National Nutrition Services

(A Mainstreamed and Integrated Approach to Addressing Malnutrition)

Directorate General of Health Services

Ministry of Health and Family Welfare

A. Specific Objectives:

· To implement a mainstreamed, comprehensive package of nutrition services to reduce maternal and child malnutrition and ensure universal access

· To develop and strengthen coordination mechanisms with key relevant sectors (especially Ministry of Food and Disaster Management, Ministry of Agriculture, Ministry of Women and Children Affairs, Ministry of Information, Ministry of Education, Ministry of Livestock and Fisheries, Ministry of Local Government and Rural Development and Cooperative, etc.) to ensure a multi-sectoral response to malnutrition

· To strengthen the human resource capacity to manage, supervise and deliver nutrition services at the different levels of the health &family planning services

· To strengthen nutrition management information systems and operations research to ensure an evidence-based response and establish linkages to HIS

B. Package of Services with Responsibility

MO: Medical Officer, SACMO: Sub Assistant Community Medical Officer, MA: Medical Assistant, HA: Health Assistant, FWA: Family Welfare Assistant, FWV: Family Welfare Visitor, CHCP: Community Health Care Promoter, ANC: Ante Natal Care, PNC: Post natal care, MNP: Multiple Micronutrient Powder, CMAM: Community Based Management of Acute Malnutrition, GMP: Growth Monitoring and Promotion, PAC: -Post Abortion Care

C. Responsibility of Line Director, National Nutrition Services

-Provide technical support, devleop policy directives, guidelines and tools

-Capacity development of service providers

- Procurement of logistics and supplies: weight and height measurement equipment (scales, MUAC tapes
etc), iron-folatetablets, Vitamin A capsules, SAM drugs and logistics

- Introduction of a structured referral system

- Development and procurement of BCC materials; Mass Media Campaigns and organizing national events (eg, breastfeeding and nutrition weeks; Technical Inputs to other OPs (eg in development of BCC materials)

- Coordination with NGOs and other Stakeholders involved in the implementation of BCC activities

- Other Mass Media Campaigns as well as IPC in collaboration with NNS

- Coordination with the concerned LDs to ensure availability of Fe/folate tablets at all levels;

- NVAC: Policy guidelines and directives, Mass media campaigns (in collaboration with ESD, HSM);
Distribution of capsules up to Upazila level; Compilation of Stats; Policy Directives and Guidelines,
Development of BCC materials; Monitoring; quality assurance/field testing of salt

- Implement special interventions for pocket areas at high risk of IDDs

- Institutional Capacity Development

- Monitoring and Evaluation/Nutrition Surveillance/Survey/Research

- Establish a national resource center on nutrition; establish a national nutrition surveillance system

- Collect routine information on nutrition service contacts and anthropometric measurements

- Establish linkages with routine data sources to get periodic MIS information by NNS

D. Related Operation Plans for mainstreaming nutrition interventions

Essential Service Delivery (ESD)

Community Based Health Care(CBHC)

Maternal Neonatal Child and Adolescent Health(MNCAH)

Maternal Child-Reproductive and adolescent Health Care(MC-RAH)

Family Planning Field Service Delivery (FPFSD)

Hospital Service Management (HSM)

E. Nutrition Interventions at different levels:

E.1 District Level Activities

At the district hospital/MCWC/Medical College level: nutrition services including IYCF package, BCC services for pregnant and lactating mothers, SAM management with ongoing other nutrition services and facilitating nutrition activities at the upazila level and below.

E.2 Upazila level activities

· Treatment of complicated cases of severe and acute malnutrition, provide feedback to facilities from where patients are referred

· IYCF: counseling to all women with under two children who come to OPD (for example for Immunization, FP methods and at the ORT corner and IMCI Corner) for any reason, for exclusive breast feeding until 6 (180 days) months of age, proper complementary foods and advice on adequate nutrition after six months of age, weight and height measurements

· Screening for malnutrition (MUAC, growth monitoring), nutrition advice for all children under five, classification and categorization of referred children by level of malnutrition, treatment of severe acute & moderate malnutrition, follow-up of referrals from the community , monitor & follow-up visits to children under treatment

· Behaviour Change Communication (BCC): In addition to BCC messages on IYCF, nutrition education and counseling to be provided to adolescents, pregnant and lactating women on topics such as, personal hygiene and cleanliness especially during preparation of food and feeding of infants and young children, general nutrition, health and nutritional importance of deworming and consumption of micronutrient supplements (Vit. A, Iron, Folateetc)

· Micronutrients: Provide advice and guidance to households on iodine, iron, and vitamin A, advocacy and monitor follow-up and compliance of iron-folic acid by pregnant women, provision of zinc in addition to ORS during treatment of diarrhea, provision of de-worming medication and post-partum vitamin A supplementation

E.3 Union level Activities

The MO assigned with public health and nutrition services at the UHC level will frequently visit union level UH&FWCs and provide nutrition services and supervise SACMO/MA and FWVs assigned in the UH&FWC to deliver the following nutrition-related services:

· IYCF: As mentioned under Upazila level

· Behaviour Change Communication (BCC): As mentioned under Upazila level

· Micronutrients: As mentioned under Upazila level

· Refer complicated cases to primary level (i.e. UHC) with appropriate follow up

E. 4 Community Clinic (CC) Level Activities

The delivery of nutrition services in community clinics will also be under the supervision of the Medical Officer (Public Health and Nutrition) assigned the responsibility of overseeing the implementation of nutrition activities through the Community Group (CG) in their designated area. HAs, FWAs, and Community Health Care Providers (CHCP) and other relevant personnel working at that CC will have the responsibility of delivering the nutrition services. Two or three female Community Health Volunteers tol be selected for each community clinic area.

The main activities to be implemented in CC will include:

· IYCF and BCC: counseling all women with children on exclusive breast feeding until 6 months of age including positioning and attachment, supporting for trouble-shooting for any breastfeeding problem, proper complementary foods and advice on adequate nutrition after six months of age, weight and height measurements. In addition, BCC messages on IYCF nutrition education and counseling to be provided to adolescents, pregnant and lactating women on topics such as, personal hygiene and cleanliness especially during preparation of food and feeding of infants and young children, general nutrition, health and nutritional importance of deworming and consumption of micronutrient supplements

· Screening and Referral: Conduct screening for malnutrition (MUAC, growth monitoring), provide nutrition advice for all children, referral for complicated cases to primary level care facility (i.e. UHC), and follow-up of referrals from the community and monitor follow-up visits to children under treatment

· Micronutrients: Provide advice guidance to households on iodine, iron, and vitamin A, advocacy and monitor follow-up and compliance of use of iron folic acid by pregnant women,provision of zinc in addition to ORS during treatment of diarrhea, provision of de-worming medication, iron-folic acid supplements, post-partum vitamin A supplementation. Service providers at the CC level (viz. CHCP, HA, FWA) will also provide micronutrients like Iron folate supplementation to target groups

E.5 Community Level Activities

The community level will be the focus of all area based Community Nutrition activities/ interventions. At the community level, nutrition services to be delivered by Health Assistants, Family Welfare Assistants and CHCP in addition to their usual duties. These activities will be supervised by their respective supervisors and will be carried out through group counseling; one-to-one counseling during home visits to pregnant women, new mothers, growth falters (that is, pregnant women, infants and young children). The HAs, FWAs and CHCPs will be supervised and guided by Health/Family Planning Inspectors and Family Welfare Visitors (FWVs) to carry out nutrition services along with other health and family planning responsibilities. In addition, services of community volunteers will be availed wherever they are available and whenever necessary.

The key tasks at the Community level will include:

· Infant and Young Child Feeding Practices (IYCF): advocacy for the main IYCF practices as well as appropriate nutrition and health/nutrition behaviors for pregnant and lactating women, growth monitoring and promotion. Specific IYCF messages, behaviours and practices to be promoted and re-enforced will include: exclusive breastfeeding for 6 months, introduction of culturally appropriate complementary foods of adequate nutritional quality and quantity at the appropriate age with continued breastfeeding up to 2 years of age, appropriate infant and young child feeding practices during illness, etc.

· Behaviour Change Communication (BCC): In addition to BCC messages on IYCF nutrition education and counseling will be provided to adolescents, pregnant and lactating women on topics such as, personal hygiene and cleanliness especially during preparation of food and feeding of infants and young children, general nutrition, health and nutritional importance of deworming and consumption of micronutrient supplements (Vit. A, Iron, Folateetc)

· Community Based Management of Malnutrition (CMAM) : screening for malnutrition (MUAC, growth monitoring), nutrition advice for all children, referral to appropriate facility for severe and moderate malnutrition, HAs, FWAs, and Community Health Providers provide follow-up visits to children under treatment.

· Micronutrients: Provide advice guidance to households on iodine, iron and vitamin A; advocacy and follow-up for use of iron/folic acid and calcium supplements, by pregnant women and post-partum vitamin A supplementation

· Coordination: HAs, FWAs, and Community Health Providers will play a key role in promoting and ensuring convergence and coordination during the implementation of nutrition sensitive interventions by other sectors in the communities that they will be working in. Examples of nutrition sensitive activities include, food security projects (including nutrition gardens and livestock/fisheries projects), livelihoods projects, water, sanitation/hygiene activities, etc.