Type of Review: Annual Review
Project Title: Impact of improved Sanitation/ Hygiene and Infant Nutrition on
environmental enteropathy, growth, and anaemia among young children in
Zimbabwe. (SHINE)
Date started: June 2010 Date review undertaken: 9-13 June 2014
Introduction and Context
What support is the UK providing?
SHINE (Sanitation, Hygiene, Infant Nutrition Efficacy project) is a community-based, clusterrandomized trial being conducted in two rural districts of Zimbabwe (Chirumanzu and Shurugwi).
SHINE will determine the independent and combined effects of two interventions (improved Water,
Sanitation and Hygiene (WASH) and improved infant feeding) on stunting and anaemia of 4,800
children followed from under 14 weeks gestation to 18 months of life. The project is being implemented
by Zvitambo, a locally based non-profit organisation in close collaboration with the Ministry of Health
and Child Care (MoHCC) in Zimbabwe (and decentralised authorities) and in partnership with Johns
Hopkins Bloomberg School of Public Health, Cornell University, and the University of London.
Behaviour change interventions are delivered by Village Health Workers (VHWs), latrine construction
was managed through a subcontract to Oxfam/UK but Zvitambo and the MoHCC environmental health
department have now assumed full responsibility for implementing this part of SHINE, while research
staff measure intermediary and ultimate outcomes.
Stunting and anaemia affect 33% and up to 75% of young children respectively growing up in low
income countries (including Zimbabwe). Often referred to as “invisible malnutrition,” these two
problems together cause 20% of under 5-year mortality, and lead to long-term cognitive deficits, fewer
years of completed schooling, and poorer performance while in school, and lower adult economic
productivity. SHINE takes an innovative approach to the hypothesis that Environmental Enteropathy
(EE) is a major underlying cause of both stunting and anaemia. EE is a subclinical injury of the small
bowel which leads to reduced nutrient absorption and increased systemic immune activation (IA). IA,
in turn, suppresses linear growth and red blood cell production. The researchers hypothesize that EE is
caused by exposure to faecal-contaminated living environments and can be prevented or reduced by
household water, sanitation, and hygiene (WASH) interventions that target faecal-oral pathways in
infants. They also hypothesize that the effects on stunting of improved WASH will be additive to those
of improved infant feeding practices.
No randomized trial of sanitation has ever looked at child health outcomes. No trial has combined
sanitation and hygiene with an infant feeding intervention, and no study of any design has documented
the pathways from household sanitation and hygiene behaviours to the enteric health and nutritional
status of infants. The study is also uncovering evidence about maternal capacities to support
pregnancy and will be able to draw associations between maternal exposure to EE and adverse
pregnancy outcomes (miscarriage, premature birth, low birth weight and stunting at birth). There are
three other trials globally, that we know of, that are looking at the impact of sanitation on stunting. The
“WASH Benefits” programmes in Bangladesh and Kenya will randomise WASH, infant nutrition and
both together1. “SHARE” in Odisha in India will randomise latrine provision and water to test
proportional impact on stunting.
1
Arnold et al, Wash Benefits Study rationale, BMJ Open 2013;3:e003476
1
Following the publication of the original hypothesis in the Lancet, DFID-Zimbabwe approved a £3
million pound contribution (over five years) to support the Zvitambo Tropical Enteropathy study in June
2010 (later called Environmental Enteropathy and now called Environmental Enteric Dysfunction, or
EED). £3m represented about 30% of the initial funding requirement over 5 years. EED results when
high concentrations of faecal bacteria are ingested, overwhelm the gastric barrier, and colonize the
small bowel. The study will test the hypothesis that the primary pathway from poor sanitation/hygiene
to under-nutrition is EED, and not, in fact, diarrhoea and that EED can be prevented or reduced in
young children by cleaning up the home environment, removing faeces (human, chicken, animal),
providing household toilets and promoting hand washing after faecal contact.
Since June 2010, the study has developed substantially. The study timeframe has extended to end of
2017. Costs have increased with the extended timeframe and complexity of the study but knowledge
and outcomes are already expected to be greater than previously anticipated. DFID Zimbabwe
therefore invested a further £1m in financial year 2012-13 towards the Zimbabwe-based costs of the
programme bringing its total contribution to £4m over 5 years.
After the last Annual Review in 2013 in recognition that there was still a significant funding gap DFID’s
Policy and Research and Evidence Divisions agreed to contribute a further £3.2m from April 2014 to
December 2017 to ensure that this trial remains on track. This brings the total investment by DFID to
£7.2m around 33% of the total contribution of around US35m by other donors including the Bill and
Melinda Gates Foundation, CIDA, Welcome Trust, NIH, UNICEF and Swiss Development Cooperation.
The accountable grant was signed at the time of this review.
There are high costs of running an RCT of this nature in Zimbabwe due to factors such as low
population density, high infrastructure costs, salary costs and inflation. However Zvitambo has an
established history in Zimbabwe, good relationships, and Zimbabwe has high levels of stunting and yet
low underweight making the study topic amenable to the population.
What are the expected results?
There are four kinds of results expected from this trial and its associated programmes:
1. Capacity building and infrastructure in Zimbabwe:
a. Laboratory capacity and infrastructure developed across four hubs in the two study
districts along with central capacity in Harare;
b. Research knowledge and skills (social science, medical, metabolic);
c. Nurses trained in using information systems, computer based research tools, motorcycle
driving, management of others (village health workers);
d. Village Health Workers (VHWs) trained and deployed, supervised and managed.
e. Improvements to tippy tap construction;
f. Development of an infant play mat to support the sustained management of infants in a
faeces-free environment.
2. Zimbabwe focused policy inputs and tools and public goods:
a. SHINE staff participate in the National Taskforce for the development of the National
Strategy for Food Security and Nutrition Policy Guidelines;
b. SHINE staff have contributed to the re-writing of the national VHW handbook;
c. SHINE staff work on Prevention of Mother To Child HIV Transmission (PMTCT) policy
guidelines and have advised MOHCC about Exclusive Breast Feeding (EBF);
d. Developing VHW teaching and training modules to facilitate nutrition and WASH
education to mothers/ households in the study districts;
e. Improved understanding of breast-feeding culture and interventions designed to address
community concerns and Shona cultural beliefs about breastfeeding, the management of
2
f.
the fontanelle and colic in very young babies; and
Mapping relevant infrastructure and sharing the databases and information systems so far
compiled, so enabling others to make use of these resources saving time, improving
outcomes and strengthening value for money across a range of programmes.
3. Contribution to science and knowledge applicable globally by:
a. Increasing knowledge about what causes infant stunting and thus support to better health
outcomes in children;
b. Improving understanding about the associations between maternal exposure to EED and
adverse maternal outcomes (miscarriages, still births, premature births);
c. An understanding about faecal-oral transmission pathways for infants (as opposed to
older members of household) and poor health outcomes in children resulting from
subclinical gut disease (as distinct from diarrhoea clinical disease);
d. Better knowledge about how to implement programmes at community level on a large
scale; and
e. Practical lesson learning about multi-sectorial programming, working across disciplines,
measuring impact, engaging communities at scale and integration into community, district
and provincial structures.
4. Immediate and direct benefits to households in two poor districts of Zimbabwe over the
study period:
a. 4800 more households with functional, high quality latrines;
b. 4800 households with tippy taps that facilitate hand-washing;
c. Knowledge about handwashing, faeces, sanitation, healthy eating, improved health;
d. Access to early pregnancy identification;
e. Immediate/ early referral for PMTCT and the prevention of HIV transmission to babies;
f. Community knowledge about exclusive breast feeding and nutrition in young babies and
children.
NB: The logframe was updated in time for this review and more stretching indicators added for the
already achieved outputs.
What is the context in which UK support is provided?
The UK supported Zvitambo (the implementing partner leading the SHINE trial) through DFID
Zimbabwe’s Mothers and Babies programme (2007-2010) to build knowledge and implementation
capacity around exclusive breastfeeding and other interventions to support Infant and Young Child
feeding (IYCF) especially in HIV exposed but negative babies. This support also allowed Zvitambo
Director, Professor Jean Humphrey (Johns Hopkins University) to develop and publish the enteropathy
hypothesis. Since its publication, this hypothesis has transformed research on the role of WASH as a
cause of stunting. Major trials funded by the Bill and Melinda Gates Foundation have been adapted to
take account of this hypothesis and the growing evidence pointing to faecal-oral pathways as an
important contributor to child stunting.
DFID Support (Subject of this Review)
This review looks at the last year of DFID Zimbabwe’s £4m contribution to the SHINE trial up to May
2014.
Zvitambo continued early pregnancy identification by Village Health Workers and introduced measures
to accelerate the rate of recruitment into the trial; finalized behaviour change interventions for exclusive
breastfeeding, WASH, and infant feeding and prepared related manuscripts; strengthened the process
of latrine building (set up brick moulding sites in the study area, modified the latrine model to one that
uses half the quantities of cement and bricks), published formative biomedical findings pertaining to
3
child health and nutrition, and started antenatal data collection visits on enrolled women. At the time of
this review the trial was well under way and data on behaviour change was starting to be analysed.
In July 2013 Zvitambo identified a serious problem with latrine and ‘Tippy Tap’ implementation by the
subcontractor, Oxfam GB: in that month, 646 women had been enrolled into the WASH arms of the
study, 467 were past due for receiving WASH hardware, yet only 45 latrines had been constructed.
Following a series of meetings, the Oxfam subcontract was discontinued and Zvitambo and the
MoHCC environmental health department assumed full responsibility for implementing this part of
SHINE. They managed to ensure ‘catch up’ and all enrolled pregnant women were receiving a
household toilet by the time of this review.
In December of 2013, the community of scientists investigating EE (Environmental Enteropathy)
changed its name to Environmental Enteric Dysfunction (EED), which we have now adopted in this
report.
Section A: Detailed Output Scoring
Output 1: Capacity of Zimbabwe Ministry of Health and Child Care strengthened in
primary health care, environmental health and Prevention of Mother to Child
Transmission of HIV (PMTCT).
Output 1 score and performance description: A+ Outputs moderately exceeded expectation
Progress against expected results:
Output Indicator 1.1 “Number of male and female Village Health Workers trained and mentored in
Ministry of Health and Child Care curriculum and new interventions designed for this project (target
320)
MoHCC Curriculum VHW training: In Chirumanzu and Shurugwi, 181 and 173 (total 354) VHWs
respectively, have been fully trained and are regularly submitting reports to their respective health
centres. As new health related information that needs to be disseminated into communities is released
(e.g. changes to the Expanded Programme on Immunization schedule, guidance on PMTCT), VHWs
have received the necessary refresher training. An additional 20 and 41 VHWs were recruited and
received training during 2013 and 2014 respectively, to (1) replace VHWs who have died or
permanently moved out of the area, (2) strengthen areas that are too large – either in geography or
number of households – and cannot be adequately covered by a single VHW, (3) serve areas that
have recently been populated as a result of resettlement, and (4) provide back up support to VHWs
who are otherwise unable to effectively deliver intervention messages due to chronic illness, visual
impairment or old age.
SHINE-specific VHW training: VHW training on SHINE-specific tasks conducted during the reporting
period are presented in the table below:
Dates
Content of training
Which VHWs trained
Number of VHWs
trained
June
2013
July 2013
July 2013
February
2014
WASH modules 4,5
WASH and WASH+Nutrition
180
IYCF modules 1,2,3,5
Nutrition and WASH+Nutrition
180
SOC messages
All
360
MoHCC
Curriculum;
Early Newly Recruited VHWs in all 41
Pregnancy Identification; SOC intervention arms
4
messages
Output Indicator 1.1 Milestone for 2014:
Replacement programme for VHWs lost to attrition in place.
1. In order to ensure consistent coverage, Zvitambo has worked with the Provincial and District Health
Teams to formulate a replacement strategy for VHW positions arising due to natural wastage (attrition).
During this period 27 VHWs have been replaced and the programme is in place. The strategy, which
is outlined below, is currently under implementation and ongoing discussion with the MoHCC:
a. Recruited 27 new VHWs through the stipulated processes of (1) community sensitization with
communication of eligibility criteria, (2) nomination of ~2 candidates by the community, (3) screening
and interview by health center staff, (4) orientation by district level MoHCC.
b. Conducted a brief (~2-3 wk) basic training to provide the 27 new VHWs with requisite knowledge
and skills.
c. In the process of ensuring on-the-job-training and support by (SHINE and MoHCC) for the 27 new
VHWs; VHW supervisors to both augment this training and introduce SHINE-specific information.
Provide additional instruction and remedial support to the 27 recently recruited VHWs during annual
refresher training sessions.
Output Indicator 1.2: Number of health centres in which Health Workers have been trained and
mentored in WHO 2010 PMTCT Guidance (target of 42 achieved in 2012)
Health workers in all health centres have been trained and mentored in delivering the WHO 2010
PMTCT Guidance. In addition, progress has been made toward accrediting all sites to initiate and
follow up ART patients. This process is slow because it is done centrally by a team from the MoHCC
head office. First, at least one person must be trained in Opportunistic Infections/Antiretroviral therapy
(OI/ART); this has now been completed in all health centres in the two districts. Next, certain physical
infrastructure must be in place (e.g., secure drug store rooms); this has been done for health centres in
both districts. To date, 8 health centres centres in Chirumanzu and 4 in Shurugwi have been assessed
and are awaiting approval. All remaining centres are ready (training and infrastructure improvements
have been completed) and are awaiting assessment visits.
Following Canadian International Development Agency (CIDA) scaling down of support to Zimbabwe in
March 2013 and given shortage of funds, Zvitambo elected to turn over PMTCT support to EGPAF who
hired and deployed a District Focal Person to Chirumanzu and Shurugwi in April 2013. Zvitambo
works closely with EGPAF to ensure a high level of PMTCT care is delivered throughout the SHINE
study area.
Output Indicator 1.3: Amount and quality of district-level WASH information (target of WASH database
dissemination achieved in 2012).
The Sanitation Survey tool and data were shared with the districts and with the National Coordinating
Unit (NCU). The Water point survey data were shared with the districts. In Shurugwi, the district
acquired a water drilling rig and received funds for drilling boreholes in the district from the Community
Share Ownership Trust. The CEO, who is also the trust administrator, asked for assistance in siting
the boreholes while maintaining the Shine study integrity. The Zvitambo Associate Director of
Statistics/Data Management and IT Services is working with the committee tasked with deciding where
the boreholes will be dug to advise them on the places where a new borehole will result in the greatest
increase of the population with access to water. Through this process Zvitambo ensured that the
randomized arms of the study remain balanced in access to water.
Progress towards 2013 Annual Review Recommendations
1. In order to ensure consistent coverage, Zvitambo has worked with the Provincial and District
Health Teams to formulate a replacement strategy for VHW positions arising due to natural
wastage (attrition). The strategy, which is outlined 1-c above, is currently under implementation
5
and ongoing discussion with the MoHCC.
2. In December 2013 Zvitambo instituted an incentive package for VHWs; this includes an
incentive for referral of eligible women to SHINE. In addition, in January 2014 Zvitambo
initiated recruitment of eligible women from antenatal clinics in addition to the VHW communitybased referral system.
3. Plans are being made to publish the behavior change modules as web-based supplements to
the publications reporting their development. Thus, the WASH modules will be published with
paper #15, the IYCF modules will be published with paper #22, and the EBF modules with
paper #23 (see section B 1.6 below for the full list of papers).
Recommendations:


Zvitambo and the wider SHINE team need to develop an exit strategy to best prepare all
stakeholders, those reliant on SHINE for income and the district health systems for 2017 when
the significant support and infrastructure may cease, or be temporarily suspended. This
strategy should highlight the optimal use of existing research ‘know how’, infrastructure and
Government staff who have been ensuring the trial is implemented. (June 2015)
SHINE needs to prepare a contingency plan for any ‘salary shocks’ that might arise due to
Government of Zimbabwe being unable to pay staff salaries through any period to the end of
the trial; this is especially pertinent for the Environmental Health Officers who at present do not
receive any ‘top up’ from the multi-donor Health Transition Fund and would therefore become
entirely reliant on incentives.
Impact Weighting : 10 %
Revised since last Annual Review? Y
Risk: Medium
Revised since last Annual Review? NO
Output 2: Interventions to improve household WASH and infant nutrition practices are
developed, piloted, implemented by male and female Village Health Workers and assessed for
uptake and effectiveness (Target Achieved in 2013)
Output 2 score and performance description: A++ Outputs substantially exceeded expectation
Progress against expected results:
Output Indicator 2.1: Progress in developing an effective intervention for improving WASH behaviours
Output Indicator 2.2: Progress in developing an effective intervention for improving infant nutrition
practices
Both fully achieved.
Progress toward implementing 2013 Annual Review Recommendations
Zvitambo proposes the addition of a set of stretch outputs pertaining to the measurement and reporting
of fidelity of implementation of the WASH and infant nutrition interventions by VHWs and increasing
uptake by a certain margin from baseline, information that we could extract from our outcome
measurement.
New Indicators for Output Indicators 2:
6
Output Indicator 2.1: Proportion of WASH behaviour change modules delivered by VHWs within the
recommended timeframe [2014 milestone – 60%]
Output Indicator 2.2: Proportion of infant nutrition behaviour change modules delivered by VHWs within
the recommended timeframe [2014 milestone – 60%]
Output Indicator 2.3: Uptake and effectiveness of WASH interventions defined and reported for WASH
households [2014 Milestone - WASH intervention uptake and impact is being documented from ongoing data collection]
Output Indicator 2.4: Uptake and effectiveness of IYCF interventions defined and reported for IYCF
households [2014 Milestone - IYCF intervention uptake and impact is being documented from on-going
data collection]
All behaviour change modules (EBF, WASH, and IYCF) have been completed, piloted, and finalized.
Intervention modules have been printed and distributed to VHWs. Production of interactive tools for
participating households is ongoing, based on maturation of the cohort.
This graph shows module timing and intervention delivery.
The SHINE protocol allows a one-month window for delivery of each module. Within the month:
 Week 1 = ideal;
 Week 2 = acceptable;
 Weeks 3 and 4 = allowable.
As of early March 2014, 91% of the WASH modules delivered so far had been delivered within the
recommended timeframe, against a 2014 milestone of 60% (Output Indicator target 2.1). Modules are
continuously delivered until all women in the trial have received all of them. Thus, Zvitambo is on track
to exceed this target if it keeps up its module delivery performance within the window required.
A breakdown of WASH modules delivered by week is presented below.
7
500
450
400
350
300
250
200
150
100
50
0
Before
Window
Mod-W1
54
Ideal
Accepta Allowabl Beyond Defaults
ble
e
Window
68
48
20
36
Mod-W2
22
397
55
42
27
34
Mod-W3
4
159
39
30
13
13
Mod-W4
2
109
11
15
6
3
Mod-W5
2
81
10
7
3
2
456
For IYCF modules, 98% of them have been delivered within the recommended timeframe for far up to
early March 2014, against a milestone of 60% (Output Indicator target 2.2). Similarly, Zvitambo will
exceed its 2014 target if it continues this performance by the end of the year.
The specific messages delivered for IYCF are presented below.
70
60
50
40
30
20
10
0
BeforeW
indow
Mod-N1
2
Ideal
65
Accepta Allowabl Beyond Defaults
ble
e
Window
9
3
1
0
Mod-N2
0
36
6
7
0
0
Mod-N3
0
6
2
1
0
0
Mod-N4
0
4
0
0
0
0
SHINE project staff trained to support WASH and Infant and Young Child Feeding programme uptake
All 32 SHINE Intervention Nurses have been trained to support and supervise Village Health Workers.
The supportive supervisory system for SHINE has been designed to continually and proactively monitor
and strengthen the delivery and implementation of SHINE interventions and assess uptake.
1) Intervention Nurses directly supervise Village Health Workers (VHWs) through individual
contacts on-site and (monthly) group cluster meetings.
2) Nurse Intervention Managers frequently (weekly) meet with the Intervention Nurses they
supervise and attend some cluster meetings.
3) Lastly, the Interventions department holds quarterly meetings wherein fidelity of implementation
(FOI) is discussed and flags indicating sub-optimal delivery or uptake of interventions are
discussed.
8
Problems pertaining to VHW capacity and performance are corrected through individual and cluster
meetings, or through annual refresher training. External reasons for problems in delivery (e.g. cultural
or religious beliefs or local misperceptions about SHINE) are addressed through community
engagement mechanisms; such as local meetings with health workers or traditional leaders and
targeted awareness-raising sessions. Serious problems (such as collapse of a poorly built latrine – this
happened to a few of the Oxfam latrines) in intervention delivery or uptake are reported to study
investigators and upon confirmation of the veracity and distribution of the problem, corrective action is
made in line with the principles outlined below:
 Fundamental changes to the interventions are made (1) across all clusters assigned to the
treatment/intervention arm and (2) in as short a period of time as possible to avoid differential
modification of study interventions.
 Detailed records of the scope and timing of changes to the interventions and intervention
delivery system are maintained centrally. When changes are made at the household/participant
level or to study inputs, this information is documented in the participant’s data record.
 Potential problems due to attrition or natural wastage (resignation, relocation, or death of VHWs)
are addressed through proactive replacement of VHWs (recruitment, training and deployment)
that minimises the time during which a cluster is not serviced by a VHW.
Data on the uptake of WASH and IYCF interventions are being collected on an ongoing basis as part of
SHINE data collection, meeting 2014 Milestones 2.3 and 2.4,
Indicators of WASH and IYCF programme uptake are summarised below.
Indicator of WASH behaviours
WASH Module
Observed
Reported
Proper disposal of Presence of latrine at household
Youngest/index child’s most
faeces
Presence of faeces in the latrine
recent defecation disposed of
Presence of faeces in yard
into the latrine (reported)
Entrance to the latrine is not obstructed
Path to the latrine is well-trodden
Latrine not being used as storage facility
Hand washing with Presence of Tippy Tap/HW station
Youngest/index
child’s
or
soap
Presence of soap near HW station or mother’s most recent HW with
liquid soap in Tippy Tap
soap
Youngest/index child’s or mother’s hands
are visibly clean
Evidence of recent Tippy Tap use (i.e.
ground is wet beneath it) Respondent
mother demonstrates handwashing using
all recommended practices
Household is storing chlorinated drinking
Water treatment
water (residual chlorine test)
Play space
Cleanliness (visible) of the flooring Index child placed on play
material/play space
space in past (1) 24 hr (2) 1-3 d
Hygienic handling of Containers with index child’s food are
complementary food
covered
Food utensils are clean
Indicators of IYCF behaviours
IYCF Modules
Observed
Reported
Continue EBF to 6
Using EBF tool developed by
months
Zvitambo
Nutributter
Number of remaining packets is Diet history includes Nutributter
consistent with days since Nutributter feeding
distribution by VHW
Preparing family foods
Diet history
for infants
9
Feeding during illness
IYCF knowledge and practices
during illness questionnaire
Diet history
Diet Diversity
Recommendations:
1. SHINE should maximize the opportunities that arise from their extensive data and experience of
implementing WASH, IYCF interventions and behavior change to:
a. Provide cost effectiveness/benefit evidence for those interventions that prove to be
successful in reducing stunting and/or changing key behaviours
b. Provide implementation research findings that demonstrates ‘how’ SHINE has provided
interventions at high quality and achieved impact, such as the delivery of the behaviour
change modules and the delivery of a combination of interventions.
Impact Weighting (%): 40%
Revised since last Annual Review? Y
Risk: Low
Revised since last Annual Review? N
Output 3: Coverage of new/improved sanitation is increased in two districts
Output 3 score and performance description: B Outputs moderately did not meet expectation
Progress against expected results:
Output Indicator 3.1: Number of households with new/improved sanitation facilities.
Milestone 2014: All women enrolled into WASH receive a toilet within 6 weeks of recruitment or by 28
months gestation.
Progress in numbers: As of March 31, 2014
Number of women consented into WASH arm of trial
Number of latrines for which construction has been initiated
Number of completed latrines
10
1590
46
998
A backlog in delivering the WASH hardware developed within the first 3 months of the trial and then
steadily grew. In the progress report on 25 March 2013, two
latrines had been constructed against a target of 240 leaving a
backlog of 238. The rate of latrine construction has been too
slow all year and reached critical levels of delay in June
regardless of the fact that Oxfam had assured Zvitambo that
they hired and trained a sufficient number of staff to clear the
backlog by the end of June and then to keep up with the
anticipated increases in recruitment. To monitor this more
closely, Zvitambo designed a tool to present numbers of women
recruited into the WASH arm of the trial each week, and
progress in latrine construction, colour-coding latrines that were
overdue (ie, not completed within 8 weeks of the woman’s entry
into the project). This report was generated weekly and shared
with all levels of Oxfam personnel. The results were
disappointing.
Oxfam failed to timeously deliver the two
outcomes specified in their proposal: latrines and Tippy Taps
were not constructed within 6 weeks of mothers’ enrolment
By July 9, 2013, 534 women had been enrolled into the WASH arm while only 42 latrines had been
constructed leaving a backlog of 492; moreover of these, 8 were not built to standard and required
rebuilding. In July, Oxfam submitted a proposal describing a plan to clear the backlog in both districts by
September 15. Oxfam proposed to contract external latrine builders instead of employing local builders
who they claimed were not adequately skilled for the work. Zvitambo accepted this proposal. However,
by August 15, three weeks into the emergency backlog clearing period, Oxfam had built only 22
additional latrines and installed no Tippy Taps while enrolment into the WASH arm had grown to 712,
such that the backlog grew to 646. The only substantial progress that had been made was in siting –
and this was done by the MoHCC Environmental Health Technicians working alone on motorbikes.
The growing backlog became a crisis for the trial in August because it was then 9 months after
recruitment had started and the cohort of pregnant women began reaching parturition. By end August,
118 women in the WASH arm had either delivered or were due to deliver their babies. From that time
going forward, the cohort was expected to deliver about 100 babies each subsequent month. While the
protocol specified that latrine and Tippy Taps be constructed within 6 weeks of enrolment (~20 weeks
gestation) the trial senior statistician decided that mother-infant pairs could still be included in the trial if
all hardware was delivered at least by birth, but that mother-infant pairs who did not receive the latrine
and Tippy Taps by the time the infant was born would need to be excluded from the primary analysis and
replaced through additional recruitment.
On September 3, as part of a new emergency strategy, Zvitambo took over latrine construction in
Shurugwi district working directly with the MoHCC environmental health team and locally engaged
builders, while Oxfam was tasked to focus all their personnel (including the subcontracted external
builders) on overcoming the backlog in Chirumanzu district. Though the July Oxfam backlog proposal
had committed to clearing the backlog in both districts by September 15, this new plan required Oxfam to
complete the backlog in one district by 31 October. In the end, Oxfam required a 2-week extension to
complete the target 307 households by November 15, an additional vehicle and driver for a week, and
assistance with procurement and delivery of bricks for 23 households. Over the same period, the
MoHCC team with locally engaged builders and Zvitambo logistical support completed 377 households
in Shurugwi district.
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By September 25, 2013, Zvitambo was satisfied that the MoHCC environmental health teams would
better achieve the WASH outcomes of the trial than Oxfam. Zvitambo notified Oxfam that the
subcontract would be terminated October 31 after Oxfam cleared the backlog in Chirumanzu. Zvitambo
hired 4 Wash Officers and one WASH Coordinator, purchased 2 lorries and 2 single cabs, hired 8 drivers
and provided EHTs with protective clothing, builders with bikes and set up an Ecocash payment system
to pay casual labourers in the field helping build latrines in the communities. As of December 1, 2013,
construction of 819 latrines had started and a total of 676 latrines were completed. Zvitambo/MoHCC is
also in ongoing consultation with Dr. Peter Morgan about latrine models that use less bricks and cement
to reduce the cost per latrine and reduce building time. Towards this end, a revised model that requires
half the number of bricks and cement has been developed and was rolled out in March 2014. This
revision will both reduce unit cost of latrines and enable faster delivery. Zvitambo has also initiated
sand-cement brick molding within the two districts to further reduce cost.
The process of catch-up was impeded by the rainy season, which began in December and was
particularly heavy during the period January through March 2014. In the study area, some bridges were
washed away or un-crossable and houses completely inaccessible. With rains slowing down, Zvitambo
and the MoHCC implemented another “blitz” in April/May 2014 to completely catch up; ensuring that all
households enrolled in WASH to March 31 received a latrine by the end of May. This entailed building
about 400 during the month of April alone.
12
Monthly and cumulative latrine completion - Nov 2012-May 2014
1800
1600
1400
1200
1000
800
600
400
200
0
Nov-12 Jan-13 Mar-13 May-13 Jul-13
Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13
Sep-13 Nov-13 Jan-14 Mar-14 May-14
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14
Completed latrines
2
4
10
0
2
12
15
18
150
185
260
148
49
72
129
111
329
Latrines built
2
6
16
16
18
30
45
63
213
398
658
806
855
927
1056
1167
1496
Households Enrolled
51
127
208
296
388
467
537
646
746
853
968
1064
1172
1325
1460
1584
1703
1790
Latrines due
0
0
51
127
208
296
388
467
537
646
746
853
968
1064
1172
1325
1460
1584
Completed latrines
Latrines built
Households Enrolled
Latrines due
Thus, from March 2014 going forward, Zvitambo met the 2014 Milestone of all WASH mothers receiving
a latrine within 6 weeks of recruitment. Furthermore, Zvitambo are now molding bricks and slabs at
several sites within the districts and will stockpile these before the next rainy season to ensure they will
not run behind again.
During the annual review the team saw that a number of households already had a latrine, however a
new Blair toilet had been built alongside these latrines. The environmental health teams explained that
the existing latrines did not match the standard required by the trial. Upon further investigation, of the
1,496 latrines built to date, only 52 (3.5%) have been built next to an existing (substandard) latrine. The
cost to build a new one is usually significantly more than to rehabilitate. So far, new latrines have always
been built (the need for uniformity and high standards), but during the field trip the specific inadequacies
of existing toilets was not always clear. Given the small additional cost implications (due to the low
number of existing latrines), the high standards expected by local authorities, and the importance of
efficacy for the trial, erring on the side of caution is acceptable, and building new latrines is likely to
continue in many cases. However, this should be monitored, see recommendation below.
SHINE is facing differential recruitment in the WASH arm, with a potential 4 month lag for the other arms,
(faster enrollment for the WASH arm compared to other arms of the trial), which could affect the
research quality. During the field visits we heard that this could be due to increased pregnancies to
ensure families get a quality latrine.
13
Progress toward 2013 Annual Review recommendations:
With latrine construction now under Zvitambo and MoHCC control, there should not be any further
delays in constructing latrines for women enrolled into the WASH arm within 2 months enrolment. The
current log frame goal is to complete 2400 latrines in 2014; given the slower than predicted recruitment,
we anticipate this goal will now be achieved by mid-2015.
Recommendations:
1. The SHINE team needs to ensure EHTs have clear guidance on whether or not existing latrines
are acceptable and the adaptations that can be made to those toilets to maintain quality. They
can consult Dr Morgan on the quality adaptations, if needed. The number of households with
existing latrines should be continually monitored in case this proportion increases significantly
and becomes a value for money consideration.
2. The SHINE team have modified the initial design (under the guidance of Dr Morgan) and
achieved substantial cost reductions per latrine. Zvitambo may want to explore any further cost
reduction potential, whilst maintaining standards, before building the bulk of toilets at the end of
the trial for all families enrolled. Beneficiary families, however, should not be left with the
impression that their promised toilets are sub-standard.
3. SHINE should further investigate the reasons for differential recruitment and whether there are
incentives for pregnancy increase. See Section B.
Impact Weighting (%): 40%
Revised since last Annual Review? Y
Risk: High
Revised since last Annual Review? N
14
Output 4: Increased uptake of improved nutrition and health interventions in two
districts
Output 4 score and performance description: A+ Outputs moderately exceeded expectation
Progress against expected results:
Output Indicator 4.1: Proportion of children being Exclusively Breast Fed (EBF) from birth to 6 months
2014 Milestone: EBF to 6 months rate is 30% based on the observed rate among participating infants
As of June 1, 2014, only 112 women had reached the 6 month visit. Of these, 71 provided complete
data, responding to whether or not they had ever fed each of 44 different foods; for the remaining 41
mothers, their response regarding at least one of these foods was missing. A problem with these early
6 month data is that it was collected just after 6 months when the mother had already correctly begun
introduction of other foods. These two problems will be addressed through modifying the questionnaire
or additional training of the data collectors.
Following are the best estimates of the proportion of women practicing EBF at 1, 3, and 6 months of
age, based on those who provided complete data to this series of questions, and assuming that a food
left unanswered was not fed to the infant:
Assumption
1 month
Complete data only
92.8%
Skipped food not fed to 88.9%
infants
3 months
88.1%
89.0%
6 months
23.9%
34.8%
Despite this being based on small initial numbers, the data shows an impressive increase in EBF for
the first month, the key time for maximum benefits, from 4% to 93%, the rate remains high at the 3
month mark but significantly drops at 6 months.
Based on that work, the EBF promotion now particularly targets the poor practices of feeding nonbreast milk foods to very young infants to prevent actual or perceived fontanelle and colic problems.
The much higher rates at 1 and 3 months among SHINE mothers indicates these messages are
effective. The Logframe indicator can be adjusted to illustrate the improvements at these different
stages.
Output Indicator 4.2. Proportion of HIV+ pregnant women receiving WHO-recommended interventions
in the project area districts
2014 Milestone: INTERVENTION TAKEN OVER BY OTHER ORGANIZATIONS
At the beginning of this DFID grant, virtually no women were receiving the WHO 2010 PMTCT
Guidance in the whole of Zimbabwe including the two SHINE districts. By December 2012, 80% of
HIV-positive women delivering in Chirumanzu, and 86% of HIV-positive women delivering in Shurugwi
received either the More Efficacious Regimen (MER) or were started on HAART for life, based on their
CD4 cell counts, in accordance with the WHO 2010 guidance. This is attributed to several PMTCT
trainings held in the district and strengthened VHW follow up – both under Zvitambo support. VHWs
also play a pivotal role in encouraging early booking and promoting the benefits of PMTCT
interventions in the community. ARVs for PMTCT were continuously in stock during the period under
review. In addition, in Chirumanzu and Shurugwi, respectively, 1772/1928 (92%) and1836/1928
(95.2%), respectively, of ANC-registered women knew their HIV status at the time of delivery, and
2288/2569 (89%) and 1928/2220 (87%), respectively, of all deliveries in the two districts were
conducted in health institutions. This is well above the national average of 70%. This high institutional
delivery rate can be attributed to efforts made by the VHWs (trained in partnership with Zvitambo) and
discouragement of non-trained midwives to conduct deliveries. Primary Care Nurses (PCNs) are
15
currently undergoing training in midwifery to improve their skills in handling deliveries. This has boosted
the nurses’ confidence in handling pregnant women right through to delivery and post-delivery care.
That this institutional delivery rate has increased is notable despite an overall drop in deliveries.
Progress toward implementing 2013 Annual Review recommendations
Because this element of the programme has been handed to Elizabeth Glazer Pediatric AIDS
Foundation (EGPAF), Zvitambo have proposed rewriting the logframe to refer only to VHW role in
PMTCT uptake; the only part of PMTCT they are now responsible for. The indicators agreed with DFID
prior to this AR are below:
New Output 4 Indicators:
Output Indicator 4.2: Proportion of women enrolled into SHINE < 14 weeks gestation disaggregated by
HIV status [2014 target: at least 67% of both positive and negative women.]
A total of 248 of 336 (74%) HIV- positive women consented into SHINE at < 14 weeks gestation.
A total of 1,238 of 1,612 (77%) HIV-negative women consented into SHINE at <14 weeks gestation.
Output Indicator 4.3: Proportion of women enrolled in SHINE who have booked for ANC at the time of
the study 32 week visit, disaggregated by HIV status [2014 target: at least 67% of both positive and
negative women.]
A total of 141 of 148 (95%) HIV-positive women who had a 32 week visit had already booked for ANC.
A total of 728 of 761 (96%) HIV-negative women who had a 32 week visit had already booked for ANC.
Recommendations:
1. SHINE needs to create a research uptake strategy that details how they envision having the
maximum policy uptake of their research products as defined by new programmes tackling child
stunting using these interventions or the evidence they create. This includes the important work
the review team heard about that is creating evidence on: maternal capacities, vaccine efficacy,
fidelity of interventions, design of interventions and intervention science. The update strategy
should be comprehensive based on a stakeholder analysis, routes of influence, and the
modalities of collaboration with researchers of other related trials for maximizing impact.
2. As previously highlighted SHINE should maximise the opportunities for evidence and lesson
learning from delivery of their behaviour change modules, especially showing these significant
improvements in early breastfeeding and the high rates of ANC attendance. This will be
important if and when the trial shows a significant result and is extremely valuable for nutrition
programmes worldwide.
3. The logframe should be updated to reflect data on EBF at 1, 3, and 6 months.
Impact Weighting (%): 10%
Revised since last Annual Review? Y
Risk: Medium
Revised since last Annual Review? N
Section B: Results and Value for Money.
16
1. Progress and results
1.1 Has the logframe been updated since last review? YES
1.2 Overall Output Score and Description:
A+ - outputs moderately exceeded
1.3 Direct feedback from beneficiaries
During the review the team visited seven beneficiary households and spoke with women enrolled in the
trial, sometimes independently. We observed taking of baseline data, WASH behaviour change module
delivery, new childcare practises (use of the play pen). We got beneficiary views on acceptability of
interventions, PMTCT provision, understanding of being a participant in an RCT, taking biological
samples (such as blood - a taboo in Zimbabwe), ethics and life changes since enrolling. Beneficiaries
were on the whole happy, appreciative and understood their role in the SHINE trial. We also discussed
with VHWs, EHTs, nurse supervisors and data collectors the experience of participants.
1.4 Summary of overall progress
Progress in numbers: As of March 31, 2014
Pregnant women referred by Village Health Workers
3555
Women consenting to join SHINE
2814
Women completing baseline surveys
2431
SHINE Intervention modules delivered by VHWs
9359
Withdrawals
51
Average SHINE maternal age
26.2
As of March 31, 2014, 3555 women have been referred by village health workers to SHINE, 2814 of
those women have consented to participate in the trial, and 2431 baseline visits have been conducted.
Referrals have been systematically higher in the WASH (n=949) and WASH/IYCF (n=994) arms of the
trial compared with the SOC (n=799) and IYCF (n=807) arms. Although consent rates are consistent
across arms, the uneven referrals have created unbalanced enrolment.
1.5 Key challenges - Research
 Slow Recruitment. In designing the trial Zvitambo estimated that there were nearly 5000 live
births per year in the study area, and planned that recruitment could therefore be completed in
15 months (at ~330/month). However, recruitment ranged from 150 through 200 participants
per month over the period November 2012 – December 2013. This was slower than expected
and has been ascribed to low referral rates of newly identified pregnant women by Village
Health Workers. Once identified, the consent rate of eligible women is very high. Thus, causes
of the slow recruitment may be: overestimation in Zvitambo’s original estimates of live births in
the study area, declines in fertility since those estimates, or inability of Village Health Workers
17


to identify all the newly pregnant women.
Zvitambo have implemented the following strategies to increase recruitment:
o Relaxed inclusion criteria in September 2013 to allow women up to 18 weeks gestation.
o Stationed a research nurse at Antenatal Clinics to talk with all women booking their
pregnancy to estimate how many newly pregnant women have been missed in the
community and their gestational age at booking; based on findings Zvitambo will use
antenatal clinics as another entry for recruitment and/or reinforce areas where the
Village Health Worker is weak.
o In November 2013 Zvitambo received approval from the MoHCC to roll out a VHW
incentive programme to reward VHWs for referral of mothers.
o Zvitambo are investigating a partnership with a local cell phone carrier to provide cell
phones and airtime to women as an incentive for trial participation and to facilitate field
operations.
o Based on the plausible assumption that the poor performance by Oxfam in constructing
latrines and Tippy Taps (see discussion on page 14) contributed to slow recruitment
(due to diminished trust of the project by the communities consequent to the failure to
provide the inputs as promised), Zvitambo caught up on the latrine backlog.
The combination of mitigating strategies appears to be working since recruitment has
surpassed and remained at 200+ per month since January 2014. Considering the timing of their
implementation against a backdrop of negative impact of the rainy season on programme
performance and community agriculture/livelihood commitments, the improvement in
recruitment trajectory is likely attributable to the set of interventions above.
Differential Recruitment. Referrals have been systematically higher in the WASH arms of the
trial thereby creating unbalanced enrolment. In terms of the validity of the trial, it is important to
understand the causes of this differential recruitment. Recruitment data suggest that the
differential is at the level of VHW referrals to SHINE – once SHINE receives a referral,
acceptance is similarly high across arms at about 95% (5% refusals during consent visits).
Village Health Workers in SOC arms believe that fertility rates are higher in the WASH arms:
that women are choosing to become pregnant to receive the latrine. Zvitambo are working to
address this issue by providing additional incentives (cell phones) for recruited women,
undertaking more community engagement events and maximizing VHW coverage of women of
child bearing age (WCBA). Furthermore, Zvitambo have identified the following potential
reasons for this problem, and will conduct a review of VHW registers to ascertain the
predominant cause:
o Greater number of WCBA in WASH arms;
o Same number of WCBA across intervention arms, but those in WASH arms are younger
and at higher risk of pregnancy;
o Same number of WCBA and similar age distribution but higher fertility;
o Acceptance rate for pregnancy testing is higher in WASH arms;
o Among pregnant women identified, acceptance rate for referral to SHINE is higher in
WASH arms; and
o VHW performance (in pregnancy identification and sensitization about SHINE) and/or
Intervention Nurses (VHW supervisor) supervisory performance is higher in WASH
arms.
Protocol deviations due to delays in latrine construction and Tippy Tap installation.
Further to the discussion above, there are 130 WASH arm women who received latrine and/or
Tippy Taps at ~0-3 months postpartum instead of receiving them ideally within 6 weeks of
recruitment (24 weeks gestation) and before the index child’s birth at the latest, as stated in the
protocol. The team of investigators who provide technical scientific guidance on the design,
implementation and integrity of the study met in March 2014, and decided that the best
response to this challenge is to include all pairs in an intention-to-treat analysis, but to conduct
an a priori per protocol analysis that excludes the 538 pairs recruited before April 1, 2014 which
would include the WASH women who did not receive hardware until after delivery and those in
other arms recruited during same period. The team advised recruiting an additional 538 to
ensure sufficient statistical power in this per protocol analysis. Oxfam have agreed to pay the
costs of recruiting these additional women.
18
Key challenges – Policy & intervention

Delayed latrine construction and Tippy Tap installation. The challenges with Oxfam
delivery are well described in detail above and payment of damages will cover the enrollment of
additional women needed to maintain the integrity and power of the trial. This shows impressive
perseverance by Zvitambo, but it would be useful to consider lessons learnt for future
management of contracts.

Research Uptake Although at this stage there is not an expectation of the evidence created
during this trial impacting on global funding for WASH and IYCF, this is the hope post 2017 if
there is a positive result. This means that SHINE needs to prepare the ground and be strategic
about facilitating research uptake as early as possible. See output 4 recommendations.

Motorbike Accidents. A total of 63 Data Collector and Intervention Nurses ride motorbikes.
When SHINE was first launched these staff experienced a high rate of accidents. SHINE
provided professional motorbike riding training (during which some applicants were deemed
unable to ride and were excluded from employment), continued training by on-site mechanics, a
full set of protective clothing, imported top-grade helmets, and frequent warnings not to speed.
Zvitambo consulted with an expert in motorbike injury prevention who confirmed they are doing
more than most projects and that the main way to reduce injury is to reduce exposure.
Zvitambo procured additional vehicles with drivers to reduce Km driven and increased safety
training and began careful monitoring of the accident rate: the accidents/1000 Km driven
declined from a peak of 0.38 per 1000 Km ridden in January to ~0.06 per 1000 Km ridden
during June – November 2013. However, in December 2013 – February 2014 the rate
increased again due to the poor road conditions during the rainy season, though it was not as
high as it had been the previous rainy season, reflecting the greater experience of the nurses.
During the review visit the team witnessed a motorbike accident involving a nurse supervisor
losing control of the motorbike.
1.6 Annual Outcome Assessment
Outcome Goal:
New knowledge in Water/Sanitation/Hygiene, Infant Nutrition, and Health systems is generated
and disseminated and informs child health programmes in Zimbabwe and globally.
Outcome Indicator 1: Number of articles published in peer reviewed literature.
Indicator 2014: 2 papers
Manuscripts prepared under DFID support that are published, in press, submitted for publication,
submitted for presentation, and in preparation are listed below with description of contribution to child
health programmes. Highlighted below are papers published since the last annual review resulting from
research supported by DFID..
Manuscript
Contribution to child health programming
Published
1. Humphrey JH: Child undernutrition, tropical
enteropathy, toilets, and handwashing.
Lancet 2009; 374:1032-35.
2. Paul KH, Muti M, Chasekwa B, Mbuya
MNN, Madzima RC, Humphrey JH,
Stoltzfus RJ.
Complementary feeding
Articulated the hypothesis that environmental enteric
dysfunction (EED) is a primary cause of under-nutrition
and that the child growth effects of improved WASH are
primarily mediated through EED rather than diarrhea.
Identified the key misconceptions regarding infant feeding
in rural Zimbabwe (children cannot eat fruits, vegetables,
meat because they cannot chew and swallow these foods)
19
messages that target cultural barriers
enhance both the use of lipid-based
nutrient supplements and underlying
feeding practices to improve infant diets in
rural Zimbabwe :Maternal and Child
Nutrition:
DOI: 10.1111/j.17408709.2010.00265.x
3. Mbuya MNN, Humphrey JH, Majo F,
Chasekwa B, Jenkins A, Israel-Ballard K,
Muti M, Paul KH, Madzima R, Moulton LH,
Stoltzfus RJ. Heat treatment of expressed
breast is a feasible option for feeding HIVexposed uninfected children after 6 months
of age in rural Zimbabwe. J Nutr 2010
Aug;140(8):1481-8.
4. Paul KH, Muti M, Khalfan SS, Humphrey
JH, Caffarella R, and Stoltzfus RJ. Beyond
food insecurity: Comparing two sites in
Sub-Saharan Africa to determine how
context can help improve complementary
feeding interventions. Food Nutr Bull 2011;
32(3):244-53.
5. Mutasa K., Ntozini, R., Prendergast, A., Iliff
P., Rukobo S., Moulton LH., Ward B.
Impact of six-week viral load on mortality in
HIV-infected Zimbabwean infants PIDJ
(2013):31:9:948-950.
6. Ngure FM, Humphrey JH, Mbuya MNN,
Majo F, Mutasa K, Govha M, Mazarura E,
Chasekwa B, Prendergast PJ, Curtis V,
Boor KJ, Stoltzfus RJ. Formative Research
on Hygiene Behaviors and Geophagy as
Part of Interventions to Improve Infants’
Growth in Zimbabwe. Am J Trop Med Hyg
(2013),89:4:709-716
7. Ngure FM, Reid BM, Humphrey JH, Mbuya
MN, Pelto G, Stoltzfus RJ. Water,
sanitation,
and
hygiene
(WASH),
environmental enteropathy, nutrition, and
early child development: making the links.
Annals of the New York Academy of
Sciences. 2014;1308:118-28.
and created messages (a child can eat anything an adult
eats if it is processed) that resulted in mothers providing
nutritionally adequate infant diets with locally available
foods alone (except for iron and zinc which were filled by
Nutributter).
Demonstrated that HIV-positive mothers could safely stop
direct breastfeeding and provide adequate volumes of
expressed and heat-treated (EHT) breast milk to their
infants for up to 4 months. With the WHO 2010 PMTCT
Guidance
recommending
ART
therapy
during
breastfeeding, EHT is still a useful feeding method for HIVpositive mothers for use temporarily when they are delayed
in refilling ART supply.
This was the first formative infant feeding research
conducted to design the IYCF intervention for the SHINE
trial. The paper describes the process to inform other
countries on how to collect and use context-specific
knowledge and practices to improve the efficacy of their
complementary feeding interventions.
This study used archived blood samples from HIV+ infants
participating in the ZVITAMBO vitamin A trial. It showed
that a single viral load measurement at 6 weeks of age
strongly predicts mortality throughout infancy. This paper
demonstrates the importance of early infant diagnosis
followed by immediate treatment.
This was formative research to
inform the SHINE WASH
intervention. 23 infants were
observed for a total of 130
hours to identify pathways for
fecal-oral transmission in <18
month
children.
Demonstrated that ingestion of
heavily contaminated soil (geophagia) and chicken faeces
in addition to frequently mouthing their own unwashed
hands are major pathways for fecal-oral transmission in
infants and young children that may not be interrupted by
conventional WASH interventions designed for older
members of the household.
In this paper, we reviewed evidence linking WASH,
anemia, and child growth, and highlight pathways through
which WASH may affect early child development, primarily
through inflammation, stunting, and anemia. Based on this
review and formative work in Zimbabwe (#6), we
concluded that current early child development research
and programs lack evidence-based interventions to provide
a clean play and infant feeding environment in addition to
established priorities of nutrition, stimulation, and child
protection. Consequently, we propose the concept of baby
WASH as an additional component of early childhood
development programs.
20
8. Prendergast AJ, Rukobo S, Chasekwa B,
Mutasa K, Ntozini R, Mbuya MNN, Jones
A, Stoltzfus RJ, Humphrey JH. (2014)
Stunting Is Characterized by Chronic
Inflammation in Zimbabwean Infants. PLoS
ONE
9(2):
e86928.
doi:10.1371/journal.pone.0086928 infants
This study used archived blood samples from infants
participating in the ZVITAMBO vitamin A trial: we identified
100 who were stunted (cases) and 100 who were not
stunted at 18 months (controls) and then used data and
specimens collected during the antecedal period from birth
to 18 months. We found that children who were stunted at
18 months were already shorter at birth and both they and
their mothers had lower IGF-1 (a hormone governing linear
growth). Throughout infancy, children who were stunted at
18 months, had high inflammatory markers, lower IFG-1,
and higher I-FABP (an indicator of gut damage) levels.
There were no associations between stunting and
diarrhea. These findings support the SHINE hypothesis
that EED and chronic inflammation impair infant growth,
and also highlights that maternal factors (possibly maternal
EED and inflammation) are also critical pathways that must
be targeted to reduce stunting.
9. Palha De Sousa C, Brigham T, Chasekwa
B, Mbuya MMN, Tielsch J, Humphrey JH,
Prendergast AJ. Dosing of praziquantel by
height in sub-Saharan African women. Am
J Trop Med Hyg (2014) 90:4: 634-7
This study was conducted following the release of a
MoHCC National Survey which demonstrated a very high
prevalence of schistosomiasis in the study area. As part of
preparing to treat women enrolled in SHINE, in accordance
with WHO recommendations, we developed a simple way
to quantify praziquantel doses for women based on height
(as is done for children). Subsequently, the MoHCC
informed us, contrary to WHO recommendations,
Zimbabwe has elected to delay dosing of pregnant women
until after delivery, so this plan was removed from the
protocol.
This study sought to determine, using DHS data (including
Zimbabwe 2010-1), the cross-country patterns of
associations of each of WHO IYCF indicators with child
stunting, wasting, height-for-age z-score (HAZ) and weightfor-height z-score (WHZ). The WHO indicators showed
mixed associations with child anthropometric indicators
across countries. This is likely due to a lack of sensitivity
and specificity of many of the IYCF indicators. The WHO
indicators are clearly valuable tools for broadly assessing
the quality of child diets and for monitoring population
trends in IYCF practices over time. However, additional
measures of dietary quality and quantity (such as intensive
24hr diet recalls) may be necessary to understand how
specific IYCF behaviours relate to child growth faltering.
These analyses are informative for our evaluation of the
effects of the IYCF interventions on practices and growth
outcomes.
This study used archived blood samples from infants
participating in the ZVITAMBO vitamin A trial: it provides
the first values for serum hepcidin in normal healthy
infants. Hepcidin is a recently discovered hormone that is
the “master regulator” of iron metabolism, but there are
currently no reference values for infancy – anan age group
at very high risk of anemia.
Hepcidin values help
distinguish anemia due to iron deficiency from anemia of
immune activation. Hepcidin will be an important marker in
SHINE to understand how much infant anemia could be
prevented by improving WASH verses improving infant
intake of dietary iron.
10. Jones AD, Ickes SB, Smith LE, Mbuya
MN, Chasekwa B, Heidkamp RA, Menon
P, Zongrone AA, Stoltzfus RJ. World
Health Organization infant and young
child feeding indicators and their
associations with child anthropometry: a
synthesis of recent findings. Maternal &
Child Nutrition. 2014 Jan;10:1-17.
11. Jones AD, Mbuya MN, Ickes SB,
Heidkamp RA, Smith LE, Chasekwa B,
Menon P, Zongrone AA, Stoltzfus RJ.
Reply to Correspondence: is the strength
of association between indicators of
dietary quality and the nutritional status of
children being underestimated? Maternal
& Child Nutrition. 2014 Jan;10:161-2.
12. Mupfudze TG, Stoltzfus RJ, Rukobo S,
Moulton LH, Humphrey JH, Prendergast
AJ, the SHINE Project Team. Hepcidin
decreases over the first year of life in
healthy African infants. British Journal of
Haematology.
2013
doi:10.1111/bjh.12567.
Accepted for Publication
13. Desai A, Mbuya MNN, Chigumira A,
Chasekwa B, Humphrey JH, Moulton LH,
This study provided initial evidence that ~40% of women
interrupt EBF during the first month of life by feeding
21
Pelto G, Gerema G, Stoltzfus RJ
Traditional oral remedies and perceived
breastmilk insufficiency are major barriers
to exclusive breastfeeding in rural
Zimbabwe. Journal of Nutrition (in press)
Submitted for publication
14. Ngure FM, Humphrey JH, Mbuya MNN,
Mutasa
K, Rukobo S, Ntozini R,
Mangwiro I, Prendergast PJ, Chigumire A,
Stoltzfus RJ. Aflatoxin Exposure among
Mothers is Associated with Severe
Stunting in 6-59 Month Old Children in
Zimbabwe.
15. Mbuya MNN, Stoltzfus RJ, Curtis V, Pelto
GH, Kambarami R, Fundira D, Malaba
TR, Mangwadu G, Humphrey JH.
Iterative Intervention Design Research to
minimize ingestion of environmental
microbes by young children in rural
Zimbabwe.
Submitted for presentation
16. Ntozini R, Marks S, Heylar W, Mbuya
MNN, Gerema G, Humphrey JH, Garikai,
Moulton LH, and Zungu LI Assessing rural
water and sanitation coverage using
Google Earth and rapid community
assessments: A case study from two
districts in Zimbabwe. For Presentation
at the UNC Water and Health Conference,
October 2013, Chapel Hill, North Carolina,
USA.
In
preparation
for
submission
for
publication in 2014: (anticipated month of
submission)
17. Desai A, Mbuya MNN, Pelto G, Humphrey
JH, Stoltzfus RJ Emic perspectives on
traditional oral remedies (such as cooking oil and water) to
treat or prevent perceived illnesses of the fontanel or
digestive system. From ~ 2 months of age, the main
reason for feeding non-breast milk foods is that mothers
believe their breast milk is not enough or insufficient to
support the infant’s needs. These findings suggest that
both misconceptions need to be specifically addressed in
programs promoting EBF.
This study analysed archived urine samples collected by
MoHCC in a previous nationally representative survey and
demonstrated very high aflatoxin exposure is prevalent
among Zimbabwean mothers (15%) and strongly
associated with stunting in their children. Based on this
study, measurement of aflatoxin exposure was added to
SHINE protocol. Will enable us to adjust for it in
determining the effects of the randomized interventions on
stunting and estimate the fraction of stunting attributable to
aflatoxin.
This paper reports the preliminary and formative research
and pilot studies undertaken by SHINE to develop the
WASH intervention.
The paper will guide others in
Zimbabwe and elsewhere in designing effective
interventions to improve household WASH. Furthermore
the methodology presented demonstrates the utility of an
iterative
intervention
design
process
wherein
interventionists or programme planners continually reflect
on new information, and undergo a series of conceptual
shifts, each leading to further modification towards an
optimal intervention package.
This paper describes the novel method SHINE took to
assess water coverage in the study areas. Water point
surveys were carried out by MoHCC Environmental Health
Technicians using handheld electronic data collection
devices programmed with GPS capacity and custom
software. The resulting data base includes information on
all water points (6000) in the two districts including:
functionality, seasonality, degree of protection, and GPS
coordinates.
All
households
were
identified by Google
Earth and mapped
together
with
the
water points allowing
us to calculate the
average distance from
households to nearest
water
point
for
communities, wards,
and districts. These distances can be compared across
communities to identify those in greatest need; the data
can also be modeled to determine which boreholes should
be rehabilitated or at which sites boreholes should be
drilled to yield the optimal cost--benefit ratio in terms of
percent of households served per dollar spent.
This study of in-depth interviews with 30 mothers of young
infants was conducted to learn more about early EBF
22
infant care are not consistent with
“optimal” feeding of rural Zimbabwean
infants less than six months old:
implications for exclusive breastfeeding
intervention development (June)
18. Desai A, Mbuya MNN, Pelto G, Stoltzfus
RJ, Humphrey JH Impact of a
complementary
feeding
intervention
implemented by Village Health Workers in
a pilot study on assimilative and
transformational
learning
of
rural
Zimbabwean mothers (August)
19. Mupfudze T, Mbuya MNN, Stoltzfus RJ,
Tielsch J, Prendergast PJ Humphrey JH
Infant and young child feeding and water,
sanitation and hygiene practices that are
predictive of anemia during infancy: an
analysis of the Zimbabwe 2011 DHS Data
(August)
20. Mupfudze T, Stoltzfus RJ, Humphrey JH,
Mutasa K, Prendergast PJ. Changes in
plasma hepcidin associated with HIV
exposure, HIV infection, and anemia in
Zimbabwean infants at 3, 6, and 12
months of age (September)
21. Mduduzi N.N. Mbuya; Lawrence H.
Moulton Goldberg Mangwadu Rebecca J.
Stoltzfus; James M. Tielsch; Andy
Prendergast;, Jean H. Humphrey; A
cluster randomized 2x2 factorial study of
the effects of sanitation/hygiene and infant
nutrition interventions on infant growth in
rural Zimbabwe: Design and methods
(October).
22. Desai A, Mbuya MNN, Pelto G, Stoltzfus
RJ, Humphrey JH. Impact of a
complementary
feeding
intervention
implemented by Village Health Workers in
a pilot study on nutritional adequacy of
diets fed to young children in rural
Zimbabwean mothers (November).
23. Cynthia R. Matare, Mduduzi N. Mbuya,
Katherine L. Dickin, Mark A. Constas,
Naume V. Tavengwa, Dadirai Fundira,
Thokozile R. Malaba, Jean H. Humphrey,
Rebecca J. Stoltzfus. A Village Health
Worker-led intervention to promote and
support exclusive breastfeeding in rural
Zimbabwe is feasible,
acceptable and effective
interruption. Two themes emerged. Soon after birth,
mothers are concerned with guarding their infants against
nhova (non-pulsating/sunken fontanel), a condition in
Shona culture considered to have metaphysical causes.
Beginning in the first month of life, mothers were
concerned with treating ruzoka (colic/stomach problems).
Both conditions are treated with home remedies and
traditional medicines that can expose infants to pathogens.
After the first month of life, mothers were concerned their
milk was not sufficient to meet the infant’s needs. The
study guided development of the SHINE EBF modules.
This paper presents the findings from the piloting of the
SHINE IYCF intervention in Gweru district which
demonstrated that Village Health Workers were able to
deliver the intervention and that it succeeded in increasing
the depth and breadth of maternal knowledge regarding
infant feeding.
In addition, substantial evidence of
transformational learning demonstrated that mothers
engaged in a process of learning that is necessary for
behavior change.
This secondary data analysis of Zimbabwe 2010 DHS data
demonstrated that the only factors collected in the DHS
that independently predicted anemia in children (in addition
to child’s sex and maternal haemoglobin) were whether the
household had a handwashing station with soap and
whether the household disposed properly of the youngest
child’s stool. No indicators of infant diet were predictive of
anemia. The analysis is consistent with the SHINE
hypothesis that improving WASH will reduce infant anemia.
This paper will describe hepcidin values measured in
archived blood samples from children who participated in
ZVITAMBO vitamin A trial who were HIV infected or whose
mothers are HIV infected.
These data will aide in
interpreting hepcidin values and the causes and solutions
to anemia among in HIV-exposed children enrolled in
SHINE.
This paper will be a detailed presentation of the
background, design, and methods of the SHINE project. It
will be submitted to a journal which allows ample word
count for all the details to be recorded in one place and
therefore be easily accessible to the public health
community.
This paper will present follow on data to paper #10 by
presenting the pilot data on the impact of the IYCF
intervention on improving the nutritional adequacy of infant
diets.
This paper will report the pilot study of the EBF intervention
designed by SHINE to address identified barriers to
exclusive breastfeeding and also impart knowledge and
skills at the critical timepoints that they are needed. The
paper will guide others in Zimbabwe and elsewhere in
designing effective interventions to (1) improve EBF
practices, (2) leverage community based health workers
towards the production of health outcomes, and (3)
facilitate EBF behaviour change using adult learning
techniques.
23
Outcome Indicator 2: Number of programmes or policies changed as a result of project
activities and research findings in Zimbabwe and globally.
Logframe indicator for 2014: Ministry of Health and Child Care representatives at national, provincial
and district levels confirm continuing strong partnership with Zvitambo
It was apparent during the field visit and with Government partners in Harare (MoHCC) that Zvitambo is
well regarded and there are very strong trusted relationships at various levels of Government of
Zimbabwe, national and local. There is a strong understanding from Govt. of the political challenges of
implementing a RCT but an understanding of the powerful evidence that will be generated. The District
Administrator in Shurugwi articulated well the importance of randomisation for evidence creation and
we heard this again and again. A Village Counsellor told us ‘we will be with Zvitambo till the Hallelujah’.
Zvitambo was obviously well respected and trusted as a long standing organisation in Zimbabwe and
Govt of Zimbabwe lend them vehicles and helpf facilitate progress.
In terms of the longer term outcome of clear policy and programme uptake from the SHINE experience
here are a few examples.
 Members of Zvitambo were asked to update the PMTCT Section of the MoHCC Manual for
Village Health Workers. This section included early identification and referral of pregnant
women and infant feeding in the context of HIV.
 The methodology for conducting a survey of water infrastructure through physical inspection,
documentation of geological coordinates and assessment of state of functionality was
summarized and shared with district and national level policy makers (the National Coordination
Unit, NCU) for possible adoption for use in building and updating water facility inventories. This
methodology has potential applications in (1) assessing baseline status (of availability and
coverage), (2) prioritization of water points for new infrastructure installation or repairs based on
better estimation of need, or (3) evaluation of impact of water access programmes with better
estimation of value for money.
 Members of Zvitambo were asked to share their experience of home HIV testing and
counselling (which is part of the SHINE protocol) with the MoHCC who is in the process of
rolling out home T&C.
In addition Zvitambom staff are now in positions of influence with Government of Zimbabwe, and using
their experience of research to support policy design.
On the basis of technical assistance to the Ministry of Health and Child Care towards stunting reduction
efforts, Dr Mbuya of Zvitambo, is a member of the government convened National Food and Nutrition
Security Advisory Group. The Advisory Group was convened in January 2011 to oversee the
development of the recently launched (May 2013) Food and Nutrition Security Policy for Zimbabwe.
The role of the Advisory Group has been to advise the Food and Nutrition Council in (1) defining the
scope, content and breadth of the Policy, (2) implementing strategies for ensuring ownership and
relevance of the Policy within the relevant national Ministries and institutions, (3) contributing to the
policy development process through designing national consultative meetings, and (4) ensuring
mechanisms for the Policy’s implementation. This is a pivotal policy role and Zvitambo had not
expected to be invited to sit on this advisory group.
The Govt will now be creating a new nutrition strategy and are keen to work with SHINE to understand
how to implement across sectors. Government officials talked about the usefulness of ‘compelling
evidence’ and the importance of SHINE in its generation (Nutrition Lead in MoHCC). They said that the
Permanent Secretary and Minister of Health both were supported of SHINE, but that there needed to
be good information to help understand which elements of the interventions could be replicated at
lower cost.
Government of Zimbabwe and other stakeholders urged that this RCT would not ‘pack and go’ but
leave behind good replication and approaches that other NGOs can implement, and ensure that the
two districts remained an example for other areas of Zimbabwe. Examples given were the potential
24
need to reduce the costs of play pens – currently imported - and toilets.
Members of the study team have held dissemination meetings with district and provincial stakeholders
and presented preliminary findings emanating from the design, planning and implementation of the trial
at national and international fora. The dissemination fora have included:



National technical groups: the Nutrition Cluster, Unicef Collaborating Centre for Operational
Research and Evaluation (CCORE) Brown Bag;
Universities seminars and teaching: University of Zimbabwe, Johns Hopkins Bloomberg School
of Public Health, Cornell University, University of London;
Technical meetings and invited seminars: Stunting Reduction Forum (2013), Experimental
Biology Meeting of the American Society for Nutrition (FASEB 2013, 2014), USAID/Washington
DC brown bag and Webinar (2013)
In addition the ‘toilet crisis’ has ensured that a cheaper Blair VIP toilet is now being used in SHINE and
a design for toilet base is being created centrally which should influence future toilet production in
Zimbabwe for rural WASH projects.
2. Costs and timescale
2.1 Is the project on-track against financial forecasts:
Yes, now that the funding gap has been filled by existing donors for the study to be completed.
DFID Zimbabwe’s contribution of £4 million up to 31 March 2014 has been fully disbursed according to
accurate forecasts submitted quarterly as per the Accountable Grant with Zvitambo.
Policy and Research and Evidence Divisions have recently signed the amended Accountable Grant
Arrangement with Zvitambo for £3.2M from1 April 2014 to 31 December 2017 for the remaining study
trial period and quarterly disbursements will commence shortly.
Zvitambo mentioned during the review that they are approaching other donors to fund elements of their
work, including communications and other areas of research.
2.2 Key cost drivers
The primary cost drivers during this fiscal year were personnel costs which makes up 55% of the total
global budget over the lifetime of SHINE) and latrine construction. This includes incentives paid to
Village Health Workers and Environmental Health Technicians.
It should be acknowledged that SHINE leans towards ‘efficacy’ with high standards, high quality
interventions involving intense behavior change, including the building of toilets and the provision of
play pens, along with the taking of samples from clients. For example the toilets being built cost $788
as opposed to much cheaper ‘bush’ toilets without surrounding high quality infrastructure. This complex
large size trial takes place in the context of low population density and resulting long distances causing
high transport costs.
2.3 Is the project on-track against original timescale: No
The trial was delayed by the length it took for Chiramanzu District to sign the MoU, delays in enrolment
of pregnant women to the study and this year by the delays caused by latrine construction and tippy
tap installation under the Oxfam contract the trial. However the trial should now be on track to complete
25
by end of 2017 as proposed during the 2013 Annual Review.
3. Evidence and Evaluation
3.1 Assess any changes in evidence and implications for the project
A great deal of evidence has already been generated from SHINE.
Formal research that’s has been instigated during this review period includes:




Efficacy of rotavirus vaccine in the study participants, hypothesizing that EED is a major cause
of vaccine ineffectiveness
Village Health Worker performance and analysis of uptake of behavior change as it relates to
performance
Maternal capacities and differential uptake of good nutritional and sanitation practices
Myotoxin and the impact on stunting
These nested studies will all use the existing extensive research to provide evidence useful for global
advances in nutrition science, and are valuable additions to understanding implementation science.
Links through to details.
Zvitambo has begun the process of ensuring research uptake by policy and programme authorities
through our linkages with UNICEF, FNC, Govt of Zimbabwe, international research community, and
WHO. Zvitambo also share learning with other relevant trials and with the EED research community
globally. Zvitambo have widely articulated the SHINE hypothesis and its implications through invited
talks at UNICEF/SE Asia and New York, the Micronutrient Forum; the European tropical medicine
congress. Zvitambo have fund-raised (so far not successfully) to enable a production of a film on
SHINE that would engage the public (especially the UK tax-payer) and policy makers; Zvitambo have
produced manuscripts reporting the development of behavior change modules which will be freely
available through journals’ open access.
SHINE is in close communication with the WASH Benefits trial in Kenya and Bangladesh that is testing
the same hypothesis, with two cluster randomised control trials in rural areas and intervention arms of
water, sanitation, hand washing and nutrition. Outcomes being measured are stunting and diarrhoea.
The SHARE trial (DFID funded) in India similarly measures the impact of latrines on stunting, diarrhoea
and intestinal nematodes infection and started in 2010. SHINE were not aware of this trial and should
ensure that lessons learnt and research uptake strategies are aligned.
The MRC and members of the Data safety Board were met as part of the review and both were
positive about the ethics and implementation of the RCT, amongst the 12 currently underway in
Zimbabwe. The MRC head said that SHINE ‘set a good example’ .
3.2 Where an evaluation is planned what progress has been made?
Not applicable
26
4. Risk
4.1 Output Risk Rating: Medium
There are still 11 Risks at the time of this review 2014 – 7 low, 2 medium, 2 high. One low risk identified
from start of project happened in 2013 (slow Latrines building and cancelling of Oxfam contract) but is
now overcome. One medium risk delayed the project significantly (MoU signing)
•
•
•
High Risks include lower recruitment rate of pregnant women than needed and differential
recruitment into WASH arm and availability of drugs in Zimbabwe through 2014.
Medium risks include breastfeeding rates don’t rise as high as needed, and focus on research
obscures development impact.
Low risks include data insecurity, a lack of understanding of research in communities and lowering
motivation of VHWs
Risks identified last year that are now not relevant include the funding shortfall, (unless costs increase
beyond expectations) and the risk of losing support in the district because of implementation of the
UNICEF WASH project in the neighboring districts. This does not seem to be the case currently although
SHINE are hopeful that UNICEF will continue with their rural WASH programme in the research districts
post trial. The Parliamentary elections did not disrupt the research.
Perceived Risk
Original
Risk
1. Administration of Chirumanzu Rural District Medium
Council does not cooperate allowing the trial to
continue (previous administration had blocked
signing of MoU; new administration much more
co-operative and has signed MoU, but evolution
of the relationship with Zvitambo will need to be
monitored carefully)
2. Pregnant women recruitment rate will be lower Low
than the estimated average of 335 newly
pregnant women per month
3. Focus
on
research
outcomes obscures Medium
development impact of the project (development
impact is high for the study area).
4. Economic hardships continue and salaries paid
by Ministry of Health and Child Care not
adequate to minimise health worker attrition and
costs continue to rise.
27
Medium
Revised Risk 2014
Probability Low: MoU eventually
signed and now District is
enthusiastic.
Impact Medium
Probability High: Risk remains
high as recruitment is still slower
than hoped and now differential in
the WASH arms.
Impact Medium: there are cost
implications is the trial takes longer
than planned
Probability Medium as benefits
are felt by households but SHINE
needs a broader research uptake
strategy.
Impact Low: development impact
is clearly being felt and monitored
closely
Probability Low : inflation is very
low. The Health Transition Fund
(HTF) is paying allowances to clinic
staff and health managers and
Zvitambo pays incentives. However
this risk is higher for EHTs who do
not receive HTF allowances.
Impact Medium: Whilst attrition
may happen, Zvitambo would likely
become the main source of income
for EHTs.
5. Ministry of Health and Child Welfare does not
Low
prioritise revitalisation of Village Health Worker
system and the implementation of the 2010
PMTCT Guidance
6. Political
instability
disrupts
implementation in project areas
project Medium
7. Oxfam
discontinues sanitation construction Low
subcontract arrangement with Zvitambo. Can be
removed for next AR.
8. VHWs are demotivated.
Low
9. Communities
do not fully understand the Medium
randomized nature of the trial and tension is
created when not all households receive their
latrines at the same time.
10. Exclusive Breast Feeding is not amenable to Low
change in response to interventions
11. Ministry of Health and Child Care and donors are
High
not successful in mobilising sufficient funding for
drugs and reagents to enable full implementation
of 2010 Guidance (for the PMTCT interventions
on which EGPAF leads – failure to provide
PMTCT could confound the results)
12. NEW risk: Data saved and backed up in
Low
Zimbabwe by Zvitambo, or samples stored in
freezers maybe lost.
13. NEW risk: GOZ is unable to pay salaries
regularly and in full, leading to outmigration of
health workers and/or absenteeism
28
Medium
Probability and Impact both Low
so no change: MOHCC is still
giving this sufficient priority and
PMTCT well established in routine
services.
Probability Low: elections did not
disrupt research.
Impact Low: previous mitigation
measures
have
been
very
effective.
Zvitambo discontinued contract
with Oxfam, as per output 3 and is
no longer relevant.
Probability Low: SHINE is
providing intensive support and
incentives
and
VHWs
are
motivated.
Impact Medium
Probability
Low:
community
sensitisation has been successful.
Impact Medium
Probability Low: EBFF has risen
significantly in the first month as
new data showed during this
review, but needs to continue to 6
months.
Impact: Medium
Probability High – the Adult
regimen has changed and there is
a funding gap next year. DFID is
likely to stop funding paediatric
ARVS post 2015. EGPAF, GF,
USG and others are actively
working to fill the funding gap.
Impact Medium: whilst important
for optimal results, PMTCT is not a
trial arm
Probability Low – Zvitambo have
moved to a permanent base with
generators
and
will
explore
international back up options.
Impact High
Probability Medium
–
The
economy generally, and GOZ’s
capacity to accommodate the
recent civil service pay rise are
both fragile.
In addition to
allowances, HTF is rolling out
results based financing, which
includes
additional
reward
payments to HWs. It is important
for Zvitambo to monitor the
situation
and
develop
a
contingency plan, particularly for
those the trial depends on who are
not HTF recipients.
Impact Medium: see risk 4 above
Probability Medium - Zvitambo is
implementing
more
accidentavoidance activities than most
projects involving the frequent use
of motorbikes. Average accidents
have reduced but the monthly rates
are still erratic. These are being
closely monitored and further
measures may need to be
considered if the rate starts to rise.
Impact Low
NOTE: Zvitambo are avoiding using local banks affected by the banking liquidity crisis, and much of their
funds are held outside of the country, to be drawn down when needed.
14. NEW risk: motorbike accidents increase, leading
to interruptions
supervision
on
data
collection
Medium
and
4.2 Assessment of the risk level
The project is low to medium risk. A low risk actually happened last year with the Oxfam contract,
however SHINE have resolved this well and reduced many other risks such as stakeholders
understanding of the need for a randomised approach. However Zimbabwe is a fragile environment with
low population density which creates a range of additional challenges for research of this nature.
Risks to the research remain differential recruitment and incentives for the WASH arm. Main risks to the
programme are the precarious salary situation of government staff.
4.3 Risk of funds not being used as intended
Low as the contribution is to the general support of the project and not earmarked for a particular
component of the project. Quarterly statements are all in order and Annual Audited Statements by
Deloitte and Touche are received annually for the DFID accountable grant.
Zvitambo has an Employee Policy Manual in place which stipulates policy on financial or other conflicts
of interests, fraud zero tolerance and Whistle Blower procedures.
A micro-assessment of Zvitambo was carried out by Moore Stephens Ltd in July 2013. The assessment
scored the implementing partner as Low risk, commenting that they were ‘A well-established entity…with
an independent board of directors in place’. They also highlighted that ‘the corporate structure of the
Implementing Partner is appropriate as it has the requisite skill and experience staff both on the financial
and programme side.’
4.4 Climate and Environment Risk
Low. Considered to have a marginal negative impact resulting from the construction of latrines from
building materials that require some energy to create and significant use of transport for a RCT in a low
population density area. Impact of latrine construction has been off-set this year as now bricks and slabs
are locally moulded and sun dried. This is generally considered to have a positive impact resulting from
the improved living conditions associated with the project and environmental cleanliness. Better
nourished and healthier children will learn better and consume fewer health care resources over their
childhoods. The major environmental impact is the high volume of road transport need to visit sparsely
populated areas of Zimbabwe to carry out the research, which due to the randomised nature of the trial
is necessarily not efficiently planned.
29
5. Value for Money
5.1 Performance on VfM measures
Effectiveness
As explained in Section 2 clinical trials are expensive, especially a rural, cluster-randomized trial, so
SHINE cannot be evaluated for VFM in the same way as a programme in which activities would be
planned very differently. However the RCT should be marked alongside similar trials and on that basis
it is expensive. For example the SHARE trial in India, within 2500 households enrolled has a total
budget of $3.5M, versus $25m for SHINE. However, direct comparison cannot be made as there are
many reasons for this cost difference, including:
a) Unit costs in Zimbabwe are generally much higher
b) The Zimbabwe health system was still recovering from the financial crisis and additional
costs were incurred (such as for the VHW programme) to establish functional systems
c) Multiple sources of funds required high managerial costs
d) Zvitambo incurred significant expenses to conduct the formative research that has had a
great impact on the potential benefit of the trial including VHW behavior change, cultural
barriers to exclusive breastfeeding, and infant injestion practices
e) The SHINE trial has a much greater laboratory component to establish biomedical causal
pathways
f) More than twice the number of households are included (4,800 vs 1,992)
If the study demonstrates a clear causal pathway (or clearly demonstrates no causal pathway), this will
contribute to clarifying which interventions (and how much of them) are necessary for children across
Africa and Asia to grow well. The policy uptake of the findings and impact on child stunting globally
improves the VFM considerably but depends on a positive result and uptake. World Bank estimates 23% of GDP in developing countries is lost due to undernutrition. If the results do, indeed, lead to a
transformational change in nutrition interventions across many countries it could be one of the most
cost effective of DFID funded programmes.
Therefore the trial needs to balance intervention standards (to ensure proof of concept is
demonstrated) with value for money; despite an ‘efficacy’ trial it still uses local infrastructure to deliver
interventions
5.2 Commercial Improvement and Value for Money
Economy and Efficiency
Examples of cost-saving measures Zvitambo have taken in the past year to increase efficiency:
1. Purchased property for its office, laboratory, and data centers. This prevents the risks of
eviction and very high rental increases they had when renting.
2. Innovative provision of mobile phones to mothers enrolled in SHINE to reduce the costs
and risks of wasted home visits in terms of transport and time when mothers are not
available and to recover missing data.
3. Obtained best prices for mobile phones used by SHINE staff and SHINE mothers from
Econet. They have given the project free handsets and have committed to putting up
additional towers to ensure complete coverage in the two districts, in exchange for
Zvitambo purchasing solar chargers and $3 per mother phone. .
4. Provision of small gifts (<$1) when mothers are available for their scheduled visits to
motivated them to keep these appointments and prevent wasted time and petrol costs and
wear and tear on motorbikes. (Costs $55 for VHW to visit client.)
5. Commissioned Peter Morgan to design a new Blair VIP latrine model that is both more
30
stable in sandy wet soils and less costly to build using less bricks at less cost.
6. Insisted that casual laborers (pit excavators, latrine builders, brick molders) have an
Econet telephone to enable Zvitambo to pay them via ecocash to reduce risks of traveling
with large amounts of cash.
7. Centralised moulding of latrine slabs and bricks. Location selected at optimum site close to
river for sand and water for moulding bricks at the local clinic for security. More efficient
use of time and transport costs. The cost of bricks when procured from a commercial
vendor is about $0.28 compared to the cost when made in the district which is $0.13.
Internal Cost Management:





The annual budget is Zvitambo’s primary cost control tool; variances from the budget are
analyzed on a monthly basis.
Each department head is responsible for controlling expenditure within budgetary limits.
Requests to spend money on items not in the budget require compelling justification before
approval is given.
Monthly stock count of inventory kept at each hub (building materials and other consumables)
to contain loss.
Daily stock counts of petrol and diesel coupons to contain loss.
Scrutinize requests for paying vendors for accuracy and completeness.
Improving procurement capacity and capability:
Zvitambo has a procurement policy which covers the procurement of goods and services. The policy
also establishes the use of competitive bidding as a priority practice. Their procurement systems are
robust, highly competitive and transparent, thus resulting in contracting of the best possible suppliers
on the market. They have documented procurement policies and procedures in place including:







Highly trained staff who are certified procurement practitioners through the Chartered Institute
of Purchasing and Supply (CIPS)
Clear communication of the procurement strategy across all departments through sharing of the
procurement policy and guidelines. This has helped to ensure that everyone is pulling in the
same direction.
Clearly documenting processes across the whole procurement cycle so that Zvitambo are able
to identify areas where activities can be streamlined and average cycle times reduced; ensuring
lean processes are followed throughout all activity. The outcome results of this so far are that
Zvitambo are able to manage more with the same resources.
Consolidating purchasing requests and intervals hence cutting down on delivery costs and
purchasing documentation especially for most of the items that are imported internationally and
regionally.
Training staff on cost effective purchasing and encourage them to save money whenever
possible.
Centralising disparate purchasing functionality, which allows for savings in staff, processes and
technology.
Registration of suppliers. Creating a database of competent suppliers with the aim of
eliminating the middle man.
5.3 Role of project partners
The relationship between the Ministry of Health and Zvitambo appears to be very positive both in
Harare and in the two districts of Shirugwi and Chiramanzu and it is to Zvitambo’s credit that the
understanding of complex research methods is apparent from the District Administrators’ office down to
the individual households. To some extent the wide range of financial incentives may play some part in
ensuring these relationships are solid, but it does seem that the long history and careful management
of relationships and investment by Zvitmabo are ensuring trust has been built.
31
Close collaboration with the MoHCC means that Zvitambo is able to hold the brick moulding at their
clinics without paying rent, store cement and other commodities securely without extra warehousing
payments, and they also share office space within MoHCC buildings in the district hospitals.
5.4 Does the project still represent Value for Money : Yes
Despite the expense, the trial still does represent value for money because the value of the findings
has scope to be transformational in the arena of tackling undernutrition. Additionally, Zvitambo has
constantly tried to trim costs and has made substantial savings across the range of its interventions,
whilst maintaining its commitment to ensuring its interventions are of the highest quality to maintain its
efficacy imperative. If the results are as expected, the value for money will need to be demonstrated
through policy uptake. We have also recommended that the research team undertakes cost benefit
analysis in order to provide recommendations on the set of interventions that will be appealing to policy
makers and accompanied by costings. Many of the cost drivers are based on conducting the research
in Zimbabwe, inflation, high staff costs, population density requiring transport costs and it would be
useful to understand the costs of implantation in different contexts. In order to ensure policy uptake
once a result in known this data should be collected.
5.5 If not, what action will you take?
6. Conditionality
6.1 Update on Partnership Principles (for all programmes) and specific conditions
Only condition was that the initial DFID funding would attract a similar or greater contribution from other
partners and this has been achieved. No other conditions are in place.
No funds directly through GoZ financial systems and procedures. This means no UK aid is managed by
or is under the direct control of the Government of Zimbabwe using its own financial systems and
procedures.
7. Conclusions and actions
Zvitambo has established strong relationships at all levels of Government and local communities;
this was especially striking in discussions about complex research methodologies where
understanding is good. The management of and passion for the research is obvious and paramount
and translates into good beneficiary understanding and ethical practises. SHINE is maximising their
research to create ‘nested’ studies that should provide good global knowledge but also ensure
better update of what are essentially long standing public health and sanitation interventions. SHINE
will not point towards a new simple solution or magic bullet for development but an intensive
community based overlaying of interventions, if the result is positive. This, with the other 3 trials we
are aware of globally studying this hypothesis, now needs to have more of a priority in their work.
Recommendations
1. Zvitambo and the wider SHINE team need to develop an exit strategy to best prepare all
stakeholders, those reliant on SHINE for income and the district health systems, for 2017 when
the significant support and infrastructure may cease. This strategy should highlight the optimal
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use of existing research ‘know how’, infrastructure and Government staff who have been
ensuring the trial is implemented. The strategy should also highlight how Zvitambo will maintain
organizational sustainability, possibly through diversifying its activities/services offered. (June
2015)
2. SHINE needs to prepare for any ‘salary shocks’ that might arise due to Govt of Zimbabwe
being unable to pay staff salaries through any period to the end of the trial; this is especially
pertinent for the Environmental Health Officers who at present do not receive any ‘top up’ from
the multi–donor Health Transition Fund and would therefore become entirely reliant on
incentives.
3. SHINE should maximize the opportunities that arise from their extensive data and
experience of implementing WASH, IYCF interventions and behavior change to:
a. Provide cost effectiveness/benefit evidence for those interventions that prove to be
successful in reducing stunting
b. Provide implementation research that demonstrates ‘how’ SHINE has provided
interventions at high quality for impact, such as the delivery of the behavior change
modules and the delivery of a combination of interventions.
c. Promote lesson learning from the effective delivery of SHINE interventions through
public services in rural areas.
4. The SHINE team needs to monitor the proportion of Blair VIP toilets built where there are
existing toilets and ensure EHTs have clear guidance on the adaptations that can be made
to those toilets to maintain quality. This is to avoid costs being incurred in building new
toilets with acceptable toilets exist. Dr Morgan can be consulted on the quality adaptations.
(October 2014)
5. The SHINE team may want to also further explore any further cost-saving modifications in
toilet design (without compromising standards) before building the bulk of toilets at the end of
the trial for the remaining families enrolled.
6. SHINE should further investigate the reasons for differential recruitment and whether there
are incentives for pregnancy increase.
7. SHINE needs to create a research uptake strategy that details how they envision having the
maximum policy uptake of their research products as defined by new programmes tackling child
stunting using these interventions or the evidence they create. The uptake strategy should be
comprehensive and based on a stakeholder analysis. This includes the important work the
review team heard about that is creating evidence on: maternal capacities, vaccine efficacy,
fidelity of interventions, design of interventions and intervention science. DFID will support this
work with examples of other research update strategies and contact with the DFID/academic
best practice on this. (June 2015)
8. Zvitambo needs to expand their discussions on WASH Benefits to reach out to the SHARE
consortium in India (as well as other Gates funded similar trials), to ensure that their similar
research is learning lessons from each other and ultimately will be ready to communicate
together a ‘policy friendly’ message for maximum uptake.
9. Zvitambo should ensure their data is also stored internationally for security, in case the two
backups are lost within Zimbabwe.
10. DFID should ensure that the accountable grant is accompanied by an agreement with Zvitambo
on our standard data policy that also covers future specimen use. Action: DFID Zimbabwe to
follow up with RED on our standard policies.
11. DFID HQ (HDD and RED) should be clear on own level of technical inputs to DFID Zimbabwe.
Action: DFID Zimbabwe to provide roles and responsibilities for management of programme
with Human Development Department in Policy Division and Climate and Environment Team in
Policy Division to confirm commitment to participate advisory time to future ARs.
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8. Review Process
This review was conducted by Anne Philpott (Senior Evaluation Advisor, Africa Directorate) and
Sally Chakawhata (Policy Officer, AIDS and Reproductive Health Team, Human Development
Department) working with the DFID Zimbabwe team, Zvitambo and the trial team, and the local
district authorities in the two study districts. The review incorporates available documentation,
interviews with stakeholders including travel to the field to observe; VHW and EHT conduct training
and interviews with household beneficiaries as well as brick moulding and latrine slab construction.
Interviews were held with other donors, Ministry officials, Dr Peter Morgan (designer of the Blair
VIP latrine) local authorities, nurses, VHWs and latrine builders as well as stakeholders and
household beneficiaries. A ‘live scoring’ exercise was conducted by Anne Philpott, the DFID
Zimbabwe programme management team and the Zvitambo team on 13th June. Final editing and
quality control of this report was done by DFID Zimbabwe’s Health Adviser, based on comments
from the Basic Services Team Leader/a/g Deputy Head and Results Adviser before final sign-off by
the Head of Office.
Meetings included: SHINE team presentations on research, IT, Data, laboratory, behaviour change
modules. Mvuma Hub members in Chirumanzu, MOHCC Districts nurse officers, Shirugwi Hub
leadership, District Administrators, enrolled households, EHT teams, Village Counsellors, VHWs and
supervisors, Nurse Supervisors, Data Collectors.
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