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Linking PSNP clients with nutrition sensitive livelihood interventions
1. Linking PSNP
clients with nutrition
sensitive livelihood
interventions
Michael Mulford
SPIR Chief of Party
2. Acknowledgement
This presentation was produced by World Vision under the SPIR
Program, Cooperative Agreement Number AID-FFP-A-16-00008, funded
by the U.S. Agency for International Development.
3. Strengthen PSNP4 Institutions and Resilience (SPIR)
• Implemented in Amhara (9
woredas), Oromia (6 woredas)
and SNNP (2 pilot woredas)
• Direct project participants:
500,000
• Goal: Resilience to shocks and
livelihoods enhanced, and food
security and nutrition improved,
for rural households vulnerable
to food insecurity
• USAID Food for Peace funded
Development Food Security
Activity (2016 – 2021)
• Implementing partners: CARE,
ORDA, World Vision
• Learning Partners: IFPRI,
Ambo and Hawassa University
4. SPIR Purpose areas
• Purpose 1: Increased Income, Productive Assets and Equitable
Access to Nutritious Food for Vulnerable Women, Men and
Youth
• Purpose 2: Improved nutritional status of children under two,
pregnant and lactating women, and adolescent girls
• Purpose 3: Increased Women's & Youth Empowerment &
Gender Equality
• Purpose 4: Strengthened ability of women, men and
communities to mitigate, adapt to and recover from human-
caused and natural shocks and stresses
5. PNSP4 Transfers to PW and PDS clients
• Targeting (10-15% of population within food insecure woredas)
• 6 months of transfers (cash / food) for public works payment,
and 12 months to permanent direct support beneficiaries
• Monthly individual ration size: 15kg wheat, 1.5kg pulse (YSP),
0.45kg fortified vegetable oil
• 34,394 MT of commodities distributed to 509,714 program
participants in FY18
• 274,224 PW, 55,372 PDS or TDS, 37,048 5% contingency
beneficiaries,143,070 drought affected individuals
6. Experience integrating nutrition in PSNP4
• Prioritization of public work
investments
• Household level pond
construction, or rope/pulley
pump with shallow well for
vegetable production for PLW
or women-headed HH
• Latrine construction (schools)
• Handwashing stations
• Large irrigation schemes
• Fruit trees included nursery
seedling support
9. Additional activities
• VESA groups – platform for reinforcing health and nutrition
messages (harmonizing with SURE+ GoE materials in PW BCC)
• messages about increasing dietary diversity with some of new income
earned, together with cooking demonstrations
• Improved poultry breed package (inputs and training) and home-
gardening package (seeds and training) initially targeted to PLWs
• Facilitate Community Led Total Sanitation and Hygiene (CLTSH)
approach to increase number of open defecation free (ODF) villages
11. Nutrition Sensitive Livelihoods
• Inclusion of nutrition considerations in value chain selection
• Example: poultry production
• potential for improving nutritional status of children through increased
availability of eggs and meat, provided that rearing practices do not
expose young children to fecal matter
• increasing income that is under women’s control, there is also the
expectation that investments in children’s nutrition will be improved.
• Focus on poultry production over other income generation activities
may reduce women’s time away from the home
• Use of feces in compost for home gardening
12. Household-level nutritional counseling
• Ethiopia Health Development Army (HDA) volunteer structure
• Timed and Targeted Counseling (TTC) by HDA volunteers for
both husband and wife at household level
• 11 total visits – 4 during pregnancy, 7 afterwards
• Reinforces key messages at appropriate time using storybooks
• Key nutrition messages communicated through multiple
channels: PW BCC session, VESA group discussion, household
level counseling (TTC)
13. Community Participatory Nutrition Promotion
• Engages caregivers in a two week learning-by-doing intensive
community based food demonstration and nutrition promotion
model for rehabilitating malnourished children using locally
available and affordable food in their homes
• Addresses gap between general IYCF promotion and CMAM
• Underweight children targeted (“MUAC Green”) – mild,
moderate and severe underweight (WAZ) young children
enrolled
• Model effectiveness tested using an RCT evaluation with
support from Johns Hopkins School of Public Health
15. Male Engagement strategy
• VESA – husband and wife both encouraged to become
members
• TTC – household level counseling not just for PLW but for
both husband and wife
• Social Analysis and Action (SAA) approach used to
enable individuals and communities to explore and
challenge social norms, beliefs and practices around
gender and nutrition that shape their lives
• Men’s groups and champions - to critically reflect on
cultural gender norms, gender relations, and explore the
positive and perceived negative effects of male
involvement in household chores, child care, etc.
16. Addressing Maternal Depression
• Postnatal depression has a significant negative impact on
breastfeeding duration. [Henderson et al, 2003]
• Infants of mothers with depressive symptoms had a 2.17 higher
odds of being stunted than did infants of mothers with few
symptoms [Black et al, 2009]
• Elimination of maternal depression could result in a reduction in
stunting of 23-29% [Surkan et al, 2014]
17. SPIR Baseline findings and IPT-G
• PHQ-9 tool used
• Women with children under three report high rates of
depressive symptoms
• 34 % feeling down, depressed or hopeless in the last 7 days
• 17 % of women had thoughts that they would be better off dead or
considered hurting themselves in the last 7 days
• Interpersonal Therapy for Groups (IPT-G) - 12-week session,
based on successful implementation in rural Uganda and
elsewhere (92% reduction in depression after treatment)
18. Impact Evaluation with IFPRI
• clustered randomized controlled trial (RCT) design
• providing rigorous estimates of the impact of the SPIR project,
• providing evidence on key project features that contribute to its
impact through comparisons of alternative implementation
strategies across treatment arms
• Including nutrition related program enhancements
19. Disclaimer
This presentation is made possible by the generous support of the
American people through the United States Agency for International
Development (USAID). The contents are the responsibility of World
Vision and do not necessarily reflect the views of USAID or the United
States Government.
21. Experience integrating nutrition in PSNP4
• Targeting: Criteria includes poor households with pregnant
women and women-headed households
• Challenge: cap for household transfer calculation is 5 members, and as
such, data often missing on younger children (household member lists
also not regularly updated based on new births)
• Annual planning: Health Extension Workers (HEWs)
represented as members of Kebele Food Security Task Force
• Challenge: HEWs are overburdened and unable to play key role in
coordinating BCC sessions for PW participants and linking TDS into
social services
22. Experience integrating nutrition in PSNP4
• Transfers: 5% contingency is used to support transitory non-PSNP
HH with malnourished children in TSF / OTP treatment
• Challenge: no good system for documenting and tracking these beneficiaries
• PW BCC sessions (6 two hour sessions over 6 months)
• Dependent on HEWs to plan, coordinate and implement
• Transition of PLWs and caregivers of moderate or severe
malnourished children from PW to TDS based on HEW referrals
• Kebele officials hesitant to transfer the latter in areas with high incidence of
moderate malnutrition among PSNP households
• Lack of documentation of referrals, adherence to ANC visits, attendance of
BCC sessions, etc. even though existence of “Client Cards” to track these
23. Experience integrating nutrition in PSNP4
• Linkage to social services through soft-conditionality
• HEW refers PLW to DA for transition to TDS, but lack of follow-through
on soft-conditionality of ensuring that ANC, PNC, immunization, GMP,
etc. all followed as a part of receiving transfers
• Documentation challenges to record, track and ensure accountability
Editor's Notes
SPIR design incorporated learning from other successful, innovative programs in Ethiopia such as Alive and Thrive and GRAD.
Chronically food insecure woredas targeted by PSNP (routinely affected by drought, severe land degradation).
As Anne mentioned, currently the government is only providing wheat, but SPIR and other DFSA’s continue to provide pulses and fortified vegetable oil as a ‘nutritional top up.’
Public work investments are identified and prioritized through a participative community process that is facilitated at the Kebele level and then fed into the overall woreda (District) level plans. The prioritization of activities is in part guided by the PSNP Program Implementation Manual (PIM), which generally targets community-level investments, but also allows for some investments on individual land, in particular support to female-headed households with severe labor shortages. These include ponds for irrigating year-round vegetable gardening, …
A Village Economic and Social Association (VESA) is a group with members from 15-25 households, used as a foundation for all economic and social activities supported by the project. The members of a VESA are self-selected groups of neighbors and peers and include both men and women (often the husband and wife from a single household).
VESA serve as an entry point for: financial literacy and business skill trainings, exposure to agricultural technologies and information, linkages to microfinance and input/output markets, and other livelihoods interventions. Development agents, model farmers, and private sector actors can interface directly with the VESAs and reach a large and receptive audience. In addition, VESAs build social cohesion and capital and are a safe and fertile environment for training/discussion on social and cultural norms that may impede development and contribute to food insecurity (e.g. gender inequality, infant feeding practices, etc.).
Nutrition related indicators in market and VC analysis were given 30% value (to make commodities selected nutrition sensitive).
Women are generally responsible for managing poultry production
Mention that HDAs are specifically included in the VESA groups – both as an incentive and also to assist in facilitating and transmitting some of the nutrition BCC messages
Similar to PD Hearth (without the PD)
Social Analysis and Action (SAA): In the SPIR program, SAA will be used to enable individuals and communities to explore and challenge social norms, beliefs and practices around gender and nutrition that shape their lives. It is a community led social change that address constraints on women’s role in intra household decision making, mobility, and choice of livelihood activities, and access to markets that are a part of cultural and social norms.
Men’s groups: The sessions will provide an opportunity for men to critically reflect on cultural gender norms, gender relations, and explore the positive and perceived negative effects of male involvement, seeking to better understand how gender inequity affects the lives of women, children and men. Afterward, community level awareness events and public campaign on men engagement will be facilitated. These may involve video or drama presentations to increase engagement by men and boys in child care, household chores and even food preparation.
Pamela Surkan’s meta analysis in 2014 which found that elimination of maternal depression could results in a reduction in stunting of 23-29%, based on the population attributable risk.
Using a survey instrument called PHQ9 that addresses both emotional/cognitive – feeling hopeless or down, and somatic symptoms – feeling tired of having little energy.
On average, women report suffering from 2.3 of the 9 depressive symptoms in the PHQ-9 for several days in the last week.
Women who are screened to be suffering from maternal depression will be invited to enroll in 12-week IPT-G sessions (approximately 5-8 women in each group). This community-based approach to addressing maternal depression will require some local piloting and adaptation of tools, which is planned for October-December 2018. Afterwards, psychologist Lena Verdeli (Columbia University), …
Uganda example After 16 weeks, depression decreased:
86% to 6.5% in the IPT-G intervention group – 92% reduction
94% to 55% in the control group. (Note: Some depression does resolve on its own.)
Significant improvements in functionality in HH tasks
N* : male engagement, TTC, CPNP, IPT-G
HEWs overwhelmed – have 18-19 core responsibilities and then get taken into other ‘campaigns’ that fully engage them in other activities
TSF – Targeted supplementary Feeding (for MAM treatment)
OTP – Outpatient Therapy Program (for treatment of SAM)
Essentially, they receive the same HH-calculated ration that serves partially as a ‘protection’ to ensure that the enriched flour and oil in the SF package is consumed by the intended beneficiary, and the same for the plumpy-nut equivalent with the OTP case
linkage of TDS to relevant social services( eg health service for ANC, PNC immunization and skilled delivery ) poorly practiced by DAs & Project staff
No feedback is requested by DA from the health service as well as no report is send from HEWs for DAS. In general no well-established feedback and taking mechanism b/n TDS referral, linkage to social service and service utilization
It is difficult to identify PSNP client who are linked to utilize health & nutrition service since all registration book in the health post has no column for identification of PSNP client except the new compressive integrated nutrition service registration &PLW nutrition screening registration book in hospital /health center
Health sector were not using the opportunity of linkage to social service to increase health and nutrition uptake of service
HEWs in general overwhelmed in different activity