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Responses to: ‘An evaluation of the impact of a US$60 million nutrition programme in Bangladesh’
1 ICDDR,B: Centre for Health and Population, Dhaka, Bangladesh and 2 University of Arkansas for Medical Sciences, Little Rock, USA
Correspondence: David A Sack, MD, Executive Director, ICDDR,B: Centre for Health and Population Research, GPO Box 128, Dhaka 1000, Bangladesh. E-mail: dasack{at}icddrb.org
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The paper by Hossain et al. (2005)
suggests that the Bangladesh Integrated Nutrition Project (BINP) budgeted at US$60 million over 5 years was an expensive and ineffective project. While every such large-scale project has faults and can be improved, we would like to clarify several points in the paper. First, the title of the paper stresses the large price tag. Certainly US$60 million is a huge sum, but also recall that this translates into less than $1 per person per year. One could easily argue that even this amount is much less than what is truly needed to substantially improve the nutrition level among those served.
Secondly, as the authors acknowledge, the ex-post study design has significant limitations and the validity and strength of the study conclusions should be considered within this context. The BINP was certainly not designed as a randomized controlled trial, but rather was intended as a phased introduction of a national nutrition strategy.
In the discussion, the authors refer to the possibility that the project might have had a beneficial effect for particular subgroups of the BINP recipients. In fact, such a beneficial subgroup effect did occur. For example, one of the BINP operational research studies, BINP-OR/HPQR-5/2 by Shaheen et al. (2000), which investigated the optimal duration of nutritional supplementation for malnourished pregnant women and its impact on birth weight of newborns, showed beneficial subgroup effect as it relates to prenatal food supplementation and birth weight. The results indicated that there is a threshold of supplementation after which it exerts a beneficial effect to both mother and baby, and it seems to be somewhere between 100 to 130 days (see Figure 1).
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One might more reasonably ask whether the nutritional status of Bangladesh has improved, and if so, has the specific project contributed to this overall improvement. Our data from a large-scale nutrition survey carried out as a baseline survey for the National Nutrition Project (NNP), soon to be published, has demonstrated continued improvement in nutritional status, especially in reduction in stunting. It also found that areas covered by the BINP were better-off compared with other areas. It is not possible to determine if the BINP has contributed to the overall nutritional improvement in other parts of the country, but by raising the profile of nutrition, a ‘spill-over’ effect is certainly possible.
It is also important to appreciate that the BINP and its successor, the NNP are part of an overall multi-sectoral strategy by the Government of Bangladesh (GoB) to improve the health of the women and children of the country. This strategy includes primary health care services, immunizations, vitamin-A distribution, education (especially for girls), improvements in agriculture, and many others; thus, the nutrition activities are a part of the overall strategy. Since Bangladesh is one of the few poor countries that will likely meet the Millennium Development Goals for health, it seems perhaps more than plausible that this overall strategy is having a beneficial impact.
The authors refer to one of the BINP-OR studies in their report but erroneously that the study was funded by the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B). While ICDDR,B managed the BINP-OR Project, it was the GoB and the World Bank that created and funded the BINP-OR activity. In this regard, the GoB and World Bank deserve recognition for commissioning an independent operations research activity as part of the BINP and now the NNP. Results of the operations research and pilot studies will undoubtedly help to guide the programme in the future.
Can the NNP do better and allocate resources better? Clearly, any such project can be improved, focusing on those components that are most cost-effective. Our studies suggest that more emphasis is needed toward nutrition education, integration of nutrition activities into primary health care, and increasing the role of operations research in the programme, as opposed to stressing distribution of food commodities. Also there may need to be an adjustment of the goals of the project to be realistic in terms of actual achievable goals. The initial goals were probably overly ambitious at the start. But these adjustments can be made to the project as it matures. When malnutrition is a key factor in about 60% of childhood deaths, we need to continue to improve on existing nutrition programmes and apply critical review and constructive criticism to the attempts at dealing with the problem.
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Dr Sack is the Executive Director of the ICDDR,B: Centre for Health and Population in Dhaka, Bangladesh. Dr Roy is a Scientist in the Clinical Sciences Division of the ICDDR,B and Dr Ahmed is the Head of the Nutrition Programme at the Centre. Dr Fuchs is a Professor of Pediatrics, College of Medicine and Professor of Maternal Child Health, College of Public Health, University of Arkansas for Medical Sciences, Little Rock, USA.
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Hossain SM, Duffield A, Taylor A. 2005. An evaluation of the impact of a US$60 million nutrition programme in Bangladesh. Health Policy and Planning 20: 35–40.
Shaheen R, El-Arifeen S, de Francisco A. 2000. A cohort study to estimate the optimal duration of nutritional supplementation for malnourished pregnant women and its impact on birth weight of newborns. In: Osendarp SJM, Roy SK, Fuchs GJ (eds). 2000. Results from the Bangladesh Integrated Nutrition Project (BINP) Operations Research Project (ORP). Volume 2. Dhaka: International Centre for Diarrhoeal Disease Research, Bangladesh.
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