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cp r C o m m e n ta r y

N o . 8 S U MMER 2 0 1 2

Improving Nutritional Status


for Women in Low-Income
Households
IUBAT

by Afifa Shahrin and John Richards


C e n t r e f o r P o l ic y R e s e a r c h

IUBATInternational University
of Business Agriculture
and Technology
Dhaka, Bangladesh
Improving Nutritional Status for Women in Low-Income Households

CPR Commentary Number 8 | Summer 2012

by Afifa Shahrin and John Richards

About the Centre for Policy Research

Created in 1999, the Centre for Policy Research is a nonprofit research and educational institution,
linked to IUBATInternational University of Business Agriculture and Technology.
Its goals are to identify current and emerging economic and social issues facing Bangladesh;
to analyse options for public and private sector responses; to recommend, where appropriate,
particular policy options; and to communicate the conclusions of its research in an accessible
and nonpartisan form, in both English and Bengali. Publications of the Centre are freely available
at www.iubat.edu/cpr
Simon Fraser University in Burnaby (Vancouver), Canada, has entered into a memorandum of
understanding with IUBAT. By this agreement, SFU will encourage participation by its faculty and
students in projects of the centre.
While the centre takes care to assure the quality of published research, the conclusions of
individual studies lie with the authors. Conclusions do not necessarily represent the opinion of
IUBAT, SFU or the members of the centres management committee.
Design and layout by Nadene Rehnby and Pete Tuepah www.handsonpublications.com.
The cover art is a reproduction of a nakshi kantha produced by women working with BRAC.
ISBN 984-70060-0005-1 | U.S. $15 | Taka 200

For information about activities and publications of the Centre for Policy Research, contact:

Dr. M. Alimullah Miyan John Richards, Ph.D.


Vice-Chancellor and Founder, Professor, Graduate Public Policy Program
IUBATInternational University of Simon Fraser University
Business Agriculture and Technology 515 West Hastings Street, Vancouver, B.C.
4 Embankment Drive Road, Sector 10, Uttara Canada, V6B 5K3
Model Town, Dhaka 1230, Bangladesh Tel: 778-782-5250 | Fax: 778-782-5288
Tel: (88 02) 896 3523-27, 01714 014933, 892 e-mail: jrichard@sfu.ca
3469-70, 891 8412 | Fax: (88 02) 892 2625
Email: info@iubat.edu | www.iubat.edu www.iubat.edu/cpr
Contents
Foreword............................................................................................................... 5

List of Acronyms.................................................................................................... 6

Executive Summary............................................................................................... 7

1. Introduction..................................................................................................... 18

2. Methodology................................................................................................... 27

3. Descriptive Statistics....................................................................................... 32

4. Statistical Analysis.......................................................................................... 45

5. Policy Analysis................................................................................................ 52

6. Conclusion...................................................................................................... 65

References.......................................................................................................... 66

Appendix A: Survey Questionnaire...................................................................... 75

Appendix B: Food Scoring Method...................................................................... 89

Appendix C: Income and Asset Index Calculation................................................ 93


About the authors

Afifa Shahrin graduated in 2012 from Simon Fraser University, Vancouver, where she obtained
a Masters in Public Policy degree. She is a former economics instructor at BRAC University.

John Richards is a faculty member of the School of Public Policy at Simon Fraser University and
overseas faculty member of IUBAT. He serves as advisor to the Centre for Public Policy at IUBAT.

Acknowledgments

We thank in particular Narayan Chandra Das, a research fellow of the BRAC Research and Evalu-
ation Division, who helped us to organize the survey work. We also thank Dr. Erum Marium,
Director of the BRAC University Institute of Educational Development, Rokeya Khatun, BRAC
area manager in Jamalpur, and Moniruzzaman, BRAC area manager in Uttara. They helped
us to organize the focus group discussions. Dr. Ameena Ahmed of BRAC Nutrition Division
provided us with information about the BRAC school feeding program.
We also express thanks to Dr. Alimullah Miyan, Vice-Chancellor of IUBAT, and Dr. Karen
Lund, Chair of the IUBAT BSN Nursing Program. Sanchay Baruha typed the Bangla version
of the questionnaire. Others at IUBAT helped us in every stage of the data collection process.
Last but not least we are thankful to the 20 surveyors who worked hard to complete the survey.
Foreword

This 8th CPR Commentary is an ambitious study of nutrition among low-income women
in Bangladesh. The authors undertook a survey of nearly 600 women in two sites, in slum
communities along the Tongi-Ashulia Road in Uttara and in four villages in Jamalpur dis-
trict. While some of the women surveyed face problems of inadequate calorie intake, the
more serious nutritional problem is a lack of dietary variety. Many of the women suffer a
deficiency in necessary vitamins and micronutrients to be found in fruits, vegetables, and
dairy products. Nearly all women in the rural sample use hygienic tube well water, but the
great majority of urban women sampled use unhygienic tap water.
The authors discuss several potential policy responses, from government promoting use
of fortified rice to setting tube wells in urban slum areas.
This Commentary is the result of a collaboration among three universities. The princi-
pal author, Ms. Afifa Shahrin, conducted the survey while a visitor at the IUBAT nursing
college in the summer of 2011. Several IUBAT students participated in the conduct of the
survey. Formerly, Ms. Shahrin was an instructor at BRAC University, and BRAC cooperated
extensively in the conduct of the rural survey in Jamalpur. An earlier version of this study
was submitted to Simon Fraser University in Vancouver, Canada, as part of the require-
ments for Ms. Shahrin to obtain her Masters of Public Policy degree. The second author,
John Richards, is a professor at Simon Fraser University and long-time overseas faculty
member of IUBAT.

Dr. M. Alimullah Miyan


Vice-Chancellor and Founder, IUBAT

Centre for Policy Research of IUBAT Summer 2012 5


List of Acronyms

ADB Asian Development Bank

BMI Body Mass Index

BBS Bangladesh Bureau of Statistics

BRAC Bangladesh Rural Advancement Committee

ESCAP Economic and Social Commission for Asia and Pacific

FAO Food and Agriculture Organization

ICDDR, B International Centre for Diarrhoeal Disease Research, Bangladesh

NGO Non-Government Organization

SEWA Self Employed Womens Association,

UNICEF United Nations Childrens Emergency Fund

UNDP United Nations Development Programme

UNFPA The United Nations Population Fund

WFP World Food Programme

WHO World Health Organization

6 Improving Nutritional Status for Women in Low-Income Households


Executive Summary

The objective of this study is to provide policy advice to improve


the nutritional status of low-income women in Bangladesh. While some suffer from inad-
equate calorie intake, the major nutritional problem is inadequate consumption of protein
and micronutrients.
We first report the nutritional status of There exist regional differences in the
a sample of nearly 600 women surveyed health and nutritional status of women.
in two sites, one rural and one urban. The Generally, people living in the slums of
rural site is a group of villages near Jamal- Dhaka region consume more calories than
pur; the urban site is a slum in Uttara, in those living in slums elsewhere. Among
the Dhaka metropolitan area. an earlier study undertaken by the nurs-
Malnutrition among women is a serious ing college at IUBAT of women living in
problem in Bangladesh as in many devel- a Uttara slum, about 12 per cent did not
oping countries. Protein-energy malnutri- have adequate calorie intake in their diet
tion, iron deficiency anaemia, and vitamin to achieve a body mass index (BMI) above
A deficiency are common. Malnutrition is the traditional threshold of 18.5. Other
a major cause of the high maternal mortal- studies have found more than 20 per cent
ity rate in Bangladesh, a rate second only of slum women in Dhaka suffering a BMI
to Nepal among South Asian countries. below 18.5.
Malnutrition passes from one generation Most studies on low-income womens
to the next as malnourished mothers give health and nutritional status in Bangladesh
birth to malnourished children. concentrate on urban and suburban slums.

Centre for Policy Research of IUBAT Summer 2012 7


One exception is a large-scale study of from deficiency of protein and micronu-
rural adolescent girls (ages 13-18 years); it trients. The central policy problem is how
found 21 per cent thin and 32 per cent to improve the quality of their diet at a
stunted. Another study found limited, reasonable incremental cost whether to
though increasing, evidence of obesity the womens families, to government, or to
among women living in Dhaka region and relevant NGOs.
other urban centres of the country.
Food security in Bangladesh has often
been assessed on the basis of the adequacy Explaining Poor Nutrition
of rice consumption. In our survey more
than 90 per cent of all women consumed Many factors at the household, commu-
satisfactory servings from the cereals and nity, national and international levels un-
potato group of foods. The majority in derlie the problem. In analyzing the survey
both samples failed to eat at least five the results, we considered separately six sets of
recommended number of servings from factors: 1) poverty and food price inflation;
the fruit and vegetables category. Women 2) low education levels among women; 3)
consumed inadequate dairy servings. Milk absence of basic nutritional information;
consumed with tea is often the only source 4) cultural barriers facing women; 5) inad-
of calcium and vitamin D. The majority equate standards of cleanliness and hygiene
consumed adequate protein, but over a (including source of drinking/cooking wa-
quarter did not. Almost all women con- ter); and 6) addiction to tobacco and betel
sumed fat, oil and sugar within acceptable nut among household members.
limits. To obtain adequate intake of micro-
nutrients, a diverse diet is required. Nearly Poverty and Food Price Inflation
a third of the low-income women received
the lowest score on this question. Given Poverty is often the root cause of food
their rural location, it is not surprising that insecurity, inadequate access to health care
the rural women scored better in terms of services, poor sanitation and unsafe water,
eating at least two vegetables, due to their low education levels, and lack of proper
access to home-grown and locally produced caring practices among pregnant women.
vegetables at low cost and sometimes free Bangladesh has experienced food price infla-
of cost. Rural women also scored higher in tion over the last decade, the most dramatic
terms of eating at least one fresh fruit and being the 2008 spike in rice prices. Even if
choosing healthy snacks. But the majority of low-income families have sufficient income
both groups did not eat any fresh fruit and for a healthy diet, spikes in food prices may
chose relatively unhealthy snacks mostly lead to a sacrifice in diversity of diet. Rural
purchased from nearby street food shops. women who reported having reduced food
While the majority of low-income consumption in the previous year due to
women may have an adequate calorie food price inflation were more likely to have
intake, the evidence is clear: many suffer inadequate diets.

8 Improving Nutritional Status for Women in Low-Income Households


Education and in household decision making. Son-
preference is rooted in the idea of higher
Independently of its effect on productivity
earning potential of sons than daughters,
and earnings of workers, education builds
and expectation of support from sons for
abilities and social skills, which in turn
parents during their old age and at times of
contribute to health and wellbeing of people
crisis. In South Asia the nutritional status of
as adults. In general, women in households
female children (age 0-4 years) is worse than
with higher education levels enjoyed better
male children of the same age. The South
nutrition.
Asian gender gap in nutrition is worse than
in other regions of the world and the gap
Nutritional Information widens as children grow up. Our survey
Vulnerable households usually have limited found no significant evidence of this effect.
access to nutrition information. Among
rural girls in Bangladesh, ages 13-18, one Hygiene and Cleanliness
study found that more than half do not
know the name of foods that are sources Frequent attacks of infectious diseases can
of protein, and a third do not know the ne- offset the value of a nutritious diet. In the
cessity of nutritional supplements for their rural sample nearly all women used safe
physical growth. Even with a low income, water from tube wells; in the urban sample,
families can often improve their nutritional only 16 per cent did.
status by substituting healthy for unhealthy Unhygienic water and sanitation may
foods, and eliminating or reducing expendi- result in a high incidence of various water-
ture on addictive products such as tobacco. borne communicable diseases. Unclean
The survey results imply in general household environment, poor personal
improved nutrition among those receiving sanitation, and improper disposal of human
advice comes from a reliable source such feces are common in poor neighbourhoods
as a nurse or doctor working in a health resulting in various parasitic infections.
facility. On the other hand, advice received Disease reduces the ability of the body to
from NGO health workers apparently had use nutrients, and poor diet increases the
no impact. incidence of disease.

Cultural Barriers Tobacco and Betel Nut

Due to the patriarchal nature of Bangladeshi Among low-income men in Bangladesh, ad-
society and a deep-rooted preference for diction to tobacco is very common. More
sons, females in South Asian countries often than 65 per cent of the rural households
face discrimination in terms of investment in and 70 per cent of the urban households
education, access to resources (such as food sampled have at least one member who
and health care), and freedom to own assets smokes. Tobacco consumption is the cause

Centre for Policy Research of IUBAT Summer 2012 9


of eight major diseases, such as ischemic Recommendations
heart disease, lung cancer, stroke, oral can-
cer, cancer of the larynx, chronic obstructive We examined numerous options, some
pulmonary disease, pulmonary tubercu- appropriate for pursuit by NGOs and oth-
losis, and Buergers disease. The average ers by the Government of Bangladesh. We
standardized rate of mortality due to lung considered options in five categories:
cancer in Bangladesh (18.2 per 100,000 promotion of nutritional supplements:
population) is the highest among all South Two options within this category are rice
Asian countries. fortified with micronutrients and forti-
In very few cases do the women them- fied yogurt (shokti-doi).
selves smoke. However in analyzing the
survey, we found in general a negative improvements in hygiene: Two options
association between womens nutrition here are setting shallow tube wells in
and the extent of tobacco consumption in slum areas of cities not subject to arse-
the household. Consumption of tobacco nic in groundwater and providing siraj
may affect womens nutrition via several mixture for treating contaminated
routes. Income spent on tobacco reduces ground water where arsenic is a serious
income available for food. Families that problem. (Arsenic is not a serious prob-
smoke may be less knowledgeable of the lem in Dhaka.)
dangers of tobacco and the requirements improvement in sources of nutritional
for a healthy diet. Whatever the nature of advice: Better training of community
the link, the survey results point to a nutri- health workers is a potentially effective
tion benefit in addition to health benefits option.
to those presently smoking of eliminating
role of social enterprises: Social enter-
use of tobacco.
prises pursue dual goals of providing a
About 65 per cent of poor households
social service and covering all or most of
have at least one member who chews betel
their costs from sale of services. There
nut. The majority of those chewing are
may be a potential to copy a Jakarta-
women. Betel quid (betel leaf, areca nut,
based project selling healthy food via
lime and sometimes tobacco) is another
street vans. Another is NGO promotion
common addictive purchase in Bangladesh
of vegetable gardens in rural areas.
and South Asia. In rural areas, offering a
decorated betel quid to guests and relatives campaigns against tobacco use: Given
is a symbol of hospitality, which people the negative link between tobacco con-
consume for recreation, breath freshening sumption and nutrition, anti-tobacco
and for digestive purpose. Chewing areca campaigns should be pursued. However,
nut may cause submucous fibrosis and used pursuing such campaigns aggressively
along with tobacco can cause leukoplakia will probably raise significant opposition
which ends as oral cancer. from adversely affected interests.

10 Improving Nutritional Status for Women in Low-Income Households


As first priority our recommendation is We have divided policy options between
the four options listed in the accompanying those better implemented by the government
table as highly effective. They address key and those better implemented by NGOs.
nutritional problems and are low cost in However, the distinction is not absolute. It
terms of cost/ household targeted or unit
may be feasible for government to contract
of service provided. Admittedly, implement-
with slum community leaders for the main-
ing a subsidized rice fortification program
tenance of shallow tube wells in slums, and
targeted to the ultra poor poses a threat of
additional corruption. There may be useful NGOs may play a role. Government might
lessons from the Female Stipend Program. also choose to mount a program providing
Potentially, the subsidy could be given to nutritional training to community health
targeted families via coupons enabling a workers.
discount on purchases of fortified rice.

Policy Options Effectiveness Cost (Taka)


Annual cost: Tk.154 crore
1. Nutritional supplements High (among
(fortified rice) government options) Annual cost per household: Tk.960
(bottom 10 per cent of population)
Annual levelized cost of tube
2. Hygienic water for wells: Tk.13.9 crore
urban slums (setting High (among
shallow tube wells or government options) Annual cost per household of tube
providing siraj mixture) wells: Tk.140 (for urban slums where
arsenic concentration low)
3. Healthy food initiative through social enterprises
Annual cost per van: Tk.49,500
Jakarta model food Low (among (10 van pilot project)
van (urban) NGO options)
Cost per meal: Tk.20
High (among
Household gardens (rural) Low cost to sponsoring NGO
NGO options)
4. Nutritional and hygienic advice
Improve training of High (among High cost relative to typical NGO budget,
community health workers NGO options) unless NGO obtains explicit donor support
Low cost for government, provided media
Medium (among
Television advertisement outlets agree to broadcast messages
government options)
as public service; high, otherwise
5. Tobacco control
Medium (among
Restrictive selling Low cost for government
government options)
Medium (among
Advertisement ban Low cost for government
government options)

Centre for Policy Research of IUBAT Summer 2012 11


12 Improving Nutritional Status for Women in Low-Income Households
Centre for Policy Research of IUBAT Summer 2012 13
14 Improving Nutritional Status for Women in Low-Income Households
Centre for Policy Research of IUBAT Summer 2012 15
16 Improving Nutritional Status for Women in Low-Income Households
Centre for Policy Research of IUBAT Summer 2012 17
1. Introduction

The objective of this study is to provide policy advice to improve


the nutritional status of low-income women in Bangladesh. While some suffer from inad-
equate calorie intake, the major nutritional problem is inadequate consumption of protein
and micronutrients.
We first report the nutritional status of and skills, most urban migrants work in
a sample of women surveyed in two sites, the informal sector as rickshaw pullers, van
one rural and one urban. The rural site is a and auto drivers, construction workers and
group of villages near Jamalpur; the urban day labourers. A few, with better education
site is a slum in Uttara, in the Dhaka met- and skills, find jobs as low-skilled office
ropolitan area. (See figure 1.1.) employees and garment workers (Hossain
Though we appreciate the value of long- 2006). In rural areas most income earners
term measures (such as improved education are agricultural workers, working their
levels) to address nutritional deficiencies, own or others lands. Some own small
we focus on programs able to yield benefits businesses such as handicrafts and poultry
within a few years some intended for farms. Though urban residents, including
implementation by NGOs and some by the those living in slums, have in general more
Government of Bangladesh. access to education, health care and other
In spite of rapid urbanization in recent services than do rural villagers, often the
decades Dhaka is the worlds 9th largest access remains inadequate.
city with a population approaching 20 mil- Rice is the basic staple food in Bangla-
lion about seven of ten Bangladeshi live desh. Generally, people consume rice twice
in rural areas.1 Lacking adequate education per day, along with curries made with fishes,
meats, eggs, vegetables, or lentils. The
1 Population Division, United Nations 2011. quantity and quality of food greatly vary

18 Improving Nutritional Status for Women in Low-Income Households


Figure 1.1 Map of Bangladesh Showing Sample Areas for this Study

We report the nutritional status of a


sample of women surveyed in two
sites, one rural and one urban. The
rural site is a group of villages near
Jamalpur; the urban site is a slum in
Uttara, in the Dhaka metropolitan area.

Uttara, in Dhaka metropolitan area Village near Jamalpur

Centre for Policy Research of IUBAT Summer 2012 19


Figure 1.2: Maternal Mortality, Total Fertility, and Under Five Mortality Rates, South Asia

Bangladesh India Nepal Pakistan Sri Lanka

100 91
90
80 71
70
59
60 55
50 40
38
40 34
26 28 30
30 23 24 23
20 16
10 4
0
maternal mortality ratio 2008 total fertility rate 2005-09 under five mortality rate 2005-09
(deaths per 10,000 live births) (average births per 10 women (deaths per 1,000 live births)
over their child-bearing years)
Source: World Bank (2011)

with the economic well-being of households. ciency are common (UNICEF 2010, Latham
Tea is a popular drink in both urban and 1997). Malnutrition is a major cause of the
rural areas. Milk consumed with tea is often high maternal mortality rate in Bangladesh,
the only source of calcium and vitamin D a rate second only to Nepal among South
among the poor. Milk, fruits, meat and fish Asian countries (UNICEF 2011). The World
are consumed by the poor but often not in Food Program (2004) estimated the preva-
sufficient quantities. In recent years, food lence of anaemia among pregnant women
consumption among the poor has included in Bangladesh in 2004 at 47 per cent. Mal-
nutritionally poor food items such as chips, nutrition passes from one generation to the
biscuits, samosas, chocolates, and carbon- next generation as malnourished mothers
ated cold drinks (such as Coke) (Halder et give birth to malnourished children. Nutri-
al. 2003). tional problems among children contribute
Malnutrition among women is a seri- to the high by world standards under
ous problem in Bangladesh as in many age-five mortality rates in Bangladesh and
developing countries. Protein-energy mal- other South Asian countries. (See figure 1.2.)
nutrition, iron deficiency anaemia, iodine There exist regional differences in the
deficiency disorders2 and vitamin A defi- health and nutritional status of women.
2
Generally, people living in the slums of
In general iodine deficiency is not a problem
in Bangladesh. More than 80 per cent of Dhaka region consume more calories than
households consume iodized salt (WFP 2004). those living in slums elsewhere. In a study

20 Improving Nutritional Status for Women in Low-Income Households


of 1900 slum households in Dhaka, Chit- ited, though increasing, evidence of obesity
tagong, Khulna and Rajshahi, 24 per cent among women living in Dhaka region and
of Dhaka slum households consumed less other urban centres of the country. In the
than 80 per cent of the recommended calorie context of Bangladesh, where many people
intake. The comparable statistic for Khulna struggle to get adequate calories, obesity has
was 31 per cent, for Chittagong 36 per cent, been considered a much less serious problem
and Rajshahi 40 per cent (Benson 2007). than insufficient calorie intake.
Among a study undertaken by the nursing Food security in Bangladesh has often
college at IUBAT of 120 women living in been assessed on the basis of the adequacy
a Uttara slum, about 12 per cent did not of rice consumption (Bose and Dey 2007).
have adequate calorie intake in their diet to Among the sample of ultra-poor women
achieve a body mass index (BMI) above the considered in her study, Haseen (2005)
traditional threshold of 18.5 (Richards et found that 90 per cent of their calories
al. 2010).3 Bloem et al. (2004) found more came from rice. Another study, of 7000
than 20 per cent of slum women in Dhaka households of all income classes residing
suffering chronic energy deficiency (BMI < in both urban and rural areas, found that
18.5); in Chittagong and Khulna about 35 rice and wheat accounted for more than
per cent of slum women suffered chronic three-fourths of per-capita protein and
deficiency. calorie intake (Bose and Dey 2007). Benson
Most studies on low-income womens (2007) reached similar conclusions: among
health and nutritional status in Bangladesh urban slum households located in Dhaka,
concentrate on urban and suburban slums. Chittagong, Khulna and Rajshahi, meat,
One exception is a large-scale study of rural poultry, milk products and sugar were ir-
adolescent girls (ages 13 to 18 years); it regularly consumed.
found 21 per cent thin and 32 per cent The inadequate consumption of protein
stunted (Alam et al. 2010).4 A compara- and micronutrients results in various long-
tive rural/urban study on 15-49 years old and short-term health problems such as
married women living in Orissa, one of the stunting, underweight, osteoporosis, and
less developed Indian states, found the BMI low bone-mass. In turn, these problems
distribution of rural women to be worse impair the physical ability to work and
than for urban women (Rout et al. 2009). undertake healthy pregnancies (Leslie 1991;
Another study (Corsi et al. 2011) found lim- Sheshadri 2001; Pathak et al. 2004; UNI-
CEF 2011). Lack of dietary diversity has
3 This previous study was conducted by nursing
students at IUBAT. The study is available on
been identified as a reason for micronutri-
line at www.iubat.edu/cpr. ent insufficiency by researchers (Ahmed et
4 Thin was defined as a woman below the al. 2009). Such deficiencies are most often
15th percentile of the WHO age-specific BMI identified during pregnancy when there is
distribution for women. Stunted was defined
as more than two standard deviations below increased need of micronutrients due to
the average age-specific height for women. changes in womens physiology (Pathak et

Centre for Policy Research of IUBAT Summer 2012 21


al. 2004). Most nutritional interventions ing water); and 6) addiction to tobacco and
have targeted maternal and child health, betel nut among household members.
and are limited to pregnant and lactating
women (Pathak et al. 2004; Leslie 1991).
Poverty and Food Price Inflation
This targeting, Leslie concludes, means a
relative under-emphasis on overall nutrition Poverty is often the root cause of food
at other times. insecurity, inadequate access to health care
While the majority of low-income services, poor sanitation and unsafe water,
women may have an adequate calorie illiteracy and low education, and lack of
intake, the evidence is clear: many suffer proper caring practices among pregnant
from deficiency of protein and micronu- women (UNICEF 2009; Haseen 2005).
trients. The central policy problem is how The most frequently cited poverty thresh-
to improve the quality of their diet at a old in developing countries is per-capita
reasonable incremental cost whether to income of USD1.25 per day in US dollar
the womens families, to government, or to purchasing power parity. The most recent
relevant NGOs. UNDP estimate of the Bangladesh popula-
tion consuming at less than USD1.25 per
day is 49.6 per cent (UNDP 2011). (Hence-
Explaining Poor Nutrition forth, those consuming less than USD1.25
per day are identified as extreme poor.)
Many factors at the household, com-
Among the extreme poor, those living with
munity, national and international levels
less than USD1 per day are identified as
underlie the problem posed by inadequate ultra poor (BRAC 2012a). They comprise
nutrition. Osmani (1997) organized his 8 per cent of the national population. The
explanation into three theories: 1) mate- rural poverty rate is higher than in urban
rial deprivation or poverty; 2) inadequate areas in the country (Narayan et al. 2007).
public health infrastructure; and 3) cultural- In order to obtain adequate calories, the ex-
behavioural effects, including quality of treme poor and even moreso the ultra poor
governance. (See Three theories to explain often sacrifice more costly foods (fish,
low population nutrition status.) meat, pulses, fruits and vegetables) that
In analyzing the survey results of low- are high in protein and/or micronutrients.
income women in Uttara and Jamalpur, we While income is relevant, so too may be
consider separately six potentially relevant food price inflation. Even if family income
sets of factors: 1) poverty and food price remains above an income threshold, low-
inflation; 2) low education levels among income families may respond to food price
women; 3) absence of basic nutritional inflation by sacrificing quality and diversity
information; 4) cultural barriers facing of diet (FAO 2010; Sulaiman et al. 2010).
women; 5) inadequate standards of cleanli- The most dramatic example of food price
ness and hygiene (including drinking/cook- inflation over the last decade was the rice

22 Improving Nutritional Status for Women in Low-Income Households


Three Theories to Explain Low Population Nutrition Status

Roughly speaking, one can discern three major strands among the theories that have emerged
to explain the secular improvement in health and nutrition observed in the developed world
and parts of the contemporary developing world
The material well-being theory explains improved health outcomes principally in terms of
the secular improvement in food consumption made possible by general expansion in material
prosperity and increased agricultural productivity. [Some] have advanced this explanation for the
vast improvement in life expectancy that occurred in the Western world in the late 19th and early
20th century. They give this explanation precedence over the technology-based explanation on
the grounds that it was not until well into the 20th century that major advances occurred in medi-
cal technology capable of fighting the major infectious diseases responsible for high mortality
This view has been challenged by proponents of the public-health or technology-based
theory. Their explanation recognizes that the most important breakthroughs in medical technol-
ogy [occurred] after and not before the most significant advances in human health were made
in the West. But they emphasize the importance of public health improvements at the local
level that were based on marginal advances in technology [that] had far-reaching implications.
Examples are access to safe water, sanitation, and pasteurized milk. The argument is extended
also to the contemporary developing world. It is suggested that the sharp decline in mortality
observed in the developing world in the second half of this century owes more to technologies
that made possible mass access to safe water, sanitation, vaccination and other public health
facilities (such as oral rehydration therapy for diarrhea) than to material prosperity as such.
The third strand, namely the cultural-behavioural theory, also extends the argument to the
contemporary developing world. The vast disparities that exist in the experience of developing
countries provide the motivation for this theory. It is well-known that several poor countries
(such as China, Costa Rica, Cuba, Mauritius, Sri Lanka) and sub-regions (such as Kerala state
in India) have achieved levels of life expectancy that are close to the levels achieved by the
richest countries in the world, which suggests that a good deal more than material prosperity
is involved in the explanation of improved health status. By the same token, a good deal more
than public health technology must also be involved, since others who havent done so well
have had access to the same technologies that were put to good effect by the more success-
ful ones. The missing element presumably lies in the cultural and behavioural pattern of the
people concerned; different cultural influences may predispose them to respond differently to
the availability of food and health technology. Among the major determinants of the relevant
behavioural pattern, researchers have identified female education and gender relationship as
especially important, along with the system of governance.
Siddiq Osmani (1997), from Poverty and Nutrition in South Asia

Centre for Policy Research of IUBAT Summer 2012 23


price spike in 2008. However other foods and wellbeing of people as adults. Among
have also experienced significant inflation countries at similar levels of economic
(Richards et al. 2010,33-36). In May 2011 development, higher female literacy rates
the annual Bangladesh food price inflation typically are associated with dramatically
rate was around 13 per cent (BBS unpub- better overall health status among women
lished, May 2011). Food price inflation has and children (Richards 2012).
been higher in rural (14 per cent) than in
urban areas (11 per cent).5
Nutritional Information

Education Vulnerable households usually have limited


access to nutrition information (FAO 2011).
Independently of its effect on labour pro- Among rural girls in Bangladesh, ages 13-
ductivity, education builds abilities and so- 18, more than half do not know the name
cial skills, which in turn contribute to health of foods that are sources of protein, and a
third do not know the necessity of nutri-
5 Bangladesh Bureau of Statistics 2011 tional supplements for their physical growth
(unpublished). (Alam et al. 2011).

24 Improving Nutritional Status for Women in Low-Income Households


Even with a low income, families can
often improve their nutritional status by
substituting healthy for unhealthy foods,
and eliminating or reducing expenditure on
addictive products such as tobacco. Poten-
tially, the provision of information can have
a beneficial impact on nutrition.

Cultural Barriers

Due to the patriarchal nature of Bangladeshi


society and a deep-rooted preference for
sons, females in South Asian countries often
face discrimination in terms of investment
in education, access to resources (such as
food and health care), and freedom to own
assets and in household decision making
(FAO 2011; Ravindran 1986; Leslie 1991;
World Bank 2011). Son-preference is rooted Hygiene and Cleanliness
in the idea of higher earning potential of
sons than daughters, and expectation of Frequent attacks of infectious diseases can
support from sons for parents during their offset the improvement of health status
old age and at times of crisis (Muhuri and arising from a nutritious diet. In Bangladesh
Preston 1991). In the South Asian region the poor people often do not have access to safe
nutritional status of female children (ages drinking water and sanitation. Among rural
0 to 4 years) is worse than male children of people 78 per cent have access to improved
the same age. The South Asian gender gap water such as a household connection, a
in nutrition is worse than in other regions public standpipe, a borehole, a protected
of the world and the gap widens as children well or spring, or rainwater collection
grow up (UNICEF 2011). (World Bank 2011). Among urban people
Because of the discriminatory cultural this per cent is slightly higher (85 per cent);
and social environment, women often obviously the living condition of urban
have low self-confidence and accept a self- slums are much worse than for the average
sacrificing role in the family including urban resident.
acceptance of her food needs as the least im- Unhygienic water and sanitation may
portant among family members. As a result, result in a high incidence of various water-
from childhood through adolescence and borne communicable diseases. The mor-
even during pregnancy and lactating peri- bidity rate due to diarrhoea in Bangladesh
ods, women consume inadequate nutrients. per 1,000 population is 9.4 per year (BBS

Centre for Policy Research of IUBAT Summer 2012 25


2000). Unclean household environment,
poor personal sanitation, and improper
disposal of human feces are common in
poor neighbourhoods resulting in various
parasitic infections (Haseen 2005). Osmani
(1997) describes an infection-nutrition
nexus, a two-way relationship between
diet and disease. Disease reduces the ability
of the body to use nutrients, and poor diet
increases the incidence of disease.

Tobacco and Betel Nut


pulmonary disease, pulmonary tuberculosis,
Among low-income men in Bangladesh, ad- and Buergers disease (GLOBOCAN 2008;
diction to tobacco is very common. More WHO 2005). These diseases are responsible
than 65 per cent of the rural households for 16 per cent of all deaths in Bangladesh;
and 70 per cent of the urban households tobacco consumption is the sole cause of
sampled have at least one member who 9 per cent of such deaths (WHO 2005).
smokes. The average standardized rate of mortality
In very few cases do the women sampled due to lung cancer in Bangladesh (18.2 per
smoke. However in analyzing the survey, 100,000 population) is the highest among
we found in general a negative association South Asian countries (GLOBOCAN 2008).
between womens nutrition and the extent The annual cost of tobacco-related illness in
of tobacco consumption in the household. Bangladesh is estimated at USD40 million
Consumption of tobacco may affect wom- (WHO 2005).
ens nutrition via several routes. Income Betel quid (betel leaf, areca nut, lime
spent on tobacco reduces income available and sometimes tobacco) is another com-
for food. Families that smoke may be less mon addictive purchase in Bangladesh
knowledgeable of the dangers of tobacco and South Asia. In rural areas, offering a
and the requirements for a healthy diet. decorated betel quid to guests and relatives
Whatever the nature of the link, the survey is a symbol of hospitality, which people
results point to a nutrition benefit in ad- consume for recreation, breath freshening
dition to health benefits to those presently and for digestive purpose. The IUBAT sur-
smoking of programs combating use of vey reported 65 per cent of households have
tobacco. at least one member who chews betel nut.
Tobacco consumption is the cause of Chewing areca nut may cause submucous
eight major diseases, such as ischemic heart fibrosis and used along with tobacco can
disease, lung cancer, stroke, oral cancer, cause leukoplakia which ends as oral cancer
cancer of the larynx, chronic obstructive (Auluck et al. 2009).

26 Improving Nutritional Status for Women in Low-Income Households


2. Methodology

The primary methodology was a survey to assess the nutritional


status of low-income women in the two sites. To explore more complex issues, two focus
group discussions were conducted, again one urban the other rural. (See figures 2.1 and
2.2.) Only married women were considered for the study.
We acknowledge here that the Asian relatively little urbanization has occurred.
University for Women conducted a parallel The urban study was conducted in a
survey, using the same survey question- large slum located in the Abdullahpur /
naire, among a sample of young women Kamarpara area in Uttara, Sector 10, in
in Raozan, a suburban community near northern Dhaka city, close to the Turag
Chittagong. Their survey was addressing River. The established residents are reason-
matters beyond the scope of low-income ably prosperous. Over the last two decades,
women and we do not here discuss their a large shanty community, mostly migrants
results. We hope in the future to compare from rural areas, has arisen on government-
the results of their sample with those drawn owned land. These slum houses are mostly
from the two samples analyzed in this study. built by local political leaders who often
For the rural survey, low-income women have no legal lease on the land but none-
were selected from four villages (Satkura, theless collect rent from the slum dwellers.
Mohadanga, Narkeli and Fatehpur) in the Most of the houses in the rural area and
Kendua union in Jamalpur Sadar, an upazila urban slums are non-pakka (without solid
in the district of Jamalpur, located in north- permanent foundations, walls and roofs).
ern Bangladesh.6 This is a rural area where The major difference in the pattern of
houses in rural and urban areas is the sur-
6 Bangladesh consists of six administrative rounding space. In Jamalpur each house is
divisions, divided into 64 districts. Jamalpur
is one of them. Each district is divided into separated from other houses and has a wide
sub-districts (upazila). Jamalpur Sadar is a open area around it. Each house has a sepa-
upazila in Jamalpur district. Each upazila is rate kitchen and washroom. Slum houses
divided into a number of unions, the lowest
administrative unit in rural Bangladesh in Uttara are spread along the two sides of
(Banglapedia 2012). a highway (the Tongi-Ashulia road). These

Centre for Policy Research of IUBAT Summer 2012 27


Figure 2.1 Rural sample area location: Kendua thana in Jamalpur Sadar upazila

Source: Banglapedia 2012

Figure 2.1 Urban sample area location: Uttara (Dhaka)

Source: Banglapedia 2012

28 Improving Nutritional Status for Women in Low-Income Households


houses are non-pakka: they share common Questionnaire Design
walls made of corrugated tin or sheets of
interwoven bamboo leaves. In most cases The survey consists of 37 questions. Origi-
each family lives in one room, and shares nally prepared in English, we translated the
kitchen, washroom and other household questionnaire into simple Bangla. The trans-
facilities with other families. lation used sensitive wording for questions
that may be uncomfortable for the women
or their household. (See Appendix A for the
Sampling Technique English version of the questionnaire.)
The surveyors restricted their sample to The broad topics for the survey were the
women who live in non-pakka houses. A following:
systematic sampling7 technique was used. The 24-hours diet recall was the key
Initially we designated a sample size of 600 component to assess the nutritional
households divided equally between rural status of the women. Each woman was
and urban. In each sample location, sur- asked to recall what she ate at breakfast,
veyors approached every third non-pakka lunch, supper and other times during the
house. If the woman did not want to partici- day. Though the measurement of quan-
pate in the survey, then the next non-pakka tity of consumed food is subjective and
house was approached. If a woman from depends on the respondents memory,
that house participated in the survey, then this is a well accepted research method
surveyors repeated the process. to assess a persons regular diet (WHO
A household included all people living 2001).
together in the same dwelling and sharing Surveyors asked whether the women
their assets and income. Both characteristics consumed iodized salt, calcium tablets,
needed to be fulfilled to define a household. fortified yogurt, vitamin sprinkles,
If two households live in the same dwell- zinc and iron either regularly or ir-
ing, then surveyors randomly selected one regularly. Surveyors also asked about
household for the interview. sources of drinking and other water for
household uses, and about household
toilet facilities.
Twelve questions gathered information
about the number of household members
who smoke or chew betel nut, and about
any change in use of tobacco or betel nut,
7 Systematic sampling is often used instead of and reasons behind those changes.
random sampling. After the required sample The survey asked whether the women
size has been calculated, every Nth record is
selected from a list of population members. received advice on nutrition, and from
(Source: statpac.com/surveys/sampling.htm) what source.

Centre for Policy Research of IUBAT Summer 2012 29


The survey assessed several socioeco- The Survey and its Limitations
nomic characteristics of the household.
Women were asked about each members In rural areas the survey data were col-
occupation and how many hours on av- lected by 10 professional surveyors in June
erage each member works per day. Also 2011. The survey in the urban slums was
questions were posed about land owner- undertaken by 10 undergraduate students at
ship, electricity connection of the house- IUBAT, from mid-June to early July 2011. In
hold, and the list of assets the household total, 276 rural and 301 urban women were
owns. Information was collected on the interviewed. Being a Muslim country, Fri-
respondents age, weight, height, highest days in Bangladesh are a religious day and
school class attainment and occupation. a holiday. Most households prepare special
Similar information (except height and meals on that day. So Friday and Saturday
weight) was also collected for all other were avoided in conducting the survey.
members in the household. (Each pair A pair of surveyors, a male and a fe-
of surveyors was provided a scale and male, went to each household to interview
a tape to measure the weight and height respondents. Questions were asked orally
of the women.) by the female surveyor. The male surveyor
To assess the effect of inflation on the took notes and assisted the female survey-
respondents food consumption and nu- ors. The reason behind female surveyors
trition, she was asked to assess in general posing questions and measuring height
the households current food adequacy and weight was the cultural sensitivity of
and food adequacy one year before. interaction between male and female. Due
Some qualitative questions were posed to security concerns of young women in
about food distribution among house- Bangladesh moving alone, each pair of sur-
hold members (who gets more food in veyors included a man. Surveyors received
the household or is food divided equally an honorarium for their work.
among all?), problems due to food price One limitation of the survey is weak
increases, and reasons for consuming less information on family income. Women are
food if so reported. reluctant to describe income to strangers
In the neighbourhood of each survey and are less knowledgeable than their hus-
area, surveyors inquired of a few shopkeep- bands of monetary matters. Accordingly,
ers about the price of regular foods pur- we did not pose direct questions about
chased by the nearby households. National income. Many women were uncomfortable
data about the price of those foods are about mentioning household toilet facilities.
available. However large regional variation Women in urban slums were less uncomfort-
exists in the retail price of daily foods. So we able regarding these questions than women
collected the local price from the neighbour- in rural areas. Answers to these questions
hood shops and market place. may be biased.

30 Improving Nutritional Status for Women in Low-Income Households


Focus Group Discussions

We conducted two focus group discussions the time of food price spikes. We also dis-
with women, one in Satkura, a village in cussed womens nutritional education, their
Jamalpur, and another in Uttara. The dis- husbands smoking behaviour, arranging
cussions took place in BRAC non-formal healthy food for the family, role of schools
schools located in those areas. Approxi- for nutritional education, short-term
mately a dozen women participated in each income-generating initiatives appropriate
focus group. BRAC provided organizational for less educated and conservative women.
supports for the interviews. Questions were semi-structured and were
We asked questions about the effects of open ended. Womens views were useful for
food price inflation and coping strategies at the policy analysis part of my study.

Centre for Policy Research of IUBAT Summer 2012 31


3. Descriptive Statistics

There are many measures of the health and nutritional status


of a population.8 The current survey uses a WHO (2001) food score measure of dietary
intake and a widely used measure, body mass index (BMI). Surveyors listed all foods and
enquired about quantities consumed by the women for the previous 24 hours. To determine
BMI, surveyors measured weight and height.
Neither BMI nor food scoring captures to 25. A BMI score below 18.5 indicates
detailed nutritional problems. However, underweight, between 25 and 30 over-
these non-intrusive techniques provide weight, and above 30 obesity. Relative
fundamental nutritional information about to those within the optimum range, those
a population. The size of the low end of the whose BMI is below and above are more
BMI distribution is a good indicator of the susceptible to a range of diseases and other
extent to which a group experiences inad- complex health syndromes. Underweight is
equate calorie intake; the food score reveals somewhat more prevalent among low-in-
the approximate extent of inadequate di- come rural than urban women. By a similar
etary intake of micronutrients and protein, margin the share falling into the optimum
of excess fat consumption, and so forth.8 range is higher in the urban sample. Over-
Figure 3.1 illustrates the BMI distribu- weight and obesity, combined, are similar
tions of the rural and urban population shares in both samples.
samples. The optimum BMI range is 18.5 The food score is a summary measure
8
derived from the 24-hour diet recall. It com-
BMI is a widely used measure, defined as the
ratio of weight (in kilograms) divided by the prises ten questions, on each of which the
square of height (in meters). respondent received a score of 1 (adequate),

32 Improving Nutritional Status for Women in Low-Income Households


Figure 3.1: Distribution of Body Mass Index (BMI), Rural and Urban Samples

Rural (Jamalpur) Urban (Uttara)


70
64.4
61.6
60

50
percent

40

30 24.3
20.5
20
12.9 12.2
10
1.1 2.9
0
underweight (BMI optimum overweight obese (30BMI)
18.5) (18.5BMI25) (25BMI30)

0.5 (minimally adequate), or 0 (inadequate). ever, women in the rural sample displayed
For example, Q6 scores diets with respect somewhat better nutrition in that they
to the variety of foods consumed within the obtained higher shares in the fair-high and
major food groups. The more variety the good categories than their urban counter-
greater the probability that the respondent parts. Figure 3.3 illustrates the distribu-
is receiving adequate micronutrients. (See tions, by question. More than 90 per cent
Appendix B for further detail on scoring of of all women consumed satisfactory serv-
questions.) A respondents food score ranges ings (score 1) from the cereals and potato
between a minimum of 0 and maximum of group of food (Q1). The majority in both
10. The WHO identifies ranges of the food samples failed to eat at least five the rec-
score as risky (3.5 or less), fair (4 7), good ommended number of servings from the
(7.5 8.5), excellent (9 10). We have sub- fruit and vegetables category (Q2). Nearly
divided the fair category into fair-low (4 5), all women sampled consumed inadequate
fair-medium (5.5 6) and fair-high (6.5 7). dairy servings (Q3). In both samples, the
Given our interest in factors associated with majority consumed adequate protein, but
nutritional inadequacy, we have for some a quarter did not. Nearly all women con-
aspects of the analysis divided the sample sumed fat, oil and sugar within acceptable
into those whose diet is deemed either limits (Q5, Q10). To obtain adequate intake
inadequate (0 5) or adequate (5.5 10). of micronutrients, a diverse diet is required.
Figure 3.2 illustrates the distribution of Nearly a third scored zero on the question
food scores in each sample, by category. probing dietary diversity (Q6). Given their
None of the women scored excellent; how- rural location, it is not surprising that the

Centre for Policy Research of IUBAT Summer 2012 33


Figure 3.2: Distribution of Rural and Urban Food Score, by Category

Rural (Jamalpur) Urban (Uttara)


45
40.0
40 38.0
35
30 28.8
percent

25 22.8
19.4 19.0
20 16.7
15
10 8.8
5 3.0 3.4
0.0 0.0
0
Risky Fair-low Fair-medium Fair-high Good Excellent

rural women scored better in terms of eating Poverty and food price inflation
at least two vegetables, due to their access
to home-grown and locally produced veg- The average age of rural women in the
etables at low cost and sometimes free of sample is 38 years, of urban women 34
cost (Q7). Rural women also scored higher years (figure 3.4). The majority of married
in terms of eating at least one fresh fruit women in Bangladesh do not work in paid
(Q8) and choosing healthy snacks (Q9). But jobs outside their home, however women
the majority of both groups did not eat any in the urban slum are more likely to do so
fresh fruit and chose relatively unhealthy than their rural counterparts (figure 3.5).
snacks, mostly purchased from nearby street An urban setting affords more opportunity
food shops (Q10). to earn income, and the high cost of living
encourages women to abandon traditional
conservative customs. The occupations of
Explanatory factors women who do work outside the home
include agricultural farming, business,
As discussed earlier, we identified six sets of handicrafts, poultry farming, house worker,
factors that potentially influence womens official job, construction worker, garment
nutritional status. In chapter 4, we attempt worker. Womens work in paid jobs con-
to assess the statistical significance of each tributes positively to their nutritional status
of the particular factors on the nutritional in either or both of two ways: households
status of the women surveyed. In this chap- where both husband and wife work will
ter we describe in some detail the actual have a higher family income; women who
survey results. work outside the home may have more au-

34 Improving Nutritional Status for Women in Low-Income Households


Figure 3.3: Distribution of Food Score, by Question

Rural
SCORE 1.0 SCORE 0.5 SCORE 0
100% 0.4 0.0 0.0
1.9 0.8 0.8
90% 20.2 22.8
30.0 99.2
80%
8.4
70%
65.4 99.2
76.4 74.1
60% 38.4
50% 99.2
97.7 51.3
40%
71.5
30%
20.9 38.8 0.0 0.4
20%
23.6 25.5
10% 18.6
13.7 0.8
0% 0.0
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10

Urban
SCORE 1.0 SCORE 0.5 SCORE 0
100% 0.0 0.0
6.8 1.5
90% 15.1 1.0 1.0
31.2 27.8
80% 7.8
99.0 99.0
70%

60% 78.5 76.6


82.9
91.7
50% 99.5 48.8
77.1
40% 54.6

30%
0.5
20%
0.0
14.1 23.4 22.9
10% 14.1 17.1
0.5
7.3 0.0
0%
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10

Centre for Policy Research of IUBAT Summer 2012 35


Figure 3.4: Distribution of the Age of Women

Rural (Jamalpur) Urban (Uttara)


40 38.0

35
30 26.6 27.0 26.2
25 22.9
percent

20 18.5

15 11.4
9.3
10 7.2
6.3
4.9
5 1.5
0
10-20 20-30 30-40 40-50 50-60 Above 60

Figure 3.5: Share of Women Who Work Outside Home

Rural (Jamalpur) Urban (Uttara)


100 91.6

80 72.7
percent

60
40 27.3
20 8.4
0
House wife Work outside home

tonomy and freedom and thus access more In the rural area the majority of the
nutritious food. However, in the context of husbands are agricultural labourers. In the
the conservative Bangladesh society, families urban area the majority of the husbands
often do not allow women to work outside work in the residual category (day labourer,
the home unless they face extreme financial hawker, rickshaw-puller and construction
difficulties. Hence, working outside the worker). One-fifth of the urban husbands
home is often a proxy for particularly low work in the low-paid formal sector, which in-
income. cludes car driver, office assistant, field work-
ers in NGOs, security guard (figure 3.6).

36 Improving Nutritional Status for Women in Low-Income Households


We constructed an estimate of household Dhaka reduce somewhat the urban income
members labour income and income from advantage. (See table 3.1. The details of the
income-generating assets. From the survey calculation are given in Appendix C.)
we obtained information on household Women who reported having consumed
members occupations, average hours less food compared to the previous year
worked per day, and household assets. were asked to explain. One explanation
In estimating money income per family given was household financial difficulty. A
member, we applied the square-root for- far more frequently offered reason was food
mula (dividing the estimate of total family price inflation. Respondents may have given
income by the square-root of total number both reasons, but even if inflation-adjusted
of household members). Rural households household income did not decline, high food
are on average poorer than the urban in price inflation may have caused women to
terms of income. The high living costs in reduce food consumption. (figure 3.7).

Figure 3.6: Distribution of Husbands Occupations

Rural (Jamalpur) Urban (Uttara)


59.4
60 55.9

50
40
percent

30
22.4 22.3
20
9.6 8.8
10 6.6 5.7 6.5
2.9
0
Agricultural Formal sector Business Other labour Unemployed
labour

Table 3.1: Distribution of Households, by Estimated Per Capita Income


Rural (Jamalpur) Urban (Uttara)
percent
Very low (Less than $1.25 per day) 25.5 4.9

Low ($1.25- $2 per day) 26.6 13.7

Medium ($2-4 per day) 38.8 69.3

High ($4-10 per day) 9.1 12.2

Very high (More than $10 per day) 0.0 0.0

Centre for Policy Research of IUBAT Summer 2012 37


Figure 3.7: Reasons Offered Among Respondents Who Consumed Less Food Than Previous Year

Rural (Jamalpur) Urban (Uttara)


100 88.6
80
63.3
60
percent

47.7
40

20 14.5
7.9
1.0
0
increase in food prices household financial other reasons
hardship

Figure 3.8: Distribution of Literacy, by Sample and Gender

rural women urban women rural husbands urban husbands


70 65.8 63.4 66.1

60 52.9
50
39.4
40
percent

30 27.4 27.0
22.4
20 14.1
10 6.8 6.9 7.6

0
cannot read can read a little can read

Education at all. The median highest level of education


among both women and their husbands,
We gathered data on both literacy and both in the rural and urban sample, is in
highest class attendance of women and the interval of class 0 2. As reported,
other members of the household (figures husbands education levels are somewhat
3.8, 3.9). Among the women sampled, ap- higher than for their wives; however the
proximately two out of three cannot read results are overall similar.

38 Improving Nutritional Status for Women in Low-Income Households


Figure 3.9: Distribution of Highest Class Attended, by Sample and Gender

rural women urban women rural husbands urban husbands

80
70 67.7 68.2
64.9
60 55.3
50
percent

40
30 24.7
18.6 20.516.3
20 13.2
10.6 11.8
10 7.7 8.2 7.7
3.0 1.5
0
Class 0-2 Class 3-5 Class 6-9 Class 10 and above

Table 3.2: Frequency of Reference to Particular Sources of Advice


Rural (Jamalpur) Urban (Uttara)
percent
Family/Neighbour 35.4 32.7

Health facility care providers (doctors, nurses) 16.0 18.5

Community health workers 49.4 38.0

Public meetings sponsored by NGOs 20.9 43.9

Radio/TV 14.4 5.9

Other 1.5 10.7

Womens husbands are primarily respon- Nutritional Information


sible for earning money income and buying
food in the household. Given the patriarchal Women who report having received advice
nature of society, husbands have more on nutritional diets are expected to have bet-
authority in household decision-making ter nutritional status than women who do
than women. A better educated husband is not (table 3.2). We defined several variables
expected to earn more and buy more nutri- specifying sources of advice: 1) family, rela-
tious food than an illiterate husband and tives or neighbours; 2) health facility care
may be more concerned about his wifes providers (doctors, nurses); 3) community
health and nutrition. health workers who visit homes; 4) public

Centre for Policy Research of IUBAT Summer 2012 39


Table 3.3: Distribution of Frequency of Use of Nutritional Supplements

Iodized Calcium Fortified Vitamin Zinc tablets Iron tablets


Sprinkles
salt tablet yogurt tablet / syrup / syrup

(percent)

RURAL

Regularly 81.4 3.4 0.0 1.5 0.0 0.0 3.4

Sometimes,
12.5 36.5 6.1 39.5 1.5 12.5 37.6
not regularly

When pregnant or
0.0 7.6 0.8 4.9 0.0 1.9 13.7
nursing children

Never 4.2 49.8 86.3 47.9 82.5 74.1 43.0

Dont know 1.9 2.7 6.8 6.1 15.2 11.4 2.3

URBAN

Regularly 90.2 2.0 0.0 2.0 0.0 0.0 1.0

Sometimes,
5.9 39.5 2.0 48.3 1.0 2.9 22.4
not regularly

When pregnant or
0.0 5.9 2.0 11.7 0.5 1.5 6.3
nursing children

Never 1.5 38.5 37.1 29.8 25.4 42.9 43.4

Dont know 2.0 4.4 10.7 8.3 22.0 16.6 2.9

meetings conducted by NGOs; 5) radio and than 90 per cent of women either did not
television announcements; and 6) other consume or had not heard about fortified
(which include posters, public announce- yogurt9 and sprinkles. Over 80 per cent of
ments, etc.). Respondents could indicate urban and rural women either had not heard
multiple sources of information. of or never consumed zinc tablet/syrup.
Community health workers are the Most women consume calcium, vitamin
most frequently cited source of nutritional and iron tablet/syrup irregularly. There was
information in the rural sample and a close little evidence of increased use of nutritional
second in the urban sample. By contrast, less supplements during pregnancy.
than one in five got advice from nurses or
doctors in health facilities. 9 Fortified yogurt is a special kind of nutritious
Most women regularly consumed iodized yogurt fortified with additional micro-
nutrients. The joint venture of Grameen and
salt, but 20 per cent of rural and 10 per cent Danone, a social business, markets such
of urban women did not (table 3.3). More yogurt (shokti-doi) (Yunus Centre 2012).

40 Improving Nutritional Status for Women in Low-Income Households


Figure 3.10: Distribution of Household Food Allocation Patterns

Rural (Jamalpur) Urban (Uttara)


50 48.0

38.4 37.2
40 35.3

30
percent

20 17.8
15.2

10 6.2
0.4 1.0 0.5
0
Everyone Everyone Husband and/ Women Conflicting
varied equally or children more answers
more

Cultural Barriers family is a three-generation family living


together. It consists of husband and/or wife,
We constructed a question on intra-house- their parents, married and/or unmarried sib-
hold variation in food consumption as a lings and the unmarried children of the hus-
measure of intra-household gender equality
band/wife and their siblings. A joint family
(figure 3.10). It is expected that households
is a type of family where three or more gen-
which divide expensive and nutritious food
erations with members like the stem family
such as milk, meat, fish and fruits equally
plus husbands/wives uncles/aunts and their
among household members are more
families live together. Women living in stem
gender-neutral compared to households in
and joint families are often dominated by a
which husbands and children get more of
those foods. Approximately a third of the number of male and older female members.
women sampled reported that their husband So, a higher percentage of women living
and children received more generous food in stem and joint families are expected to
servings than did they. have lower nutritional status compared to
We categorized families as nuclear, stem, women living in nuclear families. Nearly
and joint. A nuclear family is a two-gen- identical fractions of both rural and urban
eration family consisting of husband and/ households (78 per cent) maintain a nuclear
or wife and their single children. A stem family structure.

Centre for Policy Research of IUBAT Summer 2012 41


Figure 3.11: Distribution of Sources of Drinking/Cooking Water

Rural (Jamalpur) Urban (Uttara)


99.6
100
82.9
80
percent

60

40

20 17.1
0.4
0
Unboiled water from Water boiled/Tubewell
government tap/hose/river/pond

Figure 3.12: Distribution of Households, by Number of Members Smoking Tobacco

Rural (Jamalpur) Urban (Uttara)


80
62.9
59.3
60
percent

35.7
40 31.7

20
4.9 5.4

0
none one two or more

Hygiene and Cleanliness of the Household Addictions to Tobacco and Betel Nut

Categorical variables on sources of water We constructed a number of categorical


are a measure of household hygiene and variables such as number of household
cleanliness (figure 3.11). Almost all ru- members who smoke, monthly expendi-
ral households consume hygienic water, ture on tobacco and share of husbands
from either tube wells or boiled tap/river/ and wives smoking. Among low income
pond water. However 84 per cent of the men in Bangladesh, addiction to tobacco is
urban slum women use unhygienic water very common. Approximately two thirds of
sources. households have at least one member who

42 Improving Nutritional Status for Women in Low-Income Households


Figure 3.13: Distribution of Estimated Monthly Expenditure on Tobacco, Households with Smokers

Rural (Jamalpur) Urban (Uttara)


60 52.1
50
40.2
40
percent

29.6
30 22.1
14.8 15.4
20 12.1
8.6
10 5.0
0.0
0
< Tk.50 Tk.50-100 Tk.100-200 Tk.200-300 > Tk.300

Figure 3.14: Distribution of Households, by Number of Members who Chew Betel Nut

Rural (Jamalpur) Urban (Uttara)


46.8
50
35.6 36.9
40
31.6 31.6
30
percent

17.6
20

10

0
none one two or more

smokes. Very few households have female average monthly expenditure on tobacco
smokers (figure 3.16). in the rural households with at least one
The variable monthly expenditure on smoker is Tk.114, in the urban area Tk.139.
tobacco was constructed by multiplying (In both this is approximately one per cent
household total cigarette consumption (add- of estimated monthly income.) In both
ing cigarette consumption of all household samples, about 15 per cent of households
members) by the price of the cheapest ciga- spend over Tk.200 per month on tobacco.
rette in Bangladesh (Tk.0.24) (figure 3.13). About two thirds of households have
Since expenditure is based on the price of at least one member who chews betel nut
bidis, this is probably an underestimate. The (figure 3.14). Prevalence of chewing betel

Centre for Policy Research of IUBAT Summer 2012 43


Figure 3.15: Distribution of Estimated Monthly Expenditure on Betel Nut,
Households with Betel Nut Chewers

Rural (Jamalpur) Urban (Uttara)


33.5
35
26.2
25 22.3 23.1 22.3
percent

17.7 17.7 16.8 15.4


15
5.0
5

< Tk.50 Tk.50-100 Tk.100-200 Tk.200-300 > Tk.300

Figure 3.16: Distribution of Smokers and Users of Betel Nut

rural smokers urban smokers rural users of betel nut urban users of betel nut
90 83.8 84.8
80
70 64.1
60 52.9
percent

50
40 36.0
30 25.9
20 13.0 15.2 11.0 10.0
10 3.2 0.0
0
wives husbands other household members

nut is somewhat greater in the rural sample, expenditure varies between Tk.150 and
and rural households with members who Tk.200.
chew betel nut spend on average more than If we examine the distribution of those
their urban counterparts. The majority of who smoke and those who chew betel nut
those chewing are women. We estimated by household member, there are dramatic
monthly expenditure on betel nut by multi- differences. Very few women smoke; the
plying household total number of betel quid overwhelming majority of smokers are
consumed (adding betel quid consumption husbands and other family members (figure
of all household members) by the price of 3.16). By contrast, the majority of those
one quid (figure 3.15). The average monthly using betel nut are women.

44 Improving Nutritional Status for Women in Low-Income Households


4. Statistical analysis

We undertook to analyze the survey results via logistic regressions


run separately on the rural and urban samples.10 There are useful results to report, but we
emphasize their tentative nature. The regressions in this chapter explain some of the vari-
ance in outcomes among the women sampled but there is much more to explain than is
accounted for here.10


10

Regressions Constructed whether low-income women achieve an


adequate level of nutrition. We defined
We discuss nine regressions that attempt a binary variable: 1 if womens diet is
to explain five nutrition-related outcomes deemed adequate, 0 if inadequate. Ad-
(regressands). (See tables at end of chapter equacy means a food score of 5 or above,
for detailed regression results.): inadequacy a score below 5. In other
Food adequacy (regressions 1 and 5): words, inadequacy is defined as a score
Our primary interest is explaining falling in the risky or fair-low range.

10A logistic regression estimates the log of the odds of a particular outcome occurring as a linear
function of the regressors. Beyond noting that the sign of the coefficient indicates whether the
regressor has a positive or negative incremental impact on the outcome, interpreting the coefficients
is not intuitive. In the case of a binary regressor that assumes a value of 0 or 1, the coefficient of the
regressor, b, can be interpreted as follows: the marginal effect on the odds of an outcome due to a
change in the regressor from 0 to 1 is given be eb. If the coefficient is in the range 0 < b < 0.5, then
100*b is approximately the percentage increase in the expected value of the odds. If the coefficient is
in the range -0.5 < b < 0, then 100*b is approximately the percentage decrease in the expected value
of the odds. This approximation becomes less exact the further the coefficient deviates from 0.

Centre for Policy Research of IUBAT Summer 2012 45


Diet diversity (regressions 2 and 6): The Which Explanatory
food score is a composite index derived Factors Matter?
from ten questions. One of the central
questions is no.6 dealing with diet di- We here summarize which explanatory
versity (Did the respondent eat a variety factors (regressors) are statistically sig-
of foods within each of three main food nificant in explaining the nutrition-related
groups cereals and potato; fruits and outcomes:
vegetables; meat, fish, eggs, daal?). Family highest education level: We used
As with the other nine questions, this three binary variables to define the
question was scored 1 (adequate), 0.5 households highest education level. The
(minimally adequate), 0 (inadequate). coefficients indicate the impact relative
Prevalence of smokers in household to the reference education level of class
(regressions 3 and 7): Very few women 0 2. The first is that at least one member
in the sample smoked, but in the major- achieved class 3 5, the second class 6
ity of households there was at least one 9, the third class 10 and above. For the
smoker. This is a binary variable assum- urban regressions, the second variable
ing the value 1 if at least one household is class 6 and above. Higher education
member smokes, 0 otherwise. is positively and significantly associated
with higher food security in the rural
Prevalence of family members chewing
sample; it is not significant in the urban
betel nut (regressions 4 and 8): Similar
sample. Higher education is strongly
to smokers in household, this vari- associated with respondents reporting
able assumes the value 1 if at least one a greater diversity in their diets, both in
household member chews betel nut, 0 the rural and urban sample. In the rural
otherwise. sample, higher education is associated
Use of safe cooking/drinking water with a lower prevalence of smokers in
(regression 9): This variable assumes the household; there is no significant
the value 1 if the household uses a safe association in the urban sample. Higher
source of water (from tube well or wa- education is associated with a lower
ter boiled) for cooking and drinking, 0 prevalence of betel nut chewing in both
otherwise. We ran this regression on the samples.
urban sample only. Number of cigarettes consumed per day
in household: There is a significant nega-
tive association between nutrition and
extent of cigarette consumption in the
rural sample. This is true whether nutri-
tion is defined in terms of food security or
diet diversity. There are no comparable
significant results for the urban sample.

46 Improving Nutritional Status for Women in Low-Income Households


Women working outside home in paid Advice from home visits by commu-
job: As discussed earlier, this is probably nity health workers is significantly
a proxy for a household experiencing associated in the rural sample with
particularly low income. In the rural a lower prevalence of smokers in
sample there is a significant negative the household. However, this is the
association between a woman working only statistically significant associa-
outside the home and her food security. tion between advice from commu-
In the urban sample, working outside the nity health workers and nutritional
home does not have a significant impact outcomes. We refer to this result in
on food security, but it significantly the next chapter and suggest bet-
reduces diet diversity and is strongly ter training for community health
associated with use of unhygienic water workers.
for cooking/drinking. In the rural sample there is a signifi-
Sources of nutrition advice: Readers cant positive association between
should be particularly cautious in in- women who explicitly referred to
terpreting these results. Nonetheless, nutritional advice via the media
the presence of a statistically significant (television, radio or newspaper) and
association between a woman reporting better food security and diet diversi-
she had received nutritional advice from ty. In the urban sample women who
a particular source is evidence that the referred to nutritional advice via the
nutritional advice from the source may media were much more likely to use
have an impact. hygienic water.
The only significant association There is no statistically significant
from advice given by family and association between women attend-
neighbours occurs in the case of ing public meetings on nutrition and
the decision to use hygienic water better outcomes, either in the rural
among the urban sample. The as- or urban sample.
sociation is negative: implying that Unequal intra-household distribution
advice from this source is conducive of nutritious foods: Women who re-
to relying on unhygienic tap water. ported such inequality might be expected
Advice from doctors/nurses is signif- to have less food security and less diet
icantly associated with greater food diversity. There is no evidence to this
security and diet diversity among rural effect among the rural sample. Counter-
women. In the case of urban women, intuitively, among the urban sample is a
such advice is associated with use of significant, albeit weak, positive associa-
sanitary water but counter-intuitively tion of inequality and diet diversity.
it is also significantly associated with
less diet diversity.

Centre for Policy Research of IUBAT Summer 2012 47


Food price inflation as reason for re- Among the rural sample there is a signifi-
duced food consumption in previous cant association between women citing
year: Among the rural sample there is this reason and both less food security
a strong significant association between and less diet diversity. Also, those citing
women citing this reason and both less this reason reported a lower prevalence
food security and less diet diversity. of household smoking but a higher
There is also a strong positive association prevalence of betel nut chewing. Among
with increased prevalence of chewing the urban sample the only statistically
betel nut perhaps as a hunger depres- significant association is that women
sant. Among the urban sample are no reporting financial hardship are more
statistically significant relationships. likely to report a higher prevalence of
Financial hardship as reason for reduced betel nut chewing.
food consumption in previous year:

Table 4.1 Summary Regression Results, Rural Sample (n = 263)

Prevalence Prevalence
Food Diet diversity
of household of betel nut
security (1.) (Q6) (2.)
smoking (3.) chewing (4.)

Households highest
education, class 3-5:
2.1 (2.97) 2.7 (2.1)* -1.2 (3.04) -3.7 (2.9)*
(1: highest is class 3-5;
0: otherwise)

Households highest
education, class 6-9:
2.4 (3.3) 2.6 (2.3) -5.2 (3.4)** -3.7 (3.2)
(1: highest is class 6-9;
0: otherwise)

Households highest
education, class 10 and
4.6 (3.0)* 4.5 (2.1)*** -1.6 (3.1) -1.3 (3.0)
above: (1: highest is class
10 and above; 0: elsewhere)

Cigarettes consumed per


day by household members -0.32(0.11)*** -0.11 (0.08)*
(cardinal number)

Woman works outside


home (1: works outside -6.7 (3.6)** -0.8 (2.5) 1.1 (3.6) -2.3 (3.4)
home; 0: otherwise)

Nutrition advice from


family and/or neighbours
1.24 (1.6) 0.6 (1.1) -0.13 (1.6) -1.7 (1.5)
(1: received advice from
this source; 0: otherwise)

48 Improving Nutritional Status for Women in Low-Income Households


Table 4.1 Summary Regression Results, Rural Sample (n = 263) continued

Prevalence Prevalence
Food Diet diversity
of household of betel nut
security (1.) (Q6) (2.)
smoking (3.) chewing (4.)

Nutrition advice from


doctors, nurses and health
clinics (1: received advice 7.8 (2.8) *** 4.4 (1.98)*** -0.5 (2.9) -0.2 (2.8)
from this source;
0: otherwise)

Nutrition advice from


community health workers
who visit home (1: received -0.6 (1.89) -0.7 (1.32) -3.5 (1.9)** -0.2 (1.8)
advice from this source;
0: otherwise)

Nutrition advice from


TV, radio, or newspaper
4.6 (2.35)*** 5.25(1.65)*** -2.7 (2.4) 0.4 (2.3)
(1: received advice from
this source; 0: otherwise)

Nutrition advice from


public meeting the women
attended (1: received advice 2.2 (3.0) 0.1 (2.1) 2.7 (3.1) -3.0 (2.9)
from this source;
0: otherwise)

Unequal distribution
of nutritious foods in
household (1: unequal
-0.4 (1.98) 1.3 (1.4)
distribution; 0: otherwise)

Inflation as reason for less


food consumption this year
-4.05(2.1)*** -4.4 (1.5)*** 0.2 (2.1) 5.7 (2.0)***
over last (1: this reason
cited; 0: otherwise)

Financial hardship as
reason for less food
consumption this year over -5.4 (4.1)* -3.6 (2.9)* -7.7 (4.2)** 9.3 (4.0)***
last (1: this reason cited;
0: otherwise)

R2 .14 .13 .04 .07

Adjusted R2 .10 .10 .00 .03

Note: All regressands for Tables 4.1 and 4.2 are log of odds ratio of the respective outcome.
Standard errors in parentheses. Legend for one-tail significance: * 10%, ** 5%, *** 2.5%.

Centre for Policy Research of IUBAT Summer 2012 49


Table 4.2 Summary Regression Results, Urban Sample (n = 205)
Use of
Prevalence Prevalence hygienic
Food security Diet diversity
of household of betel nut water for
(5.) (Q6) (6.)
smoking (7.) chewing (8.) cooking and
drinking (9.)

Households highest
education, class 3-5:
2.3 (3.3) 3.3 (2.1)** 3.4 (3.0) -3.04 (3.0) -2.4 (2.3)
(1: highest is class
3-5; 0: otherwise)

Households highest
education, class 6 and
above: (1: highest is 2.8 (3.3) 5.2 (2.1)*** 2.8 (3.0) -4.9 (3.12)* -1.8 (2.4)
class 6 and above;
0: otherwise)

Cigarettes consumed
per day by household
0.04 (0.1) -0.07 (0.07)
members (cardinal
number)

Woman works outside


home (1: works outside -1.8 (2.7) -3.5 (1.7)*** -2.8 (2.5) -0.4 (2.5) -4.3(1.9)***
home; 0: otherwise)

Nutrition advice
from family and/or
neighbours (1: received 0.2 (2.3) 1.4 (1.4) -0.9 (1.96) 0.3 (2.0) -2.6 (1.5)**
advice from this
source; 0: otherwise)

Nutrition advice
from doctors, nurses
and health clinics
-3.3 (3.1) -4.4 (2.0)*** 3.4 (2.9) -1.02(2.97) 4.1 (2.3)**
(1: received advice
from this source;
0: otherwise)

Nutrition advice from


community health
workers who visit
-1.1 (2.4) -1.5 (1.5) -2.4 (2.3) -2.3 (2.3) 0.6 (1.8)
home (1: received
advice from this
source; 0: otherwise)

Nutrition advice from


TV, radio, or newspaper
(1: received advice 2.1 (2.4) -1.03 (1.5) -0.09 (2.2) 0.6 (2.3) 4.1 (1.7)***
from this source;
0: otherwise)

50 Improving Nutritional Status for Women in Low-Income Households


Table 4.2 Summary Regression Results, Urban Sample (n = 205) continued
Use of
Prevalence Prevalence hygienic
Food security Diet diversity
of household of betel nut water for
(5.) (Q6) (6.)
smoking (7.) chewing (8.) cooking and
drinking (9.)

Nutrition advice from


public meeting the
women attended
1.7 (5.0) -1.0 (3.2) 4.5 (4.7) 1.7 (4.8) -1.8 (3.7)
(1: received advice
from this source;
0: otherwise)

Unequal distribution
of nutritious foods
in household (1: 1.3 (2.5) 2.1 (1.6)*
unequal distribution;
0: otherwise)

Inflation as reason for


less food consumption
this year over last
-0.05 (2.4) -0.8 (1.5) -0.3 (2.2) -2.0 (2.2) -1.4 (1.7)
or use of unhygienic
water (1: this reason
cited; 0: otherwise)

Financial hardship
as reason for less
food consumption
this year over last -0.8 (11.9) 3.8 (7.6) 11.6 (10.9) 13.9(11.3)* -1.95 (8.6)
or use of unhygienic
water (1: this reason
cited; 0: otherwise)

Source of water for


cooking and drinking
2.2 (3.2) 0.1 (2.02)
(1: hygienic source;
0: otherwise)

R2 .02 .10 .05 .03 .09

Adjusted R2 -.04 .03 .05 -.00 .05

Note: All regressands for Tables 4.1 and 4.2 are log of odds ratio of the respective outcome.
Standard errors in parentheses. Legend for one-tail significance: * 10%, ** 5%, *** 2.5%.

Centre for Policy Research of IUBAT Summer 2012 51


5. Policy Analysis

Bangladesh has very few programs to improve overall nutritional


status of low-income women. The National Nutrition Program and Area based com-
munity nutrition program are the two major programs initiated by the government. Both
target pregnant and lactating women only. In Bangladesh only 50 per cent of women visit
health facilities during pregnancy, and only 21 per cent visit facilities as part of post-natal
care (World Bank, no date). Some NGOs currently provide food supplements (pushti)11 to
underweight (BMI<18.5) pregnant women (Ortolano et al. 2003), but the coverage is limited.

Here we concentrate on five direct Option 1: Nutritional supplements


nutrition-related policies. However, several
long-term policies will yield nutritional There are several ways to provide nutri-
benefits given sufficient time. One obvious tional supplements, starting with provision
policy is to give priority to improved female of direct oral micronutrient supplements via
school attainment; another is improvement a health care centre. Home food fortification
in the overall primary health care system through micronutrient sachets (popularly
accessible by low-income women. Creating known as sprinkles) is an effective method
income-generating opportunities will also practised among 6-24 month-old children
yield nutritional benefits.11 in many countries. Sprinkles provide iron,
zinc, iodine and vitamins (Micronutrient
11Pushtiis a bangla word meaning nutrition. Forum 2008; WFP 2009). However the
This supplement consists of rice-flour, roasted
pulse flour, molasses and oil; it provides micronutrient sachets are designed for
approximately 600 kcal per day. children aged 6-24 months, who consume

52 Improving Nutritional Status for Women in Low-Income Households


small amounts of food. More research Four main technologies can be used to
is necessary to prove the effectiveness fortify rice: hot extrusion, cold extrusion,
of sprinkles for adults (Sprinkles Global coating and dusting.15 Cold extrusion and
Health Initiative 2012). Grameen Social coating are the most cost-effective (Alavi
Business12 is producing a fortified sweet et al. 2008). With coated rice, the nutrition
yogurt (Shokti-doi) specifically designed value decreases if washed before cooking.
for children. The price of this yogurt (Tk.7 Country case studies show that rice for-
in rural area and Tk.12 in urban area) is not tification will increase the retail price by
easily affordable by poor people. Large scale 1.5 to 4 per cent (Alavi et al. 2008; World
production may reduce cost in the long run Bank 2011).
(Plante dEntrepreneurs 2012). Almost none of the women sampled have
For adults, fortifying staple foods is an heard about fortified food and sprinkles,
effective tactic for providing nutritional while the consumption of iron tablets/
supplements (Allen et al. 2006, World Bank syrups, vitamin tables, zinc and calcium
2011, Micronutrient Forum 2012). This tablet/syrup is limited to only a few. Given
tactic has the advantage of not requiring any the lack of use and knowledge of nutritional
change in population eating habits. A pilot supplementation, a potential government
project in Bangladesh identified wheat flour policy options should include the follow-
and edible oil as two potential vehicles for ing elements:
food fortification (Dary and Rassas 2004). Subsidizing fortified rice to the poor such
In 2012, six edible oil refiners in Bangladesh that its price is equivalent to the lowest
started to fortify edible oil. The cost of for- price of unfortified rice for a period of
tified oil is predicted to be higher than the at least the first year
available edible oils in the market.13
Popularizing fortified rice as an easy
In Bangladesh no initiative has yet been
and cheap way to address vitamin and
undertaken to fortify rice. Some countries14
mineral deficiencies
have mandatory rice fortification programs:
a specific per cent of total rice production Promoting the popularity of fortified

must be fortified and targeted for the poor. yogurt.

12 A wing of Grameen Bank, Bangladesh. 15 Hot and cold extrusion produces rice shape
13 www.thefinancialexpress-bd.com/more.
kernels by mixing a rice made dough flours, a
php?news_id=98443&date=2012-02-14. fortification mix and water either in hot (70-
14 Examples are Philippines, Costa Rica and 110oC) or in cold (below 70oC) temperature.
some states in United States. India, Indonesia Coating spread and layered fortification mix
and China have also successfully introduced in wax or gum form on rice and dusting
pilot programs of rice fortification for specific polish rice grains with micronutrient premix,
marginal groups. stick with rice.

Centre for Policy Research of IUBAT Summer 2012 53


Option 2: Hygienic drinking water thermore, urban slums are often transitory.
Shallow tube wells are much less costly.
According to the 2009 Multiple Indica- Large areas in Bangladesh face a risk
tor Cluster Survey, only 8.5 per cent of of arsenic in tube well water (As-arsenic
households in slum areas in Bangladesh 2012). In such areas, low-cost purification
use improved sanitation facilities that meet tablets of surface water are a potential solu-
UNICEF monitoring standards (UNICEF tion. ICDDR,B, the pioneer of diarrhoeal
2012). Ahmed (2002) estimated the cost research in Bangladesh, recently invented
of treatment for hygiene-related diseases at siraj mixture, which effectively reduces
Tk.640 crore per year. Our survey results the risk of diarrhoea (ICDDR,B 2012).18 A
show almost all rural and suburban women single siraj mixture costs Tk.0.35 and puri-
have access to either safe tube well water or fies 15 liters. Water purification tablets in
boiled water. In the Uttara slum however, arsenic-affected regions may well be justifi-
only 16 per cent use hygienic drinking water. able in terms of nutrition and improvements
Other studies (Podymow et al. 2003) have in overall health status, but our two sample
found similar results in Dhaka slums.16 populations live in areas not seriously af-
No significant initiatives have been fected by arsenic.
undertaken to supply safe water in urban
slums in Bangladesh. In1999 the Bangla-
desh Association for Social Advancement Option 3: Healthy food initiative
(BASA), a local NGO, set up 15 tube wells through social enterprises
for 700 people in slums in Gazipur, a sub-
urban area near Dhaka city. This NGO has A social enterprise has two goals: to achieve
carried out another safe drinking water social, cultural, community economic or en-
project in a slum located in Mirpur area vironmental outcomes; and to earn revenue
of Dhaka. from sale of its service or product. A fre-
Setting sufficient tube wells in slum areas quently cited example is Grameen/Danone
to ensure that slum families can access hy- Foods, a partnership between Grameen
gienic water is an obvious policy response. Bank and Danone, a French manufacturer
Tube wells can be either deep or shallow. of dairy products. The social enterprise
Deep tube wells are not suitable as they manufactures a fortified yogurt (Shokti-doi)
are expensive to drill and maintain.17 Fur- as means to introduce micronutrients into
childrens diet. The enterprise is expected to
operate efficiently, raise its revenue through
16 In this study of three slums located in sales, but pose rigid limits on any dividends
Mohammadpur, Lalbagh and Dhanmondi to the shareholders.
in Dhaka city the authors found 87 per cent
of slum dwellers do not have access to safe
drinking water. 18 Thesiraj mixture contains a precise
17 The cost of setting one deep tube well is combination of alum potash, bleaching
approximately Tk.160,000 (Biswas 2004) powder and lime.

54 Improving Nutritional Status for Women in Low-Income Households


Very few women, in either sample, have Sell Jakarta model cheap nutritious
adequate servings of vegetables, fruits and meals and snacks through street vans
milk in their regular diet. Moreover many in cities;
of them regularly consume unhealthy snacks Initiate gardening to produce vegetables
such as samosa, chips, biscuits, paratha and and fruits in the homestead gardens near
different kind of sweets. These snacks are homes in rural areas (if land is avail-
mostly deep fried, made of flour and potato. able). Women and children will work to
They are prepared without maintaining produce fruits and vegetables for their
minimum standards of hygiene and clean- households and community. NGOs can
liness. Such snacks are cheaper than fruits support the gardens via subsidized seeds,
and vegetables. fertilizer and advice.
Access to fruits, vegetables and healthy
snacks at a low cost will encourage people
to buy them. This is a potential tactic for Option 4: Behaviour change
NGO-sponsored social enterprises. Such
through nutritional advice
enterprises also create work opportunities
for women. A relevant example is Mercy
In our survey, half of the women in the
Corps, an Indonesian NGO. It has launched
rural area and one-third in the urban area,
Kedai Balitaku (My Childs Caf) selling
received advice from health workers who
through street vans in Jakarta.19 The goal
visited them at home. Such advice did not
is to provide healthy foods to school chil-
appear to have any effect on nutritional
dren, while raising awareness and increasing
outcomes. Inadequate nutritional knowl-
economic opportunity among local people.
edge among these health workers and lack
The cost of one chicken, rice, vegetable por-
of incentive to provide nutritional advice
ridge meal for a child is the equivalent of
may be the explanation. On the other hand,
Tk.16. This initiative has become popular
there appears to be a positive relationship
and has been spun off as a for-profit social
in all regions between womens nutritional
enterprise. Nonetheless, this porridge must
outcomes and receiving advice from either
compete with the favourite local snack, a
the media or from doctors or nurses at
gelatin pop, almost always made with ar-
health facilities. Media advertisements
tificial fruit flavours and selling at half the
are generally attractive and eye-catching
porridge meal cost.
presentations.
NGOs operating in Bangladesh could ex-
Moreover there are many examples of
pand nutrition-enhancing social enterprises
health-related advice programs in Bangla-
with pilot initiatives in at least two ways:
desh dealing with specific health problems
such as diarrhoea, tuberculosis, malaria,
19 The
HIV, hygiene and cleanliness, and pre- and
New York Times; May 23, 2011 (http://
opinionator.blogs.nytimes.com/2011/05/23/ post-natal care of mother and children
in-food-deserts-oases-of-nutrition/) (BRAC 2012, Khandoker et al. 2009, UNI-

Centre for Policy Research of IUBAT Summer 2012 55


CEF 2004). These programs may contribute products, and restricting the shops allowed
to better nutrition indirectly, but few aim to sell tobacco products.
to promote healthy food preparation at Tobacco is a cheap consumer products in
low cost. So, the fourth policy option is Bangladesh. The price of a 20-stick packet
the following: of bidi is Tk.6. Even the price of a 20-stick
Incorporate education on healthy food pack of one of the most expensive brands
selection and preparation, maintaining of cigarette is less than Tk.100.21 The tax
nutrition during inflation, and balanced rate on tobacco in Bangladesh has remained
diet with existing health education stagnant for almost 10 years (Unnayan
programs; Shamannay 2010).
A significant increase in the price of
Improve training of community health
tobacco is probably the most effective
workers.
way to reduce tobacco consumption and
to encourage current users to stop smok-
Option 5: Reducing ing (WHO 2003, WHO 2009, Unnanyan
Shamannay 2010). According to a WHO
consumption of tobacco
(2009) report, a 10 per cent increase in
In two thirds of the sampled households at the price of tobacco reduces consumption
least one member smokes. In Bangladesh by 8 per cent in low- and middle-income
43.3 per cent of the adults use tobacco prod- countries. The price elasticity of demand
ucts, either smoking or smokeless (GATT for cigarettes in Bangladesh has been esti-
2010). By contrast, in typical high-income mated at -0.4 in the short run and -0.3 in
countries one-fifth of adults smoke.20 the long run (Shamunnay 2010, Barkat et
Our statistical analysis demonstrates a al. 2008). Poorer households may be more
significant negative association between responsive to price changes than are rich
womens nutrition and tobacco consump- households in Southeast Asia (Guindon
tion in the household. As discussed earlier, 2003). Shamunnay (2010) estimates the
consumption of tobacco may affect nutri- price elasticity of bidi as -0.64. Nonetheless,
tion via several routes. The results point to demand for cigarette and bidi is inelastic:
a nutrition benefit in addition to health a tax increase will reduce consumption
benefits to those presently smoking of pro- but will also result in an increase in total
grams combating use of tobacco. There are household expenditure on smoking. There
three general tactics to pursue: increasing is evidence (from Canada) that young ado-
the price of tobacco by taxation, restrict- lescents are particularly sensitive to price,
ing the advertising of tobacco and tobacco that the elasticity of taking up the smoking
habit displays an elasticity between -1.5 and
-2.0 (Sen et al. 2010). This suggests that,
20 In
Canada 20.8 per cent of the population
aged 12 and above smoke (Statistics Canada, 21 Monthly Statistical Bulletin, Bangladesh
2010). Bureau of Statistics, August 2010.

56 Improving Nutritional Status for Women in Low-Income Households


Table 5.1: Rates of Tobacco Taxes in Bangladesh, 2009

Tax rate
Price segment Price range (Tk. )
Supplementary duty Value Added Tax (VAT)

Low* 14.60-17.60 32% 15%

Medium* 32.80-34.80 52% 15%

High* 46.72-58.72 55% 15%

Premium* 93+ 57% 15%

Bidi (Akiz)** 6.00 20% 15%

Jorda, Gul*** 2.00-4.00 10% 15%

Note: 1. * 20 cigarettes per pack; ** Handmade cigarettes of 25 sticks per pack; *** smokeless tobacco
2. 1 USD = Tk. 80.43
Source: PATT Policy Brief- 1, Unnayan Shamannay 2010.

intergenerationally, tobacco demand may Convention on Tobacco Control. There are


be price elastic. But this is a very long-run some restrictions on direct advertising of
policy. We do not recommend tobacco tax cigarettes, but tobacco companies can still
increases as an immediate policy.22 While advertise and sponsor popular events. Ac-
less effective than taxation, countries may cording to the tobacco control law, health
legislate to ban tobacco advertisements warning labels should cover 30 per cent of
and restrict sales. In Bangladesh there is no the tobacco package, but this too has not
restriction on buying and selling of tobacco. been adequately enforced (Campaign for
In Bangladesh the first major law on tobacco free kids 2012). Though a majority
tobacco control (The Smoking and Using of smokers know that smoking is harmful,
of Tobacco Products Control Act, No XI, very few are aware of specific health effects
2005) was passed in 2005 when Bangladesh of smoking such as cancer, respiratory dis-
became a party to the WHO Framework eases, stroke and heart diseases (Efroymson
22 In
and Ahmed 2003).
1997, South Africa increased cigarette tax
by 52 per cent, and reduced consumption In summary, this policy option involves
by 30 per cent. However, very high taxation two elements:
of tobacco was not effective in Thailand:
80 per cent tax rate on cigarettes resulted Restricting tobacco sold in specific areas
in tax avoidance and large cigarette sales in such as near educational institutions.
the black market. In Bangladesh, where law
enforcement is quite weak, high tobacco taxes Legislating a ban on an all advertisement
may result in a large black market. of tobacco and tobacco products.

Centre for Policy Research of IUBAT Summer 2012 57


Criteria for Analysis ing new physical facilities, enacting new
legislation, and is susceptible to additional
To assess how well the aforementioned corruption. The expected implementation
policy options can be expected to impact time lag will also be considered:
womens nutrition, we used the following If the policy does not require additional
criteria. Most are measured informally. staff, administrative changes and new
infrastructure, does not increase the
likelihood of additional corruption,
Effectiveness
does not require additional legislation
The effectiveness of each policy option will and can start implementation fully within
be measured in two ways: first, how effective six months, it scores high.
will the policy probably be in reducing nu- If the policy requires some additional
tritional deficiencies among those targeted; staffs, some administrative changes and
second, how effective will the policy be in infrastructure but does not increase the
reducing the likelihood of women succumb- likelihood of additional corruption,
ing to disease. If a policy fulfills both objec- does not require new legislation and can
tives, it will score high; if it fulfills any one start implementation fully within one
objective, it will score moderate; if it fulfills year, it scores medium.
neither of the objectives, it will score low. If the policy requires a large additional
staffs, significant administrative changes
and infrastructure and/or increases the
Cost likelihood of additional corruption,
requires new legislation and cannot start
This criterion estimates annual total cost
implementation fully within one year, it
and cost per beneficiary or unit of service. It
scores low.
involves the cost of implementing the specific
policy by the relevant agency (either govern-
ment or NGO) without any external funding Public Acceptance
support. Actual costs involved will vary with
extent of corruption and quality of admin- This criterion captures how the involved
istration. However due to the difficulty of parties, such as the women themselves,
estimating these dimensions of cost, we have their families and society in general, politi-
not allowed for them. Consequently, our cal parties, donors and businesses view the
cost estimates may be unduly low. policy option:
If the option is acceptable by all stake-
holders, it scores high.
Administrative Feasibility
If the policy is acceptable by the general
Here we assess whether the new policy public but not by other stakeholders, it
requires hiring administrative staff, acquir- scores medium.

58 Improving Nutritional Status for Women in Low-Income Households


If the policy is accepted by none of the of the total population.24 The need for a
above, it scores low. partnership of government, international
organizations and private rice producers
may create new administrative complexities
Evaluation of Options and some additional corruption.
The cost of rice fortification using cold
Nutritional Supplements Program extrusion comprises the cost of machinery,
fortification mix, labour and the cost of
Since almost all women consume adequate rice. Building a cold extrusion rice factory
servings from the cereals and potato group with fortifying capacity of 30 thousand to
(primarily in the form of rice), fortified rice 60 thousand metric tonnes per year will
will probably be highly effective in combat- require Tk.6 crore (Alavi et al. 2008). This
ing micronutrient deficiencies provided it will increase the final selling price of rice
sells at a price equivalent to non-fortified by an estimated 2 per cent. Considering
rice of similar quality. The average rice the current price25 of coarse rice of Tk.30
consumption among rural women sampled per kg, fortification will increase the price
is 14.5 servings, for urban 10 servings.23 of rice to Tk. 30.6 per kg. In Bangladesh,
The effectiveness of fortified food to reduce rice consumption per capita per day is
short-term deficiencies and prevent long 0.44 kg (Abdullah et al. 2006). The cost of
term illness has been established in many subsidizing fortified rice for the ultra poor
countries. The high incidence of night blind- population is accordingly Tk.154 crore per
ness in Denmark during 1900 was reduced
by fortifying margarine with vitamin A and
D. Fortification of flour eliminated pellagra
in United States and thiamin and riboflavin
24 The NGO BRAC has identified the bottom 10
deficiencies in Newfoundland. Hotz et al.
per cent population of Bangladesh through a
(2008) showed that the consumption of program named Challenging the Frontiers of
iron-fortified rice for six months resulted Poverty Reduction, Targeting the Ultra Poor.
in 80 per cent reduction of iron-deficiency The criteria include households ownership of
land (less than 10 decimals or less than one
anaemia among female garment workers tenth an acre), no active male income earners,
in Mexico. dependency on begging or female domestic
Introduction of fortified rice will require work, no ownership in productive assets and
no support from children engaged in wage
adoption of new technologies by commer- earning (BRAC 2012). The government
cial rice producers. If the fortified rice is may receive support from international
targeted to all households designated ultra organizations like Global Alliance to Improve
Nutrition. GAIN provided technological
poor, that implies a subsidy for 10 per cent support in Brazil to fortify rice (www.
gainhealth.org/press-releases/path-gain-
partner-advance-rice-fortification-brazil-
23 6servings from cereals and potato group tackle-malnutrition-globally).
considered adequate. 25 Trading corporation of Bangladesh 2012.

Centre for Policy Research of IUBAT Summer 2012 59


year, equivalent to approximately Tk.500 Providing Hygienic Drinking Water
per ultra poor household.26
However many women above the ultra A 2003/04 study of 225,000 in a rural area
poor threshold but still classified as ex- in Bangladesh showed that households
treme poor and better-off households also with greater tube well density reported
face micronutrient deficiencies. For these significantly lower incidence of diarrhoea
women, fortified yogurt may be a prefer- (Carrel et al. 2011). The effectiveness of
able option for micronutrient supplements. siraj mixture has been proved through a
Selling fortified rice at a subsidized price to randomized control trial in rural Bangladesh
an additional 40 per cent of the population (Islam et. al. 2011). Among the treatment
(includes all household members) will multi- group with siraj mixture only 0.2 per
ply by four the overall cost of the program. cent were subject to diarrhoea, among the
Fortified rice produced through cold ex- control group 5.12 per cent.
trusion is opaque and slightly off-colour, but If one tube well is set for 10 households,
the taste does not change (Alavi et al. 2008). then approximately 100,000 wells are re-
In India and other developing countries such quired for all urban slums. We estimate the
as Cambodia and Nicaragua, fortified rice initial capital cost at Tk.75 crore. Based on
is widely accepted and performed well in a levelized cost calculation, we estimate the
terms of taste. In Bangladesh the social ac- annual total cost of tube wells in slums at
ceptance of fortified food will be high. An Tk.13.9 crore, which is equivalent to an an-
initial marketing campaign might be helpful. nual cost per slum household of Tk.140.27
Implementing a subsidized rice fortifi- The initial cost of setting up tube wells is
cation program targeted to the ultra poor
poses a serious threat of additional corrup- 27 The estimated number of slum households
tion. There may be useful lessons from the in urban areas in Bangladesh is 1 million
Female Stipend Program, which provides (Centre for Urban Studies, Bangladesh 2005).
According to Water Aid (2012) each shallow
an incentive to low-income families that tube well can be shared by 10 households.
keep their daughters in school. Initially, The cost of pipes and hand pump of one 30
the subsidy was given in the form of rice; feet shallow tubewell is estimated at Tk.6,000.
Additional cost of drilling and digging is
subsequently, the subsidy has been in cash. estimated at Tk.1,500. www.wateraid.org/
Potentially, the subsidy could be given to uk/get_involved/community_groups/schools/
targeted families via coupons enabling a buckets_of_water/5422.asp. Considering the
average cost of one shallow tube well installed
discount on purchases of fortified rice.
to be approximately Tk.7,500, the total cost
will be Tk.75 crore (= 1,000,000 households
/ 10 households per well x Tk.7,500 per
26 The reported Tk.154.2 crore = 16 million well). Assume the levelized annual capital
(10% of Bangladesh total population) x 2% x cost at Tk.7.5 crore. Add Tk.6.4 crore as an
Tk.30 (cost of fortification) x 0.44kg/capita/ estimate of annual operation and maintenance
day x 365 days/year. The per household costs. This implies an annual cost per slum
estimate assumes an average of five persons household of Tk.139 (= Tk.13.9 crore /
per household. 1,000,000 households).

60 Improving Nutritional Status for Women in Low-Income Households


high, but the levelized annual cost per slum will be low if supervision is good; however,
household is low. it may well not be. Similar administrative
One packet of siraj mixture purifies problems may complicate organization of
15 liters of water and costs only Tk.0.35. a large-scale subsidized siraj program.
However, 29 million people are exposed to We rate the administrative feasibility as
groundwater with arsenic levels above the medium.
Bangladesh standard (50 microgram/liter) The public acceptance of tube wells will
and 49 million above the WHO recom- be high as people in Bangladesh are already
mended level (10 microgram/liter) (Ahmed aware of the benefit of tube well water over
and Rahman 2011). The cost of provid- other sources. Public acceptance of siraj mix
ing siraj mix to this group will be nearly requires a publicity campaign. If people
Tk.100 crore per year. The annual cost per need to buy it, acceptance will be low. If
household is slightly over Tk.100.28 Again, government distributes the mixture free of
the annual cost is high, and the cost per cost, public acceptance will be high.
affected household low. The cost to gov-
ernment depends obviously on the extent
of subsidy and total demand, which will Healthy Food Initiative
Through Social Enterprises
depend on the willingness of families to pay
the residual cost.
The cost of a van for selling healthy
Setting up approximately 100,000 tube
food and snacks will be approximately
wells requires large scale administrative
Tk.15,000. There will be additional costs
coordination. Primarily the decisions will
for cooking, storing and serving food of
be taken by the Water Resources Planning
about Tk.4,000 per month.29 A reasonable
Organization (WARPO) and will be imple-
estimate of cost per meal is Tk.20, which
mented by relevant city and municipal cor-
implies 2,500 meals served per van per year.
porations. In some cases, NGOs may take
Probably, the cost of food and the salary of a
the initiative. No additional employees need
van driver can be covered by the revenue of
be hired beyond the labour to set up tube
food sold. Initially a pilot project in Dhaka
wells and maintain them. Maintenance costs
might involve 10 vans that move around
slum areas, garment factories and schools,
28 In Bangladesh 46.4 million people (= 29 locales where the urban poor and their
per cent x 160 million) live in arsenic-
contaminated areas (Peoples Daily Online, children generally buy food. Ultimately,
2007). An adult person needs to drink 2.5 success will depend on public acceptability
litres water per day. One siraj mix purifies 15 of the food van offerings. The availability
litres water. The total cost of siraj provision
is Tk.98.4 crore (= Tk.0.35 x [(46.4million
x 2.5liters/day x 365days/year)/15liters/mix). 29 These estimates summarize our initial
Assuming five people per household, the investigation. Assume a levelized annual cost
average annual cost/household is Tk.106 (= of the van as Tk.1,500. This implies a total
Tk.98.4 crore / [46.4 million / 5 members/ annual levelized cost per van of Tk.49,500 (=
household.) 1,500 + 12 x 4,000).

Centre for Policy Research of IUBAT Summer 2012 61


of healthy foods does not ensure that people nutritional status is probably higher than
will purchase it. street van food projects. We accord a high
Family gardens may be the major source effectiveness score to community gardens;
of micronutrients for low-income rural a low score to street van food.
women who do not work outside the home,
and have access to unused land. During
1986, CARE Bangladesh, a NGO, launched
Achieving Behaviour Change
Through Nutritional Advice
a pilot project, Local Initiatives for Farm-
ers, in the district of Gaibandha and Tangail In our study, those receiving nutritional
to promote homestead horticulture among advice from doctors and nurses in health
landless and marginal farmers who own a facilities appeared to benefit. However it is
little land beside their home. The benefits beyond the scope of this study to assess the
according to the participants were increased potential of increasing the supply of profes-
earnings and more adequate consumption of sional health care providers.
vegetables and fruits (Midmore et al. 1991). In many developing countries health
After CAREs withdrawal of support, this education through community health work-
project did not unfortunately survive. The ers has proved effective (WHO 2007). By
cost of household gardens will be low contrast, our analysis showed no statistical
as gardens are located in homestead and impact from advice given in home visits by
underutilized lands in villages and subur- community workers. Currently many com-
ban areas. The initial cost of a household munity health workers in Bangladesh work
garden will be seeds, plants and fertilizers. on a voluntary basis for NGOs, notably
Households with domestic animals can use for BRAC. In the case of BRAC, the incen-
dung as fertilizer. tive to become a voluntary health worker
There are moderate administrative costs is easy access to microcredit and other
to start up a healthy snack van or house- services BRAC offers, and to earn income
hold garden project. Some new employees from selling certain pharmaceutical drugs
are needed to manage all these initiatives. (Prashad et al. 2007, Ahmed 2008). Cur-
Public acceptance is uncertain in advance. rently BRAC has 80,000 unpaid volunteer
However considering the success of the Ja- health workers and 8,000 paid community
karta food vans, public acceptance can be health workers (BRAC 2012). To be effec-
considered as medium in urban areas. The tive, the community health workers need
public acceptance of household gardening basic dietary training, which would impose
by low-income women might be high as it costs on BRAC. Furthermore, to provide
increases their earning and vegetable con- an incentive for health workers to provide
sumption potential. nutritional advice independent of selling
Both are projects suitable for NGOs not drugs, payment of a modest salary to all
government. The effectiveness of commu- health workers is probably necessary. The
nity gardens as means to improve womens cost of such upgrading of the BRAC health

62 Improving Nutritional Status for Women in Low-Income Households


worker program is high relative to the finan- Blij 2012). In South Africa, for example,
cial resources available to BRAC. strong legislation banning all advertisement
Providing nutritional advice via me- and restricting sale of cigarettes among
dia, notably television, appears to have a non-adults reduced cigarette consumption
beneficial impact. Such programming on a by 4 to 7 per cent among different groups
widespread basis involves high cost.30 Cur- of people from 1993 to 1999. Given the
rently, there is no discount on advertising strong link in our survey between extent of
rates charged for public awareness television smoking among family members and lower
advertisements broadcast by channels in nutrition among women, we are reluctant
Bangladesh (Ahmed 2011). However, given to dismiss anti-tobacco campaigns as low
the high profitability of private television in effectiveness; we award them a medium
companies, the government could prob- effectiveness score.
ably oblige private television companies to The public support of an aggressive anti-
broadcast health education spots at no or tobacco campaign will be medium. A large
low public cost. per cent of adults smoke, but there is wide
civil society support for some restrictions
on the industry. There is no direct cost to
Evaluation of Tobacco Control government upon banning advertisements.
New inspectors may be necessary to impose
Public anti-tobacco campaigns featuring
restriction on tobacco selling, which adds
bans on tobacco advertising and restrictions
some modest cost for government. The key
on tobacco sales do reduce consumption
obstacle is opposition from the tobacco in-
intergenerationally. But their short-term
dustry and media outlets receiving revenue
impact is likely modest. Countries that have
from tobacco advertising. Given the likely
achieved large reductions in the prevalence
extent of such opposition, the administra-
of smoking have maintained ongoing cam-
tive feasibility of imposing tobacco control
paigns for several decades (Willemsen and
policies is currently low.

30 Thecost of TV commercials per minute is


Bangladesh varies between Tk.40,000
Tk.60,000. This increases by factors of five
during major national and cultural festivals
(The Daily Star 2010).

Centre for Policy Research of IUBAT Summer 2012 63


Table 5.2. Summary Policy Evaluations

Administrative
Policy Options Effectiveness Cost (Taka) Public acceptance
feasibility

Annual cost: Tk.154 crore


1. Nutritional High (among
supplements government Annual cost per household: Medium High
(fortified rice) options) Tk.960 (bottom 10 per
cent of population)

2. Hygienic water Annual levelized cost of


for urban slums tube wells: Tk.13.9 crore
High (among
(setting shallow Annual cost per household
government Medium High
tube wells or of tube wells: Tk.140 (for
options)
providing siraj urban slums where arsenic
mixture) concentration low)

3. Healthy food initiative through social enterprises

Annual cost per van:


Jakarta model Low (among Tk.49,500 (10 van
pilot project) Medium Medium
food van (urban) NGO options)
Cost per meal: Tk.20

Household High (among Low cost to


Medium High
gardens (rural) NGO options) sponsoring NGO

4. Nutritional advice

High cost relative to


Improve training
High (among typical NGO budget,
of community Medium High
NGO options) unless NGO obtains
health workers
explicit donor support

Low cost for government,


Medium (among provided media outlets
Television
government agree to broadcast Low High
advertisement
options) messages as public
service; high, otherwise

5. Tobacco control

Medium (among
Restrictive selling government Low cost for government Low Medium
options)

Medium (among
Advertisement ban government Low cost for government Low Medium
options)

64 Improving Nutritional Status for Women in Low-Income Households


6. Conclusion

Our recommendation to government and to NGOs is to pursue as


first priority those options rated high in terms of effectiveness. While our ratings are
admittedly informal, the four options rated high in effectiveness unambiguously address
key nutritional problems, are low cost in terms of cost/household targeted or unit of service
provided, could be initiated reasonably quickly, and do not face insurmountable administra-
tive difficulties or public opposition.
The government is the main institution programs are primarily in the governments
to implement new programs. However, over domain.
the last two decades, NGOs have made We have divided policy options between
significant contributions to improve social those better implemented by the government
conditions for the marginalized population. and those better implemented by NGOs.
Micro-credit, non-formal education, basic However, the distinction is not absolute.
health care services, social enterprises and It may be feasible for government to con-
womens empowerment programs are exam- tract with slum community leaders for the
ples of NGO activities. Funding of NGOs maintenance of shallow tube wells in slums.
comes through overseas donors and, to a Government might also choose to mount a
limited extent, through cross-subsidization program providing nutritional training to
from profitable business ventures (such as community health workers. Also, our ef-
micro-credit) undertaken by the NGOs fectiveness evaluations may be wrong. The
themselves (Davis 2006). Given the limited Jakarta model for selling nutritious food in
administrative capacity and limited public urban areas might, for example, prove more
mandate of the NGOs, large-scale public effective than we concluded.

Centre for Policy Research of IUBAT Summer 2012 65


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74 Improving Nutritional Status for Women in Low-Income Households


Appendix A

Survey Questionnaire

Diet Recall:

We would like to ask you about the food you personally ate in the last 24 hours.

1. Looking at the largest of the cups provided, how much of each type of food did you personally
eat yesterday? (cooked volumes). If you did not eat any category keep blank under number
column.

[Be sure to emphasize the idea of a full days set of meals early morning to evening.]

Breakfast Lunch Supper Others

Rice [large cups]

Lentil (Daal) [large cups]

Beef/Mutton/ lamb [small cups]

Chicken/ other birds [small cups]

Egg [number]

Fish [small cups]


a) a) a) a) a)
b) b) b) b) b)

Leafy vegetables/shak [small cups]


a) a) a) a) a)
b) b) b) b) b)
c) c) c) c) c)

Other vegetables [small cups]


a) a) a) a) a)
b) b) b) b) b)
Potato [small cups]

Centre for Policy Research of IUBAT Summer 2012 75


Breakfast Lunch Supper Others
Milk [small cups]
a) Powder milk (mixed with water) a) a) a) a)
b) Liquid milk b) b) b) b)
Butter [small cups]
Yoghurt/ Cheese [small cups]
a) Sweet Yoghurt a) a) a) a)
b) Sour Yoghurt b) b) b) b)
c) Cheese c) c) c) c)
Tea/Coffee [actual cups consumed]
a) Tea with milk and sugar/
condensed milk
b) Tea with sugar and without milk
c) Tea with milk and without sugar a) a) a) a)
d) Tea without milk and sugar b) b) b) b)
(e.g. lime tea/ ginger tea) c) c) c) c)
Bread/ Roti [pieces]
Fruits [pieces]
a) a) a) a) a)
b) b) b) b) b)
c) c) c) c) c)
Snacks (halka/faltu foods, like
chips/ shingara) [pieces]
a) a) a) a) a)
b) b) b) b) b)
c) c) c) c) c)

Others [list and record units]


a) a) a) a) a)
b) b) b) b) b)

2. How do you identify your own or your households cooking in terms of oil?

o More oily
o Less oily

76 Improving Nutritional Status for Women in Low-Income Households


3. Compared to last year at this time, how have you changed your regular food diet?
(Put on appropriate box)

I eat the same


I eat more I eat less of I have started
amount of I no longer
of this food this food than eating this
this food as eat this food
than last year last year food recently
last year
Rice

Lentil (Daal)

Beef/mutton/ lamb

Chicken/ other birds

Egg

Fish
a)
b)

Leafy vegetables/shak
a)
b)
c)

Other vegetables
a)
b)

Potato

Milk
a) Powder milk
(mixed with water)
b) Liquid milk

Oil

Butter [woodblock]

Yoghurt/ Cheese
a) Sweet Yoghurt
b) Sour Yoghurt
c) Cheese

Tea/Coffee [Actual
cups consumed]
a) Tea with milk
b) Tea with condensed milk
c) Tea without milk

Centre for Policy Research of IUBAT Summer 2012 77


I eat the same
I eat more I eat less of I have started
amount of I no longer
of this food this food than eating this
this food as eat this food
than last year last year food recently
last year

Bread/ Roti

Fruits
a)
b)
c)

Snacks (halka/faltu foods,


like chips/ shingara)
a)
b)
c)

Others [list]
a)
b)

4. If you have stopped eating, or are eating less of, particular food(s), what are the reasons? (can
check multiple reasons)
o Dont like them
o Overall, food prices are higher and decided to buy less or cut out some foods
o Household members changed.
o Other, please specify _____________

* [If the respondent mentions high prices in question 4, please do question 5 and 6, otherwise
go to question 7].

5. How serious a problem has been higher food prices for you and your household?
(put on appropriate box)
o Very Serious
o Serious
o Somewhat serious
o No problem at all

6. How have you adjusted to the high food prices? (can check multiple reasons)
o I ate less
o Everyone in the family ate less

78 Improving Nutritional Status for Women in Low-Income Households


o Buy lower quality foods
o Spent less on non-food items
o Working family members earning more
o New family members are working. Who? ___________
o Moved to city
o Sold assets
o Borrowed money from ____________________
o Stopped sending one or more children to schools
o Received help from the government/ NGOs/ school stipend

7. Who eats fish/ meat/ milk/ fruits in your family? (put on appropriate box or boxes)
o Everybody does, but varied amounts for different family members
o Everybody does, about the same amount each
o My husband gets more
o My children get more
o I get more than others

Sources of minerals and vitamins:

8. As you may know, we need certain minerals and vitamins to be healthy. I would like to ask you
whether you are eating/consuming any of the following. (Put on appropriate box)

When I am
pregnant or
Regularly Not regularly Never Dont know
nursing my
children

Iodized Salt

Calcium Tablets

Fortified Yogurt

Vitamin tablets

Sprinkles

Zinc tablets or syrup

Iron tablets or syrup

Other supplements
or fortified foods

Centre for Policy Research of IUBAT Summer 2012 79


Hygiene and cleanliness:

9. Where do you usually get water for different everyday uses? (Put on appropriate box).

Bathing/
Washing Dish
Drinking? Cooking? hand
Clothes? washing?
washing?
Government (tap, hose)
Tube Well
Stored rain water
River/Pond

10. Do you boil water before drinking?

o Yes
o No

11. What is your toilet facility? (Put on appropriate box)

o Here and there


o Open hole
o Drain to pond/canal/ river
o Hanging latrine (over water)
o Pit (with cement)
o Ring slab
o Sanitary
o Other (specify): _________________________

Smoking and Betel-Nut chewing:

12. How many members of your household smoke, including you? ______________

[If none put 0, go to Question 16]

13. How many cigarettes/ bidis do you think members of your household smoke in a day?

Number/ Range of numbers


Self
Husband
Children
Others

80 Improving Nutritional Status for Women in Low-Income Households


14. Among members of your household who presently smoke, do they smoke more or fewer ciga-
rettes/ bidis in a day now than they did one year ago? (Put on appropriate box)

o More
o Fewer
o Same

15. Is there any member of your household who started smoking within the last year (started
smoking)?

o Yes
o No

16. Is there any member of your household who smoked earlier but does not smoke now
(stopped smoking)?

o Yes
o No

17. If your household smokes less, or any member stopped smoking, what was the reason? (can
check multiple reasons).

o Worried about health


o Too expensive
o Prices of other foods are higher now
o Religious reasons
o Disapproval of family/ community
o Other, please specify:____________________

18. How many members of your household chew paan, including you? _____________

[If none put 0, go to Question 22]

19. How many times a day does your family members take paan?

Number/ Range of numbers

Self

Husband

Children

Others

Centre for Policy Research of IUBAT Summer 2012 81


20. Among members of your household who presently take paan, do they use more or less paan
in a day now than they did one year ago?
o More
o Less
o Same

21. Is there any member of your household who started taking paan within the last year (started)?
o Yes
o No

22. Is there any member of your household who used paan earlier but does not use it now (stopped)?
o Yes
o No

23. If your household uses less, or if any member stopped using paan, what was the reason? (can
check multiple reasons).

o Worried about health


o Too expensive
o Prices of other foods are higher now
o Disapproval of family/ community
o Other, please specify ____________________

Awareness/ Education:

24. People around you, like your family members/ doctors/ health workers may talk about
health/ nutrition/ smoking etc. Also you may see programs on TV regarding these. Have you
received advice on these different things from any of these sources? (Put on appropriate
box).

Managing
healthy food Chewing
Received advice from Healthy food? Sanitation? Smoking?
during price paan?
increase?
None
Husband
Other family
members/ Relatives
Neighbours
School Teachers

82 Improving Nutritional Status for Women in Low-Income Households


Managing
healthy food Chewing
Received advice from Healthy food? Sanitation? Smoking?
during price paan?
increase?
Health facilities/
Doctor/ Nurse
Health/ Community
workers came
to house
Religious leader
Television
Radio
Newspaper
Posters
Public meeting with
health workers
Others (please
specify)

25. When you get together with other women do you discuss any of the following things? (can
check multiple reasons)

o Health issues/ problems


o Nutritious food
o No, we dont discuss any of the above issues [if this is the answer move to question 28]

26. How often do you discuss those issues?

o almost every day


o 2-3 times a week
o once a week
o once a month
o once a year or less often

27. Where do you meet?

o family home
o community center
o childrens school
o near tube well/ water tap/ pond/ river
o other, please specify:

Centre for Policy Research of IUBAT Summer 2012 83


28. Would you be interested in health classes at Oasis Medical Center?

o Yes (proceed to next question)


o No (go to question 30)

29. Which of the following classes interest you? (can check multiple reasons)

o healthy pregnancy care


o infant feeding
o breastfeeding
o child feeding
o family feeding
o using ORS
o immunizations
o diet
o diabetes
o blood pressure
o joint pain
o weakness, headache, dizziness
o family planning
o healthy eating for weight
o other:

Assets/ Wealth and Income:

[Note to the surveyor: Fill out question 30 and 31 by yourself (without asking the respondent)]

30. Material of the house in which the respondent is living: (Check multiple boxes if house
made with more than one material)

o Mud
o Tin
o Bamboo
o Plastic
o Other (specify): ____________________

31. Does the house in which the respondent is living have electricity?

[The surveyor can look at whether any electric wear is outside the house]
o Yes
o No

84 Improving Nutritional Status for Women in Low-Income Households


32. Who owns the house in which you are living? (Put on appropriate box)

o You or your husband


o Rented house
o Sharing houses with others not paying rent
o Other (specify) _____________________

33. Which of the following things do you/ your household own? Note: Assets will include only the
currently usable ones. [The surveyor should use common sense in filling out this section]. Put
0 if they do not have any.

Type of Assets Numbers Comments

Homestead Land (in katha)

Cultivable Land (in katha)

Chicken/ Duck/ Pigeon

Goat/ Lamb

Cow

Mosquito Net

Land/ Mobile phone

Radio

Fan

TV

Bicycle

Rickshaw

Motorbike

Other vehicle (please specify)

Refrigerator

Computer

DVD player

Internet

Other important asset (specify)

Centre for Policy Research of IUBAT Summer 2012 85


34. How do you assess the situation of overall food adequacy of your family/ household?
(Put on appropriate box)

Current situation Situation one year before

o Enough o Enough
o Sometimes not enough o Sometimes not enough
o More than enough o More than enough
o Never enough o Never enough

35. If your family/ household had more money, how would you spend it?
(Put on appropriate box)

o buy more rice


o buy other foods
o buy some vitamin/ mineral supplements
o spend on clothing
o spend on childrens education
o spend on health treatments
o buy a radio/ television
o repair house
o save for future
o repay debt
o other, specify __________________________

Demographic and Socio-Economic Status:

36. Name of the respondent (Optional): _______________________________________

37. Height (centimeters): _________________ Weight (kilograms): ________________

38. How many members are in your household? (write down numbers): _______________

86 Improving Nutritional Status for Women in Low-Income Households


39. Family members information:

Highest School attendance


Member Can read? Hours of children
Age class Occupation
of the (Y = Yes attended worked
household (in years) per day If C, then
N = No) (in numbers) C/F
A/ M/ S

Respondent

Husband

Child 1

Child 2

Child 3

Child 4

Other
members

1.

2.

3.

4.

Note: C = Continuing to the school, F = Finished at school


A = Always, M = Most of the days, S = Stopped attending for some days

40. If one or more of your children has stopped attending school, what was the most important
reason? Any other reason? Keep going

[Note for the surveyors: Rank the most important reason as 1, the second most important rea-
son as 2, etc].
o We could not afford the costs of school (such as tutoring, school supplies)
o The child was not interested in school work
o We needed the child to help with housework (such as caring for younger children)
o We need the child to earn some money for the family
o Other (please specify): _______________________________________

48. Any important observation by the surveyor: _________________________________________


______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Centre for Policy Research of IUBAT Summer 2012 87


[Questions to ask of local merchants]

We are interested to know about the food price changes compared to the last year. Women may
not properly know the price if the male member(s) of the household purchased the necessary
commodities. The shopkeepers near the house may ask about their selling prices. The surveyors
are advised to take help from the local people. The number of shopkeepers interviewed may vary
on the basis of spread of the interviewed households and the availability of shops nearby. Please
write down the selling prices by the local shops of the following commodities. If dont know put
0.

Commodity Current price (taka) Price one year before (taka)

Rice

Lentil (Mosuri Daal)

Flour

Chicken

Beef

Fishes:
a)
b)
c)

Egg

Potato

Onions

Oil

Milk
a) Powdered milk
b) Liquid milk
c) Condensed milk

Sugar

Salt

88 Improving Nutritional Status for Women in Low-Income Households


Appendix B

Food Scoring Method

We used a modified version of the ten- Q2: Did the individual eat at least 5 servings
question food scoring instrument proposed from vegetables and fruits group?
by the WHO (2001). Below are the ten s 5 from vegetables and fruit
WHO questions and detailed notes on our group: 1 point
scoring procedure.
2.5 s < 5 from vegetables and fruit
Legend group: 0.5 point
s: serving s < 2.5 from vegetables and fruit
cup: one cup is 250 ml. group: 0 point
tsp: tea-spoon where
cup vegetables = 1 serving
Q1: Did the individual eat at least 6 servings
from the cereals and potato group? 1 banana or 1 apple or 1 orange or
1 mango = 1 serving
s 6 from cereals and potato group:
cup grapes/ jack fruit = 1 serving
1 point
3 s < 6 from cereals and potato Q3: Did the individual have at least 2
group: 0.5 point servings from the milk products group?
s < 3 from cereals and potato group:
s 2 from milk products: 1 point
0 point
1 s < 2 from milk products: 0.5
where
point
cup cooked rice = 1 serving
s < 1 from milk and milk products:
cup potato (cooked/ fried) = 1
0 point
serving (not considered in vegetables
where
group)
1 lcup milk = 1 serving
1 roti/bread = 1 serving
4 small cups tea (with milk) = 1
1 pitha/ pan cake/ cup cake =
serving of milk
serving
1 cup puffed rice/ chips = serving
1 biscuits = 1/3 serving

Centre for Policy Research of IUBAT Summer 2012 89


We considered 1 large cup of tea (250 ml, 2 tsp sugar = 1 serving
used in the survey) equivalent to 4 small
cups of tea. Lower income people in Ban- For this question we made the following
gladesh usually use small cups. We assumed detailed scoring assumptions:
each cup of tea contains some milk and the 1 biscuit = serving from fat, oil,
milk in 4 cups equals one milk serving. sugar group
1 packet chips = 1 serving from fat,
Q4: Did the individual eat at least 1 serving
from meat and alternatives group (meat, oil, sugar group
fish, eggs, daal or other pulses)? 1 large cup of tea or 4 small cups of
tea = 2 servings of sugar (assuming 1
s 1 from meat and meat alterna-
tsp sugar per small cup)
tives group: 1 point
1 cup halka/faltu food = 1 serving of
0.5 s < 1 from meat and meat al-
fat, oil, sugar group
ternatives group: 0.5 point
1 pitha/ pan cake = serving from
s < 0.5 from meat and meat alterna-
fat, oil, sugar group (lower income
tives group: 0 point
people generally prepare pitha
where
with or without oil, but sugar/gur
cup of meat (any kind) = 1
is a common ingredient. As types
serving of pitha were not specified in the
cup fish (any kind including dried survey, we assumed each pita con-
fish/ shutki) = 1 serving tributed a small portion of a fat, oil,
1 egg = 1 serving sugar group serving)
cup daal or other pulses = 1 1 puri/ samosa/ singara = serving
serving of fat, oil, sugar group

Q5: Did the individual consume fewer than 2 We also assessed the impact of meat, fish,
servings from the fat, oils and sugar group? vegetables, eggs and daal consumption on
0 s 2 from fats, oils and sugar the fat, oil, sugar group. In Bangladesh,
group: 1 point most people use oil (as much as they can!)
when they prepare curries. Also meat and
2 < s < 4 from fats, oils and sugar
fish contain fat:
group: 0.5 point
1 cup of meat = serving of fat, oil,
s 4 from fats, oils and sugar
sugar group
group: 0 point
1cup of fish = serving of fat, oil,
where
sugar group
2 tsp of oil = 1 serving
1 cup of vegetable = serving of
2 tsp butter = 1 serving
fat, oil, sugar group

90 Improving Nutritional Status for Women in Low-Income Households


1 cup of daal = serving of fat, oil, Q8: Did the individual eat at
sugar group (usually less oil use to least one fresh fruit?
cook daal than curry) 1 or more fresh fruit: 1 point
1 egg = serving of fat, oil, sugar
0 fresh fruit: 0 point
group (fried is the most common
means to consume eggs for lower As for Q7, we considered number of items,
income people) where 1 cup egg = not quantity of servings. We awarded no
2 eggs intermediate 0.5 scores to this question.
1 sweet = 1 serving from fat, oil,
sugar group Q9: Did the individual eat
mostly nutritious snacks?
Q6: Did the individual eat a variety of
0 snacks and 1 fruit: 1 point
foods within each of four main food
groups ([1] cereals and potato, [2] fruits 0 or 1 processed snacks (shingara,
and vegetables, [3] meat, fish, eggs, samosa, puri, packet of chips) plus 1
daal) [4] milk and milk products? or more fruit: 1 point
2 items in each of 4 food groups: 1 1 or 2 processed snacks plus 1 or
point more fruit: 0.5 point
2 items in each of 2 or 3 food 2 processed snacks plus 1 or more
groups: 0.5 point fruit: 0 point
2 items in 0 or 1 food group: 0 point 0 or 1 biscuit and 1 or more fruit: 1
point
Very few low-income Bangladeshi consume 1 or 2 biscuits plus 1 or more fruit:
a variety of milk products. To include this 0.5 point
group, as recommended by the WHO, 2 biscuits and 1 or more fruit: 0
would have generated unreasonably low point
scores on this question.
0 2 pitha and 1 or more fruit: 1
Q7: Did the individual eat at point
least 2 fresh vegetables? 2 3 pitha and 1 or more fruit: 0.5

2 or more fresh vegetables: 1 point


point
3 pitha and 1 or more fruit: 0 point
1 fresh vegetable: 0.5 point
0 fresh vegetables: 0 point
As snacks we considered the halka/faltu
Here I considered leafy and other veg- foods. Respondents reported consuming
etables in terms of number of items, as biscuits, chips, shingara, samosa, puri,
opposed to quantity of servings. pitha, puffed/beaten rice (khoi/chira) as
snacks. We gave more points if the foods

Centre for Policy Research of IUBAT Summer 2012 91


contain hygienic/nutritious items and were Q10: Did the individual consume mostly
probably produced in hygienic situations. lean or low fat content foods?
Shingara, samosa, puri, and chips are widely
available in Bangladesh; however they are This question was scored identically to Q5.
often cooked in unhygienic situations by
street vendors, and most contain lots of oil.
Pithas (sweet breads or pastries) are mostly
home-cooked in more hygienic situations
and contain less oil. We considered fruits
as potential snacks.

92 Improving Nutritional Status for Women in Low-Income Households


Appendix C

Income and Asset


Index Calculation

The survey provided data on the occupation to get wage per day. For each profession
of each member of the household and we considered 2430 working days per
hours worked per day: full time worker month. We summed the income of all
(5 hrs or more per day); part time worker members in the household to calculate the
(less than 5 hrs per day). We categorized annual household income.
the occupations into six categories: To estimate income from family-owned
Agricultural labour assets we included cultivable land, cows,
Other labour chickens, ducks and income-generating
vehicles such as rickshaws. We estimated
Business
average productivity of each type of asset
Official jobs (including driver)
per unit (e.g., daily milk per cow per day).
House worker (maid servant) Adding the income from labour and
Garment worker from assets we calculated the total an-
Data for the daily wages for each nual income for the household. Per capita
category are taken from the Bangladesh income was calculated by dividing total
Bureau of Statistics. We multiplied the annual household income by the square-
hours of work times the estimated wage root of the number of household members.

Centre for Policy Research of IUBAT Summer 2012 93


Back issues

CPR Commentary No. 1

Natural Gas Options


for Bangladesh

by Mark Jaccard, Director, Energy Research


Group, School of Resource and Environmental
Management at Simon Fraser University, Mujibur
Rahman Khan, Professor, College of Engineering and
Technology at IUBAT, and John Richards, Professor,
Master of Public Policy Program at Simon Fraser
University

The very low level of available commercial energy


is a serious constraint on economic development in
Bangladesh. Fortunately, there is one bright prospect
sizeable discoveries of natural gas.
This report explores three options for how Bangla-
desh might use its natural gas endowment: exporting
gas to provide public revenues that could be directed
to many other development needs; expanding the many
possible end-uses for gas in domestic industry, agricul-
ture and households; or concentrating natural gas use
on accelerated electrification. After assessing the three
options, the authors conclude that rapid electrification
should have the highest priority.
In addition, the report discusses institutional
reforms to foster private investment and to improve
the transparency, efficiency and consistency of
government corporations, ministries and agencies.
There is an important case to be made for integrated
resource planning that includes environmental and
social objectives.
Back issues

CPR Commentary No. 2

Electricity for All

by ROSE Murphy, Research Associate with the Energy and


Materials Research Group at the School of Resource and
Environmental Management at Simon Fraser University,
nuruddin kamal, Senior Research Fellow for the Centre
for Policy Research at IUBAT, and john richards, Professor,
Master of Public Policy Program at Simon Fraser University

Only one in five Bangladeshis has access to power; among those in rural areas the ratio is about one in
seven. What can be done to improve access? This report assesses the barriers to accelerated electrification
rural electrification in particular and offers practical recommendations.
The Rural Electrification Board (REB) and its network of cooperatives Palli Biddyut Samitees now
distribute nearly a quarter of electricity consumed in the country. Despite this impressive accomplishment,
they need to do more.
The authors recommend that the REB place a high priority on power generation independent of the
national transmission grid. This expansion will require private investment and higher average tariffs
for REB customers. Securing major new investment and revising tariffs will not be easy, but the goal of
increased electrification is sufficiently important to justify the required reforms.
Back issues

CPR Commentary No. 3

Energy Policy
for Bangladesh

by Dr. M. Alimullah Miyan, Vice Chancellor and Founder,


IUBAT, and John Richards, Professor, Master of Public Policy
Program at Simon Fraser University

It is hard to exaggerate the importance of adequate supplies of commercial energy for the future
development of Bangladesh. In May 2004, the Government of Bangladesh released a draft National
Energy Policy, and invited public commentary. The government report acknowledges the serious
shortcomings of present policy and the dilemmas in designing new policy.
In this third report of the Centre for Policy Research, Dr. Alimullah Miyan, Vice-Chancellor and
Founder of IUBATInternational University of Business Agriculture and Technology, and Dr. John
Richards, Professor at Simon Fraser University in Canada and Visiting Professor at IUBAT, respond
to the draft National Energy Policy and offer a series of recommendations. The recommendations
cover major issues from export of natural gas to improvements in the utilisation of biomass fuels.
Back issues

CPR Commentary No. 4

What Parents Think of


Their Childrens Schools
A Survey of School Quality Among Parents
in Uttara, Suburban Dhaka, Bangladesh

by Sandra Nikolic, Planner, Health Services Authority of British Columbia, and


John Richards, Professor, Master of Public Policy Program at Simon Fraser University

Over the last decade, Bangladesh has made impressive gains in the quantity of education available. As
of 2004, there were 18 million children enrolled in 110,000 primary schools. Still, many parents choose
to enrol their children in private schools where parents pay, in nonformal schools run by NGOs such as
BRAC, and in madrasas. The popularity of school types other than government-run schools suggests that
parents have concerns about school quality as well as the availability of school spaces.
To assess parental attitudes to problems of school quality, student researchers from IUBAT
International University of Business Agriculture and Technology surveyed residents in Uttara, a suburb in
northern Dhaka. This study reports their findings. The study also assesses broad strategies for improving
education outcomes.
Back issues

CPR Commentary No. 5

Barriers to Girls Secondary


School Participation in
Rural Bangladesh

by JENNIFER HOVE, Bachelor of International Relations at University of British Columbia 2000,


Master of Public Policy at Simon Fraser University 2007, Visiting Fellow, IUBAT

Over the last 15 years, secondary school enrolment rates among both boys and girls have risen
dramatically. However, girls rates of progression and completion of the secondary cycle (from
grades six through ten) are disturbingly low albeit the comparable rates for boys are also low.
At grade six there is near parity between the number of boys and girls enrolled. By grade ten,
boys are significantly ahead of girls in participation in public examinations and promotion to
higher secondary school. Only 13 per cent of girls who complete the tenth grade transition to the
higher secondary grades of eleven and twelve. There are powerful forces at work within schools,
families and the broader society that dissuade girls from staying in school. Based on interview
responses among teachers, students and parents in four rural schools, this study analyses why
girls drop out of school, and offers policy recommendations to increase completion rates.
Back issues

CPR Commentary No. 6

A New Mandate for the


Rural Electrification Board

by B.D. Rahmatullah, Nancy Norris, John Richards

A lack of reliable electrical power is severely impeding Bangladesh economic development.


Seventy-eight per cent of Bangladeshi firms cite poor electricity service as a major or severe
obstacle to expansion.

Successful reform requires building on a foundation of administrative credibility. The most


credible of the major agencies in the power sector is the Rural Electrification Board (REB). Over
the last decade, it has doubled the number of customer connections, and now distributes 40
per cent of all power generated in Bangladesh. The authors of this monograph recommend an
expansion of the REB mandate to enable the REB and its network of rural cooperatives (Palli
Biddyut Samitee) to create generating capacity independent of the national grid, capacity whose
power would be distributed on a priority basis to customers in the local participating PBS.
Back issues

CPR Commentary No. 7

Benchmarking the Nutritional


Status of Women in the
Tongi-Ashulia Road Slums
Uw-Avky wjqv
Uw-Avky moKi
wjqv moKi ewew
evwm
evwm
gwnjv`i
gwnjv`icywgvb g~jg~vqb
cywgvb jvqb
by John Richards, Afifa Shahrin and Karen Lund

This Commentary reports on the nutritional status of shanty dwelling women in Uttara (near
the Turag River). Data were collected by nursing students at IUBATInternational University of
Business Agriculture and Technology. Most women have an adequate caloric intake. However,
most lack adequate servings from the full range of food groups. Inflation in rice prices may
have induced them to sacrifice other foods in order to maintain rice consumption.
The majority use non-boiled tap water from the Dhaka Water and Sewage Authority. Due to
contamination from ground water, it may contain high levels of pathogens. Tobacco and betel
nut are widely used by family members. Both pose serious health hazards if consumed on a
long-term basis. The ability of women to read, and receiving one-on-one advice from a health
worker had positive impacts on aspects of nutrition.
This monograph reports on the nutritional status of a sample of 600 women in two sites: four
villages near Jamalpur, and shanty dwellers in the Dhaka metropolitan area. While some suf-
fer inadequate calorie intake, the major nutritional problem is inadequate consumption of
protein, vitamins and micronutrients.

The authors assess the importance of factors that influence nutrition. In general, womens
nutrition is better in households with higher education levels; most women do not smoke,
but their nutrition is worse if other family members use tobacco.

The recommendation to government is to pursue two programs: rice fortification, and setting
of tube wells in slum neighbourhoods (where groundwater is not affected by arsenic). NGOs
are invited to improve training of community health workers, and encourage household veg-
etable gardens in rural villages.
US$15 Taka 200