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Study Overview

Evaluation of GoB, UNICEF, CIFF initiative to facilitate and accelerate implementation of the Bangladesh National Nutrition Services
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Undernutrition poses a serious burden in Bangladesh as 37% of children are underweight, 14% is wasted (based on weight-for-height z score), and 36% are stunted (height-for-age) in 2014. National Nutrition Services (NNS), a Government of Bangladesh operational plan, focused on implementing nutrition interventions to reduce burden of undernutrition. UNICEF attempted to overcome the key challenges that have impeded implementation of the NNS . UNICEF is undertaking initiatives to mainstream nutrition services by accelerating the implementation of NNS. The overall goal is to evaluate the impact of the UNICEF program aimed at accelerating implementation of NNS. Method: Quasi experimental design (with comparison group) for household survey (from recently delivered women, caregiver of children <2 years and < 5 years), with a before and after design for facility assessment and training evaluation (healthcare providers). Outcomes: i) Coverage of key nutrition practice indicators at population level ii) improved quality of nutrition services delivered at key service delivery platforms, iii) improved coordination and functionality of nutrition services.

Registration Citation:

Billah, S.M. and El Arifeen, S., 2016. Evaluation of GoB, UNICEF, CIFF initiative to facilitate and accelerate implementation of the Bangladesh National Nutrition Services. Registry for International Development for Impact Evaluations (RIDIE). Available at: 10.23846/ridie090

Health, Nutrition, and Population
Additional Keywords:
Evaluation of a new model for facilitating the nutrition service delivery through health systems
Secondary ID Number(s):

Principal Investigator(s)

Name of First PI:
Sk Masum Billah
International Centre for DIarrhoeal Disease Research, Bangladesh (ICDDR,B)
Name of Second PI:
Shams El Arifeen
International Centre for DIarrhoeal Disease Research, Bangladesh (ICDDR,B)

Study Sponsor

The Children's Investment Funds Foundation (CIFF)
Study Sponsor Location:
United Kingdom

Research Partner

Name of Partner Institution:
Institute of Development Studies (IDS)
Type of Organization:
Research institute/University
United Kingdom

Intervention Overview


In order to address the system-wide gap and reduce delay in NNS implementation roll-out, UNICEF embarked on a mass scale roll-out plan in 23 districts simultaneously in 2014. UNICEF deployed dedicated District Nutrition Support Officers (DNSOs), to demonstrate how efficient utilization of data can improve management of maternal and child nutrition activities. They are responsible for close collaboration with partners across relevant sectors and to provide technical support to improve planning, implementation, coordination, and monitoring for nutrition activities at district levels. The second initiative is to demonstrate how a result based training approach can improve the skills of the health care providers. This results based training approach will include introduction of a payment mechanism based on outcomes of selected indicators. This intervention aims to demonstrate and prove the feasibility and impact of an innovative method to improve skills and competencies of managers, supervisors and service providers who are already part of nutrition delivery mechanism.

Theory of Change:
Multiple Treatment Arms Evaluated?

Implementing Agency

Name of Organization:
The United Nations Children's Fund (UNICEF)
Type of Organization:
Foreign or Multilateral Aid Agency

Program Funder

Name of Organization:
The Children's Investment Fund Foundation (CIFF)
Type of Organization:

Intervention Timing

Intervention or Program Started at time of Registration?
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Evaluation Method

Evaluation Method Overview

Primary (or First) Evaluation Method:
Other (specify)
Other (not Listed) Method:
Quasi Experimental design
Additional Evaluation Method (If Any):
Difference in difference/fixed effects
Other (not Listed) Method:

Method Details

Details of Evaluation Approach:

A quasi-experimental study design with mixed method approach will be adopted to evaluate the impact on intervention coverage from household surveys. We will conduct household surveys in 21 districts in 3 arms: i) Districts where DNSO activities began early 2015, ii) Districts where DNSO activities have been in place since 2014 and iii) Districts with no DNSO activity (regular NNS). Facility assessment survey, Health Management Information System, case observations, focus group discussion and in-depth interviews will be conducted to assess the quality of nutrition services, barriers and challenges towards nutrition mainstreaming.We will adopt difference in difference analysis for the household surveys and facility assessments. To evaluate the second intervention, we will adopt a before-after design with a mixed-method approach to assess the impact of results-based training. Pre/post-training assessments plus in-depth interview/focus group discussions will be conducted to assess the impact of competency based training.

Outcomes (Endpoints):

Improved intervention coverage for pregnant woman: % of recently delivered women received iron supplementation, % of lactating woman received Vit-A Improved intervention coverage for under-5 children: % of mother of 0-6 months children received advice on exclusive breastfeeding, % of mother of 6-23 months children received advice on complimentary feeding Improved Nutrition Practice: % of children born in preceding 1 year who started breastfeeding within 1 hour of birth, % of children exclusively breastfed, % of children who continued breastfeeding at 2 years of age, % of children 6-8 months received complementary feeding, % of 6-23 month old children fed with 4+ food groups Improved knowledge, skill and performance: % of health worker adequately recalled contents of training, % of health worker with skills on Behavioural Change Communication (BCC), % of health worker with knowledge of key nutrition messages during antenatal and childhood illness case management, % of health worker with knowledge on feeding practices, % of health worker with knowledge on SAM-MAM case management.

Unit of Analysis:
Individual study participants

1. External facilitation by DNSO and improvement of skills by healthcare providers can lead to improvements in coverage of key nutrition interventions which have direct relationship with stunting. 2. Competency Based training followed by supportive supervision can improve the skills and knowledge retention of healthcare providers

Unit of Intervention or Assignment:
Number of Clusters in Sample:
604 Clusters (for Household Survey)
Number of Individuals in Sample:
3351 Recently Delivered Women, 8466 children aged 0-23 month, 2103 children 0-59 months, 1110 pregnant women, 2745 sick child under 5 years of age, 441 service provider, 231 health facilities
Size of Treatment, Control, or Comparison Subsamples:
7 Districts each from 3 arms (Households Survey), 77 facilities per arm (Facility Assessment), 441 service providers from intervention arm (Training Assessment)

Outcomes Data

1: Assess impact on coverage of key nutrition interventions- Household survey, Case observation, Exit interview 2: Assess impact of results- based training approach on health care providers’ performance- pre- post training assessment 3: Identify effectiveness of DNSO management and coordination - Facility Assessment, Data Extraction 4: Identify barriers and promoters to improve the DNSO performance- Key Informant Interview (KII), Focus Group Discussion (FGD)
Data Already Collected?
Data Previously Used?
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Data Obtained by the Study Researchers?
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Treatment Assignment Data

Participation or Assignment Information:
Data Obtained by the Study Researchers?
Data Previously Used?
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Data Obtained by the Study Researchers?
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Data Analysis

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Study Materials

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Registration Category

Registration Category:
Prospective, Category 1: Data for measuring impacts have not been collected

Completion Overview

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Preliminary Report:
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Data Availability

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Other Materials

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Study Stopped