Bangladesh National Plan of Action For Nutrition (NPAN)

EU\NGI.AD■SN NA-rlGNAL PLAN QI' AC'IION POR NUTRRION (NPAN) Ministry of Health and Family Welfare Government of the People's Republic of Bangladesh in Collaboration with Bangladesh National Nutrition Council 1997 BANGLADESH NATIONAL PLAN OF ACTION FOR NUTRITION (NPAN) Ministry of Health and Family Welfare Government of the People's Republic of Bangladesh in Collaboration with Bangladesh National Nutrition Cou11cil 1997 Published by : Bangladesh National Nutrition Council 19/1, Rasulbagh, Mohakhali Dhaka-1212 Tel :884395,882850 May 1997 Printed by: Paragon Offset Press 28/N5, 'lbyenbee Circular Road Motijheel CIA., Dhaka -1000 Tel:415123,9558922 111c follow-up activities of the International Conl"crence on Nutrition (ICN) as agreed in the conference held in Rome, Italy in l )l!cl!mber, 1992 have bcg.Lm m llangladesh. Since Bangladesh is a signatory or the World Declaration on Nutntion like nth,:r part,c,r,:1tin;:: n"'nr:t:\-:': -~f :.h~ ·.-.-~.:~. ii.;·,,. ;,. upuai.cu me Bangladesh Country Paper (BCP) on Nutrition and also prepared this National Plan of Action for Nutrition (NPAN) The Government of the Pcoptc·s Rl!public of Bangladesh has taken thl! nutritional considerations as one of the topmost priorities for the development of the human resources. It has commissioned a National Working Committee headed by the Additional Secretary, Ministr.y of Health and Family Wt~lfare and represented by different concerned ministries and sectors and agencies both from the government anJ non-government organisations for updating the l3GP and preparing the NPAN. The government has appointed 1he Joint Secretary (Public Health and I lospital) as the National Focal Po111t for lCN follow-up activities, and different Sectoral Focal Points for Nutrition were also nominated. A working committee headed by Professor M. Q-K. Talukder, Project Director, Institute of Child and }.·lather Health (ICMH) and Chairman. Standing Technical Committee of Bangladesh National Nutrition Council (BNNC) was also constituted, and the BNNC was assignc9 to coordinate the act1v1t1es and to provide secretarial support to all these committees A number of meetings and workshops were held to prepare the documents. The Food and Agriculture Organisation of the United Nations has provided all out supports for preparation of these documl!nLc;, specially by commissioning international and national consultants. As follow-up of activities of fCN the documl!nts prepared in Bang!a(.ksh are : (a) Bangladesh Country Paper (BCP) on Nutrition • Updated, 1995; (b) State of Nutrition in Bangladesh, 1995; (c) National Plan of Action for Nutrition: Some Projects from Selected Themes, 1996; (d) National Plan of Action for Nutrition (NPJ\N), 1997; (e) National Plan of Action for Nutrition: InpuLc; from Agricultural Sectors, vol-1; and (f) National Plan of Action for Nutrition : Selected Project Proposals for Agricultural Sector. vol~2. The core docwnent, National Plan of Action for Nutrition (NPAN), is the outcome of untiring efforts of a good number of ministries, organisations and individuals, who gave their valuable inputs, as well as suggestions and comml!nts on th0 draft out! ine of the Plan of Action presented in difforl!nt workshops and meetings. We are grateful to the Hon'ble Prime Minister, Ministers for Health and Family Welfare, and Agriculture, Environment and Forests for their inspiration and continued guidance at all stages of the development of the NPAN. We arc very thankful to Mr. Muhammed Ni. Secretary, Ministry of Health and family Welfare for his valuable suggestions during preparation of NPAN. We acknowledge the contnbution of the members of the National Working Committee and other Working Committee, l!spccially Profrssor M. Q-K. Talukder. Director, ICMH, Mr. Md. Ahdul Mannan, Secretary, BNNC and Dr. S. K. Ruy, Scientist, JCDDR'B for their relentless efforts, relevant inputs and for reviewing the JocW11ents. Thanks are also due to the International Consultants of FAO, Professor Indira Chakravarty, Director and Dean, All India Institute of Hygiene and Public Health, Calcutta, India and Dr. Rahamat U. Qureshi, Visiting Research Fellow, Kings College, London University, U.K. and Nation:il Consultants, Professor Harun K. !v!. Yusuf , Department of Biochemistry, University or Dhaka and Dr S.M. ?.1auddin I-fa1dcr, Nutntionist, BR.AC. We spcc1ally thank Mr. Hiroyuk1 Konuma. F AO Representative m Bangladesh for his continuous support and encouragement at al I stages of finaltsat1on of NP AN. I hope this core NPAN document wtll be wry useful to thr nutrition pl:mncrs, program implementers. and others concerned in fom1U!atmg thl!ir future course of ;idllln. Dated 3 May l 907 --1 ~~ ,1. Azlzur R:-ih~n JoUJt Secretary l Pll&./1), MOHFW and 0Ltl1011;J F,1c.1l l'lllllt r,,r f-< 1llow-11µ of ICN Acuvities FU/illl/?ORD Malnutrition is a serious health com:cm in Bangladesh. The worst victims of malnutrition arc the children and the women. The government has u11dcr1akcn a number of programs to improve the situation. During the lnlcmalional Conference 011 Nu11ilion (ICN) held in Rome, Italy some follow-up activities of lhc conlcrcnce were assigned to each of the participating countries. We arc very pleased lhal one or those acli\.ilics. "iz. , prcparalion of the Nalional Plan of aclion for Nulrition (Nl' AN) has been finalised rccc111ly. We foci happy that we h;1vc finalised our plan he fore many or lhc participaling cou111rics of ICN. This NP AN will he implemented for improvement of lhc nutrilional slat us of lhc population by the year 2010. The National Plan of Action for Nutrilion has been prepared with inputs from different sectors, professionals from the government, NCiOs. privale scclor agencies and donors. I would like lo eongr;11ulate lhc prokssionals and olhcrs c.:.onccrncd who \'vcrc involved in the prm:css of lhc development of the NPAN for their efforts. I would also lil-.c to thank the chainnan and the I members of the National Working Commiltee and other working committee, National Focal Point for follow-up of ICN acti\.ilics, and sccloral focal poinls for their hard work and continuous assistance in prcpa1i11g lhc documcnls. Special thanks arc due to the Secretary. other oflicers and staff of Bangladesh Nalional Nutrilion Council for lhcir constant hard work during preparation of lhe NP AN, in organising workshops for finalisation of it and making effective coordination among the different scclors concerned. Thanks are due to lhc development partners, particularly lhc Food ;md Ag1icul1ure Org;111is;1tion of the United Nations for their support. Let me take this opportunity to request all key sectors, organisations, agencies and persons lo follow the guidelines in the preparation of their sectoral projects on nu11ition and to extend their coordinaled and concerted efforts lo ensure the cllcctive ~md timely implementation of this NPAN. Daled: 3 May J 907. i\lu!ta111111"d All Sccrel;try .\li111stry ()( Health and J-';urnly Welfare :H>OI"t Y IA l lUJ"I.:, EXECUTIVE SUMMARY CIIAPTER 1- INTRODUCTION INDEX CIIAPTER 2- EXISTING NUTRITION SITUATION 2.1. COUNTRYBACKGROUND ., ., ASSESSMENT AND ANALYSIS < ·1tAPTER 3 - GO,\L, OBJECTIVES AND TARGETS 3.1. GOAL 3.2. OBJECTIVES AND TARGETS CIIAPTER 4- STRATEGIC FRAMEWORK FOR PLAN IMPLEMENTATION .. i I. INCORPORATING NUTRITION OBJECTIVES, CONSIDERATION AND 1-V 3 7 18 18 18 21 corvtPONENTS INTO DEVELOPMENT POLICIES AND PROGRAMMES.................... 23 .. u. IMPROVING HOUSEHOLD FOOD SECURITY................................................................. 28 -U. PROTECTING CONSUMERS THROUGH IMPROVED FOOD QUALITY AND SAFETY.................................................................................................................................. 45 4.4.' PREVENTING AND MANAGING INFECTIOUS DISEASES........................................... 50 4.5. PROMOTING BREASTFEEDING........................................................................................ 56 4.6. CARING FOR THE SOCIOECONOMICALLY DEPRIVED AND NUTRITIONALLY VULNERABLE...................................................................................................................... 61 4.7. PREVENTING AND CONTROLLING SPECIFIC MICRONUTRIENT DEFICIENCIES .. 67 4.X. PROMOTING APPROPRIATE DIET AND HEAL THY LIFESTYLE........................ ........ 75 ~ 9. PROMOTING NUTRITION EDUCATION, ADVOCACY AND CO:VIMlJ:\ilTY P.\RTICIPATION.......................................................................................................... 78 4 I O .\SSESSING. ANALYSING AND MONITORING NUTRITION SITU.\TIO~S. 85 < 11\PTER 5 - INSTITUTION.-\L FR.-\\IEWORK FOR TR.-\NSL\TING PL\~S INTO ACTION X9 ADB ARI ARMP ASSP BARD BARI BAU BBF BBS BCSIR BF BFHI BFRI BIDS BINA BINP BIRDEM BIRTAN BLRI BMS BNNC BRAC BRRI BRDB BSTI CAC CARE COP CIDA CNP cso cso DAE DANIDA DLS DOE DOF DPHE OPT EPI EPM FAO FAP FCDI FRI GOB GTI HDI LIST OF ABBREVIATIONS Asian Development Bank Acute Respiratory Infections Agricultural Research Management Project Agricultural Support Services Project Bangladesh Academy for Rural Development Bangladesh Agricultural Research Institute Bangladesh Agriculture University Bangladesh Breastfeeding Foundation Bangladesh Bureau of Statistics Bangladesh Council of Scientific and Industrial Research Breastfeeding Baby-friendly Hospital Initiatives Bangladesh Forest Research Institute Bangladesh Institute of lJevelopment Studies Bangladesh Institute of Nuclear Agriculture Bangladesh Integrated Nutrition Project Bangladesh Institute of Research and Rehabilitation in Diabetes and Endocrine Metabolism Bangladesh Institute of Research and Training on Applied Nutrition Bangladesh Livestock Research Institute Breast Milk Substitute Bangladesh National Nutrition Council Bangladesh Rural Advancement Committee Bangladesh Rice Research Institute Bangladesh Rural Development Board Bangladesh Standards and Testing Institution Codex Alimentarius Commission Cooperative for American Relief Everywhere Crop Diversification Programme Canadian International Development Agency Community Nutrition Promoter Central Storage Depot Combined Service Delivery Directorate of Agriculture Extension Danish International Development Agency Department of Livestock Services Directorate of Environment Department of Fisheries Department of Public Health Engineering Diphtheria/Pertussis/Tetanus Expanded Programme on Immumsation Energy.Protein Malnutrition Food and Agriculture Organization of the ll111ted Nations Flood Action PI.in Flood Control, Drainage and Irrigation Fisheries Research Institute Government of Bangladesh Graduate Training Institute Human Development Index HKI HRD ICDDRB ICMH ICN ICVD IDD IF IFAD IFST ILO INFS IPH IPHN 1PM ISRT IU KAP LGED MCH MIS MOA MOC MOCn MODMR MOE MOEF MOF MOFn MOFL MOHFW MOI MOin MOL MOLn MOLGRD MOP MOST MOSW MOWCA MOWR NARS NEMAP NGO NIPORT NIMCO NMDP NPAN ODA OMS PCP PEM PFDS Helen Keller International HI.Iman Resource Development International Centre for Di2.rrhoeal Diseases Research, Bangladesh Institute of Child and Mother Health International Conference on Nutrition Institute of Cardiovascular Diseases iuu::mationai ueve1opment Association Iodine Deficiency Disorders Institutional Feeding International Fund for Agricultural Development Institute of Food Science and Technology International Labour Organization Institute of Nutrition and Food Science Institute of Public Health Institute of Public Health Nutrition Integrated Pest Management Institute of Statistical Research and Training International Unit Knowledge, Attitude and Practice Local Government Engineering Department Mother and Child Health Management Information System Ministry of Agriculture Ministry of Commerce Ministry of Communication Ministry of Disaster Management and Relief Ministry of Education Ministry of Environment and Forest Ministry of Food Ministry of Finance Ministry of Fisheries and Livestock Ministry of Health and Family Welfare Ministry of Information Ministry of Industry Ministry of Law Ministry of Land Ministry of Local Govt., Rural Devt., and Cooperatives Ministry of Planning Ministry of Science and Technology Ministry of Socidl Weltare Ministry of Women and Children .--\ffairs Ministry of Water Resources National Agricultural Research System National Environment Management Action Plan Non-government Organisation National Institute of Population Research and Training National Institute of Mass Communication Nutritional Message Dissemination Programme National Plan of Action for Nutrition Overseas Development Agency Open Market Sale Project Concept Paper Protein-energy Malnutrition Public Food Distribution System PHC PHL PMED RDA RHDC RMC RMP SEID SIDA UN UNDP UNESCO UNFPA UNICEF USAID VAC VGD VGF WB WES WFP WHO WID WIF Primary Health Care Public Health Laboratory Primary and Mass Education Division Rural Development Academy Reproductive Health and Disease Control Programme Rural Maintenance Programme Socioeconomic Infrastructure Division Swedish International Development Agency United Nations United Nations Development Programme United Nations Education Social and Cultural Organization United Nations Population Fund United Nations Children's Fund United States Agency for International Development Vitamin A Capsule Vulnerable Group Development Vulnerable Group Feeding World Bank Water and Environmental Sanitation World Food Programme World Health Organization Women in Development Worldview International Foundation BAN GLAU.ESH NATIONAL PLAN OF ACTION FOR NUTRITION (NPA.N) ' - , EXECUTIVE SUMMARY BANGLADESH NATIONAL PLAN OF ACTION FOR NUTRITION (NPAN) - . EXECUTIVE SUMMARY Bangladesh is one of the I 59 countries that participated in the International Conference on Nutrition (ICN) held in December, 1992 in Rome, organized jointly by FAO and WHO. The participating countries unanimously adopted a World Declaration and Plan of Action for Nutrition and pledged themselves to prepare a National Plan of Action Nutrition (NPAN) which would identify actions to be taken for eliminating hunger and reducing all forms of malnutrition. To prepare this NPAN, the Government of the People's Republic of Bangladesh instituted a National Working Committee (N\✓C) with members from various Ministries under the Chairmanship of the Additional Secretary to Government of Bangladesh, Ministry of Health and Family Welfare. Bangladesh National Nutrition Council (BNNC) was assigned to coordinate all activities towards completion of NPAN. Joi nt Secretary (Public Health and Hospital}, Ministry of Health and Family Welfare, was appointed as the National Focal Point for ICN follow-up activities. He was supported by the Focal Points of twelve other relevant Ministries and two Departments, which are as follows: Ministries - Health and Family Welfare - Agriculture - Food - Fisheries and Livestock - Environment and Forest - Women and Children Affairs - Social Welfare - Disaster Management and Relief - Local Government. Rural Development and Cooperatives - Education - Information - Planning - Finance Departments - Primary and Mass Education Division (PMED) - NGO Affairs Bureau In addition to the Bangladesh National Plan of Action for Nutrition (NP:\NJ, it was decided that NPAN-related activities should lead to the production nf an update of the Bangladesh Country Paper (BCP) for ICN. and a paper detailing the State of Nutrition 111 Bangladesh (SN B) - I 995. A Working Sub-Committee consisting of experts in nutrition from various natiun:11 and UN agencies was formed under the Chairmanship of the Director. Institute of Child and Mother Health (ICMH), Ministry of Health and Family Welfare to prepare the NPAN. The Sub-Committee formed two working sub-groups to facilitate its activities. A senes or meetmgs or tne National workmg Commmee and the Sub-Committee and a major workshop with the Sectoral Focal Points were held to decide on the mechanism 10 be adopted for the preparation of the NPAN. To support and help the Gon:rnmen1. !-t\O provided technical assistance through a UNDP-funded project and two natioual and l\\ 11 international consultants were involved in the preparations. The NPAN provides a description of the existing nutnt10n situation, defines the policy goals, objectives and targets, outlines the strategies for implementation and provides the institutional framework for translating these plans into action. The Introduction (Chapter 1) describes the process by which the country has taken action relating to the development of the NPAN as follow-up to the December 1992 ICN meeting in Ro.me. Chapter two on the Existing Nutrition Situation provides the background to the situation and an assessment and analysis of the principal food and nutrition problems. Chapter three presents the goals and objectives of the NPAN. The goal of the NPAN is to improve the nutritional status of the people of Bangladesh to the extent that malnutrition would no longer be a public health problem by the year 2010. The objectives and targets of the NPAN are to: develop human resources in nutrition by building institutional capacity in policy making, training, research, and service to address the problems. empower the communities and households to understand the nutritional problems and, thereby, to take appropriate measures to address the problems. ensure food security to all household members: targets for increasing the consumption of particular foods and for reducing malnutrition are specified. ensure food safety and food quality. control infectious diseases and provide 1he required environmental support protect, promote and support breastfeeding. ensure support for the socio-economically deprived and nutritionally vulnerable reduce micronutrient deficiencies including nutritional a11:ien11a. Vitamin A deficiency and iodine deficiency disorders ( ID D l promote appropriate diets and healthy lifestyles promote nutrition advocacy. education ;rnd community part1c1pat1lln ensure proper assessment, analysis ,md monitoring \it 11ie nu1rn11m "illldl1, '11 using 5urveilbnce and evaluation procedures Based on a comprehensive analysis of the ex1stmg situation and on current programmes, Chapter Four presents the strategic framework for NPAN implementation and provides the names of the coordinating ministries/organizations, indicates various actions and programmes that need to be undertaken, identifies the target population, the time frame (short/long term), and a series of outcome indicators by which the activities can he ev:iluated . • '.~~;~.;.; f.;:,.· aLLauuub Liu:: guai:s anci OOJecuves ot the NPAN are provided according to priority under each of the following themes which are considered as strategic elements for nutrition programmes: l. Incorporating nutritional objectives, considerations and components into developmental policies and programmes. Strengthening Bangladesh National Nutrition Council. Strengthening the Executive Committee of the Council. Formation of Working Groups in each Sector. Field level infrastructure and support system. Incorporation of nutritional objectives. Updating the documents. Preparation of food balance sheets and food composition tables. Inclusion of nutrition in the curriculum at all levels. 2. Improving household food security. Food production. Food distribution. Food preservation and processing. Food fortification. Supplementary feeding. Food behaviour. 3. Food quality and food safety. Food legislation and its enforcement. Infrastructure development. Education of the food industry and consumers. 4. Prevention and management of infectious diseases. 1. Water and environmental sanitation. Water quality. Sanitation (latrines). Garbage disposal. Personal hygiene. Education. Use of animal waste. \lonitoring of industrial effluents. iii 2. Control, management and prevention of infectious diseases. Strengthen coverage of EPI. Better management of ARI. Better management c, f- diarrhoea. Treatment of infections 5. Breastfeeding and complementary feeding. I. Breastfeeding. Baby friendly hospital initiatives. Breastfeeding: exclusive for 6 months, continue for 2 years. Regulations on marketing of breast milk substitutes. Baby care centres/creches. Maternity leave: legislation. 2. Complementary feeding. Creation of available resources for ideal complementary foods. Education and motivation for preparation of weaning foods. 6. Caring for the socio-economically deprived and nutritionally vulnerable. Support and strengthening the care-giving institutions. Information and KAP for the care-givers and the community. Delivery of facilities till grassroot level. Proper networking among supporting organisations. • 7. Prevention and control of micronutrient deficiencies. Nutritional anaemia. Vitamin A deficiency. Iodine deficiency disorders. Other deficiencies. 8. Promotion of appropriate diets and healthy lifestyles. Generating awareness and right KAP Strengthening of institutions as well as manpower. Develop suitable strategic programmes involving the community. 9. Nutrition education, advocacy and community participation Institutional development from Union up to Natiunul le\el Human resource development from \\.'ard up to Nar1on,1I In el Formation of a coordinating committee Community participation. iv Nutrition curriculum in educational institutions. 10. Assessment, analysis and monitoring of nutrition situation Strengthening of BBS. Preparation of a comprehensive data base. Finally, Chapter Five describes the Institutional Framework for translating these plans into action. Four steps are proposed: 1. Reorganisation and strengthening of the Bangladesh National Nutrition Council (BNNC) as the main body to develop the policy guidelines needed to achieve the goals of the NPAN and guide the country in the right direction. 2. Intersectoral Steering Committee to ensure participation of all Ministries m planning and coordinated implementation of the plan. 3. Sectoral Working Groups to implement the programmes through related agencies and organisations. 4. Monitoring and evaluation from the Ward level. The NPAN document of Bangladesh is thus a comprehensive presentation of strategies that should be adopted with intersectoral coordination. The envisaged plans mention both short (2000) as well as long term (2010) strategies. It gives a clear indication of the sectoral responsibilities in relation to each theme along with strategic plans of action. Important projects and programmes that need to be strengthened and initiated have also been indicated. Lastly, the steps of implementation have also been gi·,en so that immediate adoption and execution of the plan is possible. V 1. INTRODUCTION Bangladesh, along with representatives from 158 other countries, met at the International Conference of Nutrition (ICN) which was held in December 1992 in Rome, Italy unanimously adopted the World Declaration and Plan of Action for Nutrition. At the ICN the Bangladt.:sh team, headed by the Honourable Minister for Health and Family WdLuc, presented the Bangladesh Country Paper (BCP) on nutrition to the conference. To prepare the National Plan of Action for Nutrition (NPAN) as follow-up to the ICN, the government formed a National Working Committee with Additional. Secrt.:tary. Ministry of Health and Family Welfare as its Chairperson. Bangladesh National Nutrition Clr ncil (BNNC) was assigned to coordinate the task. The National Committee entrusted the r-:s..-Jonsibilities for preparing the documentation to a working sub-committee for up-dating the BCP and the preparation of the NPAN. Through the support of a UNDP/FAO technical assistance project two national and two international consultants were appointed to help in the preparation of this document. As part of this process The State of Nutrition in Bangladesh (SNB), 1995, as well as an update of the Bangladesh Country Paper (BCP) were produced. The Bangladesh National Plan of Action for Nutrition was prepared in two phases, the first covering the goal, objectives, strategies and the framework of the plan and the second the sectoral inputs and implementation strategies were indicated. This National Plan of Action for Nutrition is a comprehensive document highlighting the existing nutrition situation in the country; its goal, objectives and targets with a time frame and outcome indicators; a strategic framework for plan implementation based on analysis of the existing programmes; and an institutional framework for translating plans into actions with effective sectoral cooperation and coordination. In addition selected interventions and activities are proposed for implementation on priority basis. Although the ICN had suggested nine themes that should be taken up while formulating the action plan, this NPAN includes ten themes which are: 1. Incorporating nutritional objee'ives. components and considerations into development policies and programmes. 2. Improving food security till household level. 3. Protecting consumers tllrough improved food 4uality and food safety. 4. Preventing and managing infectious diseases. 5. Promoting breastfeeding and proper weaning practices. 6. Caring for the socio-economically deprived and nutritionally vulnerable. 7. Preventing and controlling specific micronutrient deficit:ncics. 8. Promoting appropriate diets and healthy lifestyle. 9. Promoting nulntion rducation, ad\'ocacy a11d cn111mun1t) p.1rt1c1p;1t1on 10. :\sses:-mg, anal:-,Ling a11J 111onitoring nu1rit1011 s1tuat1nn -- :--Ln,e1lla11ce a11J evaluation. 1 To ensure inter-sectoral coordination, cooperation and support, the inputs or all 1hc concerned sectors (Ministries and Departments) have been considered. The sectoral implementation strategies indicate the programmes and projects that need strengthening nr initiation. The sectors covered incluue the following: - Health and Family Welfare - Agriculture - Food - Fisheries and Livestock - Environment and Forest - Women and Children Affairs - Social Welfare - Disaster Management and Relief - Local Government, Rural Development and Cooperatives - Education - Information - Planning - Finance Departments - Primary and Mass Education Division (PMED) - NGO Affairs Bureau Four steps are indicated as mechanisms of implementation of the various inter­ sectoral nutrition programmes: • Reorganization and strengthening of the Bangladesh National Nutrition Council (BNNC) for giving the policy guideline:, • Inter-sectoral Steering Committee • Sectoral Working Groups (Task Forces) • Monitoring and evaluation from the Ward level 2. EXISTING NUTRITION SITUATION 2.1. COUNTRY BACKGROUND "? 1 1 Bangladesh is the largest Jelta in the worlJ. Three major rivers - the PaJma (downflow of the Ganges) flowing from the west, the Jamuna (downflow of the Brahmaputra) flowing from the north and the Meghna flowing from the north-east form this huge delta. The lanJ lies hetween 2 I and 26°N latituJe anJ 88 anJ 93°E longitude, having a common horJn with India of 3715 km in the west, north and the east, a small borJa of 280 km with Mayanmar in the south-east, anJ the Bay of Bengal in the south. The coastal length along the Bay of Bengal is about 732 km. Except for the highlands of Chittagong anJ Chittagong Hill Tracts in the south-east and parts of Sylhet and Mymensingh in the north-east, the entire country is comprised of alluvial flood-prone basin land of the three major rivers mentioned above and alluvial non­ flood prone plains. Ecologically, the country thus has three different zones, namely the plain zone, the flood-prone zone an~ the hilly zone. Bangladesh is one of the monsoon lanJs in Asia. The yearly rainfall ranges from 120 to 240 cm wi~h an average of 200 cm. The alluvial soil deposits left by flood waters from the enormous rivers, coupleJ with abunJant rainfall, proviJes the country a fertile agriculture base. About 75 % of the total lanJ area (13017 ha) is agriculture land and. about 66 % of the total population depends on agriculture directly or indirectly for earning their livelihood. Agriculture plays a vital role in the national economy contributing to around 35 % of the GDP. Sixty percent of the export earnings of the country are obtained through this sector. There are at present 6 administrative Jivisions (Dhaka, Rajshahi, Chittagong. Khulna, Barisal and Sylhet), 64 districts, 490 Thanas, 4451 unions, 59.990 mauzas, ahoul 68.000 villages and about 20 million households. The average householJ size is 5.4 persons. 2.1.2. Population The population and demographic characteristics in Bangladesh have undergone dramatic changes over the past few Jecades. The population in the area which now is l3anglaJesh was ahout 42 million in 1941. It increased rapiJly to 76 million in 1974 10 l)(l million in 1981. :\ccorJing to the latest population census of 1991. the population ol Bangladesh is 111.4 million (BBS 1992-93) which. with an area of 147,570 s4.km gin:s d population density of ahout 755 per s4. km, one of the highest in the worlJ. The popuLH ion growth rate peakeJ at 2.5 percent pL'r annum in the mill 70's, anJ then JecreaseJ steaJI!y 11) the current rate of 2.17% appearing to follow the rise in urhamzation. :\hout 80% of the toLtl population live in rural are<1s anJ the remaining 20% live in urban areas . .-\hout 57.3 milli!ln 3 are males and 54.1 million are females; the male/female ratio is 106 for the country as a whole,-with the ration of 102 in rural areas rising to ·1 I 9 in urban areas. Under 5 year olds constitute 13.5% (11.7% urban and 13.7% rural) while children aged 5-9 years constitute 15.3% (13. l % urban and 15.6% rural) of the total population. 2.1.3. Demography Demographically Bangladesh is in a trans1t1on phase where, despite the recent declines in fertility but the population growth rate is still high. causing adverse effects on development. The latest Bangladesh Demograpl-iic and Health Survey (BOHS) of 1993-94 shows that the fertility rate in Bangladesh is declining at an accelerating rate. The total fertility rate (TFR) was 6.3 in 1975. which slowly decreased to 4.3 in 1989-91 but then fell rapidly to 3.4 in 1991-93. The drop over the two year period 1989-91 and 1991-93 was 21 %. This is the most dramatic drop in TFR ever achieved in Bangladesh. Mother's education is inversely rela.ted to TFR. Women with no formal education have TFR of 3.8, compared to 2.6 for women with some secondary education. Analysis of the latest Demographic and Health Survey (1993-94) confirms The number of married women of reproductive age was 22 million in 1992. This number i:.; projected to rise to 31 million by the year 2001. The total population in Bangladesh is projected to rise to 150 million by 2010. It may stabilize at 211 million by 2056 if the present success trend in programmes of family planning, maternal and child health and other socio-economic sectors can be sustained. Despite the trend of higher maternal age at first birth, childbearing still begins quite early in Bangladesh. One in three teenage women (age 15-19) (i.e. 33%) is pregnant with first child or is already a mother. Again, teenage motherhood is more prevalent in rural (34.8%) than in urban areas (20.2%). Mother's education has a profound· effect on this aspect: prevalence of teenage motherhood is 44. 8 % in women having no education. which is almost 3 times more than in women with at least secondary education (16.3%). Female education is thus a highly needed strategy for reducing teenage motherhood. The concept of a small family now appears to be accepted by Bangladeshi couples. More than half of ever-married women consider a two-child family ideal while another one-quarter think a three-child family ideal. as against only one percent willing to have six or more children. 2.1.4 Resources and Economy Bangladesh is well endowed with human and material resources: It has a large civilian labour force, fertile Lmd and enormous water resources. Also. it has forest. natural gas. coal, oil and other mineral resources. However, despite promising reserves of coal and ll1l. no coal has yet been mined and only a small quantity of oil (ahuut I 800 barrels a day) is currently being produced. 4 During the past few years, there has been a positive trend in economic growth, with 1 · per capita gross domestic product (GDP) increasing from Taka 6472 (US$ 161) in 1990 to T.,ka 10,789 (US$ 255) in 1995-96 (provisional) at the market price. The agricultural sector continues to make the highest contribution to GDP (36.8% 111 industry increased to 11.0% in 1993-94, that in the agricultural sector slightly decreased to 34.9% over the same period. The current annual growth rate of GDP is 4.6%, favourably approaching the target of 5 .0 % fixed for the Fourth Five- Year Plan ( 1990-95). The annual growth rate in agriculture sector was 2.2% in 1991-92 which decreased to 1.8% in 1993-94. This decrease was mainly due to fall in the production of crops. Bangladesh's economy has been to a great extent dependent on foreign aid which provides around 40 % of total government earnings. Hmvever, in recent years, foreign aid dependence showed a steady decreasing trend, from 45% in 1990 tn 3(1% in 1993. Prices of essential food commodities have increased by 2-4 times over the bst decade. The lowest increase in price has been observed in case of rice while the highL"st increases were seen in the prices of pulses. fish and milk. The major share of household incnme (over 85 % ) in the majority of households 111 lbr,gladesh is spent 011 food items, indicating very little opportunity to spend on other basic neL·Js of life (i.e., health, education. housing, etc.). The highest expenditure is 011 Ct:rl':ils. while the lowest arc on pulses, milk and fruits. It is, however. encouraging to note th:1t tltnl· is a gradual i11creasi11g trend in household expenditure on 111eat. fish and vcgeL1hks w1tlt concomitant reduction on cereals. Expenditure on edible oil is declining which is undesirdhk given the prevalence of calorie dct'icicncy in Bangladesh. The percentage of functionally landless households has increased over the ycJrs lrrn11 1977 to 1993-94. The current landlessness rate is about 55%. llowever. the proprntiun oltlll' population with no land has improved from 15.3% in 1977 to 3.S':; in 1988-89. Clllt\crsL·I:,. the proportion of households with marginal landholding (land up to 0.49 acre) 111crl':1Sl'll hetwccn 1977 a11d 1989 from 33.2% to ,ll).4%. Per capita incomes have risen both in rural and in urban areas over the peril id llJ83- 84 to 1988-89. llowever, rural-urban disparity in income has widrned o\'er these ye; irs ThL· average per c:..pita income in 1988-89 was higher in urban than in rural :1reas. Despite some improvements. poverty persists at an alarming level in Bangl:tdL"sh. particularly the state of hard-core po\'erty. About 45-50% of the population live in JhsllllltL· poverty (energy intake <2122 Kcal/pnsllll/day) and 20-25~7 11\e in hardcore poverty (rnng~ intake < 1805 Kcal/person/day). In a rL·cent survey conductL·d hy the PLrnning Cornmiss1011. s 60.9% of the urban population live below the absolute poverty line (income less than Taka 3.500 per month) and 40.2% live below the hardcore poverty line (income less than Taka 2.500 per month). In Dhaka. the figures are 55% and 32 % respectively. The standard of living of the urh.an r1oor i~ !)rf'~~rirnic:!y !nw arc appalling with many living in flimsy shacks (jhupri). In Dhaka. only 41 % have access to sanitary toilets: the situation in small cities and towns is even worse. The street dwellers (estimated number in Dhaka about 11.500) are the poorest of the poor with an income of only Taka 1200 per month. Most of their income is spent on food. They enjoy hardly any utility services. They use open spaces and drains for defecation and cook their food on the street. The nutritional indicator table from the Bangladesh Bureau of Statistics (BBS. 1995) estimates that per capita daily energy intakes for the rural population was 22(>7 Kcal and thal of the urban population was 2258 KCal in 1991-92. 6 ' ' ASSESSMENT AND ANALYSIS * l'HOULE,\IS/ ISSL:ES 2.2. I Chronic Food Deficit r--- ASSESSMENT A downward trend m intake per person per day of cereals, pulses, vegetables, fruits, fish, meat, egg, ~ & oil has been seen over the last few decades · ( 1962/64 to 1992/93). Cereal (rice and wheat) intake has decreased from 528g to 465 g/person/day over the Jame period. Rice intake was 423 g/person/day in 1992-93 against the recommended intake of 454 g/person/day. Intake of white potato increased from 17 g in I 975-76 to 45 g/person/day in 1981-82, while the intake of sweet potato decreased from 18 g to only 8 g/person/day over the same period. Potato intake in 1992-93 was 42 g/person/day. 7 ANALYSIS Overall food production in the country has increas::d over the last few decades. but the rate of increased productior fell behind the rate of population growth. Other reasons f :ir this are reduction in food aid, discrepancy in distribution, iHappropriate storage facilities etc. Decreased cultivable land due to river erosion, increased rate of urbanization, and splitting of extended family ir i:o nucleus family. Inadequate appropriate technology in agricultural sect<•r. Inadequacy of good quality seeds, and other agriculturnl inputs. Loss of food due •o natural and man-made calamities. Loss of food due to inadequate packaging, transport ;md storage facilities. Emphasis is now given for crop diversification, one of the programmes of which is to produce and consume mor ! potato to reduce pressure on rice. Sweet potato although rich in energy and vitamin A, is not considered as a food item of dignity. ,. PROBLEMS/ ISSUES ASSESS.MENT Intake of pulses has decreased from 28 g/person/day in 1962- 64 lo 14 g in 1992-93, as against a minimum recommended intake of 50 g/day. Vegetable intake decreased from 14.,2 g/person/day in 1962-64 to 57 g/person/day in 1992-93 (recommended intake 2 I 3 g/pcrsonfd;iy) . Intake of fruits increased from I 5 g to 34 g/person/day between 1962-64 and 1992-93 (recommended intake 56 g/personlday. Tola) animal food intake almost remained the same at the level of 56-60 g/person/day between 1962-64 and 1992-93. ANALYSIS Cereal produclion has been given the highest priority with inadequate emphasis on crop diversification for othe: essential nutrient-rich foods (e.g. pulses, nuts, and oils). Lack of HYY. Great emphasis should be given in vegetable prodLction and consumption at community and school levels to achieve the average adult requirement. Lack of use of unconventional and nutritious vegetables. Emphasis is given for increased production and consumption of fruits and vegetables (crop diversification) is now given at the national level, but the efforts are still not enough. Great loss of seasonal fruits (e.g., mango, jackfruit, pineapple, etc.) due to improper harvesting, inadequate stonge and preservation technologies, and transportation facilities. Despite increased growth in the fisheries and livestock se::tors, the intake did not increase due to increase in population at :he same rate. Lack of improved breed of livestock and vaccination facil ties. -----, Fish intake decreased from 27 g to 24 g/person/day between I Enhanced production and accessibility needed. I l 962-64 and 1991-92. g PROBLEMS/ ASSESSMENT ISSUES Intake of meat increased from 4 g to about 10 g/person/day between 1962-64 and I 992-93. Egg intake has increased from 1.2 g to abbul 4 g/person/day between 1962-64 and 1992-93. Milk conswnption remained al the level of about 20-22 g/person/day during the same period. Intake of edible fats and oils has remained at the level of 6-7 g/person/day between 1962-64 and 1992-93. 9 ANALYSIS Intake of meal, egg, and milk is much less than the recomrne1 of intake. Livestock and poultry sectors had for long not received the and importance that they deserved. The situation has now change lO a positive direction through private SCClOI enterprises. High price and non availability of poultry feed. Per capita availability of milk has decreased due to reduced p and higher price. Lack of diversified use, processing and preservation. Present per capita consumption is only about 10% of the reco amount. Per capita availability decreased, increased price hike purchasing ability. Lack of HYV. 1ded level attention begun to poultry roduction ·nrnended and low PROBLEMS/ ASSESSMENT ANALYSIS ISSUES 2.2.2 Energy intake has decreased from 2301 Per capita availability of all kinds of food decreased proportional :ly hand in Chronic Nutrient Kcal/person/day in 1962-64 10 1961 hand with the production-population imbalance. Deficiency KCal/persoo/day in 1992-93. Lack of proper distribution of food. Protein intake has fallen from 58 g/person/day in Unequitable distribution of food, low purchasing capacity, ignoran ;:e and lack 1962-64 to 52 g/person/ day in 1992-93 of nutrition education, wastage of food due to lack of transport : md storage (recommended intake 45 g/person/day). facilities. Intake of vitamin A decreased from 1590 IU to Low per capita availability. 1568 IV/person/day between l 962-64 and 1992-93 Loss of fruits and vegetables due to lack of proper post/harvest processing (recommended intake 2013 IV/person/day). and storage. Calculated dietary iron intake increased from l 0 mg Decreased bio-availability due to the plants being the major source of iron in to 22 mg/person/day between 1962-64 and l 991-92 the diet. (average recommended intake 15 mg/person/day). Per capita iodine intake is about 10 mcg/day Low iodine content in soil, food and water. (recommended intake 150-200 mcg/day). Per capita daily vitamin C intake decreased from 48 Decreased production and availability of fruits. mg 10 13 mg (recommended intake 26 Faulty cooking practices. mg/person/day). 10 PROBLEMS/ ISSUES 2.2.3. Protein­ Energy Malnutrition (PEM) Malnutrition in Children aged less than 5 years ASSESSMENT A vast majority of the total population particularly children and mothers suffer from protein-energy malnutrition. Only 6.2% of the under five children in Bangladesh are normally nourished. Remaining 93.8% are suffering from different grades of malnutrition. Percentage of mildly malnourished children has increased from 28.8% in 1981-82 to 39.8% in 1991-92. Percentage of moderately malnourished children remained almost the same during this period (46.1 %-47.2%). MUAC: Percentage of children having MUAC less than 12.5 cm was 11 % in I 990 which dropped to 10% in 1994. Stunting: in 1992, 46 % under five children were stunted (height-for-age less than 90% of NCHS median) compared to 44 % in 1981-82. Wasting: in 1992, 7 % children were wasted (weight-for­ height less than 80% of NCHS median). 11 ANALYSIS Inadequate food, compounded by inadequate health care, poor hygiene, and unhealthy em1ironmcnl. Gap in dietary energy is the major cause. Diet deficient in energy-dense items such as oil. Traditional food habits (preparation and eating) resulting in loss of essential nutrients (e.g., discarding water after CO(lking rice, overcooking of vegetables with lots of spices, etc.). Faulty intra-household food distribution pattern (e.,., mother eating last and mostly the least). Large scale adulteration of food items (e.g., cooking oil) causing health hazards and malnutrition. Faulty weaning (complementary feeding) practices. Frequent attacks of diarrhoea and other infections. Infection e.g. frequent attacks of diarrhoeal disea,es, ARI, measles, pertussis, tuberculosis etc. PROBLEMS/ ISSUES Gender Differential Rural-Urban Differential Age Differential ASSESSMENT In 1981-82, girls were more severely malnourished (22.6%) than the boys (8.0%) and the percentage of normally nourished girls was 5.7% compared to 14.1 % for boys. In 1991-92, the percentages of girls and boys suffering from various degrees of malnutrition were almost the same (e.g. severely malnourished girls 7.4%; severely malnourished boys 6.3%. In 1991-92, higher proportion of the rural children suffered from severe (7.2%) and moderate (48.3%) malnutrition compared to ·the urban children (4.3% and 38.7%, respectively). Similarly, in 1991-92, 13 .2 % of the rural children had MUAC less than 12.5 cm, i.e. severely malnourished, compa,red to 8.4% of urban children. Both wasting and stunting are highest in the age group 12-23 months; wasting declines after that but stunting stays at the same level. 12 ANALYSIS Culturally, girls are often neglected in the family for nc t being potential future earner. Current practice of intra household food distributiou often favours the males over the females. Lack of education and motivation to family. The situation is improving due to nation wide campaign :,y both government and NGOs. Rapid urbanization, creating job/work opportunities in ci1 ies and townships. Migration of rural people to the cities. Relatively no development and industrialization in th,i rural areas. Poor income most of the year and absolute joblessness in certain months (July-September). Continued breastfeeding not done due to the arrival of a new member in the family. As the child grows older he/she can feed himself/herself by all possible means. Inadequate knowledge and caring practices. PROBLEMS/ ISSUES Infant Mortality Child Mortality 2.2.4 Bre.c.tfeecling Problems 2.2.5 Complementary Feeding Problems ASSESSMENT ANALYSIS In I 990, infant mortality rate (IMR) was 94 per 1000 live births Low-birth-weight (LBW) is a strong detenninan; of infant which dropped to 77 per I 000 live births in 1994 (79 in urban mortality. Frequent morbidity ultimately leads to death. IMR and 58 in rural areas). and CMR decreased in recent times due to improved health Child mortality rate (CMR) in I 990 was 151 per I 000 live births which dropped to 137 in 1994 (146 in rural and 80 in urban areas). Colostrum rejec.lion is common (60-90%) in Bangladesh. Exclusive breastfeeding is only 4 % (i.e. almost non-existent). Complementary food is given to 100% babies at 1-12 weeks. Bottle feeding is practiced in 59% among the hospitalized malnourished children. 90% of the urban mothers use bottle for supplementary feeding. Prelacteal food is given to 100% of infants. Proper weaning at proper time (5 months) is lacking. Mean age of introducing solid food ranges from 12-13. 5 months. 18 % of slum infants receive additional foods in the first month and 47% by the 3rd month of life. Weaning food is usually lacking in adequate energy and protein density. Unhygienic weaning practice leads to intercurrent infections. 13 care facilities, e.g., immunization, mort; acce:;s to safe drinking water. The recent improvement in IMR and CMR is visualized as due to intensification of nation-wide immunization (e.!. EPI) and other child survival programmes both by the govemment and NGOs. Lack of information concerning the benefits of colo:.trum and breastfeeding. Promotion of breast milk substitute (BMS) through advertisement and widespread marketing. Artificial feeding practices in hospitals and clinics. Inadequate training on breast feeding practices to aJI level of health personnel. Change in cultural practices. Food taboos and false beliefs. Lack of information and education concerning pro~ 1!r weaning practices. Low purchasing capacity. Promotion of breast milk substitutes through adverti!;ement and widespread marketing. Lack of appropriate weaning time and food. PROBLEMS/ ISSUES 2.2.6 Maternal Malnutrition 2.2. 7 Low Birth Weight (LBW) ASSESSMENT Mean weight and height of non-pregnant women are 39 kg (range 32- 48 Kg) and 148 cm (range 135-157 cm). Mean MUAC of non-pregnant women is 21.2 cm (range 18.6 cm to 25.8 cm). Loss in mother's body weight per child birth is estimated to be I kg . 74 % of adult women and 80% of pregnant and lactating mothers suffer from anaemia (Hb < 11 g/dl blood). The haematocrit value (Hct %) is 35.9% at beginning of pregnancy which decreases to 30.0% at full term. 25% of non-pregnant slum mothers suffer from undernutrition (BMI < 17). Weight gain during pregnancy is 4. 7 kg in rural mothers and 5. 7 kg in urban mothers. Percentage of mothers suffering from severe undernutrition (BMI < 16) is 10.6% in urban slums compared to 8.4% in rural areas. Mean birth weight in both rural and urban areas is 2. 7 kg. 37-41 % babies born in rural areas are of low birth weight ( < 2500 g) as against 23-27% babies in urban areas. In urban slums, 39% babies are of low birth weight. 74 % of LBW babies are born to adolescent mothers. 84 % of LBW babies are small-for-date and the rest arc pre-term babies. 14 A~ALYSIS Social discrimination favouring mak mor female. Physical and mental stress. than Intra family food distribution favouring both the male adult and the male child Inadequate food intake during pregnancy. Food taboos during pregnancy and lactation. Intake of animal food which is rich in iron and :Jrotein is poor during pregnancy and after childbirth. Child spacing not done. Urban mothers are somewhat better off than tl •! rural mothers in terms of income, decision maki '..g and food intake. The magnitude of urban poveny is increasing alarmingly with the migration of rural poor to the urban cities. Iodine deficiency during pregnancy. Infection of the mother during pregnancy. Teenage pregnancy Heavy physical work load during pregnancy. Stress syndrome - Physical - Psychological Again, urban mothers are better off than th: rural mothers in nutrition during pregnancy, although the magnitude of urban poverty is increasing alauningly with the migration of rural poor to the urban ci1 ies. Lack of balanced diet during pregnancy. PROBLEMS/ ISSUES 2.2.8. Micronutricnt Deficiencies Anaemia V 1Lan1in A Dc::ficicncy V itan1in A Capsule (V AC) Coverage ASSESSJ\,IENT ANALYSIS Over 60% of population in Bangladesh suffer from Micronutrient deficiencies in Bangladesh accompany protein­ deficiency of one or more of the micronutrients energy malnutrition due to acute and chronic food shor .3ges and (particularly iron deficiency and iodine deficiency). Vitamin faulty dietary habits and practices. A deficiency is also wide spread in the country. 74 % of adult females, 80% of pregnant and lactating mothers, 73 % of under five children, and about 40% of adult males suffer'from iron deficiency anaemia. Among the children aged 5-14 years, boys suffer more (74%) from anaemia than the girls of the same age (63%). I. 78 % of children aged between 6-71 months in 1989 were suffering from night-blindness compared to 3.6% in 1982- 83. Thi:; is still well above the WHO cut-off point (1.0%) for a major public health problem. In 1989, 1.59% boys compared to 1.97% girls of the above age group were suffering from night-blindness. More than a million children have visible signs of vitamin A deficiency. About half a million suffer from night­ blindness. Around 30,000 children go blind every year due to chronic vitamin A deficiency and almost half of them die within a year of becoming blind. Decreased bio-availability of iron and decreased i ·1take of vitamin A, C, folate and protein rich foods. Hookworm infestation and other infections Perhaps boys are more exposed to parasitic infestation due to their wider mobility compar e cl to th~irls ()~amc:: age. , There are much higher levels of production and consurnption of cereal crops (mainly rice) compared to horticuitural crops (vegetables, fruits, etc.) Less intake of vitamin A rich food. Rejection of colostrum. Less fat (oil) intake which is essential for Vit:min A absorption. Boys have greater access to naturally grown vita.mi.Ii A rich fruits due their wider mobility compared to traditiona: iy lesser mobility of the girls. Vitamin A rich fruits and vegetables are not ,.vailable throughout the year. On average, 1.61 % population aged 6 years and abovt: suffer from night-blindness. Vitamin A deficiency is prevalent not only in children age 6-7 I months, but also in older pop11lation. V AC coverage among children aged 12-71 months has I V AC distribution programme intensified by Govemr :.ent and increased to 7 4 % in urban areas and 85 % in rural areas. N GOs. 15 l'H.OllLEl\lS/ ISSUES Iodine Deficiency Disorders (IDD) f-----· Iodised Sall Coverage ASSESSMENT 69% of the population in Bangladesh are deficient in iodine. 47% have goitre of which 9% have visible goitre. 53 % of girls aged 5-11 years and 56 % of women aged 15-44 years have goitre. 500,000 persons in Bangladesh are mentally retarded due to iodine deficiency in early life .. 100% of the population in Bangladesh are feared to be at risk of iodine deficiency disorder. An estimated 250 million IQ points are at risk of being lost permanently due to iodine deficiency. ANALYSIS Low iodine intake is the major cause of IDD which is the result of very low iodine content in soi., food and water. This is due to continuous leaching of the soil off iodine caused by heavy rainfall and recurre1 It flooding. Physiological demand for thyroxin (and L 1erefore of iodine) is higher in females than in males. Crops grown in such iodine deficient s:,il usually contains less iodine. Iodine deficiency in foetal and post natal Ii fe impairs brain growth and development leading to mental retardation and improper functioning of the t,rain. O\(er 90% of the total salt produced in Bangladesh for human Increased sensitization among policy ma,ers about consumption is now iodised. However, the iodine level is not regularly IDD. monitored. Also, percentage of population taking iodised salt is to be Activation of salt iodation programme of BSCIC. ascertained. Increased motivation of the general public in favour of more use of iodised salt. Implementation of the law is not fully satisfai:tory. 16 PROBLEMS/ ASSESSMENT ISSUES Other rruno- In addition to the micronutrient deficiencies mentioned above concern is nutrient deficiencies growing about deficiencies of other important micronutnents (e.g. riboflavin, vitamin C, vitamin D, zinc). Riboflavin Toe average daily intake of riboflavin (0.68mg) meets only 50% of the Deficiency requirement. , Vitamin C Toe intake of Vitamin-C (13 mg) meets only 26% of the requirement Deficiency Vitamin D Nutritional rickets are not common in Bangladesq, but recently some pockets Deficiency have- been identified, such as, Chokori.a in Co.;'s Bazar where rickets in children is seen in endemic form. Zinc Deficiency Bangladesh soil is repo'1ed to be deficient in zinc. Other Nutrition In Bangladesh, diseases are prevalent which are not due to dietary deficiency Related Di~ases but due to overconsumption of food items rich-iD sugar, fats and oil. Some diseases occur due to toxins present in certain food items, e.g., lathyrism • Source: Bangladesh Bureau of Statistics, Ministry of Planning, GOB', 1995. 17 ANALYSIS Chronic food deficit coupled with p< ,verty and illiteracy leads to deficiencies of a wide spectrum of nutrient deficiencies. Poor intake of food containing riboll.avin e.g. milk, green vegetables, fruits, fish and meat. Poor intake of food containing vitan1in-C e.g. fruits and vegetables Etiology is · not known. Investigation is in progrtss. Soil is zinc -deficient due to heavy rain and recurrent flooding. Poor intake of foods containing zinc ( meat, fish and milk). Associated to die~ habits and unhealthy lifestyles. Over consumption of Khesari which , :ontains a neurotoxin. 3. GOALS, OBJECTIVES AND TARGETS The high rates of widespread malnutrition in Bangladesh needs immediate attention. The situation is unacceptable and the Government of the People's Republic of Bangladesh is determined to take immediate and urgent action to arrest and reverse the situation. In this process the National Plan of Action for Nutrition is a tool for achieving this objective. It is important that realistic goals are defined, specific objectives formulated with indicators identified for measuring if success has been ac.hieved in reaching the targets. set. 3.1 GOAL The goal of the NPAN is to improve the nutritional status of the people of Bangladesh to the extent that malnutrition would no lunger be ·a public health problem by the year 2010, thereby, improving the quality of life. 3.2 OBJECTIVES AND TARGETS The objectives of NPAN are outlined below. Targets are mentioned where appropriate. 1. To develop human resources in nutrition by strengthening institutional capacity in the area of policy making, training, research and the provision of services 2. To empower the communities and households to understand the nutritional problems and thereby to take appropriate measures to address the problems 3. To ensure food security to all household members: (a) Enhance intake (consumption targets): Increase energy intake to 2150 Kcal per person per day. Pregnant and lactating mothers to take an •extra 300 Kcal of energy per day Protein intakes from plants and animals of at least 45 g per person per day Increase oil•intake to 20 g per person per day Increase pulse intake to 50 g per person per day Increase vegetable intake to 213 g per person per day Increase fruit intake to 56 g per person per day Increase animal food intake to an appropna1e level. Ensure availability of enough calories for the economically deprived and nutritionally vulnerable 1 ' •j Indicators are to be developed for different groups or population to asscss impact. (b) Reduce energy-protein malnutrition (EPM): Reduce the prevalence ot low birtn weight to 1U% by lUUU and to less than 5% by 2010. Reduce severe and moderate EPM (weight for age) in under-two children: severe EPM to 3% by 2000 and to < 1 % by 2010; and moderate PEM to 25% by 2000 and < 10% by 2010 Restore growth rate in under-two children: 50 % children hy 2000: and 80 St by 2010 Reduce EPM in under-five children: wasting to 4 % (by 2000) and < 1 % hy 2010; and stunting to 25% by 2000 and to < 10% by 2010 Reduce severe malnutrition in women (BMI < 16) to 5 % by 2000 and to < 1 % by 2010 Ensure adequate nutrition support to adolescent girls and elderly population 4. To ensure food safety and food quality: (a) Assess existing food and water qualities in special groups. viz., street food. processed food, etc (b) Ensure adoption and implementation of the revised food law along with enforcement 5. To control infectious diseases and provide the required environmental support: (a) To increase ORT use rate (to indicate the diarrhoea control status) to 96 % by the year 2000 (b) To reduce hookworm infestation rate to 5 % by the year 2000 and to < l % hy the year 2010 (c) To provide potable water to at least 90 % of the population by the year 2000 and to 100% by the year 2010 (d) To ensure sanitation facilities to 80 % population by the year 2000 and l 00 % by the year 2010 (e) To sustain EPI success and increase the coverage to 100% by the year 2000 (f) To ensure better management of ARI and reduce case fatality - reduce death by 1/3 by the year 2000 and by 3/4 by the year 2010 1) 6. To protect, promote and support breastfeeding: (a) To empower all women to breastfeed their children exclusively for 6 months and to continue breastfeeding well into the second year supported by home ~ energy dense complemeiiUify food (b) To exclusively breastfeed all infants by 80 % mothers by 2000; and 95 % mothers by 2010 (c) To transform 100% maternity service providing hospitals into baby friendly by 2000 7. To ensure support for the socio-economically deprived and nutritionally vulnerable 8. TQ reduce micronutrient deficiencies: (a) Nutritional anaemia: To reduce the prevalence of anaemia in women of reproductive age group to 50% by 2000; and 25% by 2010 To reduce the prevalence of anaemia in under-five children to 50% by 2000: and 25% by 2010 (b) Vitamin A deficiency: To reduce the prevalence of night-blindness in children aged 6-71 months to < 1 % by 2000; and to eliminate by 2010 (c) Iodine deficiency disorders (IDD): To reduce the prevalence of goitre in the entire population to 25 % by 2000; and < 10% by 2010 To iodise all edible salt by the year 1996 9. To promote appropriate diets and healthy lifestyles 10. To promote nutrition advocacy, education and community participation 11. To assess, analyses and monitor the nutrition situation 20 4. STRATEGIC FRAMEWORK FOR PLAN IMPLEMENTATION The success of achieving the objectives of the NPAN depends on two closely related issues: - emmrino thP. ~ec-toral inputs for vi:i.rious supportive !'mgr2mmP.~: :mrl - inter-sectoral coordination to make it most effective and focused. In this chapter, these two issues are discussed under following ten major themes, which are considered as strategic elements for nutritiori programmes. 1. Incorporating nutritional objectives, components and considerations into development policies and programmes. 2. Improving household food security. 3. Protecting consumers through improved food quality and food safety. 4. Preventing and managing infectious diseases. 5. Promoting breast feeding and proper weaning practices. 6. Caring tor the socio-economically deprived and nutritionally vulnerable. 7. Preventing and controlling specific micronutrient deficiencies. 8. Promoting appropriate diets and healthy lifestyle. 9. Promoting nutrition education, advocacy an~ community participation. 10. Assessing, analyzing and monitoring nutrition situation. Under each theme details of on-going programmes and an analysis of the situation is provided, the sectors involved are identified, the strategic framework and action plan described and selected interventions are proposed. The success of any developmental programme is dependent on the socio-economic status of the country and therefore the existing socioeconomic status and various on-going programmes are briefly discussed. This is important, not only for creating better linkages between the sectors, but to ensure most the effective utilization of all existing resources in a properly timed and targeted manner. Bangladesh has frequently undergone traumatic experiences like war, natural disasters. political instability at the same time as experiencing high growth rate in population. unemployment and poverty. Despite improvements in the economy, Bangladesh is classified as a least developed country (LDC) because of these negative impacts. The present per capita gross domestic product (GDP) is Tk. 10,789 (US$ 255) (BBS 1995-96) (provisional). In response to these conditions the country has had to improvise and create various types of supportive programmes, specially linked to economic development and poverty alleviation. ,... --•••-•-- --•-••--•••-- ••-•' •• ,,.t •-.·•.-- J:!.. 11 .-L---~--1 ---~ ., 1 ------•L .,L ~----·.,-.-:, & VA • \,,UU'-'AUE, aa&&.l&UUU ••ava.a ~ ,....,&A&V .... ·e, ...... y-J .., • ..,...,. --- ··---.... t,• - .. --, --- .... .., . -·· basic and underlying causes as follows are to be considered to be addressed: , Poverty allevia tion. Agricultural and food based interventions. Safe water and sanitation. Improved literacy. Empowerment in the developmental process. Child spacing and child caring practices. A coordinated inter-sectoral approach with people's participation arc the two most important factors which can make the strategies feasible and viable to achieve the goal, as envisaged in the NPAN. Poverty alleviation bas been a top priority of the Government of Bangladesh. The country has a number of poverty alleviation programmes being supported by GOB and various UN and foreign assisted programmes (WFP, ILO, UNDP, FAO, UNICEF, ADB, WB, ODA, CIDA, SIDA, NOVIB, NORAD, Aga Khan Foundation, USAID, CARE and others), which are approved by the Bangladesh Planning Commission and implemented by various government departments and agencies as well as NGOs. These programmes include: Rural maintenance programme (RMP) Poverty eradication programme Rural development programme coordinated by WFP Food for work Rural women employment creation programme NGO-community based programme for poor women and children Rural women development programme Vulnerable Group Development Programme coordinated by WFP Women vocational training for population activities Assetless women development programme Technology transfer programme for employment generation for rural women Technical assistance for women agriculture training centre Urban based women development programme Urban community development programme Use of rural mother centres (RMC) for population activities Rural social seniice programme Rural development project - 8 Development of small irrigation projects Poverty alleviation programmes through NGOs Children in especially difficult circumstances (CEDC) 22 Although the country is well aware of the policy reforms needed for development. more coordination among the various programmes, supported by properly designed approaches would definitely lead to better outcomes. Measurable indicators which specifically monitor nutritional status should be in-built into such programmes to evaluate and monitor the ultimate achievement and highlight the gaps to formulate future action strategies. SECTORS INVOLVED The various se~rs which have a significant contribution, directly or indirectly .. towards achieving the oijjectives and targets of the NPAN are identified as follows: .~ ., 1. Health an~ Family Welfare 2. Agriculture 3. Food 4. Fisheries and Livestock 5. Environment and Forest 6. Women and Children Affairs 7. Social Welfare 8. Disaster Management and Relief 9. Local Government, Rural Development and Cooperatives 10. Education 11. Primary and Mass Education 12. Information 13. Science and Technology ·- 14. Planning 15. Finance 16. Various UN Agencies like FAO, WHO, UNICEF, UNDP, WFP, WB, ODA 17. Non-governmental Organizations (NGOs) The Planning Commission has the critical role of supporting and Bangladesh National Nutrition Council of coordinating action among the various sectoral inputs. 4.1 INCORPORATING NUTRITIONAL OBJECTIVES, CONSIDERATIONS AND COMPONENTS INTO DEVELOPMENT POLICIES AND PROGRAMMES The incorporation of nutritional objectives, considerations and components into development policies and programmes of the country is the first major step for ensuring proper planning, and successful implementation of all programmes. This is essential for ensuring significant improvement in the nutritional status of the population for economic growth and development; structural adjustment; food and agricultural production, processing, storage and marketing of food; health care; education and social development. Issues that need to be covered individually are administrative, institutional as well as human resource development. 23 -- -- ---- - --- 4.1.1 On-going programmes and situation analysis The major steps already initiated by the government of Bangladesh as a follow-up action of the ICN include the following: 1. Strengthening the already existing Bangladesh National Nutr~tion Council (BNNC) , by reconstituting the Council with the Prime Minister in the Chair and the Ministers of all concerned Ministries as members. 2. Preparation of a document on State of Nutrition in Bangladesh, 1995 subsequent to the formulation of the Bangladesh National Plan of Action for Nutrition (NPAN). ·- 3. Initiation of an integrated nutrition programme as Bangladesh Integrated Nutrition Project (BINP) financed by World Banlc. 4. Strengthening of Bangladesh Institute of Research and Training on Applied Nutrition (BIRTAN) to incorporate nutritional objectives and considerations in the Agriculture Sector. 5. Several issue-based projects, details of which are provided under the section on "Ongoing Programmes". Analysis of the ex1stmg situation indicates the following gaps which need special attention when drawing up future programmes: Nutritional objectives need to be incorporated in all related programmes. A coordinated approach in policy planning is needed. Sectoral programmes should be linlced. Implementation mechanisms need to be clearly indicated. All important strategies need to be carefully considered. Impact assessment needs to be done at the grassroots level. 4.1.2 Sectors involved The sectors and agencies involved are as follows: All Ministries concerned. UN agencies and donor agencies viz., FAO of the United Nations, UNICEF, WFP, UNESCO, WB, WHO, USAID and others. NGOs. 24 4.1.3 Strategic framework 1. To incorporate nutritional objectives, considerations and components into development policies and programmes including human resource Sr. No. 4.1.3.1 rlP.ve.lnnmPnt r !lln !ll!'i.t v hnil,Hnn nnr! ::>:"n--'\--- ···"'""'"'... . . •·---··-•·•-- - - - 0 --r - .. -- ---• va ""v&&.UUUllJ.1,.1~ dllU individuals: Ensure inter-sectoral coordination for policy planning by involving the highest level government support for the nodal coordinating agency. Creation of an Inter-sectoral Steering Committee and specific working groups under each sector to fulfill the nutritional objectives. Analysis of macro-level policies by involving National and Regional level research institutions and Universities. Collection, analysis and creation of a data base at the district level for micro­ level planning. Establishment of nutritional impact assessment procedures in the formulation and implementation of development projects and programmes. Actions Agencies Target Time Frame Concerned Strengthening and MOP, 1. Ensure highest Immediate restructuring of MOHFW, level Bangladesh National MOA, commitment Nutrition Council MOFL, MOF, and support. (already formed). MOEF, MOSW, 2. Cooperation MOL, and MOLGRD, coordination MOI, from the MOWCA, highest level of MOin, MOE, all the MOF, MOC, concerned MOST, sectors. MODMR, NGO 25 Sr. No. Actions Agencies Target Time Frame Concerned 4.1.3.2 Strengthening of the As above Highest level inter- Immediate Executive Committee sectoral coordination of the Council. for policies and planning. 4.1.3.3 Formation of Working As above Preparation of sectoral Immediate Groups (restructuring action plan in line with and strengthening of nutritional objectives the technical and ensuring committee) under each implementation of the sector. plan. 4.1.3.4 Field level MOP, 1. To implement Immediate infrastructure and MOHFW, the actions till support system. MOA, the Ward level. MOFL, MOF, MOEF, 2. Coordinate and MOSW, cooperate with MOL, the working MOLGRD, groups, steering MOI, committee and MOWCA, the national MOin, MOE, nutrition MOF, MOC, committee for MOST, monitoring and MODMR, evaluation. NGO 4.1.3.5 Incorporation of As above All projects and Immediate nutritional objectives programmes of the in all the existing collntry. sectors 4.1.3.6 Up-dating the As above All relevant documents Immediate documents on nutritional status. 4.1.3.7 Preparation of food MOF, MOA, All major foods grown Immediate balance sheet and MOHFW, food composition MOE, MOA, I table. MOST I I 4.1.3 .8 Inclusion of nutrition MOE, PMED, All population Immediate I ' curriculum at all MOI I I ' levels. i 4.1.4 Action plan 1. Development of an inter-sectoral strategy for implementation of the NPAN: Inter-sectoral Steering Committee Sectoral Working Groups Union level networking 2. Macro-level policies - involvement of agencies and institutions. 3. Micro-level planning at District, Thana and Ward levels. 4. Strengthening the activities of the nodal agency responsible for creating the nutritional database and implementing the supportive programmes at the central level along with networking at the District, Thana, Union and Ward levels involving the MIS of the MOHFW. Developing a workable and effective coordinating mechanism (agency) between Sectors by ensuring the involvement of the Government at the highest level. A senior Government officer of one of the nodal sectors may act as the Member Secretary to the already existing BNNC being chaired by the Hon. Prime Minister to oversee and plan various activities. 5. Conducting regular surveys (every five years to coincide with the cycle of the national development plan) to up-date the data base on the nutritional status of the country down to Ward level. Nutrition surveillance data being generated by various organizations will be taken into consideration at this time. 6. Avoid duplication of nutrition programmes and activities, strengthen mutually supportive projects and coordinate planing for maximizing nutritional benefits in a most cost effective manner, convene inter-sectoral meetings on a regular basis. 7. Involvement of women at policy making and implementation levels. 8. Ensuring nutrition education, advocacy, motivation and trammg at all levels highlighting its importance to the planners, administrators and all concerned. 9. Food balance sheet and food composition tables to be produced for providing dietary guidelines to the researchers, planners, and implementors. 10. Inclusion of nutrition in the curriculum in educational institutions. 11. Nutritional indicators to be developed and included in all programmes. 12. Assessment of financial and resource needs by each sector for contributing to the improvement of the nutritional resources with built in mechanism for accountability. 4.1.5 Proposed interventions The following interventions are suggested in order of priority. 1. Formulation of food and nutrition policies and programmes to improve nutritional status. Policies and programmes should be well targeted and implemented with good inter-sectoral coordination. 2. Strengthen the nodal agency/committee for coordinating act1v1t1es amongst the different sectors, advise the Government on related issues and implement the NPAN. The highest policy making body should give clear recommendations. Necessary technical support has to be provided for this. 3. Workshops and training needed for human resource development (HRD). 4. Development of special policies and programmes, particularly on food security issues, targeted towards women and nutritionally vulnerable and socio-economically deprived population groups and those in distress. Studies will be made to identify such groups. This will include time required and energy expenditures for physical labour (agriculture work, water/feed/fodder collection etc.), other physical activity and morbidity, etc. to calculate actual energy requirement per person. 4.2 IMPROVING HOUSEHOLD FOOD SECURITY Food security is defined in its most basic form as access by all people at all times to the food needed for a healthy life. To achieve food security, three major aspects need to be highlighted. The first is availability of safe and nutritionally adequate supply of food at both national and household levels. Secondly, there has to be a reasonable stability in the supply of food spatially and seasonally. Thirdly each household should have physical, social and economic access to sufficient, safe and good-quality food to satisfy its needs. 4.2.1 On-going pro grammes and situation analysis Major on-going programmes are presented in the table presented below. Supportive programmes include: 1. Strengthening of plant protection. 2. Food for work. 3. Food for education. 4. Vulnerable group development programme. 5. Post harvest handling, pr-ocessing and preservation of food stuffs. 6. Support to master plan for the forestry sector (FAQ). 7. Soil fertility and fertilizer management project. 8. Strengthening of central extension resources development institute, 28 9. Marginal and small farm system intensification project. 10. Coconut development project. 11. Agriculture development in Southern regions. 12. Seed development project. 13. Strengthening of national vegetable production programme. 14. EstaoITsliineiit of regional duck hatchery. 15. Extension of animal health management project. 16. Conversion of dairy farms into breeding farms. 17. Poultry research and development. 18. Duck-weed research project. 19. Third fisheries project. 20. North-west aquaculture development project. 21. Development of Kaptai fisheries. 22. NGO-supported income generating and food production projects. 23. Integrated resource development of the Sundarbans reserved forests (FAO). Analysis of the existing situation indicates special attention is required on the following: Household food security. Nutritional considerations ·in existing programmes. Linkage of food security to poverty alleviation programmes. Food diversification. Food security for urban poor. Accessibility to food at household and individual levels. Local food preservation facilities and technologies. Balanced diet. Research and development activities to increase food production. 29 On-going major programmes and projects of the country (Theme-2) ,. SI. Projl-Ct Actions Agency Donors ,! Coverag, Duration No. Concerned I. Thana cen:a! - Technology transfer as block demonstrations in irrigated areas. MoA/DAE FAO Divisional technology transfer and - Use and management of irrigation water. Headquarte 1995-2000 : ·s i<lcntitication - Increased cropping intensity and land saving agronomy. proJect. (TCITI) - Use of agro -inputs for correction of multinutrient deficiencies. - Increased coverage of high-yielding varieties. - 1PM , - Integrated nutrient management. - Quality seed production and storage. - Income generation for farm women. - Research on germplasm. - Better linkages between research and extension. - 2. lntcgratt..-d pest - Support govt. 's accelerated cereal production. MoA/DAE FAO 120 Thanas i 1995-2000 management (1PM) - Increase farm outputs and yields. 3. Crop <liversitication Increase pulse production MoA/DAE GOB 59 Districts 1995-2000 programme (CDP) - Demonstration fanns/plot building. - Seed distribution. Increase oil seeds production - mustard. 48 Districts - Soybean. 18 Districts - Sunflower 12 Districts Increase white potato production 40 Districts - Demonstration plots - Technology transfer - 3U .. SI. I PROJECT AC'rIONS AGENCY DONORS COVERAGE [I l/RATION 1'\0. CONCERNED 4. Agricultural - Strengthening DAE DAE WB, ODA, National 1s 1 >1-98 support services · Fam1er information !'JCCd assessment. GOB pm1cct (ASSP) · Planning and implementation. · Monitoring and evaluation. · Training and management. - Strengthening homestead production. · Support homestead technology development. - Seed industry, research and training. ----~- --~-- 5 L1n:~t0<:k - Training. MoFUDLS, !FAD 80 Thanas pre sent-1998 (kvclopment - Credit. BLRI, NGO proJcct for small - Chick rearing. anJ marginal - Research. fanncrs b. Ut1ilLation of AEZ - Development of national updated agricultural development MoA FAO 225 end-users 19S 5-2000 database and planning information system. installation of GIS - Development of manpower. for agricultural development. 31 SI. Project Actions Agency Donors Coverage Duration .'\o. Concerned 7. Strengthening of national - Improved supply of vegetable seed. BARI, BADC, FAO National 1996-2001 vegetable seed production - Support to private companies. NGOs, Private programme through increased companies panicipation of private sector. 8. Bangladesh l loniculture - Devclopmc:nt of fruits, vegetables and spice crops. BARI. DAE. FAQ National 1992-1996 Resean.:h and - Diversify cropping pauem. BADC Development ProJ,:ct - lm.:rcase rural employment and income. 9. Strengthening of rural pond fish - Increase fish culture production in rural areas. MoFL/DOF FAO 3000 farmers 1994-1996 culture extension services. - Enhance fish production in aquaculture sector. 10. Thana afforestation and nursery - Upgrade and expand the capacity of forest department MoEF FAO 61 Districts 1990-1995 development and Thana Parishads. II. Establishment of dairy and cattle - Farm development MoFL/DLS GOB, ADB 3 Districts (Barisal, On-going development Chittagong & Bogra 12. Second aquaculture development - Demonstration plot. MoFL/DOF ADB Eastern zone On-going project - Fry release in open water - Training. \ 13. Beel and baor fisheries - Farm development MoFUDOF IFAD, Jessore, 1988-0n-going development and management 1 - Training DANIDA Chuadanga, project Kushtia, Faridpur 14. Aquaculture extension project - Pond development. MoFL/DOF DANIDA Mymensingh, up to 2000 (second phase) - Interest free credit to farmers. Patuakhali, ' - Training. Barguna, Noakhali 32 SI.No. Project Actions Concerned Donors Coverage Duration agency 15. Bangladesh Integrated National level: MoHFW IDA/WB 40 Thanas 1995-2000 Nutnllon ProJL"CI - Programme development and institution building. (BJNP) - Infonnation, education and communication developme·nt. - Strengthening existing nutrition activities. - Management Infonnation System. Community based Nutrition Component: - Community mobilization. - Supplementary feeding to'targeted children and women. - Growth monitoring and promotion. -IEC Inter-sectoral nutrition programme development: -Creation of inter-sectoral nutrition cell and fund to support inter- sectoral sub~projects. 16. Nutrition Surveillance - Monitoring of child anthropometric status, food price, V AC HKJ, IPHN USAID 35 rural ProJt."CI (NSP) distribution, emergency food 3.\d, foodgrain intake at household level, and NGOs Thanas and 4 magnitude of distress, and home garden implementation. urban slwns J 990-ongoing 17. Model School - Training to school teachers on nutrition and Vit. A deficiency. WIF, IPHN UNICEF 240 schools in Gardening Promotion - Education, motivation of students on malnutrition, Vit. A deficiency 4 Districts J 995-on-going Programme and night-blindness and on vegetables and fruits rich in Vit. A. - Establishment and follow-up of school gardens. - Provide seed and seedlings and support for fencing and fertilizer. - Establishment of coordination and cooperation between health and agriculture departments at local level. 33 --- --- ~-...----- :-,1. l'ruject Actions Agency Donors ( ·o\cragr Duration MJ. Concerned -- -- i ~- NGO GarJcnmg - Promotion of production and consumption of Yit. A rich fruits HKJ and partner USAID, 9o·niana ' :llld Nutnl!on and vcgt:tables. NGOs NOVIB. (315,000 hlucal!orl - Establishment of central nurseries, village nurseries, and ODA. households) I Survcillance P1 0Jt.Tt household gardens. ASSP (NGNESP) I 995-on-gning -- l ,; . Promutiun of Home - Training on home gardening to Block Supervisors and NGO HKI. DAE. ODA 5 Districts (30 Gardenrng through workers, nursery farmers. ASSP and 6 Thanas) I 995-on-going Training - Supply of seeds and fertj.lizers. NGOs · Support for irrigation by treadle pumps or tubewells. ·-- 2lJ ( 'onm1un1t} - Nutrition Education. IPHN. BNNC UNICEF National with Nutnt1on - Growth monitoring. ofMoHFW. special attention Prograimne - Advocacy and social mobilization. MOLGRD to urban areas .996-2000 - Research. · Control of PEM - Child nutrition survey. · Control of !DO - Nutrition surveillance. - Quality control of iodised salt. · Control of Vit. - Training and orientation to the salt traders. A dcficicncy - Motivation and awareness of general population. - Operation research on efficacy of iodised salt. · AnaenJla colllrol - Monitoring and evaluation of the IDD prevention and control programmc programme. - Procurement of Vit. A capsule. - Advocacy. - Home/school gardening. - Training/workshop. - Innovative research. - Procurement of iron folate tablets. - Supplementation of iron/folate. - Orientation/workshop. - Monitoring and evaluation. - ----- 34 '-I '-.,, ·1·i f 1111~r;tl l ll l ll' ·.·,: ;:.::r:·., :. '' I I\:,',, I I -:.1:, . ;.,d, .1, I ii, .. ,·.11, i, .11.d , : \i i ·I il d I : I I~ I \ '. I ; : 'I ( ! l: ! I!~ ',\ ; I I l \',·,I · I 1 \ I ( 1 r. ,, ! ·: ,1 :1 · I· .1: I· .1..1,· .:1:d IL\l' ,·:·.;,,· ,k!n,'I', .\ctiviti1-s 11,,11:,· ~11,ll,·11 !',iid,·1111H\ (l)Jlljl<l!IL'lll !·:,·Id r, .. :,·,11, !1 llJI !11111.s :111d \l'grt:1hlc prlld11ct1un. prtlLTSs111~ :111d d1•,i1:l,11111,11 ,111<111utrJ11on:d :1w:1rc11L·ss Ill t:1rgctcd pop11i;1t1u11. \11,,11 11:1111111 :: llll :1ppl1cd 11utr1t1,111 tlir field \\'l1rkcrs iii ditfrrrnt 1111111-,111L·s. :\( ;( J.s :t11d cn111111u11ity k:1dc1-; I r:1111,.·rs' 11:11111111\ lllr 'Jl1:llla/ll1:;trict lncl ,itl1L'l'IS. l 'tl111:111011 ,,t l1111ts :l!ld vcgct:il>lt:s tlir prcn·ntion ol JlllL'JI JJllilr!l'lll dcr1c1c11crcs. ,\gencic~ ( 'rn ll:Crncd llNNC lllRTAN lllRTt\N lllRTAN lllRTt\N F1mded I>~ \Vll/llJ.\ ( iOll c;rni (iOB ,.\SS!' --~ ---+------~-----+---~- \:d,· 111,,tlll'lllll1lll ( '1 ,1 l l l\L'l l l \'.I \ .Ill Jll:111< ll I i 11111 !11i:1t,· t:ii>icl d1:.tflillllltlll .-\dv r:,· nil ilL·:iltll :llld 11utrit1,111. ll1,·:1.,IIL'l'<illl:i .\l,,11v:1t1,,11, ll 11:, ,1l1c1 s. l·:11111ly pl:11111111~ I ·"1111,,·1111.~ :111.I Sllci:d 1ll:11kct111!',. 11'1 I )1:u I IH1,·:il d1sc,,.,c: co11tr,>I l'rc\,·11t1llll ,,t Vn :\ Jcrtcic11cy . . '-<11111t1ll11.ll :1w:1rc11css of the c:1rctakcr. .\dm1111st1 :1t1tl!l ,if llnc Jose of Vit. A to childrcll under I yc:1r 125.()()(J Ill during cacli visit for immunization) . ,\dn11111~tr:1tio11 of V1t. A capsule (200,000 JU to d1ildrcn aged I 6 yc:1rs two times a year). l'w111,>t1,>11 of production md consumption of Vit A rich foods. I lc:iltli educatio11 ,, ) J MOill:\V CiOll ( ·o, l'r:1gl' 1>111 :1tio11 '\; 1111 JI 1:il I'!') I j lJlJ7 I i I lt:111:1, I 11:,1, 2! X XJ '.',;;111, ,11:il I '!'J) 2tXXJ ~.1111,11:il I 1!1 15 2tXXJ 0':11i1111:il I '!'Vi ,1ngomg .\Li111kg,1n1 I 1J1J-l :'tXXJ ' I 4.2.2 Sectors involved The Sectors and agencies involved are as follows: Ministry of Agriculnir~ Ministry of Food Ministry of Fisheries and Livestock Ministry of Environment and Forest Ministry of Local Government, Rural Development and Cooperati,·es Ministry of Disaster Management and Relief Ministry of Health and Family Welfare Ministry of Women and Children Affairs Ministry of Social Welfare Ministry of Communication Ministry of Science and Technology FAQ, UNDP, WHO, UNICEF, USAID, UNESCO, CIDA, WB, ADB. Grameen Bank, BRAC, HKI and other NGOs 4.2.3 StraJegic framework Improving household food security: Poverty alleviation and economic growth. Maintain sustainable food grain production, particularly that of rice and wheat. Increase minor crops production (maize, millet) to reduce pressure on rice. Intensify crop diversification programme for increased production of roots and tubers. oil seeds and pulses along with fruits and vegetable production. Ensure availability of food till the household level with minimum food loss. Disseminate nutrition information and messages linked to food security. Highlight and intensify women oriented programmes. Involving women in all community based programmes. - - --- Sr. No. Actions 4.2.3.1 Food production I. Self sufficiency in food grain (rice and wheat) production. II. Increase production of pulses. iii. Increase production of sweet potato. iv. Increase production of white potato. V. Increase production of oilseed. vi. Marginal and small farm system crop intensification. vii. Coconut development and large scale plantation of useful trees. Agencies Concerned MOA. MOF, MOWR, MOLGRD, MOFLS, MO!, MOL. NGO J\.IOA, MOLGRD MOWR, MOF. MO!, MOL, NGO MOA, MOLGRD, MOF, MOI, MOL, NGO MOA, MOLGRD, MO!, MOF. MOWR, MOL. NGO MOA, MOLGRD, MOF, MOI, MOL, NGO MOA, MOI, MOLGRD, MOEF. MOL, NGO MOA, MOI. MOLGRD. MOEF. MOL. NGO Target Total population Total population -Do- Total population -Do- Total population -Do- Total population Marginal, small & landless farmers Total population Time Frame 2000 2000 2010 2000 2010 2000 2000 2000 2000 Outcome Indicators Adequate energy intake. Protein intake 45 g/person/day Intake 20 g/person/day Intake 40 g/ person/ day Intake 25 g/ person/ day Intake 50 g/person/day Intake 100 g/person/day Oil intake 20 g/person/day Total amount of produce Increase total amount of produce Sr. No. Actions Agencies Target Time Outcome Concerned Frame Indicators 4.2.3.1 Food production viii. Home gardening MOA, MOE, MOI, Rural 2000 Fruit Intake 20 MOLGRD, households, g/person/ day MOEF, MOHFW schools, all Yt:getablc MOWCA, MOSW, Parishads, Intake 213 I NGO religious and g/person/day I community centres 2010 Fruit intakt: 56 I (emphasis on g/pt:rson/day women and I children I I I ix. Crop diversification MOA, MOI, MOL, All rural 2000 Increased programme. MOEF, NGO farmers production I I I Low and stable food prices. MOF, MOA, MOI, Total, 2000 Stable food ' X. MOC, MOFL population prices xi. Enhance production of fish. MOFL, MOL, MOC, Total 2000 Fish intake 40 MOI, MOE, MOA, population g/person/day MOF, MOLGRD (emphasis on NGO children & Fish intake 67 mothers) 2010 g/person/day xii. Increase production of MOFL, MOL, MOI, Total 2000 Meat (from I livestock (cattle and goat) MOA, MOWCA, population cattle) intake 5 MOSW, MOLGRD, (emphasis on g/person/ day I NGO children & mothers) 2010 Meat (from I ' cattle) intake 10 I g/person/day I I I XIII. Poultry production. MOFL, MOI, Total 2000 Egg intakc I :i I - Homestead MOWCA, MOSW, population g/person/day I I - Large scale MOA, MOF, (emphasis on Meat (from I i MOLGRD, NGO children & poultry) I I mothers) gipt:rson/da1 ~ 38 4.2.3.2 · Food distribution 1. Uniform distribution throughout the country till " II I -~ I . ----o- -- . -·· 11. Open market sales (0\1S) - Urban (to strengthen) - Rural (to initiate) (to cover at least 30 % of population living under poverty line) 111. Food safety net (to strengthen) iv, Food for work ( to strength en). - ' V. Food for education (to strengthen). Vl. Vulnerable group development programme (VGD) (to strengthen). :\IOF. MOLGRD, MOP, MOHFW, J,"fl,\,Jf~ I MOCn, NGO \IOF, \IOC, \10:\, \IOLGRD, MOS\\, \10\VCA \IOF, MOC, ;\IOLGRD, /\IOA, \!OF, MOP, MODMR MOF, MOLGRD. MODMR, NGO MOE, Pi\lED. t-.lOF, MOLGRD, NGO \IOLGRD MODMR. \!OF, /\IOSW, \!OWCA, :-;co I I I I - I Entire country with special Clt: t:!l(;e 10 Jct'iut 1011e, To 111crc:1sc tile number ol O\IS dealers/ mu nic1 p al1ty To establish O1'-.!S till village level FooJ godowns at Th:.ina le, d Socio- econon11cally depri \ ed population Primary sctwol going poor children Destitute women i I I I I I ' ! ! Continuous 2310 1 \ KCalidav/ . p ·rs rn e .l I ·- I ' I jl)l)8 2:i ,.·; : c11h;rnceJ ' ', I I 2000 One OMS dealer/Uni on 30'7c coverage Contin Buffer stod at uous Thana levd Contin Adequate uous energy intake by all family members I Contin Proportion nt uous school ;1gcJ children attending school Cornin Proportion ot uous women bd,m the lc\d ot I destltU!encss I I I I I ': I 4.2.3.3 4.2.3.4 v'll. Women's empowerment for intra household food distribution. viii. Emergency food distribution under special conditions. viz., disaster (to strengthen). - Nutritionally balanced diet of requisite energy value need to be distributed. Food security for urban poor - ix. street foods Food preservation and processing i. Initiating food preservation at strategic places specially for seasonal fruits and vegetables. - Home and community level - commercial level ii. Rand D programmes to develop appropriate technologies. Food fortification i. Develop fortification methods for common foods with important nutrients e.g., vitamin A, iron, iodine, calcium, vitamin D and so on at - Home/community level - Industry level ii. Rand D programmes to develop appropriate technologies. 111. Nutritional indicators in all food security related programmes. MOWCA, MOSW, MOLGRD, MOHFW, Mnl Mn& - -- .. ··• ...... NGO MODMR, MOF, MOLGRD MOSW, MOWCA, MOI, MOA, NGO MOHFW, MOSW, MOWCA, MOF, NGO MOF, MOI, MOA, MOHFW, MOLGRD, MOF, NGO MOST, MOI, MOA, MOE, DU.NGO MOF, MOST, MOA, MOHFW, MOE, NGO '.\IOST, \1OF \10A, MOHFW, \fOE. NGO \10A. '.\IOF. \fOFL. \!OE 'l j All women 2000 Disaster victims As and when required Urban poor 1998 Total 2000 population Community 2000 Total 2000 fortification Related :woo institutions :\II rclatcd I :·-1·!, scctors i I 2000 KCal intake by all women I 00 % coverage during disaster. Safe and low cost street foods developed. 10% of total vegetable & fruit production are preserved 10% of total vegetables and frui1s preserved Fortified foods available in markets Technolog1cs adopted :ind rorntied foods av .11lable m markets lnJ1cators Jc\t:lopeJ i : I I 4.2.3.5 Supplementary feeding i. Identification of low MOSW, socioeconomic groups at village MOWCA, level to provide supplementary MULURU, feeding to: - MOHFW, MOA, MOE, - Pregnant and lactating PMED, NGO. Selected 2000 Severe CED to mothers (up to 6 months). mothers ( 600 5% KCal). 2010 Severe CEO to - Children under five years <!% (with special emphasis to under Selected 2000 Wasting to 4 % two years). severely & severe PEM malnourished to 3% U-5 children 2010 Wasting to (600 KCal). <I% & severe - Mid-day meal for school PEM to< I% going children from 5-14 Selected school 2000 Reduction of years. going children drop-out rate to (300 KCal) 25% 2010 Reduction of drop-out to <5% 4.2.3.6 Food behaviour I. Development of strategies for Pl\1ED, Adults and 2000 Change in KAP total community participation MOE, adolescents in to: MOWCA, community - Overcome wrong food MOSW, taboos. MOHFW, - Uniform distribution of MOA, MOI, food at household NGO level. - Selection of balanced food. - Proper cooking and food handling procedures. ·l l 4.2.4 Action plan 1. Identification and inclusion of specific nutritional indicators in all food related programmes. 2. Increasing household food production. ·· 3. Increasing pisciculture and small farm animal production. 4. Attain self-reliance in cereals (rice and wheat), and increase pulse, sweet potato, white potato, oil seed, maize, fruit and vege~ble production by the following processes: marginal and small farm systems. crop intensification. home gardening. agriculture support services. crop diversification. agro service centre. low and stable food price large scale plantation of useful trees. credit to small farmers. special support to disadvantaged people. 5. Assessment of nutritive value of indigenous foods and development of balanced diet. 6. Nutritional security for the urban poor: slum support programmes street foods 7. Food preservation centres at village level training technology transfer 8. Local-level food fortification. 9. Income generation linke(ji activities for women. 10. Village level extension education and training. 11. Women-oriented activities in the Agriculture Sector. 42 12. Extension and education on nutrition. 4.2.5 Proposed interventions I. Household production of different kinds of foods. Accessibility to be enhanced at home level by gardening, growing of small farm animals, fisheries etc. by a comprehensive approach - area based. 2. Household vegetable gardening. Home gardening for production of vegetables/fruits to diversify food for balanced intake, through community participation, cooperatives etc. 3. Innovation and use of appropriate technology for homescale processing and preservation of foods. Develop and use of low-cost local methods for processing and preserving seasonal foods, e.g fruits, vegetables, roots and tubers. 4. Regular training and technology transfer on local level fortification methods for fruits, green leafy and other vegetables. Use local self fortification methods, specially by usmg seasonal vegetables/fruits which grow in abundance. 5. Prevention of post harvest losses through proper processing and preservation of food at commercial level. Better facilities and technologies for processing, storage, preservation and distribute. 6. Development of appropriate technology for production of nutrient-dense complementary food and its dissemination for household preparation through nutrition education programme. Use of local ingredients to produce complementary food of high nutritive value at reasonable cost. Share information and recipe with community. 7. Food preservation centres at local level for training and technology transfer. Community food preservation centers at district level for training and provision of preservation technologies-facilities to farmers, particularly women farmers. 8. ·-comprehensive women-oriented support programmes. 31-'C\,;idi programmes tor women to have access to economic and nutritional independence like homestead production of fruits, vegetables, livestock etc. access to develop food preservation units; agricultural extension activities and support; etc. 9. Programmes on agricultural support services linked to development of KAP of women on family welfare, reproductive health and population education. Combined service programmes to link agricultural extension training activities to other issues like reproductive health, population education etc. 10. School lunch programme for children. Programme for school children on nutritional supplementation using local products, supported by school gardening/farming programmes and nutrition education. 11. Management of urban street foods. Urban street foods need special support as it is a most rapidly growing business which provides valuable nutritional support to the urban poor. Municipal corporation and police administration authorities are to be involved for effective management. 12. Credit and support programmes for intensifying production of pulses, tubers and oil seeds. Economic support, as rolling funds, to identified farmers for growing these foods. Women should be given priority. 13. Assessing nutritional impact of the agricultural policies and programmes - identification of suitable indicators and inclusion in each project/programme. Use of specific indicators - economic, agricultural, nutritional and environmental, to assess impact of programmes. 14. Training, workshops and community awareness generation with development of suitable audio-visual aides on food based approaches. Creation of awareness on "food based" strategies to control malnutrition - highlight economic benefits, nutritional support etc. 15. Development of suitable net-working to ensure availability of weaning foods to children and supportive foods to other vulnerable groups through PFDS (using locally available affordable food items). PFDS may extend its existing coverage to special weaning/supportive foods hy ??<:!r1~ .1ul.A.iiy avaiiabie ingrements. Development of locally available weaning food and supportive foods. Suitable recipes to be developed to give nutritional support to vulnerable groups using locally grown/available foods. 4.3 PROTECTING CONSUMERS THROUGH IMPROVED FOOD QUALITY AND SAFETY Safe food and water of adequate quality is essential to maintain proper nutr1t1on. Consumer protection has to be ensured through availability of special quality control and safety evaluation measures. A safe food should not contain harmful chemicals and biological contaminants which would endanger consumers' health. Food safety needs to be ensured at levels of production, handling, processing, packaging, distribution and preparation stages. Suitable legislation, laws, and standards have to be developed along with an effective inspection and monitoring system Hnked to well-equipped laboratories and well-trained staff. This is essential not only for export purposes but also for local consumption. Unsafe foods, often leads to morbidity resulting from a continuous loss of valuable nutrients from an already deprived individual. 4.3.1 On-going programmes and situation anal.ysis There are significant activities in food quality control and food safety in the country. The "East Pakistan Pure Food Ordinance 1959" is the adaptation of the "Bengal Food Act - 1939". This law has been revised and updated through an Inter-ministerial Committee to "Bangladesh Food Safety Ordinance-1994" . It proposed to make full use of the standards and practices published by the Codex Alimentarius Commission which are also applicable to Bangladesh. It covers the dosages and residues of fertilizers, fungicides, pesticides and other chemicals in crops and animal feed; food additives (colours, preservatives, flavourants, fortifying agents, etc.). Hopefully the ordinance will soon be approved by the Government and it will then be possible to formulate and implement the "Bangladesh Pure Food Rules". The food standards from the country are available from the Bangladesh Standards and Testing Institution (BSTI) Ordinance (1985). There also exists the Essential Commodity ,\cl I 990 in which provisions are rrnde for food standards and food Jdulteration. BSTI m:.ikes standards for food items but does not authorise quality con~rol. At present, there :.ire I O laboratories (8 in Dhaka and 1 each in Chittagong and Khulna)· which undertake food quality testing in the country. No such laboratory exists at District or lower levels. The laboratories are as follows: 1. Public Health Laboratory (PHL) of the Institute of Public Health (IPH) * 2. Armed Forces Food and Drug Laboratory. 3. Chemical Examiners' Laboratory. 4. Bangladesh Standards and Testing Institution. 5. Radiation Biology Laboratory. 6. Dhaka City Corporation Laboratory. 7. Food Laboratory of the Ministry of Food. 8. Bangladesh Council for Scientific and Industrial Research (BCSIR). 9. Quality control laboratories for frozen fish at Khulna and Chittagong under MOF. * Only laboratory which has the legal authority for food qua.lity testing A project on Preparation of a HACCP based Fish quality Assurance Programme, supported by FAQ is helping the Government of Bangladesh in the formulation and implementation of a national HACCP based quality assurance programme for fisheries products (shrimp/fish). The target subjects are the key Government officials and industry representatives. Food and water contamination in the country is very high. Therefore, to ensure consumer safety as well as to promote the export of agricultural products, it is essential to adopt the suggested legislation and develop a suitable support system down to the District level. Analysis of the existing situation indicates special attention is needed in the following areas: Adoption, implementation and enforcement of the Bangladesh Food Safety Ordinance (1994). Formulation and Implementation of Bangladesh Pure Food Rules. Facilities at central laboratories. Development of food and water testing laboratories at Division and District levels. Enhancement of KAP on food and water safety and quality. 4.3.2 Sectors involved The Sectors and agencies involved are as follows: Ministry of Health and Family Welfare Ministry of Local Government, Rural Development and Cooperatives Ministry of Food Ministry of Environment and Forest Ministry of Trade and Commerce Ministry of Science and Technology Ministry of Women and Children Affairs Wl-H). J:' A() 4.3.3 Strategic Framework Protecting consumers through improved food quality and food safety: The up-dated Bangladesh food law based on the relevant codes of the Codex Alimentarius Commission needs to be adopted and implemented. Providing suitable regulations for food quality and safety at all steps, viz., production, processing, fortification, packaging, labeling and storage and develop a suitable monitoring system. Effective maintenance of export quality. Education to producers and consumers (including consumers' association). Promoting food safety for locally available cheap foods, specially for the urban poor, e:g., street foods. Involving women in all community and household level programmes. Actions Agencies Target Time Outcome SI No Concerned Frame Indicators 4.3.3.1 Food legislation and its enforcement. I. Assessment of existing food MOHFW, All food handlers 1998 Detailed report ~~,. ..... . . ... ii~ "-.. - .. .1 .- - ... -" .... ~:.-.-: ;..:~--· ., ---- ---- - ·---- - ••A.... , At 11'.l'-J 1 t water quality situation with MOST, MOC, respect to special groups, viz., MOEF, NGO street food vendors, food processors, hotels and restaurants, etc. ii. The existing food laws need MOHFW, All food 1998 Updated report to be strengthened for MO!, MOF, processors, preventing contamination MOST, MOC, manufacturers (physical, microbiological and MOL handlers chemical) and improving food quality. iii. Enforcement of the above MOLGRD,MO Till Union level 2000 Overall laws and regulations by the L, MOHFW improvement of government till Union level. food quality 4.3.3.2 Designation of a competent authority / body to ensure food safety and quality I. Designation of a competent MOHFW, MOI. Creation of inter- I 997 (in Maintenance authority (main coordinator) MOF, MOST. sectoral group to conjunc-tion of strict to oversee all aspects of MOC, MOEF, oversee food low, with adoption vigilance by food control viz. permitted NGO laboratory, of food laws) authority. substances in food; good inspection system, manufacturing practices; enforcement etc. train .and empower food control officials; legal proceedings, etc. 4.3.3.3. Infrastructure development I. Strengthening of the food MOHFW, MOF, All food 2000 Improved analysis laboratory at MO!, MOC, laboratories laboratory National level. MOEF quality ii. Creation of food analysis MOHFW, MOF, One Food 2000 Improved laboratory at District MOC, MOEF laboratory at food quality level. District level iii. Creation of trained MOE, MOI. Concerned labs 2000 Skilled manpower for laboratories MOHFW, MOF, person as well as for field services MOC, MOEF power at National and District levels. Food technologists and scientists 4.3.3.4. Education or the rood industry and conswners i. Inronnation, educa~.ion and MOI, MOC, All producers, 2000 Improvement communication materials on MOL, MOLGRD, consumers, of food food safety, food laws, hygiene, CAB, MOHFW, planners and quality sanitation to be developed and NGO food traders. distributed among all concerned at National, District, Union and Village level involving the community. ii. Strengthening of consumer MOI, MOC, All producers, 2000 Improvement linked activities. MOL, MOLGRD, consumers, of food CAB, MOHFW, planners and quality NGO food traders . . iii. Strategies to educate and MOI,MOE All producers, 2000 Improvement inform all rood producers, MOC, MOL, consumers, and of food viz., industrial food processors, MOLGRD, traders. quality food vendors, etc. MOHFW,NGO 4.3.4 Action Plan 1. Formation of a coordinating mechanism at the ministerial and institutional levels to monitor various issues, policies and programmes on food safety. 2. Strengthening of the existing laboratories by the way of institutional as well as human resource development. 3. Developing a regular monitoring system down to the District level. 4. Regular consumer and producer education programmes. 5. Vending of street foods in the urban areas is a growing demand both for nutritional as well as economic benefits. This sector needs stringent monitoring of quality along with drawing up of suitable action plan linked to laboratory analysis, awareness of vendors, consumers, food inspectors, legal authorities and finance managers (banks) in a comprehensive manner. This sector needs special attention and immediate intervention. 49 4.3.5 Proposed Interventions The following interventions are suggested in order of priority: 1. Estah!ishmf>nt nf f00::! t::ti!!~ !~!;;;:-w!vi'ii.i iai: i:hc ubi.rit:t ievei ior momtoring food quality and food safety. Facilities are available only in Dhaka and for specific reasons in two more cities. These need to be extended up to district level. 2. Development of a comprehensive project to ensure quality and safety of street foods along with a city plan of action. Demand for vending street foods is increasing every day, with rise in number of consumers. There is no facility for regular monitoring and quality control. This needs to be developed, along with other issues like control of traffic, pedestrian movement etc. Hence, it would need a comprehensive planning information. 3. Development of a comprehensive networking among the central level laboratories with a focal point at Public Health Laboratory (PHL) at the IPH, MOHFW. Different laboratories existing at central and peripheral levels need to be coordinated with proper legal authority of each. 4.4 PREVENTING AND MANAGING INFECTIOUS DISEASES The vicious cycle of infection and malnutrition is well known. Its overwhelming impact on the health and well-being, specially in the socio-economically deprived groups is a point of great concern. The vulnerable groups of the population are most affected due to sickness, disability or death. Prevention, control and proper management of infections ensures improved nutritional status and enhanced productivity, resulting in economic benefits. 4.4.1 On-going Programmes and Situation Analysis Major on-going programmes are presented in the table provided below. Supportive programmes include: I. Primary health care service. 2. Expanded programme on immunization (EPI). 3. Pilot project for the control of ARI in children. 50 4. Tuberculosis and leprosy prevention and control programme 5. Diarrhoeal disease control programme. 6. Family health education programme. 7. ·-Pilot project for development of maternal and neonatal health care . 8. Intestinal parasite control project. s; . School heait:n project. 10. Rural social service. 11. Use of mother centres for population activities . 12. Urban community development programme . Analysis of the existing situation indicates following weaknesses which need immediate attention: Sanitation coverage. Coverage of water supply for all purposes. KAP on environmental management and personal hygiene. Role of women in water and sanitation. Enhancement of ORT use. Specific nutritional objectives in primary health care up to Ward level. Programmes related to control of morbidity. ~ On-going major programmes and projects : e-------··--·-- SI. Programme Activities Agencies Funded by Coverage Duration No. Concerned ! ! . Es~cnttal HeallJ, Care - Preventive and curative healt.h care services BRAC ODA, NOVIB, 170 Thanas On-going Progranrn11.: through Village Healt.h Volunteers (SS) . Aga Khan & Reproduc ti ve Health and Provision of essential <lrngs through SS. Foundation, D1)c,1sc Control Programme • Ante-natal care services. UNICEF, " • Family planning facilitation. SIDA, CIDA, I Provision of healt.h services t.hrough BRAC BRAC Health Cemres . - Special project on ARI and tuberculosis conlrol. 11 - Nutrition and health education. ... w, :-~ 2 Vi tannn A capsule (VAC) - Supplememation of V AC to infants under J year IPHN, NGOs UNICEF, WB National On-going supplementat ion (25 ,000 JU during each visit for immunization , l children aged 1-6 years(200,000 IU 2 times/year). - Supplement.ation of V AC to lactating mothers (200,000 IU 2 weeks after delivery). - Distribution of V AC 10 diarrhoeal and measles patiems. ·, 3: Combined service delivery Please see sr. no. 24 of Theme 2 (section 4.2.1). I 4. Bangladesh Integrated Nutri1ion Please see sr. no. IS of Theme 2 (section 4.2.1). \ Proje.c t (BINP) :", 52 4.4.2 Sectors Involved The Sectors and agencies involved are as follows: . MiP-istry o.f He.2-Jm a-ill! F.arnily Welfa.r~ Ministry of Environment and Forest . . .; Ministry of Local Government , Rural Development and Cooperatives Ministry of Women and Children Affairs Primary and Mass Education Division Ministry of Social Welfare WHO, UNICEF, UNFPA, UNESCO, WB, USAID, UNDP NGOs 4.4.3 Strategic Framework Preventing and managing infectious diseases: Controlling of morbidity and mortality through vari0us sectoral programmes and using nutritional indicators to assess the outcome. Ensuring health care facilities through the primary health centres till the ward level. Encouraging preventive and promotive health care. Ensuring availability of safe water, sanitation and solid waste and garbage disposal facilities at rural and urban levels . Social mobilization to ensure intensified motivation for personal and environmental hygiene. Involvement of women in all community based interventions right from planning level . I ' SL NO Actions Agencies Concerned 4.4.3.1 Water and environmental sanitation i. Assessment and MOHFW, improvement of drinking MOEF ' water quamy MOLGRD. (microbiological and MOA, MOE, chemical) NGO ii. Sanitation (latrines) MOHFW, MOEF, MOLGRD, MOSW, NGO iiL Garbage and solid based MOHFP, disposal MOEF, MOLGRD, MOSW, NGO iv. Education on MOHFP, environmental, personal MOEF, hygiene & water usage MOLGRD, pattern. MOA, MOSW, SGO V. Use of animal and other MOST, MOEF, wastes. MOLGRD, MOA,NGO vi. Monitoring of industrial MOEF, MOST, effluents in all surface and MOLGRD, ground water sources NGO Target Central institutions. LGRDtill village level Total population Total population Total population Total population Total population 4.4.3.2 Control, management and prevention of infectious diseases L Strengthen coverage of all related EPI programmes. !L Ensure better management of ARI iii. Ensure better management of diarrhoea! and other gastrointestinal disorders: L ORT ii. Water quality iii. Water management 1\' I Reduce worm infest:ition i and related diseases: ! 1. Sanitation. ii. Personal hygiene. MOHFW, MOSW, MOWCA, NGO MOHFW, MOSW, MOWCA, NGO MOHFW, MOSW, MOWCA, MOE MOEF, NGO \lOHFW. \.IOSW, \.10\VCA, \tOEF MOE, NGO Children under 5 years Children under 5 years Total population I Tot:il population Time Frame 1998 Continuous Continuous Continuous Continuous Continuous Continuous Continuous Continuous Continuous 2000 2000 2000 2()00 Outcome Indicators Drinking water . - .. , Reduction of diarrhoea Reduction of wonn infestation Reduction of diarrhoea Reduction of worm infestation Reduction of diarrhoea Increase in KAP Reduction of wonn infestation. Reduction of diarrhoea. Establishment of bio-gas plants. Bio fertilizers Published report 100% coverage Reduction in ARI ' : prevalence I i ' Reduction m diarrhoeal prevalence i I Redu.:tion m I worm 1niestat1,m I I rate 4.4.4 Action Plan 1. Ensure better sanitation and water supply coverage. 3. Incorporation of nutritional objectives in programmes related to control of infectious diseases, environmental protection and so on. 4. Development of suitable education materials for achieving the above mentioned strategies at all levels . 5. Develop a methodology for assessing the impact of infection on the nutritional status of an individual. 6. Assess the impact of water and environmental sanitation (WES) on the nutritional status of a community by using special indicators. 7. Initiate research projects to assess the correlation between environment and nutrition; protective function of nutrients to combat infection and nutrient-drug interaction . 8. Ensure role of women in water and sanitation in policy and implementation levels. 9. Strengthen primary health care system and knowledge of the community on the c:rnse. effect and control of infectious diseases. 10. Reduce worm infestation and related diseases . 11. The success of the EPI programme should be made sustainable. 4.4.S Proposed Interventions The-following interventions are suggested in order of priority : l . Undertake a comparative analysis of the relative impact of different programmes eg. water and sanitation vis-a-vis other direct nutrition programmes such as supplementary feedi ng on the nutritional status of a community. Using nutritional indicarors, prograrmnes related to water and environmemal sanitation co be compared with those on supplementary feeding, prophylaxis programmes etc . 2 . Development and use of nutritional indicators ;,ifter provision of saniu1ry latrines Evaluate success of latrine programmes using nutritional indicators. such as anemia (linked to worm infestation), wasting (linked to diarrhoea), etc. 3. Assess the time and energy saved after provision of potable water. speciall y in difficult zones s;,t,:h ;c r:H!:y ar~t . ~itl ~un-es anct 0th-:., a1c,6 iiaviiig a ilrniteti access to potabie water Energy expenditures of physical labour related to water, feed, fodder collection is very high. This needs to be known to assess energy requirement of the individual. Time saved can also be used most usefully, if these activities can be reduced. 4. Comprehensive National Environmental Management Action Plan (already formulated). Conserve nature, reduce environmental degradation, promote sustainable development and rai se quality of human life. 5. Development of workshop, training and motivational courses with supportive audio-visual aides linked to health, environmental and nutrition education. Development of comprehensive IEC material interlinking issues related to health, environment and nutrition. 6. Comprehensive project proposal on role of women in various issues linked to control of infection and improvement of the nutritional status . Enhancing the knowledge, attitudes and practices (KAP) of women on personal hygiene and handling of food/water. 4.5 PROMOTING BREASTFEEDING Medical opinion agrees that breast milk is the ideal food for the infant and young children. Apart from being the most inexpensive form of infant feeding, it has many other beneficial effects including those on child spacing and on providing imrnunocompetence against many common diseases. All healthy women should be encouraged to breastfeed their babies exclusively fo r the first four to six months and subsequently to continue with breastfeeding along with provision of appropriate supplementary food fo r two years. However, optimum breastfeeding in Bangladesh is reported to be virtually absent. In order to achieve this objective, we need to create awareness, provide maximum support to women, educate the government and concerned parties of the private sector, and develop a positive social att itude. 4.5.1 On-going Programmes and Situation .4nalysis Major ongoing programmes are presented in the tabie provided below. Supportive programmes include: i. P-i16'Cpr-oJect orrtriircetnai and nebnatal neaith care. · 2 . Coordinated nutrition programmes of BNNC. 3. Community nutrition programme. 4. Urban primary health care programme at Divisional level. 5. Nutrition education programmes of NGOs Analysis of the existing situation highlights that the following interventions are needed: Adequate information to the mother and family on nutri tional needs of a nursing mother. Nutritional support to mothers using homestead based strategies. Mandatory creches for babies at working places. IEC to mothers on proper breastfeeding . Preparation of weaning foods with local ingredients . KAP to mothers on personal hygiene and sanitation. Enforcement of BMS code. Baby-friendly hospital concept. 4.5.2 Sectors Involved The Sectors and agencies involved are: Ministry of Health and Family Welfare Ministry of Women and Children Affairs Ministry of Social Welfare Ministry of Information Ministry of Agriculture WHO, UNICEF , UNESCO, NOYIB, WB , BBF. BRAC and other NGOs . programmes and projects (Theme 5): -·-·-···- ·- SI. Progranmie Activities Agencies Funded by Coverage Duration no. Concernetl -·-~-···-~---·-··~·· -•w--,-,~, .. ·- L Bangladesh Breastfeeding - Awareness creation on exclusive and BBF WB, UNICEF National, l 996-2000 foumiauon (BBF) appropriate BF. through BINP special Implementation of Breastmilk Substitute attention to (BMS) code. BINP Thanas Training & research - Promotion and monitoring of Baby Friendly Hospital Initiatives. "" ·~-•··~- .. 2. Healt11 education progranm1e of · Health education through field level MoHFW UNICEF National (J n-going PHC workers, schools and rnass media. 3. Rqmxluc1.ive Health and Disease Please see sr. no. 1 ofTI1cme 4 (section 4.4.1). Control Programme •l B,lllgladesh Integrated Nutrition Please see sr. no. 15 of'll1eme 2 (section 4.2.1). Pro;ecr (BINP) .. --~" .. •~-~- w~••s•--•• ·- 5 Combmed st:rv1cc delivery Please see sr. no. 24 of Theme 2 (St.-ction 4.2.1). , , , 4.5.3 Strategic Framework Promoting breastfeeding and proper weaning practices: Development of appropriate technology fo r production of nutr ient dense complementary foods at home and community level. Baby-friendly hospital initiatives. Nutritional support to mothers. Increased maternity leave, particularly post-part 4.5.4 Action Plan 1. Nutritional and related economic support to mothers, through food based strategies. 2. Household based programmes to be aimed towards nursing mothers. 3. Production of nutrient dense complementary food at community and home lc\'el 4. Economic support for the vulnerable groups by targeted income generating activities, including training, loan and technology support. 5. Popularize and implement proper and exclusive breastfeeding. 6. Nutrition education on breastfeeding, proper complementary feeding , BMS code, baby friendly hospital initiative needs to be strengthened. 7. Development of proper complementary and weaning foods. 8. Baby care centres at all work places - government - pri vate 9. Stringent enfo rcement u( l3 \ 1S c(Jde SI No Actions Agencies Target Time I Outcome I Concerned Frame I lndicators ! 4.5.3.1 Breastfeeding i I I I I i. Baby friendly initiatives at MOHFW, All hospitals 2000 100% mittallon all hospi!.als, and family MOSW, and family welfare centres (Union level). MOWCA. NGO welfare centres i I ii. Education and motivation on MOHFW,MOE, Women along 2000 Increase m KAP breastfeeding and exclusive MOSW, with community breastfeeding. MOWCA, MO!. NGO i iii. Imposing standard MOC, MOL, BMS Already Enforcemem I international regulations on MOI. MOHFW, manufacturers, imposed I i commercial breast milk MOWCA importers and substitutes. traders iv. Strengthen baby care MOSW, Mother with 2QrJO 100% coverage centres/creches at places of MOWCA. MOE. children U-2 at work. MOLM, MO!, all working \ NGO places I I V. .• Period of maternity leave MOE, MOLM, Pregnant and 2000 Mothers may perhaps be extended to MOWCA, lactating availing of leave five months. MOSW mothers 4.5.3.2 Complementary feeding i. Creation of available :VIOA, MOSW. Total Cantin• i Proportion ot I resources at local level for MOWCA, community with uous I children given ideal weaning foods. MOLGRD, emphasis on U- proper weaning MOHFW. NGO 2 children food ii. Education and motivation on .\IOHFW, .\IOA. Women along Cantin- Increase m K:\P quality. quantity and hyg;enic \IOSW, with community uous preparation of weaning .\IOWCA, .\101, foods. :\GO 4.5.5 Proposed interventions The following interventions are suggested in order of priority : i. Estabiistunerit ot day care centres for the working mothers at their work ing places. Support system for mothers to keep babies safely, breastfed and weaned . as needed . 2. Assess the breastfeeding capacity of a malnourished mother to plan necessary support to her. Nutritional sufficiency of lactating mother to ensure her capac ity ro breastfeed without loss of health. 3. Enhance food intake and improve the lifestyle of mothers by increased household level production of fruits , vegetables, etc . along with nutrition education. Enhance accessibility to food of rural and urban poor mothers , through all available means of producing food at home. ' 4. Use of existing health infrastructure and manpower at the village level to promote healthy breastfeeding practices and proper weaning foods. Plan of action to enhance MIS and KAP capacities through strengthening of Thana level PHC. 5. Develop recipes using locally avai lable ingredients to produce complementary and weaning foods. Use of locally ava ilable ingredients to prepare safe, energy-dense foods fo r weaning bah1es 6. Develop comprehensive education materials on importance of breastfeed mg and safe weaning foods for community. Proper guidance and comprehensive information on all issues on breastfeeding and weantng practices . 4.6 CARING FOR THE SOCIO-ECONOMICALLY DEPRIVED AND NUTRITIONALLY VULNERABLE Caring for the deprived and \ ulner:.ibk rl'quires support not only frnm the , :mous sL'd\\rs involved but also from the cnmmunity. Time , attemion, support ;rnJ skills are needeJ !1l meet the physical, mental and social needs of tht:se groups. Priority :mention and c:1rl' needs tn be directed towards those who are physiologically vulnerable and socio-economically deprived . The growing child and pregnant and lactating women are perhaps the most physiologically challenged, with at-risk groups including women, adolescent girls, the elderly and rhe mentally, physically and sensory disabled . Disadvantaged households include displaced persons. river ,rffected [:zniliz:; , r,0.:. t-J i;'.l<11)1.c1 victims, refugees, indigenous people , isolated communities , the unemployed , recent immigrants, orphans, children in difficulr circumstances, and the landless. About 50% of the population fi t under this category fn Banglades h, specifically targeting the women and children of the socio-economicall y disadvantaged is a practical response to this situation and therefore under each theme in this plan of action specifi c actions are directly aimed towards this sector of the population. The presence , knowledge and skill of the care giver (who is often the mother) , is most important . 4.6.1 On-going programmes and situation analysis On-going programmes : 1. Rural social service programme . 2. Control of iodine deficiency through universal salt iodisation . 3. Bangladesh Integrated Nutrition Project (please see sr. no.15 of Theme 2 (section 4.2.1 ) . 4. Food for work programme. 5. Community nutrition programme (please see sr. no .20 of Theme no . 2 (section 4.2.1 ). 6. Nutritional surveillance Project (NSP) (please sr. no . 16 of Theme no. 2 (section 4.2.1 ) . 7. Institute of mentally handicapped children in Chittagong . 8. Programme for urban soc ial deve lopment fo r welfare and rehabilitation of street children . 9. Development and extension of the centres fo r training and rehab ili cation fo r the desriture and the homeless . 10. Vulnerable group development programme (VGD) 11. Advocacy , awareness and strengthening of information base for WID phase 2. 12. Self-reliance programme for rur:11 women 13 . Rural women employ ment creation projects . 14 . NGO/community based programme fo r poor women and child ren 15. Assetless women development programme. 16 . Strengthening and exoansion orog:rammP. nf B£nsladesh Sbishu Acadti 1iv. - y ... ...:,., u .I 17. Use of rural mother centres fo r population act ivities (RM C) 18. Urban community development programme . 19. Post-flood primary schools rehabilitation progranm1e. 20. Emergency relief programmes (as and when required). 21. Strengthening of early warning and flood information system. 22. Open market sales (OMS). 23. Vulnerable women development prograTIIB1e. 24 . Training and rehabilitation of vagrants . 25. Training and rehabilitation of released prisoners from jails . Analysis of the existing programmes indicates that: Though this group accounts fo r more than 50 % of the population, due importance is not recognized or reflected in the ex isting programmes . Moreover. most of the programmes do not have a nutritional objectives. Inter-sectoral coordination among various programmes specially on nutritional issues is not recognized. Nutritional needs should be assessed and the necessary support provided to the distressed population. Mechanisms of accountabil iry at the field level needs w be incorporated . 4.6.2 Sectors lll volved The Sectors and agencies involved are as follows . · Ministry of Social Welfare Ministry of Women and Children Affairs. Ministry of Disaster Management and Rei ief. Ministry of Education. Ministry of Food. Ministry of Water Resources . Ministry of Industries. Ministry of Health and Family Welfare. Ministry of Agriculture. Ministry of Fisheries and Livestock. Ministry of Environment and Forest. Ministry of Communication. Primary and Mass Education Division . WHO, UNICEF, WB, WFP. NGOs such as UCEP, Red Crescent, Grameen Bank, BRAC, HKI , etc. 4.6.3 Strategic Framework Caring for the socio-economically deprived and nutritionally vulnerable: Nutritional support to distressed population groups. Assessing the nutritional needs of selected sections of the deprived and vul nerable population. Incorporating nutritional objectives in all relief and development oriented progranunes . Caring for the deprived and vulnerable can be only done with proper inter-sectoral coordination and support from the Government, community as well as the household . Those who are both socio-economically and nutritionally deprived need to be supported. Special attention should be aimed at women , adolescent girls , the elderly, the disabled, post-disaster victims , displaced persons , the landless , the unemployed, children in difficult situation, juvenile delinquents, indigenous people and isolated communities. Planning and coordination is required to support and help those affected. Special mention may be made for: Providing the necessary support to and strengthening the care giving institut ions. Prov iding information and promoting the good at titudes and practices (KAP) of the care­ givers and the community. Ensuring the .delivery of the facilit ies to the grassroots (target) level using existing infrastructure. Net\vorking between the supporting organizations for coordination and maximizing the beneficial effects. 4.6.4 Action Plan 1. Identify and incorporate nutritional indicators in all on-going programmes. 2. Assess nutritional needs of the socio-economically deprived and nutritionally vulnerable when planning and implementing programmes. 3. Develop an information system for making available data on the existing situation. 4. Develop suitable training materials for generating awareness among the planners, implementors, the community, family and care-giver. 5. Development of suitable plan of actions for procurement, storage, distribution and availability of food (targeted). 6. Introduce a safety net programme for the landless and small farmers in lean periods. 7. Special support programmes for the socio-economically deprived and nutritionally vulnerable. growing child women and adolescent girls elderly mentally and physically disabled post-disaster victims displaced persons, Including the river erosion affected families, refugees indigenous people unemployed orphans children in difficult circumstances juvenile delinquents landless 4.6.5 Proposed Interventions The following intervention activities are proposed in order of priority: 1. ?overcy aiieviation mrougn mtroo:uctmn ot nucro-credit system mvolvmg co-operatives, groups and other channels. Enhance food security. e. g. grains, fruits, vegetable ere. through group level activities using credit facilities. 2. Re-orientation of food assisted programmes targeted to nutritionally vulnerable groups. Nutritional objectives and indicators to be incorporated in these programmes. 3. Development of a database to identify the nutritional needs of the socio-economically deprived and nutritionally vulnerable. Information available by area (Union level), gender, occupation etc. for better targeting of programmes. 4. Strengthening the existing nutrition surveillance project (HKI) through expansion and incorporation of new programmes such as follow-up of nutritional status of pregnant and lactating mothers; awareness creation on caring practices and supplementary food for the vulnerable groups. 5. Identification of socio-economically and nutritionally deprived groups by region. Regional identification of deprived population to target support programmes. 6. Imparting proper KAP to the care-givers. PHCs at Thana levels to be trained. 7. Suitable nutritious recipes for disaster victims. Dry, non-perishable, nutritious and energy-dense meals using locally available ingrediems 8. Iden.,ification and supportive programmes to 'improve the health and nutrition of street children. Special support to street children viz. shelter. education, food, security etc. 9. Credit and training facilnies for the disar,led. Suitable job oriented training and credit facilities for the disabled. 10. Assessment of accessibility to food under conditions of distress and disaster. Food channels identified and kept ready - disaster preparedness. 11. Assessment of the impact of disaster on the nutritional status of the victims. Short/long term impact of disaster on nutritional status of victims. specially childri::n. to develop suitable support programmes. 4. 7 PREVENTING Af.ll) CONTROLLING SPECIFIC MICRO!'l'1JTRIE~1T DEFICIENCIES Micronutrient deficiencies are one of the major nutritional problems in Bangladesh. They are widespread and the consequence causes a significant impact on the health and work capacity of an individual. The principal deficiencies are related to iron, vitamin A and iodine. The deficiency of vitamin A (including beta-carotene) leads to blindness, poor growth and increased severity of infection, specially in children. Iron deficiency leads to learning disabilities, increased susceptibility to infection, diminished working capacity and growth (including intrauterine); iodine deficiency leads to goitre, and physical and mental retardation. Inspne of knowing the source of these nutrients and also that they are required in very minute quantities, the problem has been difficult to control because of several interlinked reasons starting from economic issues to environmental and behavioural aspects. Bangladesh needs to tackle the problem on a war footing. Some of the other rnicronutrient deficiencies which also need to be looked into are thiamin, riboflavin, vitamin C, zinc and calcium. 4. 7.1 On-going Programmes and Situation Analysis Major ongoing prograrnmes are included in the tables provided below. Supportive programmes include: 1. Coordinated nutrition programme of BNNC 2. Urban primary health care programme 3. Home based fruits and vegetable preservation programme of BIRTAN 4. Nt1trition education, home gardening and small farm animal raising progp.mmes lJf NGOs. Analysis of the existing programmes indicates that special consideration should be .~1\en to. Inclusion of food based strategies on the on-going nutrition programmes. Inclusion of nutritional considerations in food programmes. Imnortano• of the balanced diet !'0nc~pr Intensive coordination between Ministries, agencies and organizations for home based food security strategies. Effective implementation of V AC supplementation programme. Organized distribution of iron-folate tablets. Monitoring of iodised salt distribution and iodine levels. Identification of target groups at national level. Micro nutrient requirement under special circumstances like pregnancy, lactation. Ou-going programmes ........ ··~-· )w-aHon I Programme Activities Agencies Funded by Coverage ,. Concerned U;.mgl..1tksh I lntcgratt:d Nutrition Please see sr. no. 15 of 111eme 2 (SL'Ction 4.2.1). Project (BINP) Control uf lodmc Universa.l iodisation of salt. BSCIC in WB, UNICEF National 19U9contd. Dcfo.:1t:ncy Dts1mkrs · Quality control of iodised salt. collaboration with Prognunrm: - Monitoring and evaluation of iodised salt. lPHN, BNNC, - Enacunent of edible iodised salt law. INFS, IFST - Awareness creation on IDD. - Yuamui A capsult: - Suppkment.ation of YAC to infants under l year IPHN, NGOs UNICEF, WB Narional On going (VACJ (25,000 IlJ during each visit for immw1ization) :;uppk111c11tat11)11 children aged l to 6 years (200,000 IU) l:\vo times/year, lactating mothers (200,00 IU) 2 weeks after delivery. supplementation of V AC to diarrhoeal and measles and ARI patients. .. -,-,~·-,,~-·-"•"""''"' NCO G:m.kning and - Promotion of produc1ion and consumption of ViL A HK! and paru1cr USAID, 90 ·nianas 1995-on- Nutntion Education rich fruits and vegetables. NGOs NOVIB, (315,(XX) going Surveillance Project - Establisluncnt of central nurseries and village ODA, ASSP households) (NGNESP) nurseries. Establishment of household gardens. ..... , ............. ,. SI. Progrnnune Activities Agencies li'unded by Coverage Duration No. Concerned 5. Promotion of Home .. Training on home gardening to Block Supervisors HKI, DAE. ASSP ODA 5 District, (30 I~ 95-on- Gardening through and NGO workers, nursery farmers. and 6 NGOs Titanas) il,l mg Traming . Supply of st-eds and tertilizers . Support for irrigation by treadle pumps or tubeweils. I 6. Compn::hens1ve - Intensive media approaches through women WU•. HKl ODA 3 Districts 1r•~5-0ll· Nutrition and volunteers and health workers on nutrition education. (llrnku rg aon, grlng Bhndm:ss Prevention Mass/multimedia approaches through schools, folk Panchagarh Programme singers, cinema slides, documentary films, bill and Dinajpur) r1 boards, flip chart:L I 7. Bangladesh t: Horticulture See sr. No. 8 of Theme 2 (section 4.2.1). Research and Development Project L 8. Nutrition Message •·· TV spots. BNNC, IPHN, BTV, BB. WB, Natkmal 1989 2000 Dissemination - Radio prograuunes BINP, BBF, INFS, BARI UNICEF Programme - Folk songs. /I • News letters (quarterly). • Nutrition journals (bi-yearly) 9. Community Nutrition See sr. no. 20 of Theme 2 (section 4.2.1). Programme JO. Combined service de!iYery See sr. no. 24 of Theme 2 (section 4.2.1). 70 4. 7 .2 Sectors Involved The Sectors and agencies involved are as follows Ministry of Industries. Ministry of Health and Family Welfare Ministry of Agriculture Ministry of Fisheries and Livestock Ministry of Environment and Forest Ministry of Local Government, Rural Development and Cooperatives. Ministry of Social Welfare Ministry of Education Ministry of Information Ministry of Food Ministry of Women and Children Affairs FAO, UNICEF, WHO, UNESCO, USAID, WB, etc. NGOs 4. 7 .3 Strategic Framework Preventing and controlling specific micronutrient deficiencies: · Conduct district-wide surveys with stratified sampling to identify the target population in different areas/regions. · The quality of diet (the balanced diet concept) has to be enhanced along with adequate supply of energy. The production and availability of food (e.g., fruits, vegetables and poultry), need to be increased. · The motivation and communication strategies should be specifically aimed to enhance the consumption of micronutrient rich foods with active community participation. Food fortification and food preservation technoiogies as -.,·ell :is rac:!nies Jown tu the household level should be developed. Supplementation of vitamin A capsules should be strengthened through the existing infrastructure as a supportive programme to food-based measures. Distribution of iron-folate tablets through the existing primary heaith :.::.m: system. specially for the vulnerable p<)pulation needs to he ensureJ SI No Actions Concerned 4.7.'.U Control of nutritional anaemia I i !. Provide iron-folate l\1OHFW, tablets/syrups through MOWCA. PHC. MOSW. NGO ii. Increased production of l\10A, iron rich vegetables MOLGRD, and fruits. MOSW, MOWCA, NGO I I iii. Deworming. !\tOHFW, MOSW, MOWCA, MOLGRD, P!\IED, MOE, NGO iv. Access to safe excreta MOHFW, disposal. !\IOEF. MOSW. MOE. LGRDC, NGO V. Creation of a national MOP, DU, database on the MOHFW, prevalence of anae1rna MOA. LGRDC, using clinical and bio- NGO chemical assessment criteria. I YL Nutrition advocacy and \IOHFW, education. \IOA, ~.10SW, \10LGRD. \IOE, P\1ED ~•.1owcA, :-.;co Target Pregnant and lactating mothers. and U-5 children. Adolescent girls Pregnant and lactating mothers. U-5 children and adolescent girls Total community 80 % coverage in rural areas Mothers, adolescent girls and children Total corn.munity j Time Frame 2000 2010 2000 2010 2000 2010 2000 2000 2000 2000 Outcome Indicators I ! Anaemia reduced - lO 50% - 10 25% Anaemia reduced - to 50% - to 25% Fruit Intake 20 g/person/day Vegetable Intake 213 g/person/day Fruit Intake 56 g/person/day I I l 00 % coverage Reduction in worm infestation rate. Published report i ' Improvement I ! m KAP i SI No Actions Agencies Target Time Frame Outcome Concerned Indicators -~---· -- 4.7.J.2 Control of vitamin A deficienq ""'-" i. Distribution of vitamin MOHFW, U-6 children and To continue Coverage rate A capsules (V AC). MOSW, pregnant mothers till alternative >80% MOWCA, strategies are MOLGRD, established NGO ii. Backyard gardening MOA, Total community 2000 Nightblindness for growing vitamin A MOLGRD. emphasis on prevalence < I % rich vegetables and MOWCA, women and fruits. NGQ children iii. Nutrition advocacy MOHFW, Total community 2000 Improvement in and education. MOA, MOE, KAP MOLGRD, MOWCA, NGO 4.7.3.3 Control of iodine deficiency disorders I. Universal iodisation MOI, Total community 2000 100% coverage of edible salt. MOHFW, of iodized salt MOE. MOC, LGRDC,NGO ii. Monitoring of iodine MOHFW, Salt industries. 2000 Regular content of salt at all MO~'T, traders, retailers. monitoring levels. LGRDC,NGO & consumers reports 4.7.3.4 Control of other micronutrient deficiencies L A cross sectional MOP. MOE Total community !998 Published repons survey to assess the ({NFS). prevalence rate of MOHFW, deficiencies of MOA, riboflavin, vitamin C, MOLGRD, vitamin D, calcium, NGO zinc and others. 73 4. 7 .4 Actiorz Plan 1. Development of home gardens, poultry, fisheries and other small farm animals at the village level through the active participation of the community. 2. Planning training courses, to ensure availability of these foodstuff at the grassroots level. 3. Education and motivation of the community to enhance knowledge of the importance of micronutrients in the diet. 4. Preservation of micronutrient rich seasonal foods should be encouraged at the local level. 5. Local level fortification of foods. 6. Monitoring and assessment of distribution of vitamin A capsules and iron tablets by the local government and locally active organizations. 7. Concept of balanced diet to be incorporated in all on-going programmes. 8. Integrated farming system approach. 9. Ensure universal availability of iodised salt and regular monitoring of iodine level at the consumption points. 4. 7 .5 Proposed Interventions The following interventions are suggested in order of priority: 1. Production of micronutrient-rich fruits and vegetables at household levels through community participation. Group-level organization for sustainable production of fruits and vegetables by community, Union Parishads etc. 2. Intensive monitoring of iodine levels in salt by inspectors and extension workers. Monitor the universal iodisation of salt project of Bangladesh. 3. Assessment of micronutrient levels in the average Bangladeshi diet and suggest suitable intervention measures. Assess dietary intake patterns to generate suitable lEC strategies. 4. Assess vitamin A and iron deficiencies in special physiological states, viz. pregnancy and lactation and develop suitable intervention programmes. Precipitation of micronutrient deficiencies during pregnancy and or lactation- 4.8 PROMOTING APPROPRIATE DIET AND HEAL THY LIFESTYLES A healthy lifestyle and an appropriate diet are strongly linked with the absence of many non-communicable diseases. In Bangladesh, at the same time as there are large numbers of people suffering from undernutrition due to lack of calories and nutrients, there are some sections of the population, particularly those more affluent and urbanized, who are overweight as a result of overconsumption and inappropriate diets. Quite often, such diets tend to become high in saturated fats, refined carbohydrates and salt, but low in fibre and complex carbohydrates. Other factors like lack of exercise and smoking precipitate into the production of obesity, hypertension, diabetes mellitus, cardiovascular diseases, osteoporosis and certain type of cancers, all of which cause a significant economic and social loss. 4.8.1 On-going Pro.grammes and Situation A,ialysis Efforts are being made to increase the intakes of oil, pulse, vegetable, fruits and animal products for certain groups of the population, while at the same time reducing the intakes of oil and other energy-dense foods together with more healthy lifestyles in other groups. At the national level the incidence rate of obesity is 0.1 % , diabetes mellitus around 2.0% and hypertension of around' 1. 84 % . Though the percentages do not appear very high, considering their occurrence is largely in a limited group, the incidence is rather high. On-going programmes: SI. No. Institution Action l. Bangladesh Institute of Research and . Treatment and care of diabetic Rehabilitation in Diabetes and patients. Endocrine Metabolism (BIRDEM). . Rehabilitation . - Awareness creation on healthy lifestyle through disciplined way of iife (diet counse!ing. physical exercise). . Research . . Training and education . l 2. Institute of Cardiovascular Diseases Treatment and care of patiems with (ICVD). cvo. . Rehabilita1ion Research. 5 Training and education. Supportive programmes 1. BINP (sr. no.15 of Theme no. 2 (section 4.2.1). 2. NGO gardening and nutrition education surveillance project {sr. no. 18 of Theme no. 2 (section 4.2.1). 3. Community nutrition programme (sr. no. 20 of Theme no. 2 (section 4.2.1). ·~ 4. Collaborative training with ASSP, DAE, GTI and BAU (sr. no. 23 of Theme no. 2 (section 4.2.1). 5. Combined service delivery (sr. no. 24 of Theme no. 2 (section 4.2.1). 6. Essential health care and reproductive health and disease control programme (sr. no. 1 of Theme no. 4 (section 4.4.1). 7. BBF (sr. no. 1 of Theme no. 5 (section 4.5.1). 8. Nutrition message dissemination programme (sr. no. 8 of Theme no. 7 (section 4.7.1). Analysis of the existing situation indicates a need to: Better target programmes and facilities. Raise awareness at all levels. Involve the community in decisions. 4.8.2 Sectors Involved The Sectors and agencies involved are as follows: Ministry of Health and Family Welfare Ministry of Agriculture Ministry of Social Welfare Ministry of Women and Children Affairs Ministry of Local Government, Rural Development and Cooperatives. Primary and Mass Education Division Ministry of Education Ministry of Information WHO. FAO. UNICEF, UNESCO. WB NGOs 4.8.3 Strategic Framework Promoting appropriate diets and healthy lifestyle: SI No 4.8.3.l 4.8.3.2 4.8.3.3 Generating 2wnr~n~~r the targe.~ p~ptiia.,ivai vf i.i,e tff el:tS oi inappropriate diets and lifestyles on health. Strengthening those institutions de ... ling with the related problems as it is expected that the incidence rates would rise, along with generation of requisite manpower to tackle the problem. Actions Concerned Target Time Frame Outcome Agencies Indicators Survey to know the MOP, Identified 1998 Completed report existing situation on MOHFW, population. overnutrition and MOSW, unhealthy lifestyle. MOWCA, MOE, NGO Education and advocacy See section 4.9 programmes including community. Preparation of a plan of MOP, Identified 1999 Implementation by action aimed at the MOHFW, population 2005 target groups (with 10 MOSW, years prediction) MOWCA, MOE, NGO 4.8.4 Action Plan l. Development of audio-visual aids such as bulletins, folders, leaflets, posters. TV and cinema spots to raise the awareness of the importance of a balanced diet and healthy lifescyle. 2. Assessment of the present status of inappropriate dietary pattern and unhealthy lifestyle in different sections of the population 3. Prepare a predictive assessment of the problem for the next 10 years and plan programmes to support and equip the concerned institutions. 77 4.8.5 Proposed Interventions The following interventions are proposed in order of priority: 1. A. iiui vcy u~;ug :,i.1 ai.111cJ :,wupi1ug mcti,w iu k.uuw the cause and the effect of inappropriate diets and unhealthy lifestyles. Stratified sampling, using socioeconomic criteria to establish the type, cause and effect of inappropriate diet and unhealthy lifestyle in each group. 2. Prepare a comprehensive plan to prevent, control and cure. Interlinking between existing agencies and strengthening the concerned institutions. 3. Nation-wide consciousness building campaign to enhance good civic sense on health, environment and hygiene. Mass media campaign programme on developing healthy lifestyle and practices. 4.9 PROMOTING NUTRITION EDUCATION, ADVOCACY AND COMMUNITY PARTICIPATION The promotion of nutrition education and the generation of awareness, advocacy and community participation are important issues for the success of a development programme or project Yet seldom have they been made a permanent component in planning · or implementation and rarely have the targeted population received the benefit. The involvement of women, vulnerable groups and grassroots level workers need to be given their due place during the planning, implementation and evaluation process. However many on-going programmes are conducted without proper assessment of the training and communication needs and their impact have not been monitored and evaluated to plan midstream corrections and alterations. It is necessary to involve the community, not only in the design of a programme but also to provide a feedback of information to the planners and implementors. 4.9.l On-going Programmes and Situation .4nalysis On-going programme include: 1. Nutrition message dissemination programme: - TV spots Radio programme - Folk songs - Newsletters - Nutrition journals I j 2. BINP (see sr.no. 15 of Theme no.2 (section 4.2.1). 3. BBF (see sr.no. l of Theme no.5 (section 4.5.1). 4. Control ot lUU programme (see sr.no.2 of Theme no.7 (section 4.7.1). 5. Model school gardening promotion programme (see sr.no.17 of Theme no.2 (section 4.2.1). 6. NGO gardening nutrltlon education surveillance project (see sr. no.18 of Theme no.2 (section 4.2.1). 7. Promotion of homegardening through training (see sr.no. 19 of Theme no.2 (section 4.2.1). 8. Comprehensive nutnt1on and blindness prevention programme (see sr.no.6 of Theme no.7 (section 4.7.1). 9. Community nutrition programme (see sr.no.20 of Theme no.2 (section 4.2.1). 10. Support for Bangladesh Institute of Research and Training on Applied Nutrition (see sr.no.22 of Theme no.2 (section 4.2.1). 11. Agriculture support services project (sr.no.4 of Theme no.2 (section 4.2.1). 12. Nutrition courses in primary, secondary, agriculture and medical curricula. 13. NGO-supported programmes Analysis of the existing situation indicates a need for: Coordination between agencies. Commitment at all levels to reach the target population. Highlight the importance of health, nutrition and environment in literacy projects. Sensitization of the community. Women-oriented IEC component. 4.9.2 Sectors Involved The Sectors and agencies involved are as follo\VS Ministry of Information Ministry of Health and Family Welfare Ministry of Agriculture Ministry of Fisheries and Livestock Ministry of Science and Technology Ministry of Education · J:!jmJ!¥. l!N-LM~c~.gµ~,ti9~ QhtilfQU, ' Ministry of Social Welfare Ministry of Women and Children Affairs Ministry of Local Government. Rural Development and Cooperatives UNESCO, UNICEF, WB, FAO, WHO. UNFPA, WFP NGOs such as HKI. WIF, BRAC, Grameen Bank and others. 4.9.3 Strategic Framework Promoting nutrition education, advocacy and community participation: Coordination among all mass media cells of the sectors concerned by the nodal agency. Advocacy to planners and implementors to be strengthened. Community participation strategies to be developed and suitably communicated. SI No Actions Agencies Target Time Outcome Concerned Frame Indicators ... i.3.i institutionai tieveiopment i. Nutrition education ,.;Or -=~t MOHFW,MOA, All Union 2000 100% coverage to be introduced at the Union MOLGRD, Health level health centre. MOSW, MOFL, Centres NGO ii. A basic training / MOHFW, All Thana 2000 100% coverage communication unit at the MOLGRD, Complex Thana level. MOSW, MOA, MOWCA, MOFL, NGO iii. A coordination and supervisory MOHFW, All Districts 2000 100% coverage unit at the District level. MOLGRD, MOSW, MOA, MOWCA, MOFl . NGO IV. Interministerial and interagency MOHFW, MOA, Policy 1998 I Cummittee coordination council at the MOF, MOEP, planners/ i functioning National level to indicate and MOSW, researchers guide the process of institutional MOWCA, MOFL, development in the light of the MOE, PMED NPAN objectives. This would MODMR, require strengthening of the MOLGRD, NGO, existing institutions, viz., MOC, MOI Bangladesh National Nutrition Council (BNNC) along with other institutions of the government, universities and voluntary agencies. V. Introduction of nutrition MOE, Pl\llED School 1998 Curriculum courses in all educational MOHFW, MOA, children formed and institutions. MOI, NGO ! I -,;:v fJV! ~ I into sy iabus ! I i ! ! l I SI No Actions Agencies : Concerned ! ·-* - v%, ,# .• ... ,.::,.t. I numan resource oeve1opment L ll. iii. iv. I At Ward level Women's representative .. Youth club .. Awareness programmes At Union level .. Women's groups .. Youth forums .. Awareness and motivation programmes through health centres (EPI outreach centres and satellite clinics)/block supervisors/voluntary agencies At Thana Level .. Women's coordinating committees .. Intersectoral coordination committees through existing infrastructure and possible inclusion of additional responsibil nies of Thana Nutrition Coordination acuvities. At District level The District level coordination commmee to supervise, monitor and valuate all IECM e act1vnies. v. At '.ational l~vd Already ex1stmg mterrninistenai and interagency :..:onu11Htets tu ensurt smooch anplementativn ot -1\l !ECM rt:lateJ acttvH1es Tra;nmg ar.d exchange progran-ur:e:, \.VHhin the countr'V Jnd ;1br0ad. I i l\lOWCA, MOSW, MOLGRD. MOA. MOHFW, NGO MOWCA, MOSW. '.\IOLGRD. MOHFW. NGO All Ministry & NGO representatives at Thana level All Ministry & NGO represcntanves. :\!i con..:crned ~1 H11srries ~nd '.\GOs Target Adule men, wome.1 and youths All women and youths Women groups, Thana Council District level officers Nt.aritionists .md lither :ill 1ed pro fess1onals Time Frame : 1998 2000 1998 1998 1998 2000 l ' Outcome Indicators Institutions established Increased KAP lnstimcions established Committees formed and functioning Committees formed and functionmg Improved human resource :.:apacity : I I j ' i S1 No Actions Agencies Concerned Target Time Frame Outcome Indicators -..:, . ., ., t.:oordlnntton . . - :. ' L Formation of a coordinating MOHFW, MOA, Concerned 1996 Functioning comn:iiltee by the health MOF, MOEF, sectors of the education unit of Ministry of MOSW, MOWCA, committee Health and AIS of MOA MOFL, MOE, involving all concerned units of PMEDMODMR, different collaborative sectors. MOLGRD, MOI, 'NGO ii. Ensure the community MOHFW, MOA, Continuous Contin- Improvemen partidpation till tbe village MOLGRD, and all uous t of KAP level with networking from the existing govt, and inter- National Coordinating committee infrastructure at sectoral to District to Than.a to Union to rural level, NGO coordination Village levels using all existing - infrastructures. 4.9 .4 Action Plan 1. A central committee to be set-up to coordinate act1v1t1es of different sectors working towards nutrition education, members of which would be the Chiefs of mass media cells of all sectors concerned. 2. Assessment of the impact of training . IEM activities and community participation to be conducted regularly. 3. Prioritization of messages and communication strategies . 4. Institution of regular courses (short and long term) to enhance a trainer's capabilities at the field level. 5. Nutrition courses, awareness and related issues to be made a part of the curriculum in all educational institutions. 6. Ensure community par ticipation in nutrition related working groups for women and NGOs. activities for volunteers, 7. For communitv nutrition activities, ensure individual contact, family approach, leaders approach, mass approach and institutional approach. 83 4.9.S Proposed Interventions The following interventions are proposed in order of priority: 1. Development of information, education and communication (IEC) material for household food security. Compile information on issues related to food security and its impact on nutritional status. 2. Awareness creation on socio-psychic issues for caring. Required for better caring practices of mothers, primary health workers and other care-givers. 3. A comprehensive mass media campaign on the prevention of micronutrient deficiencies at national to village level. Develop suitable IEC material and methods to reach the actual target population. 4. Information, education and communication material development and campaign for appropriate diet and healthy lifestyle. Incorporation of these materials in syllabus/curriculum in educational institutions. Develop suitable syllabi, module etc. with coordination of the Education Ministry. 5. Develop programmes to ensure community participation in nutrition activities. Involve Union Parishads, local NGOs, nutrition committees of BINP to have continuous involvement with community. 6. Strengthening the existing MIS of Ministry of Health and Family Welfare by incorporating nutritional indicators. 7. Development of a comprehensive and easy-to-carry package of important messages concerning control of malnutrition for use at the field level along with a built-in impact assessment methodology. For use by agriculture extension workers 8. Development of TV spots, plays and other mass communication strategies. Identify targeted messages to develop spots, plays etc. 9. Development of curriculum for training the trainers. For use by agriculture extension worl~ers, PHCs etc. 4.10 ASSESSING, ANALYZING At"'ID :MONITORING ~1JTRITION SITUATIONS To plan, implement, monitor and evaluate any policy or programme, it is essential to have detailed information on the nature, extent, magnitude, severity and the changes over time of different types of nutritional problems. The causes and the resources available also need to be known. Hence, comprehensive information regarding the nutrition situation will help the decision makers plan more effectively. Better plans will improve the cost­ effectiveness of programmes leading to improved social and economic benefits. 4.10.1 On-going Programmes and Situation ,4nalysis Surveys on nutritional status, dietary intake, availability, attitude and other related information are regularly conducted by several organizations of the government as well as the NGOs. Usually these singular efforts run vertically to each other without proper coordination. This can lead to apparently conflicting and confusing data and the credibility of such work is lessened as a result. Hence, it is essential to create an information a system to generate a dependable and universally accepted database. On-going programmes: SI. No. Sector Action Coverage l. Bangladesh Bureau of - Child nutrition status survey (two-yearly). National Statistics (MoP) Household expenditure survey (occasional) - Agriculture Census (yearly). - Health and demographic survey (occasional). • Labour force survey (occasional). - Disability survey (occasional). 2. NIPORT (MoHF\V) - Family planning and health survey. National Fertility survey. I 3. HKI. IPHN, ICDDR,B Nutritional surveillance project t NSP'l I National & NGOs 4. Dhaka University - National nutrition survey in rural areas eYery l O years. :--.lattonal - IDD survey 5 ICDDR.B Demographic surveillance system. Matlab<! Thana) I 6. BRAC Watch project. National I I as Analysis of the existing situation suggests that: Although efforts are being made on surveillance and monitoring of programmes, greater inter-sectoral commitment and coordination is nef'r!f"rl Use of the data by the Planning Commission needs emphasis. Identification of data gaps at national level needed. Accessibility to information needs to be easier. 4.10.2 Sectors Involved The Sectors and agencies involved are as follows: Ministry of Planning (BBS) Ministry of Health and Family Welfare Ministry of Agriculture Dhaka University (INFS, Biochemistry Dept., ISRT, Statistics Dept.). BIDS FAO, WHO, UNICEF, UNESCO, WB, ICDDR,B NGOs such as HKJ, BRAC 4.10.3 Strategic Framework Assessing, analyzing and monitoring the nutrition situation: Develop a coordinating mechanism and identify the agency/organization responsible to set-up a comprehensive information system. Identify data gaps. Ensure easy accessibility to dependable database. SI No Actions Concerned Target Time Outcome Agencies Frame Indicators 4.10.3.1 The on-going surveys conducted MOP, MOA, Total 1998 Evolve a proper ~ ~; ~~ !Iu.:!;!2-.i!~!: ,B,u:-1t··i.~ ~r a.,:~:~ .. l.1 ~ :;:.;~-"'r:~~!tj" ! ~•-•t~•\,;1'!: .... ,""'t:,,,;.. \"S "!:-Y-~ ,,... ,. •.• r:;...:;..' • ~·) IOVOU•1J• tU6 tUi1,,~: Statistics (BBS) should include MOE (DU), evaluation system more information generation NGO with properly system on nutrition related issues, trained manpower viz., maternal nutrition; rnicronutrient deficiencies; agricultural production vs. nutritional status; land availability vs. food intake and so on. 4.10.3.2 A central coordinating body MOP, All existing 1998 Coordination comprising of representatives of MOHFW,· survey body functioning all concerned ministries, non- MOA, MOF, systems government and other agencies MOEF, should be formed by th.e Ministry MOSW, or Planning to: MOWCA, - coordinate, assess, analyses MOFL, and monitor all nutrition MOE, PMED related surveys. MODMR, - Suggest and implement MOLGRD, changes in the on-going MOI, NGO, programmes as and when MOC needed. 4.10.3.3 A comprehensive database MOP, MOA, Total 1998 Published reports covering all nutritional issues to MOHFW, population be compiled and published MOLGRD, regularly. !NFS, NGO 4.10.4 Action Plan 1. Creation of a Bangladesh nutrition monitoring centre/unit (responsible agency for developing an up-to-date scientific data bank). Bangladesh Bureau of Statistics may implement it. 2. This monitoring unit/centre should be involved in the development of all nutrition programmes/projects in the country. 3. Development of computer networking to make the data easily availabk. The MIS of MOHFW may be entrusted with responsibility. 4. Proper analytical methods and models need to be developed and adopted to assess and analyses all survey data and to use them to the maximum extent by planners, implementers and individuals. 4.10.5 Proposed Interventions The following interventions are proposed in order of priority: 1. Formation of a national nutrition monitoring centre. Creation of a central monitoring unit which networks with districts and Thanas for nutritional monitoring. Linking the unit with BBS to generate annual updates on the food and nutritional starus of the country. 2. Strengthen and expansion of nutrition surveillance. Extend existing programme of HKI. 3. Monthly or quarterly (as appropriate) news bulletin for circulation among all sectors of government, UN agencies and NGOs, highlighting the latest information on nutrition. ·- To be prepared by the central monitoring unit or Planning Commission, GOB. 4. Develppment of suitable computer programmes for analyzing the data and subsequently making it available through net working. For all programrnes---suitable hard and software support and interlinking. 5. INSTITUTIONAL FRAMEWORK FOR TRANSLATING PLANS INTO ACTION The Bangladesh National Plan of Action for Nutrition describes the existing situation: the goals, objectives and targets, and presents a slrategic framework tor implementing the plan. Specific outcome indicators for both short as well as long-term programmes are suggested. A comprehensive analysis of the existing situation has been made, the concerned sectors for improving nutritional status in Bangladesh have been identified, and the related ·actions that need to be taken up have been highlighted. Lastly, the document has suggested a few important intervention activities which need special attention. A few of these have been identified as priority projects based on the suggestions made at the workshop for finalization of the NPAN organized by BNNC, MOHFW. The most important action for the country is now to translate this policy framework into action. Accordingly, strategic, targeted as well as sustainable programmes/projects need to be developed and implemented by all the concerned sectors of the government as well as the non-government organizations (NGOs). The help and advice from the various supportive UN and bi-lateral agencies would be welcome. A step-wise plan for implementation of NPAN is suggested as follows: Step 1 -Formation of the National Nutrition Council (already done). This is the highest body (committee) being Chaired by the Prime Minister for implementation of the National Plan of Action. This committee is to develop and issue the policy guidelines needed to achieve the objectives of the Bangladesh NPAN. It acts as the highest body to ensure proper intersectoral coordination among all the concerned sectors through its linkages with the Ministry of Planning. The Council has the main responsibility for improving nutrition which iS effected by providing guidance on policy to the Government. \1embership of this committee includes the Ministers and most senior Government officials of the concerned sectors. The Member Secretary of this committee would be a most senior officer of the nodal ministry. Step 2 -Formation of a Steering Committee with the Minister of the nodal Ministry as Chair. The members would be the most senior planners and policy makers from the concerned Ministries of the Government :.iiong with representation from the most effective NGO bodies. This group would draw up the specific action programmes while considering the intersectoral coordinated approach to maxunize their impact in a most cost-effective way. Step 3 -Formation of \Vorking Groups by each sector. with the nudal officer of the particular Ministries/Sectors as Chair. These \\.orkmg groups would tnsure the participation of ail concerned instttutions 1 agencies, programme 29 managers, ~~CO boJic-; :mJ uther experts working in the'><: particular sectors. It is very unrortant that the mr.:mbers of the committee h:1,e representation uniformly from all the on-going accivitit:s of the country, ,11 that the action plan prepared \vould take into consideration all the existing efforts, identify the r,~ps and ~rt>p::ir"" effPNiu.. ':t!"t~1iw1h!::- :±!:d '.'~:;.!:::!c: projects and programmes. Step 4 Monitoring and eYaluat1on of the impkmenc:iuon of the Bangladesh N PAN would be the most criricd factor for its success An in-built system of nutrition surveillance needs to be developed at the Ward level (if possible), to give a regular feed back to the working groups (through the existing sectoral infrastructures, programmes and NGOs) to keep the planners of the concerned sectors informed. The success of the Bangladesh NPAN will depend on its effective implementation by ensuring intersectoral coordination, community participation and proper analysis and evaluation of the programmes with a sense of responsibility, adaptability, flexibility and mutual understanding. ANNEXURE NATIONAL WORKING COMMITTEE (NWC) FOR NPAN 1. 2. 3. 4. 5. Additional Secretary, r~i1.1k:Jtrf ef i'+e1tilth at1dramHy Vveifare. Joint Secretary (H & PH), Ministry of Health and Family Welfare. Director General , Directorate of Health Services. Director General , Directorate of Family Planning . Prof. M. Q-K Talukder, Project Director, Institute of Child and Mother Health and Chairman, Standing Technical Committee Bangladesh National Nutrition Council. 6. Joint Chief, Ministry of Health and Family Welfare, 7. Representative , Ministry of Agriculture . 8. Representative, Ministry of Social Welfare. 9. Representative , Ministry of Women and Children Affairs. 10. Representative, Institute of Livestock Research . 11 . Representative , Directorate of Fisheries. 12. Representative, Ministry of Relief & Disaster Management. 13. Representative, Ministry of Food. 14. Representative, Ministry of Information. Chairmnn Member Member Member Member Member Member Member Member Member Member Member Member Member 15. Mr. Asad Uddin Ahmed, Member Dy. Chief {Health), Ministry of Health and Family Welfare. ,G. Ms. 3y€1ti Azt,w RahiY1af1, fv'iOtttbor Asst Chief, Ministry of Health and Family Welfare. 17. Dr. S. M. Abudullah Al Momen, Member Junior Clinician, IPHN. 18. Director, Member INFS. 19. Representative, Member Bangladesh Rural Development Board. 20. Representative, Member Institute of Food Science & Technology. 21. Representative, Member Helen Keller International. 22. Dr. S. K. Roy, Member ICOOR'B. 23. Representative, Member UNOP. 24. Representative, Member FAO. 25. Additional Director, Member Directorate of Women Affairs. 26. Representative, Member BRAC. 27. Mr. Md. Abdul Mannan, Member-Secretary Secretary, Bangladesh National Nutrition Council. WORKING SUB-COMMITTEE 1. Prof. M. Q-K. Talukder, Project Director, institute of Child and Mother Health and Chairman, Standing Technical Committee Bangladesh National Nutrition Council. 92 Chairman 2. Prof. Rezaul Karim, Director, Member Institute of Nutrition & Food Science. Dhaka University. 3. Dr. S. K. Roy, Scientist, Member iCDDfrS, Dhaka. 4. Dr. Nazmul Hassan, Professor, Member Institute of Nutrition & Food Science Dhaka University. 5. Dr. Hossain Zillur Rahman, Member Bangladesh Institute of Development Studies. 6. Mr. Md. Aminul Haque Bhuyan, Member Assoc. Professor, lnstiiute of Nutrition & Food Science Dhaka University. 7. Dr. Syeeda Begum, Junior Clinician, Member Institute of Public Health Nutrition. 8. Dr. S. M. A. A. Momen, Junior Clinician, Member Institute of Public Health Nutrition. 9. Dr. Iqbal Kabir Member World Bank, Dhaka. 10. Ms. Shahnaz Ahmed Member UNDP, Dhaka. 11. Mr. Soren Bo Madsen Member FAO, Dhaka. 12. Dr. George J. Komba Kono Member WHO, Dhaka. 13. Dr. Sadia Chowdhury, Director, Member WHOP, BRAC. 14. Ms. Nasreen Huq, Senior Technical Adviser, Member HKI, Dhaka. 15. Mr. Rashiduzzaman Ahmed, Program Officer, Member VHSS, Dhaka. 16. Mr. Abu Zafar Amanatullah, Member Deputy Secretary, Bangladesh National Nutrition Council. 93 17. Mr. Abdul Motaleb Mia, Deputy Secretary (Public Health), Minisrty of Health and Family Welfare 18. Mr. Md. Eshaque Ali, ~J~ ~~:..;;"" ~J~.4 , ,., ,u,U'V$1t..;>t.t Bangladesh National Nutrition Council. 19. Ms. Mahfuza Begum, Monitoring and Evaluation Officer, Bangladesh National Nutrition Council. 20. Mr. Abu Ahmed Shahmim, Program Officer, Bangladesh National Nutrition Council. 21. Ms. Akhtari Mamataz, Senior Assistant Secretary, Ministry of Health and Family Welfare. 22. Mr. Mohammad Saidur Rahman Nutrition Information and Documentation Officer Bangladesh National Nutrition Council. 23. Mr. Md. Abdul Mannan Secretary Bangladesh National Nutrition Council. NATIONAL FOCAL POINT 1. Mr. M. Azizur Rahman Joint Secretary (H&PH) Ministry of Health and Family Welfare (lead Ministry). SECTORAL FOCAL POINTS 1, Mr. A. Waheed Khan Deputy Chief, Ministry of Agriculture. 2. Mr. Fakhrul Ahsan I Mr. Moududur Rashid Deputy Chief, Ministry of Food. 3. Mr. Abu Mohammad Deputy Chief, Ministry of Fisheries and Livestock. 4. Mr. Md. Hafizur Rahman Member Member Member Member Member Member Member-Secretary Deputy Secretary (Dev.), Ministry of Women and Children Affairs. ·) 4 5. Mr. Md. Osman Ali Deputy Chief (Planning),' Ministry of Social Welfare. 6. Mr. M. Shukur Mohammad Pk. Deputy Secretary (Admin), Ministry of Information. 7. Mr. Motaher Hossain Deputy Chief (Planning Br.). Ministry of Relief & Disaster Management. 8. Mr. S. C. Khan Deputy Secretary (Dev.1), Finance Division. Ministry of Finance. 9. Ms. Nargis Islam Deputy Chief (Health Wing), Planning Commission .. 10. Mr. Abul Khair Deputy Chief, Ministry of Education. 1 L Mr. Md. Sherajul Islam Deputy Chief, Ministry of LGRD. 12. Mr. Mohammad Ibrahim Deputy Chief, Ministry of Environment and Forest. 13. Dr. Md. Delwar Hossain, Deputy Chief Primary & Mass Education Division. 14. Mr. Ahmed Tajul Islam Director, Project-1, NGO Affairs Bureau. 1 . Prof. Indira Chakravarty Director and Dean CONSULTANTS All India Institute of Hygiene and Public Health Calcutta, India. 2. Dr. Rahmat U Qureshi Visiting Research Fellow Kings College London University, U.K 3. Prof. H.K. M. Yusuf Dept. of Biochemistry Dhaka University. 4. Dr. Ziauddin Haider Nutritionist BRAC, Dhaka.