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MULTI-SECTORAL APPROACHES TO NUTRITION
WHEN children are malnourished during the first 1,000 days of life—from pregnancy through age two—it can cause life-long and irreversible damage like stunting or low height for age (short stature). Stunting is associated with:
• Short-term health consequences, including weaker immune systems and a higher risk of severe infectious diseases, like diarrhea and pneumonia.
• Long-term health consequences, including increased likelihood of chronic diseases like high blood pressure, diabetes, heart disease, and obesity.
• Social consequences, including fewer years of school completed and lower productivity in adulthood.
• Economic consequences, including a potential ten percent reduction in lifetime earnings, and up to three percent of a nation's GDP.
In Bangladesh, about half of children and one-fourth of women of reproductive age are undernourished. Given the scale of the problem, the question remains: what can be done, and who needs to be a part of the solution?
First, nutrition programmes need to be scaled up to reach more people, more quickly. Nutrition-specific interventions address the immediate causes of under nutrition, like inadequate dietary intake, and underlying causes like poor infant and young child feeding (IYCF) practices.
Recommended IYCF practices from 0-2 years of age include: early initiation of breastfeeding within one hour of birth; exclusive breastfeeding for the first six months of life; followed by appropriate complementary feeding through 24 months, along with continued breastfeeding. Washing hands with soap and water before preparing food and feeding a child is also a key requisite for complementary feeding.
But success lies in a multi-sectoral approach. Nutrition-sensitive interventions incorporate nutrition goals and actions across a wide range of sectors, like agriculture and education. When all sectors join the fight, we will reach more families more quickly and break the cycle of poverty.
Dr. Rukhsana Haider Chair, Civil Society Alliance for Scaling Up Nutrition, Bangladesh, Chairperson, Training & Assistance for Health and Nutrition (TAHN) Foundation Nutrition is a cross-cutting issue that requires everyone's attention and support to ensure that all children grow up healthy and lead active and productive lives. The determinants of malnutrition are multi-sectoral, so its solutions are also multi-sectoral. No single ministry can manage it alone.
Nutrition impacts Bangladesh's future development
Research has shown that investing in infant and young child nutrition can help break the cycle of poverty and increase a country's GDP by two to three percent annually. Every $1 invested results in $30 gained in health, education and economic productivity.
We are in an emergency --undernutrition is a crisis situation in Bangladesh. Nearly 6 million children are severely malnourished and approximately 53,000 children die each year from preventable complications. Undernutrition costs us approximately 7,000 crore taka in lost productivity per year.
Between 2004 and 2011, although child mortality rates have decreased significantly, the malnutrition rates did not. According to the Bangladesh Demographic Health Survey 2011 (BDHS), child undernutrition was 51% in 2004,43% in 2007 and 41% in 2011. At present,
• 41% of children under the age of five are stunted
• 36% are underweight
• 16% are wasted.
Multi-sectoral approaches to nutrition The global Scaling Up Nutrition (SUN) movement and the Civil Society Alliance for SUN in Bangladesh advocate for ensuring children's proper growth and health during thefirst 1,000 days - from pregnancy until two years of age.
The SUN approach includes a multi- stakeholder platform and multiple ministries need to be involved, including food, agriculture, livestock and fisheries, education (both formal and informal), health and family planning, social development, protection and social welfare, women and children's affairs, water and sanitation, environment and climate change, rural development, trade, planning and finance. Women's empowerment is a crosscutting issue.
Nutrition-sensitive agriculture can influence food production, consumption of diverse nutritious foods necessary for healthy and active lives, and the health and productivity of agricultural workers.
Investing in nutrition and early childhood development can prevent intergenerational transmission of undernutrition. Reports show that risk of child stunting is reduced when mothers have some schooling, and is further reduced when they complete secondaryschool.
Social protection programmes can be targeted to mothers who can influence distribution of income, and to the first 1,000 days when they can impact nutrition during the critical window of opportunity. Priority actions should include nutrition education and interventions (IYCF, growth monitoring and promotion and diverse diets). Nutrition conditions should be set for social welfare benefits.
Nutrition-specific objectives need to be facilitated through the health system, including promotion of good feeding and care, micronutrient supplementation, treatment and prevention of illness, reduction of low birth weight, improving reproductive health and family planning, and treatment of severe malnutrition.
Globally there are many multisectoral success stories: Brazil, Peru, Ethiopia all have public commitment from national leaders; Brazil has halved child under nutrition in the last 10 years; Zambia has strengthened their National Food and Nutrition Commission; in Peru, civil society and the Children's Nutrition Initiative have included nutrition goals in their poverty reduction strategy.
In Bangladesh, commitment at the highest levels of government must be urgently followed by implementation of nutrition-sensitive as well as nutrition specific programmes to ensure we achieve our goals.
Hasibur Rahman, Executive Director, MRDI
MRDI is very concerned about the nutrition status of Bangladesh and how malnutrition has impacted our social and economic development. We are working to train journalists on how to report on development issues, including proper IYCF practices and hand washing before feeding a child.
Salehuddin Ahmed, Managing Editor, The Daily Star
Bangladesh has done miracles in microfinance, garment, food production, women's empowerment, oral rehydration and with NGOs. We can also do the same in nutrition. We have to just put our heads together, work out the plan and implement it with constant monitoring.
Kawser Rahman, Deputy Chief Reporter, Daily fanakantha Malnutrition is a generational problem, and it is a serious hindrance towards building a skilled nation. We need huge investments in nutrition. We should not depend on donors. We have done many miracles on our own, so we should start with our resources. But we also have to identify our priorities.
Dr. Raisul Haque, Programme Coordinator, Health, Nutrition & Population, BRAC
In our country, 26 percent of children in the richest quintile suffer from malnutrition, with 53 percent among the lowest quintile. Exclusive breastfeeding is going well, but problems start with complementary foods. Hygiene, pure drinking water and sanitation are also closely linked with nutrition. Food security does not mean only rice. We need energy-rich food. Animal protein is not affordable to all. And, we also need to have safety net provision for poor. Dr. Ferdousi Begum, Country Manager, FANTA, FHI360 We have to establish the right to information. If the family does not know about nutrition they will not spend on nutritious food.
Dr. Lalita Bhattacharjee, Nutritionist, FAO
Bangladesh has an excellent history of multi-sectoral approaches. In 2006 we
developed a national food policy which was multi-sectoral. Bangladesh had a plan of action in 2008. In 2012-13, Bangladesh produced a report including progress across thirteen sectors.
Health and non-health sectors should work together to improve our nutrition status. Building capacity at ministries and at national and international levels is very important. We need to focus on creating nutrition focal points in each of these levels.
Shannon Young, Population, Health & Nutrition Officer, USAID
When we write anything about nutrition we put it from the viewpoint of health professionals. We also need to see how other sectors can incorporate and benefit from nutrition activities. I will urge media to frame nutrition from a general reader's point of view and to make it
interesting.
Dr. S.M. Mustafizur Rahman, Program Manager, National Nutrition Services (NNS), Directorate General of Health Services, Ministry of Health and Family Welfare
I want to emphasize the point that food security does not ensure nutritional security. In many households there is available food but they also suffer from nutrition problem. They do not know what nutritious foods are.
Monira Parveen, Nutrition Programme Officer, World Food Programme
In a multi-sectoral approach, we often talk about government ministries only; but a "multi-sector" and "multi-actor" coordination mechanism is necessary to facilitate information sharing dialogue, joint planning sharing of roles and establishing functional collaboration.
Shishir Moral,
Special Correspondent, Daily Prothom Alo
Media does not give proper attention to nutrition. Our reporters are more interested in health-sector related scandals. Ads, radio programmes and mobile activities do not get proper attention. Rather, dairy/tin milk companies spend more funds to promote their products, which have various negative impacts. Salahuddin Bablu, Business Editor, SA TV
Our nutrition problem is also a problem of our development. We replaced our high-nutrient local rice varieties with high yielding varieties, which yields more but contains less nutrition.
Farid Hossain, Former Bureau Chief, Associated Press (AP)
We can set up a food and nutrition commission like Zambia. And our Health and Family Welfare Ministry should be named Health, Nutrition and Family Welfare Ministry.
Professor Dr. Fatima Parveen Chowdhury, Director, CME, DGHS We lack coordination - that is why though we are self-sufficient in food we lag behind in nutrition. We need a national coordination council. In 1974, Bangladesh government set up the National Nutrition Council. It has been cornered for some unknown reason. People do not come to hospital to get information about nutrition. Our nutrition communication strategy should consider this aspect.
Professor Dr. Md. Ruhul Amin, President, Bangladesh Paediatric Association (BPA)
There is no nutrition ward in our hospitals, not even in children's hospitals. Very few parents come to the hospital with their undernourished children.
We should give top priority to breastfeeding programme because it is the only investment that can do miracles like the vaccination programme. We should teach our students about nutrition from the very beginning of their school life.
Dr. Selina Amin, Director Projects, Plan International
Without involving local government, we would not be able to reach rural areas with our nutrition programmes. Under multi-sectoral programmes we should also focus on livestock and home gardening which are important sources of nutrition. Livestock should be vaccinated, healthy seeds should be provided and so on.
Male participation in nutrition programmes should be well-emphasized.
Professor Dr. Soofia Khatoon, Head of Paediatrics, Shahid Suhrawardy Medical College & Hospital and Secretary General of Bangladesh Breastfeeding Foundation-BBF We have changed the curriculum of medical colleges so that our doctors can learn more about nutrition. If we train our health workers properly they can easily detect malnutrition problems and make parents aware.
Another important issue is hygiene. Without ensuring hygiene, no nutrition programme can succeed.
We have to strengthen the BMS Code so that baby food companies cannot exploit our parents. Some of our doctors are also involved here. They discourage breastfeeding and prescribe tin milk. Professor Dr. Ferdousi Begum, Department of Obstetrics & Gynecology, Sir Salimullah Medical College and Ex Secretary General, OGSB
In Bangladesh, many babies are bom with low birth weight. By six months their height goes below - 2 standard deviation, which is unrecoverable. This all happens due to mothers' malnutrition. Our doctors should spare time for
counseling mothers about nutrition in pregnancy.
Alok Majumder, Country Coordinator, Dutch WASH Alliance, Bangladesh
We need sector development programmes. In water sector we have a 25-year sector development plan. Our approach should be sector-wise, not piecemeal. We need political commitment for implementing a multi-sectoral approach.
Nurul Islam Hasib, Senior Correspondent, BDNews 24.com HPNSDP has already passed two years. 1 want to know whether the listed 13 ministries have ever sat together. In our country, both the health professionals and media are not aware of nutrition issues. Some TV shows Horlicks or Cerelac when they report any news on baby food.
Professor Dr. Asirul Hoque, Dean, Faculty of Public Health & Head, Department of Community Nutrition, Bangladesh University of Health Sciences.
We have failed to solve moderate and severe malnutrition problems, as we do not have any appropriate mainstreaming program. If a mother knows about the nutritional status of her baby by using colour zones of the Growth Monitoring and Promotion (GMP) charts then she can opt for the solution.
Dr. Arefin Amal Islam, Deputy Director, Saving Newborn Lives, Save the Children
In our 1000 days programme we should focus on girl children, because without a healthy mother you cannot get a healthy child. Although many people know about nutrition and healthy habits, they do not practice those in their daily lives. So, we need to make sure that knowledge is translated into practice.
Dr. Sushil R. Howlader, Professor, Dhaka University
The Government is apathetic to nutrition because it cannot be accessed immediately like dilapidated roads, price hike or severe diarrhea. The second issue is budget constraints. To achieve our goal we need 9% of the budget of which 1% will be for nutrition.
From today's discussion we should work out an action plan for how each stakeholder should contribute to the improvement of our nutrition status.
Dr. Ireen A Chowdhury, Nutrition Specialist, UNICEF
We need media support for successful implementation of Vitamin A campaign which could further reduce deaths in children.
Another important issue is iodized salt, which is directly linked with the development of a child's brain. In our country the reach of iodized salt is 58%. We have to put proper emphasis on the availability of micro-nutrients.
Sakiul Millat Morshed, Executive Director, Shishuk
There are many good practices in different corners of our country. For example, in Daudkandi, every year a huge amount of fish is produced by the local community which significantly covers their nutritional needs. These types of community initiatives should be highlighted.
Dr. Kaosar Afsana, Director, Health, Nutrition & Population, BRAC We must all work together by following the power of the words "Think multi-sectorally but act sectorally." We should give more time for counseling mothers and care-givers and educating people. Regular coverage of the emergency nutrition situation in Bangladesh should be published by the national newspapers. To accelerate nutrition status, we want champions and most importantly, leadership of our Honorable Prime Minister's Office.
Belal Uddin, Technical specialist, Advocacy, Alive & Thrive
To achieve our nutrition goals we have to own the programmes and have a clear understanding about how different sectors are linked to nutrition. Because we know nutrition is not only a health issue but the issue of Agriculture, Information, Education, Social Protection, etc. These different sectors can work together in a very effective way. We need to explore what we can do, together.