Findings and Reflections on the Food for the Hungry Care Group Child Survival

Project in Sofala Province, Mozambique

Henry PerryDepartment of International Health

CORE Group Fall Meeting15 September 2010

Project Background

• 1.2 million people of all ages in project area• Area A: 42% of population (54m intervention)• Area B: 58% of population (16m intervention)• Interventions: Nutrition (70%), CDD (30%),

IMCI

Area B Project Indicators

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Exc. BF Ate 3+ meals Oil added to meal Vit. A supp.

FH/Moz CS Final Evaluation: Area B Project Indicators (Pt. 1)

Baseline, Area B

Final, Area B

Area B Project Indicators

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Vit. A foods Dewormed Weighed last4m

ORS/RHF Same/more foodduring diarrhea

Correctlyprepare ORS

Knows 3+danger signs

FH/Moz CS Final Evaluation: Area B Project Indicators (Pt. 2)

Baseline, Area B

Final, Area B

Same targets as Area A (54m of interventions); 79% of targets met, 100% of changes are statistically-significant

Achievement of Nutrition Targets, Food for the Hungry Child Survival Project, Sofala Province, Mozambique, 2006-10

26.8%

19.9%

29.4%

18.9%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Area A Area B

FH/Moz CS Final Evaluation: Changes in Underweight (WAZ<-2)

Baseline

Final

36% reduction (ss)26% reduction

Severe Underweight Decreases

51% reduction29% reduction

Food CategoryArea A Area B

Baseline Perc.

Final Perc.

Base to Final Diff. Stat. Sig?

Baseline Perc.

Final Perc.

Base to Final Diff. Stat. Sig?

Commercially-produced infant formula 2% 9% 7% Y 1% 6% 5% N

Fruit juice 18% 39% 21% Y 22% 39% 18% Y

Tea or coffee (including herbal teas) 4% 29% 25% Y 15% 25% 11% N

Commercially-fortified baby food 1% 6% 5% Y 1% 4% 3% N

Bread, rice, noodles, biscuits, cookies, or any other food made from grains 69% 87% 19% Y 46% 87% 41% Y

White potatoes, white yams, manioc, cassava, or other foods made from roots 2% 15% 13% Y 17% 36% 19% Y

Carrots, squash or sweet potatoes that are yellow or orange inside 5% 22% 17% Y 13% 36% 23% Y

Dark green leafy vegetables 23% 40% 17% Y 31% 44% 14% N

Other fruits or vegetables 4% 30% 25% Y 8% 38% 31% Y

Chicken, duck or other foul 1% 6% 5% Y 10% 8% -2% N

Eggs 1% 15% 14% Y 15% 13% -1% N

Fresh or dried fish or shellfish 14% 32% 19% Y 15% 35% 20% Y

Foods made from beans, peas, or lentils 11% 15% 5% N 6% 19% 13% Y

Nuts 0% 16% 16% Y 3% 9% 6% N

Food made with other oil, fat or butter 5% 42% 36% Y 12% 49% 37% Y

3+ meals/snacks consumed past day 35% 64% 29% Y 37% 59% 22% Y

Added oil to meal 34% 86% 52% Y 61% 89% 28% Y

Supporting Evidence for Improvement in Nutrition

• Increased coverage of exclusive breastfeeding• Improved complementary feeding• Increased utilization of nutritious foods, including

addition of oil, increased feeding (24h dietary recall), and feeding during illness

• Increased growth monitoring, deworming, ORS

Rapid Indicator Changes

• In general, in both Areas A and B, the increases in coverage of indicators were rapid, achieved within 12-18 months after the implementation of the educational module for that intervention

Mortality Impact Assessment (Indirect and Direct)

• Mortality monitoring led to the realization that many deaths were occurring in the neonatal period, so a new activity was added (home visitation to neonates)

• Indirect estimates based on Lives Saved Calculator (“old” Bellagio Calculator and “new” LiST Tool)

• Direct estimates based on vital events registration

Estimated U2MR Reported through Community Vital Events System

Lesson learned: Start mortality measurement early…

Estimated Changes in Under-2 Mortality in Food for the Hungry Project Areas A and B Using Project

Vital Events Data

The estimated 0-23m mortality rates for Sofala Province have been calculated by assuming that they are 80% of the estimated under-5 mortality rates

Estimate: Lives Saved Analysis (Lancet methodology [LIST])

Districts

(Sofala)

Benefic.

Est. # of

Lives Saved

Est. % reductio

n in U5MR

Project Costs

Cost per Life

Saved

Perc. of Average Cost per

Life Saved

(25 CSHGP

Projects)

Cost per Benef.

(USAID+ Match)

Area A: Caia, Chemba, Manga, Maringue

4,706 32% $2,026,191 $431 33%

Area B: Dondo, Gorongosa, Nhamatanda

1,816 26% $997,975 $550 43%

All 7 Districts 219,617 6,522 30% $3,024,166 $464 36% $2.75

Figure 2. Cost per DALY Averted with Integrated Community-Based Interventions to Improve Child Health

Abbreviations: DALY-disability-adjusted life year; USAID-United States Agency for International Development; PHC-primary health care.References: Ricca

Lessons Learned

• Care Groups can bring about rapid changes in behavior, nutritional status, mortality, and health care utilization. Changes in Area B (16m intervention) as good as changes in Area A (54m intervention). Mini-KPCs show trend.

• Care Groups are particularly good at changing key indicators that have low coverage in most countries which are not on track for achievement MDG4 (e.g., EBF, HWWS [vs. immunizations, Vitamin A])

Lessons Learned (cont.)

• FH’s model drives costs down by:– Targeting under-twos / pregnant women only– Use Promoters from the local area (with bicycles,

not motorcyles, serving 5 rather than 10+ communities)

– Only one supervision layer– Starting in one project area and later expanding to

second project area (since most of effect achieved in less than 2 years, and CGVs say they plan to continue activities after 16m)

Census-Based, Impact-Oriented Approach (CBIO) Principles

Care Groups Respond to Two Criticisms of CBIO Approach

• “CBIO is a promising approach that deserves further development and replication in other settings”

• As implemented in Bolivia, it had two drawbacks: relative high cost ($9 per capita per year for comprehensive primary health care services) and creating of dependence (by paying health workers to visit homes)

Conclusion

As far as we know, this is among the most cost-effective child survival projects ever implemented at scale.

The preceding slides were presented at theCORE Group 2010 Fall Meeting

Washington, DC

To see similar presentations, please visit:www.coregroup.org/resources/meetingreports