Impact of Large-Scale Infant Feeding Promotion on Child Survival and Health in Madagascar
“If a new vaccine became available that could prevent one million or more child deaths a year, and that was moreover cheap, safe, administered orally, and required no cold chain, it would become an immediate public health imperative. Breastfeeding can do all this and more”………Lancet 1994
Photo: Carolyn Kruger
General Context (1) General Context (1)
• Early 1990s hospital-based efforts were successful but weakly linked to community
• Operational research/meta-analyses demonstrate that Breastfeeding promotion is an evidence-based interventions to prevent malnutrition and to improve children under five years old nutrition status (Lancet series)
• There are few impact assessment of large-scale Breastfeeding promotion
• The challenge is to develop and apply standard impact assessment methodology of programmatic behavior change strategy regarding optimal infant feeding behaviors
General Context (2)General Context (2)
• Early initiation of breastfeeding (within an hour of birth)
• Exclusive breastfeeding for first 6 months
• Timely introduction and frequent feeding of nutrient rich complementary foods
• Continued breastfeeding through the second year of life
Optimal Infant Feeding Behaviors
LINKAGES: USAID- Funded ProgramLINKAGES: USAID- Funded Program
• Sustain/advance USAID’s role as a global technical leader
• Extend coverage by working with partners
• Demonstrate exclusive breastfeeding as an achievable goal
• Improve breastfeeding behaviors at scale in 3-5 countries
• Demonstrate what works at the community level
Goal: Improve the health and nutritional status of Children and women
Key Program CharacteristicsKey Program Characteristics
Program Focus Program strategy based on Integrated Management of Childhood Illness (IMCI) approach.
Key Nutrition Behaviors Targeted - Breastfeeding- Complementary feeding- Feeding of sick children- Women’s Nutrition- Vitamin A supplementation- Iron supplementation- Iodized salt
Focus period for presentation January 2000 – September 2001
Geographical Coverage during the focus period
2 Regions10 Districts
Population Covered during focus period 1.33 million
LINKAGES: M&E FrameworkLINKAGES: M&E Framework
INPUTS
- Human Resources
- Financial Resources
- Equipment
PROCESS
- Training
- BCC/IEC
- Mass Media
-Advocacy
OUTPUTS
- Number of Key informants trained
- Number of Mothers counseled
- Number of materials developed
OUTCOMES
- Increased Knowledge
- Improved-Changed Behavior
IMPACTS
- Cost Effective
- Reduced malnutrition
Rapid Assessment (Annual)
&
Performance Monitoring
(Every six months)
Monitoring
(Annual)
Evaluation
(Baseline/Midterm/Endline)
Impact Assessment SystemImpact Assessment System
AnalysisPerformance Monitoring
Impact Assessment
Advocacy
Behavior Change
Performance Monitoring Performance Monitoring
Objective: Assess Knowledge and Counseling skills of the Key Informants (Public and Private Health Workers, Volunteers)
Methodology:
Pre and Post Test during training
Lot Quality Sampling Survey for Public Health Workers and Volunteers in both rural and urban areas (every six months)
Self Assessment for Private Workers and Hospitals in the urban area (every six months)
Behaviors Indicators
1- Timely initiation of breastfeeding (TIBF) within the first hour of birth
2- Exclusive breastfeeding (EBF) among women with infants 0-5 months of age
Rapid Assessment ProceduresRapid Assessment Procedures
# of infants 0-<6 months exclusively bf X 100
total # of infants 0-<6 months
WHO 1991,DHS and Multiple Indicator Cluster Survey (MICS)• 24-hour food feeding recall question
Objectives: Assess Behavior change indicators of the Beneficiary
Methodology:
Rapid Assessment Procedures based on UNICEF and WHO methodology at province/region level (annual)
Include both Quantitative and Qualitative surveys
Cross-sectional survey methodology
Target group: Woman with child 0-5 months
Sample size: 1800
Geographical area: 2 Regions
Rapid Assessment ProceduresRapid Assessment Procedures
Timely Initiation of BreastfeedingTimely Initiation of Breastfeeding(within 1 hour of delivery)(within 1 hour of delivery)
43
64
23
77
34
69
0
20
40
60
80
100
Jan 2000 Sept 2001 Oct 1999 Sept 2000 Apr 2000 Apr 2001
Antananarivo* Fianarantsoa* Total*
Per
cen
t
*p< 0.001
Exclusive breastfeedingExclusive breastfeeding(infants 0–<6 months)(infants 0–<6 months)
44
82
50
86
46
83
0
20
40
60
80
100
Jan 2000 Sept 2001 Oct 1999 Sept 2000 Apr 2000 Apr 2001
Antananarivo* Fianarantsoa* Total*
Per
cen
t
*p<0.001
Cost Effectiveness Analysis
1- Cost effectiveness ratio: e.g. cost per New Acceptor of promoting EBF
[cost of activities to promote EBF]
[target population] * ([EBF rate at end of period] – [EBF rate at baseline])
2- Cost per Beneficiary (per capita)
3- Cost per DALY for Breastfeeding promotion activities
Indicators
4- Mortality averted rate
Cost Effectiveness Analysis: MethodologyMethodology
1- Data Selection:
Type of costs included:- Full costs of program activities (including overhead)
that support the promotion of targeted behaviors in country for both central and district level - Direct cost of HQ costs associated with nutrition promotion activities - Direct costs of program partners
2- Data Collection: All financial data were collected retrospectively
Costs: Entire Program and Promotion Costs: Entire Program and Promotion of EBF and TIBFof EBF and TIBF
478,864
63,19032,347 35,334
136,115
27,065
745,074
299,305
59,412
0
200,000
400,000
600,000
800,000
Totalprogram cost
Cost topromote
EBF
Cost topromote
TIBF
Totalprogram cost
Cost topromote
EBF
Cost topromote
TIBF
Totalprogram cost
Cost topromote
EBF
Cost topromote
TIBF
Antananarivo Fianarantsoa Total
$ U
S
Cost per Beneficiary Cost per Beneficiary
$0.49
$0.05
$0.24
$0.69
$0.07
$0.40
$0.56
$0.12
$0.29
$0
$1
$1
$2
To
tal
Pro
gra
mC
ost
pe
rB
en
efic
iary
TIB
F C
ost
pe
rB
en
efic
iary
EB
F C
ost
pe
rB
en
efic
iary
To
tal
Pro
gra
mC
ost
pe
rB
en
efic
iary
TIB
F C
ost
pe
rB
en
efic
iary
EB
F C
ost
pe
rB
en
efic
iary
To
tal
Pro
gra
mC
ost
pe
rB
en
efic
iary
TIB
F C
ost
pe
rB
en
efic
iary
EB
F C
ost
pe
rB
en
efic
iary
Antananarivo Fianarantsoa Total
$ U
S
Cost per New Acceptor Cost per New Acceptor
$2.91
$8.12
$1.88
$14.22
$2.33
$10.09
$0
$5
$10
$15
TIBF EBF TIBF EBF TIBF EBF
Antananarivo Fianarantsoa Total
$ U
S Pop
26,594
Pop
52,859 Pop
79,453
31
132
34
18.5
9.5
9
0 20 40 60 80 100 120 140
Breastfeeding Promotion(LINKAGES/Madagascar)
ORT
Iodine fortificationprograms
Childhood Vaccinations
Growth monitoring andcounseling
Vitamin A distribution
Cost/DALY ($)Source: Disease Control Priorities in Developing Countries, 2006
Cost-effectiveness of Child Survival Cost-effectiveness of Child Survival InterventionsInterventions
Costs of Breastfeeding Promotion: Costs of Breastfeeding Promotion: Madagascar, 2001Madagascar, 2001
Estimated reduction in infant deaths due to an increase in exclusive
breastfeeding:
Increase in EBF rate: 50% to 86%
Cost per new breastfeeding acceptor: $10
Infants deaths averted: 5%
At a cost of $31/DALY
ConclusionsConclusions1- Comparability with international data
2- Comparability with different child and health survival interventions
3- Availability of crucial information on “How to improve cost effectiveness of programmatic breastfeeding promotion?”
4- Feasibility to assess the evidence-base of behavior change interventions on health and child survival
5- Need to determine how long it takes for these types of behaviors to become cultural norms
T H A N K Y O U