Improving Delivery and Uptake of Essential Nutrition Interventions Through the Health and Food System and in the Community Project

Improving delivery and uptake of essential nutrition interventions through the health and food system and in the community Project

Satkhira and Barisal

Project Completion Report Reporting Period: June 2013 to May 2015

Submitted to UNICEF Submitted by CARE Bangladesh

Prepared By: Reviewed by: Md. Anowarul Arif Khan Dr. Sheikh Shahed Rahman Acting Program Manager – Nutrition National Nutrition Coordinator CARE Bangladesh CARE Bangladesh

Table of Contents 1.0 Executrive summary ………………………………………………………………………3

2.0 Effective coverage of direct nutrition interventions: ...... 4

3.0 Signing of Project Cooperation Agreement between United Nation Children's Fund and CARE Bangladesh: ...... 14

4.0 Activities performed during the project period: ...... 14

A. SYSTEM STRENGTHENING ACTIVITIES:...... 14

B. CAPACITY BUILDING INTERVENTIONS: ...... 27

C. COMMUNITY MOBILIZATION INTERVENTIONS: ...... 29

D. FACILITATION ACTIVITIES RELATED TO SERVICE DELIVERY: ...... 37

5.0 Project sustainability: ...... 41

6.0 Lessons Learned ...... 41

7.0Conclusion……………………………………………………………………………………………………………………………………….43

8.0 Annex: ...... 44

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1. Executive summary:

Maternal and child nutrition during the first 1,000 days – from conception through the age of two – shapes a child’s future. Women’s nutrient needs increase during pregnancy and lactation. Some of the increased nutrient requirements protect maternal health while others affect birth outcome and infant health. If the requirements are not met, the consequences can be serious for women and their infants. During this critical window of opportunity, nutrition can have a measurable lasting impact on growth and brain development and disease. The impacts of malnutrition during the first 1,000 days, if not appropriately addressed, are largely irreversible—but these consequences are preventable. With adequate nourishment in the earliest years of life, children have an opportunity to grow, learn, become productive adults and break the cycle of poverty.

Despite commendable improvement in nutrition situation in last one decade, still the rates of malnutrition in Bangladesh are among the highest in the world. About 36% children are stunted, 33% are underweight and 14% are wasted among children under 5. Prevalence of micronutrient deficiency and chronic energy deficiency among women is still around 50%. To address these high rates of undernutrition among women and children, we do need to consider delivering appropriate information, services. Mainstreaming nutrition is highly recommended to ensure optimal nutrition services for universal coverage and high risk group of population in country. Operationalization of mainstreaming nutrition through Gob health system is identified as one the major focuses of this project.

Integrated Agriculture and Health Based Interventions (IAHBI) is a large project jointly implemented by UNICEF and FAO, funded by United States Assistance for International Development (USAID). Primary objective of this project is to improve the delivery, monitoring and uptake of essential nutrition interventions and practices through the local health and food system and the community under Assasuni, Shyamnagar of Satkhira and Muladi sub-districts of Barisal during the period of June 213 to May 2015. The major focus of this project were threefold:

i) To strengthen and improve capacity of health system to deliver direct nutrition services from community clinics, family welfare centers (FWC) and upazila health complex (UHC) under Ministry of Health and Family Welfare (MOH&FW) ii) Addressing nutrition sensitive interventions though key sectors like agriculture and livelihood iii) Community mobilization through community support system and engaging different community groups and support groups like adolescent girls, religious leaders, mother to mother support groups (MTMSG) at lower tier of communities. iv) Addressing mutisectoral approach at subdistrict and below level

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Community mobilization efforts were targeted to promote social and behavior changes related to infant and young child feeding (IYCF) practices, consumption of iron and folic acid (IFA) tablets, inclusion of adolescent girls in promoting nutrition interventions, promotion of hygiene practices, food and care during pregnancy and increase service uptake from community clinics, and family welfare centers. Engagement with community support system was to improve skill and capacity of the support groups to foster mainstream nutrition efforts effective and create opportunities for participation of those groups into nutrition governance activities thereby resulting into health system strengthening as a whole.

Nutrition sensitive intervention was implemented by Food and Agriculture Organization (FAO) to complement towards the results envisioned achieving within results framework of IAHBI project. Global evidences suggest that only nutrition specific intervention can result into reduction of undernutrition by one fifth of total burden of undernutrition. And CARE Bangladesh experiences suggests that community based nutrition programming essentially requires engagement of community support system and active participation of support groups will ensure increased participation of communities, improved nutrition service uptake, create an enabling environment for improving access to services and participatory governance to ensure measurable nutrition security within communities.

It has become increasingly clear that engagement of community support system for health and nutrition has unique advantage. Role of community support system in improving health and nutrition outcomes is crucially important in several ways. Firstly, it is required to bring community actors and systems into full partnership with health systems and in particular to ensure to develop wide array of relationship between community and health system to improve overall situation. Secondly, community engagement in improving nutrition outcomes can be greatly enhanced through mobilization of key affected populations and community networks. Thirdly, in order to have real impact on nutrition outcome, however community support systems must have effective and sustainable systems in place to support their activities for the development of an enabling and responsive environment. Therefore, strengthening community support system approach can be effective for the prevention, treatment and care of undernourished population who are also most marginalized and vulnerable group in the society. Essentially targeting this group, increasing access to essential nutrition services will bring real impact on nutrition outcome. Effective and sustainable support systems together with increased availability and coverage of direct nutrition interventions and supporting integration of nutrition sensitive intervention were CARE’s approach under IAHBI. A strong focus on capacity building of service providers, creation of demand for essential nutrition services in the communities, enabling community actors to play full and effective roles are the key focus of this project. 2.0 Effective coverage of direct nutrition interventions:

Project achievement at a glance: According to Project Cooperation Agreement (PCA), the project has selected 14 indicators and fixed the target benchmark for project period. After successfully completion of project activities,

Project Completion Report _IAHBI Project_CARE B Page 4 the project has evaluate the results and found that most of the indicator has reached its target successfully except four indicators. Present status was collected from service statistics which may differ from actual figure and project expected that during the project end evaluation all indicators will reach its target according the PCA.

Table 1: Status of key indicator as per PCA till April 2015 in three project upazilas:

Indicator Targe Present status t (April/15)* %of women consume at least 100 IFA tablets during pregnancy 60% 70% % of children 06-59 months supplemented with Vitamin A bi-annually 90% 98% % of children 24-59 months dewormed 90% 91% % of children 6-23 months supplemented with micronutrient powders 60% 24% % of adolescents girls in targeted youth clubs supplemented weekly with 90% 100% IFA tablets % of children 6-59 months suffering from diarrhea received ORS with 60% 100% zinc % of children under 5 suffering from severe acute malnutrition received 60% 20% appropriate treatment % of HHs are consuming iodised salt 60% 97% % of caregivers can cite at least 5 optimal IYCF practices 80% 62% % of children are exclusively breastfeed from 0-6 months 80% 86% % of children 6-23 months are receiving a ‘minimum acceptable diet 50% 84% % of PLWs consume an adequate maternal diet in quantity and quality, 50% 84% during pregnancy and post-partum % of pregnant women gain at least 5kg during pregnancy 50% 39% % of caregivers are hand washing with soap at three critical times 20% 61% (handling food, feeding child, after defecation) *Data source: service statistics and small household survey (LQAS)

The below DNI indicators’ data source is GOB MIS (service statistics) from Health and Family Planning department; a few data which is yet not included in GOB MIS collected by project using LQAS method.

2.1 Exclusive breastfeeding: The coverage of exclusive breastfeeding among 0-6 months old children have increased from 52% to 86% from October 2013 to April 2015. According to GOB MIS, the breastfeeding rate consistently more than 75% since November 2013 in the three CARE Bangladesh implemented upazilas in Satkhira and Barisal.

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Exclusive breastfeeding 100 93 93 93 92 92 90 87 86 90 82 82 83 85 85 77 79 76 79 80 74 70 60 52 50 40

Percentage 30 20 10

Jul-14

Jan-14 Jan-15

Jun-14

Oct-13 Oct-14

Apr-14 Apr-15

Feb-14 Sep-14 Feb-15

Dec-13 Dec-14

Aug-14

Nov-13 Nov-14

Mar-14 Mar-15 May-14 Fig 1: Exclusive breastfeeding

2.2 Early initiation of breastfeeding: Figure 2 describes early initiation of breastfeeding rate which was 80% in October 2013, and after that it was consistently more than 80% till June 2014. After modifying GOB reporting format, the percentage was slightly decreased from July 2014 to November 2014 but in last six months it continue with 80%.

Early initiation of breastfeeding

100 88 87 84 86 87 90 80 84 84 80 81 80 78 76 80 77 77 80 79 80 80 70 60 50 40 Percentage 30 20 10

Jul-14

Jan-14 Jan-15

Jun-14

Oct-13 Oct-14

Apr-14 Apr-15

Feb-14 Sep-14 Feb-15

Dec-13 Dec-14

Aug-14

Nov-13 Nov-14

Mar-14 Mar-15 May-14 Fig 2: Early initiation of breastfeeding

2.3 Complementary Feeding: Complementary feeding rate (4 or 4+ food group) had been increasing since November 2013 after starting of IAHBI implementation from 51% in October 2013 to 93% in November 2013 among 6-23 month old children. Complementary feeding status reaches above 90% in November

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2013 and continued above 90% till April 2014. But in last five quarter the achievement was little bit below, the reason of the below achievement was due to vacancy of FWA and FWV positions and also there have been modified of the reporting format. As a result, denominator changed and percentage of complementary feeding was also changed.

Complementary feeding

100 93 94 89 87 92 90 80 69 70 66 64 68 64 63 63 62 60 62 63 60 51

40 Percentage 20

Jul-14

Jan-14 Jan-15

Jun-14

Oct-13 Oct-14

Apr-14 Apr-15

Feb-14 Sep-14 Feb-15

Dec-13 Dec-14

Aug-14

Nov-13 Nov-14

Mar-14 Mar-15 May-14 Fig 3A: Complementary Feeding

2.4 Minimum acceptable meal frequency: The status of minimum acceptable meal frequency among children aged 6-23 months increased from 10% on October 2013 to 84% on April 2015.

Minimum acceptable meal freuency 100 90 86 83 86 87 84 84 75 80 77 80 72 71 73 72 70 60 55 44 50 36 35 40 33

Percentage 30 20 10 10

Jul-14

Jan-14 Jan-15

Jun-14

Oct-13 Oct-14

Apr-14 Apr-15

Feb-14 Sep-14 Feb-15

Dec-13 Dec-14

Aug-14

Nov-13 Nov-14

Mar-14 Mar-15 May-14 Fig 3B: Minimum acceptable meal frequency

2.5 Vitamin A supplementation:

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The status of vitamin "A" supplementation at community level gradually increased from 20% in October 2013 to 38% in April 2015 in the project three upazilas. At facility level during Vitamin A campaign in April 2015 the coverage rate was 98%.

Vitamin A supplementation (community level) 100 90 86 80 70 63 59 58 60 50 43 55 54 50 45 45 41 37 38 39 38 40 35 28 34

Percentage 30 20 20 10

Jul-14

Jan-14 Jan-15

Jun-14

Oct-13 Oct-14

Apr-14 Apr-15

Feb-14 Sep-14 Feb-15

Dec-13 Dec-14

Aug-14

Nov-14 Nov-13

Mar-14 Mar-15 May-14 Fig 4A: Vitamin A supplementation at community level

Coverage (%) of Vitamin A supplementation (Facility level) 100100 100100100 98 100 80 60

40 Percentage 20 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Fig 4B: Vitamin A supplementation at facility level

2.6 Coverage of Deworming: Figure 5 shows that the coverage of deworming at community level in October & November 2013 was 99% respectively; in April & May 2014 it was increased to 100% but in June 2014 it has decreased to 91%. Facility level data cannot be included as there was no National level deworming campaign since last three quarter. But it is expected that the coverage would be increased after national level campaign.

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Coverage (%) of deworming 99 99 100100 100 91 80 60

40 Percentage 20 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Fig 5: Coverage of Deworming

2.7 Children 6-59 months with diarrhea treated with ORS and Zinc: Diarrhea remains a leading cause of childhood morbidity and mortality in Bangladesh. Dehydration caused by severe diarrhea is a major cause of illness among children age 6-59 months, although the condition can be easily treated with Oral Rehydration Solution (ORS) and Zinc. Through the activities of the project, it has been found that, 100% of children age 6- 59 months with diarrhea treated with ORS and Zinc from the beginning of the project to till date.

% of children 6- 59 months with diarrhoea treated with ORS and Zinc 100100100100 100100100100100100 100 100100100 100100 100100100 100

40 Percentage 20

Jul-14

Jan-14 Jan-15

Jun-14

Oct-13 Oct-14

Apr-14 Apr-15

Feb-14 Sep-14 Feb-15

Dec-13 Dec-14

Aug-14

Nov-13 Nov-14

Mar-14 Mar-15 May-14 Fig6: Children 6-59 months with diarrhea treated with ORS and Zinc

2.8 MNP coverage: According to the Figure 7, Multiple Micro Nutrient Powder (MNP) coverage found high during July 2014 among the children age 6-23 months who were consumed MNP as per WHO guideline and the percentage was 56. In the initial stage of the project in October 2013, the percentage was only 15 but gradually it was increased and in April 2015 it was 24%. Actual coverage rate at

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Assasuni and Shyamnagar upazilla, Satkhira is higher but MNP is not available at Muladi upazila of Barisal district yet so total coverage rate decreased.

MNP coverage 100 80 60 56 33 41 40 32 29 28 26 26 20 21 22 24 24 23 Percentage 15 21 21 23 24 20

Jul-14

Jan-14 Jan-15

Jun-14

Oct-13 Oct-14

Apr-14 Apr-15

Feb-14 Sep-14 Feb-15

Dec-13 Dec-14

Aug-14

Nov-13 Nov-14

Mar-14 Mar-15 May-14

Fig7: MNP coverage

2.9 Iron Folic for pregnant women and lactating women: Figure 8A shows that, the coverage of Iron Folic Acid (IFA) tablet supplementation during last pregnancy that increased from 50% in October 2013 to 70% in April 2015. Though the coverage increased 50% to 82% at three months of intervention but it was decreased at 43% after seven months of intervention; the reason was under calculation of total number of pregnant women by GOB health workers previously; later we identified the gaps and provided training through MOHFW managers to frontline worker then the coverage increased 70% in April 2015.

% of woman who consumed at least 100 IFA (Iron Folic Acid) during last pregnancy 100 82 83 85 83 81 80 70 70 69 69 70 62 56 56 61 60 5054 43 5036 40

20 Percentage 0

Fig 8A: Iron Folic for pregnant women and lactating women

2.10 Iron-Folic for Adolescent: Figure 8B shows that, the coverage of IFA supplementation among adolescents’ girls was maintaining 100% and near about 100% from December 2013 to July 2014. But in August and

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September 2014 the coverage were low but then again gradually increased to 73% on April 2015. This data came through Periodic Monitoring survey which was introduced by IAHBI project to randomly selected women/girls to collect few data related to those indicators are not yet included in GOB MIS system. Earlier denominator was the members of adolescent girls group members only but from August 2014 we changed the denominator to include all adolescent girls as advised from UNICEF and USAID to in the three upazilas so in August the rate decreased. In addition, at that time project has identified that in some working areas, parents of adolescent has misconception regarding IFA that it is one kind of contraceptive so the total recipient was decreased but later on through community mobilization the misconception was taken away and the percentage was increased.

Coverage of adolescent IFA supplementation 100 100 100 100100100100 100 100 87 76 80 78 73 63 61 59 60 53

40 24

Percentage 23 20 0

Jul-14

Jan-14 Jan-15

Jun-14

Oct-13 Oct-14

Apr-14 Apr-15

Feb-14 Sep-14 Feb-15

Dec-13 Dec-14

Aug-14

Nov-13 Nov-14

Mar-14 Mar-15 May-14 Fig8 B: Iron-Folic for Adolescent

2.11Consumption of iodized packet salt: Salt used in the household is the most common source for iodine fortification to prevent the public health concerns of iodine deficiency disorders. In Bangladesh, the compound used for fortification of salt is potassium iodate (KIO3). According to the World Health Organization, a country’s salt iodization program is considered to be on a good track to eliminate iodine deficiency when 90 percent of households use iodized salt. In Figure 9 shows that, In April 2014, 94% households consuming iodized packet salt and it continue till now, according to WHO, it is considered to be on a good track to eliminate iodine deficiency. We do not have data before April 2014 as this data was not included in GOB MIS and not regularly collected by GOB staff. The project has been collecting the data using Periodic Monitoring Tool since April 2014.

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% of households consuming iodized packet salt 94 94 94 97 99 96 97 100 89 91 92 92 92 91 80 60 40

Percentage 20 0 0 0 0 0 0

Jul-14

Jan-14 Jan-15

Jun-14

Oct-13 Oct-14

Apr-14 Apr-15

Feb-14 Sep-14 Feb-15

Dec-13 Dec-14

Aug-14

Nov-13 Nov-14

Mar-14 Mar-15 May-14

Fig 9: Consumption of iodized packet salt

2.12Consumption of vitamin A fortified edible oil: Figure 10 shows that, 5% households consumed vitamin A fortified edible oil in April 2014 and in April 2015 it was 4%. As the percentage was very low, so the Project facilitated to motivate people during households visit by FWA/community meeting on consumption of vitamin A fortified oil.

% of households that are consuming vitamin A fortified edible oil 6 5 5 4 4 4 4 4 3 3 2 2 2 2 2 2 Percentage 1 1 0 0 0 0 0 0 0

Jul-14

Jan-14 Jan-15

Jun-14

Oct-13 Oct-14

Apr-14 Apr-15

Feb-14 Sep-14 Feb-15

Dec-14 Dec-13

Aug-14

Nov-13 Nov-14

Mar-14 Mar-15 May-14 Fig 10: Consumption of vitamin A fortified edible oil

2.13 Children of 0- 59 months who were screened for their nutritional status at facility level: Figure 11A shows that, children aged 0-59 months old screened for their nutritional status at facility level was more than 90% from November 2013 to July 2014.But it was decreased in August 2014 and the percentage was only 40. This was happened because in earlier denominator was the sum of who received screening at the facility. But from August 2014 we have changed the denominator as advised by UNICEF, USAID that all under five children who visited the

Project Completion Report _IAHBI Project_CARE B Page 12 facility will be the denominator as they need to screen. From October 2014 the screening rate was gradually increased and in April 2015, the percentage was 90%.

% of children 0- 59 months who are screened for their nutritional status at facility level 100 100 100 100 100 100 98 92 91 100 100 10010010010010097 96 9086 86 76 94 93 90 89 90 80 85 74 7068 60 46 39 52 Total 40 40 Male Percentage 20 0 0 Female 0 0

Fig 11A: Children of 0- 59 months who were screened for their nutritional status at facility level

2.14 SAM children 6-59 months received appropriate treatment as per national guidelines: Figure 11B shows that, the percentage of SAM children of 6-59 months received appropriate treatment as per national guidelines was increased from March 2014 to August 2014 and the proportion was increased from 37% to 100%. In last three quarter the percentage was fluctuate due to shortage of medicine at facility level.

% of 6-59 months old children with SAM receiving/ received appropriate treatment as per national guidelines 100 100 100100100100100100100 100 100 80 80 80 80 60 67 67 64 50 Total 40 37 38 29 2725 Male Percentage 25 20 17 8 20 20 7 0 0 0 0 0 0 0 0 Female

Fig 11B:% of 6-59 months old children with SAM receiving/ received appropriate treatment as per national guidelines

2.15 SAM children of 6-59 months cured/recovered, died, defaulted, non-recovered: Figure 11C shows that, in April 2014, 100% of 6-59 months old SAM children discharged from the treatment after cured/recovered from SAM. Though the percentage was little decrease in May

Project Completion Report _IAHBI Project_CARE B Page 13 and July 2014 but again it is maintained at 100% in June, August, September, October, November, December 2014, February 2015, March and April 2015.

% of 6-59 months old SAM children cured/recovered, died, defaulted, non-recovered 100 100 100 100100 100100100 100 100 95 80 60 75 Cured 40 Died

Percentage 20 Defaulted 0 0 0 0 0 0 0 0 5 0 0 0 0 0 0 0 0 0 0 0 Non-recovered

Fig 11C: SAM children of 6-59 months cured/recovered, died, defaulted, non-recovered

3.0 Signing of Project Cooperation Agreement between United Nation Children's Fund and CARE Bangladesh: The agreement was signed on May 21, 2013 and May 27, 2013 by UNICEF and CARE Bangladesh respectively. Pascal Villeneuve, Representative of UNICEF Bangladesh and Jamie Terzi, Country Director of CARE Bangladesh signed the agreement on behalf of their organization. The first tranche was released on June 11, 2013.

4.0 Activities performed during the project period:

A. System strengthening activities:

The major objective of IAHBI project was to strengthen the health system at district and below to improve access, quality and utilization of nutrition services from district hospital, upazila health complex, family welfare center and community clinics. This will eventually help to mainstream the direct nutrition services through the health service delivery points, operationalizing direct nutrition indicators (DNIs) into existing system and establish a system of periodic review of progress and challenges of DNIs at district, sub-district and union. In addition to that, IAHBI project also conducted assessment and analysis of nutrition service delivery status, supply chain of supplies like iron and folic acid tablets (IFAs), Zinc tablets and ORS and consumption of those services and supplies which reflects the improvement of individual behaviors of target population. And also the performance drivers were identified and addressed through participation of MOH&FW staffs and project staffs through different approaches like participation in nutrition coordination committee, joint supervisory visit, periodic capacity development in the monthly

Project Completion Report _IAHBI Project_CARE B Page 14 meeting of MOH&FW frontline staffs, data driven decision making at district and sub-district level.

1. Formation of Nutrition Coordination Committee at Muladi:

The Nutrition Coordination Committee was established by the government administrative head of sub-district to address multisecotral approach. This platform increased opportunity for sectoral participation to address both nutrition specific and nutrition sensitive issues at subdistrict level. This committed was formed at Muladi, a sub-district of Barisal district, comprised of 15 members representation from different ministries like administration, health & family planning, agriculture, livestock, fisheries, education, social welfare and dept. of public health engineering (DPHE) and local elected representatives Chairman, vice chairmen. (List of committee as Annex 2)

The committee is headed by Upazila Nirbahi Officer (UNO) with UH&FPO as its member secretary. The ‘Nutrition Coordination Committee’ meets bimonthly to discuss on nutrition and social safety net, challenges of nutrition service delivery issues, identify the gaps in the system and made recommendations to improve the situation and report back in the following meeting. IAHBI project provides the secretarial support to document the meeting minutes and include the agendas with consultation of MOH&FW managers. This platform was acting as a broader platform to address multisecotral approach for nutrition.

Two coordination meetings were conducted during IAHBI project period. A ToR was developed for this committee to portray the scope of work of this committee.

2. Bottleneck analysis:

IAHBI project conducted total 14 bottleneck analyses to identify to identify-

a. Assess the gaps in the service delivery system b. Challenges of supply chain of logistics like IFA, Zinc, ORS, c. Current situation of service uptake by the targeted population like pregnant d. And to draw solutions in consultation with targete population and service providers and MOH&FW managers to prevent recurrence and improve the stiation.

It was eventually support the strengthening the service delivery mechanism. To identify the actual scenario of the three upazilas, short assessment was conducted with using LQAS method, where 95 samples were taken in each upazila for each issue. After the assessment the findings were shared to the MoH&FW officials of those upazilas and joint decisions were made for next course of action.

Event details:

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Issue wise achievement Total Planned Total Achieved Issue # of achievement

IFA 5

Zinc 3 15 14 MNP 4

EBF 2

3.Quarterly review meeting with MoH & FW staff on coverage and reporting at district level:

IAHBI project organized and conducted quarterly review meeting with MoH & FW staffs on coverage and reporting at District level. The objective of the meeting was to inform the stakeholders about the progress of the project, learning and challenges: and overcoming strategies and way forwards.

Event details:

Planned in the project # of Session # of participants duration conducted 35 12 3

4. Quarterly review meeting with MoH & FW staff on coverage and reporting at upazila level:

IAHBI project has organized and conducted quarterly review meeting with MoH & FW staffs on coverage and reporting at upazila level. The objective of the meeting was to share the progress and achievement of the IAHBI project to health and family planning staffs and Managers at the upazila level and at the same time planning for further strengthening of the services at facility.

Event details:

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Planned Participants in the # of Session Upazila project conducted Male Female Total duration Assasuni 9 443 314 757

Shyamnagar 23 in 6 178 277 455 three Muladi upazila 5 170 215 385

Total 20 791 806 1597

Achievement:  GOB health and family planning managers and frontline staffs are now more sensitized for further strengthening reporting system of DNI indicators.  Managers are well informed to ensure delivery of full set of DNIs from all service delivery centers.  Online reporting systems of GO MIS have improved and all managers and staffs of concern services are now more concern then before.

5. Monthly coordination meeting with health and family planning department at upazila level:

In the project duration, Manager – Nutrition of three upazila has participated the monthly coordination meeting with both the health and family planning departments of their respective upazila in every month. During the meeting the Mangers are usually share the project update and field findings along with learning and challenges. They also facilitated health managers to include nutrition as an agenda in that meeting and its follow up. Event details: Participants from IAHBI staffs Upazila # of meeting Male Female Total Assasuni 28 34 18 52

Shyamnagar 28 45 7 52

Muladi 36 53 22 75

Grand Total 92 132 47 179

6. Facilitation of monthly meeting at union for MOH&FW staffs:

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To focus on mainstreaming DNIs in regular services through health and family planning department and to take nutrition as priority agenda, IAHBI project has facilitated monthly meeting at union for MOH&FW staffs. In the project duration total 400 meeting has facilitated by the project.

Event details:

Planned Participants number of # of meeting Upazila meeting facilitated Male Female Total facilitation

Assasuni 147 519 875 1394

Shyamnagar 163 816 990 1806

Muladi 90 391 675 1066 413 Grand 400 1526 2540 4266 Total Achievement:  Incorporated DNI topics in the MOH&FW staffs meeting as agenda.  The frontline staffs of MOH&FW staffs are now better known on system strengthening and DNI mainstreaming.

7.Meeting with Community Groups in Community Clinic for revision of action plan:

IAHBI project has facilitated total 194 meeting with community groups in community clinic for revision of action plan in different community clinic under its project areas. All the CG members of that CC along with respective MOH&FW staffs are actively participated the meeting for review and update the action plan.

Event details: Planed Participants in the Upazila # of meeting project Male Female Total duration

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Assasuni 71 898 581 1479

Shyamnagar 192 in 75 760 545 1305 three Muladi upazila 48 520 394 914

Grand Total 194 2178 1520 3698

Achievement:

 Incorporated Direct Nutrition Interventions activity in Community Clinic action plan.  Interaction among the CG and MOH&FW staffs has increased.  GMP session and screening of SAM/MAM by MUAC has increased.  Plotting of SAM cases, pregnant women and ultra poor in the social map.  Starting involvement of CSG in nutrition awareness raising and follow up.

8. Providing tools (information board) to Community Clinic for service record and analysis:

To record and keep data on different DNI indicators and its analysis for further improving service coverage and quality project has provided information board to CC. DNI indicators were written in Bangla after discussion with upazila managers with final input from National Nutrition Coordinator. A total of 44 such information boards were now displayed at the community clinics.

Distribution of Board:

Name of the Upazilla Number of CC receiving Information board Assasuni 14 Shyamnagar 20 Muladi 07 Total 41

9. Project staff monitoring visits to oversee field activities:

Program Manager – Nutrition, Manager – M&E and Upazila Managers visited three upazilas to communicate with GOB health managers, observed service delivery at the community clinic / FWC and provided necessary support / on the job training; attend different project activities, and

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provided onsite technical assistance to project staff for further improvement of GOB Health system and staff capacity. During the project period a total of 147 (Project staff and GoB health and Family Planning staff) monitoring visits has been conducted along with Health & Family Planning supervisors of Upazila and union level though we had planned for 136 visits.

10. IAHBI project visited by USAID, NHSDP and UNICEF team:

During the project duration, personnel’s from USAID, NHSDP and UNICEF have visited project field activities in different times. Detail of their visit are describe below:

Nutrition Specialist of UNICEF visited Shyamnagar and Assasuni Upazila

On 10 and 11 February 2014, UNICEF team consists of two members visited IAHBI project area at Shyamnagar and Assasuni upazila, Satkhira district.

Members of the visit team were:

 Dr. S.M. Younus Ali, Nutrition Specialist, UNICEF Bangladesh.  Sharmin Shafique, Nutrition Officer, UNICEF Zone Office, Khulna, UNICEF Bangladesh.

Objective of the visit: To observe nutritional services from Community clinic and IAHBI activities with CC level and community participation with IAHBI activities.

Visit detail:

Iswaripur CC, Shyamnagar: The visitors observe GMP session and screening of SAM/MAM.

Nurnagar FWC: During their visit at this FWC they observe Mobile Video Show.

Godara CC, Assasuni: The visitors observe GMP session and screening of SAM/MAM. They also visit Godara Girls High School and they observe the hand washing session.

NHSDP and USAID team visited Shyamnagar Upazila

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A NHSDP and USAID visit team consists of 3 members visited IAHBI project area under Munshiganj union, Shyamnagar Upazila of Satkhira district on April 02, 2014. The visit was assisted by UNICEF Zonal Office, Khulna. Members of the Visit Team were:

 Dr. Halida H. Akhter, COP, NHSDP  Muhammad Shahidul Islam, Education Team leader, USAID  Arawn Hawkins, Country Manager, SPRING Sharmin Shafique, Nutrition Officer, UNICEF, Khulna zone assisted the visiting team from UNICEF’s part. Objective of the visit: To observe different activities implemented by UNICEF and FAO partners (CARE Bangladesh and SMKK) at Munshiganj union under Shyamnagar upazila of Satkhira district.

Visit detail:

Purbo Kalinagar Community Clinic: The team reached Purba Kalinagar Community Clinic at 10.55 am. Md. Nazrul Islam UH&FPO Shyamnagar, Mr. Jahangir Alam, UFPO Shyamnagar and MD Fazlul Haque, president of the Community Group of Purbo Kalinagar community clinic received the visit team along with IAHBI project members. UH&FPO Shyamnagar made a short brief on IAHBI project assisted by UFPO before the team. He also mentioned how IAHBI project has been facilitating GoB in health system strengthening. Then the team members observed service delivery at the site. The services include GMP session, screening of SAM/MAM, ANC, and health education session conducted by FWA. They also talked with the service providers and health managers (CHCP, FWA, UH&FPO, UFPO), review documents and IEC materials in the clinic and information board. They talked with president, adolescent leader and other members of the Community Groups. They also talked with the mothers regarding how they are benefiting from this facility.

Sundarban High Schools: The team arrived at Sundarban High School at 1.10 pm. The adolescent group was in their monthly meeting and discussing anemia among adolescent and how to prevent it. The school teachers also present in the meeting of the adolescent. All the members of the visit team made a wider discussion with the adolescent groups as how they have been formed and oriented, who provide them orientation, what they are doing now and what are

Project Completion Report _IAHBI Project_CARE B Page 21 their plan for future. They also talked with the teachers and wanted to know whether adolescent reproductive health issues were being taught in their class. The adolescent replied positively. Md. Shahidul Islam, Education Team leader of USAID requested teachers and IAHBI team to make a link between existing text and nutrition so that it does not seem to adolescents as an extra burden. They also explored what are the challenges the adolescent are facing now. The adolescent leader Sharmin Sultana replied their question vibrantly. Dr. Halida H Akhter also discussed on adolescent reproductive health issue both with the teachers and with the adolescent girls group and also opined that the group can be further strengthened with other issues suitable for them such as life skill, prevention of early marriage and preparation of safe motherhood.

Population and Health Officer of USAID visited Assasuni Upazila

June 18, 2014: USAID visit team consists of 3 members visited IAHBI project area under Khazra union, Assasuni upazila of Satkhira district on June 18, 2014. Members of the Visit Team were:  Miranda Beckman, Population & Health Officer, USAID  Elaine Gray

 Christean Cole

Dr. Younus Ali, Nutrition Specialist, UNICEF, Dr. Salahuddin Ahmed, NNC, CARE Bangladesh Dhaka assisted the visiting team.

Objective of the visit: To observe service delivery and MIS system and IAHBI activities implemented by UNICEF and FAO partners (CARE Bangladesh and SMKK) at Khazra union under Assasuni upazila of Satkhira district.

Visit detail: Tuardanga Community Clinic: The team reached Tuardanga Community Clinic at 10.45 am. Md. Abdul Hakim, Health Inspector-In charge, Assasuni along with health and family planning union supervisors and IAHBI team members and Community Group of Tuardanga community clinic received the visit team.

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Then the team members observed service delivery and MIS system at the site. The services include GMP session, screening of SAM/MAM, ANC, and health education session conducted by CHCP. They also talked with the service providers and health inspectors (CHCP, FWA, HA and HI), review MIS documents, service delivery system and IEC materials in the clinic and information board, CC decoration, Tippy Tap. They talked with president and other members of the Community Groups. They also talked with the mothers regarding how they are benefiting from this facility.

After field visit the team visited UHC to know the detail of DGHS-MIS and DGFP-MIS system and also talked with Health inspector-In charge and Family Planning Assistant about MIS system as how they prepare monthly MIS reports (both wing) at upazila health complex.

On behalf of UH&FPO after field visit Dr. Hasanul Kabir, Medical Officer and Dr. Joyanta, Medical Officer arranged a short brief on IAHBI project at UHC Assasuni. They also mentioned how IAHBI project has been facilitating GoB in health system strengthening and DNI mainstreaming.

August 12, 2014:

Another USAID visit team visited IAHBI project area Assasuni, Satkhira on August 12, 2014. The Team consisted of  Miranda Beckman, Population & Health Officer, USAID  Tarek Ahmed, Education Specialist, USAID  An intern from USAID

Dr. S M Younus Ali, Nutrition Specialist, UNICEF, Dhaka; Dr. Provash Chandra Sardar, UH&FPO, Assasuni UHC; Dr. Md. Sarbojit Anwar Kamal, Program Manager, IAHBI Project;Md. Anowarul Arif Khan, Manager-M&E, IAHBI Project; Md. Abdul Hakim, HI Assasuni UHC and Bidhan John Costa, District Nutrition Support Officer, UNICEF Satkhira accompanied the team.

Objective of the visit: To observe service documentation at the Community Clinic and FWC and upward channeling of data from Community Clinic and FWC to Upazilla Health Complex.

Visit detail: Godara Community Clinic: The visitors reached Godara Community Clinic at 9.40 am. CHCP Rabidranath Biswas and HA Dipti Prova Majumder received the team. Miranda reviewed different service registers, counted the number of children screened for SAM/MAM and undergone GMP session, monthly reports of the Community Clinics those were sent to Upazila Health Complexes. UH&FPO Dr. Provash Chandra Sarder and HI Abdul Hakim assisted the team. Then the visit team seat with Community Groups and made a small discussion regarding

Project Completion Report _IAHBI Project_CARE B Page 23 their involvement in the management of community clinic and ensuring increase service coverage. The team left the Community clinic at 11.00 am.

Activity of Adolescent Girls Group: The visit team met Adolescent Girls Group in a nearby house, made discussion with them, and asked about their activities in connection with IAHBI project, early marriage and ARH. They also observed a demonstration session regarding Tippy Tap process in hand washing. HA Dipti Prova Majumder assisted the team.

Shovnali FWC: The visit team reached Shovnali FWC at 11.45 am. FWV Mrs. Afroza Akhter received the team. The team reviewed different registers at the FWC count the number of pregnant mothers, children undergone GMP session and screened for SAM/MAM.

The visitors also observed service delivery at the Community Clinic and FWC, talked to service providers. They also talked to Pregnant and Lactating women came at the facilities to receive services and provide feedback to the service providers as to how to improve quality of recording. Then the team moved to Assasuni Upazila Health Complex at 12.45 pm.

Assasuni Upazila Health Complex: After field visit the visit team reached UHC at 1.20 pm. They seat with Mr. Jahangir Alam, UFPO Assasuni and Dr. Provash Chandra Sardar, UH&FPO and shared their field findings. They also asked the Upazila Health & Family Planning Managers to show them MIS system at the Upazila level including receiving data from community and union level health facility and upward channeling to district level. Mr. Jahangir Alam and Mr. Madhusudan, Statistician demonstrated the data management system before the team on behalf of Family Planning and. Health department respectively. The visitors also made informal discussion with Upazila managers regarding improvement of MIS. They also informed them that they will talk at the national level for further strengthening MIS. Then the visit team participated at Lunch and moved to Satkhira at 3.20 pm.

USAID team visited Muladi Upazila

USAID team consists of four members visited IAHBI project area at goluivanga village under Muladi upazila, Barisal district on November 23, 2014. Members of the visit team were:  Mitchell Nelson, Economic Growth Office, Feed the Future, Agriculturist, Team Lead, Nutrition Working Group  Mohammad Shibly, Economic Growth Office, Feed the Future, Project Management Specialist  Borhaniz Sultan, Economic Growth Office, Feed the Future, Project Management Food Policy

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 Iftekhar Rashid, Nutrition Specialist, Office of Population, Health, Nutrition and Education

Dr. Md. Syedur Rahman, RMO, Muladi and Mrs. Anjuman Tahmina Ferdous, Zonal Nutrition Officer, UNICEF Barisal Zone assisted the visiting team.

Objective of the visit: To observe nutrition services delivery from Community Clinic and IAHBI project activities at CC level and community participation with IAHBI activities.

Visit detail: Goluivanga CC: The visitors reached Goluivanga Community Clinic at 12.55 pm by speed boat after observing FAO partners activities at Shafipur Union. Dr. Syedur Rahman, RMO Muladi,Ms. Tamima Sharmin CHCP, Mr. Jashim Uddin HA received the team. The visiting team observed nutrition services delivery from Goluivanga Community Clinic and discussed with CHCP regarding services of CC. Dr. Syedur Rahman, RMO assisted the team. Then the visiting team seat with Community Groups and made a small discussion regarding their action plan, involvement in the management of community clinic and ensuring service coverage. The team left the Community clinic at 1.40 pm.

Activity of Adolescent Girls Group: The USAID team observed Adolescent Girls Group meeting at Goluivanga village. They visited few house hold to observe Adolescent Girls Group activities like tippy tap and nutrition garden. They highly praised the activities of AGG in relation to nutrition. After visiting the community the team returns to Barisal.

Nutrition Officer of UNICEF visited Assasuni Upazila

On 23 December 2014, UNICEF team consists of three members visited IAHBI project area at Assasuni upazila, Satkhira district.

Members of the visit team were:

 Dr. Mohammad Mahbobor Rahman, Nutrition Officer, Nutrition Section, UNICEF Bangladesh.  Sharmin Shafique, Nutrition Officer, UNICEF Zone Office, Khulna, UNICEF Bangladesh.  Bidhan John Costa, Nutrition Consultant, DNSO-Satkhira, UNICEF Bangladesh.

Objective of the visit: To observe nutritional services from Community clinic and IAHBI activities with CC level and community participation with IAHBI activities.

Visit detail:

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Paithali CC: The visitors reached Paithali Community Clinic at 10.00 am on Dec 23, 2014. The visiting team observed nutritional services of community clinic and discuss with CHCP regarding services of CC. Then the visiting team seat with Members of Community Groups and made a small discussion regarding their action plan, involvement in the management of community clinic and ensuring service coverage. Then team also discussed with some mothers/caregivers regarding their child nutrition status. The team left the Community clinic at 11.30 am.

Kulla CC: The visitors reached Kulla Community Clinic at 12.00 pm. Here the visiting team also observed nutritional services of community clinic and discuss with CHCP regarding services of CC. Then the visiting team seat with Members of Community Groups and made a small discussion regarding their action plan, involvement in the management of community clinic and ensuring service coverage. Then the team’s makes discussion with some mothers/caregivers regarding their child nutrition status and see the plotting of GMP. The team left the Community clinic at 1.30 pm.

UHC: After field visit the team visited UHC to talk with UH&FPO at upazila health complex. Dr. Provash Chandra Sarder, UH&FPO arranged a short brief on IAHBI project. They also mentioned how IAHBI project has been facilitating GoB in health system strengthening and DNI mainstreaming.

UNICEF Country Representative visited Shyamnagar Upazila

On 19 January 2015, UNICEF Country Representative and his team visited IAHBI project area at Shyamnagar upazila, Satkhira district.

Members of the visit team were:

 Mr. Edouard Beigbeder, Country Representative, UNICEF Bangladesh.  Anjana Mangalagiri- Chief of Education Section, UNICEF Bangladesh.  Dr. Mohsin Ali, Nutrition Specialist, UNICEF Bangladesh.  SM Nazmul Ahsan- OIC, UNICEF Khulna Zone, UNICEF Bangladesh.  Sharmin Shafique, Nutrition Officer, UNICEF Zone Office, Khulna, UNICEF Bangladesh.  Bidhan John Costa, Nutrition Consultant, DNSO-Satkhira, UNICEF Bangladesh.

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Objective of the visit: To observe health and nutrition program at FWC as part of observing UNICEF funded different projects and its interventions.

Visit detail:

Nowabeki FWC: The visitors reached Nowabeki Family Welfare Center, Atulia union at 11.45 am on January 19, 2015. the Country Representative of UNICEF observed service delivery and counseling session on IYCF, Growth Monitoring and Promotion (GMP), SAM/MAM screening. He also talked to the service receiver mothers, Service providers and Health & FP Managers regarding nutrition. The country Representative highly appreciated CARE activities at Satkhira and stated that UNICEF, CARE and GoB are playing effective roles in coordination and harmony to improve maternal and child nutrition.

A. CAPACITY BUILDING INTERVENTIONS:

11. Training of the project staffs on comprehensive nutrition package:

IAHBI project organized a 5 day long training on comprehensive nutrition package. Total 20 project staffs have participated the training. The training was held at Mohammadpur Fertility Services and Training Center, Dhaka. External facilitator from IPHN, DGFP and UNICEF facilitated the training session. The staffs were gathered knowledge from the training and also well informed the field implementation strategy for smoothly implement the project.

Details of the Training:

Designation Male Female Total Community Facilitator 10 5 15 Manager - Nutrition 3 0 3 Manager – M&E 1 0 1 Program Manager - Nutrition 1 0 1 Grand Total 15 5 20

12. Two days ToT on Mother Support Group to the project staffs:

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In the 2nd quarter of the project intervention project has organized a two days ToT on Mother Support Group to the project staffs. The objective of the ToT is to enhance the knowledge and capacity of the project staff to orient the Mother Support Group. Total 20 project staffs have participated the training. Through the training knowledge and capacity of the project staffs to develop MSG was enhance.

Details of the Training:

Designation Male Female Total Community Facilitator 10 5 15 Manager - Nutrition 3 0 3 Manager – M&E 1 0 1 Program Manager - Nutrition 1 0 1 Grand Total 15 5 20 13. On the job training (OJT) of the MOH&FW Service providers:

To retain and enhance the skill and knowledge of the service providers at the Community Clinic (CC) and Family Welfare Center (FWC) to deliver DNI services adequately and qualitatively IAHBI project staff facilitated providing on the job training of the service providers including CHCP, FWV, FWA, HA at the facility level using existing job aid and IEC materials available.

Details of the OJT:

Name of the Category of service providers Upazila CHCP HA FWV FWA Shyamnagar 38 40 4 26 Assasuni 34 25 6 24 Muladi 19 20 4 20 Total 91 85 14 70 Grand Total 260

14. Facility Assessment:

For identify services and logistics availability in the service facilities related to DNI service delivery, the IAHBI project has conducted facility assessment in their respective project areas.

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All the facilities including CC and FWC were covered during the assessment. Key findings of the facility assessment are attached as annex 1.

15. Household survey to collect data on DNI practice those are not captured in GOB MIS:

In every month, IAHBI project has collected data on DNI practice those are not captured in GOB MIS through household survey in prescribe format. Data collection was conducted by Community Facilitator with active cooperation from GoB frontline health staffs. After compilation of the data, the findings were analyzed by the team and then share it to the respective Managers of MoH&FW for the future initiatives of the issues.

16. Training of the MOH&FW staff on DNI and supply chain and monitoring system:

IAHBI project has organized training on DNI and supply chain and monitoring system for the staffs of MOH&FW at its working upazillas. The objective for organize the training is to sensitize MOH&FW frontline staffs on DNIs and to enhance their capacity.

Event Details:

# unit Participants Upazila # unit condu H FW FW SACM CHC AHI HI FPI Other Total plann cted A A V O P s ed 37 48 17 12 64 11 4 10 3 206 Assasuni 52 112 22 16 67 13 4 12 3 301 Shyamnaga r 52 74 22 10 47 7 2 7 1 222 Muladi 9 14 234 61 38 178 31 10 29 7 729 Grand 9 Total 1

Outcome:

 This training has enhanced the capacity of the Health and Family Planning service providers to provide DNI services.

B. COMMUNITY MOBILIZATION INTERVENTIONS:

17. Orientation and discussion sessions with Imam / Informal Birth Attendants/ Village Doctors on nutrition promotion and monitoring in the community focusing DNI message:

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In the project duration IAHBI project has organized total 23 orientation and discussions sessions with Imam/Informal Birth Attendants/Village Doctors on nutrition promotion and monitoring in the community focusing DNI message. The objectives to organize the session were:

 To build up awareness among the community groups who plays the vital role in the community  To engage and mobilize the community people focusing on DNI messages  To involve participants to support and monitor nutritional activities  To engage male in providing support to Pregnant and Lactating Mothers, Adolescents and under 5 children

Event details: # orientation # of Participants Upazila planned orientation done Male Female Total Assasuni 127 46 173 Shyamnagar 197 74 271 Muladi 175 15 190 24 Grand 23 499 135 634 Total

Outcomes:  Awareness has increased among the participants on DNI interventions  Dissemination of DNI messages and monitoring of DNI activity by the specific groups has increased across the community  Involvement of community people has increased

18. Mobile video show:

Build and increase awareness on DNIs especially on EBF, Complementary Feeding, IFA tablet consumption, WASH among the project participants (Pregnant and lactating women, decision makers) and to facilitate sustained positive behavior, the IAHBI project has organized mobile video show in its project working areas. The project has collected some widely used video documents about Exclusive Breastfeeding, early initiation of breastfeeding, IYCF, hand washing practices at critical time and Meena carton. With hired sound system, generator, mike,

Project Completion Report _IAHBI Project_CARE B Page 30 multimedia for showing the video show and we have showed video program in a big room of respective Union Parishad hall room/FWC in the presence of local people including lactating mothers and caregivers, adolescents, elderly women, decision makers. There were provisions of rapid assessment about participants understanding through a simple tool. CG, CSG and Union Parishad members organized these events and invited people, project role is only providing the videos.

Event details:

# video # of video Participants Upazila show show planned conducted Male Female Total Assasuni 418 1373 1791 Shyamnagar 568 1478 2046 Muladi 844 1384 2228 Grand 71 1830 4235 6065 Total 76

Outcomes:

 Early initiation of breastfeeding practice has increased.  Exclusive breastfeeding practices have increased.  Complementary feeding has increased.  IFA tablet consumption has increased.  Hand washing practices at critical times has increased.

19. Selection and orientation of adolescent girls on key messages of nutrition:

To improve maternal and child health and nutrition related message dissemination and follow up of behavior and practices across the community the project has selected and oriented adolescent girls on key messages of nutrition.

Activities identified for the groups were:

 Promote nutrition / DNIs messages in school  Promote nutrition / DNIs messages in community  Counseling on DNIs with focus on anemia and IFA consumption within the groups by the adolescents  Establishing and maintaining linkage with others working on nutrition field (maternal, child and adolescent nutrition)

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Event Details:

Planed # of Adolescent in # of CC Upazila # of Adolescent group formed group oriented on project covered DNI message duration Assasuni 17 17 170 Shyamnagar 18 18 180 44 group Muladi 9 9 90 Grand 44 44 440 Total

Outcome:  Early initiation of breastfeeding practice has increased  Exclusive breastfeeding practices has increased  Complementary feeding has increased  IFA tablet consumption by the different target groups has increased  Hand washing practices at critical times has increased

20. Formation of Mother Support Groups:

With active cooperation from UH&FPO and UFPO, IAHBI project of CARE Bangladesh has facilitated to formation of Mother Support Groups in its working areas. The main purpose for formation of these groups as vehicles in disseminating and following up of DNIs related messages across the community to improve maternal, child health and nutrition as well as increase knowledge and practice level through group meeting and household visits.

Event details:

# of Mother Support # of member of # of Mother Support group Upazila Group planned for Mother Support formed formed Group Assasuni 22 220

Shyamnagar 24 240

Muladi 12 120

Grand Total 57 58 580 Outcome:  MSGs are aware and sensitize about their role and responsibilities

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 MSGs are disseminating DNI messages across the community and support other mothers on better practices.

21. Orientation of Mother Support Groups on DNIs:

After formation of Mother Support Groups project has organized orientation for the members of this group to orient them on DNIs. The purposes of the orientation were:  To orient the member of Mother Support Group on DNI messages  To use these groups as vehicles in disseminating and follow up of DNI related messages across the community to improve maternal and child health and nutrition through group meeting and household visits.

Event Details:

Upazila # unit conducted # unit planned Participants Assasuni 59 Shyamnagar 66 Muladi 30

5 Grand Total 5 155

Outcome:

• Community awareness on mother and child health and nutrition has increased • Mothers are now well-known, how to take care of themselves and their children while they are pregnant and lactating including IYCF • Consumption of IFA by pregnant and lactating women has increased • EBF practices has increased • Maternal anemia has decreased • Child under nutrition (underweight) has decreased

22. Refreshers session with Mother Support Groups:

IAHBI project has conducted Three (3) refreshers session with member of Mother Support Groups. The purpose for conducting the session is to provide them update knowledge and information on DNI message and enhance their capacity for functioning the groups in the community. Key issues were facilitated by UH&FPO and UFO.

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Event Details:

Upazila # unit planned # unit conducted Participants 108 Assasuni 132 Shyamnagar 70 Muladi

3 Grand Total 3 310

Outcome:  MSGs are aware about DNI message and information  MSGs are ready to disseminate DNI messages and ready to perform their role and responsibilities.

23. Orientation of Female UP members:

During the project duration IAHBI project has organized orientation of Female UP members. The objectives to organize the session were:

 To sensitize female UP members on DNIs  To include DNIs related agenda in Union level meeting  To mainstream maternal, child and adolescent health and nutrition  To focus on DNIs related activities by the female UP members in other forums (Multi sectoral coordination meeting)  To support CGs(Community Groups) and CSGs(Community Support Groups) in strengthening service delivery at Community Clinic and below level (Satellite clinic, EPI center)  To support and involve decision makers in promoting positive household and community level behavior change (NID, DNIs campaign, CLTS, Adolescent group, Mother Support Group) by Female UP members  To ensure participatory monitoring by the Female UP members in mainstreaming DNIs

Event details:

Orientation # of orientation Participants Upazila Planed conducted

Assasuni 2 63 6 in three upazila Shyamnagar 2 64

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Muladi 2 46

Grand Total 6 173

Outcome:  Maternal and child health and nutrition related agenda has included in monthly UDCC meeting.  Regular Community Clinic visit and observing H&N related activities and providing feedback for further improvement has ensured by the Female UP members  Female UP members are now actively attend the monthly meeting at CC and FWC and provide feedback

24. Half yearly planning sessions with adolescent girls on DNI campaign:

To identify the strategy and spell out of it in successful implementation of DNI campaign by the adolescent girls with a view to reinforce DNI related message dissemination and household level nutrition practices. The adolescents were facilitated to develop half yearly plan with particular focus to organize DNI campaign with support from GOB service providers, Community Groups and IAHBI project. A total of 17 planning sessions has been conducted covering 588 person including 440 Adolescent Girls.

Event details:

Upazila # session planned # Session No of adolescent Total no of conducted girls participated participants Assasuni 6 180 233 Shyamnagar 6 170 233 Muladi 5 90 122 Total 3 17 440 588

25. Promotion of hand washing by school teachers/HA/FWA:

To raise awareness on correct hand washing method and to draw attention on hand washing in critical time, the project has organized hand washing session by school teachers/HA/FWA in project working areas. Adolescent boys and girls are participated this session and oriented detail on technique of hand washing with practical demonstration.

Event Details:

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# session # Session Participants Upazila planned conducted Male Female Total

Assasuni 62 1278 1774 3052

Shyamnagar 60 1149 1754 2903

Muladi 59 866 1835 2701 207 Grand 181 3293 5363 8656 Total

Outcome:  Participants awareness on importance of hand washing has increased  Participants agreed to use hand washing materials at their house hold  Participants give commitment to act as advocate in disseminating message on hand washing across the household level and community  Schools make commitment for ensuring facilities for hand washing for students  Easy hand washing technique has established by the community as a result of facilitation by Adolescent girls group

26. DNI campaign by Adolescent girls/HA/FWA in CC area:

IAHBI project has organized DNI campaign by adolescent girls/HA/FWA in community clinic areas. The objective of the campaign was to build and increase awareness on DNIs among the project participants (pregnant and lactating women, adolescents, decision makers) and to facilitate sustained positive behavior. In the project duration total 20 DNI campaign has organized by the project.

Event details:

Name of the upazila # of campaign Number of Campaign Participants planned Assasuni 7 3230 Shyamnagar 5 893 Muladi 8 1996 Total 18 20 6119 Outcome:  Community people become more aware on DNI  Adolescent Girls Group and Mother Support Groups are now more active to disseminate DNI message among PLW, ADG and others people

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 PLW, ADG and others people have given more importance on DNI issues and they are now maintain DNI activity in their family and the community  Health Care Providers and Managers are more accountable and positive in delivering DNI services from facilities  Community Groups and Community Support Groups proactively take part in participatory monitoring system of CC Activities

C. FACILITATION ACTIVITIES RELATED TO SERVICE DELIVERY:

27. Facilitation to conduct GMP session at the Community Clinic and Family Welfare Center:

Government has continued the GMP session at the Community Clinic and Family Welfare Center. IAHBI project facilitated GoB health care providers to continue GMP session at the service delivery centers at appropriate way with maintain the quality.

Event Details till April 30, 2015:

GMP Session started # of 0 – 23 month children received GMP services

CC FWC CC FWC Total

Upazila

# of

Male Male Male

Total Total Total

GMP GMP

Clinic

Female Female Female

Started Started

# of FWC

Community

3 34 11 10 7433 7073 14506 1362 1279 2641 8795 8352 17147 Assasuni 4 3 38 12 11 6845 6583 13428 997 922 1919 7842 7505 15347 Shyamnagar 8 1 19 7 2 4481 5088 8738 296 271 567 4777 5359 10136 Muladi 9 9 Grand 91 30 23 18759 18744 36672 2655 2497 5127 21414 21216 42630 Total 1

28. Facilitation to continue SAM reporting to IPHN from Satkhira Sadar Hospital and Syamnagar Upozilla Health Complex:

Active facilitation by the Project, SAM report from Satkhira Sadar Hospital and Syamnagar Upazilla Health Complex had been submitted to IPHN through proper channel from October, 2013 to April 2015.

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29. Facilitation to continue DHIS online reporting from Community Clinic:

By active facilitation of the IAHBI project, Community Health Care Providers (CHCP) of CC are now providing their CC performance report to DHIS through online reporting. Out of 91 CC at CARE IAHBI project intervention areas, total 90 CCs are now providing their online report, among them 68 CHCP provide their report by themselves from their own CC and rest of 22 CHCP are providing their report by seeking help from either upazilla statisticians or other CHCP. One CC couldn’t provide the report for delaying approval of online enrolment.

30. Facilitation for screening and identification of SAM/MAM in CC and FWC:

Government has continued the screening and identification of SAM/MAM at the Community Clinic and Family Welfare Center. IAHBI project facilitated GoB health care providers to continue the screening and identification of SAM/MAM at the service delivery centers at appropriate way with maintain the quality.

D. Challenges

Integration of community support system into mainstreaming nutrition intervention usually requires additional time which was recognized as one of the challenges of IAHBI project. Mobilization of community support groups is imperative to create demand and linking the targeted communities with service facilities. Simultaneously focus on group mobilization would be beneficial to ensure participatory governance related to nutrition service delivery which also demands time to perform the desired roles as expected.

Appropriate platform to address multisectoral coordination at sub-district level is important to mobilize resources and increase access of the poor and extreme poor populations into the social services like social safety nets, access to agricultural services, education and wash services within communities. Intersectoral coordination would play a better role for targeting the vulnerable population and reach them with service package. Activation and performance of multosectoral platform needs additional resources and support from the project which was insufficient in this project.

GoB human resources in the health facilities at Upazila and Union level are critical to address the regularization of nutrition service delivery. Existing vacant posts pose a continuous challenge to promote DNI services. This issue was discussed at district and sub-district monthly and quarterly coordination meeting with MOH&FW but still it was beyond the scope of the project to address to improve the situation.

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Event Details till April 30, 2015:

# of 6 - 59 month children identified as SAM / MAM SAM screening # of 6 - 59 month children screened for SAM / MAM started at identification SAM Case identified MAM Case identified

CC FWC CC FWC Total CC FWC CC FWC

Upazila

Held Held

Male Male Male Male Male Male Male

Total Total Total Total Total Total Total

Female Female Female Female Female Female Female

Planned Planned

3 1719 300 1177 1158 34 11 11 8621 8572 3150 6158 23351 55 74 129 29 46 75 808 861 1669 323 334 657 Assasuni 4 3 8 1 0 3 1768 141 1064 Shyamnaga 38 12 12 8448 9232 1394 2809 9842 20489 20 39 59 1 0 1 147 196 343 83 110 193 r 8 0 5 7 1 19 7 7 2706 2822 5528 870 961 1831 3576 3783 7359 52 70 122 7 10 17 472 534 1006 78 82 160 Muladi 9 9 1977 2062 538 1079 2518 2601 101 Grand 91 30 30 40401 5414 51199 127 183 310 37 56 93 1427 1591 3018 484 526 Total 1 5 6 4 8 9 0 0 5.0 Project sustainability:

In February 2015, IAHBI project developed plan for smoothly transition of the project. The objectives of the transition plan were:

 Smooth shifting of the role and responsibility to appropriate stakeholder(s)  Focus on sustainability aspect of the project to ensure lasting impact for the beneficiaries

After sharing the transition plan with UNICEF, the plan was circulated at field for implement the plan accordingly. On 23 March 2015, transition plan was share with Civil Surgeon and Deputy Director (Family Planning), Satkhira. National Nutrition Coordinator of CARE Bangladesh and Project personnel were present the meeting. CS and DDFP were highly appreciating the project activities and they jointly took the following decision:

 Transition plan will share with concern upazilla health and family planning managers by the project  CS and DDFP will informed the upazilla health and family planning managers to continue the DNI activities with their own resources  Joint visit with CS and DDFP at upazilla level for sharing the transition plan.

According the decision, IAHBI project make plan and implement the above decision in Upazilla level with active support from concern Health and Family Planning department. (Transition plan as annex 3)

6.0 Lessons Learned

 Mainstreaming nutrition can be started from Community Clinic with engagement of Community Group (CG) and Community Support Group (CSG) through participatory monitoring, which can increase access to service and quality of services at Community Clinic  Involvement of CG and CSG can increase community awareness and good practices about health, hygiene and nutrition as well as help for tracking, linking and following up of underweight/SAM/MAM cases  Adolescent Girls Group can create greater opportunities to promote many direct and sensitive nutrition interventions across the community  Upazilla and union level Nutrition Coordination Committee is an innovative approach to promote nutrition sensitive and nutrition specific interventions  Interactive sessions like adolescent session and mother group meetings can be helpful to increase the knowledge about health, hygiene and nutrition and also can play important role to change their behavior  Low cost hand washing material (Tippy Tap) can be low cost instrument for low income setting community and it can be replicated at household level to increase the hand washing practice in rural setting.

Conclusion: Mainstreaming nutrition services through health service delivery channels was addressed quite successfully in IAHBI projects. From district and other tiers below were prepared through capacity building, sharing performance information in MOH&FW monthly meeting, continuous capacity development of the health service providers were addressed through on the job training, joint supervisory visits, online reporting on HMIS was monitored and continuous technical support was provided by the IAHBI project staffs at union, sub-district and district level. These combined efforts addressed the performance drivers of the health service providers of MOH&FW to improve their capacity and service delivery channels were strengthened as a whole. Multisectoral platform was created at sub-district level from the participation of different sectors who are linked with nutrition sensitive service delivery and tied with MOH&FW who are responsible to provide nutrition specific services. CARE’s approach in operationalizing the multisectoral platform at sub-district level links the union platforms but lacks from developing a forward linkage mechanism from district. Functional Union Development Coordination Committee meeting is the platform of multisectoral platform at union level which links with sub- district nutrition coordination committee. This backward and forward linkage could make an effective multisectoral approach to strengthen the delivery of both nutrition specific and sensitive services for the targeted population. Unfortunately, IAHBI projects didn’t have enough time to create these platforms to deal with the challenges and mainstream nutrition learning at three different levels and measure the impact of this approach. Still, IAHBI created opportunity to learn about, gaining experiences at union and sub-district level which can be replicated into another community-based nutrition programming in Bangladesh. CARE, B is transferring this skill and experiences from this project to replicate into another newly designed nutrition program in the north-east haor areas to see effectiveness of this approach. Furthermore, community support system was also slotted in to create enabling environment to ensure community participation in reviewing overall performance of the offered services. Segment of the population who have limited access to information and services are targeted such as poor and extreme poor pregnant and lactating women were promoted to get nutrition services and to include into social safety net services. The path of sustainability reliably addresses

Project Completion Report _IAHBI Project_CARE B Page 42 integration of nutrition sensitive and nutrition specific interventions during the project duration which also needs a considerable time realizing the context and result. Thus, community support system can anchor to create a sustainable links between communities and service delivery channels.

Project Completion Report _IAHBI Project_CARE B Page 43

6.0 Annex:

Annex 01

Key findings of facility assessment

Table 1: Availability of aids in community clinic on April, 2015

Assasuni Shyamnagar Muladi

Number of CC % of CC Number of CC Number of CC Sl # Aids with available that with available % of CC that with available % of CC that aids (total 34 available aids (total 38 available aids aids (total 19 available aids CC) aids CC) CC)

Iron and Folic 1 Acid (IFA 34 100% 38 100% 19 100% tables) 2 ORS 34 100% 38 100% 19 100% 3 Zinc tablet 34 100% 38 100% 19 100% 4 Albendazole 34 100% 38 100% 19 100% Vitamin – A 5 34 100% 38 100% 19 100% Capsules 6 Calcium tablet 34 100% 38 100% 18 95%

Table 2: Availability of supplies / equipment at CC on April, 2015

Assasuni Shyamnagar Muladi Number of CC Sl % of CC that Number of CC with % of CC that Number of CC with % of CC that Equipment with available # available available equipment available available equipment available equipment (total equipment (total 38 CC) equipment (total 19 CC) equipment 34 CC) 97% 1 Weighing scale 34 100% 37 19 100% 97% 2 Weighing trouser 34 100% 37 19 100% Mother / Child 3 electronic weighing 27 84% 38 100% 0 0% scale Infant scale for birth 4 0 0% 0 0% 0 0% weight and trouser kit Height roller tape 5 34 100% 37 97% 17 89% (adults)

6 Height / Length board 34 100% 38 100% 0 0% 100% 7 MUAC tape 34 100% 38 19 100% 100% 8 GMP card 34 100% 38 19 100% Timer or watch with 9 0 0% 6 16% 16 84% seconds hand Calibrated ½ or 1 liter 10 13 41% 36 95% 16 84% measuring jar for ORS 11 Cup and spoon 4 13% 28 74% 5 26%

Project Completion Report _IAHBI Project_CARE B Page 45

100% 12 Thermometer 34 100% 38 18 95% 13 Examination table / bed 31 91% 38 100% 18 95% Table 3: Service Available at community clinic on April, 2015

Assasuni Shyamnagar Muladi

Number of CC % of CC Number of CC % of CC Number of CC Sl # Aids % of CC provide provide services provide provide services provide provide services services (total 34 CC) services (total 38 CC) services (total 19 CC)

Breastfeeding 1 34 100% 38 100% 19 100% counseling 2 Counseling on IYCF 34 100% 38 100% 19 100% Counseling on 3 34 100% 38 100% 19 100% adolescent nutrition 100% 4 ANC 34 100% 38 19 100% 100% 5 PNC 34 100% 38 19 100% 100% 6 IFA distribution 34 100% 38 19 100% Treatment of 7 34 100% 38 100% 19 100% Diarrhea 8 GMP session 34 100% 38 100% 19 100% Screening of SAM / 9 34 100% 38 100% 19 100% MAM Child curative care 10 34 100% 38 100% 19 100% services