A solid case for nutrition-sensitive approaches
Recent evidence from Malawi suggests that nutrition-sensitive interventions can and do work, and also that agriculture interventions can increase the production and consumption of nutritious foods. Evidence from other countries confirms the clear benefit of including strong behavior change communication (BCC), and also of integrating agricultural, child development, health, and nutrition interventions. However, several questions remain. Will these effects last over time? When—and how—should we bundle interventions, and when shouldn’t we?
In addition, tackling undernutrition requires us to move beyond a production-only mindset because having enough food does not necessarily translate into having adequate nutrition. Moreover, scaling-up of nutrition specific interventions will not be enough to meet global targets and contributions from other sectors are required. Agriculture and social protection programs have strong potential due to the manifold pathways through which they can influence nutrition. However, despite recent progress in strengthening the evidence-base on these programs, there are still some critical gaps.
A workshop and policy dialogue hosted by IFPRI Malawi and Save the Children on May 17th tackled these questions and gaps, all within the Malawian context, in order to help us better understand how to make evidence relevant to investment and policy making decisions. At the event, new evidence was presented on what has worked in terms of nutrition-sensitive approaches to improving food security and nutrition in Malawi. The group included participants from government, academia, and civil society, all gathered together with several aims: to review and validate new evidence on nutrition-sensitive agriculture, nutrition, and social protection programs in Malawi; to highlight evidence-based suggestions for stronger multi-sectoral action towards improved food security and nutrition; and lastly, to discuss implications for strengthening multi-sectoral policy engagement and uptake of research findings.
In particular, the group examined new findings from the Nutrition Embedded Evaluation Program Impact Evaluation (NEEP-IE) on the effectiveness of implementing an integrated agriculture and nutrition intervention through community-based childcare centers (CBCCs) in Zomba district, as well as findings from an impact evaluation of the seasonal food assistance provided to food insecure households in Zomba.
Impact results after one year
Dr. Mangani Katundu, Associate Professor at Chancellor College, shared the results of the one-year cluster randomized trial of the NEEP package—which consisted mostly of training (on food preparation, optimal feeding practices, seasonal meal planning and production) as well as some inputs (seeds or vines, access to loans). The researchers found a range of positive results in those who received the NEEP treatment arm, namely on the production of nutritious foods at the household level, on caregiver knowledge of food groups, on meal provision in the NEEP CBCCs, as compared to non-NEEP centers, and not just on production, but also consumption of nutritious foods, such as nuts, pulses, fruits, vegetables, and eggs. Further, the study found important benefits to younger siblings at home, whose diets also improved as did their linear growth. Given the positive effects across diets, nutrition, and agriculture domains, the study confirmed that the preschool meal platform works.
The broader implications include a potential role for NEEP-type interventions within broader social protection programs in Malawi. While NEEP relied heavily on community involvement, there is potential to scale up this kind of program within the government of Malawi’s broader child development and integrated agriculture portfolio.
Cost and sustainability results
While the initial impact results are exciting, how much of this impact lasts over time? Researchers went back one year after NEEP ended to conduct a cost analysis and to survey households to see whether any benefits sustained.
On the costing side, the researchers found the full economic cost of the program to be US$101 per child per year, although around 40 percent of these costs were community’s voluntary contribution in labor and in kind to the NEEP. If we include all household members that benefitted from the intervention, the economic cost of the program is just US$14,as compared to FISP’s US$50-60 per household per year. A sensitivity analysis looked at how varying degrees of intensity can change the cost of the program. For example, are there components that can be increased (such as BCC) or decreased (such as seed or input provision) to reduce overall costs? In the end, NEEP was found to be fairly efficient relative to other programs. Important questions remain as to how the intensity of implementation affects the effectiveness of the intervention.
In terms of sustainability, the study found that one year after the intervention, some of the household agriculture production results were sustained. There were also higher scores for positive parenting and stimulation, growth (as measured by height-for-age-and BMI scores), and child development scores, in the treatment group (including beneficiary siblings). On the other hand, while some benefits from the intervention persisted a year later, some impacts did not—especially those related to diets, which was the program’s primary goal. This tells us that using CBCCs as a hub for behavior change related to agriculture and nutrition practices can work, in order to see lasting effects recurring implementation is still needed. In fact, the Ministry of Gender, Children, Disability and Social Welfare has committed to scaling-up a modified version of the NEEP-IE agriculture and nutrition intervention over the next 5 years across Malawi.
Food assistance assessment results
This component of the assessment looked at the main effects of the 2016/17 food transfer. The researchers created two groups: those who did and did not receive food transfers from the Malawi – Vulnerability Assessment Committee (MVAC), and then examined ‘areas of common support’ where the groups are most comparable, looking at indicators such as daily adult equivalent intake by nutrient and food expenditures. They found that people are using the MVAC transfers to consume more food, resulting in increased caloric and nutrient intakes. There were positive effects around agricultural production (both in terms of diversity of food groups, and also number of crops being produced at farm level). However, MVAC targeting criteria were not good predictors of program participation: about 19 percent of non-poor households received MVAC transfers (inclusion errors), while 81 percent of poor households did not receive it (exclusion errors). A separate qualitative study on the sharing of transfers further examined why this occurs, namely that village heads and local behavioral norms play a key role in the widespread practice ofsharing food transfers between households. MVAC beneficiaries consequently found the quantity of food transfers received to be insufficient, eparticularly for large households (and especially after sharing had taken place).
Implications for the Food Security and Nutrition Strategy
The workshop culminated with a panel discussion moderated by Stacia Nordin (Nutrition Education Specialist on Strengthening Agricultural & Nutrition Extension), featuring diverse experts representing both government and development partners, including Virginia Kachigunda (Deputy Director, Department of School Health, Nutrition, HIV and AIDS), McKnight Kalanda (Director of Child Affairs, Department of Child Development), Caoimhe de Barra (Country Director, Concern Worldwide), Alexander Kalimbira (Associate Professor, Department of Human Nutrition & Health, LUANAR), and Maureen Maguza-Tembo (Deputy Director of Nutrition, Department of Agricultural Extension).
Among the topics raised by the panel were issues related to behavior change, coordination and collaboration, cultural norms, the roles of government versus the private sector, and scalability. Others raised include documenting processes, leveraging existing interventions versus starting new ones, and remaining research gaps around adolescents, especially women.
In response to a question on holding policymakers accountable for interpreting and utilizing research and evidence to build strong policies, panelists suggested that implementers and researchers should play a key role. Policy makers should be supported in accessing and understanding nutrition research, to fully comprehend the data and to understand from experience what does and does not work. The private sector should also play a key role in owning and using available information to the fullest.
A lively discussion on scalability confirmed the true potential of CBCCs as platforms for change. There are close to 12,000 centers in Malawi, with over 35,000 trained caregivers, which translates to 1.6 million eligible children potentially reached. This is an incredible opportunity for Malawi and the government and development partners have already taken steps to scale up their reach through the CBCC platform. The World Bank is funding a new initiative that will allow Government to reach CBCCs across 14 districts. USAID, via Feed the Future, is already utilizing CBCCs in its nutrition interventions.
In response to why the CBCC platform has worked so well, the panel confirmed that a lot of work went into the program, particularly sensitizing the community about why they should participate in those interventions. A new government policy is seeking to address the challenge of incentivizing voluntary community engagement- a critical contributor to NEEP’s success. The new policy is examining an incentive package for caregivers, to encourage them to stay in communities and be more productive.
Some of the more immediate opportunities for the group to consider includes linking the CBCC platform approach to existing to Children’s Corner centers throughout the country. Also, the program’s success with. diversification of crops can be a jumping off point to also diversify diets. The recent transition to a ‘lifecycle approach’ that extends beyond mothers and the ‘first 1,000 days of life’ also presents an opportunity to have an impact on children beyond two years of age into adulthood, to ensure we are not leaving anyone behind.
Further resources
- Workshop agenda
- NEEP published methodology and journal study, Lean-Season Food Transfers Affect Children's Diets and Household Food Security: Evidence from a Quasi-Experiment in Malawi, Gelli et al., 2017
- NEEP Project Note, Improving Child Nutrition and Development Through Preschools in Malawi, 2018
- IFPRI Malawi blog from last year's policy discussion on this work
- IFPRI Malawi blog about qualitative study on sharing of transfers in Malawi
- IFPRI Policy Note, Traditional leadership and social support in Southern Malawi, Gelli et al., 2017
- Journal study, Effects of lean-season food transfers on children’s diets and household food security, 2017
Select workshop presentations
The impact of lean season food transfers on food security, diets and nutrition status - presented by Dr. Aulo Gelli, IFPRI
Using a community-based early childhood development center as a platform to promote production and consumption diversity: Cost analysis and sustainability study - presented by Dr. Aulo Gelli, IFPRI
Year 1 Impact Results: Pre-school meals as a platform for behavior change at community level - presented by Dr. Mangani Katundu, Chancellor College
