The Bangladesh Integrated Nutrition Programme (BINP) started in 1995 and the expected completion date for the pilot stage is 2001. A successor programme, the National Nutrition Programme (NNP), is expected to be implemented soon with activities in BINP pilot areas to be continued as part of a phasing out-phasing in scheme.
The first phase covered six thanas or upazilas 43 (subdistricts), 1,218 villages and over 55 unions reaching a total population of 1,235,576. Currently, BINP covers 60 thanas. With the programme’s expansion into NNP Phase 1 (of five years’ duration), an additional 79 thanas will be added to the original 60 BINP areas including urban areas, totaling 139 thanas. NNP Phases 2 and 3 are envisioned to cover the entire country.
BINP was implemented under two modalities. One is Government of Bangladesh-led and non-governmental organization (NGO)-assisted. Here the existing network of the Ministry of Health and Family Welfare (MoHFW) was utilized for implementation. The other modality is NGO-led and Government of Bangladesh-assisted. The major NGO player was Bangladesh Rural Advancement Committee (BRAC) 44, which was later joined by other NGOs such as PROSHIKA. Funding has come largely from the World Bank, through its International Development Assistance programme (WB-IDA). UNICEF also provided some financial, material and technical support.
Objectives of the programme
The overall goal of BINP is to reduce malnutrition in Bangladesh until it ceases to be a public health problem and to improve the nutritional status of the population particularly of young children, women, and adolescent girls.
To attain this goal, specific objectives are as follows:
BINP has 3 main components: (1) national level nutrition activities; (2) intersectoral nutrition programme development; and (3) a community-based nutrition component. The third component, which focuses on the implementation of various nutrition interventions and community empowerment to promote participation, has the following specific objectives:
Based on mid-term review of the World Bank, the following achievements were noted:
Unofficial information from BINP national staff claimed 90 percent coverage for iron and vitamin A supplementation and for the delivery of IEC messages. It was also claimed that weight gain during pregnancy increased from an average of 4 kg to 7 kg.
Community participation in the BINP areas can vary from participation for material incentives to functional participation to interactive participation. Communities in the early stages of BINP implementation are found in the lower levels of community participation. However, with the active involvement and intensive and aggressive social mobilization strategies employed by the NGOs, communities as well as community workers and local government units assume a more proactive role in decision-making and resource generation to support nutrition activities.
Strengths, weaknesses, opportunities and constraints/threats (SWOC)
Overall, BINP in the form of its successor nutrition programme, NNP, has a fair chance of achieving sustainability. Community participation ranks high in the programme’s objectives. Seventy percent of total funding is expected to be channelled to community-based activities including social mobilization and capacity-building. The programme is well established within the government structure and partner NGOs, and national nutrition institutions have been identified and their roles specified. However, because of the massive infusion of external funding, withdrawal of donor support can at any time cause the programme to collapse. GoB’s commitment at this point may not mean much since the government is unable to provide funds.
Bangladesh is a tropical riverine country that lies in the southern part of the Indian subcontinent, between India and Myanmar. It has the largest delta in the world and the longest coastal length along the Bay of Bengal of 732 km. Except for the highlands of Chittagong and Chittagong Hill tracts and some parts of the northeastern provinces, the entire country is composed of alluvial flood-prone basin land and non-alluvial flood-prone plains. The country is also one of the monsoon areas of Asia. The combination of alluvial soil deposits and abundant rainfall gives the country a fertile agricultural base. Thus, 75 percent of the land area is devoted to agriculture with 66 percent of the population dependent upon it.
Despite an alarming population growth rate and slow economic growth, remarkable improvements in some key social and health indicators, namely life expectancy at birth, school enrollment, child immunization, access to safe drinking water and better sanitation, were noted since its independence in 1971. However, reduction in the prevalence of malnutrition has not kept pace with these improvements. The levels of malnutrition in the country remain among the highest in the world. More than 54 percent of preschool-age children are stunted, 56 percent are underweight and more than 17 percent are wasted. Nearly 50 percent of women suffer from chronic energy deficiency, the incidence of LBW is estimated at 45 percent, and micronutrient deficiencies are widely prevalent.
High infant, under five and maternal mortality still persist: 77,150 and 4.5 respectively, per 1,000 live births. About 75 percent of the child’s life is spent in illness, mostly infections as a result of increased vulnerability owing to LBW and poor nutrition. Diarrhoea, respiratory infections, and neonatal tetanus are the major causes of death among infants while two-thirds of under five deaths are caused by malnutrition.
The determinants of malnutrition in Bangladesh are associated with the primary and most direct causes of malnutrition, namely food insecurity, poor health conditions and insufficient access to good health care services, and inappropriate maternal and infant feeding practices. From 1992 to 1994, the average daily per capita dietary energy supply was 1,950 kcal. Compared with FAO’s average requirement of 2,310 kcal, the supply represents a 15 percent shortfall. About 15 percent of rural households are consuming fewer than 1,600 kcal per capita per day while 10 percent consume between 1,600-1,800 kcal.
While food availability and health status are important factors affecting nutrition, caring practices also play vital role in the nutritional status of Bangladeshis. Caring practices, which include feeding and culture-specific consumption practices, intrahousehold distribution of food and personal hygiene constitute the most significant unaddressed set of nutritional determinants.
Behaviour related to the feeding of young children have much to do with the serious problem of malnutrition in Bangladesh. Recent surveys showed a marked rise in acute and chronic protein and energy malnutrition in the age group 12-23 months, attributable to behavioural aspects of feeding. While most children are breastfed up to one to two years of age and 10 percent only stop breastfeeding by six months, breastfeeding is usually combined with bottle–feeding, which often results to diarrhoeal episodes. About 15 percent of mothers do not offer colostrum to their babies. Complementary feeding is poorly practiced and complementary foods are of low nutrient density. Maternal nutrition is known to affect the nutritional status of the newborn. Ignorance, poverty and some cultural factors result in poor diets of women.
With regard to hygiene and sanitation, 44 percent of households use sanitary latrines. Open space is commonly used for waste disposal. About 96 percent of households have access to a tube well for drinking water. However, in recent years, problems associated with the presence of arsenic in drinking water have limited supply.
In response to these problems, the GoB, in cooperation with international funding and donor institutions and NGOs working for nutrition and related fields such as health and agriculture, implemented several intervention programmes. Among these are the Fourth Population and Health Project, BINP (both under MoHFW) and the Control of Iodine Disorders implemented by the Bangladesh Small and Cottage Industries Cooperation of the Ministry of Information.
About 50 percent of the population has access to health care facilities through a network of Thana Health Complexes, Rural Dispensaries, Community Clinics and Union Health and Family Welfare Centres, but the services are of poor qualiy and underutilized. Since 1982, satellite clinics were established by female field workers to deliver maternal and child health and family planning services.
Aside from building networks and linkages, recent advances in primary health care activities include: training of mothers in the preparation of oral rehydration solution for better management of diarrhoea and a wider coverage of immunization (about 70 percent) through the EPI. The GoB’s Health and Population Sector Programme is also offering an integrated package of services on health and population. Currently, there is still concern for improving accessibility to more effective and better quality health care, especially maternal and child health.
The BINP was said to be patterned on an improved version of the Tamil Nadu Integrated Programme and was the first attempt of the GoB to develop a comprehensive and coordinated national intersectoral programme for addressing malnutrition. With an offer of funding up to US$ 59.8 million from the World Bank (i.e. donor-driven), “the GoB welcomed the opportunity to undertake a national nutrition programme”. It should be made clear, however, that prior to the World Bank offer, there was already widespread recognition of the gravity of the malnutrition problem and its debilitating consequences. Unfortunately, the GoB was not financially able to underwrite a large scale nutrition programme. The support to BINP was augmented by UNICEF.
Initial activities for BINP started in 1993 when BRAC undertook a nutrition modelling project in Muktagacha to draw lessons for designing a workable strategy for a national nutrition programme. These lessons along with the Tamil Nadu Integrated Programme experiences were consolidated by a group of international and national consultants and experts in a series of project preparation and consultative meetings. From the GoB, the Ministry of Health and Family Welfare (MoHFW) was identified as the implementing agency with the actual implementation of the six-year programme beginning in 1996. However, in practice, the MoHFW acted more as a coordinating agency for all activities, which were contracted out to some NGOs and national nutrition institutions. The latter were involved as resource centres for trainers. This was a missed opportunity for the MoHFW, namely to be in the forefront of an important nutrition undertaking, inasmuch as their responsibility was relegated to monitoring which also suffered eventually due to fast turnover of programme staff.
The ultimate goal of BINP is to reduce malnutrition so that it ceases to be a public health problem. Specifically targeted by BINP are the under five children, women, adolescent girls, and newly wed couples (this was later dropped from the list of targets). To achieve this goal, the programme had identified the following objectives:
BINP has three major components namely: the national level nutrition activities, intersectoral nutrition programme development, and a community-based nutrition component.
The national level nutrition component has four subcomponents. These are: (1) programme development and institution-building aimed at developing national capacity in nutrition and promoting policy and operations-oriented research; (2) information, education, communication (IEC) for assessing current behavioral aspects relevant to nutrition and developing appropriate IEC activities through interpersonal methods at the community level and through the mass media at the national level; (3) strengthening of existing nutrition activities; and (4) project management, monitoring and evaluation. Of these subcomponents, only the IEC component was strongly implemented and to a certain extent ongoing nutrition activities were improved in terms of making them available on time, more regular and more targeted. It was unfortunate that the original intention of integrating direct nutrition interventions with development-oriented interventions was not fully realized inasmuch as intersectoral coordination proved elusive.
The second component is the intersectoral nutrition programme development aimed at improving nutrition by emphasizing the nutritional aspects of activities in various sectors and supporting innovative actions. The lack of a clear-cut mechanism for operationalizing this constrained the programme in many ways. Through this component, it was intended to provide additional human and material resources as well as make the BINP truly holistic and integrated.
The third component is the community-based nutrition component, which focuses on growth monitoring and evaluation with targeted and supervised supplementary feeding at the village level. The activity takes place in community nutrition centres, which also act as a venue for interpersonal IEC and community mobilization. Since this is the main focus of BINP, the majority of resources were earmarked for this component.
For geographical coverage, initially six thanas were selected as pilot areas. These were Gabtoli, Banaripara, Mohammedpur, Shahrasti, Faridpur, Sadar and Rajnagar. Based on the baseline survey conducted by BRAC, a total population of 1,235,576 was reached by the programme, in 1,218 villages in over 55 unions. In 1998, BINP expanded in phases until all 60 thanas were covered. This represents 15 percent of the country’s total population.
World Bank (1999) reports note marked reductions in malnutrition. Using MUAC as the indicator, the prevalence of severe malnutrition fell from 13 percent to 2 percent in the project areas. The number of underweight infants also decreased by as much as 30 percent.
During the duration of BINP implementation, the country suffered from a number of natural calamities and political upheavals. However, the GoB remained committed to the implementation of BINP, which through the years relied heavily on NGO partners. Formally adopted in 1997, the BPAN highlights BINP as one of the flagship programmes for nutrition.
With the completion of the pilot phase, the GoB is committed to expanding BINP into a nationwide National Nutrition Programme (NNP). World Bank along with other donors and international agencies have also committed to providing funding to enable the GoB to implement the improved nutrition strategy throughout Bangladesh, including urban areas. By the year 2015, it is envisioned that the entire country would have been reached. It is expected that the total funding for the first five years will reach around US$ 125 million, 92 million of which is credit from the World Bank, and the rest from the Netherlands Government, Canadian International Development Agency and from WFP through its Vulnerable Group Development Programme.
The strategy adopted by BINP is to provide a unique model of government-NGO partnership in the field of nutrition. Bangladesh is probably the first country to have formally taken NGOs as an official partner for undertaking nutrition improvement activities, from programme design, implementation through to monitoring and evaluation.
NGOs play a major role in BINP. Originally, it was envisioned to have two modalities for implementing BINP. The first model is GoB led and NGO-assisted. Here, the GoB relies on its own management structure to run programme activities with the Assistant Thana Family Planning Officer as the lead person. The partner NGO provides assistance in the areas of community mobilization, training and technical supervision of field personnel, logistics for preparation, packaging and distribution of food supplements as well as quality control.
The second model is NGO led and GoB assisted. Thanas, under this scheme, were contracted out to NGOs for the management and implementation of all community-based nutrition activities. As such, full responsibility is assumed by the NGO. These responsibilities would include training of the various field personnel, community mobilization, procurement, preparation, packaging and delivery of food supplements, procurement of equipment and supplies, quality control, supervision and monitoring. Whenever necessary, they are able to make use of government infrastructure and established service delivery systems.
Of the two models, the GoB led and NGO assisted was eventually phased out and all thanas were placed under the charge of NGOs. The lack of manpower and incentives on the part of GoB workers constrained GoB’s implementation of the programme. For the first phase, BRAC was chosen as the partner NGO. The partnership was formalized through the signing of a Memorandum of Agreement, placing 3 thanas (Shahrasti, Banaripara and Gabtoli) under BRAC.
During the first six months of village level programme operations, preparatory activities included the setting up of the management infrastructure at the thanas. Staff, particularly Community Nutrition Promoters (CNPs) and Community Nutrition Organizers (CNOs), were recruited following a set of predetermined criteria, then trained and deployed. Both CNPs and CNOs must be females and have well-nourished preschool children to set good examples for the intended targets. Community Nutrition Centres (CNCs) were also established as close as possible to existing EPI Outreach Centres and satellite clinics. These CNCs served as village counterparts for the programme. Various nutrition management committees were also established at the district, thana, union and village levels. Thana managers, field supervisors and trainers were then deployed to the field on a full-time basis. A core team composed of Management Information System (MIS) assistants, Regional Managers and Programme Manager was established. The Programme Manager serves as the overall coordinator working directly under the guidance of the Director of the Health and Population Division of the MoHFW.
In order to mobilize and build a good working foundation, various meetings were held with the different stakeholders in the community. In its three thanas, BRAC staff planned and managed meetings with local government and health and family planning staff in the community. Meetings were held to build a foundation for a good working relationship with the different stakeholders in the community. In the other three thanas, meetings were conducted by the Assistant Thana Family Planning Officer with the assistance of the BRAC staff. Several other meetings with the different social groups in the community such as the doctors, and the female and male groups were held every month to discuss health and nutrition issues. Such meetings were also conducted to mobilize and empower the people in the community.
BRAC staff also collaborated with the existing women’s group in the community created earlier by development NGOs. These groups were responsible for food supplementation management and are composed of 9-11 members. In thanas where groups did not exist, women were recruited. Selection was open to resident women with a minimum of 12 years education willing to spend several hours of the week for the programme. Final selection was done by BRAC and the Thana Nutrition Management Committee as appropriate. CNCs were established in all the thanas. All CNCs were provided with appropriate equipment and supplies. To date, all CNCs are operational.
BRAC also conducted household surveys in all six thanas from 1996 to 1997 to identify target groups or beneficiaries and estimate the population to be covered by the intervention, and to assess the type and frequency of monitoring that would be feasible for a particular population. Results of the survey were also used to assess the programme’s progress, and by the CNPs during household visits as a basis for nutrition and health counselling.
As part of manpower and capacity development, the project office conducted carefully and systematically developed training courses. Planned in a cascading manner, the training targeted programme participants at various levels. A Core Training Team was formed at the national level, composed of 12 members, four of whom came from BRAC. The team is responsible for the conduct of a four-week training course to the Thana Training Team. Thana level officers from different ministries such as Health and Family Welfare, Agriculture, Livestock, Fisheries, Youth Development, Women’s Affairs, Education, Village Defence Party, and representatives of NGOs participated in the training. At the thana level, the Thana Training Team and their supervisors facilitated a 34-day theoretical and hands-on basic training to the CNOs and CNPs. Refresher training activities were also given to CNOs and CNPs according to a planned schedule and curriculum. Special training on the MIS was also given.
The Family Welfare Visitor, Family Welfare Assistants, Health Assistants and their supervisors were oriented on BINP structure and nutrition activities. They were also informed about the identification and management of malnutrition, vitamin A deficiency, iodine deficiency disorders, LBW, family planning as well as the current nutritional status of the country. How to promote and effect intersectoral cooperation and coordination were also topics discussed. Another activity was the training of the women’s groups on food supplementation management, from procurement to distribution to CNCs. Training also included topics such as nutritional problems in the community and feasible strategies for combating them.
The training activity prepared the CNPs, CNOs and the Women’s Group for their roles in the thanas. The trained CNP played a key role in the implementing of the Community Based Nutrition Component. The CNPs were responsible for monthly home visits to all the families in the village, conduct of growth monitoring, health and nutrition counselling, supervision of micronutrient distribution and supplementary feeding at the CNCs. In addition, they referred mothers and children to EPI outreach centres, and to Satellite Clinics of Family Welfare Centres for antenatal care. They also compiled information on vital events such as births, deaths, marriages, and migration for their catchment population. Each CNP is assigned to 1,500 individuals in the community. CNPs also supervised the Women’s Group in the procurement of raw materials and in the preparation and distribution of food packets to community nutrition centres, and were responsible for the conduct of refresher and on-the-job training to these groups.
Each CNO was assigned to supervise 10 CNPs. The CNOs organized on-the-job training sessions and monthly meetings with the CNPs under their supervision. They collaborated with the Family Welfare Visitor for strengthening linkages with allied institutions and facilities and the referral of nutritionally at-risk cases to secondary and tertiary service centres. The CNOs also attended refresher-training activities conducted by field supervisors (aside from providing education and information for various groups).
With the integrated efforts of these nutrition actors, the following were implemented under the Community-based Nutrition Component: (i) growth monitoring and promotion; (ii) identifying targets for supplementation; (iii) health check-up and referral; (iv) immunization, vitamin A distribution and deworming; (v) health and nutrition education; (vi) strategy for the newly-wed couple; and (vii) management information system. The target beneficiaries were all the pregnant and lactating women and children under two years of age. In Gabtoli, a pilot intervention was conducted to target the newly-wed couples and their children and all severely malnourished children.
For the growth monitoring and promotion component, all children born in the community were registered and weighed within 72 hours of birth by the CNP. The mothers of children under two as well as those with the newly born were mobilized by the CNPs to bring their children for the growth monitoring and promotion sessions held every month at the CNC. Monthly weights were plotted on growth charts, progress assessed and explained to the mothers each month. The height and weight of all pregnant women were also monitored.
In the food supplementation scheme, children who were severely malnourished, based on the growth charts, or those with faltering weights were given food packets made from a combination of rice powder, pulse powder, molasses and oils (the latter being added just prior to feeding). They remained under supplementation for 90 days at the CNC. Their weights were monitored monthly and if no improvements were seen, supplementation was continued for an additional 30 days. Pregnant women also benefited from the programme if they were found to have a body mass index of less than 18.5 kg/m2. Two members from each of the Women’s Groups managed the supplementation programme. The amount given to children and pregnant women varied depending on the severity of the beneficiary’s nutritional status. The CNP was present to ensure that the foods were consumed. They also offered nutrition education and counselling to mothers.
Severely malnourished children and all the children whose weight failed to improve in the supplementation programme were referred to the Thana Health Complex. Children with suspected diseases such as diarrhoea, pneumonia, measles and skin diseases, and pregnant women at risk of malnutrition, identified during home visits, were also brought to the Health and Family Welfare Centres or Thana Health Complexes. If not treated at these centres, they were referred to secondary and tertiary levels. The pregnant women were motivated to visit the satellite clinics for antenatal check-ups, which included (i) documentation of the women’s general obstetric history; (ii) checking for anemia, jaundice and high blood pressure; (iii) preabdominal examination; and (iv) examination of urine for sugar and albumin. Pregnant women were also given iron and folic acid (250 mg Fe + 40 mg folate) supplements for daily consumption. Other services offered to children and pregnant women were immunization, vitamin A supplements and deworming medications for helminthiasis, at the satellite clinics and EPI sessions. Lactating women were given 200,000 IU of vitamin A at home by the CNP, within two weeks of delivery.
Nutrition education classes and fora were also held to bring about changes in feeding and health care habits of the people. Pregnant and lactating women were taught about their nutrition needs and the importance of colostrum and breastfeeding. Mothers with LBW babies (i.e. birth weight below 2.5 kgs) were provided with special education on health and nutrition. IEC materials were made available at the CNCs and were also distributed during cluster meetings and home visits.
Newly-wed couples were also targeted in the Community-based Nutrition Component. This strategy was introduced as a pilot intervention in Gabtoli Thana. Specific interventions were focused on the newly-wed women together with the husband and mother-in-law from the time of marriage until after the first child had reached the age of two. This strategy was intended to improve health and nutrition status during pregnancy, safe delivery and prevention of LBW babies.
The CNOs and field supervisors collected field-based data. Monthly performance reports on growth monitoring, nutritional status, and supplementation were submitted to the head office from the three BRAC-operated thanas using a standard format. Reports were then sent from the head office to the project office and were computerized and analysed by BRAC.
The macropolitical and policy environment is favourable for BINP implementation. There is national recognition of the importance of good nutrition in achieving overall development for the country. This, together with international events such as the 1992 International Conference on Nutrition and the 1996 World Food Summit provided the impetus for making nutrition a top priority for development. In 1997 the Bangladesh Plan of Action for Nutrition was formally adopted as the national umbrella programme for all nutrition activities, and sectoral focal points were identified along with national steering and working committees. The BPAN is a comprehensive document that identifies short and long-term strategies for addressing nutrition problems and their causes. It also incorporates an integrated strategy underscoring the need for intersectoral coordination, and identifies sectoral responsibilities.
Initially, the government formed a National Working Committee with the Additional Secretary, MoHFW, as its Chairperson. Through this, the BPAN developed with inputs from the ministries of Health and Family Welfare, Agriculture, Food, Fisheries and Livestock, Environment and Forest, Women and Children Affairs, Social Welfare, Disaster Management and Relief, Local Government, Rural Development and Cooperatives, Education, Information, Planning, and Finance. Intersectoral coordination and support also involved other government departments, namely Primary and Mass Education Division and NGO Affairs Bureau. As part of the steps considered in the implementation of the BPAN, GoB would also strengthen the Bangladesh Institute of Research and Training on Applied Nutrition to incorporate nutritional objectives and considerations in the agriculture sector. Through the BPAN, nutritional objectives and considerations are incorporated in the development policies and programmes of the government, particularly on food security issues, and targeted to women and nutritionally vulnerable and socio-economically deprived groups and those in distress.
GoB considers poverty reduction as its top priority. Hence various poverty alleviation programmes are planned and implemented. The following are some of the programmes supported by the GoB and international and bilateral organizations 45:
Incorporated in these programmes are social mobilization and motivation strategies to empower the community, especially the vulnerable groups and their caregivers.
From the original design of BINP, it is evident that its operations were largely community-based but required technical assistance and support from higher levels of administration, both aspects having implications for the final outcomes of the programme.
Training was deemed essential for achieving the desired results of the programme and was targeted to different groups. It should be emphasized, however, that since there were different key actors and roles and requirements at each operational level, the content of the training curricula and strategies need modification, which is already under way.
While the potential benefits of community participation are many, BINP has not yet fully realized these potentials because of problems associated with actual implementation. In BINP, thanas and villages are the focal points of community participation. However, since the types of interventions to be carried out have been predetermined at the national level, there appears to be a homogeneity - as if all the thanas and villages had the same problems and concerns. Very similar projects were identified repeatedly. This, as mentioned, is due to the very manner in which community participation has been structured by BINP proponents, beginning with the same standardized plan after training is conducted in which virtually the same information and techniques are introduced in each village. Moreover, since approval and decisions are usually taken at a higher level, community discretion and choice were further restricted.
In some BINP areas, people participate by being told what is going to happen or by simply giving information when asked. However, for the longstanding BINP areas, the villagers are more vocal about their views and the local workers are showing more regard for people’s opinions and needs. While material incentives may have been the impetus for participation initially, there are signs of some BINP areas graduating to functional participation although more directed towards selecting members of women’s groups, generating additional local resources rather than in the selection of projects and activities.
Judging from the strengths, weaknesses as well as opportunities and constraints in the implementation of BINP, one can conclude that the programme has a fair chance of achieving sustainability, albeit with continued reliance on external funds. The lessons learned from the BINP pilot implementation as well as those drawn from the villages have been incorporated in the revised version of NNP. Intersectoral involvement as well as making the programme more integrated and comprehensive will be intensively pursued within the NNP framework. Roles and responsibilities will be clearly defined. Financing schemes will be made more flexible, ensuring the timely and adequate release of funds for programme inputs and operations. More importantly, while it will continue to harness the goodwill of NGOs to be active partners in NNP, there will be a deliberate effort to also build capacities of national nutrition institutions and gradually mainstream them as allies. This will reduce dependence on NGOs, which by themselves are largely dependent on external funding for operations with the possible exception of BRAC, a longstanding and well-established NGO.
The effect of a strong nutrition advocacy component on the sustainability of NNP, or any nutrition programme for that matter, cannot be overemphasized. It is envisioned that these efforts will convince and influence various stakeholders toward an accelerated adoption of policies and implementation of programmes for nutrition improvement. The national scenario is cognizant of the importance of nutrition but this has to be translated into actual programmes and concrete actions that can be felt at the grassroot level. A parallel move at the village level of community organization and mobilization toward increased community participation will undoubtedly have synergistic effects.
BNNC (Bangladesh National Nutrition Council). 1997. Bangladesh national plan of action for nutrition (NPAN). Ministry of Health and Family Welfare. Dhaka.
World Bank. 1999. Bangladesh integrated nutrition project: mid-term review. Draft aide-memoire. Dhaka, March 1999.
43 Editor’s note: Bangladesh is administratively divided into six divisions, 64 districts and 507 thanas (or upazilas). Each thana is divided into unions (nine unions per thana on average; total number of unions = 4,484). Each union administers about 15 villages.
44 BRAC was established in 1972 as a relief and rehabilitation organization. It has gradually evolved into a large and multifaceted development organization with the dual objectives of poverty alleviation and empowerment of the poor.
45 WFP, ILO, UNDP, FAO, UNICEF, Asian Development Bank, World Bank, Department for International Development (UK), Canadian International Development Agency, Swedish International Development Agency, Netherlands Organization for International Development, Norwegian Agency for Development Cooperation, Aga Khan Foundation, United States Agency for International Development, CARE.