Overview on successful collaborations between researchers and implementers. Integrated Nutrition Conference, Nairobi, Kenya September 15, 2015

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1 Overview on successful collaborations between researchers and implementers Integrated Nutrition Conference, Nairobi, Kenya September 15, 2015

2 OUR MISSION Helen Keller International is dedicated to saving the sight and lives of the most vulnerable and disadvantaged. We combat the causes and consequences of blindness and malnutrition by establishing programs based on evidence and research in vision, health and nutrition.

3 HKI is working in Africa and Asia Countries covered HKI is working in 21 countries in Africa and Asia (13 countries in Africa and 8 countries in Asia) Programs: Nutrition: Community Management of Acute Malnutrition Enhanced Homestead Food Production (EHFP) Essential Nutrition Action(ENA) Food Fortification Supplementations (Vitamin A and other Micronutrients) Golden Rice Eye Health, NTD, Maternal Health, Gender and M & E EHFP is the Flagship program for HKI

4 FIRST PILOT HFP PROJECT INITIATED IN BANGLADESH Initiated the first pilot project in 1990 to improve dietary diversity and micronutrient status, particularly vitamin A Worked with 1000 marginal and landless families represented by women Based on the findings from the pilot project, eventually scaled up throughout the country to cover 210 sub-districts (one third of the country)

5 WHAT DID WE LEARN? Homestead Food Production : Increased availability of vitamin A and other MN rich foods and their consumption Talukder et al, Food Nutr Bull 2000;21: Diversification is important for increasing consumption and possibilities to increase varieties of food - Bloem et al, Eur J Clin Nutr 1996;50:s62-s67 Ensures year round availability - Talukder et al, Food Nutr Bull 2000;21: Increased family income and women s participation in decision making Bushamuka et al, Food Nutr Bull 2005;26:17-25

6 HFP to date HFP HKI TO has DATE worked in partnership with > 200 NGOs and GOs Cumulative coverage is more than 1.2 million households and 5.5 million beneficiaries over 20 years of implementation Women are primary farming beneficiaries Community based approach: Establish Village Model Farm

7 EHFP SCALE-UP IN ASIA AND AFRICA In Asia Bangladesh 1990 Nepal 1997 Cambodia 1998 Philippines 2004 Indonesia 2010 Vietnam 2013 In Africa Burkina Faso 2009 Mozambique Tanzania 2011 Four countries 2012 Creating Homestead Agriculture for Nutrition and Gender Equity (CHANGE) Burkina Faso, Cote d Ivoire, Senegal and Tanzania Mali 2014

8 Evolution of the Homestead Food Production Program I E Home gardening Bangladesh Gender Poultry and goats I E P Expansion I E Pilot with Animal Husbandry 2001 P Homestead Food Production I E P Ex p an sio n 2005 I E Asia Scale-up 2000 P BCC I E P Expansion 2011 I E Urban HFP P WASH I E ENA P Fish on Farm 2012 P Fish Talukder et al. Food Nutr Bull 2000;21: I E Enhanced Homestead Food Production 2003 I P I I: Implementation E: Evaluation P: Planning

9 Evolution of the Homestead Food Production Program Homestead Gardening (HG) Homestead Food Production (HFP) Enhanced Homestead Food Production (EHFP)

10 CORE ELEMENTS OF EHFP I. Program design: mapping, landscape analysis, strategic planning workshop II. Agriculture component: includes, horticulture, livestock, poultry and aquaculture where possible III. A Package of Essential nutrition action (ENA) IV. Village Model Farm: Community based support services system V. A multi-level behavior change and communication: VI. A gender perspective: understanding of gender roles, intrahousehold dynamics in order to design and implement gender equitable program VII. Building and link with existing system and structure: VIII. Continuous learning: through formative research, process monitoring IX. Targeting: Community mobilization

11 ENHANCED HOMESTEAD FOOD PRODUCTION KEY FINDINGS Target HHS: inputs, training in HFP, Nut Ed Control HHs: similar demographics In Target vs. control HHs: Increase in number vegs grown & eaten 13 vs. 4 veg. eaten; intake of vit A-rich foods Increase in production & consumption of animal products intake of chicken livers & eggs Increase in income earned from HFP used to purchase additional food Improved health & nutrition outcomes Sig. anemia in children in 2 countries (see Fig) Sig. anemia in non-pregnant mothers in 2 countries in night blindness in children in Bangladesh Proportion with low serum retinol lower among children living in households with a garden Talukder et al. (2010) Target basline Control baseline Philippines Cambodia Nepal Bangladesh Anemia prevalence in children 6-59 mo. Target endline Control endline * *

12 ENHANCED HOMESTEAD FOOD PRODUCTION KEY FINDINGS HHs, including children under 5 years and mothers, could diversify their diet by increasing consumption of micronutrientrich foods, including poultry and fish generating income, also to be spent on foods thereby contributing to improved household food security and nutrition HFP has the potential to improve the micronutrient status, including vitamin A status and anemia

13 WHY DO WE NEED TO COLLABORATE WITH RESEARCH INSTITUTES How do we know if our investments make a difference? 20 years of implementation experience without rigorous evidence of impact on maternal and child nutritional status Randomized control trial as gold standard Provides probability estimate of project impact Program Theory guides implementation as well as research Articulate pathways through which outcomes and impact is expected and assess the extent to which they actually do Operations research informs/strengthens implementations Process monitoring: to ensure program activities are being delivered effectively according to program theory and identify weaknesses to address

14 PARTNERSHIP BETWEEN HKI AND IFPRI In 2008, IFPRI and HKI began to work together to try to better understand how HKI s HFP program in Cambodia was working to achieve impact. Secondary data analysis of HKI s impact evaluation Process evaluation (or operations research) to examine what was working and not working within HKI s HFP program in Cambodia Agriculture supplies (e.g. seeds, saplings, small animals, gardening tools) Agriculture training Nutrition and health related trainings

15 Process/Output indicators Outcome indicators Impact indicators Enhanced Homestead Agriculture for Nutrition and Gender; Program Impact Pathway (PIP) Input Process Outputs Outcomes Impact HKI partners with local NGOs, local government and technical partners Agriculture inputs including seeds, seedlings, saplings and poultry Resource Farmers established EHFP beneficiaries targeted Community Counselors established Linkages to community counselors and health services Supportive supervision Agriculturerelated training BCC Strategy developed and integrated through Gender Inclusive Approaches Training on ENA and WASH through CCs Improved and developed gardens established Beneficiaries understand homestead agriculture Improved Small animal husbandry Beneficiaries understand & adopt ENA and WASH messages and use health facilities Increased production of nutrientrich fruits & vegetables Increased animal source food production Improved hygiene and sanitation practices at household Increased Income and more financial resources controlled by women Increased household consumption of micronutrient rich foods Improved child care and feeding practices Improved gender equity Improved maternal and child health and nutritional status Monitoring Evaluations

16 Program Logic Model Inputs Process Outputs Outcomes Impacts 6 M s Man Money Material Machinery Methods Management Training Formative Research # trained # materials produced # clinics supplied IYCF practices consumption income coverage quality CMAM services growth survival deficiency Quality Assurance/ Performance Monitoring PROGRAM LEVEL Mid Term Assessment BENEFICIARY LEVEL Evaluate Outcome Baseline/Endline POPULATION LEVEL

17 HKI-IFPRI COLLABORATION TO EVALUATE THE EHFP PROGRAM IN BURKINA FASO Collaborated with IFPRI to conduct evaluation of EHFP in Burkina RCT Process evaluation Proposed changes in the on-going E-HFP program in Burkina Faso Work with community based trainers to ensure that trainings for beneficiary mothers were being conducted as planned Provide follow-up training related to the prevention and treatment of anemia for master trainers, community trainers and beneficiaries Develop additional BCC materials as needed to reinforce trainings related to the prevention and treatment of anemia Changes made for the final process and impact evaluation of the HFP program in Burkina Faso Include husbands as key respondents for some parts of the evaluation (e.g. knowledge questions, opinions about the program and their participation in the program) to understand their role in the utilization of the different program components. Include additional modules that delved further into women s ability to control and use resources related to the program s agriculture activities.

18 CREATING HOMESTEAD AGRICULTURE FOR NUTRITION AND GENDER EQUITY Home Gardening + Animal Husbandry + Nutrition Education + Hygiene Through Gender Sensitive Approaches to improve the nutritional status of women and young children 18

19 CONTRIBUTIONS OF RESEARCH TO STRENGTHENED EHFP Process evaluation and ENA strategy Causes and cures for anemia reinforced Feeding of the sick child reinforced Mothers report of work burden led to stronger engagement of fathers Refresher training for nutrition agents Process evaluation and HFP strategy Water challenges needed much greater attention (construction/repairs of wells & boreholes, pedal pumps, supplies water conservation techniques) Fencing to protect gardens from animals Gender Impact Insights on asset ownership, decision-making and attitudes towards women s capacity Longer-term strategies WASH and malaria control must be included in strategy Translating knowledge into practice ongoing challenge to be addressed Incentives/recognition for community volunteers need strengthening

20 CHALLENGES OF COLLABORATION Opposition of partners to randomized assignment Requires careful explanation of ethics Distance between arms to prevent spillover while keeping comparability Follow-on project to reach previous control communities with treatment Implementation must await completion of baseline Careful planning to minimize lost time and lost exposure as children age Balance need for data to answer questions vs. burden on HH and implementers Complexity of EHFP (plus WASH plus health services) increases data needs Design of instruments and data collection inevitably impact implementation team Process evaluation must be quick turn-around to influence implementation of current programs but can also be used to inform future programs Match research with funding timeline Cannot answer large impact questions within a 3-year funding life

21 KEY ELEMENTS OF RESEARCH PARTNERSHIP- IFPRI Use rigorous methods including randomization for probability-level evidence of impact Develop and apply program theory to trace pathways through which impact is achieved Include process evaluation to identify and correct weaknesses in implementation (delivery, understanding, adoption, assimilation) Share evidence with local partners, national partners, global community to generate investments

22 Alone we can do so little; together we can do much. ~ Helen Keller

23 Thank you

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