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Thin on the Ground

Thin on the Ground. Bangladesh Integrated Nutrition Project (BINP): An independent review by SC-UK Questioning the evidence behind World Bank - funded community nutrition project. Acknowledgements. Prof. Michael Latham Cornell University Prof.WimVan Lerberghe, ITM Antwerpen

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Thin on the Ground

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  1. Thin on the Ground Bangladesh Integrated Nutrition Project (BINP): An independent review by SC-UK Questioning the evidence behind World Bank - funded community nutrition project

  2. Acknowledgements • Prof. Michael Latham Cornell University Prof.WimVan Lerberghe, ITM Antwerpen • Prof. Patrick Kolsteren, ITM • Prof. John Mason, Tulane University • Prof. Saul Morris, LSH&TM • Dr Helen Young, Tufts • Hon’ble Secretary,Ministry of Health and Family Welfare • Abbas Bhuiya, PhD (ICDDR,B) • Prof. Quazi Salamatullah, PhD (INFS) • Prof. Mamunar Rashid PhD (IPHN) • Prof. Ataharul Islam, PhD, (DU)

  3. Why are we concerned about the BINP? • Save the Children UK’s history • Literature reviews • Programmes raised questions • Antwerp conference 2001

  4. Bangladesh Integrated Nutrition Project (BINP)1995-2002 (US $67 million) • Project aim: improve child growth • Decrease severe underweight by 40% • Decrease moderate underweight by 25% • Main project components: • Community-based Growth Monitoring and Promotion • Targeted supplementary feeding

  5. Project M&E data • 1995 baseline: 6 project thanas, 2 control thanas • 1998 Mid term evaluation: same thanas

  6. BINP mid-term evaluation results • Rate of severe malnutrition decreased in project and control areas • Apparent greater decrease in project areas

  7. Prevalence of severe underweight (<-3 z-scores weight-for-age) in 6-23 months, 1990-2000

  8. MTE Results:Low BMI finding and (mis) interpretation • “The prevalence of low BMI <18.5) reduced from a 4.7% point higher rate to a 2.4 percentage point higher rate than in the project thanas compared to the control thanas indicating a net reduction in the prevalence by 2.3 percentage points in 3 years time”. • “BINP has made substantial improvement in the prevalence of low BMI among women of child bearing age” ----- MTE pg 61 (table 131)

  9. Data from project registers (n=998) Severe malnutrition defined as <60% weight-for-age; moderate malnutrition defined as 6075% weight-for-age; not malnourished defined as >=75% weight-for-age

  10. Save the Children’s survey • Cross sectional design 6 years after implementation began • Same project thanas (3 randomly chosen). Three new control areas selected through matching. • No comparison with baseline was possible

  11. Project (n=4,554) Non-project (N=2,261) P-value Male HH 94% 95% 0.06 Formal education of HH 42% 43% 0.74 Own land 42% 46% 0.20 Big bedroom 80% 82% 0.06 Lowest SES 15% 14% 0.35 SC UK’s cross-sectional study: HH characteristics

  12. BINP (n=1,598) Non-BINP (n=790) P-value Severe underweight (<-3 z-scores weight for age) 11.4% 12.2% 0.63 Moderate underweight (<-2 z-scores weight for age) 35.2% 36.3% 0.62 Anthropometric results (6-23 months)

  13. Outcomes of GMP and SFP • GMP understanding: 7% • SFP coverage: 22% • Use of supplementary food : 67% replacement

  14. Can GMP and supplementary feeding reduce malnutrition? • Save the Children study showed small improvements in caring practices but no differences in levels of malnutrition • Supplementary feeding is only successful if linked to health care and providing a supplementary rather than replacement diet (i.e. household food access is adequate) • 98% mothers reported receiving feeding 6 times per week but 67% reported that they did not feed the child other food at home

  15. Conclusions • Insufficient evidence to claim the project has achieved its objectives • Evidence is badly needed before further investment • Feasibility issues related to design and implementation • Questions over sustainability and cost effectiveness

  16. Recommendations • Halt further scale-up of investment in this projects until reviews / pilots demonstrate effectiveness • Independent review of cost effectiveness of current approaches including meta-analysis of data from large scale nutrition projects

  17. Recommendation (cont’d) • BINP end term evaluation in conjunction with baseline and MTE must be used to inform future investment in NNP • Immediate action to improve monitoring and evaluation

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