Community Transformation in Bolivia

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Community Transformation in Bolivia Mozambique
through a Behavior-change Focus and Targeted Food
Aid
Presentation for the 2007 International Food Aid
Conference
Tom Davis, MPH Director of Health Programs, FH
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Who are the Producers or Generators of Health
and Nutrition in Young Children?

• In any system, there are producers.
• The producers of health and nutrition should be
  the people whose actions have the most impact on
  health and nutrition outcomes and the health and
  nutrition status of a population.
• Who are they? Physicians, nurses, CHWs,
  Administrators?
• We will briefly examine our assumptions.

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What are the production tasks that relate to
the burden of disease concerning Undernutrition?
Production tasks

• food production/purchase and storage
• dietary selection and meal preparation
• family food allocation
• dietary practices in pregnancy and postpartum
• breastfeeding and complementary feeding
  practices etc.

WHO MAKES THESE DECISIONS AND TAKES ACTION ON
THESE THINGS? WHERE DO THESE THINGS HAPPEN?
WHAT IS NEEDED TO DO THEM?
Family members (mostly mothers) at the household
level, using the values (e.g., food allocation),
knowledge (e.g., dietary selection), skills
(e.g., breastfeeding), and to a lesser degree,
physical resources (e.g., food) that they have
available.
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Malnutrition demands a focus on the first two
years of life.
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The Positive Deviance Principle

• PD Principle Almost everywhere, a portion of
  children born to poor families are well
  nourished.
• One key Find the differences in values, skills,
  and behaviors between poor mothers with thriving
  children and poor mothers with malnourished
  children. Promote the values, skills, and
  behaviors of the families that are thriving
  despite their poverty.
• PD in Vietnam More than 250 communities brought
  an estimated 50,000 malnourished children out of
  malnutrition from 1991-1999. Children born after
  the PD workshops were less malnourished.

The PD Principle is seeing the glass half-full.
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What needs to happen to reduce malnutrition
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Where has this led FH in its thinking?

• Changing values, motivations, beliefs, and
  behaviors at the household level are central
  Persuading members of households, especially
  mothers, to do things differently and to think
  about things differently, in order to be more
  resourceful. 80 or more of what we do should be
  targeted at these tasks. Example of thinking
  differently Barrier Analysis in Bolivia (see
  http//barrieranalysis.fhi.net) found that
  mothers believed that the common cold was more
  serious than malnutrition.
• We need to operate more as Teachers and
  Persuaders rather than Doctors Logisticians
  Focus primarily on helping people to change
  rather than giving resources or supervising
  people to get tasks done. Use high-quality
  behavior change tools and methods.

Where it All Happens
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Where has this led FH in its thinking?

• Approaches to improving health/ nutrition based
  primarily in health facilities should be ruled
  out.
• Approaches that rely mostly on adding physical
  resources (e.g., food, cash) should be ruled out.
• Food should be used in a targeted way, as an
  incentive for behavior change (e.g., attending),
  and as a supplement.

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Importance of Integrating Approaches
Some Reasons for Integrating Programs

• Each sector supports other sectors (Ex
  production of vitamin A rich foods enables
  mothers to diversify the childs diet NRM leads
  to higher agricultural yields)

• Increasing productivity and income without
  changes in values and skills will not necessarily
  lead to changes in health and nutritional status.

• Water and sanitation is highly linked with
  nutritional status. Ex Mozambican children
  whose mothers said that their drinking water was
  purified were 3.6 times more likely to be well
  nourished. (p0.03)

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Evidence of Approach Two Examples

• Bolivia Integrated Food Security Project,
  2002-2006
• Mozambique Integrated FS Projects, 1997-2004

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FH/Bolivia Target Areas
Department Municipality
Potosí Potosí
Potosí Ravelo
Potosí Ocurí
Potosí Toro Toro
Cochabamba Capinota
Cochabamba Tapacarí
Chuquisaca Sucre
7 Municipalities
2 Cities 260 Communities
212,290 direct beneficiaries
410,000 total beneficiaries
5 of Bolivias population
Areas of Extreme Food Insecurity
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Integrated Approach
Improving nut. practices through GM/P and CHW
training, PD/Hearth model, WATSAN improvements,
IMCI, food rations).
Micro-watershed management
Separately-funded Child Development Program
Technology transfer, improved infrastructure and
market access (esp. improved roadsirrigation),
marketing TA, capitalization.
Education, health, other community actions
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Exclusive Breastfeeding
A 34 increase in exclusive breastfeeding.
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Oral Rehydration Therapy
An 85 increase in oral rehydration therapy (ORS,
RHFs, or increased liquids).
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Prenatal Care
76 increase in prenatal care.
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FH/B Health Impact Indicator
36 drop in malnutrition in five years. (Most
change in first two years.)
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Did Food Rations Contribute to the Decrease in
Malnutrition?

• Study examined differences between 2004 (n683
  children 3-35m) and 2002 baseline study (n451
  children 3-35m)
• 24.3 decrease in malnutrition at that point.
• 40.4 of children in families who received
  rations were chronically malnourished in 2004 vs.
  47.3 of children whose families did not receive
  rations. This 7 percentage point difference was
  not statistically significant (p0.09).
• Regardless, rations were a big incentive for much
  of the other work (e.g., NRM, roads).

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Watsan Handwashing
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Watsan Access to Improved Water Source
106 increase in water access
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Agriculture Impact Indicator
Agricultural Income Generation
170 increase in household income
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Agriculture Income Generation
More than doubled target.
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Income Generation Activities Road Improvement

• 4,500 families benefited directly through these
  projects, and 10,000 families benefited indirectly

154 Km of roads were improved, strengthening the
linkage to markets and commercialization of
agricultural products.
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NRM roads improvement
BEFORE
AFTER

• Farmers and those improving roads are encouraged
  to work with food rations. The monthly ration
  was given for 9 days work (72 hrs.).
• About 2,500 families have received an average of
  4 rations per year.

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NRM Improved soil/water management
Natural Resource Management
Beneficiaries 37,342 persons, 15,556 families in
162 communities from 5 municipalities in the
Departments of Cochabamba and Potosí.
26 fold increase in soil and water management
practices.
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NRM River Defensive Walls

• 55 hectares of agricultural land were recovered
  from riverbeds and is now currently in
  production. An additional 80 hectares of
  productive lands have been protected.

• In 4 years of intervention, 1,400 lineal meters
  of defensive walls have been built up.

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FFW in Sucre 84 Municipal Investment Share
Ration costs (Bs) Rations USAID Investment (Bs) Municipal Counterpart (Bs) Municipal Investment Labor and Materials (BS) Final USAID investment (Bs) TOTAL Investment (Bs)
215.1 1,418.0 305,011.8 30,501.2 1,392,952.1 274,510.6 1,697,963.9
1.8 82.0 16.2 100.0
INVESTMENT RELATION () INVESTMENT RELATION () INVESTMENT RELATION () 83.8 83.8 16.2
Final USAID Investment (us)
33,890.2
Implemented Projects 14
Families Directly Benefited 6,760.0
Families Indirectly Benefited 1,418.0
Women participation 81.21
Men participation 18.79
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• Mozambique Food Security Project
• Health Results, 1997-2000 2000-2004

• 100 monetization
• Care Group approach for health/nutrition program
  with strong focus on changes in behavior and
  values

• Groups of 12 HH established with mothers of
  children 0-59m of age or pregnant women.
• One Leader Mother (LM) is elected to represent
  each group of 12 HH.
• 10-14 LMs meet biweekly in the Care Group to
  learn from the paid Promoter, and then do health
  promotion in their households.
• Intensive behavior-change effort LMs receive
  104 hours of training/year. Beneficiary mothers
  receive 13 hours of training/year.
• Health messages/activities improved through
  positive deviance studies.

• Agriculture program focused on agricultural
  extension, applied and adaptive research,
  farmers associations and agribusiness
  development

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Care Groups A Multiplier Model for Health
Promotion
Each Health Promoter educates and motivates 10
Care Groups. Each Care Group has 12 Leader
Mothers.
Each Leader Mother educates and motivates other
mothers with children 0-59m of age and pregnant
women in 10 households.
Health Promoters
HP 2
HP 1
Care Groups
10 families
12 Leader Mother
10 families
12 Leader Mother
10 families
HP 4
HP 3
12 Leader Mother
10 families
12 Leader Mother
10 families
10 families
12 Leader Mother
10 families
HP 6
HP 5
12 Leader Mother
10 families
12 Leader Mother
10 families
12 Leader Mother
10 families
12 Leader Mother
12 Leader Mother
With this model, one Promoter can cover 1,200
children 0-59m pregnant women.
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Children receiving ORT...
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Exclusive breastfeeding...
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Vitamin A coverage...
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Deworming...
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Diarrheal prevalence...
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Malnutrition (stunting, stat. sig.)...
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Malnutrition (severe stunting, stat. sig.)...
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Other factors that may have contributed to the
Mozambique Care Group Results

• Mothers were trained to start or expand kitchen
  gardens where they grow vitamin A rich vegetables
• Agricultural production program interventions
  were conducted in the same communities as the
  health and nutrition program.

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Decrease in Child Mortality, 2000-2004
A study by Johns Hopkins University (conducted in
conjunction with World Relief and Food for the
Hungry) found that child deaths decreased by 62
in areas where the Care Group approach was used.
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What about cost per beneficiary and
sustainability??

• Cost per beneficiary for health activities was
  4.50/benficiary/year.
• WR CG project sustainability data
• 93 of the volunteer Leader Mothers (LMs) were
  still active twenty months after the project
  ended.
• Communities, on their own, replaced 40 of the 132
  vacant volunteer positions. Remaining LMs
  trained new Leader Mothers and gave them
  educational materials.
• Women in half of the households surveyed reported
  that their Leader Mother had visited their
  household within the last two weeks.

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Sustainability of Final Indicator Levels at 30m
and 48m Post-Project in the WR-Mozambique Care
Group Project Home Care of Sick Children
Actual
Goal
End of Project
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• Conclusions

1. Efforts to change behavior and values need to be
   central to our programming efforts to achieve
   program impact. Significant contact time with
   beneficiaries is required for high levels of
   behavior change.
2. Understanding coping mechanisms through positive
   deviance studies can improve messaging and
   results.
3. Integrated programming may lead to more
   significant gains.
4. Food rations can play an important role as
   incentives for program participation and as
   nutritional supplements.

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