Prevention is Better than Cure: Food Assisted MCHN Programming in Haiti

1. Prevention is Better than Cure:Food Assisted MCHN Programming in Haiti Gilles Bergeron FANTA Collaboration between IFPRI, Cornell University, World Vision-Haiti

2. Background Food-assisted MCHN programs typically target underweight children < 5 years found to be undernourished (recuperative model) However, growing evidence indicates that the first 2 years are the « window of opportunity » for nutrition interventions Missing: programmatic evidence that targeting children < 2 years is effective in reducing undernutrition

3. Main thrust of the study: Compare 2 approaches of targeting food-assisted MCHN programs: The recuperative approach: which consists of targeting children 6-59 months of age once they have been identified as malnourished (WAZ < -2 SD) The preventive approach: which involves the targeting all children 6-24 months of age, in an effort to prevent rather than cure malnutrition *Both program models also target pregnant/lactating women

4. Setting the stage: Why 6-24 months? Period of greatest vulnerability and of greatest opportunity. The quality of nutrition in the first two years affects a person for a lifetime

5. Chronic malnutrition begins early*

6. Intergenerational cycle of malnutrition

7. First 2 years: Period of Most Rapid Growth and Vulnerability to Growth Faltering

8. 2. Greatest benefits from nutrition interventionsin first 2-3 years (Guatemala)

9. 3. Long term effects of improved nutrition during early infancy (Guatemala) Body composition Physical and reproductive performance Cognitive development Educational achievement Income generation potential (Martorell, 1995; Ruel et al. 1995; Pollitt et al. 1993; Hoddinott et al. forthcoming)

10. Improving early childhood nutrition increases cognition, education and economic productivity at adulthood

11. Impacts on income (% increase)

12. Prevention vs cure: the long term effect on population distributions

13. Prevention vs cure: the long term effect on population distributions

14. Objectives, timeline, methodology of the Haiti study

15. Main objective of the study: Compare impact on childhood undernutrition of 2 approaches of targeting FA-MCHN programs: The recuperative approach: targets underweight children < 5 y (WAZ < -2 SD) The preventive approach: targets all children 6-24 months of age to prevent undernutrition *Both program models also target pregnant/lactating women

16. Timeline

17. The Context: FA-MCHN (WV-Haiti) Emphasize prenatal/lactating food supplements are the same in both program modelsEmphasize prenatal/lactating food supplements are the same in both program models

18. Program Models

19. Program Models

20. Food Assistance Package

21. Trial Profile: Cluster Randomized Trial

22. Data collected Anthropometry – children and mothers Community characteristics Household demographics, socioeconomic status, food security Maternal characteristics Behavior change outcomes Program participation

23. Approach to impact analysis Comparisons of preventive/recuperative at final survey (“intent to treat”): Paired t-tests Random effects regression models Other analyses to help interpret results: Impact by age Impact on mediating variables (food security, behavior change) Where appropriate, impact by participation (ever or current) The randomized design permits assessment of probability of impact Assessing plausibility of impact requires that changes in mediating variables conform to expectations Adequacy refers to the degree to which the impact meets the objectives of the program The randomized design permits assessment of probability of impact Assessing plausibility of impact requires that changes in mediating variables conform to expectations Adequacy refers to the degree to which the impact meets the objectives of the program

24. Results of the comparison:Nutritional Impact

25. Baseline Characteristics (2002): No differences between groups No difference between groups Community characteristics Household characteristics Maternal characteristics Care practices Randomization was successful No differences Quality of program implementation Staff motivation Supervision No implementation differences between groups Implementation was high quality No difference between groups Community characteristics Household characteristics Maternal characteristics Care practices Randomization was successful No differences Quality of program implementation Staff motivation Supervision No implementation differences between groups Implementation was high quality

26. Preventive communities had better anthropometry than recuperative at final survey

28. Prevalence of Undernutrition: Lower in Preventive Group

29. Program participation

30. Summary of Impact on Nutritional Status Preventive has: Lower prevalence of stunting, underweight, wasting Higher mean HAZ, WAZ, WHZ Results by age group: Consistent trend of preventive better than recuperative First 6-12 Months of Life: No difference between preventive/recuperative (as expected)

31. Intermediary Mechanisms for Impact on Growth Food Security

32. Household food security is higher in preventive than recuperative communities at final survey

33. Impact on Food Security

34. Impact on Food Security

35. Cost

36. Estimating Cost Direct program costs (No difference between models) Staffing Infrastructure Central office Off budget program costs (larger in preventive) Food (donated) (98% of costs): Health supplies (mostly donated)

37. Program and off-budget costs Direct costs allocated 50-50 across recuperative & preventive areas, based on similar program structures. Do we think exact? Of course not, but pretty close. Thus (1) Costs mirror beneficiary-month patterns (not quite the same, because also include P/L which are same (2) Food costs are 40% - massive underestimate without them and 98% of off-budget program costs (Food & Health) (3) $2.4 million overall NOT SAME RATIOS B/C OF THE FOOD FOR P/LDirect costs allocated 50-50 across recuperative & preventive areas, based on similar program structures. Do we think exact? Of course not, but pretty close. Thus (1) Costs mirror beneficiary-month patterns (not quite the same, because also include P/L which are same (2) Food costs are 40% - massive underestimate without them and 98% of off-budget program costs (Food & Health) (3) $2.4 million overall NOT SAME RATIOS B/C OF THE FOOD FOR P/L

38. Beneficiary months Using administrative data, we examine the number of beneficiary-months. The period bracketed by the two surveys is shown, for completeness, though clear at the outset the program was just ramping up. First row – all of Central Plateau., then preventive, recuperative, and total pilot. (1) Rapid start-up (2) 1/5 is pilot (3) Twice as many preventive child beneficiary months by FY 2004/5. Number of P/L are nearly identical across the two interventions so not shown.Using administrative data, we examine the number of beneficiary-months. The period bracketed by the two surveys is shown, for completeness, though clear at the outset the program was just ramping up. First row – all of Central Plateau., then preventive, recuperative, and total pilot. (1) Rapid start-up (2) 1/5 is pilot (3) Twice as many preventive child beneficiary months by FY 2004/5. Number of P/L are nearly identical across the two interventions so not shown.

39. Direct and Off-Budget Costs per Beneficiary-Month ($) SOME THINGS IRRELEVANT FOR COSTING due to economies of scale. Don’t have to say ignoring but whether or not include p/L this is the differential. Since main difference is food, the technique used to calculate its value is critical – open to ideas on thisSOME THINGS IRRELEVANT FOR COSTING due to economies of scale. Don’t have to say ignoring but whether or not include p/L this is the differential. Since main difference is food, the technique used to calculate its value is critical – open to ideas on this

40. Conclusions on Cost Cost per beneficiary/month slightly lower in preventive model Overall program cost higher in preventive; but this was to be expected By design: duration of participation (9 vs. 18) and different patterns of participation (73% vs 28%) ? Greater quantities of food Due to relatively low UW prevalence in population (25%). This will vary by context

41. The importance of prevalence rates in estimating food costs

42. Overall Conclusions (1) Preventive model is more effective than recuperative model Nutritional impact is greater Results are consistent through age range exposed Size of difference between groups is meaningful (4-6 pp in 3 years) Impact achieved in period of severe hardship in Haiti in population that has moderate malnutrition levels Results suggest that impact is due to: Improved knowledge, practices (small differences) Improved food security (modest differences) Greater participation in program in preventive group

43. Overall Conclusions (2) Before/after comparisons suggest some deterioration in undernutrition in recuperative communities (plausible given economic & political crisis in Haiti) Both programs helped mitigate the crisis, but preventive was more effective at doing so

44. Comparing our sample with DHS surveys 2000 and 2005 (NCHS standards)

45. Overall Conclusions (3) Both models have same direct program costs (in spite of larger number of beneficiaries in preventive) Food costs are higher in preventive approach because of larger number of beneficiary-months Costs per beneficiary/month are actually lower in preventive because: direct program costs/beneficiary-mo are lower and food costs/beneficiary are the same

46. Implications for Title II MCHN Programs - 1 First study to show in programmatic context using a randomized evaluation design that preventive approach is more effective than recuperative Is recuperative approach effective at all? Is the preventive approach replicable? Are results of Haiti study generalizable?

47. Implications for Title II MCHN Programs - 2 Is Model Replicable? Yes, but will need: Good design – guidance on designing and implementing preventive approach is needed Effective implementation and service delivery (will require operations research to monitor and improve implementation) Good incentive structure and high staff motivation (monitored by qualitative research) AND - Childhood malnutrition is similar or higher

48. Future Research Needs How can steep drop in growth in 1st and 2nd year be prevented? For preventive approach: What is the optimal design? How long is enough to achieve impact (18, 15, 12 mo?) What happens to children after 24 mo? For recuperative approach: Is it effective, if compared to “nothing”?

49. For more information… Summary (15 pages) of the study at http://fantaproject.org/downloads/pdfs/Haiti_Exec_Summary_Dec07.pdf Full report (200+ pages) (available on request from FANTA) Contains in addition design and results from the Formative Research, and two rounds of Operations Research Lancet publication at http://download.thelancet.com/pdfs/journals/0140-6736/PIIS0140673608602718.pdf gbergero@aed.org

50. Sources of Funding USAID through FANTA/AED World Vision Haiti Government of Germany World Food Programme Micronutrient Initiative (sprinkles study) IFPRI and Cornell University

51. Study Team IFPRI: Marie Ruel, Principal Investigator Cornelia Loechl (outposted in Haiti) David Coady John Maluccio (now at Middlebury College) Mary Arimond Cornell University: Purnima Menon Gretel Pelto Jean-Pierre Habicht World Vision-Haiti: Lesly Michaud Bekele Hankebo Jean-Marie Boisrond Haiti Consultants: Arsène Ferrus Elisabeth Metellus Pierre Lenz Dominique Remy Lafalaise FANTA/AED: Gilles Bergeron USAID: Carell Laurent (Haiti) Eunyong Chung (USA)