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Using the health system to deliver nutrition interventions in Bangladesh

Using the health system to deliver nutrition interventions in Bangladesh

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This presentation by Masum Billah, iccdr,b was shown at the Transform Nutrition - Evidence for Action regional meeting in Kathmandu, Nepal on 8 July 2017. This one-day event shared Transform Nutrition evidence on key issues related to nutrition policy in Nepal, Bangladesh and India, lessons on strategies for change from other contexts and discuss the relevance and applicability of the research findings to policies/programmes that aim to address nutrition in South Asia.

This presentation by Masum Billah, iccdr,b was shown at the Transform Nutrition - Evidence for Action regional meeting in Kathmandu, Nepal on 8 July 2017. This one-day event shared Transform Nutrition evidence on key issues related to nutrition policy in Nepal, Bangladesh and India, lessons on strategies for change from other contexts and discuss the relevance and applicability of the research findings to policies/programmes that aim to address nutrition in South Asia.

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Using the health system to deliver nutrition interventions in Bangladesh

  1. 1. Using the health system to deliver nutrition interventions in Bangladesh International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) International Food Policy Research Institute (IFPRI)
  2. 2. Heady et. al (2015) NEPAL Stunting reduction: Sources Health 16%! Can health do more?
  3. 3. Why does the NNS matter? Delivery of direct nutrition interventions  key to meet the development targets 47 64 67 20.9 83 60 37 81 34 52 55 65 23 78 62 44 84 38 0 20 40 60 80 100 Early initiation of BF Exclusive BF (0-6 mo) Introduction of CF at 6-9 mo 3 expected IYCF practices All basic immunizations Vitamin A suppl (<3s) Women - > 3 ANC visits ORT for diarrhea ORT + zinc Percent 2011 2014 Source: BDHS
  4. 4. History of NNS In 2009, Annual Program Review (APR) of the Health, Nutrition and Population Sector Program (HNPSP) recommended scale up critical nutrition interventions by mainstreaming nutrition services provided through the DGHS and DGFP In 2011, Operational Plan (OP) of National Nutrition Services (NNS) was approved by the GoB The OP suggests mainstreamed NNS interventions will be implemented through existing health systems (DGHS and DGFP) between July 2011 and 2016 NNS is supposed to pursue a variety of key strategies and actions targeted towards mainstreaming critical nutrition interventions Several aspects of mainstreaming process have been undertaken since 2012 National Nutrition Policy 2015 National Plan of Action for Nutrition (DRAFT) 2016 4th Sector programme (NNS OP)
  5. 5. Assessment of Implementation of NNS in Bangladesh International Food Policy Research Institute (IFPRI) International Centre For Diarrhoeal Disease Research, Bangladesh (icddr,b) Identified “what’s working”; “what needs more work”  Management and support services  Training and capacity development  Service delivery  Monitoring and evaluation  Exposure to Interventions (from DNSO evaluation)
  6. 6. What ‘New’ is being done? • NNS along with UNICEF and CIFF as implementing and funding partners is attempting demonstration components to addresses the NNS challenges • Provide a temporary dedicated human resource, the District Nutrition Support Officers (DNSOs) • Demonstrate and prove the feasibility and impact of Competency based training for managers, supervisors and service providers to deliver nutrition interventions
  7. 7. Methods Major domains Data sources to address research questions 1. Management and support services - Content review of NNS documents - National-level in-depth interviews 2. Training and capacity development - Content review of NNS documents - National-level in-depth interviews - Service provider surveys 3. Service delivery - Healthcare provider surveys - Facility assessments - Structured observations - In-depth interviews, FGDs with healthcare providers 4. Monitoring and evaluation - National-level in-depth interviews - Healthcare provider surveys - Facility assessments (record review) - FGDs & in-depth interviews with healthcare providers 5. Exposure to interventions - Household coverage survey (DNSO evaluation)
  8. 8. Management and Support Services
  9. 9. What’s working? NNS operational plans (OP) & progress in subnational coordination • Operational plans  OP outlines all components of NNS  Institutional arrangements for delivery of NNS interventions using existing health and family planning infrastructure are described in specific detail  New sector programme reemphasizes the direct interventions and community clinics • Progress in subnational coordination  Good progress in coordination of nutrition services and with levels of communication between staff managed by DGHS and DGFP at the upazila level and below Source: Saha et al, 2015, implementation assessment done in 2014
  10. 10. What needs more work? Governance and institutional arrangements Capacity and workload related challenges within NNS/IPHN  Capacity to developing feasible and specific implementation plans for intervention delivery  Ability to develop training approaches, to maintain and manage records on training roll-out and to manage a large budget Retention challenges for the Directorship of IPHN Lack of bureaucratic authority limits monitoring/coordination of NNS activities Source: Saha et al, 2015, implementation assessment done in 2014
  11. 11. What needs more work? Program design and intervention platforms Choice of delivery platforms  IMCI-Nutrition corners and Community Clinics are primarily visited by sick children  Key NNS components, especially IYCF counseling, micronutrient supplementation, and screening for SAM/MAM are targeted towards all children & current platforms not designed to reach all, no CMAM Source: Saha et al, 2015, implementation assessment done in 2014
  12. 12. What needs more work? Program design and intervention platforms Percentage of Mother-newborn pairs (care continuum) had contacts with the routine health services 26.1 13.5 9.8 5.1 4.9 ANC Delivery PNC ANC and PNC ANC and Delivery and PNC BDHS 2014 *Physicians are the predominant provider
  13. 13. What needs more work? Coordination and communication  Horizontal coordination at national level: • Lack of communication and coordination – particularly at senior levels. • Coordination across DGHS and DGFP are also reported to be challenging  Vertical coordination/communication: Local providers described how communications with NNS staff based in Dhaka were challenging, different line supervisors Source: Saha et al, 2015, implementation assessment done in 2014
  14. 14. Training and Capacity Development
  15. 15. What’s working? Training and capacity building roll-out  Training manuals are in place – Basic Nutrition, IYCF, SAM/CMAM, Competency Based Training (CBT), Supportive Supervision  Overall NNS training is ongoing and UNICEF supported CBT have started, covered 30,000+ service providers in 26 districts
  16. 16. What needs more work? Coverage of Nutrition trainings Percentage of service providers receiving trainings in nutrition (N= 364) 0 10 20 30 40 50 60 70 80 90 100 Physician Nurse SACMO FWV FWA CHCP Basic nutrition training IYCF training Any other nutrition training Initial Assessment (DNSO Evaluation), 2016* CBT coverage is not presented here *
  17. 17. Service Delivery
  18. 18. What’s being done? Integration with IMCI-N • Nation-wide establishment of IMCI-N corners is completed  All facilities include IMCI-Nutrition Corners  Basic Nutrition Training adds some value to IMCI for screening of SAM/MAM; elaborates on nutrition knowledge and includes more detail on IYCF training  NNS-trained providers appeared to offer more nutritional advice during sick child care Source: Saha et al, 2015, implementation assessment done in 2014
  19. 19. Availability of equipments and job aids 43 35 22 35 27 5 Weighing scale Height scale Length scale MUAC Tape GMP Card (both girls and boys) IYCF manual % of health facilities with key equipment in Sick child management area[N=37] 89% sick child management area had <50% essential equipment/guidelines ~70% ANC rooms had at least 7 of the 11 essential equipment/supplement/guidelines 95 54 41 54 95 46 16 Weighing scales Height Scale MUAC tape Picture cards with maternal danger signs Iron Folic Acid (IFA) tablet Calcium tablet Basic National Nutrition Services nutrition training… % of health facilities with key equipment in ANC room [N=37] Source: Saha et al, 2015, implementation assessment done in 2014
  20. 20. Delivery of Nutrition services during ANC 94 39 78 66 62 56 60 63 33 46 39 78 35 30 30 0 20 40 60 80 100 % Advice/service provided to women Weighed and recorded weight Measured and recorded height Examined anemia in eyes take more food take balanced diet take seasonal/available food take green/colored vegetables drink more water take iodized salt take rest at least for two hours/day maintain personal hygiene take routine iron and folic acid told about importnace of breast feeding told about breastfeeding within an hour told about danger signs to neonate Examinatio n Advice provided N=381 ANC observations Source: Saha et al, 2015, implementation assessment done in 2014
  21. 21. 0 10 20 30 40 50 % Advice/services provided to children Weighed and recorded weight Measured and recorded height Clinically screen the child for SAM Demonstrate IYCF practices using visual job aids Checked child's weight against a growth chart Nutritional Assessment Nutrition Counselling N=826 sick child case management observations Delivery of Nutrition services during sick U5 child management Source: Saha et al, 2015, implementation assessment done in 2014
  22. 22. Monitoring and Evaluation
  23. 23. What’s working? Indicators, performance review visits are coming together  Nutrition Information System  Considerable progress in institutionalizing the reporting of nutrition indicators in the routine RHMIS through:  Monthly IMCI-Nutrition Corner reporting format  Monthly community clinic reporting format for newborn and child health  Program Performance  Some supervisory visits are taking place at the level of the health facilities at limited scale Source: Saha et al, 2015, implementation assessment done in 2014
  24. 24.  Record-keeping within the NNS should be focused  information on implementation roll-out, performance/outputs, and development partner support to geographic and technical areas is currently not easily available to all key stakeholders  A system for technical monitoring of service quality by National Level experts and Managers What needs more work? Record-keeping on training, roll-out and service delivery monitoring Source: Saha et al, 2015, implementation assessment done in 2014
  25. 25. Recommendations • Strengthen the leadership authority of the NNS • Ensure regular technical supervision visits/support to field • Develop very specific implementation plans with rational delivery platforms • Invest in developing a cadre of workforce for delivering core nutrition messages beyond the curative platforms • Exploring other potential high coverage outreach platforms like some NGO platforms • Strengthen nutrition counseling and screening within IMCI, but invest more in an outreach- based platform for delivering core preventive NNS services • Coordination of activities among Development Partners • Emphasize rapid growing urban population and completely different health service structure • A system for technical monitoring of service quality by experts • Carefully review of the current set of NNS indicators

Editor's Notes

  • Data for the overall chart will be shared by Abdullah by tnight
  • Quality and coverage

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