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Bangladesh is a country of approximately 144,000 square kilometres and a population of more than 105 million, of which women constitute 48.5%. The per capita income is about US$ 150 per year; the literacy rate is 23.8%. This widespread poverty and inability to make effective use of educational information are the major causes of the country's malnutrition. According to one estimate, less than 5% of the total population consumes an adequate diet (World Bank, Bangladesh Food and Nutrition Sector Review, January 1985). The nutrition survey of rural Bangladesh indicated that about 76% of all rural households were calorie-deficient and about 48% were protein deficient in 1982. In general the situation appears to be the worst for lower-income groups and, within households, for mothers and children. The effects on the lives of women in Bangladesh of lack of adequate nutrition are visible in many forms, such as anaemia, low learning and working capacity, low resistance to disease and stress, and lack of proper mental and physical development. Underlying factors of high maternal mortality (6 per 1,000 live births) are the inferior status of women and related social problems.
In a country where poverty is so acute, it is difficult to advance the concept of nutrition and balanced diets. Women are responsible for family survival and child nutrition, but because of their subordinate status in the society, they cannot perform this role effectively. Because they do not have direct access to resources and services, the Grameen Bank was established to provide credit to generate income. The concept was developed by Professor Muhammad Yunus in the small village of Jobra in Chittagong in 1976, and the programme was established as a bank in October 1983.
Since then, the bank has grown to a considerable size through both horizontal and vertical expansion of its coverage and activities. As of December 1988, it was operating through 501 branches in 10,552 villages, serving 490,363 landless members through its credit programme (table 1). (Anyone who does not own more than one-half acre [0.2 ha] of cultivable land and the value of whose family assets together does not exceed the value of one acre [0.4 ha] of medium-quality land is classified as "landless.") Women constituted 86% of the members. The amounts of loans disbursed were US$83 million to women and US$30 million to men; the repayment rate by women has been almost 100%.
The primary objective of the Grameen Bank is to raise income and the standard of living in the most disadvantaged sections of the rural community. This is done by providing access to credit for poor landless people who previously were barred from formal lending institutions because they lacked collateral and who were therefore dependent on the informal credit sector at exorbitant rates of interest.
Apart from offering loans without collateral, the bank is also trying to create effective consumer demand for loans among the landless and to develop viable co-operative loanee groups at the village level through social mobilization.
Before applying for a loan, five like-minded people of similar socio-economic status must form a group. Group participants go through intensive training regarding the rules of the bank and their own obligations as members. Before extending formal recognition to a group, the bank reviews the eligibility criteria very carefully.
TABLE 1. Consolidated cumulative statement of the Grameen Bank as of December 1988
|Unrepaid after 1 year||1.6|
|Overdue (unrepaid after 2 years)||1.45|
|Loans from group fund|
|Branches in operation||501|
a. Loans for housing and
for activities involving higher technology.
b. A group member can borrow from the group fund with the consent of the other members.
c. The emergency fund is a sort of insurance fund which, when operational, will cover the members in cases of accident, death. and disaster.
Each group elects its own chairman and secretary, and five or six groups federate into a centre. Each centre elects a chief, who conducts the weekly centre meetings. She is responsible for seeing that the rules and procedures of the bank are observed and for recommending loan proposals to the bank workers.
Individual savings: Each loanee deposits one take every week as compulsory savings, together with the weekly installments.
Group fund: Each loanee is required to pay a group tax of 5% of the loan, and this is deposited in a separate account as a group fund. The group fund is operated by the chairman and secretary. It can be used by the members as agreed on by them.
Emergency fund: Each loanee pays an amount equivalent to 25% of the interest paid on the principal. This is built up as an emergency fund to be used as potential insurance against default, death, disability, and other accidents.
The Grameen Bank is not only a credit programme for the landless. Incorporated into it is a social development component, a substantial part of which is supported by UNICEF. The UNICEF co-operation began in July 1980 to integrate women's social development within the framework of the bank programme. Since then, the project has gone to scale and developed an integrated approach to basic services. The assistance from UNICEF will continue until 1993.
The objective of the social-development programme are as follows:
- to enhance the socio-economic status of rural landless women by promoting self-employment opportunities, thus enabling them to take care of their needs, ensure child survival, and address development-related issues;
- to sensitize and expose these women to the possibilities of credit services for income-earning activities, and socialize them to the discipline of loan repayment using group norms; to provide group leaders with functional education to enable them to improve their social status, with particular emphasis on women's health and nutrition.
Under the social-development component, a comprehensive training programme was formulated for the women group leaders and related bank officials. The group leaders disseminate this information to the members. So far, 37,486 group leaders have been trained under the project. During 1988-1993, a further 60,000 will be trained to work for 750,000 landless women members and 1.5 million children.
Through the training workshops, the bank plays a vital role in involving women in nutrition care, maternal health, and child care. Thus a great demand for basic services has been generated, and linkages have been established with related service agencies.
One result of the programme is that the nutritional status of women members and children has improved. Not only has food intake increased, but also better quality foods have been added to the diet. The members have adopted the habit of including low-cost nutritious items in the family diet such as vegetables, small fish, pulses, beans, and eggs. As a result, their children have better nutritional status in terms of anthropometric measures. More than 50% of the children of bank members up to nine years old have normal weight for height, while the figure for non-bank members' children is about 30% .
As an additional part of child care, bank members are taught the fundamental rights of their children, such as food, housing, and education. They have now established 5,000 centre schools, with a total student population of 131,506 (73% of whom are girls), which are financed entirely by the members from a special savings fund.
In an attempt to maintain nutritional balance, bank members secure food in several ways:
Joint ventures: Through joint ventures, some of the groups take loans together and save food for the family for a minimum of three months. Rice is the main item. Moreover, all bank members practice direct food storing from their daily rice quota.
Seeds and saplings: To enhance nutrition status, the bank has distributed 2.15 million packets (17,000 kg) of vegetable seeds and 954,055 saplings to members. The products of the seeds and saplings are stored for later use. The major purpose of this programme is to promote family food gardening so that women and families can (1) consume some of the vegetables they grow to improve their nutritional status and (2) sell surplus products to earn income.
Fish: During some seasons, especially winter, fish are dried for future consumption. Dried fish have a high level of concentrated protein.
Mahbub Hossain (presently chairman of the Bangladesh Institute of Development Studies) in his studies found enhanced economic status and increased vegetable production by the women bank members. He observed:
Two-thirds of the loanee households were involved in kitchen gardening even before joining the Bank, and their proportion was found to be about three-fourths at the time of the survey. The intensity of kitchen gardening has increased more than the induction of additional households in this activity.
The average income earned from kitchen gardens has increased by about 47 percent in real terms.
Nearly a half of the loanee households considered that their economic conditions improved because of their additional involvement in vegetables and fruits growing. 
Since there is a strong correlation between income and nutritional status, it is observed that women bank members spend more money on food and consume a substantial portion of the vegetables they grow.
Women particularly benefit, showing a noticeable increase in status in the family and community, as well as improvements in their homes and the nutritional status of their children .
Atiur Rahman has noted:
With the economic upliftment there has been improvement in the status and position of rural women. In order to sustain this newly found strength of the women, GB organizes special programmes to improve their knowledge about different aspects of every day life. Special workshops for women are being organized by GB in order to up date their knowledge and actions on aspects like dowry, sanitation, family planning, clean drinking water, nutritional status, primary health care, children's education etc. These workshops have been making significant contributions toward raising awareness about different issues, in altering attitudes and behavior of rural poor women. 
Recently, the bank has added a new dimension to the project with respect to maternal health care, with particular attention to the nutrition of women and children.
Although the process has begun, it still has a long way to go. To affect the nutrition and health status of the women bank members directly, we are looking for new ideas.
Jon E. Rohde, Mary Roodkowsky, Julian Lambert, and Rolf C. Carriere
The Growth Monitoring Task Force, a coalition of government, NGO, bilateral, and multilateral agencies interested in growth monitoring in India, has developed a new growth card that differs significantly in several respects from growth cards currently in use. The card is about to undergo a major field test to evaluate the effectiveness of its innovative elements as well as to observe actual (compared to intended) ways in which it is used.
The task force felt that a new card was needed because those currently in use in India can too easily be used as only a simple weight record for children. (Many cards used are bound into a book held by the health worker and simply provide space for recording a child's weight on a graph marked with lines indicating nutritional status.)
The task force set out to create a card that would help both mothers and workers realize that growth promotion is a process that can help to improve a young child's health. The new card is designed to promote thoughtful discussion between the health worker and the mother about the pattern of the child's growth and to help them link the direction of the growth with various health-promoting behaviours. It is also designed to reduce any feelings of intimidation the mother might feel on seeing it. To this end, it is colourful and uses numerous illustrations which will assist illiterate and semi-literate mothers in interpreting and understanding it. The card is filled out by the worker in the mother's presence and is given to the mother for retention following interpretation and discussion about the child's health.
The design of the growth record (fig. 1) follows principles previously described . The vertical dimension is accentuated with 100-gram graduations demarcated by small circles, or "bubbles," those marking 500- and 1,000-gram divisions being slightly larger. A series of narrow coloured bands show growth channels, similar to percentile lines on standardized paediatric charts , lending the popular name of "rainbow chart" to the card. The age range is limited to 36 months in order to direct attention to growth at the earliest ages. Four different prototypes, using lines versus bubbles and plain colour versus the rainbow pattern, and a standard WHO-type chart were field-tested with illiterate rural women as well as peripheral workers. The bubbles were more easily and accurately plotted than lines, and the rainbow channels facilitated identification of subtle faltering in growth by workers and mothers alike . Any plotted line which does not maintain a rate of growth sufficient to remain in the same coloured channel is perceived as "falling" - even if it is actually rising but not by large enough increments. This optical illusion is illustrated in the example of the curve in the lower right corner of the card.
The reverse side of the card (fig. 2) is a comprehensive health record and health-education tool for the mother and the health worker. It includes extensive information on basic health interventions and has a section devoted to illustrations of important health practices. Ideally, a worker and mother would see both sides of the card as part of the child's health story and would flip the card over from the weight chart to the health record and health-education material in the course of the interaction.
One panel of this reverse side, with a picture of a mother holding and admiring her child, forms a front cover for the card when it is folded into fourths pamphlet-fashion. (There are currently two versions, one of a veiled mother for use in North India, and one with an uncovered head for the South). It is noteworthy that the picture of the mother holding the baby pre-tested more favourably than one of a mother breast-feeding her baby. The title of the card is "Mother and Child Card," and below the picture is space for recording biodata.
A health-education panel illustrating important behaviours is being tested in two versions. One (not shown here) has five pictures - illustrating breast feeding, oral rehydration, supplementary feeding, acute respiratory infection, and family planning - with a line of text explaining each picture, followed by a series of boxes. Every time the mother and worker interact, they would discuss one of the issues illustrated, and a box would be marked with the date when the discussion is held. A larger box would be checked when, after a series of five discussions on that topic, the mother can described the recommended health behaviour in turn to the worker. By being directive, this version provides an incentive to the worker and mother to complete a series of discussions and may result in a fuller understanding of the key health behaviours.
The other version of this panel has ten pictures - including, in addition to those listed above, hand-washing, a protected water source, the sanitary disposal of faeces, seeking help for rashes and skin problems, and covering food to protect against flies. The pictures, without any directive text, would function as a "portable flipchart" which a trained worker could use to initiate discussion with a mother. Mothers would also be encouraged to use the pictures to help them describe any health-related problems they may have.
The other half of the reverse side of the card is devoted to two panels arranged horizontally: an antenatal health record for the mother and an immunization record for the child.
The mother's health record has a dual purpose. It serves as a record of the interventions provided to the mother during her pregnancy, including antenatal visits, provision of iron and folic acid tablets, and administration of tetanus toxoid, as well as a score representing the number of pregnancy risk factors identified. An innovative feature is a maternal weight record, which is similar to the child's weight card except that maternal weight at first contact is recorded directly on the vertical axis with a 10-kilogram pregnancy gain. The other purpose is educational and motivational: by the inclusion of the maternal record on what will eventually be the child's health and weight card, the mother can learn that her own health behaviour during the pregnancy is directly linked to that of the coming child. This obviously means that the card is to be issued to the mother when her pregnancy is confirmed.
The immunization card differs from cards currently in circulation by its use of symbols rather than text (syringes for BCG, DPT, and measles vaccines, droppers for oral poliomyelitis vaccine and vitamin A). The year of life in which the child should receive the vaccine is indicated by the drawings of girls identified during pre-testing as being of the appropriate ages. Illiterate frontline workers have been able to match the boxes with the appropriate vaccines. A record is kept by writing the date on which an immunization is administered in the box associated with that symbol, allowing the health workers to check when the next vaccination is due.
It is hoped that combining the weight chart with the mother's ante-natal records and the child's immunization history will enable the mother to understand that both she and her child need a package of health services for optimum growth and development.
All the illustrations for the card have been pretested. Now a field test is being set up, with the organizations who are using the card on an experimental basis agreeing to collect data. The card will be used by these organizations in widely divergent areas to give some indication of what aspects work best in particular areas. Among the issues being considered during the field test are the relative usefulness of the two variations of the health-education panel and possible correlations with the educational level of the health worker and of the mother, use of the mother's health panel and especially of the maternal-weight-gain chart, and retention of the card.
The results of the tests will be incorporated in later versions of the card, making it part of a new generation of tools for growth monitoring and promotion in which weighing leads directly to greater and more substantive discussion between the mother and the worker to analyse the child's overall progress.
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