Strengthening nutrition information systems to improve maternal nutrition in Bangladesh
Dr Mustafizur Rahman is Line Director of the Institute of Public Health and Nutrition, Bangladesh.
Dr Zeba Mahmud is Alive & Thrive Programme Country Director in Bangladesh.
Dr Mohsin Ali is a former Nutrition Specialist with UNICEF Bangladesh.
Pragya Mathema is a Nutrition Specialist with UNICEF Bangladesh.
Bangladesh has made considerable progress in improving nutrition over the last two decades. The reduction in the prevalence of stunted children under five years old, from 55% in 1997 to 41% in 2011 and 36% in 2014, is one of the most sustained reductions in child stunting in the world1. However, the underlying nutrition context in Bangladesh continues to be characterised by poor status of women’s nutrition, contributing to poor maternal and child health outcomes, including a high prevalence of low birth weight infants in the country.
Gaps in the public health service delivery system contribute to the sub-optimal coverage and quality of maternal nutrition interventions in Bangladesh. This is compounded by weaknesses in information systems, which are critical in guiding the planning and monitoring of health service delivery. This article highlights the country’s efforts to improve evidence-based planning and data-driven decision-making through strengthening its nutrition information systems (NIS) and how the NIS is influencing the scaling up of maternal nutrition services in turn.
Mainstreaming and scaling up nutrition interventions
In 2011 Bangladesh introduced its first integrated plan for nutrition, the National Nutrition Services Operational Plan (NNS-OP), to deliver nutrition-specific interventions to address maternal and child nutrition challenges. In order to accelerate progress, the Government of Bangladesh committed to scaling up the delivery of essential nutrition interventions.
The Directorate General of Health Services (DGHS) and Directorate General of Family Planning (DGFP) of the Ministry of Health and Family Welfare (MoHFW) are both now delivering nutrition services through their own networks of health facilities and health workers. In the past, neither directorate had a standardised system for data collection and reporting on nutrition interventions. In the absence of a harmonised set of nutrition indicators, common indicator definitions and systems to aggregate the coverage data from both directorates, the MoHFW did not have data to accurately assess the coverage of essential nutrition interventions. There were also issues with the quality and use of data for decision-making.
The challenges were highlighted in an assessment of the effectiveness of the delivery of the NNS strategies and actions, which identified a number of shortcomings in the governance and institutional arrangements, service delivery and monitoring of the operational plan2. The assessment made recommendations to strengthen the programme’s record-keeping and reporting through existing data portals and to review the existing NNS indicators, with the prioritisation of a set of indicators that are indicative of extent and quality of service delivery2. Moreover, a critical need was identified for a web-based data system for data visualisation in order to analyse and review performance at district and sub-district level.
A nutrition information and planning unit
To address the governance and institutional gaps identified in the assessment of the NNS-OP, the Government established the Nutrition Information and Planning Unit (NIPU) as part of the Institute of Public Health Nutrition in the MoHFW. The unit is staffed by six people and co-funded by the Government of Bangladesh and UNICEF.
NIPU has coordinated the review, standardisation and streamlining of indicators under the NNS-OP. This has led to development of a single information system, underpinned by a common nutrition indicator framework, to guide information collected by the data systems of the two directorates, to enable integration of data into one portal and to strengthen monitoring and reporting of nutrition services at district level.
Identifying missed opportunities
As a result of NIPU’s efforts, reporting has improved dramatically in the past three years, with an increase in reporting rates from 4% to 91% for all nine nutrition-related indicators.
This enhanced NIS has enabled identification of important gaps in provision and utilisation of nutrition services. An NIPU country-wide review of two maternal nutrition indicators – maternal counselling and iron and folic acid (IFA) distribution – revealed gaps in the services delivered through public delivery platforms. For example, of the approximately 13 million women who received IFA supplements from health facilities in the past two years, only three million also received nutrition counselling at the same. This means that only 30% of antenatal clinics and postnatal clinics provided maternal counselling, resulting in a missed opportunity and contributing to poor coverage of maternal nutrition services.
Data-driven service prioritisation
In October 2017 over 400 stakeholders made a call to action (#Unite4Nutrition) to address undernutrition collectively. At the meeting stakeholders agreed on the need to identify priority indicators for the NNS-OP as part of a wider World Bank Pay for Performance (P4P) health sector financing for results initiative, with a focus on two divisions with the worst maternal and child health indicators, Chittagong and Sylhet. Of these indicators, three maternal nutrition services were prioritised – weight monitoring of pregnant women, nutrition counselling and IFA distribution – that together constitute one maternal result, and all government facilities were mandated to provide these services as part of antenatal care. The maternal result is linked with a USD34 million disbursement on meeting nutrition results against a set annual target.
The P4P initiative is being rolled out in 3,179 community clinics in the 15 focal districts of Chittagong and Sylhet divisions. Now in its third year of implementation, the original target was 10% but, due to an intensive effort, 29% of registered pregnant women have received all three maternal nutrition interventions in one visit. As part of the initiative, innovative tracking mechanisms through an individual tracker application have been adapted to enable monitoring of the services received by each pregnant woman and the quality of care provided.
Strengthening systems and accountabilities
In line with efforts to strengthen NIS for maternal nutrition, the Government has introduced a country-wide data visualisation platform to report and track the performance of priority nutrition results in all 64 districts. Health facilities have also started registering pregnant women and recording services provided during each antenatal care visit, including nutrition services. This individual tracking system enables systematic reporting of the P4P maternal nutrition services in Chittagong and Sylhet. In all districts, the online dashboard visually describes the number of registered pregnant women in the tracker, then the number of interventions each woman has received at any given visit, and the data can be filtered by division, district and upazilla (sub-district) level.
This tool has been a huge boost to districts in enabling them to visualise their performance, easily identify low-performing districts, sub-districts and facilities, and target mentoring and follow-up support where needed. The dashboard also serves as a scorecard. Text messages are sent to sub-districts to share the status of programme implementation, which triggers analysis of performance and actions on how to further improve the coverage of services.
Lessons learned and next steps
Changes to the NIS in Bangladesh – brought about by prioritising and harmonising nutrition indicators, integrating data portals and transforming reporting into data visualisation – have resulted in a clearer picture of programme implementation and coverage. However, there is still a need to ensure this data is used to increase the coverage of maternal nutrition interventions with equity, as only one in three registered pregnant women receive all three maternal nutrition services and there are geographic variations of 20-44% between different divisions.
There is also still no information on the quality of services in the current system, such as adherence to IFA supplementation and the quality of the nutrition counselling offered. The focus should now be on including indicators that assess the quality of service provision for pregnant women in the NIS.
Other concerns focus on overloading frontline workers with record-keeping, including current issues with NIS efficiency; at present, data entry is only possible when the health worker is logged into the system online, which is a huge challenge given internet connectivity. Further work is needed to address capacity gaps for effective use of the data visualisation tools.
1Headey et al (2015). The Other Asian Enigma: Explaining the Rapid Reduction of Undernutrition in Bangladesh. www.sciencedirect.com/ science/article/pii/S0305750X14002873?via%3Dihu
2Saha et al (2015) Bangladesh NNS: Assessment of implementation status. https://openknowledge. worldbank.org/handle/10986/22377
More like this
FEX: Delivery of maternal nutrition interventions at scale and mainstreaming into the health system in Bangladesh
View this article as a pdf Lisez cet article en français ici By Deborah Ash, Zeba Mahmud, Kristen Kappos, Santhia Ireen and Thomas Forissier Deborah Ash is Project...
FEX: Using flow charts and health systems strengthening to improve antenatal nutrition services in India
Vani Sethi is a Nutrition Specialist at UNICEF Regional Office of South Asia. Archana Mishra is a Deputy Director at the Maternal Health Division, Government of Madhya...
FEX: Maternal nutrition interventions in Bangladesh: delivery at scale and mainstreaming into the health system
This is a summary of a Field Exchange field article that was included in issue 63 - a special edition on child wasting in South Asia. The original article was authored by...
FEX: A multi-sector approach to improve nutrition: Experiences of the Nutrition at the Center project, Bangladesh
View this article as a pdf Lisez cet article en français ici Click here to listen to an interview with the authors on the ENN podcast channel By Jahangir Hossain,...
FEX: Improving maternal nutrition in South Asia: Implications for child wasting prevention efforts
View this article as a pdf Lisez cet article en français ici By Zivai Murira and Harriet Torlesse Zivai Murira is Nutrition Specialist at United Nations Children's...
Nepal’s success story: What helped to improve maternal anaemia?
View this article as a pdf Dr Ram Padarath Bichha is Director of the Family Welfare Division, Department of Health Services, Ministry of Health and Population, Nepal. Kedar...
Creating an enabling environment for delivering maternal nutrition interventions in Bhutan
Creating an enabling environment for delivering maternal nutrition interventions in Bhutan View this article as a pdf Laigden Dzed is a Senior Programme Officer in the...
FEX: Bangladesh Nutrition Cluster: A case in preparedness
By Andrew Musyoki and Anuradha Narayan Andrew Musyoki is a Nutrition Specialist with UNICEF Bangladesh Anuradha Narayan is the Chief of the Nutrition Section, UNICEF...
FEX: Effectiveness of programme approaches to improve the coverage of maternal nutrition interventions in South Asia
View this article as a pdf Summary of research1 The nutritional status of women before and during pregnancy and after delivery has far-reaching consequences for maternal...
NEX: Providing district-level coverage for nutrition programming in Balochistan, Pakistan province
Hassan Hasrat is the Chief Executive Officer of the Society for Community Action Process (SCAP-Balochistan), a local NGO. He has ten years' experience in health, nutrition and...
Providing maternal nutrition services at sub-national level in Punjab Province, Pakistan
View this article as a pdf Dr Khawaja Masuood Ahmed is the National Coordinator for Nutrition and for the National Fortification Alliance in the Ministry of Health, Pakistan....
FEX: Improving complementary feeding practices through a comprehensive health systems strengthening approach: experiences from Egypt
View this article as a pdf Naglaa Arafa is a Nutrition Officer for UNICEF in the Egypt Country Office. Moataz Saleh is a Nutrition Specialist for UNICEF in the Egypt Country...
FEX: Prevention of child wasting in Asia: Possible role for multiple micronutrient supplementation in pregnancy
View this article as a pdf Lisez cet article en français ici By Kristen M. Hurley, Endang L Achadi, Clayton Ajello, Sufia Askari, Madhavika Bajoria, Kalpana...
FEX: Improving minimum dietary diversity for children aged 6-23 months when household affordability is a major constraint in northeast Bangladesh.
View this article as a pdf Lisez cet article en français ici By Md Masud Rana, Sheikh Shahed Rahman, Md Al-Amin Shovan, Bazlul Kabir Joarder and Mohammad Raisul...
FEX: An integrated multi-sector approach to improve the nutritional status among school-age children and adolescents in Malawi
View this article as a pdf By Doreen Matonga, Keisha Nyirenda, Jason Chigamba and Dalitso Kang'ombe Doreen Matonga is a Communication for Development Specialist at UNICEF...
FEX: Effects of performance payments to health workers in Rwanda
Summary of published research1 A study just published in the Lancet set out to assess the effect of performance-based payment of healthcare providers on the use and quality of...
FEX: Weekly iron and folic acid supplementation and nutrition education for adolescent girls in Africa and Asia
View this article as a pdf Lisez cet article en français ici By Anjali Bhardwaj, Lucy Murage, Shibani Sharma, Dhian Dipo, Christine Makena, Marion Roche and Mandana...
FEX: Ensuring pregnancy weight gain: An integrated community-based approach to tackle maternal nutrition in India
View this article as a pdf Lisez cet article en français ici By Sreeparna Ghosh Mukherjee, Pia Sen and Dr Nagma Nigar Shah Sreeparna Ghosh Mukherjee is Senior...
Addressing maternal nutrition service delivery gaps in Afghanistan: Policy and programming opportunities
View this article as a pdf Dr Zakia Maroof is a Nutrition Specialist working with UNICEF Afghanistan. Dr Homayoun Ludin is an Afghan doctor working with the Ministry of...
FEX: Factors influencing maternal nutrition practices in a large scale maternal, neonatal and child health programme in Bangladesh
View this article as a pdf Research snapshot1 Improving maternal nutrition practices during pregnancy is essential to reduce the high burden of maternal, infant and child...
Reference this page
Dr Mustafizur Rahman, Dr Zeba Mahmud, Dr Mohsin Ali and Pragya Mathema (). Strengthening nutrition information systems to improve maternal nutrition in Bangladesh. Nutrition Exchange Asia 1, June 2019. p29. www.ennonline.net/nex/southasia/informationsystemsbangladesh