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Using the health system to deliver nutrition interventions in
Bangladesh
International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b)
International Food Policy Research Institute (IFPRI)
Heady et. al (2015)
NEPAL
Stunting reduction: Sources
Health 16%!
Can health do more?
Why does the NNS matter? Delivery of direct nutrition interventions key to meet the development targets
47
6467
20.9
83
60
37
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34
5255
65
23
78
62
44
84
38
0
20
40
60
80
100
Early initiationof BF
Exclusive BF(0-6 mo)
Introduction ofCF at 6-9 mo
3 expectedIYCF practices
All basicimmunizations
Vitamin Asuppl (<3s)
Women - > 3ANC visits
ORT fordiarrhea
ORT + zinc
Pe
rcen
t
2011 2014
Source: BDHS
History of NNS
In 2009, Annual Program Review (APR) of the Health, Nutrition and Population Sector Program (HNPSP) recommended scale up critical nutrition interventions by mainstreaming nutrition services provided through the DGHS and DGFP
In 2011, Operational Plan (OP) of National Nutrition Services (NNS) was approved by the GoB
The OP suggests mainstreamed NNS interventions will be implemented through existing health systems (DGHS and DGFP) between July 2011 and 2016
NNS is supposed to pursue a variety of key strategies and actions targeted towards mainstreaming critical nutrition interventions
Several aspects of mainstreaming process have been undertaken since 2012
National Nutrition Policy 2015
National Plan of Action for Nutrition (DRAFT) 2016
4th Sector programme(NNS OP)
Assessment of Implementation of NNS in Bangladesh
International Food Policy Research Institute (IFPRI)
International Centre For Diarrhoeal Disease Research,
Bangladesh (icddr,b)
Identified “what’s working”; “what needs more work”
Management and support services
Training and capacity development
Service delivery
Monitoring and evaluation
Exposure to Interventions (from DNSO evaluation)
What ‘New’ is being done?
• NNS along with UNICEF and CIFF as implementing and funding partners is attempting demonstration components to addresses the NNS challenges
• Provide a temporary dedicated human resource, the District Nutrition Support Officers (DNSOs)
• Demonstrate and prove the feasibility and impact of Competency based training for managers, supervisors and service providers to deliver nutrition interventions
MethodsMajor domains Data sources to address research questions1. Management and support services - Content review of NNS documents
- National-level in-depth interviews
2. Training and capacity development - Content review of NNS documents- National-level in-depth interviews - Service provider surveys
3. Service delivery - Healthcare provider surveys- Facility assessments- Structured observations - In-depth interviews, FGDs with healthcare providers
4. Monitoring and evaluation - National-level in-depth interviews - Healthcare provider surveys- Facility assessments (record review)- FGDs & in-depth interviews with healthcare providers
5. Exposure to interventions - Household coverage survey (DNSO evaluation)
Management and Support Services
What’s working?NNS operational plans (OP) & progress in subnational coordination
• Operational plans OP outlines all components of NNS
Institutional arrangements for delivery of NNS interventions using existing health and family planning infrastructure are described in specific detail
New sector programme reemphasizes the direct interventions and community clinics
• Progress in subnational coordination Good progress in coordination of nutrition services and with levels of communication
between staff managed by DGHS and DGFP at the upazila level and below
Source: Saha et al, 2015, implementation assessment done in 2014
What needs more work?Governance and institutional arrangements
Capacity and workload related challenges within NNS/IPHN
Capacity to developing feasible and specific implementation plans for intervention delivery
Ability to develop training approaches, to maintain and manage records on training roll-out and to manage a large budget
Retention challenges for the Directorship of IPHN
Lack of bureaucratic authority limits monitoring/coordination of NNS activities
Source: Saha et al, 2015, implementation assessment done in 2014
What needs more work?Program design and intervention platforms
Choice of delivery platforms IMCI-Nutrition corners and Community Clinics are primarily visited by sick
children
Key NNS components, especially IYCF counseling, micronutrient supplementation, and screening for SAM/MAM are targeted towards all children & current platforms not designed to reach all, no CMAM
Source: Saha et al, 2015, implementation assessment done in 2014
What needs more work?Program design and intervention platforms
Percentage of Mother-newborn pairs (care continuum) had contacts with the routine health services
26.1
13.59.8
5.1 4.9
ANC Delivery PNC ANC and PNC ANC and Delivery andPNC
BDHS 2014
*Physicians are the predominant provider
What needs more work?Coordination and communication
Horizontal coordination at national level:
• Lack of communication and coordination – particularly at senior levels.
• Coordination across DGHS and DGFP are also reported to be challenging
Vertical coordination/communication:
Local providers described how communications with NNS staff based in Dhaka were challenging, different line supervisors
Source: Saha et al, 2015, implementation assessment done in 2014
Training and Capacity Development
What’s working?Training and capacity building roll-out
Training manuals are in place – Basic Nutrition, IYCF, SAM/CMAM, Competency Based Training (CBT), Supportive Supervision
Overall NNS training is ongoing and UNICEF supported CBT have started, covered 30,000+ service providers in 26 districts
What needs more work?Coverage of Nutrition trainings
Percentage of service providers receiving trainings in nutrition (N= 364)
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Physician Nurse SACMO FWV FWA CHCP
Basic nutrition training IYCF training Any other nutrition training
Initial Assessment (DNSO Evaluation), 2016* CBT coverage is not presented here
*
Service Delivery
What’s being done?Integration with IMCI-N
• Nation-wide establishment of IMCI-N corners is completed All facilities include IMCI-Nutrition Corners
Basic Nutrition Training adds some value to IMCI for screening of SAM/MAM; elaborates on nutrition knowledge and includes more detail on IYCF training
NNS-trained providers appeared to offer more nutritional advice during sick child care
Source: Saha et al, 2015, implementation assessment done in 2014
Availability of equipments and job aids
43
35
22
35
27
5
Weighing scale
Height scale
Length scale
MUAC Tape
GMP Card (both girls and boys)
IYCF manual
% of health facilities with key equipment in Sick child management area[N=37]
89% sick child management area had <50% essential equipment/guidelines
~70% ANC rooms had at least 7 of the 11 essential equipment/supplement/guidelines
95
54
41
54
95
46
16
Weighing scales
Height Scale
MUAC tape
Picture cards with maternaldanger signs
Iron Folic Acid (IFA) tablet
Calcium tablet
Basic National NutritionServices nutrition training…
% of health facilities with key equipment in ANC room [N=37]
Source: Saha et al, 2015, implementation assessment done in 2014
Delivery of Nutrition services during ANC
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39
78
6662
5660
63
33
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39
78
3530 30
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%
Advice/service provided to women
Weighed and recorded weight
Measured and recorded height
Examined anemia in eyes
take more food
take balanced diet
take seasonal/available food
take green/colored vegetables
drink more water
take iodized salt
take rest at least for two hours/day
maintain personal hygiene
take routine iron and folic acid
told about importnace of breast feeding
told about breastfeeding within an hour
told about danger signs to neonate
Examination
Advice provided
N=381 ANC observations
Source: Saha et al, 2015, implementation assessment done in 2014
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%
Advice/services provided to children
Weighed and recorded weight
Measured and recorded height
Clinically screen the child for SAM
Demonstrate IYCF practices using visual job aids
Checked child's weight against a growth chart
NutritionalAssessment
Nutrition Counselling
N=826 sick child case management observations
Delivery of Nutrition services during sick U5 child management
Source: Saha et al, 2015, implementation assessment done in 2014
Monitoring and Evaluation
What’s working?Indicators, performance review visits are coming together
Nutrition Information System Considerable progress in institutionalizing the reporting of nutrition indicators in
the routine RHMIS through:
Monthly IMCI-Nutrition Corner reporting format
Monthly community clinic reporting format for newborn and child health
Program Performance
Some supervisory visits are taking place at the level of the health facilities at limited scale
Source: Saha et al, 2015, implementation assessment done in 2014
Record-keeping within the NNS should be focused
information on implementation roll-out, performance/outputs, and development partner support to geographic and technical areas is currently not easily available to all key stakeholders
A system for technical monitoring of service quality by National Level experts and Managers
What needs more work?Record-keeping on training, roll-out and service delivery monitoring
Source: Saha et al, 2015, implementation assessment done in 2014
Recommendations• Strengthen the leadership authority of the NNS
• Ensure regular technical supervision visits/support to field
• Develop very specific implementation plans with rational delivery platforms
• Invest in developing a cadre of workforce for delivering core nutrition messages beyond the curative platforms
• Exploring other potential high coverage outreach platforms like some NGO platforms
• Strengthen nutrition counseling and screening within IMCI, but invest more in an outreach-based platform for delivering core preventive NNS services
• Coordination of activities among Development Partners
• Emphasize rapid growing urban population and completely different health service structure
• A system for technical monitoring of service quality by experts
• Carefully review of the current set of NNS indicators
