UN REACH in Bangladesh: facilitating multisectoral ... WEB/UPLOAD-2/UN...What REACH is • A UN joint agency initiative to increase the impact of nutrition actions to reduce undernutrition

National Public Health Conference

January 13-15, 2013

UN REACH in Bangladesh: facilitating multisectoral coordination for nutrition

UN REACH Country Team Dr. Iftekhar Rashid (National Facilitator) and Dr. Mary Manandhar (International Facilitator)

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

2004 2007 2011

14.5% 17.4% 15.6%

50.6%

43.2% 41.3% 42.5% 41.0%

36.4%

Wasting Stunting Underweight

Malnutrition trends in Bangladesh

HFSNA showed 13.5% GAM and 3.4% SAM in 2009. BDHS 2011. Preliminary Report

The emergence of multisectoral approaches for nutrition

Source: Garrett, Natalicchio and Bassett. May 2012

National Public Health Conference, January 2013

“We recommend working to improve nutrition not only through health,

but also through agriculture, rural development, water supply and sanitation, education, gender and community-driven development”.


Multisectoral working for nutrition in Bangladesh what’s already happening?

• Policies, plans and structures: – National Steering Committee for Nutrition (chair Senior Secretary for Health, 13 Ministries)

– Food Planning Monitoring Committee (Cabinet level committee, chaired by Minister of Food)

– National Plan of Action for Nutrition 1997 (currently under revision)

– National Food Policy (2006) and Plan of Action (2008-2015) – Revised from 1997 Food and Nutrition Policy to enhance nutrition focus)

– Country Investment Plan: agriculture, food security and nutrition (2010-2015)

– Bangladesh National Nutrition Council (chair – Prime Minister) recently inactive

• Programmes and interventions

– National Nutrition Services – National Food Policy Capacity Strengthening Programme, supported by WHO – Alive and Thrive – MDG-F – FHI360 – SCF Project Thousand Days (Signature Programme): planned …. – SPRING – FAO/UNICEF supported integrated Agriculture and Health Interventions for Nutrtion

• Research, evidence, knowledge sharing – Nutrition Working Group (with four Thematic Groups)


What REACH is

• A UN joint agency initiative to increase the impact of nutrition actions to reduce undernutrition (close to the spirit of the One UN initiative)

• Active in 13 countries, 2 in South Asia (Bangladesh and Nepal)

• A solution-focused partnership among governments, civil society and private sector to accelerate progress on MDG 1, target 3 (to halve the proportion of underweight children under the age of five years)

• A process, a methodology to support government to scale-up nutrition actions through a multi-sectoral approach

www.reachpartnership.org

as catalyst for

• The Scaling Up Nutrition SUN Global Movement and national launch • Developing innovative tools for situation analysis, multisectoral

planning and coordination, including costing • Mobilising action in the areas of:

• Country action planning and coordination through strengthening multi-sectoral mechanisms

• Knowledge sharing and building networks • Advocacy and communications on “1,000 days” • Financing and resource mobilization for scaling-up effective

interventions, and all the above • Monitoring and evaluation

• partnership with private sector (Financial, in-kind, business contribution, Project Laser Beam)

• partnership with civil society sector on advocacy and communications


Preparatory phase at national and district levels: • National stakeholder analysis, institutional mapping (July 2010)

• UN REACH Country Implementation Plan with LogFrame (June 2011)

• Decision to focus on Satkhira District

• Priority interventions agreed

• Baseline survey in Satkhira by HKI and UNICEF (2011)

• Satkhira Stakeholder Mapping by REACH Country Team (July-Nov 2011)

• Dissemination events (June 2012)

Implementation phase: • Building alliances and partnerships with private sector and civil society

• Participatory stakeholder workshop for multisectoral working: Satkhira (Feb 2013)

• Pilot of World Bank Multi-Sectoral Simulation Tool (March 2013)

Bangladesh: Key activities


Inst. of Public Health & Nutrition (IPHN)

Institute of Child and Mother Health

Food Planning & Monitoring Unit (FPMU)

Ministry of Women and

Children Affairs7

Prime Ministers Office

Department of Women Affairs

Bangladesh Shishu Academy

Ministry of Industries

BD Small / Cottage Industries Corp.

Ministry of Local Governm., Rural Devel. & Co-op.

Local Government Division

Department of Public Health Engineering

Bangladesh National Nutrition Council

BNNC

BD Fortification Alliance (on PPP)

Nat. Food Planning & Monitoring Com. (NFPMC)

Ministry of Education

Ministry of Social Welfare

Ministry of Health & Family Welfare

-MOHFW-7

BARC9

Ministry of Food

Ministry of Agriculture7

Local Consultative Group (LCG) 4

NGO Affairs Bureau

Governance of nutrition is crosscutting (Institutional mapping)

Directorate General of Health

Services (DGHS) Directorate of Nursing

Directorate General of Drug

Administration (DGDA)

Directorate General of Family

Planning (DGFP)

Nutrition Task Group

NTG2

Health, Nutrition and Population Sector

Program HNPSP (36 Programs)

National Nutrition program1 (NNP)

Nutrition Working Group (NWG)6

HNP Consortium3

HPNSDP Taskforce5

Health Advisor

Community Clinics Project

PPC8

Secretary

Ministry of Livestock

and Fisheries

BSTI9

Considered nutrition key player Involved with nutrition

Mixed or Non-gov. body

Ministry of Trade &

Commerce

Ministry of

Planning


Improve hygiene and parasite control

Hand washing with soap

Household water treatment, education and equipment

ITN (bed nets)

De-worming

Improve breastfeeding and complementary feeding

Complementary feeding

promotion

Exclusive breastfeeding

promotion

Increase micronutrient intake

Improve household food security

Supplementary feeding for MAM

Local homestead food

production

Conditional cash transfers

Therapeutic feeding for SAM

Care practices

Health

Food

The child is at the centre

Two additional interventions water sources and income generation being considered

Early initiation of breastfeeding promotion

Latrine provision and usage promotion

Added for Bangladesh country context

Vitamin A supplementation

Iron/ folic acid supplementation

Zinc for diarrhea

Adequate salt iodization

MNP/ Sprinkles

IPTp (Intermittent preventative

treatment)

Nutrition education to promote

dietary diversity

Increase treatment of acute malnutrition

UN REACH interventions for the country context


Donor4

Government and its programs

Implementer7

Touch point/ Delivery Channel

MSF

Thera-peutic feeding

MHFW11 NNP

Condition-al Cash transfer

MSF, StC; HKI; Plan; BRAC ICDDR, B; ACF, TDH

BRAC, MSF; VARD

BBF; ACF, MSF, TDG, StC, HKI, Plan; BRAC

De-worming / Vitamin A

Awareness campaign/ EPI, health centres, house visits

DSK, MSF, TDH8; StC; Plan

UNICEF; WFP; StC.; HKI ; Care; Plan

MHFW11 Dept. of PH Engin. FPMC3

BRAC; MSF; ACF; TDH, DSK; StC; Plan

WB CIDA DFID USAID

Ministry of AgricultureMHFW11

House-hold water treatment

USAID WB

NNP

TDH, ACF

Suppl- mentary feeding

Catalyst6

FAO, WFP HKI, Concern, WV

DAE, RDA

Homestead food production

AusAID, DANIDA, USAID, DFID, NOVIB, WB

Field workers; workshops, community centers

ACF; local NGOs; DSK; TDH; StC

Breastfeeding/ complement-ary feeding

Hand-washing with Soap

Health centers, EPI

Zinc ITN

IPTp

CIDA USAID

USAID

BRAC; NGO Forum12; DSK; TDH

WFP14, UNICEF Alive & Thrive GAIN, CARE, StC, HKI8 , ACF; MI8

ICCDR, B; ACF; TDH; IFRC MSF; SC

Gov. of Japan- Hashimoto initiative; Gates Foundation

WHO

GFATM5

Micro-nutrient supplem.2

Min. of prim. & Mass Educ.; Min. of Finance

BRAC, TMSS Grameen; DSK

UNICEF WFP, HKI9

UNICEF UNHCR SC USA, Concern;

UNICEF WHO

UNICEF WV GAIN

UNICEF, FAO WFP, WHO; HKI; BRAC,

USAID, WB

UNICEF WFP, BRAC; MI WV; GAIN

MHFW11; EPI-Campaign

MHFW11 (DG Health)

MHFW11 IPHN NNP

Health centers; hospitals pilot-projects; camps

Field-worker; health clinics

VO's13; MC branches; local banks credit worker/ posts

DFID EC Spanish MDG Fund

Norwegian Emb.; USAID

USAID

WFP FAO HKI

Comm. volunteers/ health centers

Domestic visits; trainings in CBOs1

Group teaching; door- to-door; volunteers

Volunteers training centers; clinics, mother- support-groups; door-to-door

Para center/ workers; pilots, house visits, EPI

MHFW11

Private sector Unilever, Reckitt

Grameen Standard Chart. Bank

BASF Grameen

Grameen Veolia

SMC Grameen Danone

Renata, Grameen-Danone BASF, SMC

Grameen

Multiple stakeholders are involved

Treatment Interventions Preventative Interventions

Iodine fortification

Only few interventions reach national coverage NNS the largest program covers 25% of the country

Source: REACH interviews, BCG analysis

Majority of interventions with unsatisfactory national coverage



Complementary feeding


Household water treatment

Insecticide treated bed nets (ITN)


Zinc supplementation/ fortification

Micronutrient powder/Sprinkles

Nutrition education

Deworming

Handwashing with soap

Iron/folic acid suppl/ fortification

Local homestead food production

Early initiation of breastfeeding

Intermittent prev. treatm. in pregnancy

(IPTp)

Latrines

Exclusive breastfeeding

Key takeaways

National Nutrition program (NNP) covering 25% of population is the largest nutrition focused program • Includes promotion of breastfeeding, complementary feeding,

nutrition education and distribution of select micronutrients Interventions included in government supported programs with high national coverage

• Inclusion of Vitamin A supplementation and deworming in National Immunization Day (NID) ensures nationwide coverage

Two large scale water and sanitation projects result in almost universal coverage in terms of access to improved water sources

• Total Sanitation Campaign and The Sanitation, Hygiene Education and Water Supply in Bangladesh Programme (SHEWA-B) result in high coverage for household water treatment intervention

Micronutrient powder/Sprinkles currently at a level of about 10% • However scale-up plans driven by private sector will likely result in

national level coverage Therapeutic and supplementary feeding with low coverage rates – scale-up and improved coordination crucial

< 25% coverage

25– 50% coverage

51– 76% coverage

> 75% coverage

National coverage

Draft

Most UN REACH-recommended interventions

coverage is low

82% 96%

39%

% children 9-11 months receiving Vit A supplements

% children 12-59 months receiving Vit A supplement % postpartum women receiving Vit A supplement Insufficient macro and

micronutrient intake 67.9% 38.8%

% children U5 with iron deficiency anemia % of pregnant women with iron deficiency anemia % households consuming salt adequately iodized

25% % households with poor/borderline food consumption scores

6.7% 85.5%

% households using water treatment methods % households with access to improved water source

Soil, water borne &

endemic diseases

58.8% % population washing hands prior to eating

44.6% % children U5 with soil transmitted helminthes

25.3% % households with access to hygienic latrines

% children 6-59 months with sev. acute malnutrition High prevalence of

acute malnutrition 10.5% % children 6-59 months with mod. acute malnutrition

36 % % infants breastfed within one hour of birth

Poor IYCF Practices 48.7% % infants 0-6 months exclusively breastfed

57.6% % infants 6-8 months who receive solid, semi-solid or soft foods along with breastmilk

Status Problem Indicator Key problems

40%

26%

% population living under national poverty line

% population undernourished Insufficient access to

food

HEALTH

FOOD

9.8% % children U5 with diarrhea

Nutrition education for dietary diversity



MNPs for children U5 IFA supplements for pregnant women

Vitamin A supplementation for children Vitamin A supplement for postpartum women


Therapeutic management of SAM

Latrine provision and usage promotion

De-worming

Hand washing with soap


Complementary feeding promotion

Exclusive breastfeeding promotion


Interventions

Zinc for diarrhea

Coverage

51%

3.4%

Availability of adequately iodized salt

National Status

REACH-BCG 2010 (National Data)

Satkhira District Stakeholder Mapping approach

Conducted July-November 2011 by REACH Country TEAM – Design, conducting self-reported questionnaires, corresponding guidelines

– Interviews

– DHS, other surveys on food security and nutrition situation

– Data collection and analysis

– Meetings, attendance at working groups, individual follow-ups, reporting

• 84 stakeholders (govt, INGOs, NGOs, academia, private sector)

• Gathered information on 17 UN REACH-recommended interventions (food security, nutrition, water/sanitation, health)


Stakeholder Map Satkhira Treatment

Interventions

Preventative Interventions

Thera-peutic/Supple-

mentary feeding

Zinc

supplemen

tation

Breast-

feeding/

Comple-

mentary

feeding

Vitamin A suppl/

Deworming

Micro-nutrient powder

Hand-

washing with

Soap

House-

hold water

treatment

Latrine

provision,

usage ,

promotion

Local

Homestead

food

production

Transfer

and

safety

nets

Donor ECHO USAID

CIDA

JICA

EU

USAID

WB

SIDA

USAID USAID

AusAid

EU-ECHO

CIDA

AusAid

DANIDA

EU-ECHO

ADB

EU

ECHO

EU

DFID

SDC

ECHO

DFID

ChristAid

Catalyst

WFP UNICEF

Alive &

Thrive,

CARE,

FAO

UNICEF MI

GAIN,

UNICEF

MI

UNICEF, Care

WVB

UNICEF

NGO

Forum

DWSS

UNICEF

NGO Forum

Oxfam

FAO WFP,

UNDP

GOB and

its

program

s

MHFW

DPHE

Civil

Surgeon

MHFW

IPHN

MHFW

DPHE

Civil

Surgeon

MHFW

DPHE

Ministry of

Agriculture

MHFW

LGED Ministry of

Agriculture

DAE

DWA,

Min. of

Finance

Impleme

n-ters Shushilan BDRCS,

RKH

PKS

EADA

NoboJibon

BRAC,

Setu

Satkhira,

VOSD,

Bhumijo

Fondation

BDRCS

Unnayan

BRAC

VOSD

SetuSatkhir

BRAC,

PKS,

VOSD

Shushila

n

EADA

NoboJib

on

HYSAWA

Solidarit

PKS

KSDO

Mukti

NaltaHos

WaterAid,

IDEAL,

Setu

Kushtia,

HYSAWA,

Concern

Solidarites

Uttaran,

Water Aid

HYSAWA

Unnayan

BRAC,

IDEAL,

HKI, TMSS

Muslim Aid

Shushlian

BRAC

Uttaran

BDRCS,

IDEAL,

Shushla

n

Bhomist

Private

sector

Unilever Unilever Unilever Kraft,

Unilever

Delivery

Channel

Field-

worker;

nutrition

centres

Health

centers,

Door to

door

promotion

Clinics, mother- support-groups; door-to-door promotion,

Awareness

campaign/,

health

centres,

house visits

CBOs

Para

center/

workers;

pilots,

house

visits,

Group teaching; door- to-door; volunteers

Domestic

visits;

trainings in

CBOs, VOs

Door- to-door promotion

Field

workers;

workshops,

community

Centers door- to-door;

local banks credit worker/ posts door- to-door;

CBOs

•Stakeholders divided into 2 groups:

Catalysts Implementers

•Kaliganj

•Assassuni *Upazilas with > 44%

Popn

•Shymnagar Extreme Poor

*Larger no. stakeholders

Stakeholder Geographic

Distribution

Satkhira 2011 Population Data

Upazila Projected Popn, 2011 % of poverty (upper

poverty line)

Assasuni 288, 419 70,30

Debhata 137, 639 56,60

Kalaroa 256, 425 49,00

Kaliganj 296, 681 74,90

Satkhira Sadr 474,852 46,20

Shymnagar 363,099 75,70

Tala 340,672 45,60

2,157,787 Avg. 59,8

Draft

Selected stakeholder activities and coverage

% infants 0-6 months exclusively breastfed Coverage indicator

National coverage 48.7%

Satkhira coverage 47%

Stakeholder (Total=20)

Est Benef.

Covered Upazilas Est Budget in

USD MoH/NNS Civil Surgeon 100 % All 7

$274,714 All programs

UNICEF*implementing through GoB --- All 7 ---

Alive & Thrive 8,505 Deb,Kali --

Hellen Keller Intl (Planned) 960

Assa,Deb, Kali,Shym

$1 mil Multiple Projects

CARE Bangladesh 100 % All 7 $3 mil

Multiple Projects

PKS/ Smiling Sun 5,313 SS $1,371 Bangladesh Red Crescent Society/IFRC (w GoB) 3,042 Shym,Tala

--- (Educ)

Muslim Aid 1,000 All 7 $1,429

Bhomisto 1,118 Deb,SS,Shy

m, Tala $4,800

Multiple Projects

Nalta HCHFounation 800 Kali $81,744

Multiple Projects

Exclusive breastfeeding Intervention factsheet – Upazila level estimation

DGHS

DGHS

DGHS

Most interventions in Satkhira require

improved coverage

< 5% coverage

36 – 64 % coverage

5 – 35% coverage

65 – 95 % coverage

National coverage

> 95% coverage

Adequate salt iodization

Estimated coverage


Complementary feeding promotion



Deworming



MNP/ Sprinkles

Nutrition education to promote dietary diversity

Zinc for diarrhea

Handwashing with soap

Iron/folic acid supp/ fortification



Latrine provisioning and usage promotion

Exclusive breastfeeding promotion

Intervention Type

Estimated Coverage

(%)

1- Vitamin A supplementation 99* 2- Iron/folic acid

supplementation/fortification 11

3- Adequate salt iodization 13

4- Micronutrient powder/Sprinkles 23

5- Zinc supplementation/ fortification 3

6- Nutrition education for dietary diversity 19

7- Therapeutic feeding for SAM 0

8- Supplementary feeding for MAM** 52

9- Local homestead food production 19

10- Social Transfers and safety nets

(including conditional cash transfers) 15

11- Household water treatment, education

and equipment 22

12- Hand washing with soap 24

13- Deworming 99*

14- Latrine provision and usage promotion 17

15- Early initiation of breastfeeding 50

16- Exclusive breastfeeding 38

17- Complementary feeding 47

Contextual factors for multisectoral nutrition

Nutrition is a chosen development priority, is neutral and cross-party, has high-level support

Yes – in conjunction with evidence

Advocates build a shared vision and a sense of urgency to promote action

Yes - develop an operational timeline

Organisations have strong capacities Strong capacity in lead organisations, not necessarily in all partners. Good leadership and management essential

Organisations possess values that promote collaboration

Yes

Organisations provide incentives for collaboration, including accountability mechanisms

Incentives (including financial?) for the institution and for individuals. Accountability, not essential to creation but may build support

Partners perceive benefits outweigh costs Yes


Source: Garrett, Natalicchio and Bassett. May 2012

If you want to go fast, go alone

If you want to go far,

go together

African proverb


Documents

UN REACH in Bangladesh: facilitating multisectoral ... WEB/UPLOAD-2/UN...What REACH is • A UN joint agency initiative to increase the impact of nutrition actions to reduce undernutrition