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Mainstreaming Nutrition into the Public Sector Health System in Bangladesh

RESEARCH OVERVIEW 

TRAction funded research examining the effectiveness of mainstreaming nutrition interventions and services in Bangladesh.  With three main objectives examining constraints to coverage and quality of nutrition services, the overarching purpose of the protocol was to help inform improvements in implementation by identifying strengths and weaknesses in current implementation practices. 

Although Bangladesh has experienced impressive gains in population health (reduced under-5 mortality and maternal mortality, reductions in poverty, among others) malnutrition rates measured in underweight, stunting, and wasting remain alarmingly high.  This is despite the role of the Government of Bangladesh (GoB) in prioritizing nutrition since at least the 1970s with the establishment of the Institute of Public Health Nutrition (IPHN).  Since then, the design of both nutrition specific and nutrition sensitive programs as well as the government agency (formerly IPHN) tasked with implementation and priority setting, has changed a number of times.  Under increasing pressure to improve nutrition outcomes and against criticism of poor cost-effectiveness, the National Nutrition Service (NNS) was established in 2011 and charged with leading the mainstreaming nutrition process.  The TRAction funded study evaluated the progress of this process at the community clinic (CC) level employing a mixed methods, pre-post evaluation design.

To understand the potential hurdles to implementing a program transitioning from a vertical design to an integrated model, it is important to understand both the Bangladesh health system and the human resource constraints.  The Upazila Health Service (UHS) is three-tiered model composed of Hospitals, Health Centers, and Community Clinics (CC) which are located at the ward or village level with a catchment area not to exceed 6,000.  Since 1998 there have been a number of GoB initiatives aimed at revitalizing primary service delivery at the CC level who are also tasked with providing nutritional education, micronutrient supplementation, screening, and referral.   However, according to the WHO, Bangladesh was identified with a ‘severe shortage’ of health workers and shortages in human resources at the CC level was indeed one of the constraints identified over the course of the study.

PROJECT LOCATION

 Sirajganj and Mymensingh districts, Bangladesh

STUDY APPROACH

Primary Objective: To assist the government in implementing national nutrition services at the community clinic (CC) level.

Secondary objectives:

  • To improve coverage and quality of nutrition services by training of the community clinic staff and mobilizing the community groups. In the project nutrition service is being referred to growth monitoring and promotion (GMP) and nutrition counseling to pregnant and lactating women
  • To explore the constraints of implementing nutrition services at the community clinic level
  • To determine actual work load of CC service providers to implement nutrition services

Researchers utilized a mixed methods, case-control approach.  Fifteen randomly selected intervention CCs were located in Kamarkand and Belkuchi of Sirajganj district and 15 randomly selected control CCs were located in Phulpur and Gouripur of Mymensingh district.  The interventions involved training CC service providers and supervisors and providing opportunities to mobilize community groups.  Specifically this involved facilitating implementation of and monitoring the growth monitoring and promotion (GMP) program at the CCs, developing Information Education Communication (IEC) materials, and monitoring daily nutrition service activities.  Data collection for the qualitative component involved focus group discussions of training participants, community members, and CC staff, key informant interviews, and observational data at the facility.  The quantitative component comprised two cross-sectional surveys (baseline and endline, n=3150 under-2 children) each capturing household characteristics, water, sanitation and hygiene practices, IYCF practices, dietary diversity and meal frequency.

RESEARCH INTO ACTION 

The results of this study will be directly applicable for policymakers and program implementers who are seeking to raise the quality of nutrition services provided at the community-level to facilitate improvements in nutritional status countrywide.

LESSONS LEARNED

  • Training duration and quality was inadequate to cover whole range of nutrition-related issues;
  • Health system gaps existed in provision of maternal health care, especially with community health worker provided antenatal care;
  • Coordination between the different stakeholders remains a major hurdle to success; and
  • Creating an enabling environment through training of all CC staff, provision of supplies and operating CCs for 6 hours daily per week is essential for CHCPs to perform the NNS activities alongside other activities.

RESEARCH PARTNERS

International Centre for Diarrheal Disease Research (icddr,b)

PROJECT STATUS 

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