Food Utilization and Nutrition Security - BIDS

Food Utilizationand Nutrition SecurityBinayak Sen, Purnima Menon, Akhter U. Ahmed, and Fatema Parveen ChowdhuryBangladesh Food Security Investment Forum, 26–27 May 2010, Dhaka

FOOD UTILIZATION AND NUTRITION SECURITYBinayak Sen, Bangladesh Institute of Development StudiesPurnima Menon, International Food Policy Research InstituteAkhter U. Ahmed, International Food Policy Research InstituteFatema Parveen Chowdhury, Institute of Public Health and Nutrition,Ministry of Health and Family WelfarePrepared for theBangladesh Food Security Investment ForumMay 2010

CONTENTSEXECUTIVE SUMMARY ............................................................................................................................................................................... 5OVERVIEW OF THE NUTRITION SITUATION IN BANGLADESH: ISSUES AND TRENDS ................................................................................. 6Introducon and framework ....................................................................................................................................................... 6Policy focus on the “window of opportunity” ............................................................................................................................. 7Prevalence of maternal and child undernutrion ....................................................................................................................... 8Trends in maternal and child undernutrion .............................................................................................................................. 9The link between maternal and child nutrion ........................................................................................................................... 9DIRECT ROUTES FOR IMPROVING NUTRITION .......................................................................................................................................... 9The channel of targeted nutrion and health programs ........................................................................................................... 10Status of direct intervenons .................................................................................................................................................... 13INDIRECT ROUTES FOR IMPROVING NUTRITION ..................................................................................................................................... 13Poverty reducon ...................................................................................................................................................................... 13Agriculture-led improvement in diet quality ............................................................................................................................. 15Women’s empowerment .......................................................................................................................................................... 15LOOKING FORWARD: POLICY LEVERS FOR IMPROVED NUTRITION ......................................................................................................... 15Direct intervenons to reduce undernutrion ......................................................................................................................... 16Indirect intervenons to reduce undernutrion ....................................................................................................................... 16CONCLUSION .......................................................................................................................................................................................... 18REFERENCES ............................................................................................................................................................................................ 19*Note: All references to taka (TK), the currency of Bangladesh, are based on the official exchange rate as of May 20, 2010: TK 69.35 per US$1.

EXECUTIVE SUMMARYThe consequences of high maternal and child undernutrion cannot be emphasized enough. A combinaon of poor maternal nutrionand postnatal factors cause child undernutrion, which in turn can have far-reaching consequences for naonal and global developmentoutcomes. The levels of stunng, underweight, wasng, and childhood anemia are very high in Bangladesh, as are levels ofmaternal chronic energy deficiency and anemia. Notwithstanding previous posive trends in these indicators, the pace of improvementsin maternal and child undernutrion in the country needs rapid and sustained acceleraon.Three guiding principles are used to idenfy policy priories for addressing food ulizaon and nutrion security in Bangladesh:First, in considering an individual’s nutrional health, the period between his or her mother’s pre-pregnancy (including adolescence)and his or her first two years of life is viewed as a crical pivot point for targeng intervenons. Second, the United Naons Children’sFund (UNICEF) conceptual framework for nutrion is used to frame the role of mulple factors that influence maternal and childnutrion. Third, linked to this framework, a set of linked direct and indirect intervenons that need to be in place to achieve rapidreducons in undernutrion is mapped. Direct intervenons are those that have short-term impact on direct determinants of nutri-on (such as dietary intakes and health status) and include age-appropriate infant and young child feeding, immunizaon, populaoncontrol, hygiene intervenons, and access to prevenve and curave health care. Indirect intervenons are those that can modifythe influence of direct intervenons, or themselves affect dietary intake and health status through routes of household food security,poverty, women’s empowerment, and agriculture. Bringing both direct and indirect intervenons together and targeng them duringkey periods of opportunity will maximize benefits.Based on this approach and empirical evidence from Bangladesh, we propose the following acons to address the high burdenof undernutrion: (1) Idenfy, cost out, and sharply scale up a priority package of direct nutrion and health intervenons targetedto adolescents, women of reproducve age, pregnant and lactang women, and children under two years of age. This will requireaddressing design and implementaon constraints in the Naonal Nutrion Program as well as the use of the health, water sanita-on, and educaon sectors to more strongly address nutrion. (2) Generate impact and operaonal evidence to build consensusaround contextually appropriate intervenons to address childhood anemia and acute malnutrion. (3) Recognize the crical natureof underlying factors such as food security, gender, food prices, and agricultural policies in improving nutrion to ensure appropriateintervenons and policies are in place to address these; not doing so could severely compromise the impact of direct intervenons.(4) Invest in a solid monitoring and evaluaon framework and process for nutrion that is linked closely to the monitoring and evaluaonframework for the health sector and other relevant sectors. (5) Ensure an effecve, authoritave, and funconing naonalcoordinang mechanism to convene, facilitate, mobilize, and hold accountable the mulstakeholder plaorm that must deliver theacvies needed to improve nutrion.In summary, a solid policy focus and substanal investments are needed both on direct and indirect intervenons, targeted at thewindow of opportunity of pre-pregnancy and the first two years of life, for addressing maternal and child undernutrion. Prevenonof undernutrion should be front and center in an overall strategy, with curave intervenons integrated. Neither by itself will be sufficientto bring about change at the scale needed for significant improvements. This is well recognized by the government of Bangladeshin the areas of intervenon for nutrion specified in the Naonal Food Policy Plan of Acon. Our analyses and recommendaons areintended to sharpen the policy focus and priorize high-impact intervenons.5

OVERVIEW OF THE NUTRITIONSITUATION IN BANGLADESH:ISSUES AND TRENDSIntroduction and frameworkThe economic consequences of high maternal and child undernutrioncannot be overstated. A combinaon of high maternalundernutrion and postnatal factors cause child undernutrion,which in turn can influence children’s school performance andtheir future occupaonal choices, and can undermine the futureproducvity of naons. Notwithstanding rapid economic growthin a number of South Asian countries (including Bangladesh andIndia), the pace of improvements in maternal and child undernutrionin the region remains deeply unsasfactory. Bangladeshhas made considerable progress in addressing the non-incomepoverty indicators for the first Millennium Development Goal(MDG1)—that is, reducing the prevalence of underweight childrenunder five years of age—but improvements are slowing,which raises quesons about whether the target will be achievedor not. Furthermore, the overall levels of maternal and childundernutrion are sll high in Bangladesh, and further investmentsare needed to accelerate improvements and preventthe negave impact of maternal and child undernutrion onlong-term development. This paper is, therefore, about thepolicy focus that is needed to greatly improve the current statusof maternal and children nutrion. Although overweight andobesity are emerging problems in Bangladesh, this paper will notaddress this aspect of undernutrion. However, it is a potenalconcern in the future, and this trend should be monitored.The UNICEF conceptual framework for nutrion, whichspecifies that maternal and child nutrion outcomes are determinedby immediate, underlying, and basic factors (see Figure1), is at the heart of this paper. The immediate and underlyingfactors, and the related “direct” and “indirect” (or “short route”and “long route”) intervenons they map to, form the basisfor our framing of policy opons for reducing undernutrionin Bangladesh. Evidence from countries that rapidly reducedundernutrion show clearly that invesng in both kinds of intervenonsis crucial to success (Von Braun, Ruel, and Gula 2009).Neither one is likely to be sufficient to sustain rapid reduconsin undernutrion. This is because there is no single magic bulletsoluon to the persistent problem of high maternal and childundernutrion in South Asia, including Bangladesh. Thus, thereare two routes to address undernutrion:a. The route of direct intervenons that aim to improvethe nutrional status by directly providing health andnutrion inputs. This includes expanding the reach ofpublic health measures (such as water and sanitaon,maternal and child health care) as well as “targetedFigure 1— The link between the UNICEF conceptual framework and direct/indirect interventionsIntervenonsChild NutrionSHORTRBreaseedingComplimentary feedingVitamin AZincHygieneFood/nutrient intakeHealthImmediatecausesOUTESLONGROUTES- Agriculture- Poverty Reducon- Educaon- Health Systems Strengthening- Income generaon- Women’s empowermentAccessto foodMaternaland child-carepraccesWater/Sanitaonhealth servicesUnderlyingcausesINSTITUTIONSPOLITICAL & IDEOLOGICALFRAMEWORKBasiccausesECONOMIC STRUCTUREAdapted from UNICEF 1990Source: Ruel, SCN News 2008RESOURCESENVIRONMENT, TECHNOLOGY, PEOPLE6

nutrional intervenons” (Bhua et al. 2008). Animportant component of direct nutrional intervenonsrelates to behavior change communicaon aimedat influencing health and nutrional behaviors athousehold and community levels. This encompasses arange of acvies such as exclusive breaseeding andcomplementary feeding, promong hygienic behavior,changing intrahousehold allocaon paerns of food,reducing ferlity, and other pracces.b. Indirect routes that influence the household capacity toinvest in maternal, adolescent, and child nutrion. Theseinclude various economic and social empowermentmeasures that can reduce consumpon poverty,increase non-cereal food and micronutrient intake, andincrease women’s empowerment, thus having effectson health and nutrional outcomes more indirectly.Both avenues are important for discussing the policieson improving nutrional security in the present context ofBangladesh. The routes of poverty reducon and women’sempowerment can have important influences on undernutrion(Monteiro et al. 2010) and contribute significantly to enhancingthe effects of most of the direct nutrional intervenons. On theother hand, lack of access to direct intervenons and poor healthand nutrional behavior can constrain nutrional improvementseven in resource-rich households.Policy focus on the “window of opportunity”This paper is based on the basic understanding that in order toimprove undernutrion, it is crical to ensure that nutrion intervenonsare priorized for women and children in the biologicalperiods when they are most vulnerable to the effects of poor nutri-on. This is the window between pre-pregnancy and two years ofage, which is also the window within which ensuring good nutrionyields the greatest returns in terms of educaon, income, chronicdiseases, and other outcomes (Victora 2010; Hoddino 2008). It isalso the window in which prevenve intervenons yield substanalbenefits (Ruel et al, 2008). Given high rates of adolescent undernutrionin Bangladesh, and the link between adolescent pregnancyand poor maternal and child health and nutrion outcomes, it iscrucial that the window of opportunity encompass the vulnerableperiod of adolescence in Bangladesh and, in fact, in all of SouthAsia (Rah et al. 2008 and 2009).Data from Bangladesh substantiate global findings onthe age and timing of growth faltering and poor nutrition inchildren (Victora et al. 2010; Black et al. 2008). Figure 2 belowshows that anthropometric outcomes among Bangladeshichildren reflect global patterns; using height-for-age we seedramatic declines between 0 and 2 years of age with littlechange thereafter. Very importantly, the figure also showsthat children in Bangladesh are already substantially undernourishedeven at birth. This highlights the need to focus onthe mother-child dyad and window of opportunity to achievenutrition improvements.Figure 2—Height-for-Age Z-Scores by Age, Bangladesh, 2007HEIGHT-FOR-AGE Z-SCORES BY CHILD AGE, BANGLADESH, 2007HAZ0-0.5-1-1.5-2-2.5Child age (months)1 3 5 7 9 11131517192123252729313335373941434547495153555759Addressing maternal health andnutrion prior to and duringpregnancy and childbirth iscrucialSource: Bangladesh Demographic and Health Survey 2007 data.Intervening with evidencebasedintervenons toprevent irreversible growthfaltering and brain damage isalso cricalData on stunng and underweight show that thesemeasures of undernutrion also increase dramacally in the0−2 year age range, with lile change thereaer. For wasng,the 0−2 age period shows a peak, with highest wasng ratesseen in the 9−21 month age period. Anemia also peaks in thisage group, demonstrang the importance of this age windowfor intervenons.High levels of undernutrion in early infancy (0−3 monthsof age) reflect poor nutrion in utero and of the mother priorto pregnancy. Studies of intervenons that aimed to improvebirth outcomes by targeng the period of pregnancy have foundlimited success. More recently, research in Bangladesh hasreinforced the pre-pregnancy state of the mother as being a keydriver of the success of intervenons during pregnancy (Shaheenet al. 2008).Prevalence of maternal and child undernutritionNotwithstanding some noceable progress over the past decade,the prevalence of child and maternal undernutrion remainsalarmingly high. The proporon of underweight children was 41percent in 2007, according to Demographic and Healthy Surveys(DHS) data. 1 The proporon of stunted children is as high as 43percent (Figure 3). Anemia is also a widespread problem, withesmates suggesng that anemia rates among young infantscould be as high as 90 percent.From a gender perspecve, child undernutrion is 42percent for female children and 40 percent for male children;however, differences in undernutrion between boys and girlshave increased during 2000−2007. Furthermore, some analysessuggest that although there are no gender differenals earlyin infancy (0−2 years of age), they become more prominent as1This is according to the new World Health Organizaon standard. The previousNCHS standard would place it at 46 percent (see REACH-Bangladesh: SelectedResults from Situaon Analysis, PPT, 5 April 2010, p. 2).7

Figure 3— Prevalence of anemia and undernutrition (anthropometic indicators) among children and women in BangladeshPrevalence of maternal and child undernutrionChildhood anemia (HKI, NSP 2006) Anthropometric indicators (BDHS 2007)1009080706050403020100Child age groups6–11 mo12–23 mo24–35 mo35–47 mo48–59 mo50454035302520151050Anthropometric indicatorsStunngUnderweightWasngWomen with low BMIWomen

also declining from 28 percent to 16 percent in a maer of onedecade between 1996/97 and 2007. The declines in stunng areparcularly encouraging given the long-term impact of stunngon later cognion, schooling, and other development outcomes.Sll, given the stalling of the trend in underweight, accelerangefforts to improve nutrion will be essenal to achieve the MDGtarget of 33 percent child underweight by 2015.Figure 4— Trends in maternal and child undernutrition(1996–2007)well-nourished mothers. The sharp contrast in the child nutri-onal status between severely malnourished and well nourishedmothers largely holds true for all three child anthropometricmeasures and all four household poverty categories.High levels of anemia among children 6−11 months of agealso reflect poor iron stores among children at birth, which inturn is linked to iron status anemia in adolescents and women.The key takeaway here is that the link between women’snutrion and health and children’s nutrion and health is inextricable,and both need to be addressed simultaneously.6050403020042007DIRECT ROUTES FOR IMPROVINGNUTRITIONThe channel of targeted nutrition and healthprograms20100Stunng Underweight Wasng Low BMI(women)Source: Bangladesh DHS (1996-2007); child anthropometry trends are esmatedusing the NCHS reference standards for parity across years and with the MDGindicator. Graph courtesy of Helen Keller Internaonal, Bangladesh.Data on trends in micronutrient deficiencies are not available;therefore, ensuring availability of naonally representavedata on micronutrient deficiencies among women and childrenshould be a high priority.The link between maternal and child nutritionThere is a strong link between maternal and child undernutri-on. This can be seen from both household and spaal data .There is ample evidence that undernourished mothers tend tohave undernourished children, operang mainly through theroute of in-utero nutrion and immediate postnatal care (such asbreaseeding and illness). The proporon of underweight childrenin the category of malnourished mothers is 51 percent; incontrast, the matched indicator for the well-nourished mothersis 38 percent, according to DHS 2007 data.The above is true even when one controls for the variaonin the household poverty status. In the case of the extreme poor,the proporon of children underweight for severely malnourishedmothers (those with a body mass index of less than 16)is 76 percent while the matched figure for the well nourishedmothers (those with a body mass index of more than 18.5) is 53percent (Begum and Sen 2009). Similarly, in the case of a middlenon-poor group, the matched figure for the severely malnourishedmothers is 56 percent as opposed to 33 percent for theDirect routes for improving nutrion are those intervenonchannels that aim to improve the immediate determinantsof undernutrion depicted in the UNICEF conceptual framework,specifically, dietary intake (including diet quality) andhealth. There is now a core of global evidence, including fromBangladesh, which lies behind some of the recommended directintervenons to address maternal and child undernutrion.These include evidence reviews and syntheses in the LancetSeries on maternal and child undernutrion (2008) as well as themore recent analyses on the costs of scaling up direct evidencebasedintervenons globally (Horton, Shekar, and Mahal 2009;Bezanson and Isenman 2010).Broadly, the evidence base idenfies a set of core interven-ons that should reach women and children at a coverage rate ofat least 90 percent to yield improvements of up to 30 percent inundernutrion (Bhua et al. 2008). These intervenons must bedelivered primarily by the health sector and by direct and targetednutrion programs that focus on the window of opportunity agegroup . They include the following types of direct intervenons:• Direct intervenons for maternal nutrion: Iron-folatesupplementaon, food supplementaon during pregnancy,calcium supplementaon, antenatal care (includingcounseling for improved food intake and supplementaon,increased rest, and preparaon for breaseeding).• Direct intervenons for child nutrion: Behavior changecounseling for early and exclusive breaseeding, ageappropriate complementary feeding and micronutrientsupplementaon (if needed), provision of micronutrientsupplements or forfied complementary foods, hygieneintervenons (via behavior change communicaonsand increased access to water/sanitaon facilies), andnutrional management of severe-acute undernutrioneither in facilies or communies.9

Choices about which direct intervenons to priorize in acountry nutrion strategy must be based on a careful analysisof the current gaps in the coverage of each of the crical knownintervenons, the context-specific impact of each crical intervenon,and the potenal channels through which access to anduse of crical intervenons might be scaled up.Intervenons to improve the quality of infant diets inBangladesh have included peer counseling to encourage exclusivebreaseeding, homestead food producon combined withnutrion educaon to improve quality of complementary feedingdiets, counseling to improve use of family foods that enhance thequality of complementary foods fed to infants, the use of micronutrientpowders (“Sprinkles”) to improve the micronutrientcontent of home foods, and distribuon of food supplements(cereal-pulse mixes) (Haider et al. 2000; Roy et al. 2005; Hyderet al. 2007). Unfortunately, few studies in Bangladesh provideinsights into how best to address the parcular challenge ofimproving diets of young children at a large scale .Health sector intervenons that can have an impact onnutrion outcomes for women and children include immuniza-on, hygiene promoon, provision/supply of appropriate toilets/latrines and safe sources of water, vitamin A supplementaon,provision of iron-folate supplements, zinc and oral rehydraonfor diarrhea treatment, and promoon of breaseeding at welland sick child visits .Status of direct interventionsBangladesh has had policies and policy instruments to addressmaternal and child undernutrion for many years now. Notableamong these are the Naonal Nutrion Policy and the NaonalStrategy for Infant and Young Child Feeding in Bangladesh, bothof which are well focused on direct intervenons targeted to the“window of opportunity” meframe. The major policy instrumentfor direct intervenons such as food supplementaon andcounseling for improved feeding of infants and young children isthe Naonal Nutrion Program (NNP). A variety of other stakeholdersare implemenng supporng and smaller-scale interven-ons related to direct nutrion inputs. Other health and nutrionintervenons (such as immunizaon, iron-folate supplementa-on, etc.) are implemented through the public health systemand private health care providers. Intervenons to improveinfant and young child feeding are currently implemented withvarying intensity and scale, and by different stakeholders acrossBangladesh, but need beer harmonizaon of messages andmaterials, and beer outreach to influenal household andcommunity members. Recent analysis suggests that interven-ons to promote exclusive breaseeding, a crucial intervenonfor improved nutrion and decreased rates of neonatal andinfant mortality, currently reach less than 35 percent of mothers. 2Progress toward scaling up breaseeding promoon and supportintervenons is oen compromised by violaons of the Code of2REACH landscaping analysis (WFP-Bangladesh and partners).Markeng of Breast Milk Substutes; capacity and funding formonitoring code violaons are currently lower than needed. Acall to acon for addressing exclusive breast feeding and otheraspects of infant and young child feeding more forcefully is ofutmost importance (Talukder and Talukder, 2009)In relaon to quality of complementary foods, in addion tobehavior change communicaon intervenons through differentchannels, nongovernmental organizaons (NGOs) have been implemennghomestead food producon intervenons for many yearsnow. However, many of these have not been effecvely integratedwith nutrion counseling, diminishing the impact of this interven-on. The use of micronutrient powders to improve diet quality hasalso been well studied in Bangladesh and has been shown to beeffecve at reducing anemia. This program is now being implementedon a small scale within the NNP, as well as by differentinternaonal agencies. Addionally, the local private sector haslaunched the sale of micronutrient powders in the market.The status of many health sector intervenons is reasonablyhigh in Bangladesh. Sll, sustaining already high coverageof certain intervenons, and “going the last mile” to scale themup further to 90−100 percent coverage can help substanally. Areview of the status of a range of key intervenons/inputs forchild nutrion in the Bangladesh DHS data from 2007 (Figure5) shows that for many key inputs, the coverage levels are wellbelow even 50 percent. A core set of intervenons and a call toscale these up in Bangladesh is also highlighted in Ahmed andAhmed (2009). Intervenons that are parcularly important toaddress are early and exclusive breaseeding (EBF), age-appropriatecomplementary feeding, ensuring diet quality throughdiversified diets and addional food/micronutrient supplementsas needed, treatment of acute malnutrion when needed, andimproved maternal nutrion and sanitaon intervenons.Figure 5— Status of key direct interventions for child nutritionin Bangladesh10090807060% 50403020100Inputs for ensuring good child nutrionBF = breast feedingCF = complementary feedingSource: BDHS (2007)Early iniaon of BFExclusive BF (0–6 mo)Introducon of CF at 6–9 mo3 expected IYCF praccesIron-rich foodAll basic immunizaonsVitamin A suppl ( 3 ANC visitsWomen - normal BMIHH - access to improved waterANC = antenatal careIYCF = infant and young child feedingSource: Bangladesh Demographic and Health Survey [BDHS] 2007; we includematernal nutrion, access to prenatal care and access to improved water asdirect inputs to nutrion given their cricality in the window of opportunity)Of some concern in relation to nutrition outcomes isthe poor status of sanitation, both from the perspective of10

sanitation behaviors and access to facilities. Only 25 percentof households have access to improved sanitation, eventhough more than 95 percent of households have access toimproved sources of water (BDHS 2007) . Less than 40 percentof households use safe disposal practices for children’s stools,which can be a major source of microbial contamination of thehousehold environment (personal communication). Becausepoor sanitation can influence nutrition through more routesthan just diarrhea, sanitation interventions deserve greaterattention to reduce undernutrition further (Humphrey 2009).A mid-term review of the Health, Nutrion and PopulaonSector Programme (HNPSP) in early 2008 highlighted a number ofissues that need to be addressed to achieve health and nutrionobjecves of the sector program. Box 1 below highlights someof these from the perspecve of the Naonal Nutrion Program,though other direct health intervenons are also highly relevantto addressing nutrion objecves. A specific review of theoverall health sector implementaon from the perspecve ofnutrion is outside the scope of this paper but is likely to beimportant to do to achieve objecves of beer integraon ofhealth and nutrion acvies within the health sector. Table 1,following Box 1, lays out the crical package of direct interven-ons that should be considered for scaling up, and discussesthe current status of these intervenons and consideraons forscaling them up.Box 1— An overview of the National Nutrition Program, current known challenges, and the way forwardBackground: The government’s Ministry of Health and Family Welfare, with the assistance of development partners, has made substanalinvestments in nutrion, including the Naonal Nutrion Program (NNP), which provides comprehensive nutrion services to childrenand women at a community level. NNP aims to reduce malnutrion in children, adolescent girls, and women through community-basednutrion intervenons and intersectoral efforts to improve nutrion of vulnerable segments of the populaon. The core NNP servicesinclude (i) behavioral change communicaon (BCC) acvies, (ii) training, (iii) birth weight recording and registraon, (iv) growth monitoringand promoon (GMP) acvies, (v) food supplementaon to the malnourished children under 2 years of age and severely malnourishedmothers, (vi) micronutrient (vitamin A and iron folate) supplementaon, and (vii) awareness building forums for adolescent girls and newlyweds.The NNP was designed to provide services from community nutrion centers (CNCs), each covering a populaon of approximately1,200 and managed by nongovernmental organizaons (NGOs), which were contracted out through compeve bidding. Currently, 10NGOs are contracted to deliver services for NNP through 23,246 CNCs in 109 upazilas in 34 districts, with considerable variaon in thenumber of CNCs managed by each NGO—ranging from 5,226 CNCs for one NGO to only 253 CNCs for another. Recently, NNP coverage wasexpanded to 63 new upazilas, making the coverage around 35 percent of all upazilas.Known design and implementaon Issues: The government’s response to malnutrion in Bangladesh has focused on Area BasedCommunity Nutrion (ABCN) intervenons under the NNP. However, the program has been plagued by regular interrupons in servicedelivery due to delays in contracng the service-delivery NGOs and weakened by design flaws idenfied when the program was implementedas the Bangladesh Integrated Nutrion Program (BINP). Weak technical capacity to design, manage, and effecvely supervisethe nutrion programs remains a major impediment of delivering effecve services. Monitoring and evaluaon has not been invested inadequately; since the end of BINP, which raised many cricisms around program design and evaluaon approaches, there have been nomajor investments in evaluang the impact and processes related to NNP itself.Looking forward: Specific intervenons in the current package of NNP services should be carefully reviewed in light of naonal and globalevidence. Explicit consideraon should be given to how to integrate and scale up a priority “nutrion package” of known effecve interven-ons idenfied through the Lancet Nutrion Series (2008) and new global recommendaons (Scaling up Nutrion 2010) into the programand beyond, into the health and other sectors. Highest priority for scaling up should be given to those intervenons that are feasible andacceptable for rapid scale-up in the Bangladeshi context, both through the NNP and other delivery plaorms of the health system, includingfamily welfare assistants and other community and local health center-based workers. Using non-NNP NGOs to scale up intervenonssuch as behavior change communicaons (BCC) for improved infant and young child feeding, hygiene and sanitaon intervenons andwomen’s nutrion could also help achieve scale more rapidly. There is an urgent need to build operaonal evidence and move toward technicalconsensus on intervenons that need more local adaptaon, such as those to address acute malnutrion through community-basedmanagement programs. From an implementaon perspecve, NNP needs to further invest in adding nutrionists to the NNP team andbuilding skills and technical capacity to supervise and monitor the implemenng NGOs. Ensuring an overarching monitoring and evaluaonframework for nutrion is crucial, as is strengthening impact and process evaluaon to build evidence on what works to ensure availabilityof high quality nutrion intervenons at scale. Using new monitoring plaorms such as the Food Security and Nutrion Surveillance Project(FSNSP) can also aid with monitoring of outcomes.11

Table 1—Overview of status and trends in direct interventions and factors to consider in relation to scaling up direct interventionsDirect intervenon Status, trends Policy instrument/programimplementaon modaliesFactors to consider for accelerang scaleupEarly iniaonof exclusivebreaseeding &exclusivebreaseeding for 6monthsRates of early iniaon increasingbut sll low overall (43%); colostrumfeeding is high . EBF rates (43%) havenot changed in the last 15 years.HNPSP/NNP (antenatal care,counseling during pregnancy);NGOs; mass media to raiseawareness.BBF helps with code monitoring butviolaons connue to be rampant.Lack of workplace and home-basedsupport for EBF leads to high dropoff rates at 3−4 months.Constraints to EBF for 6 months operateat different levels: individual, family,workplace, community, private sector(formula companies). Strengthening,harmonizing, and expanding acons inthe Naonal IYCF Strategy, using DGHS/DGFP/NNP plaorms; NGOs; mass media.Expanding current monitoring mechanismsof code of markeng of breastmilksubstutes.Age-appropriatecomplementaryfeeding (mingof introducon,diet diversity, dietquality, frequencyof feeding,consumpon offorfied foods orsupplements whereneeded, responsivefeeding)Iniaon of complementary feedingbetween 6-8 months is now at 74%but diet quality, frequency andamounts fed are a major issue (only16% of 6-8 month old children, 36%of 9-11 month old children were fedappropriately for their age). Ageappropriateinfant and young childfeeding is, therefore, a major concern.Vitamin A supplementaon levels arehigh (>95% according to UNICEF) butare lower for 6-24 months. Iodizedsalt consumpon is high but anemiais a crical issue and urgent soluonsare needed. Responsive feeding needsto be addressed through behaviorchange communicaon.HNPSP/NNP, but low coverage(counseling at community nutrioncenters, growth monitoring,provision of food supplement).Coverage by NGOs also low;quality is variable and needs tobe harmonized across partners. Mulple channels are beingexplored for use of micronutrientpowders but confusions remainabout formulaon.Addressing quality of communicaonsand tailoring communicaons to knownlocal barriers is crical . Strengthening,harmonizing, and expanding acons inthe Naonal IYCF Strategy, using DGHS/DGFP/NNP plaorms; NGOs; mass media.Improving diet quality of push packet inNNP . Broad scale awareness raising withmulple stakeholders on the importanceof the complementary feeding periodfor undernutrion is crucial. Addressingfood security, access to and use of highnutrientvalue foods. Operaons andimpact evaluaon of different modalies forimproving CF.Hygieneintervenons(hand-washingand stool disposalbehavior; water andsanitaon facilies);deworming &appropriate careand treatment fordiarrheaAccess to improved sources of waterhigh (97%) but arsenic a concern;drinking water treatment low.Improved sanitaon low (25%); only22% of households safely disposeof children’s stools . ORT use fordiarrhea is high, but zinc use very low .Deworming use is high among childrenunder five (80%) but does not reach12-24 months .Coverage of hand-washingintervenons not high. Economicconstraints can dampen adherenceto hand-washing . ORT use iswidely promoted by providers, andORS is widely available throughpharmacies, health workers, etc .Current modality for deworming(NIDs) does not cover children

Direct intervenon Status, trends Policy instrument/programimplementaon modaliesFactors to consider for accelerang scaleupMaternal nutrion(BMI, anemia)Only 60% of women have normalBMI; 15% are below 145 cms. The% of women with low BMI has gonedown since 2004. Anemia is known tobe a serious problem for women ofreproducve age.Data on adolescent nutrion arelacking but important to considermonitoring because of knownhigh rates of adolescent marriageand pregnancy, and links betweenadolescent pregnancy and maternal,newborn, and child health andnutrion outcomes, including lowbirth weight.(1) Few intervenons currentlyexist at a large scale to improvewomen’s nutrion other than ironfolatesupplementaon through theHNPSP, counseling and provisionof food supplements through NNP,where it is present. (2) Intervenonsto reach pre-pregnant women andimprove their health and nutrionare fewer, but contracepve useis moderately high, and newlywedcounseling programs are operaonal(but at small scale). (3) NGOs areoperang programs to improvehealth and nutrion of adolescentgirls. The GoB secondary schoolspend and other social transferprograms can also have an impacton adolescent health and nutrion,and subsequent health of children .Advocacy to highlight the cricality ofadolescent and women’s nutrion andhealth to child undernutrion is essenal.Strategies to reach all adolescent girls andwomen of reproducve age (pregnant ornot) with key nutrion intervenons andsupporve family planning to delay firstpregnancies and space births must be apriority. Addressing social norms in relaonto these will need mass awareness raisingthrough media campaigns, and othermodalies . Household food security andpurchasing power, gender constraints suchas bargaining power, mobility, violenceagainst women need addressing throughcommunicaons, legislaon, and socialmobilizaon .Source: Based on Maintaining Momentum to 2015? An Impact Evaluaon of Intervenons to Improve Maternal and Child Health and Nutrion inBangladesh (2006 World Bank); Mid-Term Review of HNPSP 2008; and discussions with development partners.INDIRECT ROUTES FOR IMPROVINGNUTRITIONIndirect routes that are known to have substanal potenal forimproving nutrion include intervenons and policies relatedto poverty reducon, agricultural intervenons, and women’sempowerment. Although other indirect intervenons might alsohave an impact on nutrion, these three are predominant channelsthat are important to consider in the Bangladeshi context.Poverty reductionHousehold poverty—whether defined as asset poverty orconsumpon poverty—is an important correlate of maternaland child poverty. Reducing poverty strengthens householdcapacity to invest in child and maternal nutrion through greaterpurchasing ability of food, non-food goods, and services. Forasset poverty, the proporon of underweight children variesfrom 51 percent in the poorest asset quinle to 41 percent inthe middle quinle, dropping further to 26 percent in the highestasset quinle, according to DHS 2007.Recent studies show that microfinance programs haveimportant health and nutrional effects for the parcipants,including higher vaccinaon, higher level of contracepve use,beer behavior change communicaon, and more importantly,lower child undernutrion rates for the poor and the poorest(World Bank 2008). Empirical evidence suggests that the presenceof NGO programs in a village is associated with a strongreducon in child undernutrion in the boom consumponquinle (Deolalikar 2005). The evidence also suggests that publictransfer and relief programs that provide food to the poor, such asthe Vulnerable Group Feeding and the Food-for-Work programs,have a significant effects on reducing child undernutrion amongthe poor (Deolalikar 2005).The main policy point to emphasize here is that reducingpoverty through pro-poor growth as well as targeted an-povertyintervenons will indirectly reduce the prevalence of child andmaternal undernutrion.Agriculture-led improvement in diet qualityA large share of the Bangladeshi populaon is food-insecuredue to poor diet quality. The usual diet is heavily dependent onrice and most of the energy in the diet is contributed by cereals.Given the low micronutrient content of the diet, a high prevalenceof micronutrient deficiency is common in Bangladesh. Thesoluon lies in increased consumpon of high quality foods(such as fruits, vegetables, fish, meat, milk, etc.), which the poordesire but cannot afford. Agriculture can play an important roleby contribung to the improved quality (diversity) of the familydiet, reducing micronutrient undernutrion.Food consumpon paerns in Bangladesh show very lilediversity even at the naonal level. A comparison of the paernsof food consumpon in terms of calorie and protein shares inthe average Bangladeshi diet shows lile change over a 10 yearperiod, from 1995−2005. Rice accounted for 71 percent of totalcalorie consumpon in 1995−96; the share was 68 percent in2005. Although rice is a poor source of protein, it constuted13

about half of total protein consumpon in both 1995−96 and2005 (Figure 6).Figure 6— Percentages of total daily protein consumed per capitaby food items at national level, 2005 and 1995–96Share of daily per capita protein consumpon %80604020051.651.313.6 13.97.04.7 5.6 5.4Rice Fish Meat &eggs2005 1995–96Pulses1.23.2Milk & milkproductsSource: Data from the BBS Household Income and Expenditure Surveys.21.0 21.6OtherfoodsFig. 7— Trends in real price of coarse rice, iscal year 1983 to2009 (Base: 1995/96=100)The demand for non-rice, nutrient-rich food items suchas milk, meat, fish, and fruits is more responsive to changes inincome than that for rice. Real gross domesc product (GDP) percapita increased by 33 percent from 1995−96 to 2005. Despitesuch a significant increase in real per capita income, why do thefood consumpon paerns remain virtually the same over the 10year period? The analysis of food price trends may help explainthe apparent paradox.We examine the trends in the real (inflaon-adjusted) priceof rice over the period of 1983 to 2009. The real price of ricefell by 38 percent from 1983 to 2007, before the remarkablerice price surge in 2008. Even the exceponally high rice pricein 2008 was 20 percent lower than the price in 1983. The fallingprice of rice has helped the rural landless and the urban poor,who purchase the rice they consume. There are about 40 millionBangladeshis—the ultra poor—who cannot purchase enough riceto meet energy requirements, despite a falling real price of rice.Therefore, the level of technology and instuonal innovaonsthat made this price decline possible must be maintained.However the real price of several foods that are rich in nutrientsdemonstrates increasing price trends (see Figures 7 to 10).The price of fish has risen more rapidly. The increase in the realFig. 8— Trends in real price of lentil pulse, iscal year 1983 to2009 (Base: 1995/96=100)Real price of rice (Taka/kg)25201510501983198619891992199519982001200420072009Real price of lenl (Taka/kg)60504030201001983198619891992199519982001200420072009Fiscal YearFiscal YearFig. 9— Trends in real price of Brinjal (eggplant), iscal year1983 to 2009 (Base: 1995/96=100)Fig. 10— Trends in real price of Hilsha ish, iscal year 1983 to2009 (Base: 1995/96=100)Real price of brinjal (Taka/kg)18161412108642018016014012010080604020019831985198719891991199319951997199920012003200520072009198319851987198919911993199519971999Real price of Hilsha fish (Taka/kg)20012003200520072009Fiscal YearFiscal YearSource: Price data from the Department of Agricultural Markeng and GDP deflator data from the World Bank.14

price of non-rice foods probably reflects supply-side constraintssince these products are very responsive to demand-side increasesin income. Food demand esmates in Bangladesh reveal that thepoor are more price-responsive than the rich (Ahmed and Shams1996). If policies are not undertaken to increase supply of noncereal,nutrient-rich foods (such as pulses, fruits, vegetables andfish), prices of these foods will connue to increase in the faceof income and populaon growth. Consequently, the diet qualityand nutrional status of the poor will deteriorate further. Theseobservaons have important implicaons for agricultural policy.Women’s empowermentWomen’s empowerment is an important factor influencing women’sown well-being as well as children’s well-being (Murthi et al. 1995;Sen 1999). Research shows that improvements in women’s empowermentcan yield substanal improvements in child undernutrion.What is oen less emphasized is that maternal nutrion also variesby a considerable degree with the level of women’s empowerment(or agency), the laer captured by proxy indicators. The term“proxy indicators” is important to take note of however. “Agency” isa measure of the ability to take control over one’s own life and theability to make own choices; such a measure is not easy to capturedirectly from the convenonal survey instruments. Proxy indicatorssuch as women’s educaon (level of formal schooling), exposureto media (radio, TV, or newspaper), and role in the “domesc decisionmaking”are found to be posively correlated with improvedmaternal nutrion, as measured by body mass index.It is also useful to consider how women’s empowermentoperates in relaon to the window of opportunity for reducingchild undernutrion. Recent analyses using the BangladeshDemographic and Health Survey (BDHS) 2007 data and panel datafrom studies conducted by the Internaonal Food Policy ResearchInstute (Quisumbing et al. 2009) show that different measuresof women’s empowerment are associated with different aspectsof child undernutrion. In parcular, findings underscored therole of women’s atudes and exposure to domesc violenceas having negave effects on stunng, a measure of chronicchild undernutrion. These findings are also substanated byother research in Bangladesh showing that women exposed toviolence consume smaller amounts of nutrional food supplementsduring pregnancy, have greater fetal stress, etc. Women’smobility, another proxy empowerment measure, is associatedwith greater diversity of diets for infants and young children.Last but not least, the role of women’s empowerment as itrelates to adolescent girls is also important to consider. Recentresearch demonstrates that adolescent childbearing has nega-ve impacts not only for the child, but also for the mother,completely stunng her own height growth in the adolescentgrowth spurt period (Rah et al. 2008 and 2009). This in turn hasserious implicaons for subsequent births that she might have,because low maternal height is a known severe constraint oninfant growth in-utero, and predisposes mothers to negaveoutcomes for mother and child during the birth process.The main policy point here is the need to emphasize theimportance of women’s empowerment as correlate of child andmaternal nutrional outcomes. This needs to be recognized as animportant indirect route capable of making difference to child andmaternal well-being, along with poverty reducon. Policy intervenonshence need to be judged from their degree of success inenhancing women’s empowerment, whether they relate to growthprojects, an-poverty measures, or public health intervenons.LOOKING FORWARD: POLICY LEVERSFOR IMPROVED NUTRITIONAlthough Bangladesh has witnessed improvements in nutrionaland health-related measures over the past decade, the overarchingneeds, are to:1. idenfy a high-impact, feasible, and locally appropriatepackage of intervenons that can be sharply scaled upthrough mulple channels and sectors, and developa detailed cosng and implementaon plan for thispriority package at the country level. Prevenon shouldbe a central aspect of the package of intervenons, withcurave intervenons integrated.2. build further evidence on those intervenons andstrategies that, though plausibly effecve, might currentlybe controversial (such as micronutrient powders,strategies for addressing acute malnutrion, etc.),3. recognize and address the role of factors such as foodsecurity, women’s empowerment, and agricultural andprice policies, as not doing so can compromise effortsdriven solely by direct intervenons,4. develop a naonal monitoring and evaluaon systemto ensure that evidence on programs, policies, andproblems is used to recalibrate and adjust policies andprogram priories , and5. develop and agree upon a framework for coordinangthe work of all partners and idenfy one naonalcoordinang authority with a broad mulsectoralmandate that is empowered to take on stewardshipof the nutrion movement . Finding and sustainingstrategic partnerships for ensuring coordinaon ofmulple acvies is key to success; for this, excellentcoordinaon is crical.In relaon to the intervenons that need to be in placeto address undernutrion, there are two kinds of challenges.The first relates to sustaining successes in areas where posivetrends have been seen. The second relates to achieving certainmilestones that have not received adequate aenon to date.The policy recommendaons for direct and indirect routes aregrouped from this angle.15

Direct interventions to reduce undernutritionSome of the direct intervenons that are high priority for maintainingearlier successes and scaling up further to “close the gap”include the following:— Timing of introducon of complementary feeding: Buildingbroad awareness and ensuring inclusion of behaviorchange communicaons in the public and private healthsector are essenal to close the gap for this intervenon.— Vitamin A supplementaon: The main challenge thatremains is to ensure that younger children and childrenin remote areas, who are currently missed fromsupplementaon efforts (for reasons not well known),receive supplements regularly.— Use of iodized salt: Scaling up of iodized salt producon isessenal to ensure that all households can use iodized salt.The challenges to scaling up include addressing availabilityof hardware for local forficaon of salt, advocacy andmonitoring to ensure compliance with iodizaon, andawareness raising to ensure that families and caregiversare aware of the importance of using iodized salt.— Deworming: High coverage of deworming for childrenunder five in Bangladesh is extremely posive.Sustaining this and enhancing the impact of dewormingon undernutrion rates requires an assessment ofinclusion of children under 24 months for deworming,improved hygiene educaon, and awareness-raisingabout the importance of deworming.A number of high impact direct intervenons for addressingundernutrion are either not included in current health andnutrion packages, or not reaching the scale that they shouldin order to accelerate reducon in undernutrion rates. Thefollowing intervenons are parcularly important to address in aforward-thinking strategy to improve nutrion:— Improving women’s nutrion and health: Intervenonsto address women’s nutrion, starng in earlyadolescence, are essenal to migate what is a majorboleneck in Bangladesh, and to set an example forSouth Asia . Direct intervenons for women’s healthand nutrion include access to contracepon to delayfirst birth and ensure adequate birth spacing, accessto adequate and diverse diets in the home, increasingaccess to and use of iron-folate supplements and toantenatal care when pregnant, ensuring adequate restwhen pregnant, etc. Innovave approaches to shi socialnorms related to gender norms that are detrimental towomen’s health are essenal to invest in .— Appropriate breaseeding and age-appropriatecomplementary feeding: Scaling up intervenons toaddress early iniaon of exclusive breaseedingthrough the public and private/NGO health sector andcommunity mobilizaon is crical; linking to iniavesfor safe motherhood and newborn health can helpaddress this parcular issue. Addressing exclusivebreaseeding will require a mul-pronged approachthat confronts the major known challenges to exclusivebreaseeding: training of health workers to promoteand support women in exclusive breaseeding,mobilizaon of communies, support from olderwomen and fathers for women to breaseed in thehome, mobilizing work places and industries to providefacilies and maternity leave to enable exclusivebreaseeding, and monitoring of the Code of Markengof Breast Milk Substutes to prevent violaons of thecode . Improving complementary feeding will requiretraining investments for community-based healthworkers to counsel caregivers and families about ageappropriatefeeding; investment in media and otherchannels to increase broad awareness; and ensuringaccess to high quality foods as well as micronutrientsupplements (vitamin A, iron, mulple micronutrientpowders, etc.) and/or forfied foods to address dietquality. These issues are well arculated in Bangladesh’sNaonal Strategy for Infant and Young Child Feeding;the challenge is operaonalizaon at scale, for whichmulple plaorms and delivery channels must be used.— Addressing poor hygiene: Poor hygiene is a significantcontributor to undernutrion, and intervenons toaddress hygiene are crucial. These include scaling upaccess to hygienic latrines and to improved sources ofwater in rural and urban areas, and raising widespreadawareness of appropriate handwashing and stooldisposal pracces to reduce contaminaon.— Ensuring appropriate and adequate treatment for severeacute undernutrion: Ensuring severely malnourishedchildren have access to appropriate and effecvetreatment in a mely fashion is important to save livesand rehabilitate children. Developing locally appropriateapproaches to address severe acute undernutrionand to improve and scale up of known facility-basedapproaches within the current health system is cricalto move this issue forward .Indirect interventions to reduce undernutritionPoverty reducon, women’s empowerment, and revitalizing agriculturalproducon for ensuring the adequate supply of micronutrientrich food should be the three key focus areas here. In allof these areas some considerable successes have been achievedin the past decade. Poverty declined by 10 percentage pointsbetween 2000 and 2005. Women’s empowerment—captured bya multude of indicators—has increased considerably over the16

past decade. Cereal producon has increased considerably. Thepolicy challenge is to sustain this success in the medium-term.There are also new (emerging) challenges in each of these areas.Improve nutrition through strengthening growth−povertylinkagesMaintaining a decent per capita GDP growth rate of 4−5 percentshould be a major target in the medium-term to sustain theimpressive poverty reducon rate recorded in the past. Thiscannot be achieved by relying on agriculture alone. In Bangladesh,structural transformaon that has taken place underscores theimportance of non-agricultural sectors, especially the industrialsector. Unl 1990, for instance, Bangladesh was predominantlyan agrarian economy with agriculture accounng for nearly 30percent of GDP. Between 1990 and 2008, the share of agriculturein GDP has decreased to about 20 percent while the shareof industry increased from around 20 percent to about 30percent, with the share of the service sector remaining virtuallyunchanged at around 50 percent. Thus, the structural transformaonsince 1990s seems more like a transion from agricultureto industry rather than to service. Sustaining the pace of growthin industrial sector will help maintain the desired growth rate inper capita GDP and the desired pace of poverty reducon neededto improve the nutrional status .With higher economic growth it will be possible to allocatemore public investments in women’s educaon and health, and toincrease female workforce parcipaon by creang more remuneravejobs and through providing support to targeted programsand instuons that foster women’s economic and social empowerment.Agriculture needs to get connued priority in order toensure food security at the naonal and household level.New challenges in the area of poverty reducon are also noteworthy.From a nutrional point of view, it is important to reducethe present high level of extreme and chronic food insecurity inBangladesh. This will demand a pro-poor growth that combinesremunerave employment generaon in the course of the country’sgrowth process with much more effecve safety net programsto reduce seasonal hunger and food insecurity of the poorest.Enhance women’s empowerment for better child andmaternal nutritionEmpirical evidence underscores the key role of women’sempowerment in shaping child and maternal well-being and thesignificance of female agency for beer health care access andpracces . Female empowerment (or female agency, broadlyspeaking) is related to many economic and social factors suchas woman’s educaon, her control of assets and income, herexposure to media, and her exercise of autonomy, control, andchoice over domesc decisionmaking processes. Policy instrumentsto address women’s empowerment will therefore have toaddress these various factors. Some of these policy instrumentsare in place while other challenges need to be confronted. Forexample, violence against women, which has serious negaveconsequences for women and children, must be addressed, andcommunies and individuals mobilized to address violence.In addion to empowering women, addressing the issue ofadolescent health and empowerment through connued supportfor the secondary school spend program and through focusedhealth, nutrion, and empowerment programs for adolescentgirls and boys can have far reaching benefits. Mobilizing communiesto address some of the social barriers to improving adolescenthealth is key to success, parcularly in relaon to keepingadolescents in school, reducing early marriage, delaying childbearing,and empowering young women to care for and feedtheir babies and themselves.Reorient agriculture for ensuring improved diet qualityWhile cereal food producon has increased, it has not beenmatched by increased producon (and consumpon) of noncerealproducon of vegetables, fruits, fish, eggs, and meat. Thishas adverse implicaons for micronutrient intake, especially forthe poor and the poorest. This brings to the fore the policy issueof reorienng agriculture for ensuring the supply of improveddiet quality. Several aspects are noteworthy:First, in Bangladesh, investments in agricultural research toimprove producvity of non-staple foods have been somewhatneglected in favor of cereal-centric investments to improveproducvity of rice and wheat. Review of agricultural investmentsin non-staples that are high value added and high nutri-on value added is urgently needed.Second, year-to-year price fluctuaons are much largerfor non-cereal crops than for cereals, indicang relavely highlevels of market-induced risks for producon of non-cerealcrops. Non-staple crops, especially fruits and vegetables, havethin domesc markets due to relavely low levels of domescdemand for these crops. These crops also have high price elasci-es of both supply and demand. At the same me, horculturalcrops face problems related to perishability and quality . Interplayof all these factors contributes to the risks in producon of horculturalcrops. However, these factors also imply that addressingthe market efficiency issues is likely to be an effecve means ofreducing the risks associated with adopon of horcultural crops.Third, investments in research can potenally minimizeproducon risks. Research can play an important role in increasingproducvity of non-staple crops, thereby reducing the cost ofproducon. In addion to improving producvity of non-staples,research should focus on developing vegetable variees that (1)grow well in off-seasons, (2) are disease- and pest-resistant, and(3) have high contents of important micronutrients.Fourth, recent agricultural research iniaves by the centersof the Consultave Group on Internaonal Agricultural Researchand the Bangladesh Rice Research Instute suggest that it maybe possible to get the plants themselves to do the work offorficaon, an intervenon strategy referred to as “bioforfica-on.” There are at least two inherent comparave advantages17

of such an approach. Bioforficaon is cost-effecve. Once theplants are developed and being grown by farmers, there are norecurring costs of buying the forficants and adding them to foodduring processing. The other benefit of bioforficaon is that itis sustainable. Once the research and extension investments aremade in developing and disseminang the nutrionally improvedcrops, farmers will be driven by incenves to connue to producethese crops, because this strategy has the potenal to significantlyimprove crop producvity. Rice, because it is consumed bythe enre populaon, is an excellent vehicle for bioforficaon(with iron and zinc).CONCLUSIONOur conclusions are based on the guiding principles of (1)targeng the period of pre-pregnancy and the first two yearsof life; (2) using the UNICEF conceptual framework to capturemulple determinants of nutrion; and (3) mapping direct andindirect intervenons and policy instruments . The need formul-level intervenons is well recognized by the government inits Naonal Food Policy Plan of Acon. The analyses and recommendaonspresented here are intended to sharpen the policyfocus on the “window of opportunity” and to priorize highimpact intervenons.Thus, we propose the following acons to address the highburden of undernutrion :1. Idenfy, cost out, and sharply scale up a priority packageof direct nutrion and health intervenons targeted toadolescents, women of reproducve age, pregnant andlactang women, and children under two years of age .This will require addressing design and implementaonconstraints in the Naonal Nutrion Program as well asthe use of the health, water-sanitaon, and educaonsectors to more strongly address nutrion.2. Generate impact and operaonal evidence to buildconsensus around contextually appropriate intervenonsto address childhood anemia and acute malnutrion.3. Recognize cricality of underlying factors such asfood security, gender, food prices, and agriculturalpolicies in improving nutrion, and ensure appropriateintervenons and policies are in place to address these;not doing so could severely compromise the impact ofdirect intervenon.4. Invest in a solid monitoring and evaluaon framework andprocesses, linked closely to the monitoring and evaluaonframework of the health sector and other relevant sectors.5. Ensure an effecve, authoritave, and funconingnaonal coordinang mechanism to convene,coordinate, mobilize, and hold accountable themulstakeholder plaorm that must deliver theacvies needed to improve nutrion.In summary, substanal investments are needed both indirect and indirect intervenons for addressing maternal andchild undernutrion. Neither by itself is sufficient to bring aboutchange at the scale necessary to prevent the pernicious impactsof poor nutrion on the future development of Bangladesh.Priority investment areas:Direct interventions– Promoon and support for age appropriateinfant and young child feeding, includingmicronutrient intervenons– Scaling up hygiene and sanitaon intervenons– Scaling up basic prevenve health services– Adolescent and women’s nutrion(micronutrients, food supplements, as needed)– Idenfying appropriate curave intervenonsfor acute malnutrion– Delaying first-me child birth and limingferlityIndirect interventions– Social protecon and economic growth policiesto reduce household poverty– Targeted intervenons to address women’sempowerment and status, including secondaryeducaon and adolescent programs– Social protecon, agricultural and price policiesto improve supply of, and access to, high nutrientvalue foods18

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This paper has been commissioned by the Government of the People’s Republic of Bangladeshfor the Bangladesh Food Security Investment Forum, 26–27 May 2010. The Forum is organizedby the Ministry of Food and Disaster Management with technical support from the InternationalFood Policy Research Institute (IFPRI), the Bangladesh Institute of Development Studies (BIDS),and the Food and Agriculture Organization of the United Nations (UN-FAO). Financial supporthas been extended by the United States Agency for International Development (USAID), theUnited Kingdom Department for International Development (DFID), and the EuropeanCommission (EC). The views and opinions contained in this paper are those of the authors.Cover graphics adapted from photography by © 2010 Hand Crank Films/IFPRI, © 2009 Pradeep Kumar Saxena/iStockphoto,and © 2006 G.M.B Akash/Panos.