and are sometimes diverted to those selected by local offi-cials. There are also other reasons for non-participation by the poor: forexample, inconvenient food distribution centers, and food quotas that aresmall and often unavailable.

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3.22 Open Market Sales (OMS), recently undertaken by the Government,are designed to stabilize prices in the market, particularly in the leanseason. The concept involves controlling increases in rice (and wheat)prices during lean seasons through government stockpiling of foodgrains,and subsequently releasing these stocks when needed through OMS. The wheatpresently provided by the United States of America (USA) on a grant basiscan only be used in OMS or to build up stocks. Negotiations between thetwo governments are required when changes are deemed necessary to make thesystem work better.

3.23 The OHS system was constructed to initiate sales when prices rose15% above the procurement price equivalent for rice (20% for wheat). Thesales were to be made at half the percentage increase above the 15% levelfor rice and 20% for wheat. (The trigger points of 15% and 20% price in-creases were to provide traders with an incentive to store). It took untilthe 1982/83 crop year to get the OMS working well, including adjustment toinclude rice as well as wheat in sales operations. Rice sales have agreater impact on prices of both rice and wheat than sales of wheat have onrice prices. The cross-elasticities involved indicate that it takes almosttwice as much wheat as rice iaserted into the market to achieve the sameprice effect. 30/ In September 1982, retail prices rose to 27% above pro-curement prices for rice and to 37% above procurement prices for wheat.OHS sales were initiated in September amounting to 26,000 tons in thatmonth, 74,000 tons in October and 11,000 tons in November. The ratio ofrice sales to wheat sales was 3:7. At its peak in October, OMS accountedfor 27% of the total PFDS. By November 1982, retail prices of both coarserice and wheat had been lowered to 22% above procurement price levels,although normally prices in that month remain fairly close to the Octoberlevel; and by December, with the harvest, they were back to the startingpoint of 16% above procurement for rice and 19% for wheat. It is estimatedthat OMS sales during the lean period, September-November 1982, kept marketprices from rising an additional 15% 31J. In the absence of OHS, thepoor would have had to reduce purchases by about 10%, while the better-offgroups would not have restricted purchases much.

30/ R. Ahmed. Foodgrain Supply, Distribution and Consumption Policies, ACase Study of Bangladesh. IFPRI Research Report No. 8, Washington:May 1979. The cross elasticity of wheat to rice was estimated to be0.58.

31/ Based on an estimate of about 30% (excluding food given as wages tofarm laborers) of annual production marketed (about 4.1 million tonsin 1982-83), negligible procurement (about 100,000 tons) and publicdistribution offtake less OMS (about 1.9 million tons). This totaled5.9 million tons for the year and the monthly movement to consumersaveraged 490 thousand tons. However, consumption during the lean per-iod averages perhaps 10% less before aman than after aman, and probab-ly 5% less than the annual average. Thus, the total availability dur-ing Sept. - Nov., excluding OMS, was about 1.350 million tons. OMSIncreased the supply by lll thousand tons, about 8%, and with a priceelasticity for foodgrain of about -0.5, lowered the price by about15%.

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3.24 After December 1982, the price of rice rose, as is usually thecase seasonally. Market prices of paddy and rice in mid-April 1983 wereabout 15% above procurement, which had been raised from the previous year,and about 14% above the ration price, barely enough to trigger some OMSsales of 2,700 tons. However, wheat market prices, after rising in January1983, declined with the new harvest to a level close to the higher procure-ment price and slightly below the ration price. During the 1983-84 cropseason, there was little procurement because market prices were higher thanprocurement prices. There was also very lirtle OMS, partly because theGovernment considered stock holdings to be inadequate to protect againstpossible shortfalls in production, reserving its stock for ration distribu-tion. Thus, at the end of April 1984, market prices of rice were 22percent higher than procurement prices and 17 percent above ration prices.It seems likely that lower prices could have ensued with a larger distribu-tion through OMS and raising the ration price closer to the market price.

3.25 A survey of 39 of the 68 subdivisions was undertaken to examinethe effectiveness of OMS In the field. There is substantial autonomy forthe subdivision controllers of food as to when to start OMS; and the allo-cation by the Central Government appear to have been adequate, thus makingit possible for them to be fairly responsive to local situations. In onlyfive of the subdivisions surveyed were there any upazila in which OKS wasnot operating, and in each of these only a single thana did not have OMS,mostly because of remoteness. According to dealers who purchased grainfrom subdivision officials and agreed to sell at prices fixed by the Gov-ernment, the major recipients were daily laborers, the poor, and the float-ing populations. In some areas, the major recipients were workers in teagardens. Of course, there were some cases of abuse. But generally it ap-pears that OMS had a wide benefit in keeping prices below where they mighthave been, both for the poor and the not-so-poor.

3.26 The net financial costs of the OKS i: 1982-83 are estimated tohave been about Tk 190 million 32/. Assuming that a total of about350,000 tons would normally have been sold monthly, and that the averageprice decrease due to the OMS was about Tk 35 per maund (i.e., for ricefrom about Tk 255 to about Tk 220), then the benefit to consumers over atwo-month period would have been about Tk 670 million -- i.e., about threetimes the net cost to the Government. Essentially this would have been anincome transfer from speculators and grain dealers to consumers. Unfor-tunately, data are not available to assess whether the market demand forfoodgrains may have risen due to the OMS. On the supply side, however, itis believed unlikely that the OMS caused any decrease In domestic produc-tion. This is for two reasons: first, farmers probably store relativelylittle foodgrains themselves, with most storage being done by foodgraintraders and speculators; and second, foodgra-i production of both

32/ This estimate is based on gross costs of Tk 7,260/ton for rice andTk 6,520/ton for wheat -- i.e., a total gross cost of about Tk 740 m.assuming that 33,000 tons of rice and 77,000 tons of wheat weredistributed. The revenue to the Governmeat is estimated at aboutTk 550 m, assuming average sale prices of Tk 256/maund and Tk 154/maund for rice and wheat respectively.

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rice and especially wheat has been steadily rising. As far as the externalsupply of foodgrain is concerned, on the other hand, it would seemreasonable to argue that the Government's policy may have encouraged donorsto provide more food aid (particularly PL 480) than would have been sup-plied if this policy had not been followed. If this is so, then the OMSmay have had a secondary benefit of bringing about a slight increase in thetotal availability of foodgrain in the country (as well as quite success-fully moderating seasonal price fluctuations).

3.27 The Food for Work Program is aimed at providing employment andpayment in the form of foodgrali to landless laborers in rural areas in thenon-agricultural season. More recently partial cash payment has been auth-orized. This program was started in 1975 following severe floods in theprevious year which resulted in widespread distress in rural areas. Theprogram uses food aid resources donated to the country to provide employ-ment during the non-agricultural season to the poor landless and near land-less. The labor working on these projects are paid wages-in-kind for con-structing needed rural infrastructure. These projects are generally of twokinds: the local initiative projects which are small and medium sizeschemes and which are initiated by local authorities at the thana level;and the larger schemes of national importance which are generally initiatedby the Bangladesh Water Development Board. The wage rates for the labor inthese projects are around the level, or slightly below that, of the pre-vailing agricultural wages in the area, so that only those persons who are-unable to get employment in normal agricultural operations offer themselvesfor employment in these projects.

3.28 The FFWP is now an important national program for employment gen-eration in rural Bangladesh, and is perhaps the main means by which cheapergrain can be made available to poor people in rural areas, particularlyduring the lean season of agricultural employment when the landless poornormally have no income. In 1982-83, some 98 million man-days of work weregenerated, and about 405,000 tons of wheat were distributed. At 40 daysworked per person and allowing for food leakages, about 2.3 million peoplewere employed; and at average family size of six, close to 15 million peo-ple benefited.

3.29 The FFWP is implemented using wheat donated by aid agencies. Theprogram using wheat donated by the USA is decided in consultation withCARE, which supervises the program. Similarly the program using wheat do-nated through the World Food Programme (WFP) is subject to supervision andcheck by that organization. A third category of program uses food aiddonated by other donors and also wheat from the Government's own stocks.However, the Ministry of Relief and Rehabilitatlon has overall responsi-bility for coordinating the FFWP. There is a coordinating committee at thenational level consisting of representatives of the various ministries con-nected with the execution of the schemes. At the district level there is asteering committee, and there Is a subdivision project implementation com-mittee at the subdivision level. At the upazila level, there is an upazilasubcommittee. These committees provide coordination between the centralgovernment level and the individual project level. At the individualscheme level, project implementation committees are formed consisting of

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the local government officials in collaboration with the representatives ofthe executing bodies. The project implementation committees areresponsible for the execution of the schemes: for recruiting labor, keepingrecords and distributing wheat to the workers. There is also a project im-plementation officer who is an official at the upazila level and who over-sees implementation. The large number of scheme proposals submitted by lo-cal authorities for implementation is indicative of the employment andimpact of the schemes at the grass root level, although much of theinfrastructure developed does not appear to be well planned or of lastingvalue. However, a number of pilot schemes have been initiated recently toimprove the quality of the FFWP, e.g., the use of destitute women foryear-round road maintenance work, and partial payment of workers in cash(generated from foodgrain sales). Under the FFWP, the cost (includingoverheads) per worker averages Tk 882 under that part supervised under theWFP, and Tk 1,135 under that supervised by CARE. The difference in theunit cost is primarily due to the different types of projects - with theWFP projects on average being considerably larger than the CARE ones.

3.30 The Vulnerable Group Feeding Program and Gratuitous Relief aim toprovide food to certain high risk groups. The vulnerable groups includedestitute women, particularly in rural areas, and in some areas, pregnantand lactating mothers with their children. Selection of the target groupsis based on recommendations made by various authorities - either sub-divisional staff, upazila level government staff, elected local bodies andsome NGOs. Under this program, a family of one mother and three childrenreceives 1,250 gms of wheat per day for 25 days per month, which providesabout 900 cal/day/person. No other commodity is distributed. An estimated1.1 million beneficiaries receive wheat from this program which is financedby WFP and some bilateral donors. In addition, there is a group feedingprogram for specific groups such as orphans. There are about 50,000 bene-ficiaries under this program financed by the WFP, and it distributes 350gms of wheat for a mother and 300 gms of wheat for a child, together with40 gms of pulses, 20 gns of vegetables and 40 gms of milk powder whenavailable. The cereal, pulses and vegetables are cooked, and the cookedmeal is provided to the mDther and child. Finally, the gratuitous reliefcovers relief to victims of natural disasters like floods, cyclones andfamine. The demand for this relief depends upon the type and severity ofnatural disasters and, therefore, varies from year to year.

3.31 In contrast to the seasonal and temporary nature of the FFWP, theVGFP is continuous. The cost per family per year is about Tk 1,974, ofwhich food accounts for almost 80%. The annual value of food per family inthe VGFP is about 24 times that in the FFW, which is for only 40 days. Ininstitutional feeding, the total cost per child for a year is aboutTk 6000 of which about 40% is for food alone. While the latter is the mostexpensive program per beneficiary in the PFDS, it only amounts to 0.3% ofthe total. Nevertheless, it is clearly not financially feasib ' to pursuethis method to encompass all eligible children.

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3.32 Recipients and Costs of the Public Foodgrain DistributionSystem. There have been some important changes in the composition of thePFDS in the last few years. These include: (i) a decline (to about onesixth) in the SR as a proportion of total PFDS; (ii) a relative increase(to about one third) in the allocation of the PFDS to the priority groups;(iiI) a relative decline (to about one quarter) in the allocation to theMR; (iv) year-to-year fluctuations in the allocation to the relief program,which, however, has remained a relatively small proportion of the total;(v) an increase in the proportion of the PFDS going to the FFWP up to1980-81, after which there was a drop in both the relative and absoluteamounts; and (vi) the initiation of free market operations (of which OMSwas a small part) accounted for 7.7% of the PFDS in 1981-82, and OMSaccounted for about 8.3% in 1982-83. The various programs of the PFDSbenefit the various socio-econoulc groups to varying extents. A quanti-tative assessment of this is given in Table 5 below. Although the programsof OKS, food for work and vulnerable group/relief feeding reduce to someextent the disparities in benefits received by the low and high incomegroups from the PFDS, the imbalance is still heavily weighted in favor ofthe higher income urban group.

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Table 5: DI UCN O PUO IC F0CGAIN DITIRUON SYSTM BY SCIONND4IC GJP 1982-3(OOOs MNS)

1.1ArIaess 2.Sm11 3.dim 4.MB1aum 5.JarI 6A.Vey 7.Rural 8.Rural. 9.Urban 1O.Urban TotalFarm Faners FarEr Farmrs Farmers IaN3e rfo nul Foril Infozual FozulWorkers (Tenans) (>W ) Fa.

iLtlon-jstemRice 117 42 21 23 39 91 65 87 485Wheat 95 34 17 19 32 331 141 283 950Total 212 76 38 42 71 442 206 370 1435

Arket

Rice 9 5 36 50Wheat 21 10 84 115Total 30 15 120 165

modforirk

Ricewahat 231 99 330Total 231 99 330

-lief~~.QGP

Ri.ceWtmat 42 18 60Total 42 18 60

Rice 126 42 21 23 54 91 101 87 545Wkeat 389 34 17 19 182 331 205 283 1480Total 515 76 38 42 236 422 326 370 2025

ce: Clatre for World Food Studies, utrdam; and mLs.on esti .

* See Annc 2, Tble 2.22 for dscriptioa of doc clasS.

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Notes: (i) It is assumed that the SR benefits the urban formalgroup more than the urban informal group, and thus thepopulation share is raised from 40% to 45%.

(ii) For the priority groups, it is assumed that the distributionis proportional to the population shares of both formalgroups.

(iii) The MR is assumed to benefit the lower income groups mDre.In line with this, it is assumed that: (a) the two mediumfarm groups obtain half of their respective populationshares; (b) the small farmers, the rural informal group andthe urban informal group receive amounts in proportion totheir respective population shares; and (c) the remainingofftake is received by landless farm workers.

(iv) It is assumed that the open market sales benefit primarilythe urban informal group, the landless farm workers and therural informal groups in that order.

(v) For the FFWP and VGFP, it is assumed that the benefitsaccrue to the landless farm workers and the rural informalgroup, but proportionately more to the former. The popula-tion share of the former has, therefore, been raised from66% to 70%.

3.33 In order to appreciate the differential impact of these programs,it is appropriate to relate them to the relative sizes of the varioussocio-economic groups, and also to these groups' respective calorieintakes. These are shown in Table 6.

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UNb.1a 6: UICAMRIES t7 ME RELIC FDGRAIN IRIBUflCU SYST BY S=O-EMNam (IoI 1982-83(OOOs IWS)

1.ladaless 2.1m. I 3.dium 4.U ium 5.large 6.Very 7.Rural BJural 9.Urban dO.Urban TotalFarm Faraers Farmers Farars Farmers Large Thformal Formal ITnfouml FozmBlWor_ers (1inanLs) (Owms) Farmers

(M) 19.3 11.1 11.3 12.4 9.8 4.0 10.0 6.7 5.1 3.4 93.0C) 20.7 11.9 12.2 13.3 10.5 4.0 10.8 7.2 5.5 3.7 100.0

cals.per 1529 1638 1764 1965 2150 2087 1482 2118 1708 2080 1782capitaper day1976-77

FEDSPercapdtafoci-gran

(Kg)Rice 6.5 3.8 1.9 1.9 4.4 13.6 19.8 25.6 5.8gheat 20.1 3.1 1.5 1.5 15.9 49.4 44.1 83.2 15.6Total 26.7 6.8 3.4. 3.4 20.3 63.0 63.9 108.8 21.4

Subsidypercapita(taka)Rice 10.7 6.2 3.1 3.1 7.2 22.4 38.2 42.1 9.5

wheat 57.7 8.9 4.3 4.3 45.6 141.7 56.5 238.8 44.8Total 68.4 15.1 7.4 7.4 52.8 164.1 164.7 280.9 54.3

Source: Ceintre for World Food Studies, Amstetdai; arl mission est-imts

flotes: 1. For the subsdy3 estimawes, asstnptions of taka 1.64.5 per kg and! taka 2.869 per kg bhabeen ueedrespectively for rice anid ieeat. (See tAmec 2, Table 2.22 for description of sxio-e=omaidgrcups.)

2. See Annex 2, Table 2.22 for &scidption. of so )-ecooct cLusses.

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The landless farm workers and those in the rural informal group, for whomtotal food intake averages only about 1,500 cal/day/capita, receive anaverage of 27 kg foodgrain/capita, and 20 kg respectively, from the PFDS.The small farmers, whose per capita caloric intake is estimated at 1,650,receive about 7 kg of foodgrain. In contrast, the urban formal class withper capita intake over 2,000 calories receive about 109 kg per capita. Thebenefits of the subsidies iavolved in the PFDS occur in about the sameratio; Tk 281 per capita for the urban formal class; Tk 68 for the landlessworker; Tk 53 for the rural informal worker; and Tk 15 for the smallfarmer.

Health Programs

3.34 Oral Rehydration. Approximately 250,000 children die each yearfrom the dehydration and malnutrition linked to diarrhoeal infections.Most of them could be saved by oral rehydration, which is as effective as,and much cheaper than, cumbersome intravenous therapy. The Government'sNational Oral Rehydration Program (NORP) produced and distributed about 5million packets of oral rehydration salts (ORS) in 1983; but in 1978 therequirement for such packets was conservatively estimated at 19 million fortreating children under five years of zge, and 32 million for all others.While the Government expects to have doubled its production of ORS packetsin 1983, the supply is still clearly inadequate. Furthermore, three quar-ters of the population live beyond the reach of the health services, andmore than three quarters of the mothers would not be able to read the in-structions on the back of the packets.

3.35 To try to overcome these problems, BRAC has developed a home-madesaline solution similar to the packet, which can be produced at the villagelevel. A trained cadre of village women instruct other women on the treat-ment of diarrhea with this home-made salt-sugar solution. To date, some2.5 million households (comprising a population of 15 million)in five dis-tricts have been taught the importance of oral rehydration and how to pre-pare the solution. Phase II of this program will expand coverage toanother four million households in seven districts.

3.36 National Blindness Prevention Program. Xerophthalmia is esti-mated to affect about 5% of rural children, while 3% of rural children suf-fer from night blindness. Severe vitamin A deficiency may lead to perma-nent blindness. The Bangladesh National Blindness Prevention Program(NBPP), with the support of UNICEF, WHO, and the Helen Keller InternationalOrganization, aims to distribute high potency Vitamin A Capsules (VAC)every six months to all children aged 0-6 years in rural areas and to thosechildren in urban areas that can be reached by the existing health infra-structure. In 1982/83, 45% of the target population was reached in ruralareas, and 22% in urban areas. Data from the xerophthalmia prevalence sur-vey conducted by the NBPP in 1982-83 revealed a prevalence of night blind-ness of 3.8% in rural areas, a rate 2-3 times higher than previously re-ported. It is difficult to evaluate the direct effect of VAC distributionon eliminating nutritional blindness in pre-school age children due to theother causes of vitamin A deficiency. However, it can be said that withoutthis program, many more children would be blinded each year or suffer fromusual impairment as a direct consequence of vitamin A deficiency.

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3.37 Nutrition Education has not yet evolved into a significant pro-gram. There is a number of relatively small scale programs, such as theJurain Project of the Institute of Diabetics, and the two mobile teams fornutrition education rua by the INFS. Nutrition education is also includedin some NGO projects, e.g., the CARE Women's Development Program. Phase IIof the BRAC ORT program will also include a nutrition education component,wiith the hope of expanding into a large-scale program. Considering thew'idespread misinformation and lack of knowledge among women of what consti-tutes proper cbild nutrition, nutrition education is an area that urgentlyneeds attentiou.

3.38 Other Programs. The INFS has tried some pilot work to combat theproblem of iodine deficiency, which causes goiter and related mental retar-dation, and which afflicts about 20 million Bangladeshis. Following theresults of the 1975/76 survey, a program of lipiodol injections wasstarted. Within a period of 6 months, 95% of all those injected with lipi-odol had no visual enlargement of the thyroid. In late 1983 the MOHPC alsocarried out a trial program of providing these injections to all childrenaged 0-15 years and all women aged 15-45 years in one upazila with endemicgoitre. Some 85,000 people were covered in the 4 week campaign, and 3additional upazilas will be served in 1984. However, while this treatmentis effective, it is also expensive. Iodized salt provides a much cheapermethod of introducing iodine on a mass basis, and a trial of iodized saltundertaken in Tangail Upazila showed that good results could be obtained.There were no problems of consumer acceptance and no toxic symptoms.

3.39 Iron deficiency anemia is only being partially addressed throughthe Government's maternal and child health care program. Expectantmothers, those most severely affected by the problem, are entitled to ironand folic acid pills as part of antenatal care, but outreach of the healthdelivery system is poor, and only a small proportion of the target groupactually receives these pills. Noticeably absent are services which linkmaternal and child health activities to specific nutrition interventionssuch as growth monitoring, food supplementation and anti-parasitic drugs.Relatively few advances have been made in the prevention and cure of lath-yrism, but the INFS is now experimenting with the effects of vitamin C as acure and as a preventive measure reducing the toxicity of khesari-dhal.

IV. ISSUES AND CONSTRAINTS

4.01 The magnitude and severity of malnutrition in .Bangladesh requiresubstantial government and non-government intervention for conditOns to bealleviated. However, there are several major issues. First, most peopledo not have enough to eat to provide them with sufficient calories (energy)for day-to-day activity. About one third of the population, the absolutepoorest, live at the edge of starvation. Second, the available diet con-sists predominantly of foodgrains and lacks basic nutrients essential forgood health. Third, the lack of adequate amounts of food is compounded bypoor feeding practices, misbeliefs and lack of knowledge of propernutrition. Fourth, inadequate sanitation, poor personal hygiene and

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chronic ill-health further reduce nutrient absorption. And, fifth, thereare some vulnerable groups for whom the situation is particularly criti-cal. These include pregnanc and lactating women, infants and young child-ren. Malnutrition in early years of life is especially critical, since itstymies the development of children into adults, and thus breeds successivegenerations of malnourished people.

National Nutrition Policy

4.02 There are several constraints which have impeded the Government'sefforts to address the problems. First and foremost, there is as yet nei-ther a national nutrition policy nor an integrated strategy to coordinatethe diverse efforts and activities of the different goveramental and non-governmental agencies concerned. Such a policy should be focussed on thosegroups most in need, and should have clearly defined objectives. This iscritical for the planning and management of appropriate programs. Todevelop the most practical and meaningful national nutrition policy, allexisting information on food and nutrition, as well as other nutrition-related matters, should first be brought together within Bangladesh. Theanalysis of the data, matched by an accurate appraisal of the socio-political environment, should serve as a good basis for a national policy.The Nutrition Policy and Programme prepared by the NNC does not give appro-priate weight to the linkage of food production and import policies withfood intake and autrition, especially of the poor, the role of donors andNGO's in alleviating the problem, the issue of responsibilities for imple-mentation and coordination of policies and programs of various ministries,and, considering the scarcity of resources, the priorities and timing ofprograms.

4.03 Likewise, serious consideration should be given to the inclusionof. a food and nutrition chapter in the next national development plan.This is also receiving some preliminary attention in the Planning Commis-sion. Of greatest concern would be inclusion of realistic production andconsumption targets for other nutritionally important crops as well asfoodgrains; further readjustment of the foodgrain distribution programs toaddress the most serious malnutrition problems; development of appropriateapproaches to deliver an integrated package of maternal and child healthand nutritioa services at the village level; and reiuforcement of the rolesand responsibilities of NGOs in achieving nutritional objectives.

4.04 There is an urgent need for a data management plan to decide whatdata should be collected, by whom, -how, and particularly for what pur-poses. At a minimum this should encompass seasonal surveillance of vulner-able groups on a sample basis. This would contribute to an early warningsystem which is needed so that appropriate plans can be made for reliefwork when required, it could also improve the geographical targetting ofvarious food distribution programs. In the meantime, a "nutrition module'should be developed for inclusion in the proposed nat4onaL household surveyto provide continuous data on the national nutrition situation. A needalso exists to coordinate the ongoing efforts of the WFP, UNICEF and theGovernment so that a detailed nutrition map of Bangladesh can be createdshowing problem areas and the existing or proposed programs which addressthem. Technical assistance may be needed to facilitate this exercise.

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lstitutioual Aspects

4.05 There is a need to clarify and strengthen existing institutionalarrangements for dealing with nutritional problems. The recently estab-lished FPC should have the sole responsibility for the determination ofpolicies and overall strategies, but consideration should be given to theinclusion of the Minister of Industry and the Minister of Health and Popu-lation Control on it. To complement the FPC, the NNC should have an advis-ory and advocacy role, and should be responsible for the development andmonitoring of nutrition intervention programs. To do this, however, itshould be strengthened and expanded to include more private sector repre-sentation, especially from NGOs. This would also facilitate the coordin-ation of gover,mental and non-governmental programs.

4.06 The high-level FPC also needs technical support within the civilservice. This could be provided in a number of ways. For example, theFFPMU could be expanded, especially with the establishment of a nutritionsection. It could then have the responsibility for assessing the foodneeds of the undernourished, evaluating the impact of food policies andprograms on nutritional status, and making recommendations to policy makersconcerning courses of action oriented to improve nutrition among the poor.Alternatively, the nutrition section of the Planning Commission could bestrengthened, although this has the disadvantage of not being located inthe Ministry responsible for chairing the FPC. Thirdly, in view of theurgency to develop an appropriate nutrition policy and strategy in time forthe next national development plan, urgent consideration should be given toforming a special full-time task force based in the MOF specifically forthis purpose. This could be considered as an interim measure, and furtherthought could be given to the longer-term institutional arrangements.

4.07 The FPMS should be strengthened by filling existing vacancies,especially in the economics section. It should also become the principalinstrument in providing policy and program analyses to help food managersanticipate problems and take appropriate action. The unit should beresponsible for continually assessing: incentive prices and procurement offoodgrains; offtake requirements; the need for changes in PFDS policies andinterventions, particularly to benefit the poor; ration and market prices;subsidies on foodgrains and fertilizers; and the scheduling and makeup ofimports and stock levels. In addition, further consideration should begiven to implementing the recommendations previously made 33/ by the FAOand the World Bank to strengthen the organization and operational effi-ciency of the Department of Food.

4.08 The Agricultural Extensloan Department is already being reorgan-ized and with particular emphasis being placed on the use of the trainingand visit extension system, it should be able to facilitate better

33/ Feasibility Study for Setting Up of a Food Corporation in Bangladesh.FAO, December 1979.

Staff Appraisal Report of the Third Grain Storage Project, World BankReport No. 4048.

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local level operations. However, the respective functions of the INFS andthe IPiHN should be clarified in order to avoid unnecessary duplication ofeffort. In view of the large amount of nutrition tralning required forexisting and new health workers, it may be advisable for the IPUN to focusits efforts on applied training work, while the INFS would continue withuniversity-level training in nutrition related subjects and associatedresearch. And, finally, there is an increasing need for a mechanismthrough which NGOs can be coordinated, both amongst themselves and alsowith the Government. It is possible that this could be achieved by expand-ing the membership of the NNC to include several major NGOs (para. 4.05).

Food Production Policy

4.09 Self-sufficiency in foodgrains, defined as the supply availabil-ity of 15.5 oz/cap/day, is the central focus of food production policy. Asnoted earlier (paras. 3.02-3.04), there is reasonable expectation that thisgoal will be realized from domestic production in about seven years. Inorder to attain this goal of providing 15.5 oz/cap/day, however, theGovernment and particularly the MOA must give serious thought as to how theeffectiveness of the agricultural extension activities can be improved.The field staff is generally poorly trained, paid and motivated. Theintroduction and institutionalization of the training and visit system(para. 4.08) may be expected to upgrade performance, but of particularimportance are the supervision and in-service training aspects. Inaddition, for the projected 4% annual growth in the production offoodgrains to be achieved, greater use must be made of HYVs, which in turnrequire more land under irrigation, improvement of irrigation management,and more intensive use of fertilizers.

4.10 While production goals might be achieved, this will not by itselfsolve the distribution problem since the poor will continue to lack effec-tive demand. In the next five years, the population is projected toi-ncrease by about 10 million, from 93.6 million to about 104 million. Therural population would rise from 83.3 million to about 91 million, anincrease of about 10% in five years, while the urban population would risefrom 10.3 million to about 13.5 million, an increase of about 31%. In thesame period, the rural labor force is projected to increase some four mil-lion, a gain of 14%, while the urban labor force would rise over onemillion, an increase of 36%. The exodus of the rural poor to join theurban poor is expected to accelerate in the intervening years. 34/

4.11 Even with the annual growth rate of foodgrain production at 4%(and the growth of all agricultural production at slightly less), andallowlng for a commensurate increase in the processing of agricultural com-modities, the additional rural labor force in the next five years is

34/ Population and labor force estimates are derived from BangladeshSelected Issues in Rural Employment, No. 4292-BD, March 11, 1983,Annex Tables 1.4 and 1.8.

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likely to exceed new employment by about one million. 351 At a 3% %,rowthrate in agricultural production, the increase in the rural labor forcemight well exceed employment opportunities by two million. Employment willalso be extremely difficult for the increase of over one million projectedin the urban labor force, and the casual urban labor market is, therefore,likely to swell.

4.12 In such circumstances, with a growing surplus of labor and con-tinuing downward pressure on wage rates, it is uxlikely that the averageincomes of landless laborers and of the participants in the informal non-farm rural and urban labor markets would be improved. Indeed they mighteven be reduced. The small farmers would also be affected since on averageabout half of their family income is from wages from outside work.However, increased farm production would likely bring a modest improvementin their incomes. The landless laborers and informal rural non-farm groupsare already at the critical minimum diet level, and any reduction of foodintake could lead to massive starvation. These two groups probably accountfor about 35% of the total population, with the small farmers and the urbaninformal workers amounting to an additional 15% or so. Creating employmentand iacome opportunities for these disadvantaged groups is, therefore,critical. A 10% increase in income would raise per capita intake by about100 calories/day, and would provide some margin over the critical level.

4.13 The poor would apparently gain only a little by a redistributionof land. Most farm holdings are already small; and compared to mDst otherdeveloping countries, incomes are more evenly distributed in Bangladesh. Amoderate land redistribution program, if it were administratively andpolitically feasible, might improve food consumption of the poor by perhaps50-75 calories per day; but at the same time, it would increase the numberof malnourished because some at the margin would fall below the nutritionalstandard as a result of redistribution. 36/ However, legal restriction ofthe proportion of crops paid to landowners, as in some other South Asiancountries, could substantially benefit the tenant farmers, who typicallytura over 50% or more of production at present.

4.14 The projected increase in foodgrain production would definitelybenefit the other 50% of the population. For the 40% of the populationengaged on their own farms (including the small farmer), the spread ofirrigation and technology is projected to lead to agricultural growth ofabout 4% per year. With the rural population projected to rise about 2%per year, average per capita real income would therefore rise about 2% peryear. Furthermore, those with regular employment in public and otherenterprises in the rural and urban formal labor markets might also beexpected to increase their incomes at a similar rate. These growth rateswould lLkely be reflected in increased per capita demand for calories of

35/ This assumes 4% annual growth for foodgrains; some increase in laborrequirements for increased production of pulses and mustard; but onlynegligible changes in the jute, livestock and fisheries sub-sectors.

36/ Toward Greater Food Security for Bangladesh. World Bank AGREPDivision Working Paper, No. 9, December 31, 1977.

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about 100 cal/day for the medium farmers (owners and tenants) amd abouthalf that amount for small farmers. 37/ The average caloric intake of themedium farmer (tenant) would still falL short of the 2,020 calorie standardby about 150 cal/day and that of the small farmers by about 300 cal/day.However, the caloric intake of medium farmers (owners) which is slightlybelow the standard would rise above it. The remaining classes -- largerfarmers, and rural and urban formal groups -- already consuming above thestandard, would increase caloric intake perhaps by 50 calories per day,since they have a low income elasticity and would continue to shift towardobtaining a diet of preferred foods.

Food Procurement and Pricing Policy

4.15 In 1982-83, market and ration prices were close together andabove procurement prices, so the Government's procurement of foodgrains wasnegligible. The OMS were then a key factor in stabilizing these prices inappropriate relationships (paras. 3.22-3.26); but in 1983-84 the managementof pricing policy encountered difficulties aid did not perform as well asin the previous year. However, looking ahead, say seven years, when domes-tic production might be self-sufficient, the question remains as to whetherdemand would then be strong enough to support the present price structurewithout the need for the Government to accumulate large foodgrain inven-tories. Further analysis of this possibility is needed. In addition, inorder to begin to develop consumer acceptance, maize might be requestedfrom donors as part of food aid and distributed in the PFDS 38/. Thiswould provide the recipients with the option of receiving more maize thanthe usual distribution of other foodgrains. Mostly the maize would probab-ly be used in the homes in the form of grits.

Agricultural Research and Crop Diversification

4.16 Greater emphasis is needed in the research and cultivation ofalternative crops, especially those which are calorically dease and inex-pensive, such as maize and sweet potatoes. In view of the maize productionpotential, every opportunity should be explored to stimulate demand forit. Consumption of white potatoes, also a good and cheap source of calor-ies and vitamins, has increased considerably over the last five years,despite some problems of spoilage due to the tropical climate. However,over-production is projected co lead to a subsequent decline in productionfrom 1.2 million tons in 1982-83 to 1 million tons in 1983-84 (see Annex 1,Table 1.02). Its possible other uses over time could include: as anextender in wheat flour for bread, as poultry feed and as industrialstarch. Consideration should also be given to its use in the PFDS. Sweetpotatoes, in addition to being calorically dense, contain large quantitiesof vitamin A in their leaves. Given the general deficiency of vitamin A inthe Bangladeshi diet, widespread use of these leaves could substantiallyreduce xerophthalmia and other vitamin A deficiency-related diseases.

37/ This assumes an income elasticity of about 0.7 for small farmers, and0.6 for medium farmers (tenants).

38/ The use of maize in food aid in Bangladesh is also suggested in theReview of the Bangladesh Experience for the WFP Committee on Food AidPolicies and Programmes. WFP/CFA Sept. 1983.

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4.17 MilLet, another low-cost crop, merits experimentation due to itsspecial advantage in drier areas. Oil production desperately needs togrow, necessitating further research and extension efforts in the cultiva-tion of oil seeds, such as mustard and sesame, and of oil palm. The pro-duction of protein in the form of rabi and summer pulses must be furtherencouraged, especially in view of the alarming deterioration in per capitaconsumption of them (para. 1.11). Also, with regard to protein, Bangladeshhas a large potential for fisheries development, particularly in aquacul-ture. Fish production has declined In the past 10 years, a disappointingperformance considering substantial assistance from outside agencies.There is a need to improve the technical aspects of fish pond culture, tostrengthen the capabilities of the Department of Fisheries and to managemarine and inland fishery resources much more effectively. However, fishis among the most expensive sources of protein and thus, even if productionis substantially increased, it is likely to have only a marginal contribu-tion to the diet of the poor. An exception might be the development ofgovernment owned fish ponds leased to groups of landless families (as notedin para 3.'7).

4.18 Current initiatives toward crop diversification are not iuconsis-tent with the policy of self-sufficiency in foodgrains. Summer pulses arelargely grown on land which is not used between major harvests of foodgrainand would greatly increase the supply of quality protein. The increase inmustard seed for oil could come mostly from higher yields on land alreadyused for oil bearing crops. The 'imited program to test the feasibility ofmaize production and its potential market might well increase the supply oflower cost foodgraias, because higher yields can be obtained from HYV maizevarieties than from rice or wheat. The issue of the potential conflict ofpolicies of crop diversification and foodgrain self-sufficiency would onlyarise when commodities other than foodgrains displace foodgrain acreage.At such a time, the costs and benefits of the diversion, including thepotential for receiving food aid or other aid, would need to be evaluated,especially in terms of its impact on the poor.

4.19 The Bangladesh Agricultural Research Council has delineated theareas and timing suited for these crops. 39/ The research establishment,recently reinforced by some 15 outside scientists under the InternationalAgricultural Development Service, financed by a USAID agricultural researchproject, appears to be well-equipped to promote these commodities. Themajor immediate constraints appear to be the limited supply of seed forpulses and mustard, the lack of market demand for maize, and the inadequateservices of the local agricultural extension staff (see paras. 4.08-4.09).

Home Gardens

4.20 All of the crops with potential for diversification, such as theprotein rich pulses and energy-dense sweet potatoes, are suitable for pro-duction in home gardens. Also appropriate is local cultivation and con-sumption of fruits and vegetables to address the most common vitamin andmicro-nutrient deficiencies. Promotion of home gardens has considerablepromise for the poor, as has already been demonstrated by various programs

39/ A Strategy for Crop Diversification. November 1982.

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sponsored by government agencies and NGOs. Although available land is verylimited, there is still scope for home garden production. A serious con-straint, however, is the absence of a nationwide program to enlist women'sgroups and to mobilize the supporting services of trained personnel, derun-stration plots, seeds and perhaps modest amounts of credit. NGOs wouldneed to make important contribution, but such a program would also have tobe supported by the Government. For example, a major responsibility wouldfall on the agricultural extension service to train and provide large num-bers of women workers to give local instruction. The Government would needto focus its support at the upazila level, for example by providing nur-series for seeds and saplings, carrying out demonstrations, and doing sometechnical training. The link between home production and home consumptionshould also be formalized through an outreach program of nutrition educa-tion and growth monitoring.

4.21 The NGOs, on the other hand, and particularly agencies like CAREand SCF, appear to provide a model institutional structure for implementinga home garden program. Their ability to function effectively at the com-munity level is of parti-ular importance as they can promote activecommunity involvement and provide the essential intensive personal interac-tion and education needed to change cultivation as well as consumptionhabits. Rome gardening presents a possible opportunity to familiarize thecommunity with maize and millet production and consumption. Indeed, alocal millet (kaon) is already grown in some dry areas of the north insteadof boro. A few plants could be introduced in home gardens and tbus facili-tate the spread of these important low-cost calorie crops. The Governmentmight, therefore, consider formulating arrangements with NGOs whereby thelatter would be contracted to carry out village-level crop productionschemes. The NGOs could undertake these activities in conjunction withintegrated nutrition activities targeted at the vulnerable groups in thecommunity. Even the production of livestock (e.g., poultry in backyards)and fish (in village tanks) could be contemplated under an NGO-managed pro-ject, as some of the usual constraints (e.g., absence of protective fenc-ing, inadequate irrigation and inexperience in technical aspects) could beaddressed by the NGO. At the same time, however, the proposed scaliag-upof NGO activities would have to be done gradually to avoid diluting theireffectiveness.

Public Foodgrain Distribution System

4.22 Ration System and Open Market Sales. The ration system was ori-ginally conceived to provide cheap grain to the poorer classes. Experiencehas shown that it provides more subsidized grain per person to higherincome groups than to the poor. The Government is committed ultimately togive up the ration system and depend on OMS to assure the availability ofadequate supplies at relatively stable prices. But in the past year pro-gress toward this goal has come to a halt. In recent years the Governmenthad taken some steps in this direction: the reduction of the SR rationquota; raising ration prices closer to market prices to reduce the subsidy(though this seems not to have been continued to be done in 1983-84); andiucreasing the use of OMS. These trends should be reinforced. Inparticular, the rice portion of the quota should be eliminated and the

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supply redirected to OMS. Nevertheless, there are still some serious con-straints. Uaderstandably, authorities are reluctant to give up the longstanding ration system and rely only on the market system unless adequatebuffer stocks are available in government storage to meet contingencies ofpoor crops or delays in receiving imports. In July 1983, government stockswere only about 630,000 tons, compared to a figure of about 1 million tonswhich would be a more satisfactory level. Further, there is extreme reluc-tance to give up the subsidized ration to the priority groups.

4.23 While the Government may not find it feasible ac this time torely solely on the OMS to provide supplies and maintain relatively stableprices, it could move toward redirecting the ration system to the poorwhile at the same time furthering the OMS. If it is assumed that the Gov-ernment requires priority distribution to be maintained, the present SR andMR could still be eliminated and "fair price shops" or ration shops estab-lished instead. These could be aimed at poor people in cities as well asin rural areas. These shops could be open to all wishig to use them, butthey would only offer low-cost and low-quality foodgrains at market prices,generally unacceptable to people who could afford better. Such commoditiesmight consist of maize, sorghum or nillets, which would need to be promotedfor coasumption, or the lowest qualities of rice and wheat. Even for thesame amount of money presently expended on the purchase of foodgrains, morecalories could be provided in this way. For example, while rice and maizeare converted to roughly similar amounts of calories per ton, the cost ofthe latter is only about half of the former. In 1979 there was indeed anattempt to introduce sorghum into the PFDS; and although purchases of itwere very low in the urban ration system (given its largely middle classconsumers), consumption in the rural ration shops was high. In addition,there was a bias, among rural ration shop users who purchased sorghum,towards the lowest income consumers. The greatest advantages of such asystem are the improved targetting and reduced costs. 40/ To do this,however, would require action in a number of areas: imports required forfair price shops would need to be adjusted accordingly; separatedistribution channels would need to be established for the priority groups;and most rice would need to be removed from the ration system and madeavailable for the OHS, where it is more effective than wheat in stabilizingmarket prices of rice and wheat.

4.24 Under the present agreement with the United States Government,wheat shipments under Title III, which are on grant basis, can only be usedin open market sales or added to stock. (Some wheat can be exchanged forpaddy on a 1:1 basis and for rice on a 3:2 basis, and shipped to flourmills). Under the present need to build up stock levels, it would seemprudent to do so to provide the means to counter any emergency, such asfailure of the aman crop, providing that the rice formerly scheduled forthe SR and MR is made available for the OHS.

40/ Rogers, B. and J. Levinson, "Subsidized Food Consumption in Low-IncomeCountries: The Pakistan Experience," (Cambridge, MA.: MIT,International Nutrition Planning Program, Discussion Paper No. 6,April 1976) describes a successful scheme based on lower quality wheatflour (atta) which is traditionally consumed by the lower incomegroups.

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4.25 Food for Work Program. This program provides more graln for therural poor than the ration system; and without it a large number of land-less and their families would be in great nutritional difficulty, espe-cially in the lean agricultural period when work is scarce. Because theprospects for increased employment are not favorable, expansion of thisprogram is very much needed. Some of previous constraints in the FFWP havebeen alleviated recently. Funds have been allocated in FY 85 for equip-ment and supplles to construct permanent structures rather than roads andbridges which deteriorated rapidly. Better arrangements have been made formaintenance of projects, and some work has also been provided for women.However, projects have been poorly planned and implemented because of ashortage of qualified technical staff and managerial manpower, and delaysin planning have also impeded the program. Misappropriation of wheat iscommon, and leakages are as much as 25%-30% in some schemes. The Govern-ment, through CARE and the WFP, is undertaking some measures to improve thesituation. To improve control, it has set up a program for the planning,sanction and monitoring of individual schemes under the authority of thethanas. Specific timetables are established and these are checked by moni-toring teams from headquarters. This procedure is expected to providebetter projects and more orderly implementation. The upgrading of thanasinto upazilas will enable the thana parishads to call on the service of allthe technical staff located at the upazila level for the preparation of theprojects under the FFWP. The upazila staff would be supervised and assist-ed by the district authorities, and the manpower available would thue beadequate. In addition to this, some donor agencies have agreed to allowpart of the wheat provided to be sold through the market and the cashderived to be used for equipment and supplies. The Government is planningconstruction of culverts and bridges on improved roads, and it has alsorequired that thana parishads should contribute to such works, 2j% of thecost in 1982-83 and 5% in 1983-84. Finally, for maintenance, the Govern-ment has initiated a scheme to provide funds for maintenance throughout theyear, and this is to be tested on a pilot scale in 18 thanas (150 unions).

4.26 Some problems remain to be addres3ed. In most of the FFWP, thepaymert of laborers is entirely in wheat (though by substituting maize forpart of the wage, the workers could receive a larger quantity of food-grain). While this provides food to the landless poor, the recipients ofwheat have to sell part of it In order to buy other essential Items, suchas firewood, oil, salt and spices, etc. Furthermore, in the rural areasthe preference is still for rice and some wheat Is sold for rice purchase.When this occursi, the laborers get a much lower price than the marketprice, and thus effectively lose part of their wages. SLnce some cash isnecessary to buy essential needs, it would be desirable to change to asystem in which wages are partly paid in cash. Partial cash payments arenow being made to some women workers and consideration is being given toextending the system to other FFWP projects. The main dlfficulty is to getdonors' agencies to agree to this system, although initially there would beadtinistrative difficulties. With cash available, the chance of misappro-priation might increase, but this could be mlnimized by making an arrange-ment under which the cash Is paid by banks, of which there are largenumbers in the rural areas, aga-ist authorization slips issued by theauthorities in charge of the FFWP.

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4.27 At present, most of the FFWP is carried out mainly during the dryseason, i.e., from November to the end of June. While this is primarilythe lean season for agriculture, this is not the leanest season for foodsupplies, which is usually during the months of September-November immedi-ately before the amen harvest. Most projects (such as the construction ofroads, and digging of canals, etc.) are not possible in this season becauseof heavy rains. The attempt of the Government to start a system of roadmaintenance work throughout the year is, therefore, a welcome step.Further consideration should be given to more types of work which can becarried on continuously throughout the year.

4.28 Other issues remaining to be addressed include whether (and if sohow) nutrition could be made a more explicit objective of the FFWP. Forexample, if this were done, then more attention would be focussed on themost appropriate type of food provided from a nutritional point of view.In addition, there may be room for improvement in the procedure used forthe targetting of programs. At present, the programming is done accordingto distress criteria, which take into account such local conditions as foodproduction deficits, drought and flooding. This procedure, however, shouldbe tied in with a nutrition surveillance system and with the exercise tocreate a nutrition map of the country (see para. 4.04), so that the FFWPcan be targeted to those most in need.

4.29 Finally, there is the issue of the future scale of operations ofthe FWP. Pending the development of other employment possibilities, thereappears to be a need to increase the FFWP. However, an indepth study isnow being carried out jointly by the Bangladesh Institute of DevelopmentStudies and International Food Policy and Research Institute. The primaryobjective of the study is to find out how effective these programs are inbuilding up rural infrastructure and in stimulating the development of therural economy. However, the study is also covering the administrativeaspects of the FFWP, and its results should help the Government and donoragencies to determine how large a role the FFWP could and should play inthe future.

4.30 Vulnerable Group Feeding Program. This program had an interimevaluation in 1980, and it was concluded that the overall performance ofthe project was generally satisfactory. 41/ It also concluded that theVGFP has contributed to reducing the daily hunger experienced by many needywomen and children. In addiL.on, the program appeared to have encourageduse of services in health, nutrition and family planning. However, theevaluation reported that no long term improvements occurred in the nutri-tional status of the beneficiaries. Logistical problems in food distribu-tion, insufficient food rations and compounding factors related to morbid-ity were cited as the most likely explanations for this finding.

41/ UN/FAO World Food Programme. Report on Interim Evaluation of WFP -Assisted Project. Feeding and Rehabilitation of Vulnerable Groups."November 1980.

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4.31 There are many issues still to be resolved about the VGFP - forexample, the extent of food leakages, the potential to make logisticalimprovements, the possibility of modifying the type of food used, andespecially in the targetting and selection of beneficiaries. While on theone hand it is unlikely that the program has no short term aational impact,there are several reasons to suspect that the program may not be particu-larly cost-effective. The entry and exit criteria for the program areextremely vague, the food is handed out for home consumption and there isno nutritional surveillance program. In contrast to this program one canmake a comparibon with the IDA-assisted project in Tamil Nadu. Whereas theper beneficiary cost in the Tamil Nadu project is quite similar to the VGFPprogram in Bangladesh, the Tamil Nadu project involves the weighing andscreening of children aged 6-36 months, objective criteria for feedingthose who are not gaining weight, and nutrition education. Preliminaryevaluation results suggest that the Tamil Nadu program is already having asignificant effect on nutritional status, and it may be possible to re-design the Bangladesh VGFP to improve its effectiveness with relativelylittle additional cost. In particular consideration should be given toinvolving local communities in the process of selecting those most in need(para. 4.48). A recent evaluation of the VGFP may prove to be a usefultool In redesigning the program to be more efficacious in reducing the numr-bers of the malnourished.

4.32 The Future Need for Food Aid. Employment opportunities are quiteinadequate to accommodate the increasing labor force, and the numbers ofthe poor are likely to increase. The need for food aid will, therefore,also increase substantially over the medium term. To provide the under-nourished population in 1987-88 with the government standard of 15.5oz/person/day of foodgra4n would require about 1 million tons more than iscurrently received as food aid. Unless administrative constraints can beovercome, such an enlargement of distributions to the targetted groupscould not be achieved effectively. More realistically the goal should beto provide enough foodgrain to increase caloric intake by about100/cal/day/person by increasing distribution by about 500,000 tons throughthose programs which channel food directly to the disadvantaged groups.These include the FFWP, VGF, and "fair price shops' should the latter beestablished. While food intake would still be inadequate, the situationfor those at the edge of starvation would be improved. However, even anincrease in foodgrain distribution of this nature would require substantialadministrative changes.

Health Programs

4.33 Oral Rehydration Therapy. The crucial role of oral rehydrationin the treatment of diarrhea is now widely accepted. It is also a verycost-effective approach. According to a study 42/ carried out at theICDDR/B, the cost per patient was one-third less When a rehydration regime

42/ Samadi A.R., et al. "Replacement of Intravenous Therapy by OralRehydration Solution in a Larger Treatment Centre for Diarrhoea withDehydration. WHO Bulletin: Vol. 61, No. 2. 1983.

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was used instead of intravenous fluid therapy. In another study, 43/ alsocarried out under the auspices of the ICDDR/B, it was estimated that thecost per patient with diarrhea treated at the Matlab Treatment Center wasbetween $20.81 and $21.93. These costs are relatively high compared tofigures from other countries for oral rehydration programs, though they areprobably comparable to figures reported for hospitals elsewhere. Thisserves to emphasize that a western-style hospital-based approach to thetreatment of diarrheal cases is unlikely to be appropriate for poor devel-oping countries.

4.34 There are five main options open to Bangladesh to produce or pur-chase oral rehydration salts (ORS) packets. The first would be to useimported UNICEF ORS packets -- the unit cost of these is put at about $0.06(i.e., taka 1.4), including freight, etc. The second and third optionsrelate to production by the Government itself. Under the NORP, ORS is man-ually packaged at four centers, and the cost of production in this way hasbeen estimated to be between $0.07 and $0.10 (i.e., between taka 1.7 andtaka 2.4). Although this cost estimate is slightly higher than the cost ofImported UNICEF ORS packets, this metbod of production has the advantage ofdomestic employment generation, etc. In addition to this cottage-industryapproach, the Government has also imported some machinery to undertakelarge-scale production, and the cost of such production is about taka 2 perpacket. The fourth option relates to private productioa of ORS packets. Amajor private producer in the country at present is Gonoshasthaya Pharma-ceuticals, Ltd., an NGO established on a trust basis, and its cost of pro-duction is claimed to be $0.08 (taka 1.8) per packet. A reasonable sellingprice would be about taka 2.0 per packet, but approval has apparently beengiven by the Government for these packets to be sold at taka 2.7 each.And, finally, the Social Marketing Project (SMP) plans to sell ORS packets,manufactured and packaged in the Philippines, at $0.25 (taka 6) per packet,based on a very successful test market trial in 1981-82. The SMP believesthat there is a great unmet demand for ORS packets, and that this could bepartially met through its 100,000 retail outlets. Clearly, at presentlocal production levels the supply of packets is considerably below demand,and there would seem to be plenty of scope for a variety of methods of pro-duction. The supply costs for production by the Government, production bythe private sector, and importation by UNICEF are all probably quite simi-lar, though the selling price proposed by the SMP appears to be undulyhigh. Furthermore, if sales are made though the SMP, it would be importantto ensure that any advertising efforts do not unintentionally undermine thevalue of oral rehydration usiag other types of ORS packets (and indeed theORT programs).

4.35 Another issue relates to the cost-effectiveness of alternativeORT programs. Under the BRAC program, it is estimated that it costs about$2.4 million to reach about 2.5 million households; and for the expansion

43/ Horton, S. Calquin, P. "Cost-Effectiveness Study of Hospital and ofAmbulance Services at Matlab Treatment Centre." ICDDR/B WorkingPaper No. 26. 1982.

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of the program, it is estimated that the cost will be about $3.3 millionfor a further four million households. In approximate terms, the cost is,therefore, just less than one dollar per household and is attributed tocight management and Incentives for workers. Although data on the impactof this program are not yet available, it may well be a very cost-effectiveapproach, and should be viewed as complementary to the ORS programs.Finally, recent experiments have been made at the ICDDR/B with the use ofrice powder electrolyte solution instead of the common salt and sucrosesolution. Initial results suggest that such a solution may be just aseffective in the treatment of acute diarrhea, and less expensive than ORS.

4.36 Only recently has the Government has adopted a national strategyfor the oral rehydration program. The need is now to translate the strat-egy into specific projects which complement the work of BRAC and otheragencies, obtain the necessary resources to carry them out, and implementthem as soon as possible.

4.37 National Blindness Prevention Program. Although distribution ofhigh potency vitamin A capsules reaches about one-half of the rural targetpopulation, prevalence of pre-school age blindness has not been reducedaccording to estimates made over the past five years. There are severalpossible explanations for this. One is that the lack of protein in thediet iahibits effective utiLization of vitamin A; and a second is the highincidence of diarrhea and measles, which, when compounded by malnutrition,precipitates blinding eye lesions. However, were it not for the programwhich is exclusively directed towards preventing nutritional blindness Inpreschoolers, many more children would suffer ocular impairments and totalblindness. In these terms, the NBPP is one of the more effective programsin the health/nutrition sector.

4.38 Nevertheless, questions still need to be raised about the cost-effectiveness of the program, and whether it could be improved through bet-ter targeting. Although the values of some of the major parameters areuncertain, one can illustrate this in the followiag way. On the basis of atarget population (i.e., between six months and six years of age) of 18million children, if it is assumed (on the basis of best estimates) that:(i) the coverage of the program is 45%; (ii) the prevalence of xeroph-thalmia is 6%; (iii) the incidence of corneal lesioas in children withxerophthalmia is 10%; (iv) the incidence of actual blindness among childrenwith corneal lesions is 50X; (v) the efficacy of the vitamin A capsules is75%; and (vi) only 23% of those children whose sight could be saved throughthe program in fact survive from other diseases (particularly measles anddiarrhea), then about 6,000 cases of blindness are prevented each year.The annual basic cost of the vitamin A capsules is about $950,000, but thisfigure should probably be multiplied by a factor of perhaps two or three toinclude the cost of staff time involved in the distribution program. Thecost per case of blindness prevented would therefore be in the range$340-510. Of course, such a calculation. depends critically on the variousassumptions made, and the cost figures are also only broad approximations.

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In addition, an issue still unresolved is whether or not the funds used forthis program are fungable, i.e., whether they could be transferred toanother program if it were found to be more cost-effective. (This questionis difficult to aaswer because although most of the funds are provided byUNICEF, they were raised specially for this program and might not have beenavailable otherwise). Regarding better targeting of the program, its cost-effectiveness could possibly be improved either by the elimination of asecond round of capsule distribution each year with the remaining round ofdistribution being done in the pre-monsoon period, or by focusing on thoseareas with the highest prevalence of xerophthalmia. Also, given the multi-ple etiology of child blindness, of which cataracts, accidents and glaucomaare only marginally considered, in the existing program, the NBPP shouldconsider a more comprehensive strategy to prevent blindness rather thanfocus all of its efforts on a single micro-nutrient distribution approach.Finally, in the long run it is hoped that adequate vitamin A could even-tually be procured from home garden production and from changes in familyfeeding practices, and thereby eliminate the need for vitamin A capsuledistribution altogether.

4.39 Goiter Program. Goiter is a nutritional deficiency which can becontrolled effectively and cheaply by iodizing salt. A salt fortificationtrial undertaken in Tangail Thana indicated considerable improvement in re-ducing the incidence of goiter, with no problem of consumer acceptance ofthe fortified salt by the people. There has also been a preliminary feasi-bility study of the market structure for salt in Bangladesh, and this hasshown that the iodizatioa of salt (with 0.01% of potassium iodate) by allmajor manufacturers (which would be needed to prevent the consumption ofcheaper, non-fortified salt) would provide a means of reaching 90% of theestimated 9 million people affected by goiter in Bangladesh. It would alsoprovide prophylaxis to the rest of the population using iodized salt. Theannual cost of fortification to cover the entire population would beapproximately the same as the ongoing program of lipiodol injections whichcover only about one million people. Clearly, the cost-effectiveness ofsalt iodization in Bangladesh cannot be questioned--but rather the relevantissues concern the Government's interest in the problem, its commitment todo something about it, and how the capital and operating costs of saltiodization could be financed. As far as the latter is concerned, the pos-sibility of using an existing IDA credit for the purchase of the necessaryequipment, and the possibility of UNICEF or another agency supporting theoperating costs for a limited period (probably on a declining basis),should be urgently explored further.

4.40 Lathyrism Program. Although lathyrism affects only a very smallpercentage of the total population, the spastic paralysis which results isa very serious problem. Until recently, no cure for this disease was known-but now the INFS has achieved a possible breakthrough in its treatment byusing vitamin C. The cost-effectiveness of this treatment cannot yet beassessed, partly because the efficacy of the treatment is still uncertain,but mainly because no information is available on the cost side. As far asprevention of the disease is concerned, there are several possible non-exclusive strategies. The main strategy used to be to try to persuade

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people not to grow khesarL, but many of the poorest people had littleoption. The INFS has also identified a process for making khesari non-toxic, but the possibility of such a process being used on a widespreadbasis is questionable. Another strategy lies in the promotion of home gar-dens (and notably the production of food rich in vitamin C), or even in adistribution program for vitamin C capsules. Further work is needed on thelogistics and the relative cost-effectiveness of these possible approaches.

4.41 Nutrition Education. The need to address the macro policy andplanning issues and the production/consumption aspects at the nationallevel must be balanced by also focusing on the delivery of nutrition andnutrition-related services to those most in need at the community level.Of particular importance is the need to develop a nutrition education pro-gram. Because behavloral change (e.g., concerning eating during pregnancy,weaning habits and feeding during sickness) is required to achieve long-term improvements in nutritional status, continuous and persistent personalinteraction is required. This could be supported by appropriate ue- ofmass media. Continuous observation and reinforcement of simple messages isof paramount importance. Raving someone from the same socio-cultural back-ground delivering the messages is beneficial because it increases theclient's trust and confidence.

The Need for an Integrated Aproach

4.42 The various food, nutrition and health programs have been discus-sed largely in isolation. However, for maximum impact at the communitylevel, it is necessary to offer a mix of integrated services to improvenutritional status. While existing community-based programs may differ indetail, it is possible to identify key features which facilitate change andwhich are likely to be needed in future programs.

4.43 One of the essential key features is the monitoring and surveil-lance of children's growth. This can be done in a variety of ways - forexample, by weighing all under-fives each month to identify malnourishedchildren; or by screening them first using measurements of mid-upper armcircumferences and then weighing those children found to be malnourished.This latter method reduces the amount of time spent on the mechanical exer-cise of weighing, and permits the worker to spend more time providingspecial attention to those most requiring it. By focusing on the 'at risk'children, the maximum impact can be achieved while continuing to providebasic services and maintaining periodic surveillance over the entire com-munity. Growth charts are also a useful surveillance tool for monitoringgrowth trends.

4.44 To increase knowledge and to change behavioral patterns that aredetrimental to children's development, it is necessary to carry out nutri-tion education (para. 4.41). This should focus on such topics as earlysupplementation of breast-feeding, the importance of caloric-dense weaningfoods, the need for frequent feeding of young children, the use ofnutrient-rich foods locally available, proper feeding habits duringillness, special nutrition requirements of pregnant and lactating women,hygienic food preparation and health education.

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4.45 Because one worker is required for every approximately 200 fami-lies to maintain the necessary level of surveillance and intensity fornutrition education purposes, the same structure can be utilized to delivera variety of nutrition-related services. Of major importance are the pri-mary health care components, such as basic immunization (DPT, BCG, polio),antenatal care, ORT, deworming and vitamin A capsule distribution. Becausethe village worker's primary contact person in each household is themother, very little added expense is incurred by also deliverIng familyplanning services. The close connection between nutrition, health and pop-ulation matters makes family planning education and contraceptive supply anatural part of an integrated package. In some ongoing projects active con-traceptive user rates have reached as high as 50%.

4.46 Promotion of home gardens (paras. 4.20-4.21) can coincide with,and strengthen, the nutrition education aspect of the integrated program.Local production of nutrient-rich crops could Include: calorie supplements(sweet potatoes, cassava); high quality protein sources (pulses, lentils);and vitamins arnd minerals (fruits and vegetables for vitamins A and C aswell as iroan). In addition, fish cultivation and the ralsing of backyardpoultry could be attempted.

4.47 Environmental sanitation, especially clean water and sanitary la-trines, should also be an integral part of a community-based autrition pro-gram. Such efforts require time and intensive education to change long-standing behlavioral patterns, but agencies such as UNICEF have had verysuccessful tubewell installation projects. The construction and institu-tionalized use of latrines takes a longer time, but can be achieved (asSAVE's experience documents).

4.48 Wasteful use of food resources in the VGFP could also be addressedby attaching the feeding program to a village-level nutritional surveil-lance program. The cost of the expensive food component could be reducedby targeting explicitly for the most severely "at risk' or severely mal-nourished children, thus achieving maximum impact for the food distri-buted. Impact could be raised by virtue of the integrated nature of theprogram. However, problems of appropriate project design, food leakages,appropriate administration and logistics all need very careful attention.

4.49 In the long-run, community-based operations should involve andlead to active community involvement and a high degree of self-reliance.Genuine community participation (i.e., needs assessment capability, equityof benefits and contributions, and organizational capacity) takes specialeffort and requires technical personnel with skills in community organiza-tion or rural development to orient all classes and factions within a vil-lage. As part of this approach, highly specialized efforts at income gem-eration for the poor could be attempted. Of special interest would beschemes to raise employment by involving the landless in service jobs sup-porting agricultural work, by assisting the poor to acquire assets (e.g.,pumps) which can provide a livelihood, and by initiating credit schemes toenable the poor to 1ncrease production.

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The Role of Non-Government Organizations

4.50 Very little is likely to be achieved in nutrition and healthwithout intensive interpersonal contact and interaction with the targetgroup. The Government has acknowledged this fact and has placed primaryattention on upazilas (each covering about 250,000 people) and unions (eachcovering about 15,000-20,000 people). However, these are still too remoteto maintain the close contact with individuals required to achieve nutri-tion rehabilitation and effective preventive care; and the Government hashad little success in its outreach efforts into the villages.

4.51 In contrast, some NGOs have already achieved some notable suc-cesses in delivering services at the village level, particularly throughusing an integrated approach. With poverty being such an integral part ofthe malnutrition causal chain, some NGOs have addressed the issue of how toassist the poorest groups (especially the landless and destitute) so thatlong-term effects on nutritional status can be realized. BRAC, for one,works with homogenous groups made up of only the landless, and devotes con-siderable time having them identify their problems and causes. Other NGOsstress broad-based community participation and attempt to assist the poor-est community members through agricultural groups, credit schemes, serviceemployment and asset procurement. Women's groups are also formed forincome generation as well as for social and educational benefits.

4.52 The administrative process by whicb the NGOs deliver their ser-vices is as important as the services themselves. Of particular signifi-cance are: specific objectives for supervision, in-service training,administrative flexibility and community interaction. The costs for suchcommunity-based projects might be considered expensive on a per capitabasis, $1-2 per year, but they are extremely inexpensive when considered interms of cost-effectiveness. NGO efforts have proven to be a successfulmeans of making the most out of scarce resources.

4.53 Because of the Government's difficulties in operating at the vil-lage level, it is suggested that arrangements be worked out so that NGOsare given more responsibility for administrating community-based nutritionprograms. A positive feeling of cooperation and complementarity must beestablished between NGOs and the Government. The former could act as amediating structure between the bureaucracy and the village, and so assistthe Government to achieve its desired improvements in the quality of lifeof the people.

4.54 The first step would be to have one or more NGOs establish inte-grated health/nutrition projects in several upazilas to test the approach.This experience could provide the opportunity to work out and document howimpact is achieved. It is the "process' or management aspects (managementby objectives, personnel factors, management information systems, supervi-sion and in-service training) that are essential parts of any success andwould have to be part of any expanded program. An important second stepwould be to extend the initial effort to an intermediate size (i.e., a

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district) to provide an opportunity to test the approach in a morerealistic organizational and political environment. The newdecentralization policy which places thana officials in control ofarranging local development projects should serve such a nutrition program,as it would also allow local managers the flexibility to react to specialconditions and situations.

4.55 While the NGOs could be primarily responsible for the actualdelivery of services in the village, the Government could still play anessential role at the intermediate level. The outreach activities couldnot possibly work without the efficient and effective operation of backupsupport and referral services. Mbreover, technical and supply aspects areoften more in keeping with the Government's capabilities. There should be,therefore, a natural complementarity between the Government's and NGOactivities.

V. RECOMMENDATIONS

5.01 Malnutrition in Bangladesh will remain an enormous problem unlesscomprehensive steps are taken to reduce poverty through effective employ-ment generation programs. Nevertheless, there are some other actions whichcould also be taken by the Government and external agencies in both theshort-term and the mediumr-term to overcome some of the mnst critical prob-lems especially of the vulnerable groups. These concern the development ofa coherent nutrition strategy; improvement of appropriate Institutionalarrangements; promotion of low-cost, calorie-dense crops and home gardens;increasing food aid and improving its targetting and effectiveness; andpromoting specific health and nutrition interventions.

5.02 National Nutrition Policy.

- There is a critical need for the developmeut of a nationalnutrition policy and this should be done urgently. A firststep would be to bring together all food and nutrition-relatedinformation as a basis for policy and program design (para.4.02). Particular attention should be paid to the need togenerate more rural employment to help reduce the povertydimension of the nutrition problem. While the NutritionPolicy and Programme prepared in NNC provides a starting pointfor discussion, some issues need to be given detailed atten-tion, such as the relation of food policies to nutritionalstatus, the implementation and coordination of programs, therole of NGOs which are making important contributions, and themost effective means of promoting nutrition knowledge to thepopulace.

- Serious coasideration should be given to the inclusion of afood and nutrition chapter ia the next national developmentplan (para. 4.03), a matter presently under review).

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- There is an urgent need for a nutrition data managementplan to provide early warning of significant seasonalchanges in national and regional nutritional status (para.4.04).

- A "nutrition module' should be developed for inclusion inthe proposed national household survey (para. 4.04).

5.03 Institutional Aspects.

- Consideration should be given to expand representation onthe FPC, particularly with the inclusion of the Ministerof Industry and the Minister of Health and PopulationControl (para. 4.05).

- The NNC should have a primarily advisory and advocacy(rather than policy-making) role, and should be responsiblefor the development and monitoring (but not execution) ofnutrition intervention programs. To do this, it should bestrengthened and expanded to include more private sectorrepresentation, especially from NGOs (para. 4.05).

- A technical unit should be set up within the Government tosupport the policy and strategy work of the FPC. TheGovernment should examine the relative desirability ofdifferent iustitutional arrangements to achieve this, butparticular consideration should be given to the possibleestablishment of an interim food and nutrition task forcebased in the MOP (para. 4.06).

- The FPMS should be strengthened by filling existingvacancies, especially in the Economics Section (para.4.07).

- Further consideratlon should be given to implementing therecommendations of the FAO and World Baak to strengthen theorganization and operational efficiency of the Departmentof Food (para. 4.07).

- The respective roles of the INFS and the IPHN should berevised, with the latter focussing on applied trainiang ofhealth workers ln nutrition subjects, and the formercontinuing to be responsible for university level trainingin nutrition related areas and associated research (para.4.08).

- A mechanism needs to be designed to coordinate thenutrition-related work of NGOs, both amongst themselves andalso vis-a-vis the Government. This could possibly beachieved through significant NGO representation on the NNC(para. 4.08).

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5.04 Food Production Policy, Agricultural Research andCrop Diversification

- Although increased production of foodgrains is the major ob-jective of production policy, attention should also be focus-sed on other products, particularly those which improve thenutrieats in the food supply such as potato, pulses, oilcrops, fruits, vegetables and fish, and those with exportearning potential such as tea, prawns and tobacco. Most ofthese products have favourable benefit/cost ratios, particu-larly tobacco (para 3.11), though improved quality is a pre-requisite for exploiting export opportunities. This couldlead to increased farm incomes and more employment for thelandless farm workers.

- Efforts should focus on increasing the domestic produc-tion of alternative low-cost high-calorie crops and proteinsupplements, that could be produced and/or consumed by thepoor. Foodgrains oriented to the poor include maize, sor-ghum, and pearl and finger mnillets. Of these, maize has thebest production potential, but requires action to develop con-sumer acceptance. This could be initiated by Including somemaize In the food aid from abroad, and also by introducing itin the PFDS (especially the FFWP). Fruits and vegetables richin iron, and vitamins A and C should be promoted through homegardens (paras. 4.16-4.18).

- Prcduction of summer pulses should be strongly promotedand the process of rehabilitating inland fisheries, particu-larly fish ponds, should be initiated (para. 4.17). Leasingof government owned fish ponds to groups of landless should beexplored.

5.05 Rome Gardens

- Home gardens should be promoted through educational programs,and necessary inputs (such as seeds of indigenous vegetables)should be provided.

- The Government should consider carrying out a review of theexperience of NGOs with home garden projects in order to iden-tify the most successful and promising approaches (paras.4.20-4.21).

- Intensified efforts should be made to produce high-calorie crops, pulses, fruits aod vegetables, through homegardens promoted in womenls activities in the existing popula-tion program (paras. 4.20-4.21).

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5.06 Public Foodgrain Distribution System

- Foodgrain stocks should be increased to about 1 million tonsas soon as possible in order to provide the Government withthe flexibility to meet contingencies. Donor cooperation willbe needed to accomplish this (para. 4.22).

- Government needs to manage food policies more effectively andmake progress toward its commitment to reduce the importanceof the ration system and to rely increasingly on OMS. Theration quota of rice should be eliminated, and the rice savedshould be reserved for OMS. Also, the appropriate relation-ships of procurement prices, ration prices and market pricesneeds to be managed toward reducing the influence of theration system and the subsidies involved. Food distributionshould be directed and targeted more directly for the poor.If programs for priority groups (e.g., defense, police, civilservants) cannot be eliminated, the Government should makeevery effort to assure that the maximum amount of foodgrainreaches the poor. -Fair price" shops distributing only lowerquality/cost grains (e.g., maize, sorghum, millets, lowerquality rice, wheat and pulses) should be tested to determinethe feasibility of making a significant nutritional impact onthose most in need. In this way considerably more caloriescould be provided even for the same amount of money now spent(para. 4.23). In particular, these foodgrains could beattractive to the industrial labor force, which is particu-larly vulnerable to changes in the market price and availabil-ity of food. The supplies of these grains could either comefrom local production (para. 4.24), or from a change in theimport mix or quantity.

- Communications efforts and a promotion campaign would be re-quired to gain acceptance by consumers of the new foodgrains.

- Donors should consider Increasing food aid by up to 1 milliontons per annum by 1987-88 (para. 4.32).

- The FFWP should be thoroughly re-examined in light ofthe study now being undertaken. The use of lower cost food-grains (thereby increasing rations to those most in need),partial payment in cash, upgrading of projects through moreequipment and better technical support, and year-round employ-ment for the poorest groups, should all be encouraged.Improved nutritional status should also be made one of theexplicit objectives of the program and further considerationshould be given to ways in which the program could be bettertargetted, once data from the nutritional surveillance systemare available (paras. 4.25-4.29).

-53-

The VGFP should also be thoroughly reviewed in the light ofthe results of the evaluation of the WFP-assisted program.Particular attention should be paid to ways in which it couldbe LUnked to health and family planning services, and also bebetter targetted to the priority groups, for example throughthe involvement of local communities and the establishment ofa well-functioning nutrition surveillance system (paras.4.30-4.31).

5.07 Health Programs

- The Government has now developed an overall and agreed stra-tegy for the oral rehydration program. Specific ORS and ORTprojects should now be designed and implemented as soon aspossible (paras. 4.34-4.36).

- The Government should substantially increase its production ofORS packets, and encourage other sources of supply too. TheSMP should be allowed to supply and distribute ORS packets,though only with safeguards to ensure that other supplies andalso ORT programs are not undermined unintentionally by anyadvertising campaigns (paras. 4.34-4.35).

- Ways in which the cost-effectiveness of the NBPP xeroph-thalmia program could be improved should be explored and fol-lowed up if considered appropriate (paras. 4.37-4.38).

- The Government should legislate to ensure the iodizationof salt. Monitoring activities would then be needed toensure compliance with the law (para. 4.39).

- Further research should be undertaken into the possibleuse of vitamin C to cure lathyrism, as well as theappropriate means to prevent it (para. 4.40).

- The MOHPC in consultation with NGOs and the MOE should developan appropriate nutrition education strategy and program as apriority to introduce behavioral change in such areas as theadoption of weaning foods (para. 4.41).

5.08 Integrated Approach

- Pilot upazila level nutrition projects focussing on vulnerablegroups should be initiated to test the feasibility of deliver-ing an integrated package of nutrition, primary bealth,sanita-tion, and population services to villagers. To the extentfeasible, the communities should be involved in the projectdesign (paras. 4.42-4.49).

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5.09 Use of Non-Government Organizations

- NGO0 should be actively involved in the implementationof community-based integrated nutrition projects.Mechanisms to permit better coordination and coopera-tion between the Government and NGOs should be ex-plored, and NGOs should be included in the member-ship of the NNC (paras. 4.50-4.55).

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ANNX 1Page 1 of 16

STATISTICAL ANNEX

Page

Table 1.01: SUMMARY OF THE FOODGRAIN SITUATION, 1978/79-1983/84 ..... 2

Table 1.02: TRENDS IN AGRICULTURAL PRODUCTION AND VALUE ADDED,1978/79-1983/84 ............... ............... *...*.... 3

Table 1.03: ESTUIATED GOVERNNENT FOODGRAIN STOCKS (END OFMONTH), 1972/73-1982/83 ............ o.o .................. 4

Table 1.04: PADDY PRICES AND PROCUREMENT, 1979/80-1983/84 ........... 5

Table 1.05: INDEX OF MINIMUM MARKET PRICE FOR COARSE RICE,1979/80 - 1983/84 * .............................. 6

Table 1.06: AVERAGE MINIMUM RETAIL PRICES FOR PADDY, COARSE RICEAND WHEAT, 1980 - 1983 .................. 7

Table 1.07: PUBLIC FOODGRAIN DISTRIBUTION SYSTEM 1972/73-1982/83 .... 8

Table 1.08: WEEKLY CEREAL QUOTA PER ADULT CARDHOLDER UNDERSTATUTORY RATIONING, 1973-1983 .............-.............. 9

Table 1.09: RATION ISSUE AND SALES PRICES FOR FOODGRAINS,1965-1983 .............................. .... 10

Table 1.10: FOOD INTAKE BY NUTRIENTS, 1975/76 ....................... 11

Table 1.1 1: NUTRIENT INTAKE EXPRESSED AS PERCENT OF REQUIREMENTS .... 12

Table 1.12: THE COST OF NORMATIVE MINIMUM DIETARY PATTERN ASRECOMMENDED BY FAO, 1963/64-1980/81 ..................... 13

Table 1.13: DAILY CALORIC DEFICITS PER CAPITA, 1976-77 .............. 14

Table 1.14: CALORIC DEFICITS OF SOCIO-ECONOMIC CLASSES, 1976-77 ..... 15

Table 1.15: AVERAGE DAILY WAGE RATES OF UNSKILLED AGRICULTURALLABOR BY DISTRICT, 1973/74-1981/82 ................... o... 16

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ANNX IPage 2 of 16

Table 1.01: SUMMARY OF IHE FOODGRAIN SITUATION, 1978/79-1983/84(in ,000 tons)

Projected78/79 79/80 80/81 81/82 82/83 83/84

Domestic Production, gross 13,029 13,349 14,738 14,367 15,122 16,000Domustic Production, net a/ 11,726 12,014 13,264 12,930 13,610 14,400

Donestic Supply, net b/ 11,785 11,822 13,172 12,814 13,468 14,353

Government Operations

Opening Stocks 591 209 779 1,229 625 630Domestic Procurement 355 348 1,017 298 192 560Imports 1,146 2,739 1,059 1,236 1,844 1,673

Total Distribution 1,796 2,402 1,522 2,036 1,935 1,700Statutory Rationing (417) (492) (343) (307) (307) (250)

Priority Groups (754) (907) (601) (656) (647) (570)11dified Rationing (312) (385) (179) (483) (368) (350)Relief and Food-for-Wobk (261) (497) (399) (435) (495) (440)Market Sales C/ (52) (121) () (154) (118) (90)

Losses 87 .i 104 80 96 96Exports - - - 20 - -Closing Stocks 209 779 1,229 625 630 1,067

Total Availability d/ 13,227 13,876 18,677 14,552 15,211 15,493

Apparent Consumption PerPerson Per Day (ounces) e/ 15.19 15.53 15.00 15.90 15.95 15.84

a/ Gross production ninus 10Z for seed, feed and waste.

b/ Adjusted for crop cycle overlap with fiscal years.

c/ Includes open uarket sales, marketing operations and free sales.

d/ Domestic net supply minus gover3nmnt procurement plus public distribution.

e/ Including increases/decreases in private stock holding.

Sources: ministry of Food; World Food Programm, Dhaka; and World Bank estimates.

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AN1_E 1Page 3 of 16

Table 1.02: TRENDS IN AGRICULTGRAL PRODUCION AND VALUE ADDED, 1978/79-1983/84

Projected78/79 79/80 80/81 81/82 82/83 83/84

A. Production (,000 tons, uoless indicated otherwise)

Foodgrains 13,081 13,400 14,790 14,419 15,122 16,000Rice 12,543 12,539 13,663 13,415 13,991 14,850Aus (3,288) (2,809) (3,237) (3,218) (3,018) (3,150)Aman (7,326) (7,303) (7,837) (7,095) (7,483) (8,100)Boro (1,929) (2,427) (2,589) (3,102) (3,490) (3,600)

Wheat 486 810 1,075 952 1,078 1,150Others 52 51 52 52 54 54

Jute (,000 bales) 6,442 5,963 4,943 4,648 4,881 4,900Cotton (,000 bales) 7 6 10 24 36 40Pulses 225 224 218 214 215 215Oilseeds 265 246 247 252 250 270Sugarcane 6,828 6,340 6,495 7,023 7,359 7,200Potatoes 895 930 983 1,067 1,199 1,000Sweet Potatoes 782 779 693 681 714 720Tea (mMll. lbs) 84 81 88 85 90 100Tobacco (mi. lbs) - - - 52 50 54

B. Value Added, in constant 1972/73 prices (million Taka)

Crops 26,941 26,841 28,481 28,050 29,032 30,177Livestock 3,308 3,392 3,477 3,567 3,699 3,790Forestry 1,520 1,579 1,703 1,803 1,890 1,967Fisheries 2,103 2,097 2,101 2,105 2,200 2,333

Total Agriculture 33,872 33,909 35,762 35,525 36,821 38,267_z~ ~ __-= = =

Real Growth in Value Added (% p.a.)

Crops 1.8 -0.4 6.1 -1.5 3.5 4.6Livestock 4.5 2.5 2.5 2.6 3.7 2.5Forestry 2.0 3.9 7.9 5.6 4.8 3.5Fisheries -27.8 -0.3 0.2 0.2 4.5 5.0

Total Agriculture -0.4 0.1 5.5 -0.7 3.6 4.3

Source: World Bank estimates.

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ANNEK 1Page 4 of 16

Table 1.03: ESTIMAIED GOVERNMENT FOODGRAIN STOCKS (END OF MONTH), 1972/73-1982/83(,000 long tons)

1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982Mbnth /73 /74 /75 /76 /77 /78 /79 /80 /81 /82 /83

July 456 218 349 661 768 415 584 383 1,026 1,235 721

August 362 199 386 635 714 558 577 601 1,225 1,198 820

September 332 223 206 601 644 626 559 818 1,268 1,388 804

October 214 330 162 649 547 547 674 709 1,274 1,343 695

November 219 267 130 707 437 522 823 677 1,236 1,062 705

December 136 267 181 902 420 714 848 726 1,344 987 866

Ja2ary 214 189 319 949 503 756 767 642 1,388 907 904

February 535 171 224 990 509 688 688 502 1,324 685 818

March 493 138 252 931 407 627 502 558 1,255 610 684

April 374 182 282 822 304 557 424 470 1,252 568 640

May 298 210 438 802 296 611 289 582 1,169 514 623

June 297 214 729 823 376 591 209 779 1,229 615 630

Average 327 217 305 789 494 601 579 621 1,248 926 743

High 535 330 729 990 768 756 848 818 1,388 1,388 904

Low 136 138 130 601 296 415 209 383 1,026 514 623

Source: MIriIstry of Food.

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ANNEX 1Page 5 of 16

Table 1.04: PADDY RICES AND ERCaRM4ET, 1979/80-1982/83

Growers' Price Procurmnt Price Difference Procurementof Paddy of Paddy (7k/md) (,000 tons rice)(Tk/u!) (Tklmd)

Amnan Boro Aman Boro Aman Boro Other Total al

(1) (2) (1-2)

1979/80 131 124 110 21 14 175 49 124 3481980/81 105 100 115 -10 -15 501 252 264 1,0171981/82 132 136 124 8 12 117 148 33 2981982/83 158 138 134 24 4 93 75 24 192

a/ In rice equivalent, including wheat

Sources: World Food Programni-, Dhaka; Bangladesi Bureau of Statistics; Mnistry of Food;World Bank estimates.

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ANNEX 1Page 6 of 16

Table 1.05: INDEX OF MIENMUM MARKET PRICE FOR COARSE RICE, 1979/80 - 1982/83(in 1980/81 prices) a/

InstabilityAverage July-Oct. Nov.-Jan. Feb.-April I Index

1979/80 136.7 154.1 131.7 138.2 122.8 9.8Z1980/81 100.0 101.6 95.4 101.3 101.6 4.7%1981/82 111.5 95.4 104.6 135.0 111.4 14.9%1982/83 108.1 111.9 107.8 101.1 102.4 5.0%

a/ NMiimm uarket prices deflated by a non-food consumer price index

b/ Coefficient of variation of monthly niLnimm market prices

Sources: World Food Programme, Dhaka; Ministry of Food; World Bank estimates.

ANINEX 1Page 7 of 16

Table 1.06: AVEMtAE KUNIWM 1EWAIL PRICES FOR PAUDY, CYIRSE RICE AND WMiFA, 1980 - 1983(in dka/MhK4)

Jan. Feb. March April May June July Aug. Sept. Oct. Nov. Dec.

1980

Paddy / _ _ _ _ _ _ _ _ _ _ _

Conrse Rice b/ 190.5 194.0 - 206.2 190.2 178.3 166.5 158.1 158.2 158.2 157.2 156.9

what C/ 117.1 135.5 - 115.7 116.3 113.9 109.3 107.3 112.3 110.2 111.8 107.9

1981

Paddya/ _ _ _ _ _ _ _ _ _ _ _ _

Coarse Rioe b/ 160.2 168.1 174.0 184.1 194.6 175.9 171.5 170.8 171.7 188.6 194.8 198.1

Wheat c/ - - - 106.5 107.7 108.6 110.3 110.2 114.2 188.4 118.9 119.1

1982

Paddy a/ _ _ - - - - - - - - 137.2

Coarse Rice b/ 210.1 243.1 263.1 283.0 225.1 211.1 218.1 218.3 241.3 255.6 231.4 220.1

Wheat C/ 127.2 160.3 153.9 155.2 152.1 143.0 149.2 151.9 170.0 171.7 151.0 147.8

1983

Paddy a/ 147.2 149.6 154.6 155.5 146.9 139.5 138.6 136.3 144.0 150.9 145.1 '48.7

Coarse Rice b/ 234.1 235.8 243.0 245.3 241.3 227.6 227.7 224.6 238.2 246.5 235.6 238.2

Wheat c/ 162.6 160.6 148.6 138.3 144.6 144.0 146.1 148.2 158.8 163.2 153.7 150.6

a/ Reportlnrg of paddy prioes by the DSER started from Nbv. 23, 1982.I Awvrage of 63 Subdivisvla reportiug rice prices.

c/ Average of StikLvisions reportlrg wheat prices. U1nber of Subdivision teportin wkeat prices variesbetwaf a low 20 &wring lean period and high 45 folc*mtng *bat han-t.

Nbte: these are the price series uad to trigger OM sales.

Source: Dinectorate of Supply, Distribution and Raticwdng (SoR), Ministry of Food.

AMU IPap 8 of 16

Table 1.07: PUBLIC EOORIN DISRIBUICIN SYSM 1972/73-1982/83(,000 lag tons)

Food forYear Statutory Priority Modifted Relief Wbrk and Market Oen Total

Rationing Groups Ratimaing and VFP Canl DlggLryg Operations Market Sales

Aunmt % Aountt X Ammt % XAmot Z Amornt % Amomt % I Ammt % Ammt %

1972/73 465 17.8 350 13.4 1592 60.8 207 7.9 - - 4 0.2 - - 2618 1001973/74 502 29.1 396 22.9 777 45.0 52 3.0 - - - - _ _ 1728 1001974/75 471 26.1 554 31.4 578 32.8 161 9.1 - - - - _ _ 1764 1001975/76 359 21.4 584 34.8 496 29.6 110 6.6 116 6.9 11 0.7 _ _ 1677 1001976/77 377 25.6 551 37.4 288 19.6 33 2.2 166 11.3 58 3.9 _ _ 1473 1001977/78 451 24.4 753 40.8 353 19.1 30 1.6 255 13.8 6 0.3 - - 1847 100 a1978/79 417 23.2 754 42.0 312 17.4 45 2.5 216 12.0 9 0.5 43 2.4 1796 1001979/80 492 20.5 907 37.8 385 16.0 57 2.4 440 18.3 10 0.4 111 4.6 2402 1001980/81 343 22.5 601 39.5 179 11.8 50 3.3 349 22.9 - - - - 1522 1001981/82 307 15.1 656 32.2 483 23.7 70 3.4 365 17.9 104 5.1 50 2.5 2036 1001982/83(pro- 308 15.9 647 32.9 368 18.5 85 4.4 410 21.2 70 3.6 48 2.5 1935 100Jected) I I I _

Sourwe: IBDM Report 4277-ND. Bangladesh: Pecent Econordc Trends and Medium Ternm Development Issues. 1983.

ANNEX 1

-63- Page 9 of 16

Table 1.08: WEEKLY CEREAL QUOTA PER ADULT CARDHOIDERUNDER SIAIUTORY RATIONING, 1973-1983

(in seers per cardholder)(1 seer - 2.057 lbs.)

Cereal Quota a/Rice/Wheat

Period Total Rice Wheat Ratio

March 19, 1973- Feb. 23, 1975 3.0 0.75 2.25 1:3

Feb. 24, 1975- Sept. 5, 1975 2.5 0.5 2.0 1:4

Sept. 6. 1975- Aug. 30, 1976 2.5 1.5 1.0 3:2

Aug. 31, 1976- Oct. 15, 1976 3.0 2.0 1.0 2:1

Oct. 16, 1976- March 4, 1977 4.0 2.5 1.5 5:3

March 5, 1977- Dec. 2, 1977 3.0 2.0 1.0 2:1

Dec. 3, 1977- May 2, 1980 b, 3.0 1.5 1.5 1:1

May 3, 1980- Jan 2, 1981 3.0 1.0 2.0 1:2

Jan. 3, 1981- Dec. 11, 1981 2.5 0.75 1.75 3:7

Dec. 12, 1981- July 17, 1983 2.0 0.5 1.5 1:3

July 18, 1983- Present c/ 2.0Kg 0.5Kg 1.5Kg 1:3

a/ Weekly quota for adults. Children are entitled to half the adultquota. The official cereal quota remamied constant during theperiod indicated. The breakup into rice and wheat as shown herereflects the initial policy announcement, but the mix has variedoccasionally during the period depending on availability. Inmanay cases the decisions to change the mix were ad hoc, suw-aryand different for different areas, and records are not available.

b/ From early October to early December 1979, for the statutoryrationing area of Dhaka only, the cereal quota was changed to 2seers of rice and 1 seer of wheat to help lower rice prices in thefree market.

c/ Ration quota set in Kg.

Source: Ministry of Food.

-64-ANNEX 1Page 10 of 16

Table 1.09: RATION ISSUE AND SALES PRICES FOR FOODGRAINS, 1965-1983(in Taka per smund)

Rice Wheat

Wholesale Retail Wholesale RetailEffective Date Issue Sale Issue Sale

NDv. 1, 1965 25.40 26.40 (17.62) a/ (18.80) a/Jan. 1, 1970 29.62 30.80 19.62 20.80Jan. 11, 1971 29.00 30.00Ja.n. 15, 1973 28.82 .. ....

July 1, 1973 38.82 40.00 28.82 30.00Sept. 3, 1973 38.00 ... 28.00May 27, 1974 58.00 60.00 48.00 50.00Dec. 20, 1975 68.00 70.00 53.20 55.00Feb. 7, 1976 87.00 90.00 67.00 70.00Dec. 31, 1977 97.00 100.00 77.00 80.00May 19, 1979 117.00 120.00 87.00 90.00Hay 3, 1980 137.00 140.00 107.00 110.00Nov. 13, 1980 136.00 140.00 106.00 110.00Apr. 11, 1981 151.20 b/ 155.20 112.00 b/ 116.00Dec. 12, 1981 171.00 175.00 120.00 c/ 124.00July 3, 1982 191.00 195.00 130.00 a/ 134.00Jan. 3, 1983 209.00 215.00 139.00 T/ 145.00Jan. 2, 1984 229.00 235.00 149.00 T/ 155.00

-no change.a- Since April 15, 1961.T, Since April 11, 1981, ex-godowan/ex-mill issue prices payable by ration

dealers have been differentiated slightly in accordance with thedistance of the dealers' shops from the nearest MDF warehouse or mill,while retail prices have been maintained at a uniform level throughoutthe statutory rationing areas. As of Jan. 3, 1983, the actual issueprices vary by up to Taka 0.50 per maund for rice, paddy and wheat.

cl Effective Dec. 12, 1981, the issue price for wheat sold to flour millsand large employers was set at TK 129 per maund.

d/ Effective July 3, 1982, the issue price for wheat sold to flour millsand large employers was set at TK 139 per maund.

e/ Effective Jan. 3, 1983, the issue price for wheat sold to flour millsand large employers was set at Tk 150 per maund.

f/ Effective Jan. 2, 1984 the issue price for wheat sold to flour millsand large employers was set at Tk 160 per maund.

Note: The wholesale issue price is the exc-godown/exr-mill price charged toration dealers (and includes the cost of gunnies), while the retailsales price is the price charged to ration care holders buying theirpermissible quota at ration shops. The difference between wholesaleissue price and retail sales price, thus, represents the officialmargin for the ration shop dealers.

Source: Ministry of Food.

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Page 11 of 16

Table 1.10: FOOD INTAKE BY NUTRIENWS, 1975/76(Per person per day, seasonal locations)

3rd Round 4th RoundMonth of Visit Oct.-Nov., 1975 Feb.-pril, 1976

Season Before Aman After Aan

Location Chittagog Rangpur Dacca Chittagong Rangpur Dacca

No. U/R 38 50 50 38 50 51No. Nmebers 249 304 274 236 301 274

NutrientsCalorie 2586 1731 1766 2754 2129 2060Protein (gm) 64.3 49.5 48.9 67.2 55.8 55.9

(AnIml) (11.0) (7.0) (5.6) (6.5) (2.9) (5.1)Fat (gm) 19.5 11.2 9.2 16.9 12.3 12.4Carbohydrate (gm) 551 363 377 591 452 437Calcium (mg) 437 228 193 492 235 312Iron (ug) 27.6 23.5 19.3 29.5 22.3 19.5Vitauin A (I.U.) 571 346 275 1234 325 282Taiamine (mg) 0.73 1.37 1.35 0.96 1.78 1.59Riboflav,n (mg) 0.61 0.69 0.72 0.94 0.85 0.81Niacin (mg) 16.42 19.67 19.19 17.33 23.39 21.34VitamLn C (mg) 3.17 3.47 3.18 15.43 12.27 13.39

Source: Nutrition Survey of Rural Bangladesh, 1975-76, Institute of Nutrition and FoodScience, University of Dhaka

-66-AN= 1Papg 12 of 16

Tae 1.11: NLTM MHA (P. CeT PER DAY) E AS 7IE P CP REWXMJrFM. D 1FRN AGE AND SEX Ges, 1975-76

Ape Fry Prot1 cim IrI. 1Vitamin A L |RbOfnI 1acin V C(yearz) M _ I ___ I (Z) I (% ) I()Cb-ldren Both Sexs

1-3 46 68 32 101 30 93 38 71 134-6 64 98 46 180 50 127 46 102 317-9 68 102 57 230 44 139 50 111 34

Adoesents F M F M F M F P F FM F M F M F

10-12 77 76 114 109 50 42 293 264 44 22 150 155 54 54 121 123 53 3013-15 81 86 140 134 60 55 281 188 52 25 158 170 58 162 126 133 36 3316-19 100100 158 129 97 53 634 159 43 15 192 176 701 61 154 155 53 25

AMilt N F M FM F M F HF FM F M F N F

20-39 95 123 140 156 97 86 441 177 34 35 187 238 64 82 155 200 40 3140-49 101 121 136 15B 96 89 644 194 38 27 200 253 71 90 161 195 43 2750-59 106 124133 142 112 80 600 106 31 20 215 231 73 82 173 192 42 3660-69 113 133 124 136 75 88 379 117 27 69 239 276 82 100 189 221 31 3470+- 132106 124 96Ill 55 401 89 41 47 249 226 89 86 201 178 54 31

P 35ant (P) 103 127 24 51 35 236 79 105 30

tatacing (L) 97 96 33 89 23 244 84 158 40

P & L 68 65 18 118 12 190 67 112 13

of al agesand sexes 90 125 66 292 35 179 64 115 35

Source: Nhtrition Survey of Rural Bangl4adh, 1975-76, Institute of Nbtritici and Food Science,University of Dhaka.

Nbte: Average per capita oomsuuption of fat wns found to be 12.2 gis., 5.2cnrIibtng 5.Z2of caloric Intake. In 1982, awerage daily Intake fell to 9.8 gm., coqrisingonly 4.4%. of calories. 1. Is eEraUly beievea that detary fat sbhld provde atlprt 15-20Z of daily caloric intake. AcorHdng to the FAD/W3D eqLdrents, thefipr oc 9.8 gs. accoumts for less than 25% of daily nidnlm ureeds.

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Pag 13 of 16

Table 1.12: M1E COST CF NM-%TI lMM D1ErAR PATMNW AS 1FW ) BY FAO, 1963/64-1980/81

Cost (in Takas) f/

Food Item Oz/perso/day Calorie/day 1963/64 1966/67 1973/74 1975/76 1976/77 1978/79 1980/81

Rice / 12.7 1,238 0.30 0.45 1.16 1.48 1.28 1.78 2.07

*eat b/ 1.3 124 0.02 0.03 0.04 0.06 0.07 0.09 0.11

Pulses 2.6 258 0.08 0.08 0.33 0.48 0.36 0.56 0.83

Gur & Sugar c/ 1.2 138 0.03 0.04 0.14 0.27 0.21 0.24 0.31

mLmk 3.5 66 0.09 0.10 0.22 0.46 0.47 0.52 0.64

MBat d/ 1.3 41 0.10 0.09 0.31 0.44 0.44 0.69 0.82

Fish & Eg3 0.9 33 0.07 0.06 0.28 0.39 0.46 0.62 0.76

Fruits & 0.29 0.83 1.12 0.81 1.44 1.41gtables e/ 13.6 291 0.31

Oils & Fats 0.6 143 0.15 0.09 0.25 0.36 0.31 0.44 0.57

Total 2,332 1.15 1.23 3.56 5.06 4.41 6.38 7.50

Cost Index(1973/74 - 100) 32 35 100 142 124 179 211

a/ Price for meaun quality rice is used in calcu1ating cost of diet.6/ Rice/whet mix is based a: saiahility in Bwgladeslh/ Price of gur is used In calailatg cost of diet.r/ Price of bf is used in aalclOati cost of diet./ Price of potato is used in calailatirg cost of diet.

Costs are based an natial averap prices.

Scurce: Statistical Year Bodos of B1gladesh, IBS.

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Table 1.13: DMLY CALORIC DEFICITS PER C&PI'rA, 1976-77(Assuming a standard of 1620 cal. from foodgrain and 400 cal. from other food)

Per Capita Total Per CapitaCaloric Deficit Equivalent Caloric Deficitfrom Foodains Rice GRI from Other Foods

Class (pTer day) l k,W itas. (per &ay)

Landless farm workers 230 396 271Small farmrs 118 116 264Medium fA rs (w1stly tenants) 22 22 234Medium farnrs 0 0 298Large farmrs 0 0 156Very larg farmrs 0 0 131Rural inforal nan-farmrs 269 243 269Rural foral no-farmers 0 0 137Urban nfomil 90 41 222Urban formal 0 0 23

Average or Total 20 818 182

Sotrce: Derived from 1976-77 Bangladesh Household Expediture Survey, Bangladesh Bureauof Statistics and Center for World Food Studies, Free University, Aiterdam.

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ANNE IPage 15 of 16

Table 1.14: CALORIC JEFICrrS OF SOCIO-ECONOMIC CLASSES, 1976-77(Compared with per capita norm of 2,020 cal/day)

Equivalent EquivalentDeficit R1ice Gap Popuation Rice Gap

Deficit C__s_ (cal/dayTcap) (Kg. per cap) U 113-LiisT 1,00tons

Landless farm workers 501 50.8 16.85 856

Sll farmers 382 38.7 9.67 374

Medium farnurs(mainly tenants) 256 25.9 10.04 260

Medium farmers(m:inly owers) 64 6.5 10.92 71

Rural informal(non-farmers) 538 54.5 8.88 484

Urban itformal 312 31.6 4.50 142

Total population with caloric deficit 60.86 2,187

Source: 1976-77 Bangladesh Household Expenditure Survey, Bangladesh Bureau of Statisticsand Center for World Food Studies, Free University, Amsterdam

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Table 1.15: AVERAGE DAILY WAME RAMES OF UNSEULED AGRICULUTRAL LABORBY DISTRICT, 1973/74-1982/83

(Taka per day)

Division 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982District /74 75 176 /77 178 1J79 /80 /81 /82 /83

RajsbabiDinajpur 5.62 7.89 8.30 8.00 8.00 10.00 10.83 10.50 11.83 14.00Rangpur 6.18 6.79 7.35 7.54 7.50 9.58 10.17 14.08 15.17 14.33Bogra 5.33 6.83 7.92 8.42 8.42 9.58 10.00 10.00 12.08 15.00Rajsbahi 5.61 7.88 8.08 7.29 8.00 9.17 13.00 15.50 15.67 14.92Paboa 5.81 7.55 8.63 7.91 7.67 10.58 10.17 11.83 14.67 15.82

hnaKushtia 4.83 7.42 7.32 8.C) 8.84 9.50 11.50 11.17 10.92 11.58Jessore 4.91 6.92 7.50 7.67 9.00 i.67 10.33 12.50 12.92 13.58hulna 5.40 7.09 8.55 7.50 9.09 10.00 13.75 15.00 15.17 15.58BarIsal 8.52 10.83 10.20 10.08 10.00 11.33 13.83 15.42 15.83 16.00Patuakbali 6.82 9.75 8.81 9.92 9.59 9.33 11.33 13.75 14.83 16.92

DbakaM(ymensingh 6.87 8.43 8.09 8.50 10.00 11.83 12.50 12.50 13.50 15.00Tangail 6.60 8.21 7.27 6.71 8.00 9.58 11.67 14.50 15.00 15.00Vaaka 8.92 11.74 9.29 9.29 10.00 10.92 13.83 16.25 21.25 23.25Faridpur 5.58 7.83 7.27 9.17 10.00 11.42 12.50 13.08 14.08 15.00Sylhet 8.86 11.52 11.55 10.29 11.17 12.42 15.00 15.00 15.42 20.00

Couilia 6.51 10.14 9.42 8.96 8.67 12.42 14.75 15.00 17.08 18.75Noakbasl 8.50 12.38 11.27 9.33 10.25 11.75 16.42 16.42 19.02 22.75Chittagoog 8.77 12.08 11.07 12.27 12.84 13.00 13.75 18.50 20.25 24.25Chittagong H.T. 8.27 10.86 11.29 13.42 12.84 14.50 16.67 17.25 20.83 24.75

Country Average 6.69 9.05 8.82 8.93 9.44 10.88 12.46 13.98 15.38 17.05

4L/ Includes Jamal4ur.Note: All districts and country averages are uimeighted averages of the wage rates In the

respective constituent adbinlstrative units. Wages e=x-ude value of any food received.

Source: Bangladesh Bureau of Statistics.

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TECHNICAL ASPECTS OF NUTRITION

1. The data used in the following analysis come primarily from thefollowing surveys of food consumption and nutritional status: (i) 'Nutri-tion Survey of East Pakistan 1962-66," conducted by U.S. Department ofHealth, Education and Welfare (NSEP 62-66); (ii) "Nutrition Survey of RuralBangladesh 1975-76," conducted by the Institute of Nutrition and FoodScience, University of Dhaka (NSRB 75-76); (iii) 'Report on NutritionaLStatus of Vulnerable Groups of Rangunia, Chittagong and Dhaka," undertakenby the Institute of Public Health and Nutrition. December 1976 (IPEN 76);(iv) 'Study of the Children of Bangladesh,, by UNICEF/Foundation for Re-search of Education and Development Planning 1978-81 (FRXDP 78-81); (v)Nutrition Survey of Rural Bangladesh 1981-82," conducted by the Instituteof Nutrition and Food Science, Dhaka University, (NSRB 81-82). Not yetpublished; (vi) 'Survey of Vulnerable Group Feediug Beneficiaries by theWorld Food Programme (VGF)"; (vii) "Report on the Deterioration of Nutri-tion in Bangladesh," by Cipriano A. Canosa, WHO Consultant, Feb-May 1983;(viii) "Goiter Prevalence Survey," conducted by the Institute of PublicHealth and Nutrition (1981-83). Not yet published; (ix) "XerophthalmiaPrevalence Survey," Bangladesh 1982-83 (XPSB). Initial Data Report. May1983; and (x) -Report of the Household Expenditure Survey of Bangladesh1976-77," Bangladesh Bureau of Statistics. Not yet published. (BES76-77).

Patterns of Food Consumption

2. The available data poignantly illustrate the deterioration of percapita food consumption over the last 20 years. Average daily per capitacaloric intake fell from 2,301 calories in 1962-66 to 1,943 calories in1981-82, a decline of 16.0x. The degree to which this figure representscaloric deficiency varies with estimates of minimun required calories forthe Bangladeshi population. Previous World Bank studies 11 have estimateda daily per capita requirement of 2,020 calories, the fgigure which has beenused consistently by the Planning Commission. Even if a slightly lowerstandard is used, the average per capita caloric intake of the Bangladeshipopulation still falls below the estimated minimum requirements; and theintake of the poorest is significantly below the average.

1/ Odin K. Knudsen and Pasquale L. Scandizzo. Nutrition and Food Needs inDeveloping Countries. World Bank Staff Working Paper No. 328. May1979.

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Table 2.01: DAILY NUTRIENT INTAKE PER CAPITA

Nutrient NSEP 1962 - 66 NSRB 1975 - 76 NSRB 1981 - 82

Calories 2,307.0 2,096.0 1,943.0Protein g 57.9 58.5 48.4Fat 15.8 12.2 9.8Carbohydrate g 482.0 439.0 412.0Calcium mg 273.0 305.0 260.0Iron mg 10.3 22.2 23.4Vitamin A 1,870.0 730.0 763.0Thiamine mg 1.5 1.7 1.4Riboflavin ug 0.5 o.9 .7Niacin mg 23.2 22.3 13.2Vitamin C ng 48.0* .9.6 13.3

* Did not allow for losses in cooking.Source: NSEP 62-66: NRRB 75-76: NSRB 81-82.

3. Average per capita consumption of protein fell from 58.5 g in1976 to 48.0 g in 1982, a decline of 18Z. Two important points must bemade regarding protein consumption. First, the source of protein (animal,legumes, cereal) determines metabolic use and efficiency. For example,only half of wheat protein can be used for metabolic purposes unless eatenwith protein from animal or legume sources. Given that less than 10% ofdaily protein is derived from animal sources the quantity of protein avail-able for metabolic purposes in the typical Bangladeshi diet is severelydeficient. Second, a calorie deficient diet preempts part of the proteinconsumed for energy purposes, Which turns marginal protein intake into pro-tein deficiency. Given the magnitude of caloric deficiency among theBangladeshi population and the restricted quality of dietary protein avail-able, average per capita protein consumption is undoubtedly lower thanminianum requirements.

4. Average per capita consumption of fat declined by 18% from 12.2 gin 1975-76 to a low of 9.8 g in 1982. This figure of 9.8 g represents 4.4%of total calories consumed, and accounts for only 25% of the FAO/WHO recon-mended level. Adequate dietary intake of fat is especially critical forpregnant women and young children, due to its important role in cellstructure and membrane formation, among other things.

5. Of the major micronutrients, only thiamine at 1.38 mg and iron at23.4 mg per capita per day meet minimum requirements. As discussed later,

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the pervasiveness of anemia among the Bangladeshi population implies sig-nificant losses of iron due to malabsorption. Average per capita intake ofVitamin A, at 763 I.U., is markedly deficient, meeting about one-third ofthe recommended intake. Average daily Vitamin C consumption, at 13.26 mg.per capita, meets about 50% of the recommended level. However, this isenough to prevent scurvy, the clinical mamifestation of Vitamin Cdeficiency. Riboflavin, at 0.7 mg per capita per day, is less than onehalf of the requirement.

6. It is important to remember that these food intake figures repre-sent the average and do not reveal the severity nor the magnitude of fooddeprivation among the lower income groups; nor the dramatic seasonal varia-tions; nor the differences between and within the districts; nor the biasesintroduced in the household.

7. The Nutrient Value of Food. Cereal grains, consisting of 90%rice and 10% wheat, are by far the most important item in tl-e Bangladeshidiet. Cereals are the easiest way to meet the caloric requirement; butthey are short of some essential nutrients. In the recent past, averaleper capita daily intake has been 405 g of rice and 45 g of wheat. _/Comparison of the nutrients from these quantities of cereal with daily re-quirements reveals the average nutrient gap (see Table 2.02).

Table 2.02: COMPARISON OF NUTRIENTS FROM DAILY CEREAL CDNSUMPTION WITHDAILY REQUIREMENTS

Item Weight Protein Energy Ca Vit.A Ribo- Vit.Cg g per NPU Net cals mg mg flavin mg

-00 g Z g mg

RiceParboiled,Milled 405 8.5 66 22.7 1413 40.5 12.15 0.49 0

Wheat flourwhole 45 12.2 49 2.7 153 21.6 4.35 0.13 0

Cereal Total 25.4 1566 62.1 16.5 0.62 0

Requirement 30.0 2020 450 700 1.2 30

Shortfallfrom cereals 4.6 454 388 684 0.58 30

(15.5%) (22.2%) (86%) (98%) (48%) (100%)

Source: Nutritive Value of Indian Foods. 1977; and FAO/WHO Handbook onHuman Nutrition Requirements, 1974.

2/ 1976-77 Bangladesh Household Expenditure Survey, Bangladesh Bureau ofStatistics.

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8. The NSRB 75-76 Report includes data on other foods consumed percapita per day, but not in a consolidated form. Table 2.03 is aconsolidated list of noncereal foods consumed per capita per day, with anestimate of their energy yield. Uafortunately, classifications such as"other vegetables" and "other fruits" involve guesswork to assess thecalories per gram. The INFS has calculated the nutrient intake from thesefoods together with cereal consumption (see Table 2.01). The results indi-cate a low intake of calcium, vitamin A, riboflavin and vitamin C. TheNSRB 1981-82 reveals a lower calorie intake, and an even lower intake ofthe micro-nutrients quoted above. When closing the caloric gap, diversifi-cation of the extra food consumed would be essential to meet therequirements for micro-nutrients.

Table 2.03: INTAKE OF NON-CEREAL FOODS PER CAPITA PER DAY

Food Weight (g) Calories per Gram Total Calories

White Potato 17.10 1.00 17.10Sweet Potato 18.50 1.20 22.20other roots 16.70 0.80 13.36White Sugar 0.40 4.00 1.60Jaggery 3.60 3.80 13.68Other sugars 3.30 3.50 11.55Pulses 23.80 3.34 79.49Green Leafy Vegetable 20.20 0.45 9.09Green and Yellow Veg. 32.00 0.40 12.80Other vegetables 73.50 0.70 51.40Mango 4.00 0.74 2.96Jackfruit 7.30 0.88 6.42Citrus 3.50 0.50 1.75Other Fruits 5.80 0.60 3.48Meats 3.80 1.00 3.80Fish 22.30 0.80 17.84Milk 16.80 0.05 0.84Fat 3.20 9.00 28.80

298.20

Sources: NSRB 75-76 Report; Nutritive Value of Indian Foods, 1977.

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ANNEX 2Page 5 of 31

Nutritional Status of the Populstion

9. Nutritional status may be assessed by anthropometricmeasurements, biochemical determinations or clinical examination. The mostcommon method is anthropometry, whicb uses measurements such as weight-for-age, height-for-age, -weight-for-height, rate of weight gain and mid-upper-arm circumference. Each measurement is compared to a normal distributionof similar samples taken from one of several reference populations. Thedegree of malnutrition is then defined in terms of deviation from the stan-dard. The Gomez classification, based on weight-for-age measurements,defines malnutrition as follows:

Weight-for-Age(as a percent of standard)

First DIegree (mild) 75Z-90%Second Degree (moderate) 60%-74%Third Degree (severe) Below 60%

weight-for-age is used to assess the degree of long-term nutritionaldeprivation, as it affects skeletal growth. Height-for-age less than 90%of the reference population is evidence of chronic malnutrition.

10. Weight-for-height is an age-independent proxy of nutritionalstatus. A child is considered acutely malnourished or "wasted" if height-for-age is normal (i.e., above 90% of standard) and weight-for-height islow (i.e., below 80% of standard). A child is considered chronically mal-nourished or 'stunted" if weight-for-height is normal, but height-for-ageis low. The final category is referred to as concurrent acute and chronicmalnutrition, whereby the child has both low weight-for-height and lowheight-for-age.

11. Children Aged 0 - 4 Years. Young children have relatively highmetabolic energy needs for growth and development and they respond quicklyto changing levels of food intake. Assessment of their nutritional statusmay be used as a proxy of nutritional status for the general population.Three of the surveys provide data on the prevalence of protein-calorie mal-nutrition (PCM) among children aged 0-59 months. The results are set outin Table 2.04.

Table 2.04: COMPARISON OF PCM PREVALENCE BY WEIGHT-FOR-HEIGHT OF CHILDREN0-4 YEARS

Survey Year N Normal Mild Mod/Severe

NSRB 75/76 4296 33.3% 45.1% 21.6%FREPD 79/80 1905 45.8% 28.3% 25.9%NSRB 81/82 NA NA NA 20.0%

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ANNEX 2Page 6 of 31

12. The noderate/severe cases are all acute ralnutrition. Table 2.05is based on the Gomez weight-for-age classification and sets out second andthird degree PCH by age and by income group. In this table, group A repre-sents the very poor who pay no tax; B, the poor who pay a little tax; C,the moderately well off who pay more tax; and 1, the better off who payfull tax.

Table 2.05: SECOND AND THIRD DEGREE PCM BY AGE AND INCOME GROUP(According to Gomez Weight-for-Age Classification)

1981-82

Age %Gomez 2nd and 3rd Degree PCM Combinedin months (By Income Level)

A B C D All

0-11 35.13 57.90 51.85 33.33 45.5312-23 74.29 71.43 71.88 57.85 70.2524-35 57.15 67.86 64.29 45.00 58.8936-47 65.21 78.26 75.00 42.10 65.4348-59 70.37 71.42 86.37 38.89 68.42

0-59 59.34 68.42 69.37 43.30 61.18

Source: NSRB 1981-82. Preliminary Results.

13. The most striking feature of Table 2.05 is that all rural incomelevels are seriously affected by PCM. Even the highest income level, D,has 43.3% of children under five years of age classified as moderately orseverely malnourished. The poorest category, A, appears to be lessaffected than the higher socio-economic categories B and C. This may, inpart, be due to differential rates of infant and child mortality. Althoughinfant mortality, at a rate of 140 per 1,000 live births, may have affectedthe poorest group more than the o -.ers, it alone cannot account for the 9%difference between A and B plus the 10% difference between A and C.

14. The 1979/80 FREPD study investigated the nutritional status ofchildren by income levels of households. Table 2.06 illustrates theresults for children 0-59 months. These results confirm the finding thatall income levels suffer from a high prevalence of PCM. The smll samplesize of those with an income of less than 2,000 Taka per year may reducethe value of comparison, yet it is interesting that 40% of mothers in thepoorest category are apparently able to bring up their cnildren to benutritionally normal.

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Table 2.06: NUTRITIONAL STATUS OF CHILDREN 0-59 MONTHS BY INCOME LEVEL OFHOUSEHOLDS

Over- Mild Moderate SevereAnnual Income nourished Mal- Mal- Mal-

Taka N and Normal nutriton nutrition nutrition

Less than 2,000 65 40.00% 32.31% 20.00% 7.69%2,000 - 4,999 558 37.07% 29.75% 20.43Z 10.75%5,000 - 9,999 659 42.49% 28.07% 20.18% 9.26%10,000 - 20,000 298 48.33% 27.85% 17.11% 6.71ZGreater than20,000 97 45.37% 34.02% 14.42% 6.19%

Overall 1,677 41.79% 29.10% 19.38% 9.12Z

Source: The Situation in Bangladesh 1981. UNICEF/FREDP. Uaiversityof Dhaka.

15. Between the ages of 12 and 59 months, mid-upper arm circumference(MUAC) should increase by an average of 1 cm., and thus is 8 measurementrelatively independent of age. Although insensitive to recent changes Innutritional status, the MUAC provides a useful means to assess the nutri-tional status of communities. As part of the 1982-83 Xerophthalmia Preva-lence Survey, Bangladesh data on the MUAC of children 12 to 59 months werecollected. The nutritional status of these children is presented In Table2.07 by division and district.

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ANNEX 2Page 8 of 31

Table 2.07: MID-UPPER ARH CIRCUMFERENCE OF CHILDREN 12-59 MONTHSBY DIVISION AND DISTRICT

Division &District Nutritional Status (2)

Severe Moderate Normil N12.4cm 12.5 - 14.0cm 14.1cm. +

Dhaka 10 37 53 683

Dhaka 12 40 48 264Faridpur 10 32 58 125Jamalpur 14 38 48 42Mymensingh 8 35 57 201Tangail 2 47 51 51

Chittagong 10 38 52 821

Chittagong 11 46 43 263Comilla 10 40 50 183Noakhali 13 45 42 148Sythet 5 23 72 227

Khulna 13 47 40 563

Barisal 16 53 31 260Jessore 3 50 47 40Khulna 14 36 50 187Kushtia 3 52 45 63Patuakhali - 69 31 13

Rajshahi 7 37 56 756

Bogra 6 44 50 124Dinajpur 4 42 54 97Pabna 7 66 49 113Rajshahi 11 28 61 148Rangpur 6 34 60 274

Overall 10 40 51 2,823

Source: Xerophthalmia Prevalence Survey: Initial Data Report: May 1983.

16. The overall prevalence of severe malnutrition at 102 is con-sistent with the 9.12% found In the FREPD study. An important aspect ofthe xerophthalmia survey is the data on the geographical distribution of

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ANNEX 2Page 9 of 31

malnutrition. The highest prevalence of severe malnutrition was found inthe following districts: Barisal 16X, Khulna 14%, Jamalpur 14%, Nbakhali13%, Dhaka 12%, Rajshahi llZ and Chittagong 11%. In the FREPD study, whenmoderate and severe PCM were combined, the highest prevalence was found InRajehahi Division at 34.5Z, followed by Chittagong Division, 32.3Z, DhakaDivision, 22.7%, and Khulna Division, 21.7%. Clearly, PCH is a nationwideprobl-em, tbough some districts are much nore severely affected than others.

17. Stunting. The body adapts to insufficient food intake byreducing energy expenditure and/or by reducing body growth. Initially, theyoung child receiving insufficient food will become thin and wasted,weight-for-height will be low, but height-for-age will remain normal. Asadaptation takes place, weight-for-height will become normal and height-for-age will become low. The rate of growth at the lower height will benormal. The body size will have adapted to a lower food intake and thechild will be physically stunted. Investigations continue to determinewhether physical stunting is coincidental with retarded development andfunctioning of the central nervous system.

18. The NSRB 1981 data bave been analyzed for stunting by age and byincome groups. Preliminary results are shown in Table 2.08. The numberof stunted children is comparatively low for the first year of life; ittakes time for the body to adapt, but the obvious adaptation by year twopoiats to serious deprivation of food intake during the first year.Stunting affects all rural socio-economic groups; category D, the best-off, has only half of its five year old children stunted compared withover three quarters stunted In the other socio-economic groups. The over-all result, that three quarters of all rural children are stuated by theage of five years, reveals a history of food deprivation throughout earlychildhood.

Table 2.08: STUNTING BY AGE AND INCOME GROUP 1981-82

Age X Stunting Low Weight-for-Age NDrmal Weight-for-HeightIn Mionths A B C D All

0-11 29.73 28.95 22.22 14.90 25.2012-23 51.43 45.71 65.63 63.16 55.3724-35 71.43 82.14 57.14 50.00 67.7836-47 69.57 86.96 81.25 57.89 74.0748-59 85.19 78.57 86.36 50.00 76.84

0-59 58.67 60.53 60.36 46.39 57.25

Source: NSRB 1981-82. Preliminary results.

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ANNEX 2Page 10 of 31

19. Pre-adolescent School Age Children. Table 2.09 presents a com-parison over the last decade of the prevalence of PCM among children 5-14years of age by weight-for-height. As would be expected In view of thehigh prevalence of stunting, the number of moderate/severe cases of acutePCM is much less than in the 0-4 year age group. However, a prevalence inthe range of 12% to 19% is still a matter of grave concern.

Table 2.09: COMPARISON OF PCH PREVALENCE (WEIGHT FOR HEIGHT) 5-14 YEARS

Survey Year N Normal Mild Med/Severe

NSRB 1975-76 788 36.2 51.5 12.3FREPD 1979-80 2741 46.4 34.6 19.0NSRB 1981-82 NA NA NA 12.3

20. The FREPD Study 1979/80 included children 5-12 yeirs of age inits investigation of the nutritional status of children by household in-come levels. The results are shown in Table 2.10. Using weight for heightas the criterion, normal children will include a proportion of stuntedcbildren, yet it is noteworthy that about 55% of the mothers in the poorestcategory seem able to feed their children adequately. Severe malnutritionremains high in the poorest category at 6%, compared with 8% in the 0-4year age group. In all other categories the prevalence of severe malnutri-tion has halved. All socio-economic categories continue to be affected.

Table 2.10: NUTRITIONAL STATUS OF CHILDREN 5-12 YEARS BY HOUSEHOLD INCOMELEVEL

Over- Mild Moderate SevereAnnual Income nourished Mal- Mal- Mal-

Taka N and Normal nutrition nutrition nutrition

Less than 2,000 112 54.47% 28.57% 10.71X 6.25%2,000 - 4,999 847 43.21% 35.77% 15.67% 5.55X5,000 - 9,999 1076 43.35% 35.97% 14.22% 4.46%10,000 - 20,000 537 49.92% 33.15% 14.9% 2.23%Greater than 20,000 164 53.05% 28.66% 14.63% 3.66%

Source: The Situation of Children in Bangladesh, 1981. UNICEF/FREPD.University of Dhaka

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21. Pregnant and Lactating Women. During pregnancy extra caloric In-take is needed for growth of the fetus and the placenta, for the increasedenergy Involved in moving a heavier mother, and for the deposit of fatnecessary for lactation. An extra 285 calories per day throughoutpregnancy has been recommended by WHO/FAO (1973). During lactation, WHO/FAO (1973) recommends a daily per capita increment of 550 calories. Basedon the NSRB 1975-76 data, however, pregnant and lactating women are themost nutritionally deprived members of the Bangladeshi population. Averagedaily caloric deficit among pregnant and lactating women was found to be32%. Inadequate food consumption is attributed to several factors:culturally biased food practices which restrict both the quality andquantity of food consumed; and deleterious fertility practices, includingparity of 6 to 7 children, childbearing before age 20 and after age 40, andclosely spaced births. Socio-economic status is not significautlycorrelated with maternal nutritional status. 3/. Recent data collected ina perinatal nutrition survey by Canosa 41 reveal the magnitude of mal-nutrition among pregnant and lactating women: 44.8Z and 32.4% of pregnantwomen of the urban elite fall below 50 kg in weight and 147 cm in height,respectively (Table 2.11). Among the rural poor, 100% of pregnant womenfall below 50 kg, and 57% below 147 cm.

Table 2.11: WEIGHT AND HEIGHT OF PREGNANT WOMEN, 1983

Socioeconomic Z with Weight below 50 kg % with Height below 147 cmSector

High income Urban 44.8Z 32.4%Low income Urban 83.4% 44.6ZHigh income Rural 76.9% 38.5%Low income Rural 100.0% 57.1%

Source: C. Canosa. Deterioration of Nutrition in Bangladesh. WHO, 1983.

22. Canosa's data on post-delivery maternal weights (Table 2.12) areconsistent with the low mean weight of adult females and with the data onthe low weight of pregnant women. The pervasiveness of maternal

3t S. Huffman. Determinants of Postpartum Amenorrhea inRural Bangladesh. Thesis. Baltimore. Johns Hopkins University.1977.

4/ Cipriano A. Canosa. Deterioration of Nutrition in Bangladesh.WHO. April 1983.

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malnutritlon In Bangladesh is also evidenced by the high incidence of lowbirth weight babies (Table 2.13). Data on birth weights and gestationalage are not routinely collected in Bangladesh. However, In a recent surveyon perinatal nutrition, 48.42 of rural newborns were found to weigh lessthan 2.5 Kg. In developed countries, 2.5 kg. is regarded as the cut-offpoint for intensive care. Although a lower cut-off point might be moreappropriate for the Bangladeshi population, the severe consequences of lowbirth weight should not be treated lightly. Low birth weight is normallycoupled with low body stores of iron and vitamin A; resistance to infectionis substantially reduced; and subsequent growth and development areadversely affected. Small babies have much lower survival potential aswell as a higher likelihood of permanently short stature. Although nutri-tional status of the pregnant woman plays a critical role in fetal andinfant development, other factors (such as young maternal age, closely-spaced births, infections, anemia, and lack of antental care) also contri-bure to low birth weight babies.

Table 2.12: MOTHERS' WEIGHTS AFTER DELIVERY (Kg)

Socio-EconomicCategory N Meau Weight S.D.

High Urban 112 51.5 9.7Low Urban 339 43.6 7.2High Rural 16 43.2 5.9LOW Rural 29 41.8 3.6

Source: C. Canosa. Deterioration of Nutrition in Bangladesh. WHO,April 1983.

Table 2.13: BIRTH WEIGHT OF NEW-BORN BABIES (Kg)

Socio EconomicCategory N Mean Weight S.D.

High Urban 112 2.80 0.55Low Urban 339 2.63 0.46High Rural 16 2.33 0.61Low Rural 29 2.38 0.37

Source: C. Canosa. Deterioration of Nutrition in Bangladesh. WHO.April 1983.

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Micro-Nutrient Deficiencies

23. Vitamin A. Vitamin A (retinol) cannot be synthesized bymetabolic processes In the body, and thus must be derived from food. Lackof vitamin A in the diet impairs growth, reduces resistance to infection,and causes changes in the epithelial surfaces. The ocular manlfestationsof vitamin A deficiency are referred to as xerophthalmia, which includesnight blindness, Bit8t spots, and destructive lesions of the cornea. Xero-phthalmia is reversible up to the point of destructive corneal lesions(ulceration and keratomalacia), at which point total blindness results.The Bangladesh National Blindness Prevention Programme (NBPP) recentlyconducted a Xerophthalmia Prevalence Survey. 5/ At 83 rural sites, 18,660children (aged 3 months - 71 months) were examined; an additional 3676children were examined at 17 urban sites. The prevalence of night blind-ness In rural areas was found to be 3.8%, two-three times higher than hadbeen reported previously. The prevalence of Bit8t spots was only 0.9%.Peak prevalence of cornesl involvement occurs between two and four yearsof age. The greatest incidence occurs during the monsoon season, partic-ularly in the northwest and southeast regions of the country. Night blind-ness and non-corneal xerophthalmia increase consistently with age and aboveone year, the rates for males are strikingly higher than for females. Thecurrent annual estimate of blind children under 6 years of age Is 30,000.However, between 3X% to 50X of blinded children do not survive, as theirpoor nutritional status predisposes them to acute illness followed bydeath. All told, 15-18,000 children less than 6 years of age arevictimized etach year by blinding malnutrition.

5, Xerophthalmia Prevalence Survey, 1982-83, Initial Data Report, May 83.IPEN, Ministry ot Health and Helen Keller International.

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Table 2.14: PREVALENCE OF NIGHT BLINDNESS, CONJUNCTIVAL XEROSISAND BITOT SPOTS BY DISTRICT AND DIVISION

XN XIA XIBDivision Night Blindness Xerophthalmia Bit8t SpotsDistrict N Z N Z N Z

Dhaka 168 3.6 130 2.8 41 0.8

Dhaka 64 3.9 62 3.8 22 1.4Faridpur 36 3.5 11 1.1 4 0.4Jamalpur 14 5.6 7 2.8 3 1.2Mymensingh 44 3.2 43 3.1 11 0.8Tangail 10 3.0 7 2.1 1 0.3

Chittagong 242 4.6 123 2.5 57 1.1

Chhittagong 63 4.1 50 3.2 27 1.8Comnlla 75 6.3 33 2.8 17 1.4Noakhali 23 1.9 6 0.5 6 0.5Sylhet 81 6.5 34 2.7 7 0.6

Khulua 115 3.0 47 1.2 22 0.5

Barisal 54 3.2 17 1.0 8 0.5Jessore 9 2.4 4 1.1 3 0.8Khtulna 33 2.3 17 1.2 9 0.6KushbItia 14 3.O 9 1.9 2 0.4Patuakhali 5 7.1 0 - - -

Rajshahi 149 2.9 63 1.3 49 1.0

Bogra 19 2.7 16 2.2 10 1.4Dinajpur 21 3.6 12 2.1 8 1.4Pabna 23 2.7 10 1.2 7 0.8Rajshahi 20 1.8 7 0.6 6 0.6Rangpur 66 3.8 18 1.0 18 1.0

Source: Xerophthalmia Prevalence Survey 1982-83. Initial Data Report, May1983.

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24. The NBPP, with support from UNICEF, has launched a national pro-gram to distribute high potency vitamin A capsules (VAC) every six monthsto all children in rural areas. The Xerophthalmia Survey of 1982-83 foundVAC distribution coverage to be 45Z in rural areas and 22Z in urban areas.Prevalence of night blinduess among children who had received VAC in thepast year was 26 per 1000, compared with 43 per 1000 for children not givenVAC. Bowever, less than half the mothers surveyed knew that the capsulehad anything to do with the eyes and only 2% had seen the UNICEF flip bookon vitamin A deficiency and feeding habits.

25. Iodine Deficiency: Goiter. The thyroid gland produces a hormone,thyroxine, which has an important-role in controlling reactions in the bodyinvolving cellular energy. An essential element in thyroxine is iodine.The body has no source of iodine other than from food. In the absence ofiodine, the gland tries to compensate for the deficiency by Increasing itsactivity and thus the thyroid gland swells. The condition is known as goi-ter. In the early stages goiter may cause no symptoms, but untreatedgoiter causes difficulties in breathing and coughing, as well as changes inthe voice. A severe form of iodine deficiency is cretinism, which is mani-fested in a wide range of symptoms: mental retardation, impaired physicalgrowth, deafness, deaf-mutism and neurological abnormalities. Cases ofdeaf-mutism in highly endemic areas of Bangladesh have been reported, butthey are rarely encountered. Foods grown on soil low in iodine contain In-sufficient iodine to meet human needs, hence iodine deficiency is affectedmore by geology than by dietary habits. Data collected in the Goiter Pre-valence Survey reveal widespread prevalence of goiter throughoutBangladesh. An estimated 4.75 million school age children and 4.25 millionadults suffer from some grade of goiter. The situation is particularlysevere in the districts of Jamalpur, lRangpur and Dinajpur.

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Table 2.15: PREVALENCE OF GOITER: RURAL DISTRICTS. 1981-82

District Population N Grade of Goiter Total ZGroup _ la lb 2 3 4 A Positive Positive

Dhaka N.A.

Faridpur Community 3076 178 21 5 1 3 - 208 6.76ZSchool 6150 280 76 16 3 - - 375 6.10Z

Jamalpur Community 1289 219 126 71 37 15 3 471 36.54ZSchool 1885 381 109 71 24 3 - 588 31.19%

Mymensingh N.A.Tangail Community 1429 63 38 31 23 9 - 166 11.48%

School 1657 141 31 10 6 - 2 190 11.47%Chittagong Community 1985 279 43 8 2 1 - 333 16.78%

School 1799 216 68 6 - - - 290 16.12ZComilla N.A.Noakhali Community 1417 3 - - - - - 3 0.21%

School 4392 158 64 10 2 - - 235 5.35%Sylhet Commumity 7181 254 84 25 20 3 2 388 4.97%

School 8631 480 72 15 7 - - 579 6.71%Barisal N.A.Jessore Community 9241 297 29 9 2 1 - 338 3.66%

School 6473 457 97 21 - - - 575 8.88ZKhulua Community 6605 427 46 12 6 1 3 485 7.34%

School 5870 642 123 14 6 - 4 789 13.24%

Kushtia Community 1839 35 29 6 7 2 - 79 4.30%School 2481 83 14 - - - - 97 3.91%

Patuakhali N.A.Bogra Community 3761 381 104 78 9 7 1 580 15.42

School 3724 325 121 81 14 1 - 544 14.61Dinajpur Community 2013 652 179 42 13 7 1 894 14.87

School 5150 639 261 120 23 58 4 1105 21.46Pabna Commnmity 4274 202 74 44 18 10 2 350 8.19

School 5151 298 77 30 4 - - 409 7.92Rajshahi Community 7323 152 22 3 12 1 - 190 2.59

School 7821 195 24 19 1 - 1 240 3.07Rangpur Community 6456 864 454 194 123 18 - 1655 25.64

School 7853 1650 549 116 19 12 265 2623 33.40

Source: Derived from Field Data: Goiter Prevalence Survey, 1981-82.Institute of Public Health and Nutrition.

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26. Of the various methods that have been proposed for assuring ade-quate iodine intake, the use of iodized salt has proved to be the most costeffective and the most widely adopted. Far more costly is the use of lipi-odol, an injectable solution of iodine in oil. The Institute of Nutritionand Food Science conducted a trial of lipiodol Injections aimed at bringingrelief to 50,000 goiter victims. While 95% of all those treated had nofurther visual enlargement of the thyroid, the iijections were tooexpensive for general application.

27. A trial of fortified salt was undertaken in Tangail Thana. Noproblems arose regarding acceptance of the fortified salt by thecommunity. After six months the test village showed a reduction in theprevalence of goiter compared with the control village. During the secondsix months, however, no significant differences were found between the testvillage and the control village. This was probably due to the iodation ofthe salt having become ineffective during storage. Techniques for iodationof salt are now well established so that any difficulty experienced on theexperimental scale should be overcome easily.

28. Iron Deficiency: Nutritional Anemia. A relatively small amountof iron is absorbed by the body from food. Absorption of iron from meat isabout 30X; from soybean 20%; from fish 15%; and from cereals, vegetablesand pulses, 10% or less. Although undermilled cereals, the dietary staplein Bangladesh, contain iron, they also contain phytic acid, which binds theiron making it unavailable for absorption. The result is a very lowabsorption level of iron from the high cereal diet of Bangladesh. Datafrom the NSRB 1981-82 indicate that iron in the diet amounts to 23-24 mgper capita per day; even at 10% absorption this intake is nearly threetimes the recommended daJly intake for all groups other than menstruatingand pregnant women.

Table 2.16: DISTRIBUTION OF CHILDREN, 0-4 YEARS BY LEVEL OF HEMOGLOBIN

Hemoglobing per 100 ml of Blood . Children

Below 10 54%10-10.9 28%11-11.9 13%12 and over 5%

Source: NSRB 1975-76

29. Yet the prevalence of nutritional anemia is extremely highthroughout Bangladesh, as shown by the NSRB 75-76 data (Table 2.16). Chil-dren, aged 0-4 years, are the most adversely affected population

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group. Eighty-two percent of this age group were found to be anemic, witha mean hemoglobin level of 9.7 g per 100 ml. (The WHO minimim level forchildren 0-4 years is 11 g per 100 ml of blood.) Among the 5-14 year olds,74% of boys and 75% of girls were anemic; among adults, 62% of men and 70%of women were anemic. Based on the sample population, anemia affects anestimated 12.1 million children, 0-4 years; 21.5 million children, 5-15years; 15.8 million adult men; and 17.3 million adult women. Dietarydeficiencies of vitamins A and C, both critical to the successfulabsorption of iron, together with widespread prevalence of bookworm havebeen identified as the primary causal factors by the Institute of Nutritionand Food Science.

30. Vitamin C Deficiency. The recommended daily allowance (RDA) ofvitamin C is 30mg/capita/day. Data from the NSRB 81-82 reveal that theaverage daily intake of vitamin C is 13.26 mg, a figure well below theRDA. The clinical manifestation of vitamin C deficiency, scurvy, is rarelyseen, bowever, as a minimum of 10 mg daily prevents its occurrence. TheRDA could easily be met with the daily consumption of half an orange or asmall helping (50 mg) of a green leafy vegetable.

31. Riboflavin Deficiency. Riboflavin is involved in metabolizingenergy and protein for use by the body. Experimental work with laboratoryanimals has demonstrated that liberal intakes of riboflavin result in aloag productive life, an extended period of adult-efficiency and vigoroushealth. Riboflavin deficiency may result, in sores at the angle of themouth, chapped lips, or swollen, fissured and painful tongues. TheRDA is 1.8 mg for adult men and 1.4 mg for adult women. However, the datafrom the NSRB 81-82 reveal an intake of 0.687 mg/capita/day. Clinicalsigns of riboflavin deficiency are reported in abundance throughout ruralBangladesh. Parboiled, hand-pounded rice provides 0.12 mg per 100 g ofrice and 0.17 mg per 100 g of whole wheat. The high cereal diet of thepopulation is unlikely to provide sufficient riboflavin. Some green leafyvegetables, such as amaranths, are a good source as are mDst pulses. Meat,eggs, fish and dairy products are rich sources of riboflavin, although thedairy products depend on the diet of the animal producing the milk.

32. Lathyrism. This is a spastic paralysis of the lower limbs causedby one or more toxins in the seeds of Lathyrus sative (khesari dhal). Theseverity of the paralysis depends on the amount of toxin ingested and thenutritional status of the individual. The incidence of lathyrism is nega-tively correlated with income level. Khesari-dhal is inferior to rice andwheat, and is only consumed in large amounts when the cereal crop hasfailed and foodgrains are scarce. Little data exist on the magnitude ofthe problem. However, the northern and western regions of the country seemto be most affected.

The Etiology of Malnutrition

33. Malnutrition has affected the vast majority of the Bangladeshipopulation for the last 20 years. Evidence suggests that the situation may

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be getting worse, particularly for the poorest members of the population.In absolute terms, the number of malnourished has increased by an estimated720,000 cases per year over the last decade. Within this group, theinfants, young children and pregnant and lactating women suffer the gravestnutritional insult.

34. Infants, 0-11 Months. From birth, Bangladeshi children are smal-ler, both by weight and linear measure, than healthy children from theNorth American reference population. 6/ As shown in Table 2.17, growthcurves of Boston and Bangladeshi. infants are similar and parallel up tothree nDuths of age, attributable to the fulfillment of nutritional re-quirements through breastfeeding. 7/ By the age of four months, however,when infants begin to require food in addition to mother's milk,Bangladeshi infants fall behind the Boston infants in both height andweight gain, at which point the pattern of malnutrition has beenestablished.

Table 2.17: GROWTH PATTERNS OF INFANTS 0 TO 11 MONTHS

Indicator Birth-2 months 3-5 months 6-8 montb 9-11 months

Z weight gain forBangladeshi infants 84 22 9 7

Z weight gain forBoston infants 68 33 20 11

s height gain forBangladeshi infants 20 10 5 5

Z height gain forBoston infants 20 10 7 6

Source: Moslemuddin Khan, George Curlin, J. Chakraborty. Growth andDevelopment Series: Meheran International Centre for D±arrhoealDisease Research. Report No. 28. July 1979.

6/ Bangladeshi infants are 1-2 kg. lighter and 4.5 cm. shorter than theirBoston counterparts. BangLadeshi infants of the same length weighed90% at birth of this reference population.

7_ S. Huffman. Determinants of Postpartum Amenorrhea in RuralBangladesh. 1977.

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35. Infant Feeding Practices. Ninety-nine percent of all Bangladeshiwomen breastfeed their children. The median duration is 30 months 8/ butrural women continue even up to 5 years. 9/ However, the practice o? dis-carding the yellowish colostrum, secreted during the first 3-6 days afterbirth, places the infant at risk of illaess. The protein found incolostrum protects the infant against a number of infections and may helpto prevent the onset of allergies. Otherwise, breastfeeding is the normalpractice. Table 2.18 details the duration of breastfeeding.

Table 2.18: DURATION OF BREASTFEEDING

At Birth 1-12mo. 13-24mo. 25-36mo. 37-48mo. 49mo. +

Urban Poor 98 90 63 }5 I 0Rural 100 98 85 58 10 5Urban Elite 78 25 4 1 - -

Source: Moslehuddin Khan: -Infant Feeding Practices in Rural Meheran,Comilla, Bangladesh. American Journal of Clinical Med. 33:2356-2364. Nov. 80.

36. Milk from an adequately nourished mDther provides all the nutri-ents which a child needs for the first few months of life. Supplementaryfeeding depends on the Individual and should start from four to six monthsafter birth. The low mean weight-for-age of Bangladeshi infants would sug-gest that supplementary feeding should be started from an early age. How-ever, starting too early risks diarrhea; starting too late risksmalnutrition. Because of the high risk of diarrhea, the practice inBangladesh has been to delay the start of supplementary feeding. The FREDPstudy found that supplementation prior to 10 months of age is negligibleamong the poor. When given, it consists of rice, wheat, or barley in aliquid mixture, a supplement of low caloric density. By the age of 10months a maximum of 25% of rural infants have received such a mixture, thebalance receive nothing additional to breast-milk. They must be regardedas being half-starved and PCH is inevitable, due particularly to culturalbeliefs rather than lack of available food.

8/ S. Huffman, Ibid.

9/ Moslemuddin Khan. "Infant Feeding Practices in Rural Meheran, Comilla,Bangladesh. American Journal of Clinical Nutrition. 33:2356-64.Nov. 1980.

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37. The weight-for-age of male and female children less than 60months old was collected in the surveys of 1975-76, 1978 and 1981 and com-pared with the NCHS standard. Female Infants under 12 months were found tohave a much greater deviation from the standard than did male infants ofthe same age. For both sexes, the rate of weight gain among theBangladeshi infants begins to slow down in the third month. By thefifteenth month, the difference between the mean weight of Bangladeshichildren and the standard is over 3 kg. Thereafter, the growth ofBangladeshi children continues more or less in parallel with the standard.Thus it appears that the main nutritional damage is done between the age of4 to 15 months. This is a particularly critical juncture in infantdevelopment, as it is during months 5 to 10 when brain tissue normallygrows at its fastest rate. Of the 3 million infants in this age group, atleast 2.3 million, from all socioeconomic groups except the highest, sufferfrom varying degrees of PCM.

38. Children 12 - 59 Months. Most infants who are nutritionally de-prived during their first year do not manifest overt PCM until year two.Table 2.19 illustrates the percentage of acutely and chronically mal-nourished young children by age.

Table 2.19: DISTRIBUTION OF ACUTELY AND CHRONICALLY MALNOURISHEDCHILDREN BY AGE GROUP

Age in Months % of Acutely Malnourished % of Chronically Malnourished_Children Children

0-11 12.20 25.2012-23 36.36 55.3724-35 20.00 67.7836-47 11.11 74.0748-59 16.84 76.84

Source: NBRB 1981-82. Note: these figures include those children whichsuffer concurrently from both acute andchronic malnutrition.

39. The greatest prevalence of PCM is in the second year of life.As the body adapts itself to a lower level of calorie and protein intake,acute malnutrition ceases to be as pervasive. However, the cuumlativeeffect of long-term nutritional deprivation results in an increased preva-lence of physically stunted children, until, by the age of 4 years, threequarters of all Bangladeshi children are stunted. The 25.22 of stuntedchildren in the 0-11 months age group may appear to be surprisingly high,given that stunting results over time. Recalling that nearly half of allrural babies weigh less than 2.5 kg at birth, the explanation becomesobvious: many Bangladeshi children are already stunted at birth. Based on

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estimates of the population for 1983, Table 2.20 shows the number ofchildren who are acutely or chronically malnourished. The most criticaltime to prevent the onset of PCM is during the first year of life. Twelveto thirty-five months is the peak period for prevalence of acute mal-nutrition and this age group should have priority in the application ofmeasures to bring about rehabilitation. After the third year, adaptationhas usually taken place, and the majority of the damage has been done.

Table 2.20: NUMBER OF ACUTELY AND CHRONICALLY MALNOURISHED CHILDRENBY AGE GROUP

Age in Months Estim.Population 1983 Acut. Malnour. Chron. Malnour.

0-11 3,089,000 377,000 778,00012-23 2,996,000 1,089,000 1,657,00024-35 2,996,000 599,000 2,031,00036-47 2,996,000 333,000 2,216,00048-59 2,684,000 452,000 2,062,000

2,850,000 8,749,000

Source: Derived from Table 19. Note: these figures include thoseclassified as "stunted and wasted."

40. Table 2.29 summarizes the number of people affected by the mainnutritional deficiency diseases in Bangladesh. With the possible exceptionof vitamin A deficiency, the absolute numbers of those affected have beenincreasing annually.

Table 2.21: MALNUTRITION IN BANGLADESH(Numbers of People Affected, in millions)

--- PC!M-- Vitamin A Goiter AnemiaDeficiency

Age Group Acute Chronic XN XIB -

Pre-school Children 2.85 8.75 1.0 0.20 N.A. 12.1School Age 3.5 20.40 N.A. N.A. 4.75 21.5Adult N.A. N.A. N.A. N.A. 4.25 33.1

Source: Derived from data quoted earlier, plus estimates of the urbanpopulation at high risk.

41. Although foodgrains are the most important item in theBangladeshi diet, the colsumption of foodgrains should not be equated with

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total food intake, nor is food purchased the same as total food Intake.Many wild plants and fruits are gathered by the rural poor, and small fishare also caught. The urban poor, however, do not share a similar non--market food contribution, and thus may be even worse off than the ruralpoor. Tables 2.05 and 2.06 referred to the nutritional status of childrenby socioeconomic classes. Both tables indicate that the surviving children(although there may be proportionally fewer survivors) in the poorest ruralclasses are better off nutritionally than some other classes with higherincomes, due perhaps to the additional consumption of non-market foods.

42. For the purpose of analysis, the population may be divided intotwo categories: urban and rural. The urban population is divided intourban formal (those households whose head has a permanent job with govern-ment or private sector) and urban informal (those whose heads do not). Therural population is divided lnto agricultural and non- agricultural. Thelatter is also divided into formal and informal The rural agriculturalgroup is divided into six classes based on size of land farmer and owner-ship status.

Table 2.22: CRITERIA OF SOCIOECONOMIC GROUPS

Classification Characteristic

1. Landless farm worker 0 land of own cultivated

2. Small iarmers 1.5 acres

3. Medium farmer (tenant) 1.5 - 5.0 acres

4. Medium farmer (owner) 1.5 - 5.0 acres

5. Large farmer 5.0 - 7.5 acres

6. Very large farmer 7.5 acres

7. Rural informal non-agr. Non-agr. rural populationminus rural formal

8. Rural formal non-agr. Permanent job with govern-or private sector

9. Urban informal Urban population minusurban formal

10. Urban formal Permanent job with govern-ment or private sector

Source: Center for World Food Studies, Amsterdam.

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43. Foodgrain consumption does relate to socioeconomic classes 10/and the landless farm workers, small farmers and rural informal nonfarmersare those who purchase the least. Ninety-three percent of the populationlive in rural areas, 40Z (1980) own no farmland, and the number of landlessis increasing annually. The 1-4 year old death rate among famil ies owningless than 0.1 acre has been reported as 86.5 per 1 000 compared with 15.2per thousand among families owning over 3 acres 11/. The very high 1-4year death rate may explain wby those who survive appear to be better offnutritionally. If the 8.65% who tie were classified as severely mal-nourished, the whole picture would change. The estimated monthly percapita income required for caloric adequacy in 1974 was 76 Takas in ruralareas and 83 Takas in urban areas. More than 66% of the population fellbelow this minimum monthly income required for nutritional adequacy 12/.In the 1975-76 NSRB, further deterioration in the relationship betweenincome and nutritional adequacy was revealed.

44. Knowledge and Beliefs. Many dietary beliefs affect the nutri-tional status of both mother and child. During pregnancy, adequate quanti-ties of food are not consumed lest the baby's size increase abnormally.Eggs are not eaten for fear of destroying the fetus. Many pregnant womenassociate eating vegetables with edema; and meats are avoided to preventthe child from inheriting the characteristics of the relevant animal. Theconsequence is that babies are born with unduly low birthweights as well asinadequate stores of vitamin A and iron.

45. As discussed earlier, the vast majority of mothers regard milk asthe most valuable child food and believe that breast feeding is essentialfor children. However, the practice of discarding the colostrum deprivesthe baby of its natural food supply during the first few days of life andrenders it more liable to infection. Food beliefs also affect the qualityof breastmilk. Lactating mothers do not eat vegetables lest the baby suf-fers from stomach diseases and they do not eat meat for fear that it mightpoison the milk. Others avoid fruit and fish. Abstention from these foodsresults in breastmilk which is dangerously low in essential vitamins.

46. Some time between the age of four and six months, breast milkalone is no longer sufficient to maintain normal growth and supplementaryfoods are required. Seventy-five percent of infants in the rural areas re-ceive no supplementary food in addition to breast milk until after the

10/ 1976-77 Bangladesh Household Expenditure Survey. Bangladesh Bureauof Statistics.

11/ Mujib R. Khan. Socioeconomic Determinants of Nutrition. UNICEF 1979.

12/ Household Expenditure Survey. 1973-74.

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age of 10 months. 13/ Nutritionally, this practice is disastrous and maylead to PCM. The reason is fear of diarrhea. Unhygienic environmentalconditions are closely related to poverty and the introduction of supple-mentary or weaning food carries a high risk of infecting the infant withcontaminated food. The onset of PCM is so gradual that it passesunnoticed; the onset of diarrhea cannot be ignored. The effect of povertyis not so auch an inability to purchase food for the infant, but thecreation of an environment which leads to the child being half starved.

47. When supplementary food is given to the infant it is usuallyrice, wheat, or barley in a liquid form. Such a supplement has a lowcaloric content per unit of volume. The infant has a small stomach andsuch a supplement is too bulky to provide adequate caloric Intake. Amongrural mothers and the urban poor, weaning to a solid diet is deferred untilthe child is between 24 and 27 months.

48. Environmental and Social Factors. Periodic cyclones, massiveflooding and man-made disasters have changed, and may continue to change, aprecarious nutritional situation into the need for an emergency reliefoperation. Variations in food availability occur from one year to thenext, as well as from season to season, and are often reflected as changesin nutritional status. Tables 2.23 and 2.24 taken from the CompaningojHealth Project in Noakhali illustrate the marked influence of seasonalvariation on nutritional status. Bairagi found that male children werebetter off in both seasons and that nutritional status declined with in-creasing birth order during the season of scarcity.

Table 2.23: SEASONAL VARIATION IN NUTRITIONAL STATUS(in percent)

Weight-for-Age November-January May-July

Less than 60% of standard 15.0% 26.5%60%-80Z 73.9% 67.7%

Greater than 80% of standard 11.1% 6.7%

Source: R. Bairagi. -Is Income the only Constraint on Child Nutrition inRural Bangladesh." WHO Bulletin 58/5:767-772. 1980.

49. Seasonal variation is not uniform throughout the country. Asshown by Clay's analysis of NSRB 75-76 data in Table 2.24, Dhaka is at itslowest point in per capita caloric consumption when Chittagong is at itshighest. Variations also occur within each district, as a function of thesocioeconomic status of any particular household. In those areas where

13/ M. Khan. Infant Feeding Practices in Rural Meheran, Comilla.American Journal of Clinical Nutrition. 33:2356-2364. Nov. 80.

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traditional subsistence farming is practiced, greater undernutrition existsbefore the aus harvest (June to July) and before the aman harvest(September to mid-November). The variation in diet is almost entirely avariation in the consumption of rice. The preharvest period of the amanrice crop, from October to November, is the period of least food con-sumption. The proportion of cereals in the diet increases, although abso-lute foodgrain consumption per capita declines. Non-grain foods, such asvegetables and root crops, become scarce, resulting in a total reduction offood intake by as much as 20X.

Table 2.24: DAILY CALORIC INTAKE BY REGION AND SEASON

Period Chittagong Dhaka Rangpur

May-July 1975 130 75 83Aug-Sept 1975 126 95 95Oct-Nov 1975 122 83 82Feb-Apr 1975 130 95 100

Source: Edward J. Clay. Poverty, Food Insecurity and Public Policy inBangladesh. Institute of Development Studies, Univ. of Sussex,1980.

50. Sex and Age Discrimination. Sex and age discrimination inthe household distribution of food have been well documented among theBangladeshi population. No children less than 15 years of age met the re-quired minimum dietary intake of food. Pregnant and lactating women were32% deficient In calories and 35Z deficient in protein. The average percapita food intake of males consistently exceeded that of females in allage groups by 17%. For children under 5 years the difference was 16%; forchildren 5-14 years, 11%; for adults, 29% (without allowing for pregnancyand lactation); among adults over 45 years ma'es consumed 61Z more thanfemales. Among young children, based on weight-for-age, 14.4% of femaleswere severely malnourished compared to 5.1% for males. Child mortalityamong the severely malnourished was 45% higher in females than males.

51. Food scarcity may not explain sex disparities in mortality andmorbidity rates. In the male-dominated Bangladeshi society, women are per-ceived as having little economic value. Daughters, almost withoutexception, marry by the age of 17 years and leave the family. A daughterunfortunate enough to return to the house of her parents, due to separationfrom or death of her husband, experiences tremendous adverse discriminationin food distribution as she is seen to be a burden. Security for theparents in old age depends on the son's economic position. These contrastsare obvious from an early age; sons are favored compared with daughters,receiving more food, more education and better health care.

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52. Health Care. The ICDDR,B, has maintained a Demographic Surveil-lance System (DDS) 'i Matlab, Bangladesh. The DDS area comprises 149 vil-lages with a population of 175,887 in 1979. Of the 2429 deaths registeredin 1979, 35% were infants, 19% aged 1-4 years, and 23% in the age group 60and above. Among the 8,071 total pregnancies terminatinX In 1979 in theDDS, there were 7,190 live births. The reported fetal wastage was 953,yielding a rate of 133.9 fetal losses per 1,000 live births. These con-sisted of 93 miscarriages and 41 stillbirths per 1000. The infantmortality rate was 116.4 per 1,000 live births. Table 2.25 gives detailsof the causes of death.

Table 2.25: CAUSES OF DEATH, CHILDREN 0-11 MONTHS, 1979

Cause Male Female Total

Tetanus 181 150 331Respiratory 43 46 89Fever (all forms) 15 14 29Diarrhea 8 12 20Dysentery 10 5 15Measles 3 8 11Other 180 161 341Unknown 1 _ 1

All causes 441 396 837

Source: Derived from DSS - Matlab Vol. 9, Vital Events and Migration1979. ICDDR,B. Report No. 56, 1982.

53. For the age group 1-4 years, the pattern of causes of deathchanges from the pattern for those under one year of age. Dysentery anddiarrhea account for 30% of the deaths, with significantly more femalechildren dying. Table 2.26 gives details of the causes of death among 1-4year old children.

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Table 2.26: CAUSES OF DEATH - CHILDREN I TO 4 YEARS, 1979

Cause Male Female Total

Dysentery 35 81 116Diarrhea 7 19 26Measles 32 46 78Dropsy 16 31 47Drowning 29 17 46Fever (all forms) 19 22 41Respiratory 15 21 36Other 27 50 77

All causes 180 287 467

Source: Derived from DDS Matlab, Vol. 9, 1982.

54. The ICDDR,B has calculated the cause-specific death rates per100,000 for 1-4 year old children. These are shown in Table 2.27.

Table 2.27: CAUSE-SPECIFIC DEATH RATES PER 100,000 CHILDREN,1-4 YEARS

Cause 1976 1977 1978 1979 1980 1981

Diarrhea 109.6 89.1 144.9 120.3 140.4 154.1Dysentery 624.0 695.7 656.2 536.4 493.6 362.1Dropsy 182.6 214.3 149.3 217.3 221.9 220.6Fever 292.2 197.9 257.9 189.6 267.2 199.8Measles 907.0 52.8 199.1 360.7 244.5 262.3Tetanus 51.7 39.6 40.7 41.6 113.2 79.1

Source: Selected Cause-Specific Death Rates, MATLAB. Preliminary results.

55. Diarrheal Diseases. In 1981, approximately 462,000 childrcLi aged1-4 years died from diarrhea and dysentery in Bangladesh, well over 1,000each day. For children less than 12 months, diarrheal disease is not amajor killer due to the minimal amouat of food received before reaching 12months of age. Diarrheal diseases are a major contributory factor to mal-nutrition. During an episode of diarrhea, about 9% of the food eaten isexcreted. In addition, withholding of food and fluids is a widespreadtreatment for diarrhea. A moderately malnourished child may be precipi-tated to a very serious nutritioaal condition by the onset of diarrhea andits traditional treatment. Malnourished chiUdren have up to a 50% higherincidence of diarrheal disease and suffer more severe attacks than

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normally nourished children. Studies 14/ demonstrate the high mortalityrisk associated with severe states of PCM. They found that such risks arenot graduated, but display a threshold effect, below which the riskincreases five-fold. Acute diarrhea can cause life-threatening dehydrationvery quickly. Rehydration is the obvious remedy and should take the formof oral rehydration, coupled with feeding the patient. Replacement of lostfluids is always the first step. The possible use of drugs comesafterwards and depends upon the probable cause of the diarrhea and thefacilities available to confirm diagnosis. However, neither rehydrationnor drugs deal with the basic causes of diarrheal diseases. Most arecaused by intestinal pathogens transmitted from the intestine of theinfected person to the hands and then mouth of a susceptible person. Thisfecal-oral transmission can take place directly, or via contaminated foodand water. Action to deal with improved personal and environmental hygieneentails behavioral change which is both long-term and difficult to achieve.

56. Belminthic Infections. In areas with inadequate sanitatioa mostpersons get infected with intestinal parasites. The most common infectionin Bangladesh is ascaris lumbricoides (roundworm). Ascaris needs noalternative host and is transmitted from person to person in food or watercontaminated with feces containing its eggs. A WHO Expert Committee 15/cites relationships between ascaris infection and stunting, general under-nutrition, avitaminosis, decreased protein absorption, xerophthalmia, andascorbic acid deficiency, all of which are of nutritional concern.

57. The nutritional and economic implications of ascaris infectionhave been studied in Kenya. 16/ Ascariasis is a significant healthprobLem as it retards the growth of children and is an important cause ofmorbidity. The study also indicates that children with light infections ofascaris have an average food loss of 3% of ingested calories. Heavyinfections could result in a caloric loss as high as 25%. Having reviewedvarious possible control measures, Latham recommended mass deworming treat-ment, which is both therapeutic for the individual, as well as prophylacticfor the community. Deworming, undertaken on average twice a year, was cal-culated to represent a benefit/cost ratio as high as 10:1. This does nottake into account the large benefits from simultaneously controllilng otherintestinal parasites.

14/ Chen, et al. Classification of Energy Protein Malnutrition byAnthropometry and Subsequent Risk of Mortality." Bangladesh ThirdNutrition Seminar Series. INFS. 1979.

15, Control of Ascaris. Report of a WHO Expert Committee: TechnicalReports, ND. 314, Geneva: 1965.

16/ L. Latham, N. Latham, S.S. Basta. The Nutritional and EconomicImplications of Ascaris Infection in Kenya: World Bank Staff WorkingPaper: 1977.

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58. Data on the prevalence of intestinal parasites in Bangladesh aremeagre. Khan 17/ studied 644 children in a medical. ward and found thatintestinal parasites were present in 46.7% of the patients. Table 2.28provides details of the parasites identified.

Table 2.28: PREVALENCE OF INTESTINAL PARASITES IN CHILD PATIENTS(N = 644)

Age Group Ascaris Hookworm Trichurisis HymenolepsisYears No. Z No. % No. % No. Z

Less than 1 2 2.0% 3 3.0% 3 3.0% 2 2.0%1 - 5 48 25.5% 11 5.5% 6 3.1% - -6 - 10 100 44.6% 60 26.8% 10 4.4% 4 1.7%11 - 12 20 13.1% 45 29.6% 18 5.2% - -

Total 170 25.6% 119 16.4% 37 4.1% 6 1.0%

Source: Third Nutrition Seminar Series 1977, INFS Bangladesh.

59. Hookworm. Hookworm has been present in Bangladesh for genera-tions. Prevalence of infection is very high due to the lack of propersewage disposal. Each hookworm lays many thousands of ova which are ex-creted in the feces. Larvae develop from the eggs in stages and remain inthe soil waiting for contact with skin, whereupon they bite and enter thebody and make their way to the intestine, ingesting from 0.03 to 0.15 ml ofblood daily 18/, An individual may be infected by the larvae from thefeces of others or may be reinfected from the individual's own feces.

60. Infection of hookworm is a common cause of anemia. The combina-tion of low iron absorption and loss of iron resulting from loss of bloodis responsible for much of the widespread nutritional anemia found amongthe Bangladeshi population.

61. Morbidity, Mortality and Malnutrition. Several studies 19/ haveshown the direct relationship between poor nutritional status and childmortality. Among children 12-36 months of age, those children identified

17, Bangladesh Third Nutrition Seminar Series, 1979, INFS.

18/ Davidson and Passmore. Human Nutrition and Dietetics.

19/ Somner and Lowenstein. Nutritional Status and Morbidity: AProspective Validation of the QUAC Stick." American Journal ofClinical Nutrition. 28:287-292.

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as moderate to severely malnourished based on weight-for-age, had a mortal-ity rate of 3 to 4 times greater than the normally nourished groups over atwo-year period.

62. Child mortality attributed to measles and respiratory infectionswas 3 to 7 times greater among the severely malnourished than among thenormal population. 20/ The synergism between measles and malnutrition isparticularly fatal. Of all measles cases, 45% had some form of mal-nutrition. Those malnourished children between 7 and 12 months of age withmeasles show a higher rate of complications, longer recovery times, andgreater mortality rates than normally nourished children.

20/ Sharhid Nigar. Complications of Measles in Rural Bangladesh.ICDDR,B. Report No. 3, Dhaka, June 1981.