1. PM2A: From Haiti to Guatemala and Burundi Gilles Bergeron May 9, 2011 Food and Nutrition Technical Assistance II Project (FANTA-2) Academy for Educational Development 1825 Connecticut Ave., NW Washington, DC 20009 Tel: 202-884-8000 Fax: 202-884-8432 E-mail: fanta2@aed.org Website: www.fanta-2.org

2. Organization of presentation Key ideas associated with PM2A – The window of opportunity (“1000 days”) – Prevention – The UNICEF model What started it all: the Haiti study (2002-2006) What next? The rationale behind the Guatemala and Burundi studies

3. Key idea #1 of PM2A: Why up to 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

4. 1. Chronic malnutrition begins early* *Lancet series on Nutrition 2008 www.GlobalNutritionSeries.org, www.GlobalNutritionSeries.org WB Repositioning Nutrition as Central to Development, 2006 http://siteresources.worldbank.org/NUTRITION/Resources/281846-1131636806329/NutritionStrategy.pdf

5. Intergenerational cycle of malnutrition Child growth failure Teen pregnancy Small adult women Low birth weight babies Low weight and height in teens ACC/SCN, 1992 PM2A Key Entry Points

6. 2. First 2 years: Period of Most Rapid Growth and Vulnerability to Growth Faltering Shrimpton et al. 2001

7. 3. Period of greatest opportunity from nutrition interventions in first 2-3 years (Guatemala Oriente study) Annual length gain (mm) 0-36 mo36-84 mo Schroeder et al. 1999 Change in length by age, with consumption of additional 100 kcal/d of Atole (high-energy/protein supplement) Age

8. 4. 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. 2008)

9. Key idea #2: Why prevention? -3-2 0 +2 +3

10. Key idea #2: Why prevention? -3-2 0 +2 +3

11. Child Nutritional Status UNICEF, 1990. Access to adequate food Access to essential health services and a healthy environment Care practices for mothers and children Underlying Causes Direct Causes Health Diet Basic/ Fundamental Causes Formal and non-formal institutions Appropriate education Political, economic and cultural environment Potential resources Key idea #3: the UNICEF Model

12. Core package of PM2A Food. Usually includes – Family ration to improve HH FS and access to foods of higher quality (FBF). – Individual ration for direct beneficiaries to increase nutrient intake. Health: Includes: – regular visits to health centers to seek preventive/curative H/N services for: PLW (pre- and postnatal care, assisted delivery & postnatal controls) Children under 2 (immunization, Vit A, deworming, DD prevention/management, malaria prevention strategies, prevent/treat iron deficiency, GMP – Active case finding and referral of children with SAM Care practices. BCC strategy to: – improve IYCF, hygiene, health seeking behaviors – stimulate adoption of recommended practices/use of available services, – teach how to use donated/local foods – ensure targeted beneficiaries access the services and donated food. As any preventive intervention, PM2A targets ALL children -9/+24)

13. In sum: PM2A Key Elements Focus on the 1000 days Follows public health notion of prevention (all children are covered) Interventions are based on the UNICEF conceptual model Those three elements are key. The “How” can change, not the “what”

14. Summary of Haiti study findings

15. Based on a MYAP implemented by World Vision in Haiti’s Central Plateau between 2002 and 2005 Cluster randomized trial (no controls) Study carried out by IFPRI Goal: compare the relative merit of preventive vs recuperative programming to reduce population level of child malnutrition Refs: Lancet paper, Propensity Score Matching paper, various documents on FANTA-2’s website The FANTA/IFPRI/World Vision study

16. At final survey preventive communities had better anthropometry than recuperative ones Outcome (final survey) Preventive (n=752) Mean Recuperative (n=748 ) Mean Difference (preventive – recuperative) HAZ-1.53 *-1.67+ 0.14 WAZ-0.96*-1.20+ 0.24 WHZ-0.22*-0.46+ 0.24 *p<0.05; random effects regression using child-level data, controlling for child age, gender, and adjusting for clustering at pair-level

17. Initial roll- out; No full BCC The effects were consistent across age groups

18. Comparing with DHS surveys 2000 and 2005 (NCHS standards) Stunting increased by 10ppt in the region Stunting stayed same in Recup. arm Stunting reduced by 7ppt in Prev. arm

19. Impact on Food Security * *

20. Costs Both models have same direct program costs (in spite of the larger number of beneficiaries in preventive) Food costs are higher in the preventive approach due to the larger number of beneficiary-months Costs per beneficiary/month are lower in preventive: – direct program costs/beneficiary-mo are lower and – food costs/beneficiary are the same

21. Summary of findings from Haiti study Preventive model generated: – Lower prevalence of stunting, underweight, wasting – Higher mean HAZ, WAZ, WHZ – Results were consistent across age groups Preventive model also improved HH food security Cost per unit of improvement were lower in the preventive model

22. PM2A: Preventing Malnutrition in Children under 2 Years of Age

23. FFP’s PM2A initiative Based on Haiti findings: – FFP modified its guidance, specifying PM2A as the preferred MCHN approach for its Development Programs – FFP funded additional study of PM2A in 2 countries (Burundi, Guatemala) to improve efficiency of PM2A What makes the preventive model works? Can the cost of PM2A be reduced? MYAPs will receive $10M/yr for 5 years in each ($100M total); study will cost $8M total for 5 years in 2 countries MYAPs started 2010; study enrollment started 2011

24. Specific Objectives of the PM2A study Assess the impact and cost-effectiveness of PM2A on child nutrition Assess the importance of food ration (size/type) – Large, Reduced, or No Family Rations? – Individual Rations, Lipid-based Nutrient Supplements, or Micronutrient Sprinkles? Assess the impact of the duration of exposure on child nutrition Not an objective: – Assess the impact of BCC only – Assess the impact of no food at all (no individual nor FR)

25. Key outcomes examined Child nutritional status – Linear growth – Micronutrient status Other child outcomes – Motor development – Cognition – Morbidity Secondary outcomes – HH FS – Maternal nutrition (Hb)

26. Burundi MYAP implemented by CRS-led consortium (with participation of IMC, FH, CARITAS/Bur) Study carried out by IFPRI Cluster randomized controlled trial 2 cross sectional surveys (Baseline/Endline) 3 study arms –PM2A (-9 to 24mo, full FR, BCC, HS) – PM2A until child is 18 mo (instead of 24) –Control” No services from MYAP (only regular Gov’t ones)

27. Guatemala MYAP Implemented by Mercy Corps in Alta Verapaz Study carried out by IFPRI Cluster randomized controlled trial 2 cross sectional surveys (Baseline/Endline) Longitudinal study repeated at 1, 4, 6, 9, 12, 18, 24 mo Six “study arms” i.PM2A: “Full” PM2A (-9 to 24mo, full FR, BCC, HS) ii.PM2A/.5FR: PM2A with smaller (1/2) family ration iii.PM2A/0FR: with no family ration iv.PM2A/LNS: PM2A w/LNS (no food) as individual child ration v.PM2A/MNP: PM2A w/MNP (no food) as individual child ration vi.Control: No services from MYAP (only regular Gov’t ones)

28. Questions to study size of family rations and comparisons used Does PM2A with a reduced FR improve child NS? PM2A/.5FR vs CTRL Do large FR have a larger impact on child NS than reduced FR? PM2A/.5FR vs PM2A Does PM2A without a FR improve child NS? PM2A/0FR vs CTRL Are FR necessary for PM2A to impact child NS? PM2A/0FR vs PM2A

29. Questions to study the composition of individual rations and comparisons used Does PM2A w/LNS improve child NS? `PM2A/LNS vs CTRL What is the impact of PM2A w/LNS vs PM2A w/CSB? PM2A/LNS vs PM2A Does PM2A with MNP improve child NS?PM2A/MNP vs CTRL What is the impact of PM2A w/MN vs PM2A w/CSB? PM2A/MNP vs PM2A Does PM2A w/LNS have the same or more impact than PM2A w/MNP on child NS? PM2A/MNP vs PM2A/LNS

30. Questions to assess the impact of different duration of PM2A and comparisons used Does a PM2A program that provides benefits to children up to 18mo have an impact on NS? PM2A/18 vs CTRL Is it necessary to provide benefits up to 24mo for impact on child NS, or is 18 months sufficient? PM2A/18 vs PM2A

31. Questions to assess the impact & cost- effectiveness of PM2A on child nutrition Does PM2A improve child NS compared to Ctrl? PM2A vs Control What is the cost & cost- effectiveness of PM2A? PM2A vs Control

32. Additional studies Formative research (to develop the BCC strategy) Operations research (throughout implementation) Cost study to assess cost effectiveness and cost benefit of the different study arms Special studies: tbd – Intra-HH utilization of food commodities – Side effects of food aid on production, fertility decisions

33. Next steps Studies to be finalized in 2015… Publications in peer-reviewed journals Revision of the FANTA-2 TRM Development of additional tools to help programming, e.g.: – Costing tool – Ration size calculator Meanwhile, FANTA-2 will continue to provide technical support to PVOs in PM2A implementation

34. This presentation is made possible by the generous support of the American people through the support of the Office of Health, Infectious Disease, and Nutrition, Bureau for Global Health, and of the Office of Food for Peace, Bureau for Democracy, Conflicts and Humanitarian Assistance, United States Agency for International Development (USAID) under terms of Cooperative Agreement No. GHN-A-00-08-00001-00, through the Food and Nutrition Technical Assistance II Project (FANTA-2), managed by AED. The contents are the responsibility of AED and do not necessarily reflect the views of USAID or the United States Government. Food and Nutrition Technical Assistance II Project (FANTA-2) AED 1825 Connecticut Ave., NW Washington, DC 20009 Tel: 202-884-8000 Fax: 202-884-8432 E-mail: fanta2@aed.org Website: www.fanta-2.org