1 Web Appendix 17 Large-Scale Nutrition Programs ICDDR,B

ICDDRB Large-scale nutr programs

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Web Appendix 17

Large-Scale Nutrition Programs

ICDDR,B Global Nutrition Review Team

BACKGROUND AND GRADING OF EVIDENCE FOR LARGE-SCALE

NUTRITION PROGRAMS

Large scale nutrition programs are those that are designed to function at national or state

level with specific nutrition objectives and, therefore, cater to the needs of populations of

several hundred thousands or even millions. Large scale nutrition programs are, in most

of the cases, vertically designed although horizontal programs are believed to be more

sustainable. Although the primary focus may be improving nutrition of the population at

large, the programs also address health in most of the cases, and also increase in literacy

and improvement in livelihood in others. This is derived from the fact that both nutrition

and health are vital for child health and development, and that health interventions

without addressing nutrition may become less effective (1). Most of the programs depend

on a combination of interventions including growth monitoring and promotion (GMP)

and health/nutrition education, supplementary feeding, micronutrient supplementation,

care and immunization. Few programs include school feeding, home food production

(home gardening, poultry), cash-transfer, small income generation and referral of sick

children and pregnant women. They operate through interaction with households to

protect health and nutrition of women of reproductive age and children. They play an

important role in changing behavior and in promoting good caring practices (2).


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The role of contextual factors is important in evaluating the success or failure of large-

scale nutrition programs. Such factors would include resource constraints, female

education and role in home and in society; livelihood; availability of microcredit; control

of infectious illnesses, etc. Contextual factors are important but programmatic factors, for

example, the presence of trained community health workers and societal mobilization

have been found to make programs effective. This is observed from programs in

Thailand, Indonesia and Bangladesh (3, 4). Other important factors responsible for

success or failure of such programs are program intensity, defined as resource input per

person, targeting and coverage. In most of the programs both counseling (health and

nutritional) and feeding suffered from problems of inappropriate targeting strategies and

a failure to reach intended groups.

Cost of large scale nutrition programs has always been a major point of contention world

wide. Programs usually start with the active support from donor agencies but then

phasing out almost always turns out to be difficult due mostly to the political under

currents of stopping food supplementation. However, cost is associated with the

performance of programs. Gillespie, Mason and Martorell conclude that US $5-10 per

beneficiary per year is a workable level of cost in nutrition programs, though not

generally including supplementary food costs (5). At these levels of expenditure,

effective programs are expected to reduce prevalence of child under weight by 1-2

percentage points per year. Except in Sub-Saharan Africa, prevalence of underweight

improves at around 0.5 percentage points each year (6). Therefore, providing optimum

resources through appropriate costing is key to success of the programs. It has been


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shown that expenditure and outcome of large scale programs follow a dose-response s-

shaped curve. This means that at low levels of expenditure, a program will yield sub-

optimal outcomes (7). The efficacy of health and nutrition interventions in developing

countries is largely accepted (7). Smaller scale studies in India, Guatemala, Jamaica and

The Gambia show that health interventions with or without food supplementation

resulted in better growth of children (8, 9, 10, 11,12).

For the purposes of this review, large-scale nutrition programs are defined as programs

having coverage of a large population (national or sub-national / provincial level) along

with at least three of the following attributes: nutrition / health education, GMP,

breastfeeding, supplementary feeding, micronutrient supplementation, and immunization.

The efficacy or effectiveness of large scale nutrition programs has hardly been evaluated

to yield estimates of impact on growth of children. Because of the nature of the programs,

they are usually not subjected to the rigors of evaluation characteristic of randomized

controlled trials. Reports – published or otherwise – on the evaluation of large-scale

nutrition programs were collected through electronic search of data bases as well as by

hand. The following attributes were considered in grading the level of evidence for

nutrition programs:

1. External evaluation of the program

2. Intervention and its implementation are adequately described

3. Methods are presented in sufficient detail

4. Appropriate design - given the nature of the intervention


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5. Adequate sample size

6. Statistical analyses appropriate for type of outcome measure and clustering

7. Appropriate statistical analyses

8. Plausibility - alternative explanations for the results are discarded

9. Peer review

10. Selection bias ruled out or minimized by design or analytic strategy


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SEARCH STRATEGY

For PubMed

Pre-set search methods were used to search and retrieve reports using the electronic data base

PubMed . A combination shown below yielded 61 articles. Only 8 articles related to large

scale nutrition intervention were initially selected from the search. Also, 6 articles were

selected from the related link files of Pubmed’s abstract plus option. The following search

strategy was used.

1. nutrition[Text Word] OR nutrition[MeSH]………………..………………………337584

2. food[Text Word] OR food[MeSH]………………………………………..……… 493721

3. micronutrient[Text Word] OR micronutrient[MeSH]……………………..………..25991

4. national nutrition program OR national nutrition programme………………….……1572

5. nutrition program OR nutrition programme……………………………..………….11878

6. food supplementation program OR food supplementation programme ……………….610

7. national micronutrient program OR national micronutrient programme………………217

8. large scale nutrition intervention ………………………………………………………..96

9. large scale nutrition program or nationwide nutrition program ……………………….174

10. large scale food supplementation………………………………………………………..91

11. community based intervention ……………………………………………………….4822

12. community based growth monitoring………………………………………………….175

13. nutritional recovery……………………………………………………………………1631

14. evaluation OR assessment OR impact estimation OR feasibility…………………1476423

15. evaluation of nutrition programs………………………………………………………1247


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16. process evaluation……………………………………………………………………44522

17. under developed countries OR developing countries OR less developed countries OR

least developed countries OR poor countries OR third world countries…………….72986

18. #1 OR #2 OR #3…………………………………………………………………....716476

19. #4 OR #5 OR #6 OR #7……………………………………………………...………12287

20. #8 OR #9 OR #10 OR #11 OR #12 OR #13…………………………………………6910

21. #14 OR #15 OR #16………………………………………………………..……..1476423

22. #18 AND #19 AND #20 AND #21……………………………………………………237

23. #22 AND # 17……………………………………………………………….………… 61


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For Cochrane Database

There were 126 results out of 4655 records for: "Large scale nutrition program in Title,

Abstract or Keywords or Large scale nutrition intervention in Title, Abstract or Keywords or

National nutrition program or Community based nutrition program and (developing OR

underdeveloped OR third world) country in The Cochrane Database of Systematic Reviews".

From these 126 results, only one was selected for full text reading. This single review was

not accepted as the sample sizes of programs in different were small.

There were 161 results out of 489167 records for: "Large scale nutrition program in Title,

Abstract or Keywords or Large scale nutrition intervention in Title, Abstract or Keywords or

National nutrition program or Community based nutrition program and (developing OR

underdeveloped OR third world) country in The Cochrane Central Register of Controlled

Trials". From these 161 results, 5 papers were selected for full text reading. None of these

papers, however, fulfilled the definition of large scale nutrition programs.

For World Bank publications database:

There were 1335 results out of 5711 records for: nutrition program in Title. This 1335

implementation completion and result reports were checked and only 7 were selected for full

text reading.


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Hand search

Extensive hand search was done in order to overcome the scarcity of relevant papers in the

PubMed and Cochrane databases.


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Panel 1: Content, coverage and impact of large-scale nutrition programs Program Year

established Program content Coverage

Impact Limitations

ICDS (India)

1975 GMP, supplementary nutrition, immunization, health check-up, referral services, nutrition and health education, pre-school education, IFA & VA supplementation

28 million beneficiaries, 62% of villages covered in states having the ICDS. Key intervention provider is the Anganwadi worker (AWW)

8.5% reduction in prevalence of underweight, reduced incidence of LBW, early initiation of BF, increased coverage of vitamin A supplementation and institutional delivery (13)

70% of AWW time spent on supplemental food & pre-school education; wide target group age (up to 6 years)

BINP and NNP (Bangladesh)

1995 GMP, supplementary feeding to underweight under-2 children, malnourished pregnant & lactating women, health & nutrition education, to women & adolescent girls, IFA & VA supplementation, home gardening & poultry rearing

BINP had 15.6 million beneficiaries, NNP covers 25% of the population

Resulted in increased participation in GMP sessions (75-95%), moderate coverage of nutrition education sessions (66%), positive impact on colostrum & EBF (14), increased health & nutrition awareness and practice among adolescent girls & women, low incidence of LBW (4), inconsistent evidence for an effect on child anthropometry

Food supplementation takes away most of the costs & efforts at the expense of health & nutrition education; mis-targeting of food supplementation not uncommon; food supplements not rich in micronutrients

Progresa (Oportunidades, Mexico)

1997 Micronutrient-rich food supplements to under-4 children, pregnant & lactating women, health services and cash transfers to families

4.5 million low-income families (20%) in rural & urban Mexico

Resulted in better height and hemoglobin levels among children (15)

Child Pastorate Programme (Brazil)

1983 GMP, oral rehydration, breastfeeding promotion, immunization, health education, and referral services

Concentrated in areas of high incidence of poverty, high child mortality & malnutrition rates; currently functioning in 32,265 communities covering more than 80,000 pregnant women and 1.6 million under-six children

Between 1988-2001, levels of malnutrition among children decreased from 18% to 4%, LBW 14% to 6%, malnutrition among pregnant women 20% to 4%. EBF during the first 4 months increased from 60% to 80% (12, 16).


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Programme on good nutrition for health: LAKASS (Philippines)

1989 GMP, micronutrient supplementation, supplementary feeding, IEC and weaning food production, community, school and home food production. Combines nutrition interventions with literacy projects, infrastructural development, poverty alleviation i.e. small income-generating projects.

Regional coverage Reduction in prevalence of severe & moderate underweight by 71% & 47% respectivey (12)

The Madagascar Food Security and Nutrition Project- SECALINE Expanded School and Community Food and Nutrition Surveillance and Education Programme – SEECALINE (Madagascar)

1993-1997 1998-2003

• monthly growth monitoring of the children; • weekly nutrition and health education sessions to women; • referral to health services for unvaccinated children and pregnant women, for severely malnourished children, for sick beneficiaries; • home visits to follow up on beneficiaries who were referred or who do not come to the services • food supplementation to malnourished children (locally bought non-manufactured food); •Referral to a social fund for income generating activities (12, 17, 18) Operates through community nutrition and school nutrition programmes, post cyclone and drought intervention, and Information, Education and Communication (IEC). Nutrition interventions include GMP, supplementary feeding (500 kcal/day) for undernourished children, nutrition education through demonstration, micronutrient supplementation to children and mothers, deworming of school-aged children along with education on personal and environmental hygiene.

Two most vulnerable regions of the country, and has directly attended over four years 241 000 children under 5 years of age and their mothers in 534 villages. Up to 2002, the programme has treated 431,000 students and 250,000 pre-schoolers and non-enrolled children for intestinal parasites, provided iron supplements to 425,000 students, and trained 14,000 teachers.

The coverage rate by the project in the targeted zones increased from 50 to 87% by September 1997, while malnutrition rates among beneficiary children diminished steadily. The percentage of malnourished children among the project beneficiaries (weight for age <80% of median) was 35 - 24% in 1994 which was reduced to 16-5% by the year 1997 (18). Over the period 1998-2001, there has been a 15 percentage points reduction in prevalence of malnutrition (12). In two of the most food insecure provinces of the country (Toliary and Antananarivo) moderate malnutrition among children under five was reduced from 45% to 38% in

Heavily dependent on external funding; the government contributes only 3.7% of the total cost.


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Antananarivo province, and from 28% to 18% in Toliary province over the last four years (1992-96).(12, 17)

The Child Survival and Development (CSD) Programme (Tanzania)

1985, based on the success of Iringa project

The promotion of the activities in the villages through social mobilization and activities are immunization, growth monitoring, health and nutrition counseling and HIV/AIDS attention with new approaches, addressing low birth weight prevention, psycho-social development, de-worming and hygiene promotion, multi-micronutrient supplementation and safe motherhood initiatives And no supplementary feeding (19).

By 1991 nine out of twenty regions in mainland Tanzania were implementing CSD community based programs. Population total approximately 12 million; 2 million children). Aimed for complete coverage (21).

Since the early 1990s, however, these reductions have stagnated. Child underweight remains at roughly 30 percent, stunting at 43 percent and wasting at 6 percent. Low-birth weight, which increased from an average of 12-14 percent in the 1980s to around 16 percent in 1996, is reported to have declined to 13 percent in 1999 (19, 20).

Primary Health Care Program Poverty Alleviation Program Basic Minimum Needs Program (Thailand)

1982 to 1989

In health, service delivery focused particularly on prevention and promotion, antenatal care for pregnant women in order to promote adequate maternal weight gain and ensure a healthy birth weight, control and prevent micronutrient deficiencies, and reduce the risk of preventable maternal mortality. GMP to ensure proper child growth and development, Protection, promotion and support of breastfeeding and appropriate complementary feeding, immunization, oral rehydration therapy, deworming, treatment of local endemic diseases, and provision of potable water and sanitary latrines, formed integral components of program activities. Service providers worked as a team with community leaders and “facilitators” for community activities. Women group, field manager, service

Expanded over about 5 years to cover 95 percent of villages. 600,000 village health communicators (1 percent of population) trained; 60,000 village health volunteers (21).

During the nine years from 1982 to 1991, Thailand reduced malnutrition (underweight) rates among preschool children from over 50 % to under 20 %(22) In 1982 the prevalence of mild, moderate and severe malnutrition were 35%, 12-13% and 5-6% respectively. In 1996 severe malnutrition eradicate and only 10-12% children were underweight.(23) (estimated from graph) In 1982 the rate of malnutrition(according to Gomez's classification) was Grade-1=35.66%, Grade-2= 13.00% and Grade-3=2.13%.


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provider Community health/nutrition volunteers worked as a team (22)

In 1989 this rate reduced to Grade-1=19.66%, Grade-2 = 1.25% and Grade - 3= 0.01%. Anaemia, using WHO criteria for diagnosis, was 27.32% for pregnant women and 27.29% for children aged 6-14 years in a 1988 survey (51).

Posyandus, Indonesia 1975-90 GMP, nutritional education, supplementary feeding (later stopped), food demonstration, Vit A, iron tablets, oral rehydration salts, advice for home gardening and supply of contraceptives. UPGK, village family nutrition programme, run by village volunteer who received 5 days training for GMP (24).

By late 1984 more than 80,000 posts in 34,000 villages provided services to ten million children, half of Indonesia’s total (24).

Studies constantly show level of severe PEM (<60% W/A) declined to 1% (0.5%-1.8%) from 3%-5% 15 years back. Moderate PEM again 12% (8%-20%) only marginally lower than the mid 1970s (24).

Inclusion of too many ‘health’ issues in the program probably led to dilution of nutrition issues.

AIN-C, Honduras Could not be known

The AIN/C program has been the centerpiece of Honduras' community Integrated Management of Childhood Illness (IMCI) program. Objectives include increased access to maternal/neonatal care at the community level and improve caretaker behavior, strengthen community capacity to manage acute respiratory illness and combat communicable diseases (ARI/CDD ) and growth promotion (25).

With community health volunteers, AIN-C covers > 50 percent of health areas (expanded 1991 onward), covering > 90 percent of U-2 children in these areas; growth monitoring and home follow-up, plus referral and treatment (26).

From an early round of information collected in AIN/C communities, more children under 2 are gaining weight now than they were a year ago. In communities with different starting rates of malnutrition, there were major improvements. High malnutrition, defined as below the 3rd percentile of -2SD, declined from 39 percent to 8 percent. Medium malnutrition declined from 25 percent to 10 percent, and mild malnutrition was eliminated (25). In1987, stunting stood at 44 percent, but it had fallen to 38 percent by 1996 and to 33


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percent by 2001. Overall malnutrition, as measured by weight-for-age, fell from 24 percent to 18 percent in the same period (26).

TINP-1 India

1980-1989 GMP, Supplementary feeding to underweight under-3 children, malnourished pregnant & lactating women & whose growth was found to be faltering, health & nutrition education to women, IFA & VA supplementation and deworming, immunization and health services (27)

Some 9,000 community Nutrition Centers established, each serving an average of 1,500 people. 77% children participate in GMP sessions (27).

77% of eligible children were enrolled to program. 82% children weighed. 78% of enrolled children fed supplementary food. Vit A and deworming done in 80% of children. The data indicate a statistically significant improvement in weight-for-age <-2 SD over the period 1982 to 1990 (77.4–74.0% to 67.3 -60.4%). Once they were enrolled monthly weighing was fairly regular and systematic (in 1986, 82 percent of the maximum, a figure that compares very favorably with other efforts to use growth monitoring). Other indicators suggest that the procedures laid down - e. g., for beginning and ending supplementary feeding, providing educational inputs, encouraging community participation, and keeping accurate records - were carefully followed. Leakage of supplemental food to non-participants (i.e., by reducing beneficiary food intake at home) was probably small

Health issues other than immunization were not implemented at scale


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(27). Ethiopia (LINKAGES) 2003-2006 Intervention was given through the ENA

(Essential Nutrition Actions) approach which compromised an integrated package of seven scientifically proven nutrition actions including the promotion of optimal breast feeding, optimal complementary feeding, nutritional care of the sick child, women's nutrition, the control of anaemia, vitamin A deficiency and iodine deficiency.

direct presence in 64 focus districts of ESHE bi-lateral in 3 regions covering 15 million and indirect presence across country via training of partner staff from government health bureaus, 23 PMTCT sites in 6 regions, 7 uiversities, UNICEF, World Bank and multiple NGO/PVO projects.

In May/June 2006 Linkages and ESHE Project collaborated in a community assessment of behavior change. The assessment targeted 2200 households each in three regions (SNNPR, Oromia and Amhara). Initiation of breast feeding within one hour of birth increased sigificantly in project sites in Amhara (23% to 60%) and Oromia (43% to 77%) but showed no statistical significant change in SNNPR (45% to 50%). For all three regions, the exclusive breastfeeding rate in 2006 ranged from 62 percent to 81 percent which ranged from 39 to 74 percent in 2003/2004. (28)

No other data except optimal breastfeeding (EBE and initiation of breastfeeding) All data collected for 24 hour recall method.

Madagascar (LINKAGES)

1997-2006 Linkages built a community approach on the IMCI strategy. This strategy also included messages and materials and messages on child survival and nutrition. The nutrition component of the strategy was based on Essential Nutrition Actions (ENA) that promote optimal breast feeding, optimal complementary feeding, nutritional care of the sick child, women's nutrition, the control of anaemia, vitamin A deficiency and iodine deficiency.

2-6 million population in 4 provinces at different phases of the program. 4 provinces with 10 districts in Antananarivo, 13 in Fianarantsoa, 2 in Tulear, and 1 in Mahajana

he result presented below are after five years (2000-2005) of programme implementation: Timely initiation of breastfeeding: baseline - 34%, 2005 - 68%; Exclusive breastfeeding in first six months: baseline - 46%, 2005 - 70%; Continuation of breastfeeding upto 23 months: baseline - 52%, 2005 - 71%; IYCF indicator: baseline - 37%, 2005 - 81%; Vitamin A supplementation of women within first two weeks of delivery: baseline - 17%, 2005 - 54%; Iron and


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FA supplementation among pregnant women: baseline - 28%, 2005 - 76%; Additional meals among breastfeeding women: baseline - 62%, 2005 - 74%; LAM use: baseline - 2%, 2005 - 24%. (28).

Community Supplementary Feeding Programme (CSFP) (Zimbabwe) Community Food and Nutrition Programme (CFNP)

1982 1987 continuation of CSFP

The overall objective of the programme is 'to maintain or improve the nutritional status of children under five in drought affected areas'. A daily supplement of maize, groundnuts and oil in the form of a porridge is given out at feeding points to children between the ages of one and five years old. This provides approximately 550 kcals per capita. * sensitization of community members to form groups and develop garden plots; * provision of agricultural inputs: seeds, fertilizers, insecticides as well as fencing material to enhance agricultural production especially legumes and vegetables; * training and technical advice pertaining to production, access and consumption; * promotion of food storage, processing, preservation and other related technologies; * community-based growth promotion and nutrition education (31).

Population served: 56,000–96,000 with supplementary feeding; up to 60 percent of all children in community-based growth monitoring. Nation wide

Between 1982-1999, prevalence of childhood stunting decreased from 36% to 27% and underweight from 23% to 10%. LBW, however, increased from 7% to 11% over the period 1990-99 (29, 30). No outcome objective exists. It was not possible to measure impact (31).

Only SF

Iringa Joint Nutrition Support Programme (JNSP)

1982-1989

The framework provides the context within which a continuous search for ways to attack the causes of malnutrition is made through repeated cycles of Assessment, Analysis and Action (Triple-A Cycle). Programs were Systems Development and Support, Maternal and Child Health, Water and Environmental Sanitation, Household Food Security, Child Care and Development, Income Generating Actions, Supplementary feeding (20, 32, 33).

250,000 in 6 districts, 610 villages, 46,000 children, of which 33,700 participated (73 percent). Progressed from 168 to 610 villages 1984–88 (34).

In 1988 Severe malnutrition was reduced by 71.4 percent from a high 6.3 to 1.8 percent and total underweight was reduced by 32.0 percent from 55.9 to 38.0 percent over a period of five years (32). Other key outcome indicators like the possession of an MCH card; mother's

SF, HE, NE, small coverage


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knowledge about the growth chart; ability to recognize malnourished children; knowledge about “kimea” (power flour); personal knowledge about the Village Health Worker (VHW) indicated programme reached nearly 85 percent of the mother/child pairs in a positive way (32).

Complementary Food Program Costa Rica

1951 To improve the nutritional status of the most vulnerable population groups (nursing infants, preschool children, and pregnant women). • To promote good food habits. • To promote the consumption of foodstuffs of high nutritional value which are produced or could be produced in the country. • To impress on the population the need for periodic medical checkups for children and pregnant women. • To deepen community awareness of the nutrition problems of mothers and children and to foster community participation in the solution of these problems. In its initial phases, the complementary food program was implemented by the medical and nursing staff of the Sanitary Units (later to be called health centers). Additionally, Nutrition Centers, attached to the Sanitary Units, were built progressively. Types of food included warm meals, milk distribution, food rations and packages (35).

In 1955, there were only 18 Nutrition Centres; by 1960 the number had increased to 45; by 1968 to 124; by 1978 to 471; and in 1990 there were 550 functioning Nutrition Centers or Integrated Centers for Child Health Care (CINAI) that included nutrition. In 1977-1978, the program had approximately 32,000 beneficiaries, 72% of whom were preschool children. In 1978, the program served approximately 15 million warm meals: 9 million lunches and 6 million breakfasts. At the national level, however, this tremendous effort translated into a coverage of only 10% of all preschool children, and a coverage of barely 2% of all pregnant and breast-feeding women for warm food distribution. Milk distribution: In 1978, at the national level, the

The services offered contributed to better the nutritional status of children (beneficiaries) by 2.3% according to the weight/age indicator (36).

No data on impact on nutritional status


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program covered 36% of all preschool children, 10.4% of all pregnant women, and 10.9% of all breast-feeding mothers. Food rations: In 1978, there were 7,625 recipient families for Food Rations and Packages (35). Annual average distribution since April 2006: Served Meals: 31,435 beneficiaries Milk Distribution: 67,014 beneficiaries Distribution of foods to families: 15,839 beneficiaries (36).

Community Nutrition Project (CNP) Senegal

started in 1996

monthly growth monitoring of the children; • weekly nutrition and health education sessions to women; • referral to health services for unvaccinated children and pregnant women, for severely malnourished children, for sick beneficiaries; • home visits to follow up on beneficiaries who were referred or who do not come to the services • food supplementation to malnourished children. • improved access to water stand pipes. (18, 37)

Poor peri-urban areas, and has directly attended 100 000 children up to 3 years of age along with 131 000 women in 14 cities.

After 17 months of project implementation, severe malnutrition (weight for age below –3 Z scores) disappeared among children of 6–11 months (going from 6 to 0%, p = 0.0053), and moderate malnutrition among those of 6–35 months went from 28 to 24% (weight for age below –2 Z scores, based on an exhaustive survey) (18, 37).

Nutrition enhancement programme (NEP) Senegal

Phase 1: 2002-2006 Phase 2: 2007-2011

• Growth monitoring of the children; • weekly nutrition and health education sessions to women;

• Micronutrient supplement • home visits to follow up on beneficiaries who were referred

or who do not come to the services • Capacity building (38).

Started in 3 poorest rural region. 34 health districts. 200000 under 3 year children with their mother.

• Prevalence of severe under nutrition reduced 5.7% (2004) to 4.5%(2006). • Prevalence of under nutrition reduced 26.8% (2004) to 23.1%(2006). • Exclusive breast feeding coverage improved from


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30%(2004) to 58%(2006) (38).

Community-Based Poverty Reduction Project- Community Based Nutrition and Food Security Component. Ghana

Started in 1999

• Growth monitoring of the children; • Nutrition and health education sessions • home visits to follow up on beneficiaries who were referred

or who do not come to the services • Exclusive breast feeding

•Income generating activities such as pineapple and vegetable gardening, fruit tree cultivation, small ruminants/snail rearing, poultry keeping and mushroom cultivation. • food security

•Immunization

The Community Based Nutrition and Food Security component was implemented in 40 communities of four focus districts of Ghana, namely Sefwi-Wiawso, Komenda Edina Eguafo Abirem (KEEA), Kadjebi and Bongo. By the end of the project, the nutrition and food security component had covered a total of 10,728 children of 0-5 years old (7,081 children under two years old and 3,647 children of 2-5 years old) and 4,466 women (39).

• Underweight children of 0-2 years old. decreased by 34.5% in KEEA, 17.2% in Kadjebi, 54.0% in Sefwi-Wiawso, and 77.3% in Bongo, • Underweight incidence of 2-5 years old children declined by 16.5% in KEEA, 10.7% in Kadjebi, 19.8% in Sefwi-Wiawso, and 16.5% in Bongo. • all beneficiary children were fully immunized by the prescribed ages. • The share of women practicing exclusive breast feeding increased significantly in all four districts, with Sefwi Wiawso having the largest percentage increase at 325% (increases in the other districts went from 34% to 250%) (39).

Nutrition, food security and social mobilization project- Community nutrition program component. Mauritania

Started in october,1999 and closed by april 2005

• Growth monitoring of the children; • Nutrition and health education • Micronutrient supplementation. • Promotion of exclusive breast feeding

•Promotion of locally made weaning food. • Micro credit or micro grants to improve nutritional status.

•Income generating activities (40).

Nationwide, chidren under 3 years and pregnant and lactating mothers. Total number of population coverage not mentioned.

Unsatisfactory • Under weight reduction 16%. The reduction was only found in the urban areas of Nouadhibou and Nouakchott, while the three regions in the interior of the country showed an increase in the number of underweight children (underweight increased from 22% to 30.4% in Hodh-el-Gharbi and from 21% to 27% in Gorgol). • Exclusive breastfeeding

• Drought, locust invasion and loss of agricultural production and cattle may be the reason for the deterioration in nutritional status in rural areas, but no conclusive evidence can be reached due to the lack of control communities at baseline. •Data contamination between control and intervention communities is reported to be a problem by the authors of the impact study.


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until 6 months of age has decreased (from 83% in 2000 to 78% in 20049) • Prevalence of diarrhea has increased (to 23% from 19% in 2000). • Housing conditions have likewise deteriorated and access to food has reportedly decreased during the last years due to drought and locust invasion (40).

• A selection bias of women especially in the rural area where only beneficiaries who were members of the cooperatives were eligible in the sample is a concern. •The sample selection appears to be less inclusive than the selection in the base line study. Participation in nutrition activities dropped significantly over time at most of the CNCs and data available seem to show that the most vulnerable and malnourished children were not participating anymore •Different seasonality in data collection affects data comparability: while both the rural surveys (baseline and end-line) were carried out during normal seasons, in urban areas the baseline was taken during the soudure (hunger) season, characterized by higher malnutrition rates, while the end-line was taken in a more normal season. Different seasonality may therefore be responsible for much higher urban malnutrition rates at baseline and possibly, for the obtained reduction in malnutrition in urban areas (40).

Early childhood development project (ECD) Philippines

Started in 1998 and closed in 2005

• Growth monitoring of the children; • Nutrition and health education • Micronutrient supplementation. • Food fortification

Nationwide. Total number of population coverage not mentioned (41).

• Reduction of wasting 59% • Immunization 100% target achieved. • 53% reduction of childhood


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•Immunization anemia •16.7% reduction of under 5 mortality rate (41).

Participatory Health, Population, and Nutrition Project (PHPNP): Component 3 -improving nutrition services for women of reproductive age, infants and children Gambia

Started in 1998 and closed in 2005

• Growth monitoring of the children; • Nutrition and health education sessions • Exclusive breast feeding

• develop and implement a nutrition education strategy •Community and Micronutrient Approach

•Capacity building (42).

Nationwide. Total number of population coverage not mentioned.

• Reduction of Child Malnutrition Rate by 25 Percent. This indicator is rated highly satisfactory. At the beginning of the PHPNP, 26 percent of children under age five in The Gambia were underweight. Results from a survey conducted by National Nutrition Agency (NaNA) at the end of project found that 18.8 percent of children were underweight, indicating a reduction of 27.8 percent over the life of the project. Detailed analysis showed that stunting decreased in the country from 23 percent in 1996 to 19 percent in 2000 to the current figure of 17.8 percent. Earlier figures indicate that stunting was more than 30 percent in The Gambia. The findings of NaNA's survey are consistent with the World Health Organization’s Global Database information on The Gambia. • An improvement exclusive breast feeding over 36 percent (42).

Women and child development project India

Started on 1999

Service Quality Improvement: Improving the quality of ICDS with particular emphasis on (a) the provision of supplementary feeding

The main project beneficiaries are children 0-6 years of age, pregnant and

'Reduction in moderate malnutrition in 0-36 month old children (<-2SD, NCHS


21

and nutritional supplements to children and pregnant and lactating women and the regular monitoring to detect malnutrition and promote growth; (b) immunization against six childhood diseases; and (c) promoting overall psycho-social development of children. (2) Adolescent Girls' Empowerment: Activities included the provision of iron supplements and deworming treatment. (3) Staffing and Infrastructure Development: (a) staffing; (b) construction of new facilities for Anganwadis and block offices; (c) installation of hand-pumps; and (d) procurement of equipment, vehicles, and other items (43).

lactating women, and adolescent girls, who have attended the Anganwadi Centers (AWCs), especially in the poor, scheduled caste, and tribal communities. The project covered approximately 111,206 AWCs, which have provided services to about 18.5 million direct beneficiaries and about 2.3 million indirect beneficiaries in about 10.8 million at-risk households. As a result of the restructuring of the project in 2003, the direct beneficiaries were increased by 5.3 million children and 1.3 million pregnant and lactating women in the additional six states. Originally, the project covered 318 new (uncovered) blocks with about 44,000 AWCs which were operationalized under the project and 685 old (existing) blocks with about 68,000 AWCs wherein some specific interventions were added to strengthen the ICDS Scheme. These old and new blocks were situated in the states of Uttar Pradesh, Rajasthan, Maharashtra, Kerala and Tamil Nadu (43).

Growth Standards) has been achieved to the extent of 85% of the target. Uttar Pradesh achieved a maximum reduction of 13.7 percentage points, followed by Tamil Nadu with a reduction of 11.4 percentage points. Next comes Maharashtra with a reduction of 9.2 percentage points, followed by Kerala with a reduction of 7.83 percentage points and Rajasthan with a reduction of 4.1 percentage points. All these reductions have been found to be statistically significant with p<0.0001. The reductions in the proportions of severely malnourished children (0-36 months; <-3SD) is only 1.4 percentage points (43).

Barangay Integrated Development Approach for Nutrition Improvement of the

1978 to 1989 (44)

supplementary feeding, nutrition education, growth monitoring, home food production, adjunct health services, development projects:land reform, irrigation, road

6 pilot villages, expanded to 122 by 1986 and now replicated in 136 more villages in other regions.

From 1983 to 1985, there was an overall reduction in undernutrition (Grade II and Grade III) from 28.3% to

The levels of food consumption were low; foods produced were sold for cash income which was used


22

Rural Poor (BIDANI)/ Philippines

construction, income generation, marketing, environmental sanitation. (44) The BIDANI Program is a complementary effort to the Lalakas ang Katawang Sapat sa Sustansiya (LAKASS) Program of the National Nutrition Council. (66)

(44) 18.7%. Breastfeeding practices were maintained at 79%. (44)

for non-food commodities. Hence, an intensification of nutrition advocacy was needed. (44)

Family Nutrition Improvement (UPGK) Indonesia

1974 to 1989

Growth monitoring, suupplementary feeding, nutrition and health education, Vitamin A & iron supplementation, other adjunct MCH services, family planning (44)

58,355 villages in all regions, 17 million under-five have access (80% of under-five population) (44)

The overall programme data of the UPGK activities in the past year showed that access is provided to 81% of all children under five years in Indonesia (about 21 million children). Of these children, approximately 77% received some services. In addition, 11.6 million or 47% of the total under-five populations are reported to be weighed regularly every month, and an average of 54% of the children who regularly attended the monthly Pos Yandu services showed consistent weight gain. (44)

Health and Social Development Programme (HSDP), Costa Rica

1970 - (44)

Development of rural health workers, health and nutrition education, antenatal care and MCH services, anaemia control (treatment of anemia), clinics developed for treatment/follow up (including immunization with most available vaccines to cover more than 80% of the susceptible population) (44)

387 health centres or health posts in 1983. 115,000 in 1973 and 777,000 in 1983. (44)

There is good evidence to show that coverage, duration and intensity of the intervention of the HSDP correlated with the marked decline in infant mortality and increased life expectancy at birth in

Health and Social Development Programme (HSDP), Costs Rica


23

Costa Rica during the decade of 1970. The most significant change was a reduction in rates of infectious and parasitic diseases (44)

ICDS: Integrated Child Development Services BINP: Bangladesh Integrated Nutrition Project, 1995-2002 NNP: National Nutrition Program, 2004-2005 (now functioning as the Nutrition Sub-sector of Health, Nutrition and Population Sector Program) PHPNP: Participatory Health, Population, and Nutrition Project (Gambia). ECD: Early childhood development project (Philippines). NEP: Nutrition enhancement programme. (Senegal).


24

Panel 2 A summarizes the grading of evidence on which there was consensus amongst the members of the writing team of this paper as well as members of the steering committee PROGRAM ATTRIBUTES

ICDS (India)

BINP / NNP

(B’desh)

Progresa (Mexico)

Child Pastorate Program (Brazil)

SECALINE (Madagascar)

SEECALINE (Madagascar)

Lakass (Philippines)

CSD (Tz)

Thailand Posyandus Indonesia

External evaluation of the program

+++ ++ + ++ + + ++ +

Intervention and its implementation adequately described

++ ++ +++ ++ ++ ++ + ++ +

Methods presented in sufficient detail

+++ +++ +++ + ++ + + +++ +

Appropriate design - given the nature of the intervention

++ ++ +++ + ++ + + +++ +

Adequate sample size

+ ++ ++ + + + ++ +

Statistical analyses appropriate for type of outcome measure and clustering

+ + ++ + + +

Appropriate statistical analyses

+ + ++ +

Plausibility - alternative explanations for the results discarded

+ ++ + + +

Peer review

+ ++ ++ + ++ ++

Selection bias ruled out or minimized by design or analytic strategy

++ ++


25

Panel 2 B summarizes the grading of evidence on which there was consensus amongst the members of the writing team of this paper as well as members of the steering committee PROGRAM ATTRIBUTES

AIN-C Honduras

TINP-1 (India)

LINKAGES Ethiopia

LINKAGES Madagascar

CSFP Zimbabwe

Iringa Tanzania

CFP Costa Rica

CNP Senegal

NEP Senegal

External evaluation of the program + +++ + + + Intervention and its implementation adequately described + ++ +++ +++ + +++ + + + Methods presented in sufficient detail ++ +++ +++ + +++ + + Appropriate design - given the nature of the intervention + +++ + + ++ ++ + + Adequate sample size

+ ++ +++ +++ + ++ ++ ++


+ + + + +


+ + + + +


+ +

Peer review

+ ++ +


+ + + +


26

Panel 2 C summarizes the grading of evidence on which there was consensus amongst the members of the writing team of this paper as well as members of the steering committee PROGRAM ATTRIBUTES

Community-Based

Poverty Reduction

Project Ghana.

Nutrition, food security

and social mobilization

project Mauritania

ECD Philippines

PHPNP Gambia

Women and child

development project

India

BIDANI Philippines

UPGK Indonesia

HSDP Costa Rica

External evaluation of the program ++ + + Intervention and its implementation adequately described + + + + ++ ++ + + Methods presented in sufficient detail + + + + ++ + + Appropriate design - given the nature of the intervention + ++ + + + + + Adequate sample size

++ ++ + ++ ++ ++ ++ +


+ + + + + +


+ + + + +


++ + + +

Peer review



27


28

Panels 3 and 4 show the impact estimates of large-scale nutrition programs in Bangladesh

and India, namely the Bangladesh Integrated Nutrition Project (BINP) (4) and the Tamil

Nadu Integrated Nutrition Project (TINP) (45). All districts in which the TINP-I operated

were divided into three strata: Stratum 1 included all districts where TINP was initiated in

1982, Stratum 2 covered districts where TINP started in 1983, and Stratum 3 included

districts where the TINP was initiated in end 1984/early 1985 (Karim R, Larnstein SA,

Akhtaruzzaman M, Rahman KM, Alam N. The Bangladesh Integrated Nutrition Project:

Community-based nutrition component. Endline evaluation: Final report. University of

Dhaka, 2003; Tamil Nadu Integrated Nutrition Project: Impact evaluation report.

Opeartions Evaluation Division, The World Bank, report no. 13783-IN, 1994) (27, 46).

The denominator in the analysis was children 6-36 months old while the numerator was

number of underweight children (less than -2 z-score weight-for-age). In BINP as well as

all the strata of TINP, there was a significant reduction in prevalence of underweight

among children living in program areas; the risk of underweight being reduced by 44%

(OR 0.56, 95% CI 0.50-0.63). However, another analysis showed no effect of BINP on

prevalence of underweight among 6-23 months old children as compared with children

living in the comparison area (panel 4; OR 0.90, 95% CI 0.77-1.05).


29

Panel 3

Review: Large-scale nutrition programsComparison: 01 Changes in the weight for age Z score (Endline vs. Baseline) Outcome: 01 Prevalence of underweight (<-2 Z score weight for age)

Study Endline Baseline OR (random) Weight OR (random)or sub-category n/N n/N 95% CI % 95% CI

BINP endline 1201/2567 253/425 23.63 0.60 [0.49, 0.74] TINP S-1 IER 637/947 856/1106 25.90 0.60 [0.49, 0.73] TINP S-2 IER 305/505 860/1116 20.92 0.45 [0.36, 0.57] TINP S-3 IER 618/996 977/1319 29.54 0.57 [0.48, 0.68]

Total (95% CI) 5015 3966 100.00 0.56 [0.50, 0.63]Total events: 2761 (Endline), 2946 (Baseline)Test for heterogeneity: Chi² = 4.22, df = 3 (P = 0.24), I² = 28.8%Test for overall effect: Z = 9.62 (P < 0.00001)

0.1 0.2 0.5 1 2 5 10

Favours treatment Favours control


30

Panel 4

Review: Large-scale nutrition programsComparison: 02 Changes in the weight for age Z score (Intervention area vs. Control area) Outcome: 01 Prevalence of underweight (<-2 Z score weight for age)

Study BINP Comparison OR (random) Weight OR (random)or sub-category n/N n/N 95% CI % 95% CI

BINP endline 1201/2567 416/842 0.00 0.90 [0.77, 1.05]

Total (95% CI) 2567 842 0.00 0.90 [0.77, 1.05]Total events: 1201 (BINP), 416 (Comparison)Test for heterogeneity: not applicableTest for overall effect: Z = 1.32 (P = 0.19)

0.1 0.2 0.5 1 2 5 10

Favours treatment Favours control Results from the Baseline Survey of National Nutrition Program of Bangladesh showed that the BINP was associated with increased prevalence of

good health practices relating to pregnancy i.e. increased food intake, more rest, and increased antenatal care (panel 5) (4). These good practices

showed an increasing trend with increase in maternal education and household asset index. Mothers’ involvement in NGO activities was also

related to good pregnancy-care practices. In the BINP project areas, pregnancy care in terms of more food intake and ANC, was better than in the

NNP project areas (where the program had not started when the survey was carried out). The higher the maternal education and household asset

index, the higher was the odds ratio of receiving iron supplement during pregnancy, but not receiving vitamin A capsule after delivery (panel 6).

Women in the BINP project areas were more likely to receive iron supplement than women in the NNP project areas. The prevalence of food

insecurity was much higher among illiterate and poor women. Surprisingly, the prevalence of receiving iron supplement was higher and food

insecurity was lower in the BINP project areas than in the NNP project areas.


31

Panel 5. Adjusted odds ratios (95% confidence interval) of good practices during pregnancy of mothers of children aged 24-59 months for different background characteristics (n=4852) Background characteristics More food intake More rest Receive ANC Age of mother (years) Maternal education

None Primary incomplete Primary complete Secondary incomplete Secondary+

Food deficit in last 12 months No deficit <4 months 4 months+

Asset index Lowest Second Middle Fourth Highest

Member of any samity (NGO): No Yes

Survey area: NNP project NNP comparison BINP project

0.96** (0.95-0.97) 1 1.22** (1.01-1.47) 1.21 (0.97-1.50) 1.07 (0.87-1.30) 1.41* (1.00-1.98) 1 0.90 (0.72-1.12) 0.76** (0.62-.92) 1 1.18 (0.96-1.45) 1.50** (1.19-1.89) 1.23 (0.99-1.54) 1.32* (1.02-1.72) 1 1.04 (0.90-1.20) 1 1.32* (1.05-1.66) 1.40** (1.21-1.61)

0.98** (0.97-0.99) 1 1.10 (0.91-1.32) 1.26* (1.01-1.58) 1.66** (1.35-2.03) 2.29** (1.65-3.18) 1 0.96 (0.75-1.22) 1.03 (0.84-1.25) 1 1.08 (0.86-1.34) 1.01 (0.80-1.27) 0.94 (0.74-1.19) 1.04 (0.81-1.35) 1 1.15* (1.01-1.30) 1 1.21 (0.99-1.47) 1.05 (0.90-1.22)

0.96** (0.95-0.97) 1 1.20 (0.99-1.45) 1.60** (1.28-2.00) 2.01** (1.64-2.48) 6.56** (4.41-9.74) 1 1.12 (0.88-1.41) 0.96 (0.78-1.18) 1 1.21 (0.96-1.52) 1.40** (1.11-1.78) 1.61** (1.27-2.03) 2.79** (2.15-3.62) 1 1.29** (1.12-1.49) 1 1.20 (0.91-1.57) 2.28** (1.85-2.81)

Wald Chi-square (14 df) 682.6 , p<0.001 561.5, p<0.001 399.9, p<0.001 Note: The dependent variable equals to 1 if a mother has had more intake, more rest or received ANC during

pregnancy, 0 otherwise *p<0.05, **p<0.01


32

Panel 6. Adjusted odds ratios (95% confidence interval) of taking iron supplements during last pregnancy and vitamin A capsule after delivery by mothers of children aged 24-59 months for different background characteristics (n=4852) Background characteristics Intake of iron tablet Intake of vitamin A

capsule Household food insecurity in last yr

Age of mother (years) Maternal education None Primary incomplete Primary complete Secondary incomplete Secondary+ Food deficit in last 12 months No deficit <4 months 4 months+ Asset index Lowest Second Middle Fourth Highest Member of any samity (NGO) No Yes Survey area NNP project NNP comparison BINP project

0.96** (0.95-0.98) 1 1.23* (1.02-1.49) 1.26* (1.00-1.59) 2.03** (1.64-2.51) 3.98** (2.80-5.64) 1 1.04 (0.82-1.32) 0.97 (0.77-1.21) 1 1.13 (0.92-1.40) 1.35* (1.07-1.70) 1.35* (1.05-1.73) 2.10** (1.60-2.75) 1 1.16* (1.00-1.34) 1 1.10 (0.83-1.44) 2.69** (2.23-3.25)

0.98 (0.96-1.01) 1 0.85 (0.52-1.39) 1.19 (0.74-1.92) 1.02 (0.68-1.52) 1.93* (1.13-3.31) 1 0.95 (0.58-1.54) 0.67 (0.38-1.17) 1 0.88 (0.54-1.42) 0.97 (0.60-1.55) 1.04 (0.63-1.71) 1.45 (0.86-2.44) 1 1.01 (0.76-1.36) 1 0.38** (0.21-0.69) 1.04 (0.75-1.46)

1.02** (1.00-1.03) 1 0.77* (0.63-0.95) 0.53** (0.40-0.70) 0.48** (0.37-0.63) 0.06** (0.02-.018) N/A N/A N/A 1 0.50** (0.41-0.61) 0.31** (0.25-0.38) 0.11** (.09-0.15) 0.05** (0.03-0.07) 1 1.05 (0.80-1.48) 1 1.09 (0.80-1.48) 0.73** (0.59-0.89)

Wald Chi-square (14 df) 682.6 , p<0.001 561.5, p<0.001 399.9, p<0.001 Note: The dependent variable equals to 1 if a mother has received iron supplement when pregnant with the current child aged 24-59 months, or has had vitamin A capsule after delivery or has food insecurity in last year, 0 otherwise *p<0.05, **p<0.01

Another large scale program carried out with the help of the NGO sector is CARE India’s

Integrated Nutrition and Health Project II (45). This project targets the window of

opportunity – pregnancy to 36 months of age – and is now active in nine states of India.

Panel 7 summarizes the beneficial effects of the program on practice of optimal

breastfeeding, complementary feeding, immunization and vitamin A supplementation.


33

Panel 7. Infant feeding practices under CARE India’s Integrated Nutrition & Health Project II

Indicator All Low SES High SES

Intervention areas (%)

Non Intervention areas (%)





Initiation of breastfeeding (within 1 hour)

65.2 n=181

38.3* n=149

75.4 n=65

42* n=81

59.5 n=116

33.8* n=68

Exclusive breastfeeding for at least 6

months

69.3 n=189

57.6* n=151

69.6 n=69

63.9 n=83

69.2 n=120

50.0* n=68

Complementary feeding (CF) initiated (among 6-9 mth olds)

65.3 n=121

43.6* n=110

66.1 n=55

36.5* n=52

63.6 n=66

50 n=58

Dietary diversity in CF

Vegetables given 68.0 43.6* 62.9 50.7 71.9 37.0*

Oil added to food 41.9 20.5* 38.2 22.7* 44.7 18.5*

Dal/animal foods given 79.8 55.8* 73.0 58.7 85.1 53.1*

n=203 n=156 n=89 n=75 n=114 n=81

Appropriate quantity, frequency and 6.1 0.5* 2.8 0 8.7 0.9*

diversity in feeding as per age n=244 n=218 n=106 n=109 n=138 n=109

Measles immunization by 12 months 55.4 n=121

35.1* n=111

47.3 n=55

25.0* n=52

62.1 n=66

44.1 n=59

Vitamin A (one dose) among 59.5 43.2* 49.1 44.2* 68.2 42.4*

children 9-11 months n=121 n=111 n=55 n=52 n=66 n-59


34

Panel 8. Caregivers’ Key Health Promoting Practices in Honduras (47) AIN-C Control

1998 2000 1998 2000 1998 2000 Variable (baseline, %) (%) (baseline, %) (%)

Exclusive breastfeeding of children under 6 months of age 21 39 15 13

Offering complementary foods at an appropriate time 70 76 70 63

Giving oral rehydration solution to children with diarrhea 32 50 30 32

Giving oral rehydration therapy to children with diarrhea 37 57 36 42

Giving children fluids and continued feeding during a bout of diarrhea 21 33 17 16


35

Panel 9A. Interventions included in different large scale nutrition programs

Program Supplementary Feeding

Nutritional education/GMP

Health education

Immunization

Micronutrient supplementation

School feeding

Poultry/ Home gardening/ Home food production

Cash transfer

Referral Health service

Small income generation project

ICDS (India)

√ √ √ √ √ √ √

NNP/BINP (Bangladesh)

√ √ √ √ √

PROGRESSA (Mexico)

√ √ √ √ √

Child Pastorate Programme (Brazil)

√ √ √ √ √

LAKASS (Philippines)

√ √ √ √ √ √ √

SECALINE (Madagascar)

√ √ √ √ √ √ √

SEECALINE (Madagascar)

√ √ √ √ √

CSD (Tanzania)

√ √ √ √ √

Basic Minimum Needs Thailand

√ √ √ √ √ √ √ √

Posyandus, Indonesia

√ √ √ √ √ √

AIN-C, Honduras

√ √ √ √ √

TINP-1 (India) √ √ √ √ √ √ √


36

Panel 9B. Interventions of different large scale programs

Program Supplementary Feeding

Nutritional education/GMP

Health education

Immunization

Micronutrient supplementation

School feeding

Poultry/ Home gardening/ Home food production

Cash transfer

Referral Health service

Small income generation project

LINKAGES Ethiopia

√ √ √ √

LINKAGES Madagascar

√ √ √ √

CSFP Zimbabwe

√ √ √

Iringa Tanzania

√ √ √ √ √ √ √

CFP Costa Rica

√ √ √ √

CNP Senegal

√ √ √ √ √ √

NEP Senegal √ √ √ √ √ √

Community-Based Poverty Reduction Project Ghana

√ √ √ √ √ √

Nutrition, food security and social mobilization project Mauritania

√ √ √ √ √ √

ECD Philippines

√ √ √ √ √ √

PHPNP Gambia √ √ √ √ √

Women and child development project India

√ √ √ √ √ √

BIDANI Philippines

√ √ √ √ √ √ √


37

UPGK Indonesia

√ √ √ √ √

HSDP Costa Rica

√ √ √ √ √


38

Panel 10. Comparing Cost per beneficiary (US $) and intensity of selected large scale nutrition programs

Project/Country Main programme

components

Cost per beneficiary (US$) Intensity

ICDS/India Growth monitoring, supplementary feeding, nutrition education, health services.

7.5 (not including food) (44) 700-1000 population/angonwadi worker. (48)

TINP/India Growth monitoring, supplementary feeding, nutrition education, health services.

9 (over-all cost), 7 (weighing-screening), 12 (weighing-feeding) (44)

A Community Nutrition Centre was established in each village (population 1500) and run by a Community Nutrition Worker (CNW).(44)

UPGK/Indonesia Growth monitoring, supplementary feeding

2 (weighing), 11 (weighing and feeding) (44)

NNCHP/ Costa Rica Pre-school and school feeding and nutrition education

21 (44), but from another source 12.50/child/year (49)

2 health workers per 5000 population (appr. 1:350 children) (49)


39

JNSP/ Tanzania Growth monitoring 8 (recurrent costs), 17 (total costs) (44, 49)

2 village health workers/village = 1220 total (appr. 1:40 children) (49)

CSD/ Tanzania Immunization, growth monitoring, health and nutrition counseling, multi-micronutrient supplementation and safe motherhood initiatives

2-3/child/year (49)

BINP/Bangladesh GMP, supplementary feeding , health & nutrition education, micronutrients supplementation, home gardening & poultry rearing

18/child/year (49) One CNP (community nutrition promotor) for every 1,000 population (appr. 1:200 children) (53)

CSFP/Zimbabwe Supplementary feeding 0.50/ child/year (49) Appr. 1:10-200, based on number of projects(49)

AIN-C/ Honduras Growth promotion and monitoring, health services, health check-up, follow-up and referral.

6/child/year (49) Volunteer teams 3:25 children, about 3.5 hours /volunteers/week. (49)


40

CNP/Senegal Growth monitoring, nutrition and health education, health services, food supplementation, water supply

21/direct beneficiaries/year (18) 1 community nutrition worker/465 population (half children and half mother. (50)

Child Pastorate Programme/Brazil GMP, oral rehydration, breastfeeding promotion, immunization, health education, and referral services

Appr 4.07/beneficiary/year (16) 37 children (<6yrs)/community volunteer. (51)

Ethiopia (LINKAGES) Essential Nutrition Actions (ENA) approach

2 health extension workers (HEWs) for every kebele in Ethiopia. Each worker is responsible for around 500 households. To support the work of health extension workers, the ESHE Project trains community health promoters (CHPs). With 1 community health promoter to 30–50 households, the CHPs expand the promotion and organizational work of health extension workers.(52)


41

Madagascar (LINKAGES) Essential Nutrition Actions (ENA) approach

The cost of replicating the package of activities to promote EBF, TIBF, and LAM is $6.23 per targeted child, while the cost per new EBF, TIBF, and LAM acceptor are $10.09, $2.33 and $4.44, respectively. (53)

Nutrition enhancement programme (NEP) Senegal

• Growth monitoring of the children; • weekly nutrition and health education sessions to women;

• Micronutrient supplement • home visits to follow up on beneficiaries who were referred

or who do not come to the services • Capacity building. (38)

Cost per beneficiary $ 4.5 in urban areas and $3.7 in rural areas (38).

Posyandus, Indonesia

GMP, nutritional education, supplementary feeding (later stopped), food demonstration, Vit A, iron tablets, oral rehydration salts, advice for home gardening and supply of contraceptives. UPGK, village family nutrition programme, run by village volunteer who received 5 days training for GMP (24).

2-11/ child/year depending on supplemental food.

Village workers (approxamately 3 million total), 1 per 60 people, approxamately 1 per 10 children.


42

Nutrition and Primary Health Care Program/ Thailand

Growth monitoring, nutrition surveillance activities, nutrition training and Education, supplementary food,adjunct anemia and IDD control, wide variety of supportive programs(e.g. adjunct MCH services, school nutrition programme) (21)

Appr. 11/head/year (21) 1 village health communicator or volunteer per approxately 20 children. (21)

BIDANI Philippines supplementary feeding, nutrition education, growth monitoring, home food production, adjunct health services, development projects:land reform, irrigation, road construction, income generation, marketing, environmental sanitation. The BIDANI Program is a complementary effort to the Lalakas ang Katawang Sapat sa Sustansiya (LAKASS) Program of the National Nutrition Council. (54)

40/child/year in targeted areas. (21)

Village workers (barangay nutrition scholars) appr. 1:300 (21)

HSDP Costa Rica

Development of rural health workers, health and nutrition education, antenatal care and MCH services, anaemia control (treatment of anemia), clinics developed for treatment/follow up (including immunization with most available vaccines to cover more than 80% of the susceptible population) (54)

1.70/child/year (21)


43

Panel 11: Nutrition programs not included Name of the programme

Year Program content Coverage Impact Cause of exclusion

Determinants of weight and length of Indonesian neonates.

1997-1999 Weekly supplementation during pregnancy with iron and vitamin A on infant growth

9 out of 19 rural villages in Leuwiliang sub-district, West Java (n=366 pregnant mothers)

Iron and vitamin A statusduring pregnancy did not influence neonatal weight and length significantly (55).

The coverage was not adequate

Results of a community-based low-literacy nutrition education program. USA

8 weeks Comparison group received messages focused on food budgeting, food safety and healthy eating. The intervention group received a low- fat nutrition education (sessions on low-fat snacks, healthy eating for kids, low-fat fast foods, weight loss, quick and easy meals, recipe modification, menu planning and grocery shopping

Subjects were adult participants of the EFNEP in the Twin Cities Metropolitan area. Over-all 130 intervention and 70 comparison subjects completed both pre- and post -test phases of the study

The low- fat intervention was associated with significant inprovments in eating behaviors related to substitution of high-fat foods with low-fat alternatives and significant inprovments in over-all low-fat eating beaviors (56).

The study coverage was not adequate and study took place in a developed country.

Nutrition and education: a randomized trial of the effects of breakfast in rural primary school children. Jamaica

1994- A total of 16 primary schools (grade 2-5), 407 children whose WAZ <= -1SD formed the undernourished group and 407 children with WAZ >-1 SD formed the nourished group. They were stratified by nutritional group and class in each school and randomly assigned to the breakfast or control group (57).

There was no significant difference between the breakfast and control group within each nutritional group in school achievement scores, attendence or nutritional status. Children in the breakfast group gained more weight and increased in height and BMI significantly more than those in the control group(57).

The coverage was not adequate and also did not meet the large scale nutrition program criteria.


44

Monetary incentives in primary health care and effects on use and coverage of preventive health care interventions in rural Honduras: cluster randomised trial.

2000-2002 70 municipalities with a total population of 660,000. 70 programme municipalities were randomly assigned to one of the four - (1) household-level package alone, (2) service-level package alone, (3) both packages, (4) standard services (control group)

The household level intervention had a large impact (15-20 percentage point;p<0.01) on the reported coverage antenatal care and well-child check-up. Childhood immunization series could be started more oppertunely, and the coverageof growth monitoring was markedly increased (15-21 PP;p<0.01). Measles and tetanus toxoid immunization were not affected. The transfer of resources to local teams could not be implemented properly because of legal complication (58).

The study dealt with cash transfer

Impact of nutrition education and mega-dose vitamin A supplementation on the health of children in Nepal.

24months (ended in 1992)

Approximately 40000 children(aged under 10 years) from 75 locations in seven districts took part in the study and were randomly allocated to intervention cohorts or control group.

The reduction of the risk for xerophthalmia was greater among children whose mothers were ableto identify vitamin A rich foods (RR=0.25; 95% CI = 0.10-0.62) than among the children who received mega-dose capsules (RR = 0.59; 95% CI = 0.41-0.84). Receipt of a vitamin A capsule was associated with a slight but significant reduction of risk of wasting.Children who participated in the nutrition education programme had an RR = 0.61-0.89 for wasting. The greatest reduction of risk for wasting was associated with knowing that wild greens are a good source of vitamin A (59).

The study did not meet the large scale nutrition program criteria.


45

Zimbabwe Take home child supplementary feeding programme

two months between July 1995 and May 1996

Children enrolled in the program received a take-home ration of 2 kg Nutrimeal porridge flour containing maize, soya bean flour, sugar, and salt and mothers were instructed to return in two weeks for growth monitoring and porridge resupply (60).

Sakubva, Mutare city's densely populated high density suburb.

190 study subjects received over 2500 kg of porridge and achieved a total weight change of 170 kg. 158 children (83%) showed improved growth as a result of program participation and 112 (59%) experienced recovery growth (0.2 kg/month or more). 32 children (17%) did not improve and 15 (8%) of these children lost weight while participating in the program (60).

Zambia A Basic Education Sector Investment Programme - school health component

Piloting deworming and micronutrient delivery to improve student nutrition and reduce iron deficiency anaemia. Also intends to document the benefits for improvement in cognitive capacity and learning outcomes.

Whole project is Nationwide. School Health component is in 5 Districts. No of school= 30, This segment of the project is for 3 years (61).

The study did not meet the large scale nutrition program coverage criteria.

Zambia B Integrated Education Sector Improvement Program (ESIP): School Nutrition and Health Programme

To improve children’s educational performance by targeting basic nutrition and health problems through simple, low cost interventions. A ‘School Health Team’ would be created under the joint auspices of the ministries of Education and/or Health; this team would visit schools to provide micronutrient supplements such as iodine and vitamin A, and treatment for helminth infections (61).

Nationwide. Target population: School children. Project period: 5 years (61).



46

Zambia C CHANGES: The Ministry of Education's School Health and Nutrition Programme

Since 2001, ongoing.

CHANGES is the school health and nutrition component of the Zambian Government's Basic Education Sub-Sector Investment Programme (BESSIP) and follows the FRESH framework. Interventions include: deworming (albendazole and praziquantel); micronutrient supplements (iron and vitamin A); skills-based health education (HIV/AIDS and malaria) and improvements in water and sanitation facilities. Phase 1 of the programme was designed to evaluate the impact of interventions of the children's health, nutrition, cognition and educational achievement.

Initially Eastern Province, with plans for Nationwide coverage. Phase 1 of the programme covered 80 schools over 3 year period. Target population: >3000 children (61).


Benin Nutritional rehabilitation at home(NRH)

Screening and rehabilitation protocols were developed for the project and were defined before the study began. The implementation process was evaluated by checking whether the children registered for NRH had received adequate treatment from the health agencies. Intervention was judged to be adequate if it was consistent with that previously set out in the rehabilitation protocol. The variables studied concerned whether the health workers had adequately implemented NRH and had applied UNICEF's three. "A" (Assessment, Analysis and Action). The results of the rehabilitation process were recorded. The weight and age of the children were determined to evaluate changes in their nutrition status.

Done only in 2 districts of Benin At inclusion, 191 children (42.3%) were suffering from mild malnutrition and 146 (32.3%) were suffering from severe malnutrition. Seventy children (15.5%) were rehabilitated as defined in the protocol standards. One hundred and fifty nine children (35.2%) were lost to follow-up, 83 (18.4%) stopped the treatment and 83 (18.4%) were declared rehabilitated when they were not. The nutrition status of 69 of the 70 children who completed NRH had improved (62).



47

Malawi Tulimbe Nutrition Project

Started on 1995

Among 300 families with children ranging from 3 to 7 years (63).


Bolivia Community-based ComprehensivePrimary Healthcare Programme on Infant andChild Mortality in Bolivia

Programs started on 1983 and evaluation was done on January 1992 to December 1993

ARHC provided community-based comprehensiveprimary healthcare services in the intervention communities.These included: provision of immunizations and vitaminA capsules in accordance with MoH policies, growthmonitoring, prenatal healthcare, health education(particularly relating to the prevention and treatment ofdiarrhoea, the early warning signs of childhoodpneumonia, and the promotion of appropriate infantfeeding), treatment of pneumonia and diarrhoea,emergency assistance with complications arising duringchildbirth, and treatment of acute and chronic conditionsfor persons of all ages

In two areas—Carabuco and MallcoRancho—Andean Rural Health Care (ARHC) had been coordinating health services since 1983 and 1987 respectively and were, therefore,referred to as intervention areas. Data were compared with those from two geographicallyadjacent areas— Ancoraimes and Sipe-Sipe. InAncoraimes, eight comparison communities with a total population of 2,008 and in Sipe-Sipe, eight comparison communities with a total population of 2,064 were included.The population of intervention areas were 9000 and 6400 respectively. In the comparisonareas, limited services were available which reached only a small percentage of the population, whilein the intervention areas,prenatal care, immunizations, growth monitoring, nutrition rehabilitation,and acute curative services were readily available to the entire population (63).

2.6% cases of <5y death were due to severe malnutrition in intervention areas (n=4206). And in comparison area it was 8% (n=596) (64).

The study did not meet the large scale nutrition program criteria.


48

LINKAGES Zambia

1997-2005 National Policy on Breastfeeding Practices and HIV/AIDS transmission from mother to child. Project focusing on infant feeding in an antenatal clinic in an area of high HIV prevalence.

60 sites in 6 districts Results from baseline and endline surveys in districts showed that HIV counseling and testing uptake increased significantly among mothers. Exclusive breastfeeding rose from 50% in 2002 to 64% in 2004 in Livingstone and from 57% in 2000 to 74 % in 2004 in Ndola (28).

The study did not meet the large scale nutrition program criteria

LINKAGES Jordon

1998-2004 Integration of lactational amenorrhea into the national reproductive health care service delivery system. LAM is based on the natural infertility resulting from certain patterns of breastfeeding.

1.0 million In 1997 national Demographic and Health survey in Jordan only 11.9 percent of the infants less than 6 months old were exclusively breastfed. The rate rose to 26.7% in the 2002 DHS. During this time MOH/MCH and LINKAGES were actively promoting breastfeeding nationwide (28).


LINKAGES Ghana

1997-2004 In 2000 the GHS and LINKAGES Project began implementation of a nutrition behavior change communication strategy to improve infant and young child feeding . The interventions included radio, print, interpersonal counseling, community events and mother-to-mother support groups.

3.3 million Results of the annual rapid assessment procedure indicate improving infant feeding practices between 2000 and 2003. Exclusive breastfeeding: from 68% to 79%; Timely initiation of : from 32% to 40%; Timely complementary feeding: from 74% to 79% (28).



LINKAGES Bolivia

1998-2003 LINKAGES and PROCOSI (NGOs) implemented a programme to improve infant and young child feeding practices and expand access to LAM.

1 million An endline survey in 2003 tracked program progress and impact. EBF: baseline(2000) - 54%, endline - 65%; TIBF: baseline - 56%, endline - 74%; TCF:baseline - 80%, endline - 84%, LAM: baseline - 3%, endline - 7% (28).

Breastfeeding and complementary feeding CARE LINKAGES

India 1997-2004

Supplementary feeding 3 districts, Madhya Pradesh: total population (2001): 2.8 million; 132 blocks,

Phase I end-line results from CARE’s pilot project


49

in Angarah Block, Ranchi District, Bihar, showed

PVO Pilot (Phase 1, 1997-2001) coverage: 288,500

Uttar Pradesh: total population 15.8 million, beneficiary

82 percent of pregnant women receiving and

Capacity Building (Phase 2, 2002-2004) coverage:

population 1.4 million (28) consuming their food ration, compared with 38

7 million percent in 1999 (28). • Initiation of breastfeeding within 1 hour of birth from <1% to 6% • Initiation of breastfeeding within 0–8 hours from 15% to 54% • Exclusive breastfeeding for 6 months from 12% to 28% • Consumption of CSB by pregnant women from 38% to 82% World Vision • Increase in initiation of breastfeeding within 1 hour of birth from 7% to 22% • Increase in exclusive Covered 60 villages of about 60,000

people.(28) breastfeeding from 52% to 44%

• Increase in median frequency of breastfeeding of infants 0–<6 months old in previous 24 hours from 9% to 10% • Increase in timely complementtary feeding of infants 6–<10 months old from 42% to 77%


50

Kenya Applied Nutrition Project

1983 to present

Food production, food security and income generating activities such as : introduction of drought-tolerant crops, group seed banks, small live stock, credit and improve water supply and sanitation (12)

Three food insecured divisions that comprises arid and semi-arid land. No information on population coverage.

Not mentioned No specific nutrition component(12).

SriLanka National Programme for Poverty Alleviation- Samurdhi.

1994 to present

Community participation. Income support to the poorest families, income generating activities, skill training and infrastructural and social development activitis (12).

Nationwide. No data to assess the programme's impact on health and nutrition.

No specific nutrition component(12).

Honduras PROLESUR project.

1988 Food production, food security, income generating activities and agricultural support.

Southern municipalties of Honduras No data to assess the programme's impact on health and nutrition.

No specific nutrition component(12).

Child development project Yemen

2000 GMP, Capacity building Under 5 children of 30 targeted district No sufficient data to assess the programme's impact on health and nutrition.

No sufficient data (65).

Pilot Food Price Subsidy Scheme, Philippines

1983-1985: project delivery

Consumer food subsidy on rice and cooking oil; nutrition education; and technical, economic and administrative evaluation. Subsidies in the form of price discounts on rice and cooking oil were made available to half of 14 villages selected for their high incidence of malnutrition, while the other half acted as a control population (54).

7 project villages and 7 control villages in 3 provinces: 14,788

Increases in calorie consumption of 138 calories per adult equivalent unit per day, which is roughly 7% of the current calorie consumption. The scheme also reduced the prevalence of underweight preschoolers from 32% to 20%. Nutrition education had a small positive effect in households where it was accompanied by the subsidy(54).

The study does not meet the coverage or the large scale nutrition program criteria.

Alternative School Nutrition Programme (ASNP), Philippines

1983 to 1989

supplementary feeding, income generating activities, nutrition education, food production, environmental sanitation(54).

1047 schools in 11 regions A weight survey in one region showed that 75% of the severely underweight children who participated in the ASNP improved their weights significantly.

The study does not meet the large scale nutrition program criteria.


51

Community- Based Nutrition Intervention/North-East Thailand (A pilot project)

1982 to 1985

Growth monitoring, supplementary feeding, nutrition education, weaning foods preparation, home visits/follow up, establishment of drug cooperative stores (54).

4 intervention villages, with 3 control villages. Population in the intervention = 270.

In villages where cooperation was good, a marked decline in frequency of illness was observed (54).

The study does not meet the coverage of a large scale nutrition program .

Project COPACA/ Peru 1985 (pilot), in 1989 it expanded to the present.

Nutrition surveillance, agriculture extension, health and nutrition education (54).

Pilot in 22 communities in one region A baseline survey was conducted in 1989. Anthropometric and health data were collected from 754 children and data of weaning practices were obtained from 323 households with children under 6 years. The survey showed - Percentage of children (between 6 and 24 months) with normal weight-for-age values increases from 59% (1989) to 72% (1992).Percentage of children who get weaning food before 6 months decreases from 55% (1989) to 36% (1992) and percentage of children who get nutritious weaning food (cereal, fat or oil, legumes, vegetables) increases from 26% (1989) to 45% (1992) (54).

The study does not meet the coverage of a large scale nutrition program.

Improving Child Nutrition, Weaning Food Project/Ghana

1986 to 1988 (44)

Provision of corn mills, training of workers and trainers, nutrition surveillance (including growth monitoring), nutrition and health education, baseline data collection. (44)

Around 100 villages.(44) Maternal knowledge of basic nutrition improved in project communities compared to non-project communities. The program contributed to greater household food security and improved nutritional status of children. (39)

The study does not meet the large scale nutrition program criteria.


52

Community-based supplementary feeding for promoting the growth of young children in developing countries.

A review of 4 RCTs. (2 in Indonesia and 1 each in Guatemala and Jamaica.

Supplementary feeding or food supplementation defined as the provision of extra food to children or families beyond the normal rations of their home diets. The intervention has to be community- based - i.e. young children could consume the supplementary food at home, at a supervised feeding centre, or other places adapted for this purpose such as health care centres and crèches. Trials in hospital and refugee settings were excluded. (66)

Indonesia in 1991(20 Day Care Centres, n = 113 children), Guatemala included four villages as unit of analysis (exact sample sizes were not provided), Jamaica (n = 65 children) and Indonesia (n = 75 children). (66)

Based on the small number of available trials, no firm conclusions of the effectiveness of supplementary feeding to the growth of preschool children could be drawn. Issues of research design such as blinding and sample size calculation need to be addressed in future studies. (66)

The study does not meet the coverage or the large scale nutrition program criteria.


53

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Documents

1 Web Appendix 17 Large-Scale Nutrition Programs ICDDR,B