1. Impact of Large-Scale Infant Feeding Promotion on Child Survival and Health in Madagascar

2. If a new vaccine became available that could prevent one million or more child deaths a year, and that was moreover cheap, safe, administered orally, and required no cold chain, it would become an immediate public health imperative. Breastfeeding can do all this and more………Lancet 1994 Photo: Carolyn Kruger General Context (1)

3. Early 1990s hospital-based efforts were successful but weakly linked to community Operational research/meta-analyses demonstrate that Breastfeeding promotion is an evidence-based interventions to prevent malnutrition and to improve children under five years old nutrition status (Lancet series) There are few impact assessment of large-scale Breastfeeding promotion The challenge is to develop and apply standard impact assessment methodology of programmatic behavior change strategy regarding optimal infant feeding behaviors General Context (2)

4. Early initiation of breastfeeding (within an hour of birth) Exclusive breastfeeding for first 6 months Timely introduction and frequent feeding of nutrient rich complementary foods Continued breastfeeding through the second year of life Optimal Infant Feeding Behaviors

5. LINKAGES: USAID- Funded Program Sustain/advance USAIDs role as a global technical leader Extend coverage by working with partners Demonstrate exclusive breastfeeding as an achievable goal Improve breastfeeding behaviors at scale in 3-5 countries Demonstrate what works at the community level Goal: Improve the health and nutritional status of Children and women

6. Collaborate and Harmonize at all levels Health workers Public Private Communities (families) District MOH Team NGOs Hospital Administration Community Leaders Community volunteers Existing Groups National Districts Health Facilities Planners Donors Academia Journalists Program Strategies

7. Key Program Characteristics Program FocusProgram strategy based on Integrated Management of Childhood Illness (IMCI) approach. Key Nutrition Behaviors Targeted- Breastfeeding - Complementary feeding - Feeding of sick children - Womens Nutrition - Vitamin A supplementation - Iron supplementation - Iodized salt Focus period for presentationJanuary 2000 – September 2001 Geographical Coverage during the focus period 2 Regions 10 Districts Population Covered during focus period1.33 million

8. LINKAGES: M&E Framework INPUTS - Human Resources - Financial Resources - Equipment PROCESS - Training - BCC/IEC - Mass Media -Advocacy OUTPUTS -Number of Key informants trained -Number of Mothers counseled - Number of materials developed OUTCOMES - Increased Knowledge - Improved- Changed Behavior IMPACTS -Cost Effective -Reduced malnutrition Rapid Assessment (Annual) & Performance Monitoring (Every six months) Monitoring (Annual) Evaluation (Baseline/Midterm/Endline)

9. Impact Assessment System Analysis Performance Monitoring Impact Assessment Advocacy Behavior Change

10. Performance Monitoring Objective: Assess Knowledge and Counseling skills of the Key Informants (Public and Private Health Workers, Volunteers) Methodology: Pre and Post Test during training Lot Quality Sampling Survey for Public Health Workers and Volunteers in both rural and urban areas (every six months) Self Assessment for Private Workers and Hospitals in the urban area (every six months)

11. Behaviors Indicators 1- Timely initiation of breastfeeding (TIBF) within the first hour of birth 2- Exclusive breastfeeding (EBF) among women with infants 0-5 months of age Rapid Assessment Procedures # of infants 0-<6 months exclusively bf X 100 total # of infants 0-<6 months WHO 1991,DHS and Multiple Indicator Cluster Survey (MICS) 24-hour food feeding recall question

12. Objectives: Assess Behavior change indicators of the Beneficiary Methodology: Rapid Assessment Procedures based on UNICEF and WHO methodology at province/region level (annual) Include both Quantitative and Qualitative surveys Cross-sectional survey methodology Target group: Woman with child 0-5 months Sample size: 1800 Geographical area: 2 Regions Rapid Assessment Procedures

13. Timely Initiation of Breastfeeding (within 1 hour of delivery)

14. Exclusive breastfeeding (infants 0–<6 months)

15. Cost Effectiveness Analysis 1- Cost effectiveness ratio: e.g. cost per New Acceptor of promoting EBF [cost of activities to promote EBF] [target population] * ([EBF rate at end of period] – [EBF rate at baseline]) 2- Cost per Beneficiary (per capita) 3- Cost per DALY for Breastfeeding promotion activities Indicators 4- Mortality averted rate

16. Methodology Cost Effectiveness Analysis: Methodology 1- Data Selection: Type of costs included: - Full costs of program activities (including overhead) that support the promotion of targeted behaviors in country for both central and district level - Direct cost of HQ costs associated with nutrition promotion activities - Direct costs of program partners 2- Data Collection: All financial data were collected retrospectively

17. Costs: Entire Program and Promotion of EBF and TIBF

18. Cost per Beneficiary

19. Cost per New Acceptor Pop 26,594 Pop 52,859 Pop 79,453

20. Source: Disease Control Priorities in Developing Countries, 2006 Cost-effectiveness of Child Survival Interventions

21. Costs of Breastfeeding Promotion: Madagascar, 2001 Estimated reduction in infant deaths due to an increase in exclusive breastfeeding: Increase in EBF rate: 50% to 86% Cost per new breastfeeding acceptor: $10 Infants deaths averted: 5% At a cost of $31/DALY

22. Conclusions 1- Comparability with international data 2- Comparability with different child and health survival interventions 3- Availability of crucial information on How to improve cost effectiveness of programmatic breastfeeding promotion? 4- Feasibility to assess the evidence-base of behavior change interventions on health and child survival 5- Need to determine how long it takes for these types of behaviors to become cultural norms

23. T H A N K Y O U