Section A:
Strategic Case
Context Analysis
Bangladesh is one of the fastest urbanizing
countries in the world, its urban population growing at an estimated six
percent each year since Independence, at a time when national population growth
was at 2.2 percent (World Bank: 2007i).
This phenomenal growth is partly driven by the reclassification of rural
areas into urban areas and natural urban population growth but largely by rural
to urban migration.
A recent study by
PPRC found that just 21 percent of metropolitan residents were born in the city
they resided in, this figure dropping to 16 percent for Dhaka residents. While the study found that pull factors such
as employment and education opportunities were the main reasons for migrants to
shift to urban areas, displacement by natural disaster was a factor for more
than one in ten migrants (PPRC: 2010).While the number of urban areas increased
five-fold in less than twenty years, 60 percent of the total urban population
of 35 million people resides in the four largest cities: Dhaka, Chittagong,
Khulna and Rajshahi. The megacity of
Dhaka is the epicenter of Bangladesh’s urban expansion, the World Bank labeling
it the fastest growing city in the world with an estimated 300,000 to 400,000,
mainly poor, rural migrants arriving each year (World Bank: 2007ii). The rate of poverty in urban areas, while
decreasing over time, still remains high.
Of an urban population of 34 million people in 2005, an estimated 15
million people, or 43 percent, are absolute poor, consuming less than 2,122
Kcal per day. Of this group, more than
half, or 8 million people, are extreme poor and consume less than 1,805 Kcal
per day (BBS: 2005).
Efforts to manage or respond this incredible
urban population growth to date have been extremely inadequate. No policy exists to guide or regulate the
urban sector and political will for such a policy is almost non-existent – the
current draft of the Urban Sector Policy has been in the drafting phase for
almost ten years. In fact, many
policymakers strongly oppose efforts to develop urban areas, particularly in a
pro-poor manner, their arguments drawn from misperceptions that developing
urban areas only encourages further rural-urban migration and that migration
flows can be stemmed by further developing rural Bangladesh. While the Pourashava Ordinance 1977 and the
Town Improvement Act 1953 both provide that Master Plans be drawn up for urban
areas for which the laws apply, many towns do not have such master plans and
those which do are rarely implemented (Payne & Shafi: 2007). With demand in urban areas increasing
substantially, housing and land prices have increased far beyond the
affordability of the general population, with land prices in certain parts of
Dhaka surpassing those in Los Angeles and New York (World Bank: 2007i). In Dhaka this has created a situation where
57 percent of the population does not own land while 4 percent own as much as
28 percent of the land (Payne & Shafi: 2007). Strikingly, 70 percent of Dhaka’s population
is forced to live on just 20 percent of its land (Mahmud et al: 2001). In the absence of affordable housing, the
constant flow of rural poor migrants have no other option than to move into
established or construct new informal housing, resulting in the flourishing of
slums.
While physical conditions can vary
significantly from slum to slum, they typically lack access to basic public
services such as water, sanitation, electricity, drains, etc., have very
cramped living conditions and are built on precarious public and private land
without permission from the landowners, leaving them constantly at threat of
eviction. Socio-economic conditions also
vary significantly, however, slum populations can be typically characterised as
having very low incomes generated from employment in often hazardous
environments; low levels of education and literacy; high incidences of dowry,
early marriage and early pregnancy; and poor health and nutrition indicators.
Evidence that demonstrates the
need for interventions
Under-nutrition
imposes a staggering cost worldwide, both in human and economic terms. It is
responsible for the deaths of more than 3.5 million children each year (more
than one-third of all deaths among children under five) and the loss of
billions of dollars in forgone productivity and avoidable health care spending.
Individuals lose more than 10 percent of lifetime earnings, and many countries
lose at least two to three percent of their gross domestic product to under-nutrition
(World Bank: 2010).
Poor nutritional status is
one of the most important health and welfare problems facing Bangladesh. The
Bangladesh population is known to have one of the highest rates of under-nutrition
in the world, with both nutritional deficits and micronutrient deficiency being
very common. Young children and women of reproductive age are especially
vulnerable to nutritional deficits and micronutrient deficiencies. While Bangladesh has made
considerable progress in child survival rates over the last several decades,
major inequalities still need to be addressed. The Bangladesh Demographic and Health Survey
2007 (BDHS) shows the under-five mortality rate is 86 per 1,000 live births for the
poorest quintile while the richest quintile records a rate of 43 per 1,000 live
births, with malnutrition a contributing factor. At the individual level,
inadequate or inappropriate feeding patterns lead to malnutrition. Numerous
socioeconomic and cultural factors influence patterns of feeding and
nutritional status. Recent data from national surveys
suggest reductions in under-nutrition in women of reproductive age, but rates
are still too high. Data on the nutritional status of adult males is scarce (NIPORT:
2008, 2009).
While levels of
malnutrition in Bangladesh are quite high, the limited figures available
indicate that rates of malnutrition in urban slums are even higher. Comparison of the figures presented in the
BDHS and the 2006 Bangladesh Urban Health Survey (BUHS) illustrates the
severity of malnutrition among the urban poor:
·
56 percent of children under five years of age
living in slums are stunted and 28 percent are severely stunted, compared with
43 percent and 16 percent among children of the same age in the general
population.
·
17 percent of children in slum areas are wasted,
compared with 10 percent in non-slum urban areas.
·
46 percent of children in slums are underweight,
against 28 percent in non-slum urban areas.
·
Adults in slums are twice as likely to be
undernourished (27 percent of women/35 percent of men) than those in non-slum
urban areas (13 percent of women/19 percent of men).
·
Anemia affects around 46% of pregnant women,
39%of non-pregnant women, and almost one-third of adolescent girls in
Bangladesh (UNICEF: 2009)
Poor nutritional practices
contribute significantly to high rates of malnutrition, especially among
children, and conditions for the urban poor are worse than in the general
population.
· Overall
24 children in slums are breastfed within one hour of birth and 75 percent are
breastfed within one day after delivery, compared with 43 and 89 percent in the
general population.
· Only one
third of children below six months living in slums are exclusively breastfed
for six months, compared to 43 percent of children in the general population.
· One
quarter of women in slums receive Vitamin A supplements within two months after
giving birth, compared to 40 percent of women in non-slum urban areas.
Existing nutrition interventions
in UPPR areas
Direct interventions
Through the National
Immunisation Day and National Vitamin ‘A’ Plus Campaign, UNICEF
provides Vitamin A supplements, as well as deworming tablets, twice each year
to approximately 95 percent of the 6-59 month population; provides iron/folic
acid supplements to tackle anemia among pre-school children and adolescent,
pregnant and lactating women living in selected low income areas; and conducts
nutrition behaviour change campaigns.
Coverage of urban areas is patchy.
Helen Keller
International(HKI) works in Dhaka, Rajshahi,
Chittagong and Barisal divisions and provides Vitamin A supplements to
approximately 15,000 5-59 month old children, implements a Homestead Food
Program that benefits over 4.5 million people and conducts health and nutrition
surveillance. HKI’s work is focused on
rural areas and therefore does not cover UPPR populations.
Medecins Sans Frontieres (MSF) operates a
health and therapeutic feeding centre in Kamrangirchar slum in Dhaka. The centre aims to improve access to free
care and treatment for children, focusing on severe acute malnutrition.
Pregnant and breastfeeding women also receive treatment for malnutrition, and
antenatal and postnatal care are provided.
The centre does not cover any UPPR community members.
Urban Primary Health Care Program 2 (UPHCP-II) operates in six city corporations and five municipalities in Bangladesh
and provides a range of primary health services. In terms of nutrition,
UPHCP-II has a limited nutrition component that provides maternal nutrition,
control of micronutrient deficiency, child nutrition, vitamin A and iodine
deficiency services. Coverage of urban
slums is also limited. UPPR is
partnering with UPHCP-II in Barisal, Savar, Comilla and Bogra to give urban
slum populations access to health and nutrition services.
Smiling Sun Franchise Programme (SSFP) operates
323 satellite clinics in the 64 districts of Bangladesh and provides health and
limited nutrition services. Coverage of
urban slums is low and the nutrition component is weak, limited to zinc and
vitamin A supplements. UPPR has
partnered with SSFP in Gazipur, Tangail, Rangpur, Naogaon, Tongi and
Chapainawabganj to ensure slum populations can access the health and nutrition
services provided.
Indirect Interventions
Environmental Improvement
UPPR’s environmental improvement component comprises
a range of indirect nutrition activities such as settlement improvement and
hygiene promotion. Regarding settlement
improvement, the construction of latrines, footpaths and drains have a direct
impact on the sanitary conditions in urban slum communities which indirectly
improve health and nutrition statuses.
Tubewells constructed by UPPR provide communities with access to
improved water sources and leads to reduced incidence of illness and improved
nutrition. In addition to water and
sanitation infrastructure construction, UPPR is also monitoring the quality of
water produced by its tubewells, promoting household water treatment and safe
water and food storage options, promoting WASH and nutrition behaviour in
schools, promoting construction and use of improved cooking stoves and vector
control in its communities.
UPPR’s socio-economic development component
consists of human capital development activities, social protection and social
empowerment activities. The programme’s
human capital development activities comprise urban food production and health
and day care centre services. Urban food
production activities give community members the means and knowledge to improve
their own nutrition and supplement incomes.
Improving community access to health services directly improves health
conditions and allows for early identification and treatment of undernutrition. Day care centres reduce the burden of child
care on mothers and give them an opportunity to earn an income which in turn
can lead to improved household nutrition and empowerment.
UPPR’s social protection activities are
largely made up of apprenticeships, education grants and enterprise development
block grants. These conditional cash
transfers improve community members’ ability to generate income, which in turn
increases their ability to purchase nutritious foods and access nutrition
services. Education grant beneficiary households
are discouraged from marrying their daughters before 18 years.
UPPR has also initiated a targeted employment
programme that encourages municipalities and the private sector to employ
extreme poor slum dwellers in labour intensive projects, particularly
large-scale infrastructure construction.
UPPR is increasing its focus on the disabled members of its slum
communities who often present with the worst malnutrition.
The programme’s social empowerment activities
focus on supporting the homeless, social and legal empowerment, adolescent and
youth development and preventing violence against women. UPPR has partnered with Concern Worldwide to
setup homeless shelters that provide a range of services, including primary
healthcare, day care centre and cooking facilities which can have a positive
impact on nutrition. UPPR’s social and legal empowerment activities are
building awareness among women and girls on discrimination against girls, early
marriage and early pregnancy, dowry, domestic violence and social violence and
illegal divorce which can lead to increased decision-making in the
household. Coupled with increased
knowledge of nutrition practices this can have an indirect impact on household
nutrition.
Why the proposed intervention is
justified?
Current large-scale nutrition programmes in
Bangladesh do not sufficiently cover the at-risk population and focus largely
on the rural population. There is no
urban-focused nutrition programme in the country, resulting in millions of
urban poor and extreme poor people continuing to suffer from malnutrition due
to poor nutrition behaviour and lack of access to vitamins and
supplements. From a life-cycle
perspective, failing to improve the nutrition of infants and children gravely
impacts their ability to learn and generate income in the future, thus
reinforcing the generational cycle of poverty.
Is the proposed intervention
feasible?
Nutrition interventions of this scale have
been implemented in many low income countries for several years, generating a
pool of knowledge on best practices. In
the case of Bangladesh, several nutrition interventions have been implemented
and covered large segments of the population, evidence that the proposed
intervention is feasible.
UPPR has the capacity and experience to
successfully carry out the activities grouped under the four outputs of the
proposed intervention:
Output 1: Effective internal management systems
established and operationalised. UPPR’s
management system has been operational since 2008. The nutrition programme’s management system
will be integrated into the three current management layers of SEF management:
HQ, town teams and communities. Lessons
learned from UPPR’s long established management structure will add value to the
nutrition programme delivery.
Output 2: Organisational capacity strengthened to deliver direct
nutritional interventions. UPPR has been building the
capacity of CDCs since its inception and thus has the experience to build CDC
capacity for raising awareness on nutrition among target groups.
Output 3: Target groups received direct nutritional interventions. With
the proposed human resources in place (Health and Nutrition Promoters and
Health and Nutrition Volunteers) , UPPR Can guarantee that the proposed
treatment regiment reaches beneficiaries.
Output 4: Evidence-based research conducted to promote nutrition at the
national level. One significant component of UPPR
is to ensure an enabled pro-poor policy environment, thus the programme already
has the human resources and capacity in place to ensure successful completion of
the output.
What is the consequence of not
taking action?
From a life-cycle perspective, failing to
improve the nutrition of infants and children gravely impacts their ability to
learn and generate income in the future, thus reinforcing the generational
cycle of poverty. Deficiencies of
essential micronutrients such as Vitamin A and Iodine impair both the growth as
well as the physical and mental development of children, reduce both their
resistance to infections and their survival rates, and curtail their future
intellectual and reproductive performance as well as economic
productivity. Foetal and early childhood
malnutrition has life-long consequences on the growth and development of the
population. Its effects also include
poor growth and muscle mass in childhood and the risk of serious degenerative
disorders in the later part of adulthood; poor cognitive and educational
performance, poor immunity and work capacity and the risk of chronic diseases
like respiratory infections, diarrhea, diabetes, hypertension, cardiovascular
diseases, stroke, cancer, etc., later in life (CARE: 2008).
Experts believe that investing in nutrition
is a great economic investment and provides significant inputs for the human
and economic development of the country.
Since the economic growth of the country must be linked to healthy
infant growth, malnutrition also poses a threat to the long-term economic
development of Bangladesh. A study
conducted by IFPRI in 2008 in Guatemala found that adults who had received
nutrition supplements as children earned incomes 46 percent higher than adults
that did not receive nutrition supplements as children. There is, thus, strong evidence that
improving nutrition in early childhood is a long-term economic investment
(Hoddinott, J. et al: 2008).
What are the
risks associated to the interventions?
|
SI
|
Description
|
Category
|
Impact/Probability
|
Countermeasures
|
Owner
|
|
1
|
Change
in PSC leadership leads to leadership vacuum or lack of support for project
activities
|
Organisational
|
I = 1; P
= 3
|
1) Arrange continuous dialogue
with the concerned officials of LGD to develop ownership of the project.
|
PD
|
|
2
|
Establishing
partnerships with key nutrition organizations is difficult
|
Organisational
|
I = 2; P
= 3
|
1) Town teams trained to
establish partnerships with nutrition organisations.
2) Project management holds
dialogue with national nutrition programmes to establish partnerships.
|
TMs
PM
|
|
3
|
Partnerships
formed with nutrition organisations fail to produce the intended results
|
Operational
|
I = 1; P
= 3
|
1) MoUs with partner
organisations indicate responsibilities, deliverables and monitoring
framework.
|
PM
|
|
4
|
Outputs
are completed as planned but fail to produce the outcomes expected
|
Operational
|
I = 1; P
= 3
|
1) Monitoring framework has
been produced and will indicate whether progress towards outcomes is being
achieved as planned or if changes are needed.
|
PM
|
|
5
|
Nutrition
staff may not be properly equipped with adequate expertise to implement the
project activities
|
Operational
|
I = 2; P
= 3
|
1) Staff recruited for the
project must have the skills and expertise to successfully carry out the
activities.
2) Workshops will be held to
build the capacity of town team staff and community members involved in the
project
|
PM
|
|
6
|
Activities
are successful but not sustainable
|
Financial
|
I = 2; P
= 3
|
1) Nutrition project activities
are being conducted in concert with livelihood development and social
protection activities which by improving incomes of beneficiaries allow them
to purchase the necessary supplements and foods required to improve nutrition
into the future.
2) Behaviours and practices
learned through training and awareness raising activities can be adopted and
shared into the future, ensuring a long term impact.
|
PM
|
Explain sustainability issues
To sustain the impact and benefits of the nutrition intervention, UPPR
will leave behind the following:
v
Established targeting mechanism available with CDC
(PIP data) to identify and prioritize households according to their poverty and
vulnerability status[1]
v
Sustained behavioral change among mothers and
adolescents for inter-generational transfer of acquired knowledge and behavior;
v
Community-paid health and nutrition workers and
CDC’s support in identifying malnourished children, and pregnant and lactating
women;
v
Awareness materials for CDCs, training manual for
community health workers, municipal health staff and clinics that will continue
to be use by community paid health workers;
v
Established linkages between CDCs and health
clinics through UPPR community-managed Cluster Resource Centres[2];
v
Continuing nutrition activities such as urban food
production by community members and schools;
v
Improved income of poor and extreme poor
households, coupled with acquired knowledge on nutrition, will enable them to
have dietary diversity and include nutritious food items on a sustained basis;
v
Enabling environment in slums and towns created through
awareness of stakeholders such as religious leaders, teachers, local leaders
(counselors) and social workers, who can influence attitudes and local social
norms;
In addition to the
above, this direct nutrition program together with all UK Aid-supported extreme
poverty programmes will advocate to i) integrate nutrition intervention in the
existing health system; ii) increase national budget allocation on nutrition,
and iii) strengthen policy focus on nutrition.
Section
B: Appraisal Case
Critical Success Criteria
To accelerate
progress in reducing malnutrition in Bangladesh, the most urgent policy changes
include expanding the scale, improving the targeting, and strengthening the nutrition
focus in the implementation of existing health and adolescent development
programs and policies; building analytical and monitoring capacity; and
ensuring that programs and policies are effectively pro-poor and pro-nutrition
and focus on improving women’s status and preventing gender based
intra-households discrimination.
Special
attention is needed in the towns and slums that carry the highest burden of
child malnutrition and maximum number of extreme poor households. Furthermore, the different health and social safety net
programs are often poorly integrated, with some households receiving benefits
from a number of sources and others remaining excluded.
Stronger
programs and better coordination among them would increase their efficiency and
effectiveness. Although these programmes absorb substantial public funds,
Bangladesh’s level of public investment in nutrition is far below that of other
developing countries. Thus there seem to be three problems that call for action:
scale, design, and implementation. Bangladesh needs greater accountability at
all levels—not only for programs, but also for nutritional improvement in
general.
Following are
the critical success criteria as well as assumptions for:
v Ownership of municipal authorities and ongoing health
programmes and health organizations;
v Targeting the most vulnerable slums and households -
inclusion and exclusion error;
v Participation of targeted community, especially women, civil society
groups (such as women’s group, adolescent or youth groups) and other ward and
town level stakeholders in targeting, service delivery and monitoring the
progress;
v A gender enabling condition where women are able to decide on their own
well-being and investment in child care;
v Design and effectiveness of targeted awareness;
v Transparency and accountability mechanism in designing and implementing
service delivery system;
v Inter-sector convergence or complementary
interventions to address other determinants of malnutrition, such as food distribution
(such as VGD/ VGF and mid-day meal for school children), safe drinking water,
sanitation, hygiene promotion, child and adolescent education and urban food
production;
v Robust monitoring system especially setting up town level nutrition
surveillance system;
v Policy maker’s decision to strengthen nutrition focus in its health and
poverty reduction programs, upscale urban health and nutrition intervention and
increase national budget on direct nutrition;
|
Outcomes of UPPR nutrition
intervention
|
||
|
Target group
|
Intervention
|
Outcome
|
|
Extreme Poor (EP) pregnant and breast feeding women
|
Awareness and counseling on IYCF
|
Improved knowledge among trained women and their families on IYCF
practices and reduced mortality among infants and you children
|
|
Provision of micronutrients, iron and folic acid and de-worming
tablets
|
Decreased risk of anemia among the pregnant women and congenital
malformations among children
|
|
|
EP Children aged 7-23 months
|
MNP
|
Decreased risk of blindness, under-nutrition and stunting
|
|
EP Children aged 13 to 59 months
|
De-worming tablets
|
Decreased risk for parasitic problems such as weight loss, poor growth
and anemia leading to poor educational achievement of children (UNICEF)
|
|
EP Adolescent girls 10-16 years
|
Training on nutrition, hygiene and Urban Food Production (UFP)
|
Improved knowledge of the importance of nutrition and hygiene to
prepare adolescent girls for their future roles as mothers
|
|
Iron and Folic Acid Tablet
|
Decreased risk of anemia
|
|
|
De-worming tablets
|
Decreased risk for parasitic problems
|
|
|
Poor and EP Women
|
Training in UFP and linkages to nutritious food
|
Improved knowledge on the link between nutrition and food and improved
UFP skills
|
|
Training in hygiene and environmental health
|
Improved knowledge of hygiene and the connection to nutritional status
|
|
|
Health Nutrition Volunteers (HNV) and Health Nutrition Promoter (HNP)
|
Training in nutrition related awareness, counseling and services
|
Improved nutrition related services
|
|
Stakeholders
|
Awareness raising activities e.g. workshops, day-celebrations,
dissemination workshops, etc.
|
Increased knowledge among policymakers and other stakeholders about
nutrition which may improve related policies and programmes
|
|
UPPR staff and volunteers
|
Training to disseminate nutrition and hygiene messages and distribute
supplements and antihelmentics
|
Increase capacity among staff and volunteers to disseminate nutrition
messages and distribute nutrition supplements and antihelmentics to the
community
|
UPPR Nutrition
Strategy 
|
|
|
The implementation of
community-level activities will be overseen by the Cluster-level Health &
Nutrition Committee, comprised of five to six members. Different members will be assigned specific
roles with respect to planning and monitoring, awareness, counseling and
provision of nutrition supplements and antihelmentics.
The Health & Nutrition
Promoter (HNP) will cover 100 to 120 pregnant and lactating women per Cluster
(generally representing 5-6% of the cluster population). A cluster typically comprises 1,600 to 1,800
households. The HNP is responsible for
household counseling of pregnant and lactating women and their husbands and
mothers-in-law, distributing nutrition supplements and antihelmenticsand facilitating
monthly group meetings for pregnant and lactating women.
One Office Bearer from each CDC
will be trained as a Health & Nutrition Volunteer (HNV) and will be
responsible for all raising nutrition awareness among the wider CDC population
in general and adolescent girls in particular.
[1]Participatory
Identification of Poor (PIP) is community led survey to identify extreme poor,
poor and non-poor households with their vulnerability status (such as HHs with
disable people, Women Headed Households, Ethnic minority and Adiboshi)
[2]UPPR
has been training CDC cluster leaders to develop their skills in identifying
community needs, matching government or NGO services and developing linkages.
To institutionalize these linkages UPPR has successfully piloted two community
run Cluster Resource Centres, which help and link poor and extreme poor
households with the services provided by different government departments and
NGOs.
No comments:
Post a Comment