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

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

2. Photo: Carolyn Kruger General Context (1) “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

3. General Context (2) • 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

4. Optimal Infant Feeding Behaviors • Early initiation of breastfeeding(withinanhour 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

5. LINKAGES: USAID- Funded Program Goal: Improve the health and nutritional status of Children and women • Sustain/advance USAID’s 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

6. Key Program Characteristics

7. LINKAGES: M&E Framework Evaluation (Baseline/Midterm/Endline) Monitoring (Annual) • 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 • PROCESS • - Training • - BCC/IEC • - Mass Media • Advocacy INPUTS - Human Resources - Financial Resources - Equipment Rapid Assessment (Annual) & Performance Monitoring (Every six months)

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

9. 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)

10. Rapid Assessment Procedures 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 # of infants 0-<6 months exclusively bfX 100 total # of infants 0-<6 months WHO 1991,DHS and Multiple Indicator Cluster Survey (MICS) • 24-hour food feeding recall question

11. Rapid Assessment Procedures 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

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

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

14. Cost Effectiveness Analysis Indicators 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 4- Mortality averted rate

15. 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

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

17. Cost per Beneficiary

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

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

20. 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

21. 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

22. T H A N K Y O U