Nutrition Governance in Bangladesh A National and Upazila-level Assessment R4A: Research for Action in International Development 3/6/2014 This report is composed by Sanaul Mostafa, Kevin Robbins and Jonathan Rose (team lead and main contact: [email protected]). The views expressed in this document are those of the authors and do not necessarily reflect the views of Save the Children. The authors thank Save the Children for their support, as well as numerous individuals from government, civil society, development partners, academia and local communities. 1 R4A: Research for Action in International Development Nutrition Governance in Bangladesh TABLE OF CONTENTS Acronyms and Abbreviations ........................................................................................................................ 1 Executive Summary ....................................................................................................................................... 4 1.0 Introduction and Method for the Assessment .................................................................................. 17 Part 1: Literature Review and a National Level Assessment of Nutrition and Nutrition Governance .................................................................................................................................................................... 18 2.0 A Policy Framework for Nutrition Intervention ................................................................................. 19 2.1 Nutrition Sensitive Interventions: an Undeveloped Concept for Governance .............................. 21 2.1.1 Multi-sectoral Coordination of Nutrition Governance ............................................................ 22 3.0 Trends and Current Status of Nutrition in Bangladesh ..................................................................... 24 3.1 Manifestation of Malnutrition ....................................................................................................... 24 3.2 Overview of Immediate and Underlying Causes ............................................................................ 26 4.0 Current Nutrition Plans and Programs in Bangladesh ....................................................................... 29 4.1.1 Nutrition specific activities through the LANCET lens ............................................................. 29 4.2 Nutrition Sensitive Plans and Activities ......................................................................................... 31 4.2.1 Country Investment Plan 2011 ................................................................................................ 31 4.2.2 Other ministries ....................................................................................................................... 33 5.0 Governance Challenges to Nutrition ................................................................................................. 34 5.1 Nutrition Specific Challenges: the NNS .......................................................................................... 34 5.1.1 Lessons from the Past ............................................................................................................. 34 5.1.2 Current challenges to the NNS ................................................................................................ 38 5.1.3 Current challenges to Community Clinics ............................................................................... 39 5.2 National Nutrition Multi-Sectoral Committee Challenges ............................................................. 39 5.2.1 Overview ................................................................................................................................. 39 5.2.2 The Existing Multi-Sectoral Committees ................................................................................. 40 5.2.3 Limited Scope for a High Level Multi-Sectoral Committee ..................................................... 43 5.3 Governance Challenges to Nutrition Sensitive Initiatives within Ministries ................................. 45 5.3.1 Governance Challenges to Health Services in the MoHFW .................................................... 45 5.3.2 Governance challenges to the Ministry of Agriculture, especially the Diversification of Agricultural Production ........................................................................................................................ 47 5.3.3 Governance challenges to other efforts ................................................................................. 48 6.0 Recommendations for the National Level ......................................................................................... 50 Part 2: An Assessment of Nutrition Governance in Two Upazilas .............................................................. 55 7.0 Background for the Study .................................................................................................................. 56 7.1 Methodological Context ................................................................................................................ 56 8.0 The Context for Sylhet and the Two Upazilas.................................................................................... 58 8.1 Sylhet and Nutrition ....................................................................................................................... 58 8.2 The Two Upazilas and Nutrition ..................................................................................................... 60 9.0 Nutrition Governance in the Two Upazilas ....................................................................................... 64 10.0 Nutrition Governance by Sector ...................................................................................................... 66 10.1 Health and Nutrition – Community Clinics .................................................................................. 66 10.1.1 General Health and Nutrition Situation ................................................................................ 66 10.1.2 Main Health and Nutrition Programs at the Local Level ....................................................... 66 2 R4A: Research for Action in International Development Nutrition Governance in Bangladesh 10.1.3 Human Resources .................................................................................................................. 67 10.1.4 Drug Management and the Supply Chain Management in CCs ............................................ 68 10.1.5 Management and Supervision .............................................................................................. 69 10.2 Agriculture ................................................................................................................................... 69 10.2.1 General Agriculture Situation ................................................................................................ 69 10.2.2 Nutrition-sensitive programs ................................................................................................ 70 10.2.3 Governance Challenges ......................................................................................................... 71 10.2.4 Some Technical Options for Consideration ........................................................................... 72 10.3 Fishery .......................................................................................................................................... 72 10.3.1 General Status of Fishing in the Areas .................................................................................. 72 10.3.2 Current Nutrition-Sensitive Programs ................................................................................... 73 10.3.3 Governance Challenges ......................................................................................................... 73 10.3.4 Some Technical Options for Consideration ........................................................................... 73 10.4 Livestock....................................................................................................................................... 74 10.4.1 Suitability of areas for livestock and motivation of farmers ................................................. 74 10.4.2 Nutrition-sensitive programs ................................................................................................ 74 10.4.3 Governance Challenges ......................................................................................................... 74 10.4.4 Some Technical Options for Consideration ........................................................................... 75 10.5 Water and Sanitation ................................................................................................................... 75 10.5.1 Coverage ................................................................................................................................ 75 10.5.2 Nutrition-sensitive Program .................................................................................................. 76 10.5.3 Governance Considerations .................................................................................................. 77 10.5.4 Some Technical Options for Consideration ........................................................................... 77 10.6 Women Affairs ............................................................................................................................