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
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
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
1. Chronic malnutrition begins early*
*Lancet series on Nutrition 2008 www.GlobalNutritionSeries.org,
WB Repositioning Nutrition as Central to Development, 2006
http://siteresources.worldbank.org/NUTRITION/Resources/281846-1131636806329/NutritionStrategy.pdf
Intergenerational cycle of malnutrition
Child growth failure
Teen
pregnancy
Low birth
weight babies
Low weight and
height in teens
Small adult women
PM2A Key Entry Points
ACC/SCN, 1992
2. First 2 years: Period of Most Rapid Growth and
Vulnerability to Growth Faltering
0.5
Weight for age Z-score (NCHS)
0.25
0
-0.25
-0.5
-0.75
-1
-1.25
-1.5
-1.75
-2
0
3
6
9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60
Age (months)
Africa
Latin America and Caribbean
Asia
Shrimpton et al. 2001
3. Period of greatest opportunity from
nutrition interventions in first 2-3 years
(Guatemala Oriente study)
Annual length gain (mm)
Change in length by age, with consumption of
additional 100 kcal/d of Atole (high-energy/protein supplement)
10
9
8
7
6
5
4
3
2
1
0
-1
Age
0-36 mo
36-84 mo
3-12
12-24
24-36
36-48
48-60
60-72
72-84
Schroeder et al. 1999
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)
Key idea #2: Why prevention?
-3
-2
0
+2
+3
Key idea #2: Why prevention?
-3
-2
0
+2
+3
Key idea #3: the UNICEF Model
Child Nutritional
Status
Direct
Causes
Underlying
Causes
Health
Diet
Access to
adequate food
Care practices for
mothers
and children
Access
to essential
health services
and a healthy
environment
Appropriate education
Formal
and non-formal
institutions
Basic/ Fundamental
Causes
UNICEF, 1990.
Political, economic and cultural environment
Potential
resources
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)
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”
Summary of Haiti study findings
The FANTA/IFPRI/World Vision study
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
At final survey preventive communities had
better anthropometry than recuperative ones
Outcome
(final
survey)
HAZ
Preventive
(n=752)
Mean
-1.53 *
Recuperative
Difference
(n=748 )
(preventive –
recuperative)
Mean
-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
The effects were consistent across age groups
WAZ (final) by age and program group
0.5
0.0
Initial rollout; No
full BCC
WAZ
-0.5
-1.0
-1.5
-2.0
0-6
6-12
12-18
18-24
Child age
Preventive (final)
Recuperative (final)
24-30
30-36
36-42
Comparing with DHS surveys 2000 and 2005
(NCHS standards)
Stunting reduced by 7ppt in Prev. arm
Precentive
Stunting stayed same in Recup. arm
Recuperative
Stunting increased by 10ppt in the region
DHS 2005
Baseline
0
5
10
15
20
25
30
35
40
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
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
PM2A:
Preventing Malnutrition in Children
under 2 Years of Age
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
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)
Key outcomes examined
• Child nutritional status
– Linear growth
– Micronutrient status
• Other child outcomes
– Motor development
– Cognition
– Morbidity
• Secondary outcomes
– HH FS
– Maternal nutrition (Hb)
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)
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.
ii.
iii.
iv.
v.
vi.
PM2A: “Full” PM2A (-9 to 24mo, full FR, BCC, HS)
PM2A/.5FR: PM2A with smaller (1/2) family ration
PM2A/0FR: with no family ration
PM2A/LNS: PM2A w/LNS (no food) as individual child ration
PM2A/MNP: PM2A w/MNP (no food) as individual child ration
Control: No services from MYAP (only regular Gov’t ones)
Questions to study size of family rations
and comparisons used
Does PM2A with a reduced FR improve
child NS?
Do large FR have a larger impact on child
NS than reduced FR?
Does PM2A without a FR improve child
NS?
Are FR necessary for PM2A to impact
child NS?
PM2A/.5FR
vs CTRL
PM2A/.5FR
vs PM2A
PM2A/0FR
vs CTRL
PM2A/0FR
vs PM2A
Questions to study the composition of
individual rations and comparisons used
PM2A/LNS
vs CTRL
What is the impact of PM2A w/LNS vs PM2A/LNS
PM2A w/CSB?
vs PM2A
Does PM2A with MNP improve child NS? PM2A/MNP
vs CTRL
What is the impact of PM2A w/MN vs PM2A/MNP
PM2A w/CSB?
vs PM2A
Does PM2A w/LNS have the same or
PM2A/MNP
more impact than PM2A w/MNP on
vs
PM2A/LNS
child NS?
Does PM2A w/LNS improve child NS? `
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?
Is it necessary to provide benefits up to
24mo for impact on child NS, or is 18
months sufficient?
PM2A/18
vs CTRL
PM2A/18
vs PM2A
Questions to assess the impact & costeffectiveness of PM2A on child nutrition
Does PM2A improve child NS
compared to Ctrl?
What is the cost & costeffectiveness of PM2A?
PM2A vs
Control
PM2A vs
Control
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
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
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