Delivering Community-Based Interventions to Reduce Food Insecurity and Malnutrition in Children Under Five
Save the Children has implemented the USAID Development Assistance Program, Jibon-O-Jibika (JoJ), meaning “Life and Livelihoods” in Bangla , since October 2004. The integrated program includes interventions to increase household food availability and access, enhance maternal and child health and nutrition, and improve community disaster preparedness. JoJ’s impact area covers 11 upazilas of three coastal districts in southern Bangladesh. The area is highly vulnerable to food insecurity and has some of the country’s highest malnutrition rates. Located in Bangladesh’s “cyclone belt” and subject to seasonal flooding, the threat of natural disasters is nearly constant, particularly in villages along the coast or major rivers. Total population about 3 million. In 2009, JoJ’s fifth year of implementation, an external consulting team (TANGO International) conducted a randomized, statistically representative end-line survey. This included a health and nutrition survey covering all 11 program upazilas and analysis of anthropometric measurements of 2,577 children aged 0-24 months. Results were compared with baseline figures (2004) to help assess impact. Findings demonstrate significant progress for core nutritional indicators and key practices. 413,642 children < 2 participated in the GMP (~88% of total est. < popn.) - 180,000 targeted GMP sessions are well planned and organized with GoB. 177,676 pregnant women participated in ANC check-ups (72,000 targeted) Coverage area?
(stunting 20% reduction over the baseline, underweight 15% reduction over the baseline)
The HFP households have benefited from the project Received project input and services Vegetable production increased Vegetable crop diversity increased A greater proportion of HH are preserving seeds Egg production increased Income increased Women gained more access to income Consumption increased— Collective marketing has been widely adopted in most of the VMF areas. The two most important benefits of collective marketing include: Small quantities of vegetables and eggs can easily be sold Women gained greater control over the proceeds The poultry vaccinators Income increased Learned new skills Ultra poor households that received a goat that survived have hope for the future Challenges: Access to a small amount of land was a key criteria for selection, which limited the participation of the ultra poor. Households that are more food insecure are more concerned about increasing access to food (quantitative aspect of food security) than diversifying the diet (qualitative aspect of food security) through vegetable and poultry. Cyclones Sidr and Aila had a negative impact on program process by destroying assets. Working with the ultra poor was not well integrated with other strategies. Many of the ultra poor households do not have a consistent income source. Although some households acquired additional assets, these assets did not help improve immediate food security. Although the project works with women beneficiaries, most of the project staff are male. Sustainability Households will likely continue home gardens on raised beds. Poultry rearing households will likely continue creep feeding, which was found to be a useful technique by many households in increasing egg production. Vaccinators who are profitably running the business will likely continue. Some of the VMFs whose livelihood depends on agriculture will likely continue vegetable, seedling and sapling production and provide technical advice to the households that may ask for help. Collective marketing will likely continue. In many villages the system has effectively been established, is viewed as convenient and provides easy access to market. MCHN: Services and Practices Community - Integrated Management of Childhood Illnesses (C-IMCI) Community Case Management (CCM) Community Health Volunteer (CHV) Growth Monitoring Program (GMP) Antenatal Check-ups (ANC) Behavior Change Communications - of 10 key family practices
Sustaining GMP, ANC, CCM services without CHV - high participation is due to CHV’s mobilization and education efforts. Limited CCM coverage - 27 out of 110 unions. Increased knowledge / awareness doesn’t always change practice. Improved partnership with MoH and links to community services (Sat.Clinic, GMP and EPI Center - same day / place) CHVs provide early treatment - ORS and Cotrim - in 27 out of 110 unions CCM reduced health care expense of households Expand the integrated approach linking all of the sectors in all target areas so the program can have a wider impact.
2002 and 2008, Save the Children, Bolivia (SCB) Integrated Food Security Initiative in seven rural municipalities of Boliva and the city of El Alto. Funded by USAID Food for Peace (FFP), 246 selected communities 5,680 households 7,690 < 5’s Integrated package addressing maternal and child health & nutrition, water & sanitation, income generation, and natural resource management. These interventions were designed to reduce high levels of malnutrition and food insecurity.
Boosting Nutrition Impact via Integrated Program Strategies
The PepsiCo Foundation Meeting March 31, 2008 Boosting Nutrition Impact via Integrated Program Strategies Presentation CORE Spring Meeting Save the Children April 30, 2010 Heather Danton and Paige Harrigan
Undernutrition Magnitude of the Problem <ul><li>Over 178 million children under age 5 stunted </li></ul><ul><li>Undernutrition is the largely preventable cause of 35% of child deaths (3.5 million annually) and 20% of maternal deaths </li></ul><ul><li>Poor fetal growth or stunting (low height for age) during pregnancy and the first 2 years of life leads to irreversible damage, with permanent reductions on physical growth, intellectual development, and economic productivity </li></ul><ul><li>Proven maternal and child nutrition interventions are available to reduce undernutrition childhood illness, and deaths in poor communities. </li></ul><ul><li>We seek the most effective and sustainable strategies to reduce undernutrition. Integration recommended. </li></ul>
Outline Boosting Nutrition: Integration <ul><li>Review select program results SC portfolio </li></ul><ul><li>Present some SC standard practices in program design </li></ul><ul><li>Identify gaps in our knowledge </li></ul><ul><li>Discussion </li></ul>
Jibon o Jibika (Life and Livelihoods Program) <ul><li>Bangladesh 2004-2009 </li></ul><ul><li>Implemented in collaboration with Helen Keller International (HKI), the NGO Forum for Water and Sanitation, the Cyclone Preparedness Programme (CPP) of the Bangladesh Red Crescent Society and 14 local NGO partners with offices in Barisal Division, Bangladesh. </li></ul><ul><li>Jibon o Jibika explicitly directed at reducing high levels of food insecurity and malnutrition and is being implemented in 13 upazilas in three districts of southwest Bangladesh. </li></ul><ul><li>Targeted 200,000 children U2 </li></ul>
AN INTEGRATED PROGRAM DESIGN Jibon-O-Jibika Decreased household food insecurity in three districts of Barisal Division SO1: Food availability and purchasing power at the household level will have increased SO2: Health and nutrition of pregnant women and children under the age of two will have improved SO3: Communities and households will be more resilient to shocks that threaten their livelihoods IR1.2: Improved marketing practices adopted and utilized IR 2.1: Increased adoption of key MCHN practices and utilization of key MCHN services IR 3.1: Improved community response and preparedness to natural disaster IR 3.2: Improved agency response to natural disaster IR 1.1: Improved household level food production practices adopted and utilized IR 2.2: Improved access to safe water and sanitation facilities
Key Program Results: Integration Disaggregated data show that reduction of prevalence in stunting, wasting and underweight is much higher in unions where all program components were implemented.
Key Program Results: Integration The median dietary diversity score improved in unions where all program components were working together.
Key Achievements JOJ <ul><ul><li>Production of vegetables in home gardens and consumption of vegetables and poultry increased. </li></ul></ul><ul><ul><li>78% of HFP HHs have successfully increasing egg production </li></ul></ul><ul><ul><li>34% of HHs have adopted improved production techniques. The end line survey shows that the adoption increases over time. </li></ul></ul><ul><ul><li>Income increased, Women gained more access to income, Consumption increased </li></ul></ul>
<ul><li>Reduced incidences of dehydration and ARI </li></ul><ul><li>ANC visits (3) increased <20% baseline to 85% </li></ul><ul><li>Exclusive breastfeeding increased from 30% BL to 64% EL </li></ul><ul><li>Complementary foods in addition to breastfeeding at >6 months increased from 50% BL to 94% EL </li></ul><ul><li>Continued feeding child when sick increased from 60% BL to 80% EL </li></ul>Key Achievements JoJ
Key Achievements Integrated FS Initiative Bolivia <ul><li>Reduction in stunting (low height for age): among children 3-35 months from 37 percent in 2002 to 23.3 percent in 2008. </li></ul><ul><li>Reduction in underweight (low weight for age): among children 3-35 months from 16.7 percent in 2002 to 9.7 percent in 2008. </li></ul><ul><li>Improved exclusive breastfeeding from 75.4 percent in 2002 to 85.1 percent in 2008 i. </li></ul><ul><li>Improved access to water : the proportion of households with year-round access to new or improved safe water sources increased from 59 percent in 2002 to 88 percent in 2008. </li></ul><ul><li>Increased income : on average, beneficiary households experienced a three-fold increase in annual earnings from $513 in 2002 to $1,673 in 2008. </li></ul>
Strategic Objective Increased Use of Key Health and Nutrition Practices and Services Increased Use of Key Livelihood Practices and Services Increased use of key DRR Practices and Services Intended Impact: Reduced Malnutrition in Children Reducing Malnutrition The SC Approach Intermediate Result 1: Increased Access to, & Availability of, food and health services Intermediate Result 3: Improved Knowledge, Attitudes, and Skills Intermediate Result 4: Enabling Social & Policy Environment Intermediate Result 2: Increased Quality Of Services
Addressing Malnutrition The Window of Opportunity Source: Shrimpton et al., 2001 We target children under the age of two
Reducing Malnutrition Proven Interventions We focus on proven interventions
Enhanced focus on Cross-Cutting themes integration <ul><li>Child Focus </li></ul><ul><li>Community mobilization </li></ul><ul><li>Gender </li></ul><ul><li>Equity </li></ul><ul><li>Monitoring and Evaluation </li></ul><ul><li>Extending BCC and Formative Research beyond MCHN </li></ul><ul><li>Documenting Program Experience </li></ul><ul><ul><li>E.g., Breastfeeding promotion, complementary feeding, CMAM, income generation/child well-being </li></ul></ul>
GAPS/Questions <ul><li>How to define integration (program and to larger scale) </li></ul><ul><li>How to balance high coverage with highly integrated multi-sector approaches (and cost per beneficiary) </li></ul><ul><li>How does one prioritize interventions within an integrated strategy? </li></ul><ul><li>How can we strengthen the evidence base to determine strongest (livelihoods) determinants to reducing undernutrition? </li></ul><ul><li>To what degree does one need to prioritize HHs with PLW and Children U2 for optimal and sustained results? </li></ul>
Discussion: <ul><ul><li>If you want to go fast, go alone. </li></ul></ul><ul><ul><li>If you want to go far, go together. </li></ul></ul><ul><li>African proverb (from Ellen Piwoz): </li></ul>