Improving Food Security and Nutrition in Malawi

Context

Malawi is a predominantly rural, agricultural country. Poor agricultural planning and practices, combined with environmental degradation and erratic weather, afflict the sector and affect the livelihoods of smallholder farmers—who constitute 80 per cent of the population. To address food insecurity and spur agriculture-led growth, the Government of Malawi has developed a National Nutrition Policy and Strategic Plan closely linked to its Comprehensive Africa Agriculture Development Program (CAADP) investment plan (titled the Agriculture Sector-Wide Approach [ASWAp] in Malawi), which together aim to coordinate food security and nutrition programming at the national and community levels. However, agricultural production and household diets still focus primarily on one food group—staple foods (mostly maize with some rice, cassava and potatoes)—and limited production and consumption of five other food groups (fruits, vegetables, legumes and nuts, animal products, and fats). Poor food diversification is exacerbated by seasonal unavailability and/or lack of understanding about the food diversity that is available naturally. The result is family diets that do not include the recommended six food groups every day of the year.

Background

Since 2007, the Food and Agriculture Organization (FAO) of the United Nations has supported the Government of Malawi with the implementation of Improving food security and nutrition (IFSN) policies and programme outreach. In phase 1 (2007-2011) the programme focused primarily on the agriculture sector with few linkages to the health system, but in phase 2 (2011-15) the project expanded the integration of agriculture and health with the goal of improved diversity of household food production and consumption so that they both follow the Malawi six food group guide, with particular emphasis on complementary foods for children aged 6-23 months. The capacity building component reached Farmer Field Schools (FFSs), Junior Farmer Field and Life Schools (JFFLS), primary schools, health centres, health and agriculture extension services, and volunteer Community Nutrition Promoters (CNPs) with a package of BCC interventions.

In order to support improvement in IYCF practices in a sustainable way, the project supported government staff to work closely with all its partners across sectors and at all levels. This included joint development of IEC materials, joint training sessions for capacity building, and support to the coordinating bodies: National Agriculture and Nutrition Committees and Technical Working Groups (TWGs) and District Nutrition Coordinating Committee (DNCC). The project supported supervisory staff in two sectors at the level of Extension Planning Areas (EPAs) for agriculture and health centres.

The project was funded by FAO with the support of the German Ministry of Food and Agriculture (BMEL) and independently evaluated by Justus Liebig University (JLU).

Programme design

Situational analyses were conducted using the Demographic Health Survey (DHS) and other available data related to IYCF and food security. The project conducted Trials of Improved Practices (TIPs) over two seasons (September 2011–July 2012) with caregivers (primarily mothers) in 10 intervention villages (selected by the research team) in order to test the feasibility and acceptability of enriched porridge recipes containing 4-5 food groups (based on locally available foods), as well as key practices and nutrition messages.

Formative research showed that several IYCF practices needed improvement: premature introduction of food to children aged 2-4 months; giving children water with herbs (dawale); provision of watery starchy porridge; inadequate frequency of feeding; lack of food diversity (low provision of vegetables, fruit, legumes, nuts, Animal Source Foods [ASF] and fats); premature transitioning to family foods; feeding from the family plate rather than a separate child’s plate; and poor hygiene and sanitation practices. Underlying issues that needed to be addressed were women’s workload; lack of, or underuse of available, diverse foods; planning for meals and snacks using substitutions within food groups appropriately; food preservation and storage; and agricultural diversification for family diets, especially with regard to ASF, legumes and nuts, fats, vegetables, and fruit.

Interventions

Based on formative research and programme monitoring, several materials were developed/adapted to improve extension services and promote understanding of good nutrition as well as specific behaviour changes.

The IYCF Facilitator’s Guide and Counselling Cards were designed to provide technical support to the CNPs by guiding them through ten nutrition education sessions with background information and examples of dialogue. The IEC materials were adapted from the UNICEF Child Feeding template for Africa but with improved sessions and pictures on food-based nutrients, dietary diversity, age-appropriate quantities of complementary foods, food preparation, water, sanitation, and hygiene, as well as danger signs of childhood diseases. An IYCF Recipe Book in the local language contained tested recipes to enrich porridges with local and seasonal nutrient-dense foods. Participatory cooking demonstrations took place during specific nutrition education sessions (2, 4, 6 and 7) and for the graduation ceremony, in order to display and describe to the community what was learned. A 250 ml cup was provided to each CNP to help demonstrate amounts of food. (Measuring containers are extremely rare in rural settings.)
Photographs of individual foods on small cards assisted CNPs and mothers in identifying food groups and demonstrating/practicing how to put meals and snacks together. Larger photographs of prepared meal and snack examples helped to graphically portray what colourful balanced meals can look like.
A Food Group poster and food group calendar aided each CNP in helping the community identify and address gaps in locally available foods. A food group cloth wrap given to each CNP and key community leaders to serve as a reminder of the food groups and the key message of feeding diverse foods from all the six food groups every day.
An Integrated Homestead Farming (IHF) manual was piloted and tested during the project and rolled out during the last year of the project. The manual showed how the combination of agricultural department messages regarding crops, horticulture, livestock, fisheries, bee keeping, water and land conservation, gender, and nutrition can be applied around the home.

Capacity Building: The project supported improved food security with the Ministry of Agriculture’s extension services through an existing system of lead farmers and FFS, JFFLS, and Nutrition Groups. Where groups had not yet been formed, guidance was provided on why and how to form a group. FFS and JFFLS training curricula covered the basics of nutrition including promotion of diversified food production (i.e., livestock, crops, etc.) to improve availability, access, and utilization of all six food groups using seasonal food availability calendars; the importance of dietary diversification, food processing and preparation; community action planning for food security; and promotion of income-generating activities (fruit trees, bee keeping, mushrooms, vegetables, cassava, Irish potatoes, and yellow-fleshed sweet potatoes).

Programme households were identified in June of 2011 and received training and support in improved food security awareness, advocacy, and inputs from July through harvest the following March. During that time, DNCC members worked with FAO staff and consultants to become IYCF Trainers of Trainers (ToTs). Starting in about March, as the food security component was finishing its first round, holding review meetings and moving on to Round 2, the IYCF component began in Round 1 areas, first with the ToTs conducting half-day sensitizations with supervisors and local leaders, then training front line agriculture and health extensions staff and CNPs in eight-day training sessions. CNPs then volunteered within their own villages to form groups of about 15 caregivers who had a child aged 6-18 months on enrolment, and facilitated the ten nutrition education sessions and five cooking demonstrations. After one group completed the course and graduated, communities would start new caregiver groups when needed. The ToTs would then introduce the programme in the next round of villages, again following on the Food Security component. Three rounds of villages were completed during the life of the project.

In total in the two districts, 30 ToTs sensitized over 283 supervisors and front line extension staff and led to the training of 1,118 volunteer CNPs. These volunteer CNPs supported 12,012 caregivers, spouses and community members in their own 546 villages, affecting 9,664 children 6-23 months of age.

Monitoring, support, supervision, and reporting was supported by IFSN project staff. During the roll out of the program, the IYCF ToTs included review and planning meetings at community, EPA, and district levels. National coordinators from agriculture, health and nutrition, together with staff from FAO, usually attended district level reviews. Monitoring led to programme adjustments, such as increasing the number and improving the quality of community sensitizations, and improvements to the IEC materials.

Assessment methods included observation of ToTs, CNP nutrition education sessions and home visits to observe food preparation and home surroundings; focus group discussions; in-depth interviews; and pre- and post-training knowledge tests prior to, directly after, and six months after the training sessions.

The following key issues were identified through monitoring.

The agriculture component did not cover a large proportion of families with children under two years of age: The focus of the IYCF intervention was therefore limited to foods that were already available. This was not the original design of the project, but the food security targeting process focused on households identified by community members to be considered poor, burdened by chronic disease, widowed, or caring for orphans. These homes usually did not have young children 6-18 months of age.

There were at least two key sustainability issues. The number of caregivers available in a village dwindled with each new group, as there were fewer children in the 6‒18 month age range over time. About 10 per cent of trained CNPs moved out of their villages; the program had no volunteer replacement strategy.
National nutrition policies and strategies were often not implemented well at district, area, and community levels. Nutrition was still considered a health issue rather than an issue for agriculture and other sectors. IYCF and other nutrition activities were often perceived as project-based and there was a lack of government resources for critical on-going activities.
Coordination and collaboration were found to be weak but are key for multi-sectoral projects that link agriculture and health services. Staff vacancies and work overload existed at all levels. Vacancies at district level resulted in weak coordination within and between the District Executive Committee (DEC) and the DNCC. Vacancies among area supervisors and at field levels affected ability to support communities and monitor progress. Positions were vacant in both agriculture and health at all levels. Nutrition extension requires additional staffing below district level, specifically at area supervision level and ideally within the front line worker level, to support nutrition mainstreaming with all sector extension staff.
Supervision, monitoring, and reporting were challenging for all levels. Transport was limited and inadequate to cover all villages. Funding for fuel and lunch allowances was also limited. The three-month rainy season allowed for fewer visits. Although it is unusual to supervise staff from other sectors (e.g., a district agriculture officer giving advice and guidance to a health extension worker) this is sometimes appropriate in multi-sector programs. But difficulties like this can be overcome with time and dialogue.
Volunteer CNP capacity was limited. Training sessions were not designed well enough for community level understanding. CNPs were often unskilled in facilitation and were not incentivized enough internally or by their communities to perform their role adequately.

Results

Outcomes

The JLU research team conducted a randomized controlled trial starting with a cross-sectional baseline survey of households to assess the nutritional status of children under two years old as well as IYCF practices of caregivers and related determinants. A cross-sectional midterm survey was conducted two years later and an impact survey was conducted in August of 2014.

Minimum acceptable diet improved only in the intervention cluster (58 per cent at baseline, 63 per cent midterm, and 67 per cent impact). Minimum dietary diversity also improved only in the intervention cluster (63 per cent at baseline, 71 per cent midterm, and 71 per cent impact). Meal frequency did not change in either intervention or control groups.

The results were corroborated by the findings of a longitudinal cohort of children in both intervention and control areas. That study also found that child consumption of animal source foods increased in the intervention area from 1.5 days per week at enrolment to 3.5 days per week in the follow-up rounds. Consumption of vitamin A-rich foods (i.e., vegetables, roots, and fruits) might have been affected by seasonality; it was 5.5 days per week during the rainy season and ranged from less than 2 to less than 3.5 times per week during the dry season. Participation in the nutrition education activities was more predictive of improved child diet diversity scores than participation in the FFS. Nutrition education was effective in promoting adoption of IYCF practices and adoption was highest where families and communities had been engaged through community mobilization and sensitization activities and were supportive. Nutrition education increased knowledge and reduced beliefs in unhealthy practices. The level of participant education was not associated with knowledge gain.

Qualitative research showed that adoption of improved IYCF practices was facilitated by four factors:

Improved caregiver knowledge, especially on meal frequency, preparation of enriched porridges, and hygienic practices. After caregivers were informed about the importance of dietary diversity, they fed more food groups, particularly ASF and vitamin A-rich foods.
Caregiver perception that children liked the taste of enriched porridges. Children ate more once enriched porridge was prepared and fed to them.
Caregiver perception that their children’s health had improved.
Supportive grandmothers, fathers and other community members. A caregiver’s ability to put the program recommendations into practice was mediated by workload, seasonal food availability and accessibility, community support, and the others’ acceptance of the improved foods (in particular, grandmothers’ acceptance).

Participation in group sessions was lower than expected. Achieving a high coverage level with both food security and nutrition education (on IYCF) activities was a challenge.

Project Recommendations

Programme partners shared the following lessons and recommendations based on implementation experience:

Provide timely agricultural support according to the seasonal agricultural calendar, with a special focus on producing diverse nutrient-rich foods from all the six food groups.
Strengthen the DNCC and the regularity of its meetings.
Establish a comprehensive, continuous training system at all levels of health and agriculture extension systems.
Streamline the workload of government staff so that projects support local systems and structures and are not implemented in isolation.
Greater emphasis should be put on health promotion, with agriculture supporting all issues of food security (availability, accessibility, and utilization). Until now nutrition strategies have focused on curative approaches.

References

National Statistical Office (NSO) and ICF Macro (2011) Malawi Demographic and Health Survey 2010. Zomba, Malawi and Calverton, Maryland, USA: NSO and ICF Macro.

FAO, IFSN and IMCF project. Dissemination meeting Report. 18th February 2015. Improving food security and nutrition policies and programme outreach (IFSN) and Improving the dietary intakes and nutritional status of infants and young children through improved food security and complementary feeding counselling (IMCF).

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