In SouthAsia, social accountability practitioners have been addressing failures in the ‘standard’ health and nutrition model. What can we learn from them? New research report Social accountability initiatives in health and nutrition: lessons from India, Pakistan and Bangladesh from Transform Nutrition and the Institute of Development Studies.
In Bangladesh, undernutrition is estimated to be the underlying cause of about 60% of childhood deaths
From 2011-2017 Transform Nutrition has been strengthening the content and use of nutrition-relevant evidence, to accelerate the reduction of undernutrition.
On the 8th July 2017 in Kathmandu, Nepal, it will host a regional meeting; ‘Evidence for action in South Asia’ the day before the joint ANH Academy Week and Feed the Future Nutation innovation Lab Agriculture-Nutrition Scientific Symposium, to highlight experiential learning from South Asian countries on key drivers to improve nutrition status.
It will feature evidence on what works in nutrition-sensitive interventions, presented to policymakers from Nepal and international donors and NGOs in the South Asia region. The meeting aims to inform and equip attendees in order to address the particular challenges of tackling child undernutrition in their current contexts.
Avoiding soundbites on project success or failure…
By Dr Nick Nisbett, IDS research fellow and theme 3 research leader for Transform Nutrition and Ferdous Jahan, Professor of Public Administration, Dhaka University
Last week in Dhaka we were hosted generously by BRAC and ICDDR,B at a conference on the boosters and constraints to delivery of large health and nutrition programmes, where we presented the results of the project Impact Evaluation of DFID Programme to Accelerate Improved Nutrition for the Extreme Poor in Bangladesh. This was a three year, multi-methods mammoth evaluation of the nutritional impact of two of DFID’s Bangladesh programmes focusing on the extreme poor and another benefitting the urban poor. These were Economic Empowerment of the Poorest (EEP) (AKA Shiree), the Chars Livelihoods Programme (CLP) and Urban Partnerships for Poverty Reduction (UPPR). We got a lively reaction from the audience and some tips on how we might better present our results in future, where all too often failure to find the expected, ambitious impact (in this case on child stunting) is translated into the soundbite that programme x failed, or approach y is not worth repeating.
This would be a sad outcome of the evaluation – ignoring the valuable lessons of these programmes and DFID’s innovative and much needed approach to try to link up the livelihoods needs of the extreme poor more holistically with specific actions designed to improve child nutrition.There is a lot riding on such models working in future, particularly in Bangladesh, where as one of us argued at the conference, most nutritional gains have not come from such holistic nutrition programming but wider improvements in aspects of people’s lives which may now start to plateau.
Supporting child outcomes in poor families more holistically…
The evaluation began in 2013 when DFID and partners recognised that the livelihoods elements of the programmes alone were not leading to nutritional improvements in the children of beneficiary households. The food security and productive asset transfer / income creation/support elements of these programmes were likely to benefit broader household food security. But ensuring household food security and boosting income is a necessary, but not sufficient, measure to ensure improvements in the nutritional status of children. Among other things (including sanitary, healthy environments) mothers and carers need the right support for breastfeeding and feeding in the early years so that children receive the immunity, nutrient boosting and pathogen-free benefits of breastfeeding, and are then fed sufficient, diverse diets alongside breastmilk in the critical developmental years until two.
Three to four years into the operation of these programmes, therefore, DFID added an additional component of nutritional support for mothers, children and adolescent girls. This was to be delivered by women recruited within the community (community nutrition volunteers – or CNVs), trained to deliver a package of iron and folic acid tablets to benefit mothers and adolescent girls along with collective (e.g. courtyard meetings) and individual level (home visits) awareness raising activities. Children below two were to benefit directly from a combination of breastfeeding/feeding support to their mothers, with provision of deworming tablets and five nutrient micronutrient powders to be sprinkled on their food.
Getting ahead of our ambitions…
Ultimately this was a big ask of the three programmes, already tasked with running complex livelihoods delivery. Ideally it would have been designed in at the beginning, rather than as a separate component, but given that this combination of support (livelihoods + nutrition) was untested, it seemed like a reasonable plan. Perhaps what was difficult though in this case was the usual donor pressures to show results within the space of two years – a theoretically possible but practically ambitious target of reducing child stunting.
We are all guilty of pushing ambitious targets on stunting, because it is a marker of chronic undernutrition – a risk factor in 45% of all child deaths and a sign of other profound deficiencies which can lead to poorer, less healthy lives. However, those who have been in the evaluation and nutrition game for some time now, including Purnima Menon, who was at the conference, have been arguing that this doesn’t necessarily mean we should be applying ambitious stunting targets to all nutrition programmes – because so many things need to happen in concert to produce both well nurtured but also all round healthy children. As Purnima’s presentation showed, even the best run programmes which focus only on child feeding practices will not show a result on stunting and nor should they be expected to, particularly within a short evaluation time span. Asking mothers to diversify children’s diets also requires time and money to do so. Perhaps the programmes we evaluated, because of their wider and more holistic approach to livelihoods, had this opportunity, but it was untested water in this combination and at this scale.
Learning what worked…
The evaluation (randomised between ‘livelihoods only’ and ‘livelihoods plus nutrition’ recipients) was therefore set up to look at impacts earlier on in the ‘impact pathway’ – e.g. in changes in the knowledge and behaviours around particularly optimal child feeding practices (e.g breastfeeding within three hours of birth, which hugely boosts immunity, avoiding feeding water before the child is six months, having a sufficient, diverse diet whilst still including breastmilk thereafter). And we wanted to explain why and how all this happened or didn’t, so a process evaluation element monitored how the programmes were implemented, whilst a qualitative community based element considered barriers, constraints and wider contexts within the communities themselves.
To cut to the chase, what we learnt at the conference was to be even more careful not to say, in future, that there were no impacts on child nutrition resulting from this type of model (to be fair that’s not what we said or exactly how the audience responded – we exaggerate!). And ultimately, we saw that the community nutrition volunteer based model did not fail. The programmes delivered some of the key outputs in terms of getting nutrition workers in place, and they visited most families, delivering the IFA tablets, mircronutrients and deworming tablets and some counselling. Mothers generally had positive things to say about the workers – they trusted them and when we tested the workers’ knowledge at endline they scored reasonably highly, so they were well trained. Mothers’ knowledge about the benefit of iron in diets increased; children consumed the supplements or other iron-rich food as a result and we also saw improvements in some cases in terms of non-introduction of water or other substances before six months.
…and what didn’t…
But where things fell down were not on general programme delivery, but on the long neglected specifics of implementation– not on whether the nutrition volunteers went to households, but how often they went there, how long they spent there, how many topics they discussed, whether they were age appropriate for the situation of the mother and child (for example, too much time was spent on explaining the benefits of exclusive breastfeeding when mothers already had children too old for this). The worker’s caseloads were too high, they were travelling too far in difficult to reach areas, spending less time with mothers than ideal and were not receiving the type of supportive supervision and monitoring which would have detected and improved these critical aspects of delivery earlier. So the types of indicators most likely to be of long term benefit to immunity or child development (ie consuming diverse and sufficient food high in micronutrients) and/or likely to actually lead to improved growth (e.g. diets including animal source-food) did not shift. No surprise, then, that neither, ultimately, did stunting.
In the qualitative study communities mothers reported the difficulties of following prescribed practices when they were time poor, or couldn’t afford diverse diets, or time to cook separate meals for fussy children, or didn’t have the freedom to decide on child feeding practices themselves, or were equally likely to value opposing advice from e.g. mothers-in-law.
Despite the enormous pressure DFID are under to produce results, they have not shied from commissioning these types of evaluations which get to the heart of implementation complexity, particularly for these new types of much needed models. We’re slowly getting the evidence through that such mixed models (e.g. in a much smaller trial in Bangladesh, combining cash transfers and child feeding support) can have significant results (yes, even on stunting). We’re still not convinced that similarly ambitious goals for stunting should be set for two year programmes experimenting at scale, even while it is still instructive to try to measure any change. But what we have learnt is immensely valuable for future programming (and again, to their credit, DFID have taken on board all the recommendations so far). Ultimately, therefore, such knowledge leaves us better prepared for “delivering success at scale”.
The evaluation programme was led by IDS in partnership with IFPRI, BRAC Institute of Governance and Development (BIGD) and Prof. Ferdous Jahan of Dhaka University; ITAD, CNRS and was part of the MQSUN programme led by PATH. See here for the final report and here for a shorter report brief. The Delivering for Success Conference was hosted by BRAC and ICDDR,B in collaboration with the Transform Nutrition and Future Health Systems Consortia.
Conference on Delivering for Success at Scale 7- 8 February 2017, BRAC Auditorium, Mohakhali, Dhaka, Bangladesh
This conference built on the longstanding partnership between BRAC, ICDDR,B and the Institute of Development Studies (IDS) to explore the role of knowledge in the conceptualisation, design, delivery and management of development programmes and policies. Bangladesh has been a lead player in the use and integration of research into development decision-making, notably in relation to health systems, nutrition, social protection, agriculture and poverty. Evidence will continue to be important in strategic development planning by the Government of Bangladesh among others.
The conference included examples of how high quality research can be embedded within programmes, showcased research findings, discussed the challenges of integrating research with programmes, highlighted successful examples and discussed future needs. The UK Department for International Development funded Transform Nutrition and Future Health Systems presented relevant research.
Read an article about the conference in the Bangladesh Financial Express ‘On health and nutrition’. We also published a blog by Rittika Brahmachari, IIHMR Pathways to scaling up interventions: reflections from delivering for success at scale
For more information contact Aazia Hossain firstname.lastname@example.org
By Masum Billah and Shams El Arifeen, ICDDR,B
Despite important economic progress and reaching lower middle-income status in 2015, Bangladesh remains one of the high under nutrition burden countries. This is not due to a lack of political will. In 2009, the Annual Program Review of the Health, Nutrition, and Population Sector Program of the World Bank recommended scaling up nutrition interventions in Bangladesh through mainstreaming critical nutrition interventions in health and family planning services. To achieve this goal, the country made nutrition a priority.
The National Nutrition Services (NNS) has since been pursuing a variety of key strategies and actions. In 2011, the operational plan (OP) of NNS under the current Health, Population and Nutrition Sector Development Programme (2011-16) was approved by the Government of Bangladesh which meant mainstreamed nutrition interventions should be implemented through the existing health system from July 2011 onwards.
But how well is this program working? A new report Bangladesh National Nutrition Services: Assessment of Implementation Status, published by the World Bank presents the findings of a research study done by IFPRI and icddr,b, partly supported by Transform Nutrition, to assess the implementation of the Government of Bangladesh’s National Nutrition Services Program (NNS). Importantly it also identifies the achievements, identifies key bottlenecks that adversely impact these achievements, and highlights potential solutions to ensure smooth delivery of the program in the future.
The overall objective of this study was to assess the effectiveness of the delivery of the different components of NNS. The report was written by a team from IFPRI and ICDDR,B, including Drs. Shams El Arifeen and Purnima Menon, who lead Transform Nutrition’s work on making health systems more nutrition-sensitive. The study focused on assessing issues related to management and support services; training and capacity development; service delivery; monitoring and evaluation, and; exposure to interventions. A mix of quantitative and qualitative methods were used to assess the quality of service provision related to integration of nutrition with antenatal care services and sick child care in health facilities: The research also focused on elements of the enabling environment to support the roll-out of the NNS interventions, examining institutional arrangements and the policy environment at the national level.
The study indicated that NNS lacked specificity in choice of interventions and preventive service platforms resulting in attempts to deliver too many interventions with limited coverage and quality. Frequent changes in leadership, coordination, capacity and workload-related challenges faced by the NNS have hampered the implementation of nutrition interventions. The study also reported slow roll-out and poor coverage of training, especially among the frontline health workers. Although the quality of nutrition service during antenatal care, one of prioritized health service delivery contacts, was somewhat better; height and weight measurements, provision of appropriate nutrition counselling and screening for severe acute malnutrition during sick child management contacts were sub-optimal. Critical challenges relating to service delivery at community and outreach level (preventive platforms), lack of systematic supportive supervision, poor recording and reporting of service statistics, and weak monitoring mechanisms have jeopardized the NNS’s ability to achieve adequate delivery of quality nutrition services.
Our study found that the overall NNS effort is an ambitious, but valuable, approach to support nutrition actions through an existing health system with diverse platforms. The results indicate that although the maintenance of strong and stable leadership of NNS is an essential element to ensure integrated and well-coordinated service delivery, the current arrangement is unable to ensure effective implementation and coordination of NNS. So how can this be improved?
- Focusing on some of the critical challenges related to leadership and coordination and then embedding a smaller set of priority interventions into well-matched health system delivery platforms is most likely to help achieve scale and impact.
- Strategic investments in ensuring transparency, engaging available technical partners for monitoring and implementation support, and not shying away from other potential high coverage outreach platforms, such as some NGO platforms, also could prove fruitful.
- The Government of Bangladesh, and the health system in particular, must lead the effort to deliver nutrition and the NNS is an important start towards this goal. Nonetheless, it is clear that development partners who have expressed a commitment to nutrition must coordinate their own activities both among themselves and with the government and provide the support that can deliver nutrition’s potential for Bangladesh.
Bangladesh is ranked 142 of 187 countries on the 2014 Human Development Index and 57 among 120 developing and transitioning countries on the 2014 Global Hunger Index. There is still some way to go to to ensure the population of Bangladesh is well nourished and able to make the most of economic progress. icddr,b, IFPRI and Transform Nutrition are working to generate evidence on effectiveness of different nutrition-specific and nutrition-sensitive interventions in Bangladesh to support strategic policy and intervention choices that can improve nutrition in Bangladesh.
A new report Bangladesh National Nutrition Services : Assessment of Implementation Status presents the findings of an operations research study conducted to assess the implementation of the Government of Bangladesh’s National Nutrition Services Program (NNS). It identifies the achievements and determine the bottlenecks that adversely impact these achievements, and highlight potential solutions to ensure smooth delivery of the program.
South Asia has long had persistent and unusually high rates of child undernutrition—the so-called Asian enigma. Yet Bangladesh has managed to sustain a rapid reduction in the rate of child undernutrition for at least two decades. How? [Read more...]
ICDDR,B research fellow Dr Mohd Anisul Karim spoke at this year’s TEDxDhaka. He spoke for 15 minutes on ‘The butterfly effect of small changes: lessons from Bangladesh and beyond’ in which Transform Nutrition research and the importance of education in making good choices around healthcare and nutrition were highlighted. He said of the experience “it was an absolute pleasure, with truly riveting and inspiring speakers from not just Bangladesh, but around the globe.” Youtube video of the talk available here.
South Asia has long been synonymous with persistent and unusually high rates of child undernutrition—the so-called Asian enigma. Yet contrary to this stereotype, Bangladesh has managed to sustain a rapid reduction in the rate of child undernutrition for at least two decades. In a new discussion paper funded by LANSA and Transform Nutrition The Other Asian Enigma: Explaining the rapid reduction of malnutrition in Bangladesh we aim to understand this success.