Presented by Dr. Aulo Gelli, International Food Policy Research Institute (IFPRI) at IFPRI Malawi workshop and policy dialogue, 'Nutrition-sensitive social protection and integrated programs in Malawi: Evidence from a longitudinal study in Zomba spanning the 2016-17 food crises,' in Lilongwe, Malawi, May 17, 2018.

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Cost analysis and sustainability study one year after implementation ended.
Using a community-based early childhood development center
as a platform to promote production and consumption diversity
Aulo Gelli (IFPRI), Amy Margolies (JHU), Marco Santacroce (IFPRI), Aisha Twalibu (Save the Children), Natalie Roschnik (Save
the Children), Helen Moestue (Save the Children), Mangani Katundu (Chancellor College), Roshan Daryanani and others…
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citeThe NEEP-IE trial and sustainability study
• Rigorous impact evaluation of an ECD center-based behavior change,
and parent and community trainings and engagement intervention,
aimed at improving the diets, nutrition and development of young
children

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citeBackground: NEEP-IE trial findings
• RCT found increases in nutrient intakes in preschoolers and in dietary
diversity in preschoolers and their younger siblings
- No impacts on anthropometric indicators in preschoolers, though large
protective effect on HAZ and prevalence of stunting was found in their
younger siblings
• Plausibility of impact of BCC on nutrition supported by effects on
caregiver’s knowledge of IYCF practices and on strategies to improve
diets
- In context of high levels of food insecurity, effects along impact pathways
may have combined to provide a protective environment at critical age when
young children are introduced to complementary foods

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citeStudy aim and objectives
• Aimed at assessing full costs of the intervention and if impacts
persisted one year after implementation ended
• Costs:
- What are the financial and economic costs of the intervention including all
programme and community level contributions?
- What is the cost-efficiency of implementing the integrated agriculture and
nutrition intervention through a preschool meal platform?
• Sustainability
- What are the effects of the intervention 1 year after the implementation
ended?

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citeData and methods: Cost analysis
• Map implementation activities to a standardised supply chain
framework for school feeding programs
• Qualitative and quantitative data were collected retrospectively using
semi-structured questionnaires following an ingredients approach,
including both financial and opportunity costs
• Costs were standardized to a 200-feeding-day year and 700 kcal daily
• Combined cost and meal service data to estimate cost-efficiency
• Sensitivity analysis included varying intensity of programme
components

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citeData and methods: Sustainability study
• Longitudinal study, 4 survey rounds
1. Baseline October 2015
2. Midline March 2016
3. Endline October 2016
4. Sustainability survey October 2017
• Estimate treatment effects using single difference ANCOVA (round 4)
adjusting for baseline levels
• Mixed effects models with random effects at cluster level

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citeResults: Costs

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citeIntegrated farm to preschool model

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citeCost analysis
• Cost per child per year:
- Financial cost of the programme US$63
- Full economic cost of US$ 101
- Standardized (meal service) economic costs US$ 72
• Main cost drivers included operational costs (34%
of total costs), food costs (29% of total) and staff
support costs (36% of total)
• Community contributions accounted for 38% of total costs
• Sensitivity analysis scenarios suggested that economic costs range
from a maximum of US$ 113 per child to a minimum of US$ 14
per beneficiary per year

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Model
St. Cost
per child
(US$)
Cost per
100
kcals
Cost per
mg of
iron
NEEP-IE Malawi “farm to preschool” model 72 10 6
Operational benchmark from centralised model* 50 14 11
Bangladesh cluster kitchen model 110 16 31
Cost-efficiency of meal delivery service
(*adapted from Bundy et al., 2009)

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citeResults: Sustainability

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Summary of results 1 year after implementation
ended
• Some evidence of sustained effects on agricultural production system
• Higher scores for positive parenting and stimulation activities in
treatment group compared to control
• But
- No sustained effects on caregiver knowledge of complementary feeding
practices and food groups
- No effects on CBCC being open, meal provision, enrolment or attendance (for
those children still not in primary)
- No effect on dietary intake of preschoolers or younger siblings

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citeAnthropometry and child development
• Effects on HAZ (+0.13 SDs) and BAZ (-0.11 SDs) of preschoolers, but
no effects on younger siblings
• Younger siblings had substantively higher child development scores
(aggregate MDAT score, and in 3 out of 4 domains) in NEEP group
compared to control group
• No significant differences between groups in math and literacy scores
in preschoolers who were older than 60mo

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citeDiscussion: Costs
• Integrated farm to pre-school model incorporates a range of innovations
- Preschool as a community hub for behavior change
- Meal provision model relies entirely on voluntary contributions from parents and
other community members, no transfers from external agencies were involved
• Evidence suggests that integrated farm to preschool model is cost-
efficient when compared to cross-country benchmarks
• Understanding cost-effectiveness remains an important gap

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citeDiscussion: Sustainability
• Despite being highly effective during implementation period,
evidence from this analysis suggests that most of the effects
were not sustained 1 year after implementation ended
• Importantly, some benefits from the intervention persisted 1
year after the implementation ended, including effects on
- Growth and child development in the different age groups
- Household agriculture production and crop-mix

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citePolicy implications
• Community owned pre-schools can provide an effective platform to
scale-up nutrition interventions, influencing decisions that can have
important benefits for household members at different stages of
lifecycle even 1 year after implementation ended
• Cost and cost-efficiency of intervention compare favourably with
cross-country benchmarks
• Recurring implementation likely required to maximise benefits
- Financing heavily subsidised by communities receiving the program,
highlighting potential opportunity for scale-up as part of Government ECD
policy
• Synergies between child development and nutrition

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citeThank you very much!
• Acknowledgements
- Research by the International Food Policy Research Institute (IFPRI), Save the
Children, Chancellor College at the U. of Malawi and Wadonda Consult Ltd
- Programs implemented by Save the Children with local partner NGOs
- Research funded by NEEP, IMMANA, Save the Children Sponsorship, USAID,
Gender, Agriculture and Assets Project (GAAP), CGIAR Research Program on
Agriculture for Nutrition and Health (A4NH) led by IFPRI
- Program and research participants!

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citeAttrition
• Baseline survey included 1,191 households and year 2 survey
included 1,092 households, leading to a 8% attrition rate,
however:
- Attrition rate not significantly different across treatment groups
- Probability of attrition not correlated with treatment assignment
- No statistically significant differences in child level dietary
outcomes between attrited and non-attrited children