Optimal Nutrition
for Optimal Life
PROJECT PHASE 2
....Achieving
MALAWI
ENHANCE
Life In All Its Fullness For
Children Of Malawi
E xpanding
N utrition and
H ealth
A chievements through
N ecessary
C ommodities and
E ducation in Cambodia
Main Goal of ENHANCE
To Improve the Survival and Growth of all Boys and Girls U5 in ADPs by
Enhancing Access to Basic Health and Nutrition Requirements
OUTCOMES
1. Improved Quality of diet
2. Improved Access to Essential Health services to
Prevent and Treat Diseases
3. Improved Household Food and Nutrition security
World Vision Malawi collaborates with several partners to tackle the
underlying causes of child malnutrition and child deaths.
By working with World Vision Malawi in six area development programs
(ADPs) within two regions, ENHANCE targets to maximize the growth
and development of 25,000 children under five years of as aw well as
7,300 pregnant women. Indirectly, a total of 146,000 people will benefit
from the program.
Launching ENHANCE in Malawi
A one-year pilot of the ENHANCE program was completed in February 2006 in Ghana and
Tanzania prior to launching ENHANCE in Malawi and three additional countries (Kenya,
Mozambique and Cambodia). In June 2006, representatives from these six countries met in
Nairobi to reflect on learnings from the pilot in order to plan for future programming.
In June 2006, key stakeholders from Malawi met together to discuss the situation surrounding
health and nutrition needs in program areas, gaps in programming and recommendations for
ENHANCE Malawi. A draft program design was prepared, including six area development
programs. These are rural farming communities where gaps in health services are a challenge,
especially in more remote communities. ENHANCE was launched in April 2007 based upon
successful strategies used during the pilot, and identification of needs within the six ADPs.
WV Malawi chose to implement their first phase of programming on selected interventions
including:
• Distribution of vitamin A supplements for children under 5 and mothers with newborns
• Malaria prevention with distribution of long-lasting insecticide treated bed nets for
women and children and malaria medication for pregnant women
• Provision of equipment needed to expand immunization coverage to reduce vaccinepreventable diseases,
• Improved prevention and management of pneumonia, diarrhea and intestinal parasites
among children
• Improved infant and young child feeding practices, including the promotion and
production and use of diversified, culturally acceptable foods for children and pregnant
and lactating mothers.
• Training to health centre staff, government health surveillance assistants, and extension
agents (village health volunteers, traditional birth attendants)
• Monitoring of program (baseline and impact surveys)
To support the above interventions, both training of health staff and community health
volunteers as well as education of families to improve their children’s health were emphasized.
The program is adequately staffed with an overall program manager, as well as a facilitator for
each of the six ADPs in which the program operates. It also enjoys the support of the Senior
Health and Nutrition Manager.
Partnering to Build
Sustainability
implement essential nutrition, health and food security interventions
is needed. Training and sensitization activities have strengthened
relationships between communities, community based volunteers
and government health workers. Other partners and their respective roles are as follows:
The ENHANCE partners want children to grow to their full potential in communities for generations to come. Increasing the capacity
of families to do so requires the cooperation of many stakeholders
to be involved in the planning and implementation of essential nutrition, health and food security intervention ENHANCE partners
desire to see children in communities grow to their full potential for
generations to come. In order to increase the capacity of families to
achieve this aim, the cooperation of many stakeholders to plan, and
Tunduma
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MALAWI
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The Canadian International Development Agency
(CIDA) provides funding for commodities in child survival interventions and program evaluation.
World Vision Canada provides technical
support and funding.
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UNITED NATIONS
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Map No. 3858 Rev. 3
January 2004
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The boundaries and names shown and the
designations used on this map do not imply
official endorsement or acceptance by the
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National capital
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Ministry of Food and Agriculture
extension workers advise farmers in the planting
of new crops and the improvement of food security situations. ADPs will collaborate with the
agriculture ministry in supporting the production
of vegetables, fruits and raising small animals.
UNICEF is a significant partner in implementing
the vitamin A campaigns.
Ministry of Education teachers reinforces
nutrition and health messages in schools.
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The Ministry of Health - delivers health
services such as immunization, treatment of illness and health education. ENHANCE provides
refresher training for government health staff and
support them in reaching remote communities.
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Department of Peacekeeping Operations
Cartographic Section
World Vision International – Malawi
National Office
Area Development Programs (ADPs)
provide support to all children to access essential primary health care. ENHANCE improves
the quality of child health and nutrition activities
by providing training and resources to ADP staff.
The national office provides additional technical,
administrative, and financial support.
ENHANCE Communities want to
improve the lives of their children. The heart
of WV Malawi’s transformational development
programming is to help communities identify
and overcome barriers to child well being. A key
area to accomplishing this is working closely with
Community-based Health Surveillance Volunteers – providing them with regular training and
strengthening their role as the main link between
community members and health workers. In addition, local authorities, traditional birth attendants, village health committee members are key
community-based extension agents.
Baseline Assessment
The baseline survey was conducted in April 2007 among mothers, at their homes, to assess coverage of key health
practices in maternal and child health as well as disease prevalence. The process built capacity of ADP staff and
their collaborators, and enabled comparison of needs among ADPs and realignment of limited resources. The
results helped refine project design and overall coverage targets. A health facility survey was also carried out to
assess needs and capacity for health services delivered to surrounding communities.
Evaluation
Coverage of key indicators was measured in April 2008 after one year of programming, and compared to baseline
data to determine impact of selected interventions. Coverage in non-project areas was also assessed to measure
and compare changes over time between areas where WV is and is not operating. After one year of ENHANCE
programming in ADPs, significant improvements were observed. The proportion of children under age 5 who
received vitamin A capsules VAC in the previous 6 months increased by 22%, as did the children who received
rehydration treatment for diarrhea. Children who sleep under specially treated bed nets increased dramatically
from 15% to 75%. More pregnant women slept under bed nets as well, and immunization coverage increased.
Results are provided in the table below.
ENHANCE Cambodia Baseline and Follow-up Survey Results
2007
2008
ENHANCE
COVERAGE
%
NON-ENHANCE
COVERAGE %
ENHANCE
COVERAGE
%
NON-ENHANCE
COVERAGE %
Wasting (thin for height)
3
N/A
N/A
N/A
Stunting (short stature)
49
N/A
N/A
N/A
Underweight (thin for age)
19
N/A
N/A
N/A
29
N/A
N/A
N/A
N/A
N/A
N/A
N/A
% of clinics that experienced a stock-out of
rehydration salts for at least one week in the last
3 months
57
40
67
20
% of clinics with improvement in outreach services
14
80
50
20
% of children 6-59 months who received Vitamin A
capsule within the previous 6 months
59
67
81
75
% of postnatal women who received vitamin A
supplementation after delivery
51
36
44
37
% of households with iodized salt
87
N/A
N/A
N/A
% of households with specially treated bed nets
15
N/A
N/A
N/A
% of children 6-59 months who slept under a
specially treated bed net the previous night
15
3
75
8
% of women who received malaria prevention
medications during last pregnancy
60
74
60
51
% of children 12-23 months fully Immunized
79
72
90
83
% of children with diarrhea given rehydration
solution
53
68
75
73
% of children with pneumonia symptoms who
received antibiotics
71
N/A
N/A
N/A
KEY INDICATORS
Malnutrition levels in children 6-59 months
Child Feeding Practices
% of children 0-6 months exclusively breastfed
Children 12-23 months who were breastfed, ate
sufficient and diverse foods
Health Facilities
Micronutrients
Essential Health Practices
1
Quality of Diet - Infant
And YoungChild Feeding
Practices
Increased
exclusive breastfeeding
Increased Micronutrient
Intake
The World Health Organisation recommends all infants
be exclusively breast-fed from birth to six months of
age to address the problem of under-nutrition and
illness among infants. ENHANCE aims to increase
the exclusive breast feeding rate of 30% by working
with health staff to actively promote this in “Baby
Friendly Health Institutions”, intensifying education at
community levels and encouraging mother-to-mother
support groups.
Diversifying the types of food eaten is proven to
improve the quality of the diet for children and their
families. Our assessment indicates families are not
consuming adequate vegetables and protein-rich foods,
due to lack of knowledge on their importance and
the reluctance to try “new things”. Teaching families to
incorporate more nutritious foods into their diet will
require strategies to increase the availability of fruits,
vegetables, meat and fish throughout the year.
Appropriate complementary
feeding with continued
breastfeeding for two years
When a young child receives nutritious first foods
at the right age, malnutrition is less likely. Enhance
addresses this with a focus on continued breastfeeding
for two years and feeding children more often each
day with more diverse foods, including meat, milk and
eggs. Currently, less than half of the children between
1 and 2 years of age in the project areas are being fed
properly. To reverse this problem, community based
growth promotion will be scaled-up. Community
members will learn how to assess the growth of young
children and caregivers will be counseled on nutritional
feeding practices. Since grandmothers play a significant
traditional role in child feeding practices, every effort
will be made to include them in the teaching provided.
Adequate Vitamin A intake is essential for resisting
infections and preventing blindness and anemia. During
Child Health day campaigns, conducted every 6 months,
children under five years are given a vitamin A capsule
and de-worming medication. ENHANCE assists in the
distribution of capsules, in partnership with the health
centers and service providers and promotes awareness
campaigns. Resources from our funding partner, CIDA,
support community education sessions, capacity
building for local staff, and information posters. During
the child health days there is also promotional material
on vitamin A rich foods that are locally available in
Malawi. The proportion of children 6-59 months who
received Vitamin A within the last 6 months increased
from 59% to 81%, meeting the target.
Vitamin A supplements are also beneficial to new
mothers and their breastfeeding infants and it is
national policy for all new mothers to receive vitamin
A supplementation within 8 weeks of delivering her
child. In partnership with religious and local leaders,
traditional birth attendants, and health committees, the
ADP can work to advocate for support for vitamin
A education and distribution, growth monitoring,
and checking the Health Passbook every time a child
comes to the hospital or health centre.
Adequate iron intake is essential to supporting
physical and mental capacity and lowering anemia
levels. Anemia is a major public health problem
affecting 80% of children under five years and 42% of
mothers. Only 9% of women took iron supplements
for at least for 120 days during their last pregnancy.
Coverage and compliance needs to improve
at the health facility and communities.
Use of Iodized Salt
Iodine deficiency is the world’s greatest single cause
of preventable brain damage. It also causes neonatal
deaths, stillbirths and miscarriages. According to the
initial survey, 87% of households are using iodized salt
in project areas. ENHANCE supports national efforts
in encouraging access to iodized salt through major
salt producers and local traders and by teaching the
health benefits of using it regularly.
Besides supplements, iron-rich food sources
will be part of the long-term solution to
iron deficiency in these communities. A total
of 48% of children were consuming animal
source foods at the beginning of the project.
Prevention and treatment of malaria and
other infections is also expected to lower
the anemia prevalence.
2
Essential Health Services
and Health Environment
Improved Prevention and Management of Malaria
Special bed nets, treated with long-lasting insecticide, protect sleeping children from mosquito
bites. Using them can dramatically reduce malaria-related deaths. The government now issues
free bed nets to pregnant women and children, but often is challenged to meet the demand.
The policy has assisted in increasing the rate of children who sleep under nets from 15% to
75%, within one year. Maintaining this coverage required concentrated efforts. ENHANCE will
utilize networks in the communities to advocate for the proper and consistent usage of specially
treated bed nets and provide proper information to overcome barriers.
ADPs support the government’s National Malaria Policy which states: “All women should receive
at least two treatment doses of medication to prevent malaria during pregnancy.” However,
only 60% of mothers with infants reported taking these two doses of recommended treatment
during their last pregnancy. During the first year of the project, the coverage of this treatment
remained constant; however, outside the ADP areas, only half the pregnant women were reached.
ENHANCE utilizes networks to create awareness for early visits to the clinic, encourage good
record keeping, and utilize the drug revolving funds within the communities to ensure a reliable,
local supply of the malaria medication.
Improved Management of Pneumonia (Acute Respiratory Infection)
Approximately 70% of children with pneumonia symptoms received appropriate treatment, at project onset. The current national strategy for
treatment of pneumonia among children includes quick referral, proper diagnosis and prescribing antibiotics.
ADPs purchase and distribute antibiotics to health facilities. ENHANCE educates mothers to improve practices, identify symptoms and
improve the quality of care by health staff. In addition, ENHANCE works to improve access to medicines through local drug revolving funds
To address barriers of cost for poor families, funding through CIDA and ENHANCE will secure purchase and delivery of antibiotics for
treatment of pneumonia.
Improved Prevention of Vaccine-Preventable Disease
Immunizations reduce child illness and death from preventable diseases like measles. The proportion of vaccinated children increased from
79% coverage at the program onset to the target of 90%. The current national strategy to ensure all children are fully immunized by their
first birthday is to conduct immunization sessions each month in remote areas, and clinics are provided with the supplies to carry out the
immunizations on time.
Fuel, transport and allowances for health staff and adequate cold chain equipment are provided to ensure continual access to this important
service. The ADPs also assist the health centers to maintain the cold chain by
providing large cooler boxes and cool bricks. CIDA funds solar powered cold chain
equipment as well as supplies for immunization. ENHANCE assists to help establish
new outreach clinics to educate via community networks and liaises with religious
leaders to advocate for immunization to increase coverage.
Improved Prevention and Management of
Diarrhea and Other Infections
Only 55% of households have access to clean water sources and 7% use proper
toilets in ENHANCE ADPs. The proportion of children U5 with diarrhea in the past
2 weeks dropped from 40% at baseline to 35% in ADP areas. Further improvements
in hygiene and sanitation are required to further reduce the prevalence of diarrhea.
The national strategy to promote rehydration therapy for treatment of diarrhea in
young children is to promote the use of special salts. Within the first year, children
with diarrhea who were treated properly increased from 53% to 75%. Community
health volunteers and mothers are trained to give children oral rehydration solutions
and zinc supplements to shorten the duration of diarrhea. ENHANCE utilizes
existing networks to promote awareness of proper treatment, promote homebased practices to treat diarrhea, and educate village health committees. ENHANCE
promotes greater access by freely distributing necessary salts and zinc supplements
through the community drug fund. The program also works to formalize the use of
zinc supplements for diarrhea treatment. In addition, regular de-worming treatment
for children is provided during the regular child health days.
3
Household Food and
Nutrition Security
Food security issues persist despite past efforts. Less than half of households
have backyard vegetable gardens and fruit trees. Most animals raised are sold
instead of consumed to boost dietary intake. Intra-household decision-making
is caught up in the cultural roles as to who decides what their children will
eat.
Working closely with the department of agriculture, ENHANCE empowers
households to increase the quantity of micronutrient-rich crops, small animals
and fish.Vegetable seeds, citrus seedlings, small animals (rabbits, chickens,
guinea fowl), and drip irrigation kits will be supplied to households and
farmer groups. Households are encouraged to get involved in the “pass it on”
concept whereby new small animal offspring are given to another household
who in turn do the same. Access to credit for small food-insecure farmers is
increased through micro-finance institutions and promotion of grant loans to
women through collective actions or village banking.
Conclusion
World Vision International – Malawi Office continues
to build on its strong successful partnership with
World Vision Canada Office and CIDA. The successful
completion of the Micronutrient and Health Program
provided many lessons learned and provided the
basis for a new partnership with CIDA to continue to
address the health needs of the children in the poorest
countries of the world.
Our Vision for every child,
life in all its fullness;
our prayer for every heart,
the will to make it so.
CONTACTS
World Vision is an international
partnership of Christians whose mission is
to follow our Lord and Savior Jesus Christ
in working with the poor and oppressed
to promote human transformation, seek
justice and bear witness to the good news
of the Kingdom of God.