Suchana: Ending the Cycle of Undernutrition in Bangladesh

Breaking the Cycle of Undernutrition in Bangladesh

Suchana — meaning “beginning” in Bengali — was a large-scale, multi-sector nutrition programme that worked to break the intergenerational cycle of undernutrition in north-east Bangladesh. Implemented from July 2015 to December 2023, with active cohort delivery running from 2017 to 2022 across four overlapping phases, the programme worked in Sylhet and Moulvibazar — two districts in a region with some of the worst nutrition indicators in Bangladesh. During this period the programme supported 235,500 poor and very poor households, women and adolescents across 157 unions (local administrative areas below the sub-district level) in 20 upazilas (sub-districts).

Suchana was built on a straightforward but often overlooked insight: that undernutrition cannot be solved by addressing food insecurity alone. Poverty, gender inequality, weak health services, poor sanitation, limited women’s agency, and repeated climate shocks all combine to make good nutrition difficult to achieve and even harder to sustain. The programme’s response was correspondingly integrated — combining actions that directly addressed malnutrition (nutrition-specific interventions) with wider approaches to tackle its underlying causes (nutrition-sensitive interventions) at household level with sustained efforts to strengthen the government systems, services, and market structures that families depend on long after a programme ends.

Why a Multi-Sector Approach?

When Suchana was designed, Sylhet and Moulvibazar had some of the most severe nutrition challenges anywhere in Bangladesh — and significant gaps compared to national averages across almost every relevant indicator:

Stunting affected nearly 50% of children under five in the region, compared to 36% nationally. Under-five mortality stood at 67 per 1,000 live births against a national rate of 46. Immunisation coverage was just 61%, compared to 84% nationally. Antenatal care coverage was lower than the national average, and the region had the highest rates of undernutrition among women and adolescent girls anywhere in the country. Levels of gender inequality were high, and women’s decision-making power over their own health and nutrition was severely constrained.

Geographically, the region adds another layer of complexity: high hills and hillocks along the border give way to vast low-lying floodplains — locally called haors — that are among the most flood-prone areas in Bangladesh. Recurrent flooding in 2017, 2019 and 2022, combined with the COVID-19 pandemic from 2020 onwards, created a consistently difficult operating environment throughout the programme period.

That is why Suchana combined actions that directly addressed undernutrition with wider approaches to tackle its underlying causes. It worked to improve access to essential health and nutrition services, strengthen access to quality inputs, climate-smart technologies and skills for homestead food production and resilient income-generating activities, and empower women and girls to make better choices affecting food, health and care at home. At the same time, it aligned closely with government priorities and systems so that lessons and good practice could travel beyond the programme itself.

Building Better Diets, Livelihoods and Systems

Suchana used a phased “graduation” model, working with each cohort of households for 36 months across four stages: targeting and registration, orientation and household classification, delivery of core interventions, and progressive transition to independence and graduation. At household and system level, the programme delivered across three interconnected areas.

Better food and livelihoods. Suchana supported homestead food production — vegetable gardening, poultry, aquaculture — alongside income-generating activities including both on-farm and off-farm options. Asset transfers reached the poorest households, and climate-smart production techniques were integrated throughout to help families maintain production in the face of floods and other shocks. Market linkages helped households move from subsistence toward small-scale commercial activity.

Better care and feeding practices. Through intensive social and behaviour change communication, practical demonstrations, group learning sessions and individual counselling, Suchana worked to improve infant and young child feeding, maternal nutrition and care during pregnancy, antenatal and postnatal health-seeking, and hygiene practices including handwashing. The programme worked across the full first 1,000 days while also engaging adolescent girls as future mothers. Key tools included accessible materials such as “baby food rules” and simple prompts like a bowl as a reminder for correct portion size and feeding frequency — practical, low-cost approaches that proved highly effective.

Better systems and governance. Beyond the household, Suchana worked to strengthen nutrition governance at sub-national and national levels. It built the capacity of frontline workers, strengthened coordination across eight government line ministries — including Health, Agriculture, Fisheries, Social Welfare, Women and Child Affairs, and Disaster Management — and advocated continuously for nutrition to be embedded in annual planning and budget processes. Working through existing government service delivery systems, rather than creating parallel structures, was a deliberate design choice intended to support sustainability after the programme ended.

Over time, the programme increasingly demonstrated that sustained nutrition gains depend as much on systems and relationships as on the household package itself. Hence, it continued supporting nutrition governance, built the capacity of frontline actors, encouraged stronger coordination across sectors, and engaged government, private-sector and local institutions to improve service delivery and replication of good practice.

Final Evaluation Findings 

The final evaluation was conducted in 2023 by the Institute of Development Studies (IDS), Sussex, with support from the Development Research Initiative (dRi), Dhaka. It used a mixed-methods approach combining household survey data, anthropometric measurements, qualitative research and stakeholder consultations. Suchana was rolled out in four overlapping phases, with Phase 4 joining last. This meant Phase 4 could serve as the comparison group, allowing the evaluation to compare households already receiving support with those scheduled to receive it later, without leaving any group permanently excluded from the programme.

Food security and diet quality

Suchana sustainably improved household food security and dietary diversity. The proportion of food-secure households rose from 14% at baseline to around 30–31% by the final evaluation. Conversely, the proportion of severely food-insecure households fell from just under 30% to 7%. Household involvement in homestead food production was strongly and statistically significantly associated with better food security outcomes across all measures. Egg consumption doubled from 20% to 41% of households, and the proportion consuming dark leafy green and vitamin A-rich vegetables rose from around 40% to 62%.

Women’s dietary diversity also improved substantially: the proportion of women meeting minimum dietary diversity (consuming at least five out of ten food groups) rose from around 26% to 45% across phases. The evaluation found some evidence that dietary diversity gains were partially offset after the active programme phase ended due to external shocks — particularly COVID-19, food price rises, and flooding — underscoring the continued pressure poor households face in sustaining nutrition improvements without ongoing support.

Infant and young child feeding

Exclusive breastfeeding among children under six months rose from around 60% to nearly 90% by the final evaluation, with no significant differences between boys and girls or across programme phases. The proportion of children 6–23 months receiving a minimum acceptable diet (a combined measure of dietary diversity and meal frequency) rose from 9% at baseline to almost 30% by the final evaluation. The proportion of children consuming at least four food groups increased from 12.5% to 35%. These improvements were statistically significant and consistent across cohorts.

The evaluation highlights that Suchana’s SBCC approach — grounded in formative research, practical and accessible messaging, and hands-on demonstrations — was a key driver of these sustained feeding practice changes.

Maternal care and health-seeking

The proportion of women attending at least four antenatal care visits rose from 15% at baseline to 72% at the final evaluation — a transformative shift. Women receiving vitamin A capsules after delivery increased from 16% to 63%. The proportion taking iron and folic acid supplements during pregnancy more than doubled, from 41% to 85%. The proportion of women eating more during pregnancy increased from 26.5% to 47%. These improvements reflect both increased demand for services and improved supply through workforce training and stronger community clinic linkages.

Hygiene

The proportion of mothers washing hands at all six critical times rose from 16% at baseline to just under 60% at the final evaluation. Handwashing with soap at a minimum of three critical times rose from around 62% to nearly 89% — changes that are statistically significant and large across both programme phases.

Livelihoods and income

Involvement in income-generating activities remained high even after the active programme phase ended. The proportion of households making a profit from IGA and homestead food production activities reached 63–74% across phases by the final evaluation, compared to 20% at baseline. Homestead gardening was especially sustained, though the variety of vegetables grown decreased over time. Climate-smart horticulture techniques, up from 1% at baseline to 63% by final evaluation, proved practical and resilient to maintain.

Women’s and adolescent girls’ empowerment

Suchana produced statistically significant improvements in women’s decision-making power over food purchases (+25 percentage points), food preparation (+4.5pp), and their own health (+30pp). For adolescent girls, 96% were aware of the legal minimum age of marriage by the final evaluation (up from 90% at baseline), and the proportion unable to name a single consequence of early pregnancy fell from 38% to 3.5%. Qualitative evidence suggests adolescent girls felt more empowered to voice their opinions within families and communities. The evaluation notes, however, that broader empowerment gains — particularly outside the domestic domain — were more limited and less sustained.

Children’s nutritional status

Stunting among children 12–23 months fell sharply, from around 53% at baseline in 2017 to 22% and 19% respectively in the two main programme phases by the final evaluation — a rate of decline of approximately 10 percentage points per year, well above the programme’s own target of 6pp. The proportion of underweight children was halved, from 37% to 18%, across both cohorts. The evaluation was explicit, however, that this drop in stunting cannot be statistically attributed directly to Suchana. The decline was observed similarly in both programme and comparison areas, reflecting broader national trends — national stunting fell from 31% in 2018 to 24% in 2022 (BDHS 2022). The evaluation is clear that this does not diminish Suchana’s story: it shows a programme that made a strong and genuine contribution to the conditions that drive stunting, while being honest about the limits of attribution in a complex and rapidly changing context.

Resilience

Suchana strengthened household resilience to climate and economic shocks in meaningful and measurable ways. Nearly two-thirds of households adopted at least one climate-smart horticulture practice by programme end. Disaster preparedness awareness improved. Access to social protection schemes increased. And critically, the ability to produce food at home provided a buffer during the COVID-19 pandemic and periods of market disruption — households that had maintained homestead food production were better protected against dietary collapse during crises.

Nutrition governance

The evaluation found meaningful improvements in nutrition governance at both sub-national and national levels. Suchana integrated nutrition considerations into the planning and budgets of multiple government departments including Fisheries, Agriculture Extension, and Disaster Management. The programme’s sustained advocacy, technical support, and use of existing government systems helped build government ownership that outlasted the programme itself.

What the Evidence Tells Us

Suchana’s legacy is not limited to the households it directly served. The final evaluation identifies several areas of sustained impact beyond the programme period. Homestead food production, climate-smart practices, and income-generating activities remained widespread after the active phase ended. Health-seeking behaviours — particularly ANC attendance and facility-based care — showed durable shifts. Nutrition governance gains were embedded in government systems and budget processes at both local and national levels.

At the same time, the evaluation is candid about limits to sustainability. Some dietary diversity gains were partially reversed after the programme ended, particularly for women in earlier cohorts, in the context of COVID-19, food price shocks, and flooding. This points to a structural constraint that a programme alone cannot fully resolve: when external shocks hit, poor households remain vulnerable, and the nutrition gains they have achieved are not always protected. Suchana’s evidence reinforces the case for sustained social protection and market stabilisation measures alongside programmatic nutrition investment.

The final evaluation concludes that Suchana is a rare success story for large-scale multi-sector nutrition programming. Several lessons stand out for future programme designers, funders, and policymakers.

A multi-sector approach genuinely works — but takes time. Beneficiaries consistently valued the integrated support, describing it as more comprehensive than previous single-purpose interventions. But the operational complexity is real: Suchana was labour-intensive, resource-intensive, and required sustained management of a large and diverse consortium. Replication requires realistic assessment of those demands.

Intensive behaviour change communication, grounded in formative research and delivered practically, produced striking and sustained changes in feeding knowledge and practices. These findings should be widely shared and replicated.

Working through government systems, rather than around them, supported alignment and ownership — but does not automatically guarantee sustainability where those systems are weak. Strengthening service delivery platforms alongside programme delivery is essential.

Longer active implementation periods are needed for complex programmes targeting stunting. The evaluation recommends that future programmes use indicators that are achievable in shorter timeframes as proxies for progress, rather than relying solely on stunting as the primary measure of success.

Gender programming needs to go beyond nutrition-focused women’s empowerment and engage more broadly with household decision-making dynamics and structural gender inequality if sustained change across all domains of women’s lives is the goal.

Overall, the final evaluation presents Suchana as a programme that improved many of the building blocks of better nutrition: food security, diet quality, care practices, service uptake, women’s agency, livelihoods, resilience and governance. Even without claiming direct attribution for the reduction in stunting, the findings show that Suchana made a substantial contribution to tackling the conditions that drive undernutrition — and to strengthening the case for a coordinated multi-sector response in Bangladesh.

A Multisectoral Collaboration

Suchana was led by Save the Children Bangladesh and implemented by a consortium of national and international partners including Centre for Natural Resource Studies (CNRS), Friends in Village Development Bangladesh (FIVDB), Helen Keller International (HKI), International Development Enterprises (iDE), Rangpur Dinajpur Rural Services (RDRS), WorldFish, and icddr,b as research partner. The programme was funded by the UK’s Foreign, Commonwealth & Development Office (FCDO) and the European Union (EU), and contributed to wider government priorities on nutrition and food and nutrition security in Bangladesh.

Have Questions?

For more information about the Suchana programme and its evidence base, please contact Md Masud Rana, Senior Nutrition Adviser at Save the Children UK, at M.Rana@savethechildren.org.uk, or explore the full collection of reports, briefs, case studies, scientific publications and videos below.