Coverage
Phase I: In 1993-1997 under the name of SECALINE (Sécurité alimentaire et nutrition élargie - expanded food security and nutrition), the programme began in two provinces.
Phase II: In 1998-2003 under the name of SEECALINE (current name), the programme offered nationwide coverage in areas with an underweight prevalence rate of 43 per cent and above. Its fate after 2003 is unknown. The programme management would like an extension, in the form of a Phase III, while many want to see the programme institutionalized and the activities integrated.
Operational funds
The programme is mainly funded by the World Bank. For Phase I, the budget was about US$ 32.4 million. The allocation for Phase II is estimated to be US$ 45 million. It includes purchase of supplementary food through the World Food Programme (WFP). Of the US$ 45 million, US$ 1.7 million is estimated to be the government contribution, mostly in kind, and 0.98 percent beneficiary contribution mostly in kind, mainly labour31. There has not been any change in the government funding for the programme but the World Bank has made a substantial increase as indicated above.
Objectives of the programme 32
The programme has four major components: community nutrition, school nutrition, natural disasters preparedness and intervention (cyclones, drought and floods), and information, education, communication.
Implementation
The programme is administratively autonomous and operationally vertical. It is under the Office of the Prime Minister with its own strong, well-equipped and staffed secretariat with five categories of experts in various fields at the central level and in all six faritany (provinces). It has subcontracted non-governmental organizations (NGOs) to coordinate the programme activities below the provincial level with the support of animators for supervision at the commune level, and salaried community nutrition agents at the fokontany (village) level. Teachers are responsible for the nutrition activities, including the distribution of iron and folate tablets and the anti-helminthic drug (mebendazole).
Programme impact
A 15 percent reduction in the prevalence of underweight (ranging from 8 percent to 26 percent) between 1998 and 2001 has been reported in the recently concluded mid-term review. In fact, for some areas in the south, a reduction of 50 percent was reported. The Community-based Nutrition Project (NAC) supported by the United Nations Children’s Fund (UNICEF), which competes for similar community nutrition interventions, also reported a reduction of 10-15 percent. Both reports were based on data from growth monitoring sessions, generally acknowledged to be unreliable unless validated by well-designed surveys. The last Demographic and Health Survey (DHS), conducted in 1997, did not find any change in the prevalence of stunting and underweight compared to 1992.
Coordination and community participation
The linkage between the various components of SEECALINE is weak, collaboration with sectoral ministries and other projects agencies is loose and coordination is generally informal and limited. Community participation, in the real sense of empowerment has a long way to go. Currently, it is mostly one of consultation and participation in providing labour (paid and unpaid). Hence, could be rated as consultative or participation for material incentives.
Strengths, weaknesses, opportunities and constraints/threats (SWOC)
SEECALINE is a programme with an ambitious mission, but which appears to be short of a long-term vision and a clear conceptual framework of what constitutes a nutrition security programme. There is no clear idea as to how it will be sustained when external funding stops. Despite that, the programme has made valuable contributions and opportunities exist for improvements and changes.
Strengths
Weaknesses
Opportunities
Opportunities might have been lost in the last nine years of existence of the programme. Some of the resources could have been used to strengthen institutional and community capacity and establish more sustainable approaches. Whatever the case, there are still many opportunities that could be capitalized on to sustain the efforts made:
Constraints/Threats
Sustainability
Given the above facts, namely the programme’s vertical nature, reliance on substantial external funding, focus on immediate causes, limited community participation and community capacity development, lack of integration of activities, and inadequate coordination, it is unlikely to be sustainable in its current form.
Lessons learned
SEECALINE is now a nationwide programme, active in all provinces but with identical administrative arrangements, activity packages and approach everywhere. For the purposes of this case study, two provinces (Antananarivo and Toamasina) were visited. Antananarivo province was selected because the programme started there in 1993, it is near the capital, and hence could have benefited from close supervision. Toamasina is 450 km away and entered the programme in Phase II, in 1998. In each province, several villages were visited, activities observed, discussions held with SEECALINE regional programme teams, sectoral agency officers, community members, extension workers and community volunteers.
Although the programme under review was SEECALINE other projects with similar objectives operating in the same area were also examined briefly to help in the analysis of the impact and coordination aspects of SEECALINE.
In 2000, the population of Madagascar was estimated at 15.5 million with a growth rate of 2.8 percent. Of these, 77.8 percent lived in the rural areas (World Bank, 2000). Urban migration is high, and 68 percent of the migrants to the urban centres are within the young productive age group. Administratively, the country is divided into 6 faritany (provinces), 110 fivondronana (prefectures), 1,252 firaisana (communes), and about 11,000 fokontany (villages).
It has a tropical climate, which is humid and semi-arid in the south and semi-temperate in the central highlands. Agriculture is the mainstay of the people. It provides 74 percent of employment, 34, 9 percent of the gross domestic product and 70 percent of the export earning (FAOSTAT, World Bank, 2002). Rice is the staple of the diet, contributing 40 percent of the total food and 80 percent of cereals. Thus every economic policy is centred around rice and agricultural research and technology are mostly geared towards it. According to officials of the Ministry of Agriculture, awareness on diversification is slowly gaining momentum.
Following the introduction of the Structural Adjustment Programme and liberalization of the market implemented since 1991, the economy has gradually improved. Since 1997, the gross domestic product has been around 4.7 percent and it is expected to go up to 6.3 percent between 2001-2003 (DSRP, 2001 33). Inflation has been contained as well. However, despite such stabilization, there has not been any improvement in the social services and the conditions of the poor (USAID, 2000). The health budget declined from 9.6 percent to less than 4.5 percent over the last 20 years (Ministry of Health, 1995). The same trend applies to the other social services.
Despite high agricultural potential and a stabilized economy in recent years, 67 percent of the population do not meet their basic food needs and 14 percent were at high risk (World Bank, 1996). The average energy availability was barely 2,115 kcal/day/person in 1995-1996. The supply of rice, which was estimated at 150 kg/person/year, had gone down to 115 kg in 1995. “At the national level, it is estimated that the country currently meets about 98 percent of its internal demand (internal production, commercial imports and food aid). A growing food gap is expected in the future if the current situation does not improve, which may be unlikely” (UNDAF, 2001). Frequently occurring natural disasters such as cyclones, floods and drought continue to aggravate the situation.
Madagascar had the third highest prevalence of stunting and underweight, after Ethiopia and Angola, in Sub-Saharan Africa between 1990-1998 among children under three years of age (UNICEF, 2000 - see also Appendix 1). The 1997 DHS revealed prevalence rates of 48 percent for stunting and 40 percent for underweight among children below three years of age, with some variation between the provinces. The incidence of low birth weight (<2.5 kg) was 26 percent. Maternal undernutrition was high too, with 21 percent of women having a BMI of less than 18.5 percent. The prevalence of anaemia among women was 42 percent and Vitamin A deficiency 29 percent.
A recent national micronutrient survey undertaken by the Ministry of Health in collaboration with USAID, DDSS and laboratories, revealed a prevalence of 42 percent and 67 percent of Vitamin A deficiency and anaemia respectively among children below three years of age. Among schoolchildren aged 6-14 years the prevalence of anaemia was 38.5 percent (UNICEF/USAID, 2001).
The programme’s plan is to establish over 4,040 community nutrition sites, to cover 6,800 primary schools and organize 560 PICS sites in areas prone to drought and cyclone, all to be achieved by 2003. The areas targeted are those with an underweight prevalence rate of 43 percent and above. Primary beneficiaries include children below three years of age, pregnant and lactating women, schoolchildren 6-14 years and children aged 3-14 years who do not attend school. In the long term, an overall effect of the programme on the general population is also envisaged.
Interventions include growth monitoring and promotion, take-home supplementary feeding (500 kcal/day) for undernourished children, nutrition education through demonstration, micronutrient supplementation to children and mothers, deworming of school-aged children along with education on personal and environmental hygiene.
Prior to 1993, there were no meaningful nutrition interventions in the country. Some activities were piloted by the Food Security Directorate in the Ministry of Agriculture (MinAgri) and later by the Ministry of Scientific Research. With the initiation of the micronutrient programme, especially iodine deficiency, UNICEF made some progress in advocacy and community sensitization, and the multisectoral approach.
Based on a few experiences, a food security and nutrition programme (SECALINE) was initiated in 1993, with financial assistance from the World Bank in partnership with the World Food Programme on the aspect of supplementary food procurement. The initiative was a mutual interest of the Government, the World Bank and WFP because of the high prevalence of malnutrition in the country, aggravated by frequent cyclones and drought.
Implementation started in the province of Toliara, deep in the south, and Antananarivo in the centre, which had a very high rate of undernutrition (stunting stood at 55.5%). Phase I came to an end in 1997 and the programme entered its second phase of nationwide coverage in 1998, to end by 2003. Few additions and modifications were made in Phase II. One notable inclusion was the school nutrition component, reflected in the current name SEECALINE.
The programme has four major components:
Community Nutrition Programme (PNC)
The primary beneficiaries are children below three years of age and pregnant and lactating women with an overall effect on the population in the intervention localities. Activities include growth monitoring, micronutrient supplementation, take-home supplementary feeding for the undernourished, referral of severe cases for therapeutic feeding and intensive care. Counselling on child feeding and nutrition education through demonstration form important activities of the programme. To date 50 percent coverage of the planned 4,040 sites has been achieved (SEECALINE, 2001). Many professionals query the wisdom behind such fast and wide expansion without intensity and any clear formula for its sustainability.
Entry criteria for eligibility for supplementary feeding is a weight-for-age below 80 percent of the reference median, but the exit criteria is arbitrarily based on a set time, rather than on nutritional improvement. Initially it was six months. Then World Bank and WFP suggested reducing it to four months, and strengthening nutrition education on child feeding practices from locally available foods. Now a further reduction to three months is proposed. The relapse rate was reported to be high according to information gathered from the field but it was not easy to quantify from the records.
The rationale for lowering the duration of supplementary feeding is not clear35. Decisions seem to be based on logistical constraints rather than on scientific grounds, because there was no evidence presented to show that the undernourished children gained adequate weight within three months of supplementation, or that there was a change in child feeding practices. In fact, it is only assumed that the mother gives the ration only to the child for whom the supplementary food was prescribed, but in poor households that assumption may not hold true. Even the community nutrition agents could not answer this question, but they said they were advised to see if the child had gained 200 g/week as a proxy indicator that the mother is indeed giving the supplementary food to the target child.
School Nutrition Programme (PNS)
This component is targeted at students 6-14 years of age and those who do not attend school within the age range of 3-14 years. The specific objectives of this component are to reduce the prevalence of anaemia and helminthiasis each by 25 percent by 2003 (SEECALINE, 2001). The activities are undertaken by trained teachers and include iron supplementation every three months, deworming every six months, nutrition education, personal and environmental hygiene. The health posts are not formally involved. So far, about 4,585 schools (about 67 percent) of the planned 6,800 schools have been covered by the programme; but there are no surveys carried out yet to evaluate the impact of the intervention (SEECALINE, 2001).
In the schools visited, it was observed that the teachers were performing well. They hold nutrition education classes and keep good records of the SEECALINE activities. However, the number of attendants among those who do not attend school is low. According to information gathered from reports and discussion with teachers, there is a feeling of unease among both teachers and parents because sometimes children get nausea and faint after taking the drugs. In one of the schools visited, teachers showed us expired iron tablets36, which they were told by SEECALINE staff are still safe to use but the nearby health post (only 300 metres away) does not collaborate. This confirms the statement in the mid-term review report of the faritany (province) of Toamasina (where we visited the school), “Inacceptation des agents de santé du protocole de distribution adopté par le SEECALINE” (non-acceptance by the health agents of the protocol of distribution of the supplements adopted by SEECALINE). Such problems could be easily resolved by establishing good collaboration and formal coordination with the health sector through mutual understanding.
SEECALINE could have done much more in the development of school gardens. Teachers believe that school gardens would help them to augment the theoretical training they give to students and could also stimulate students to do the same at home and in their community. This point was raised with the National Programme Director, who thinks that it is not for SEECALINE to engage in such activities, but rather the responsibility of others.
Programme for Post-cyclone and Drought Intervention (PICS)
The country is prone to frequent cyclones, drought and floods. The programme provides technical and financial support in disaster preparedness and interventions. The plan is to establish and strengthen 560 PICS sites, a useful intervention in view of the vulnerability of the country to such disasters, which could aggravate the level of malnutrition and the associated morbidity and mortality.
Information, Education and Communication (IEC)
This is a cross-cutting activity mainly carried out by the NGOs through the animators and ACNs. It is technically guided and coordinated by the national and regional SEECALINE experts. Various methods are employed, such as brochures, posters, theatre, and video films. Interpersonal communication, a method used, involves the interaction between the ACN and mothers during counselling on child growth promotion, nutrition education and demonstration. There are some concerns on how effectively this is being applied. The best way to measure the effectiveness of such an activity is to study changes in behaviour expressed in terms of knowledge, attitude and practices. That has not been done. The IEC activities are more intensive and effective during the initial opening of a site in order to sensitize and mobilize people for collaboration. From information gathered it is generally well done during the opening of a new site, but gradually diminishes in intensity as the focus shifts to other new sites for expansion.
Subsidiary component
In addition to these four components, the programme was also given the mandate to prepare a National Food and Nutrition Strategy, which it successfully concluded in 1997 by forming an ad hoc multisectoral committee. In 2000, the strategy was incorporated in the PADR.
Table 1: Comparison of three community-based nutrition projects
Project |
Planned |
Entry |
Target group |
Comm. |
Intervention |
Supplementary |
CCD |
Funding partner |
|
SEECALINE |
4,040 sites |
GMP |
<3 yrs old and mothers |
Paid |
Vertical |
Yes- wheat flour, but supply irregular |
Minimal |
World Bank |
|
CRS |
252 sites |
GMP |
<3 yrs old and mothers |
Volunteer But some incentive in kind |
Vertical |
Yes ** - wheat flour, oil, Bulgar/CSB -Supply regular |
None |
USAID |
|
NAC |
550 sites |
GMP |
<5 yrs old and mothers |
Volunteer Some incentive given in kind |
-Triple A -Integrated (MOH, MOA MOE, Com) |
None |
Yes |
UNICEF |
MOH =Ministry of Health MOA = Ministry of Agriculture; MOE Ministry of Education, | ||||||||
Table 1 shows similarities and differences between SEECALINE and some community-based nutrition projects (NAC and CRS’s community-based nutrition programme), which began at almost the same time. They have similar objectives, but differ in approaches. There is more competition than collaboration and coordination among them, so the services communities receive in the same prefecture differ. Communities can have access to supplementary food from both CRS and SEECALINE, from either one of them, or neither.
The PSSA started in 1999. The objective is to maximize production in the high potential areas and assist other non-high potential areas to improve household food security by employing appropriate interventions, monitoring and evaluation.
The project has the following features:
Teams of expert Vietnamese professionals and technicians live in the communes and work with the villagers in the project areas. It is still too early to make any valid judgement, but their approach and techniques are promising and likely to be adopted by the farmers because they are built upon local knowledge and local materials, and have demonstrated up to four fold increases in the production of rice per hectare.
With good coordination one would assume that SEECALINE would support the initiative for further expansion towards meeting its objectives of improving food security. Unfortunately, the coordination between the two projects is very loose. SEECALINE had some involvement in the PSSA initially, but soon the relationship ended because of agency frictions. The new Coordinator of the PSSA is trying improve the collaboration.
The Adventist Development and Relief Agency (ADRA), supported by USAID, also implements a pilot project on food security with the objective of improving productivity and diversification, processing and preservation. It is similar to PSSA. This project has a good community capacity development approach and a good relationship with MinAgri.
Although very limited in coverage, the approach of these two projects (PSSA and ADRA) is quite realistic and likely to succeed beyond the project period. SEECALINE, which has better financial resources, should collaborate and enhance further expansion through integration.
The ASA, a mini-project executed by FAO and supported by SEECALINE, developed education materials related to food production, processing, preservation and consumption. Through a series of participatory approaches involving communities, a multisectoral and multidisciplinary group of experts, impressive prototype materials were developed and tested. The project ended recently and unfortunately no one, not even the FAO office, seems to know who will produce, distribute and follow up the appropriate utilization of the materials. Another phase should have been negotiated to see to it that at least the materials have been distributed and used at the field level. With good collaboration, one would assume that the Ministry of Agriculture would be the appropriate agency to do it, provided that the appropriate department of the Ministry is financially supported by SEECALINE.
The programme is administratively autonomous and operationally vertical. It is under of the Office of the Prime Minister. Being under the Prime Minister’s office and headed by a strong Director (an ex-Minister) appointed by the Government, the programme has easy access to higher levels, the donors, and enjoys full political backing. It has five categories of professionals, a strong administration with its own fleet of vehicles, and strong logistical support from the WFP. Many people feel that while the high profile management has advantages, it has not been easy to intervene professionally.
At the provincial level there is a replica of the same structure as at the national level, with directors, well-equipped offices, five categories of experts (nutritionist, IEC expert, social mobilization expert, pedagogy expert, a strong administration), transport and other logistics support staff from WFP. At the fivondronana (prefecture) level, numerous local and international NGOs have been subcontracted to sensitize and mobilize communities, distribute supplementary food to the sites and provide training and supervision. While their participation is positive, there are various reports that indicate that some of the NGOs abuse the mandate given to them.
At the fokontany (village) level, hundreds of female ANCs (currently over 2,000) have been recruited with the help of community members but paid a salary and provided with a bicycle by the programme. They are accountable to a designated NGO. They submit their reports to the NGO animators (supervisors), not to the community.
One ACN is assigned to about seven or eight villages within a radius of 5 km. The estimated number of children is on average 200/site. The number of children assigned to each session is 30, but according to the records, observations made in a few sites and information gathered, the number of attendants is not more than 50 percent of this figure. The reasons for poor attendance have not been systematically studied but according to ACNs interviewed they include distance, workload of mothers, discouragement as a result of the child’s failure to gain weight, or the child’s adequate nutritional status. Besides, when supplementary food is in short supply, attendance decreases, and if there is a CRS site nearby, they prefer to go there because the supply is better in quantity and quality. Moreover, CRS provides supplementary feeding for pregnant and lactating women. This was observed during the field visit to one of the SEECALINE sites (Marolondu, commune of D’Ambodimanga II in Taomasina): only one mother had come for the session. According to the ACN, as there had been no supplementary food for the previous six months, most mothers could have gone to the nearby CRS site. Indeed, 60 children, lactating and pregnant women were present at the CRS site.
The designated NGOs have animators (paid by SEECALINE) stationed at the commune level to supervise the ACN. One animator is assigned to supervise and assist 20 sites and is supposed to visit each at least once a month. However, according to the mid-term review, this has not been possible. So, there are plans now to lower the period of stay in supplementary feeding from four months to three months, to reduce the number of fokontany (villages) per ACN, in order to give the ACN more time for counselling. Similarly, it is proposed to reduce the number of sites per animator to allow him to make more frequent visits to supervise, assist and collect the reports on time. Clearly, there has been poor planning, and decisions are being taken without a proper analysis of the situation. Whatever the reasons, it means increasing the number of ACNs and animators, which in turn means more salary to pay, more motor-cycles (for animators) and bicycles (for ACNs) to buy. All these may appear to improve effectiveness and efficiency but in fact it might prove to be difficult for the faritany (provincial) staff to control quality, and impossible to sustain when external funding ends.
Links between the various SEECALINE activities are weak, as observed in the field and indicated in the recent mid-term review report (SEECALINE 2001). Collaboration with other sectors is loose and, where it exists, coordination is informal and limited at all levels except with the education sector. Although there are some kind of formal (but not strong) links with the ministries of Health and Agriculture at the central level, there is no formal communication between SEECALINE programme personnel and activities with those of health and agriculture at the provincial, district and the community levels. There are many reasons for the lack of intersectoral collaboration and coordination, major amongst which are:
The Director of the Nutrition Services in the Ministry of Health acknowledged that the Ministry could give the technical directives that have to be followed, which are essentially the NAC approach. Some use it, others do not, and the Department has little influence to harmonize or control programmes which do not have an agreement directly with the Ministry e.g. SEECALINE. Every NGO project is accountable to a particular ministry and donor agency with which an agreement was signed. The Food Security Services of MinAgri expressed the same opinion on the lack of a formal mechanism of coordination.
In an effort to improve collaboration between the various projects and sectors an informal Intersectoral Action Group for Nutrition (GAIN) was established in 1997 on the initiative of NGOs. The objectives were to harmonize nutrition actions, to facilitate exchange of information and new scientific knowledge. The group has over 50 participating Governmental and NGO members (both national and international). It is chaired by the Ministry of Health, Nutrition Services Department. It has also set up similar groups at provincial level. It still holds quarterly meetings but, being non-formal with no legal recognition, its meetings do not go far beyond exchange of information. Although some consensus is reached at times, implementation is lacking owing to agency and/or donor policies. The group has made a valuable contribution in the formulation of the National Food and Nutrition Strategy and the preparation of project plans of action, such as the SEECALINE II and others.
No matter how informal the group may be, it is a commendable initiative and an important precursor that could in the future become a formal subcommittee of the GTDR for food security and nutrition. It is worth mentioning that there is also a coordination body for the various UN, multilateral, bilateral agencies and NGOs supporting the development programmes financially and technically called Donors’ Group, with a Stakeholder Secretariat.
The programme has a regular reporting system and reasonable supervision by the animators and occasional visits to the communities but there was no evidence of feedback to the community, except the informing of mothers by the ACN that the number of undernourished children is either increasing or decreasing.
There have been good mid-term reviews and various excellent consultancies sponsored by various agencies: the World Bank, UNICEF, FAO, WFP, WHO, USAID, and the French Cooperation. A mid-term review of Phase l was undertaken in 1996 and the Implementation Completion Report of the same phase was compiled and documented by the World Bank (World Bank, 1999). A comprehensive mid-term review of Phase II involving a series of activities was completed in September 2001 (SEECALINE, 2001). The review of 2001 was mostly based on information received from SEECALINE but data analysis was done by the DDSS of the National Statistics Institute. A workshop was organized in which a number of agencies were invited after each province finalized its internal review. A health expert from the World Health Organization/Africa Regional Office, a nutrition expert consultant from the World Bank and a national principal counsellor on the school health and nutrition programme took part in the workshop and visited some programme sites. They highlighted a number of very pertinent and critical issues (especially the nutritionist from the World Bank) and gave a long list of recommendations (World Bank/Madagascar, 2001). In 2000, there was also an excellent review done by two international consultants, jointly sponsored by the World Bank and UNICEF (Mulder-Sibanda and Clerelot, 2000). The recommendations of all these reviews and missions of consultants are remarkable for their similarity.
Unfortunately, there is little evidence of change based on recommendations. In fact, some changes made were contrary to what was suggested: discharge criteria for supplementary feeding, the issue of quality versus rapid expansion and the need for community capacity development. Applying the recommendations would entail a slow process of integration and quality assurance, which does not fit with the aim of covering 4,040 sites by 2003.
One of the vital opportunities missed of SEECALINE was that it did not have a component for developing the human and institutional capacity of the existing structures for the implementation of nutrition security interventions. Rather, it became a vertical programme, establishing systems that could not be easily maintained and sustained, with minimal community capacity-building.
Communities have not been given the opportunity to engage in the planning and management of the activities. They were not given the responsibility to supervise the ACNs and to have control over the services. This has been reported by others and confirmed through interviews during the field visits. Those interviewed said that ACNs report to the concerned NGO animator. This is not surprising because they are paid by the programme and must show loyalty to it. Focus group discussions held in three places revealed the same. There is no monitoring system that would allow communities to express their concerns and give their views in an organized manner. It must, however, also be acknowledged that there is no formal village council in the system unless created by each project as NAC and PSSA had done.
According to the mid-term review of September 2001, there has been a 15 percent reduction in the prevalence of underweight since 1998 (SEECALINE, 2001). The analysis was done by DDSS based on reports from growth monitoring sessions. There was no independent study or survey done to compare the results. UNICEF, which supports the NAC and competes with SEECALINE, also reported a reduction of 10-15 percent between 1994 and 2000 (UNICEF/Madagascar, 2000). UNICEF’s findings were also based on growth monitoring data. The last demographic and health survey undertaken in 1997 did not observe any reduction in the prevalence of stunting and underweight compared to the findings of 1992 (DHS, 1997). Looking at the kind and intensity of interventions, and the percentage of attendance to the sessions (<50 percent), the reduction appears to be too good to be true and must be taken with caution in the absence of a survey such as the DHS. The same concern was expressed by the World Health Organization (WHO) and the World Bank team that participated in the review (World Bank/Madagascar, 2001). Even if the reduction is real, SEECALINE cannot claim all credit as many other programmes and projects are in progress.
Table 2 shows some interesting observations. Toliara, which is the remotest part of the country and known for its high levels of food insecurity and prone to frequent drought and cyclone, had the highest reduction rate. In fact, it was reported that some fokontany had a reduction of 50 percent. Similar observations were made in the 1997 DHS. The reasons were not given. However, many projects are being implemented by various agencies in health, agriculture, water supply and disaster mitigation so the reduction could be attributed to the combined efforts rather than to SEECALINE alone. It may be that better community organization could explain the findings. However, Antananarivo, the central province, closer to the capital city and where the programme started together with Toliara in 1993, had the lowest reduction (8 percent), while Toamasina, which has the highest rate of undernutrition and where the programme started only towards the end of 1998, demonstrated a 21 percent reduction.
Table 2: Comparison of the prevalence of malnutrition in 1998 and 2001 in four provinces
Province |
Number of fivondronana |
Underweight% |
Underweight % |
% Reduction |
Antananarivo |
11 |
48.9 |
45.1 |
8 |
Fianarantsoa |
10 |
53.2 |
46.2 |
13 |
Toamasina |
13 |
54.7 |
43.1 |
21 |
Toliara |
7 |
51.7 |
38.2 |
26 |
Total |
41 |
51.6 |
44.1 |
15 |
Source: SEECALINE, 2001. Revue à mi-parcours : Rapport. | ||||
The mid-term review states that 50 percent of the programme period had elapsed, 50 percent coverage of the targeted 4,040 sites was achieved, and the claim of 15 percent reduction in the prevalence of underweight represents 50 percent of the target (30 percent by 2003). If indeed, things go at this pace and precision, one would assume that by 2003, 100 percent of the objectives will be achieved. Such a “perfect” pace of implementation in time, coverage and achievements in a community-nutrition programme in Africa should be viewed with some scepticism.
There was neither enough time nor was the intention of the exercise to go into details of the above observations. From a programming point of view, however, it would be very interesting to study in detail the reasons for the differences between provinces. In as far as this exercise is concerned, it sends a message that caution should be taken in measuring impact of community-based nutrition interventions, not to link “success” or failure” to a particular intervention or project, but also to a host of other confounding sociocultural and political factors and the convergence of actions of different actors.
Macrocontextual factors have clearly played a role in influencing both the strengths and the shortcomings of the programme. There are also favourable developments that could enhance better coordination and performance in the future.
Some of the favourable conditions are:
If the decentralization materializes and the above strategies and plans are implemented effectively and efficiently, the objectives and activities of SEECALINE could be gradually and systematically integrated to ensure complementarity and sustainability.
From the top management to the ACN level, when asked, “In what ways do communities participate?”, invariably the answer was that they identify the ACN, provide labour for the construction of the sites and centres, help in unloading and distributing supplementary food to the sites, and the women participate in cooking during demonstration, help the ACN during weighing and bring ingredients for the demonstration from their homes. The responses received from community members during focus group discussions were identical.
The implementation criteria have already been set, “to reach areas with a prevalence rate of 43 percent and above”. The activities have already been identified. The beneficiaries have already been classified. So what has to be done is generally proposed from above and there has been little room for communities to change the course of action. What is discussed with community members is the need to identify a female ACN and the construction of the nutrition sites. Since NGOs are subcontracted to collect the information monthly from the ACN, there was no role for the community in receiving and reviewing the report, and taking necessary actions.
The money given to the ACN to buy ingredients for the demonstration, and the supplementary food she receives to distribute, is her responsibility alone, to ensure its appropriate use and to submit a report. One could argue that there is supervision by animators. The issue is not a matter of use or misuse, it is about the responsibility given to the beneficiaries, which would give them the sense of ownership. Community members are expected to unload and distribute the supplementary food, but not given the responsibility to keep stock and ensure appropriate utilization. The contact of the ACN is only with the women who come to the sites, not with community leaders. The programme is not concerned about funds, so communities were not sensitized to mobilize resources but to participate in what is being done. They were provided with all the necessary materials and mobilized to provide only labour to construct the sites. They were not sensitized to support the ACN, but only to select her and then she would be paid by the programme. The programme even buys ingredients (oil and meat) for every demonstration session, although mothers also come with some ingredients, which the programme considers to be good “participation”.
In general, the communities have not been given the chance or the tools to develop their capacity to assume any responsibility for their own development, so as to continue with the management of the services in the long run. Given all these shortcomings, the community participation in the programme could be rated as consultative or participation for material incentives only.
SEECALINE has done an excellent job in sensitization over the last eight years. However, in view of the absence of a mechanism to enhance intersectoral collaboration, the absence of a ministry or a body with full responsibility and authority to guide and harmonize nutrition programmes, the weak human and institutional capacity in nutrition, the heavy dependence on external funds, the precedents created by SEECALINE (paying for every aspect of every activity), and the low level of community capacity building, sustainability is unlikely.
In the absence of changes towards better integration of the various activities into the existing structures, even if the inputs are doubled, sustainability is not assured. This, however, does not mean that all achievements will be lost. The awareness it has created will be a cornerstone for the future development of nutrition programmes, the skills developed by the thousands of ACNs and the knowledge that might be gained by mothers will gradually contribute to improving child feeding practices. The programme personnel who have accumulated a wealth of experience are assets to the country.
DHS. 1997. Demographic and Health Survey, 1997. Madagascar. Macro International Inc. USA.
FAO/GAD. 2001. Protocol d’accord entre FAO et GAD: Projet PSSA. Antananarivo, Madagascar.
FAOSTAT. 2002. FAO, Rome.
Ministry of Health. 1995. Direction administrative et financière (DAF) et Système d’information geographique (SIG). Madagascar.
Mulder-Sibanda, Menno & Crelerot, Françoise. 2000. The World Bank/UNICEF Nutrition Programmes Assessment in Madagascar (draft report).
PNUD. 1994. Études sur les dépenses budgetaires de l’état Malgache dans le secteur santé.
SECALINE. 1996. Évaluation à mi-parcours du projet Madagascar 4553: Appui au projet SECALINE. Rapport technique. Madagascar.
SEECALINE. 1998. Les objectifs du projet, les composantes, les activités (programme objectives, components, activities). Project booklet. Madagascar.
SEECALINE. 2001. Revue à mi-parcours. Rapport, Septembre 2001. Madagascar.
SEECALINE. 2001. Rapport d’évaluation regionale. En vue de preparer l’évaluation à mi-parcours, avril 1999 au juin 2001. Direction provinciale de Toamasina, Madagascar.
The World Bank. 1996. Évaluation de la pauvreté - Madagascar Poverty Assessment Vol.1. The World Bank, Washington, DC.
The World Bank. 1999. Food Security and Nutrition Project, Implementation Completion Report. Republic of Madagascar. The World Bank, Washington D.C.
The World Bank. 2001. Revue à mi-parcours nutrition commmunautaire II: Septembre 18-28 , 2001. Aide memoire.
The World Bank 2002. World Development Indicators, 2002
UNDAF. 2001. Joint Review, June 2001.
UNICEF. 2000. State of the World Children 2000. New York.
UNICEF/USAID. 2000. A Multiple Approach to Improve Nutrition in Madagascar.
UNICEF/USAID. 2001. National Vitamin A Deficiency and Anaemia Prevalence Survey. (MOST-USAID/UNICEF (available at www.mostproject.org/countryprograms.htm).
USAID. 2001. Gilles Bergeron report. Food Security in Madagascar: A Situation Analysis. Food and Nutrition Technical Assistance Project. Academy for Educational Development. USAID, Washington, D.C.
Victora, C.G. 1992. The Association between Wasting and Stunting: An International Perspective. J.Nutr., 122: 1105-1110.
Prevalence of undernutrition among children below 3 years of age in the Eastern and Southern Africa Region (ESAR) countries
Country |
Underweight % (moderate & severe) |
Wasting % (moderate & severe) |
Stunting % (1990-98) |
Angola |
42 |
6 |
53 |
Botswana |
17 |
11 |
29 |
Burundi |
37 |
9 |
43 |
Cape Verde |
14 |
6 |
16 |
Comoros |
26 |
8 |
34 |
Eritrea |
44 |
16 |
38 |
Ethiopia |
48 |
8 |
64 |
Kenya |
22 |
6 |
33 |
Lesotho |
16 |
5 |
44 |
Madagascar |
40 |
7 |
48 |
Malawi |
30 |
7 |
48 |
Mauritius |
16 |
15 |
? |
Mozambique |
26 |
8 |
36 |
Namibia |
26 |
9 |
28 |
Rwanda |
27 |
9 |
42 |
Sao Tome & Principe |
16 |
5 |
26 |
Seychelles |
? |
? |
? |
South Africa |
9 |
3 |
23 |
Swaziland |
38 |
? |
42 (NNC,1994) |
Tanzania |
27 |
6 |
42 |
Uganda |
26 |
5 |
38 |
Zambia |
24 |
4 |
42 |
Zimbabwe |
15 |
6 |
32 |
Regional Average |
32 |
9 |
41 |
Source: UNICEF - The State of the World’s Children, 2000: Based on data available for the most recent year on each country during the period specified in the column heading | |||
Informants
Ms. M. Ratsivalaka, |
National Director |
SEECALINE |
Mr. N. B.Andriamparany |
Directeur adjoint et administrative |
SEECALINE |
Ms. N. Rakotoniana |
Nutritionist |
SEECALINE |
Ms. C. Yaohita |
Provincial Director – Toamasina |
SEECALINE |
Mr. R.M. Rambelo |
Responsible - Provincial PNC, Toamasina |
SEECALINE |
Ms. T.F. Rasoloarisoa |
Responsible - Provincial PNS, Toamasina |
SEECALINE |
Ms. F.L. Boto |
Responsible - Provincial PNS, Toamasina |
Ministry of Health |
Dr. S. Rakotonirina |
Chief, Nutrition Services |
Ministry of Health |
Ms. B. Razafiarasoa |
Coordinator, PNSAN |
Min. of Scientific Research |
Ms. S. Ramarolahy |
Chief, Food Security Services |
MinAgri |
Mr. J.L. Ranaivohanana |
Chief, Regional Agriculture- Taomasina |
CirAgri |
Mr. Constant |
Regional Coordinator, PSSA |
MinAgri |
Mr. Lala Rakotozan |
Chief, CirAgri, Feverive-Est |
CirAgri |
Mr. S. Benjamin |
Specialist in community organization |
CirAgri |
Prof. Dang Dinh Vien |
Expert in pisciculture |
Anjepy Viet Nam Team |
Mr. Tranvarpham |
Irrigation Expert- Feverive-Est |
Viet Nam Team |
Mr. George Rakotozaphy |
Director |
GAD |
Mr. Wagner Herrman |
Programme Director- Food Security |
ADRA |
Mr. Randeriantelomanana |
Monitoring and Evaluation Officer |
ADRA |
Mr. B. Rivolala |
Responsible-Agriculture |
ADRA |
Ms. Sophie De Coninck |
Coordinator PSSA |
FAO |
Mr. Robert M. Brown |
Charge d’affaires courantes |
FAO |
Mr. RAZ. Andrimanona |
Coordinator, PAI project |
FAO |
Mr. Cyridion Ahimana |
Administrateur du Programme nutrition |
UNICEF |
Three experts in the Ministry of Scientific Research.
ACNs, community volunteers of NAC and CRS
Teachers
Community members
31 Source: SEECALINE Administration
32 Extracted from the French version of the SEECALINE programme booklet and the mid-term review (Revue mi-parcours) report, September 2001.
33 Document de stratégie pour la réduction de la pauvreté (Poverty Reduction Strategy Document), 2001.
34 Extracted from the French version of the SEECALINE programme booklet and the mid-term review (Revue mi-parcours) report, September 2001.
35 If the primary nutrition problem is stunting (rather than wasting), as is the case in Madagascar, short duration supplementary feeding is unlikely to have much impact. Moreover, Victora (1992) suggests that micronutrient deficiencies (often related to poor dietary diversity) rather than energy or protein deficiencies, may be the cause of stunting. Hence the food supplement may be inappropriate. This technical point highlights the need to use indicators of wasting (weight for height) and stunting (height for age), rather than underweight (weight for age, which does not distinguish between wasting and stunting) as entry and exit criteria for feeding programmes.
36 Iron supplements should be given daily, or at least weekly. To see any impact (albeit minimal) from iron supplements given once every 3 months, as done by SEECALINE, a mega-dose would be needed, which would not only cause serious side effects, but is also potentially dangerous. This could explain the non-acceptance by health agents of the SEECALINE distribution protocol.
