Developing the second National Plan of Action for Nutrition in Bangladesh

Dr Md. M. Islam Bulbul is the Deputy Programme Manager with National Nutrition Services and a technical specialist in the Public Health and World Health Wing of the Ministry of Health and Family Welfare in Bangladesh.

Dr Iftekhar Rashid is the leader of the Health Systems Strengthening Team in the Office of Population, Health, Nutrition and Education, U.S. Agency for International Development (USAID) based in Bangladesh. 

The views expressed in this article are solely the views of the author and do not reflect the views of the United States Agency for International Development or the United States Government.

Click here to listen to an interview with the authors on the ENN podcast channel

Introduction

Bangladesh, the most densely populated country in the world with an estimated 162 million people living in a land area of 148,000 square kilometers, has shown remarkable improvement in human development in the past decades, with a significant reduction in poverty. Despite progress, child and maternal malnutrition remains as a major challenge for the country to reach the 2030 Sustainable Development Goals and graduate from its categorisation among the least-developed countries.

The 2014 Bangladesh Demographic and Health Survey shows that overall indicators of economic growth and greater household wealth are strongly related to nutrition. For example, children whose mothers are in the lowest wealth quintile are almost two and a half times more likely to be stunted (50 per cent) than children whose mothers are in the highest wealth quintile (21 per cent). More than one in three (36 per cent) children under five (CU5) are stunted and 14 per cent are wasted. However, even in the highest household wealth quintile, stunting is quite high at 21 per cent; wasting is also high at 12.8 per cent, which clearly highlights that undernutrition is a cross-cutting problem for all Bangladeshis, although it is more pronounced in lower wealth quintiles (NIPORT, 2016). This situation reflects the underlying causes of undernutrition in the country, which include lack of maternal education; child marriage and early first birth; sanitation and handwashing practices; access to food and healthcare; infant and young child feeding practices; and the status of girls and women in the family and in society.

Losses in economic productivity due to undernutrition are reported to amount to an estimated US$1 billion of revenue per year (Howlader et al, 2012). Realising the importance of improving nutrition in the overall development agenda, the Government of Bangladesh (GoB) has been focusing on nutrition policies, strategies and programming and on developing a second National Plan of Action for Nutrition (NPAN2).

Bangladesh was an ‘early-riser’ country, joining the Scaling up Nutrition (SUN) Movement in 2011 and establishing a SUN multi-stakeholder platform (MSP) at the national level in 2012. Led by the GoB, members from the different SUN MSP networks (such as UN, donor and civil society) have actively participated in the NPAN2 formulation process as members of different committees and by providing financial, consultancy and temporary secretariat support for smaller sector committees and mobilising their respective GoB counterparts.

Building a multi-sector narrative

In 2014 the key development partners in nutrition published a common narrative¹. While there was a renewed promise to work together, stakeholders identified the need for a multi-sector nutrition policy. The recent National Nutrition Policy 2015 (NNP-2015) clearly articulates multi-sector programming and inter-sector coordination as objectives and places an emphasis on both nutrition-specific and nutrition-sensitive interventions.

National commitment to combat malnutrition is in line with the country’s Vision 2021 and the seventh Five-Year Plan (2016-2020). Other factors such as the revitalisation of the Bangladesh National Nutrition Council (BNNC), with the Prime Minister as chair, have also catalysed the development of an action plan to operationalise the NNP-2015.

A national technical committee was created in January 2016 to guide the overall development of NPAN2 (2016-2025). This was further sub-divided into four different sector committees: Health, Urban Health and WASH; Food, Agriculture, Fisheries and Livestock; Women Empowerment, Education, Social Safety Net, Information; and Institutionalisation of NPAN2: Finance, Planning, Budget. The committees all had high-level representation from relevant government ministries, along with members from UN agencies, NGOs, donors and academia. Each committee developed an action plan for its respective sectors following a common format and highlighted cross-cutting areas, which were harmonised later in the process. Experts from Bangladesh and international consultants were engaged to ensure that each section of the action plan is not only technically sound but also feasible in terms of overall capacity, utilising global learning from different sectors. A costing exercise was involved, which is included in the NPAN2 to help in advocacy for resource mobilisation and financial planning.

A core group was formed during the final step of the exercise to merge the different parts and produce the final document, in which cross-cutting areas were harmonised. The draft NPAN2 went through several rounds of revisions as stakeholder comments were incorporated. The plan addresses the current and emerging nutrition problems of all citizens, especially CU5 (with particular focus on the first 1,000 days), women of child-bearing age (including pregnant and lactating mothers) and adolescent girls. Target indicators for 2025 include reducing CU5 stunting to 25 per cent and wasting to eight per cent, and increasing the rate of exclusive breastfeeding to 70 per cent in infants under six months of age. 

Making key nutrition actions operational

The NPAN2 specifies priority key action areas and major activities under three thematic areas:

1. Comprehensive and integrated social behaviour change communication agenda;
2. Research to generate evidence to inform policy and programming; and
3. Capacity-building, which targets all relevant sectors at different administrative levels.

The plan identifies the ministries and collaborating partners responsible for tracking progress and achievements of indicators, timeframes and costs involved in implementing the agreed priority interventions. It builds on existing platforms and delivery mechanisms that have proven to be effective, such as the agriculture extension network and frontline community workers. The plan includes a common results matrix for different sectors to work together and seeks coordinated financing of key sectors as well as tracking of investments.

A total of 17 ministries will be involved along with other stakeholders and partners. The costing exercise has estimated that a total of approximately US$1.6 billion is required for the NPAN2 (2016-2025) to carry out the priority activities, institutional development and capacity-building, as well as monitoring and evaluation (M&E) over the next ten years. This M&E will not only track progress made in the implementation of NPAN2 and investments in nutrition, but will also serve as the basis for the annual reports to be submitted to the Prime Minister through the BNNC office, which will be responsible for monitoring NPAN2’s progress. The plan provides a breakdown of nutrition-specific and nutrition-sensitive interventions, with the highest budget allocation (and priority) on women’s empowerment, education and social safety net (US$820,577,795); followed by health and urban health (US$675,721,493). Strategic budgeting and funding will take place within each sector or ministry in alignment with NPAN2. Sub-national dissemination of the plan is underway through division/district-level events (although GoB is a centralised government system, so each ministry takes the lead for programme design, in consultation with sub-national-level personnel).

Lessons learned and next steps

Developing NPAN2 has been a great journey that brought highly motivated people on board to improve nutrition. However, bringing key actors under one plan is quite challenging due to the large number of different types of nutrition programming in various sectors, many of which are applying a nutrition lens to programme design. For example, nutrition messaging is now part of the work of agriculture extension workers; safety-net programmes now target pregnant and lactating women; and education has updated the school curriculum with basic nutrition information at the primary level, with plans to update it further.

Leadership and political commitment were key to success: the Ministry of Health and Family Welfare has played a strong leadership role in convening different sectors/stakeholders and development partners have worked with their respective GoB counterparts to ensure their involvement. Dividing into four sector committees and giving leadership of each committee to its respective GoB sector and development partners was another effective strategy.

Next steps are to ensure that the BNNC is fully functional and working with all relevant sectors to make certain that implementation is on track and ensure wider dissemination of the action plan, advocacy and resource mobilisation.

¹Undernutrition in Bangladesh – A Common Narrative (http://docs.scalingupnutrition.org/wp-content/uploads/2014/06/Common-Narrative_BANGLADESH-Final.pdf)