Scaling Up Impact on Nutrition: Four Case Studies

Transcription

1 Scaling Up Impact on Nutrition: Four Case Studies Supplementary material for the paper: Gillespie, S, Menon, P., Kennedy, A (2015) Scaling up impact on nutrition: what will it take? Advances in Nutrition 6: Case Study 1: Scaling up a high quality IYCF counseling intervention in Bangladesh: Alive & Thrive(1,2) The levels of stunting, underweight, wasting, and childhood anemia are very high in Bangladesh, as are levels of maternal chronic energy deficiency and maternal and child anemia. A combination of poor maternal nutrition and postnatal factors cause child undernutrition, which in turn can have far-reaching consequences for national and global development as well as individual health. Studies in Bangladesh show that infant and young child feeding (IYCF) practices, a critical determinant of child nutrition, are poor. Interventions to address them at a large scale are urgently needed, including behavior-change counseling for early and exclusive breastfeeding, age-appropriate complementary feeding and micronutrient supplementation, provision of micronutrient supplements or fortified complementary foods, hygiene interventions, and nutritional management of severe-acute undernutrition. Goal/vision: Alive & Thrive (A&T) seeks to develop scaled-up models for preventing child undernutrition by improving IYCF practices. The positioning of Alive & Thrive as a learning grant programme to generate proof of concept that implementation and impact could occur at scale within a limited time frame (5-6 years) acted as an incentive, as it required a high level of accountability for results at scale. Drivers (and barriers): The drivers of scale for A&T in Bangladesh included ideas and models from former successes in breastfeeding and complementary feeding programmes and endorsement of proven, high-impact IYCF programmes. Visionary leaders at BRAC, A&T, and the Gates Foundation with the encouragement of the government s nutrition leadership drove the scaling-up process forward. In the aftermath of the dismantling of Bangladesh s National Nutrition Programme, in part due to its limited scale, the search for a better option worked as an external catalyst. Scaling up strategy: A&T s interventions focus on achieving behavior change through existing servicedelivery platforms, especially the health network of BRAC, the largest nongovernmental organization in Bangladesh (and the world), but with added personnel to address long-standing issues of skilled counseling. The strategy, therefore, included an explicit testing and expansion model which first tested a pilot model of integrating IYCF counseling into BRAC s existing platform in four sub-districts (each subdistrict would be an implementation unit in the scaled up model too) and refined this over several months. The pilot was then scaled up to 50 upazilas across the country in two phases over about a year. This was monitored carefully by BRAC monitoring systems and A&T s technical experts, to ensure quality and coverage. Data and evidence-gathering was a key part of the strategy and the initial documented successes of the model, along with frequent in-country dissemination and stakeholder engagement led to further investments in the model by other donors such as USAID and DFID. Processes and pathways: Since IYCF promotion and counseling was already a known effective intervention, A&T relied on expansion through replication and aimed to enhance impact of the counseling with supporting activities to address social and policy barriers to IYCF practices. To scale up counseling, IYCF was integrated into existing programmes reaching the same target age groups, but an additional skilled worker was added. This was more rapid and affordable than establishing a new infrastructure and helped ensure that other preventive and disease control interventions would be offered alongside IYCF interventions. To address social barriers, social mobilization and mass media were emphasized. For example, through social mobilization, local opinion leaders such as imams, government health workers, and village doctors were engaged through forums and meetings to highlight the importance of nutrition, particularly in IYCF. A national IYCF alliance came together to define and support a national communications plan for IYCF, which included space for mass media campaigns, policy initiatives, and partnerships with other community-based organizations.

2 Capacity: The A&T model includes three cadres of BRAC community health workers who are responsible for counseling, coaching, training, and helping mothers use good IYCF practices: volunteers assigned to households each, health workers who specialize in pre- and postnatal health services, and dedicated IYCF promoters who record services provided and filling gaps in home visits. Capacity building on technical issues related to IYCF and the programme model were done end-to-end, with all staff at all levels, and even evaluation staff, being trained in core content areas. Capacity strengthening is embedded through careful pre-intervention training, quarterly refresher trainings, and discussions during monthly meetings of BRAC local staff. Governance: A&T community-based interventions were tightly managed by a small group of managers and technical specialists at BRAC, with inputs to design and quality issues by FHI 360 and national technical experts. BRAC s management systems include extensive field visits by BRAC staff as well, and routine monitoring through two different mechanisms. Additionally, during the first phase, especially, regional managers with decentralized responsibility and authority were deployed, and performance incentives were introduced. Managers were held responsible for ensuring coverage targets. Financing: Adequate funding from the Bill & Melinda Gates Foundation removed initial financial constraints and ensured both pilot testing and scaling up of the model within BRAC s system. Further funding through other sources at BRAC provided the ability for BRAC to expand the model to other upazilas in their maternal, newborn and child health (MNCH) programme areas. Successful implementation of the model and early results from the process evaluations spurred funding from other donors (e.g., USAID) to support further expansion and continuation beyond the lifetime of the initial A&T grant. Monitoring and evaluation, learning and accountability: The entire A&T programme was built on data to inform design and implementation. First, a series of formative research studies brought together the evidence-base for the content design of the counseling. A pilot in four sub-districts of varying characteristics tested the implementation platform, and thus helped to improve the monitoring indicators, the process for identifying children and tracking home visitation, and the quality of service delivery. As the programme progressed, monitoring by BRAC and supervision visits by technical experts helped identify continued issues, including incentives for scaling up coverage of home visits, and development of methods for ensuring accountability of cash incentives, and honing of further technical aspects of the counseling. Case Study 2: Scaling up iron-folic acid supplementation in Nepal(3) Nepal has struggled with a serious anaemia problem for years, caused mainly by inadequate intake of iron and other nutrients. Maternal anaemia is the second most common cause of maternal mortality in South Asia. The National Micronutrient Survey of 1998 found that 75% of pregnant women in Nepal were anaemic. Maternal anaemia results in lower birthweight babies with a higher risk of death. Ongoing facility-based supplementation programmes were not effective, with only 23% of pregnant women consuming any iron-folic acid (IFA). Thus, in 2004 the Government of Nepal launched a new intervention, the Iron Intensification Programme (IIP). By 2011, the programme had been scaled up to 70 of Nepal s 75 districts, substantially improving coverage of IFA and other interventions, contributing to the reduction of maternal anaemia in the country. Goal/vision: The goal of the government s IIP was to reduce the prevalence of anaemia in pregnant women by providing iron-folic acid (IFA) supplements via community health workers. The efficacy of IFA supplementation is well recognized. A recent review reported that daily iron supplementation reduced the incidence of anaemia at term by 73%, and that maternal IFA supplementation for two years had been shown to reduce mortality among children between birth and seven years by 31%. A community-based platform with experience in delivering supplements to households was the primary vehicle for addressing the challenge of increasing coverage. Drivers (and barriers): The 1998 National Micronutrient Survey (using the same sampling frame and methods as DHS), which found that 75% of pregnant women were anaemic, was a catalyst to change the

3 status quo. It was used to raise awareness about the problem of maternal anaemia, and trigger action to address it. A lack of demand for IFA tablets due to appearance and taste was a previous problem that the programme was able to solve. The traditional method of dispensing tablets and wrapping them in newspaper caused the heat and humidity to spoil them. Thus, small clear plastic bottles were introduced to stop spoilage and discoloration of the IFA tablets. Scaling up strategy: Similar to A&T, IIP was built upon an existing community-based platform, making use of female community health volunteers (FCHVs). The programme was geographically scaled up (via expansion through replication) over seven years, from 2004 to 2011, to cover 70 of Nepal s 75 districts, thus achieving substantial coverage of interventions, including mothers taking IFA supplements. Capacity: The FCHVs, who deliver the interventions, proved to be successful in a previous vitamin A supplementation programme. Operations research confirmed that FCHVs could effectively deliver IFA to pregnant women and counsel them on using it as recommended. Trainings (and ongoing refresher trainings) further enhanced their motivation, knowledge, and counseling skills. Further, the use of these trusted and respected near-peers built trust between communities and the government health system. Governance: Substantial coordination (vertical coherence) among community, district, and national levels was necessary for achieving quality implementation. Implemented at the district level, the District Health Office (DHO) was responsible for the management of the programme within its area, ensuring that supplies, training and supervision were provided to the cadre of FCHVs. The Nutrition Section of the Child Health Division of the Ministry of Health had overall responsibility for the IIP, ensuring that the programme aligned with the government s priorities and strategies. Financing: The IIP was a government project, with long-term, committed support for scaling up from external donors: The Micronutrient Initiative and UNICEF. Monitoring and evaluation, learning and accountability: There was effective monitoring at the community, district, and national levels. Operations research on implementation in two pilot districts in 1999 was crucial in establishing that FCHVs could deliver IFA effectively and counsel on using it with high compliance. Further monitoring in five districts in 2004 motivated further scale up. A 2009 evaluation of the IIP compared three different groups of districts (those with more than 12 months of programme presence, those where implementation would begin in 2010, and those where there were no plans to implement in 2010) and confirmed sustained effectiveness in coverage and compliance in districts covered by the programme. Forthcoming analysis will allow the determination of the impact of the programme on anaemia prevalence. Case Study 3: Scaling up social protection in Mexico: Progresa- Oportunidades The Oportunidades (formerly named Progresa) conditional cash transfer (CCT) programme is one of the largest social protection programmes in the world. Started in 1997 to reduce poverty by integrating health, nutrition, and education, it reached 6.5 million families, or 30 percent of the country s population, by 2012.(4) Several evaluations have been conducted, demonstrating impact on consumption, malnutrition, school enrolment and achievement, and access to healthcare.(5 12) Most of the key factors to Oportunidades success (as summarized in Santiago Levy s book Progress against poverty: sustaining Mexico s Progresa-Oportunidades programme(13)) can be mapped to all of the elements in our framework for scaling up impact. The programme is novel in that it was designed to be an all-or-nothing package. Oportunidades is a homegrown, country-owned initiative created during the economic crises of mid- 1990s. A growing consensus developed at this time that the existing food subsidy programmes (including for tortillas and milk) were inadequate to protect the poor during crisis.

4 Goal/vision: The programme was designed to have measurable and sustained impact on human capital, reaching virtually all of the poorest groups in Mexico. CCTs are one way of scaling up demand for essential nutrition-relevant public services. Drivers (and barriers): The visionary leadership and involvement of Mexican President Ernesto Zedillo, and following elections, a continued push to national scale from President Vicente Fox are what primarily drove the initiative forward. Also, large scale could not have been reached without its chief architect, Santiago Levy, illustrating that a strong design and proper targeting are indispensable. Scaling up strategy: Due to political sensitivities, as well as budget and operational considerations, there was a gradual phasing out of existing subsidy programmes and a gradual expansion of Oportunidades (from 300,000 families in 1997 to 5 million by 2004).(13) The programme was built on previously existing health and educational infrastructure, capacity, and personnel. A strong emphasis was placed on targeting. Using existing infrastructure, capacity, and personnel allowed for wide geographic expansion. The programme was designed to be horizontal (in contrast with ministries vertical modi operandi) which necessitated interagency coordination. Capacity: The programme was built on previously existing health and educational infrastructure, capacity, and personnel. On financing, a mechanism was created for controlling the budget across ministries and agencies. Governance: Transparency, accountability, and credibility of the programme helped it to remain outside the realm of partisan politics. A new agency was formed, made up of representatives from various ministries, with sufficient power to coordinate participants and align intersectoral incentives, bringing horizontal coherence. It was also able to foster national-local (vertical) linkages between federal policy makers and implementers on the ground. Political and financial sustainability were key linked issues. Trade-offs were confronted openly, for example the political impulse to make additions to the programme being tempered by the need to ensure sustainable financial management.(13) Financing: As mentioned, strong senior leadership, backed by evidence, drove the expansion of the programme. Thus financial resources were secured and increased rapidly over time, while remaining a small share of GDP.(13) Monitoring and evaluation, learning and accountability: An emphasis on monitoring, evaluation and learning. The programme was first piloted in one State, and evaluated for effectiveness. This garnered support and brought to light ways to improve operations.(14) Further evaluation data have shown significant impacts on various health, nutrition, education, and poverty outcomes, all for a cost of less than 0.5 percent of GDP.(14) Data and information and the way such information is framed and communicated were viewed as important. The scope, duration and strategy for scale up who the target population were, why they were being targeted, how long it would take to reach them were emphasized in a transparent manner. Expectations were clear, and this in turn helped guide programme development through unpredictable but inevitable political and economic hurdles. Case study 4 Scaling up homestead food production in Bangladesh Bangladesh had a severe vitamin A deficiency problem in the 1980s. Evidence indicated that children from homes with gardens were less likely to suffer night blindness.(15) The comprehensive homestead food production programme launched by the NGO Helen Keller International (HKI) in Bangladesh is an example of a large-scale agriculture intervention with a nutrition component. Starting with a successful pilot with 1000 households in 1990, by 2003 the project covered more than 870,000 households.(16) These households were growing fruits and vegetables for a longer period of the year, and growing greater quantity and variety, and had increased production of animal-source foods compared to nonparticipants.(17) Goal/vision: The goal of HKI s programme was to increase dietary quality (and increase dietary intake of vitamin A) in order to combat micronutrient deficiencies, particularly vitamin A deficiency and its

5 consequences. To achieve this, HKI laid out the following objectives: increase year-round home garden horticultural production, quantities, and varieties; promote small animal husbandry; increase consumption of micronutrient-rich foods through increased household production, income, and nutrition knowledge; improve health and nutritional status of women and children; empower women.(18) Drivers (and barriers): The initiative was driven by HKI (after being catalyzed by evidence that more than a million children less than six years of age suffered from xerophthalmia) in partnership with more than 70 local NGOs and the government of Bangladesh (GoB).(18) Barriers to success included environmental factors, civil conflicts, animal diseases, as well as cultural and economic barriers such as production and consumption norms.(18) Scaling up strategy: As mentioned, HKI worked with many local NGOs and the GoB to implement the programme at large scale. The programme evolved through a repeated process of implementation, evaluation, and planning. Partners integrated homestead gardening into their existing community-based health and development programmes, expanding the programme geographically. The programme promoted local technology and modifications to local gardening practices rather than introduction of external practices. Capacity: The local NGOs involved were instrumental in funding, designing, and implementing the programme. Innovative management staff were successful at motivating programme staff. Village nurseries served as the source of crucial inputs (seeds, saplings, a water system, pest control, fencing, etc.) as well as knowledge.(18) Governance: This programme linked the agriculture sector and the health sector, which required new partnerships and information sharing. HKI maintained a high level of flexibility with partner NGOs in implementation and management to maximize programme effectiveness.(18) Financing: The programme was cost-effective since the gardening activities were integrated with ongoing activities of the NGOs. The programme proved to be financially sustainable, with the costs shared among participating households, partner organizations, and HKI; joint ownership ensured local buy in, which played a role in financial sustainability. Further, the potential for households to earn income from their efforts was a key factor.(19) Monitoring and evaluation, learning and accountability: The success of the pilot, as shown by evaluation results,(20) enabled expansion of the programme to nearly half of the country s sub-districts. Throughout, HKI invested in information systems that provide feedback and enable improvements in the interventions. Regarding impact, more rigorous impact evaluations of homestead food production are needed to determine its effectiveness in addressing micronutrient deficiencies.(18) Supplemental Literature Cited 1. Baker EJ, Sanghvi TG, Hajeebhoy N, Martin L, Lapping K. Using an evidence-based approach to design large-scale programs to improve infant and young child feeding. Food Nutr Bull. 2013;34:S Haque R, Afsana K, Sanghvi TG, Siraj S, Menon P. Alive & Thrive: Expanding community interventions to improve nutrition in Bangladesh Vision for food, agriculture and the environment. International Food Policy Research Institute; Pokharel R, Maharjan M, Mathema P, Harvey P. Success in delivering interventions to reduce maternal anemia in Nepal: A case study of the intensification of maternal and neonatal micronutrient program. Washington, D.C.: FHI 360; Oportunidades web page [Internet]. [cited 2014 Mar 26]. Available from: 5. Skoufias E. PROGRESA and Its Impacts on the Welfare of Rural Househoulds in Mexico. Washington, D.C.: International Food Policy Research Institute; Adato M. Final Report: The impact of PROGRESA on community social relationships. Washington, D.C.: International Food Policy Research Institute; 2000.

6 7. Adato M, Coady D, Ruel M. Final report: An operations evaluation of PROGRESA from the perspective of beneficiaries, promotoras, school directors, and health staff. Washington, D.C.: International Food Policy Research Institute; Adato M, de la Briere B, Mindek D, Quisumbing A. Final report: The impact of PROGRESA on women s status and intrahousehold relations. Washington, D.C.: International Food Policy Research Institute; Behrman J, Sengupta P, Todd P. Final report: The impact of PROGRESA on the achievement test scores in the first year. Washington, D.C.; Behrman J, Hoddinott J. An evaluation of the impact of PROGRESA ON pre-school child height. Washington, D.C.; Gertler P. Final report: The impact of PROGRESA on health. Washington, D.C.: International Food Policy Research Institute; Hoddinott J, Skoufias E, Washburn R. The impact of PROGRESA on consumption: A final report. Washington, D.C.: International Food Policy Research Institute; Levy S. Progress against poverty: sustaining Mexico s Progresa-Oportunidades program. Washington, D.C.: Brookings Institution Press; Skoufias E, McClafferty B. Is Progresa Working? Summary of the Results of an Evaluation by IFPRI, Food Consumption and Nutrition Division Discussion Paper. Washington, D.C.; Cohen N, Jalil MA, Rahman H, Matin MA, Sprague J, Islam J, Davison J, Leemhuis de Regt E, Mitra M. Landholding, wealth and risk of blinding malnutrition in rural Bangladeshi households. Soc Sci Med. 1985;21: Bushamuka VN, Pee S De, Talukder A, Kiess L, Panagides D, Taher A, Bloem M. Impact of a homestead gardening program on household food security and empowerment of women in Bangladesh. Food Nutr Bull. 2005;26: HKI. Homestead food production improves household food and nutrition security. Homestead Food Production Bulletin 2. New York; 2004; 18. Iannotti L, Cunningham K, Ruel M. Improving diet quality and micronutrient nutrition: Homestead food production in Bangladesh. Washington, D.C.: International Food Policy Research Institute; Asia-Pacific H. Homestead Food Production A Strategy to Combat Malnutrition & Poverty. Jakarta: Helen Keller International; HKI-Bangladesh. Home gardening in Bangladesh, evaluation report. Dhaka: Helen Keller International; 1992.