Once a month, Arentsoa, who is 18 months old, and her mother Larissa visit the community health and nutrition site in Ambatombositra for Arentsoa to be weighed and examined. During the visit, Arentsoa gets to meet and play with other children, as well as taste the dishes prepared by the mothers during their cooking class at the site.
The opening of the Ambatombositra community site has been a great help for Larissa and other mothers in the village. Malala, mother of three-year-old Frédéric, who regularly visits the site, says, “The site and the community workers who work there provide us with tremendous services. They are like mothers to us. I trust them, and I follow their advice to the letter.”
Community health and nutrition workers are essential to implementing the Improving Nutrition Outcomes Project or FAFY Program in Madagascar, which aims to increase use of reproductive, maternal, and child health and nutrition (RMCHN) interventions and improve key nutrition behaviors known to reduce stunting.
In Madagascar, stunting is a significant development issue that the government has been concerned about for a long time. Stunting happens when children do not grow properly. It means they are too small for their age, and happens when a child lacks nutritious food, access to health services, and clean water. The results can reduce cognitive and physical development, which can affect their entire life. Inadequate breastfeeding practices and mothers not having enough food to eat during pregnancy can also contribute to stunting.
In 2016, Madagascar had the fourth-highest prevalence of stunting in the world. Through the Improving Nutrition Outcomes Project, supported by the World Bank and the Power of Nutrition multi-donor trust fund, the country initiated a 10-year program in 2018 to alleviate chronic malnutrition in children under 5. This program focuses on improving the quality and coordinating nutrition and health sectors at all levels, starting from the community level to ensure that each child has access to all the services they need to grow and thrive.
“Despite the strong connection between health and nutrition, primary care and community-based services in these two areas in Madagascar have remained separate and uncoordinated. The FAFY Program has facilitated the connection between these two crucial sectors,” explains Cedric Ndizeye, Senior Health Specialist at the World Bank in Madagascar. “There is evidence that priority interventions for nutrition and health can bring significant benefits for the child, their family, and the country. Better-nourished children are likely to have improved cognitive abilities and could earn 5 to 50% higher incomes in adulthood,” he adds.
Nearly 9,000 community workers have been trained using a new approach that combines health and nutrition interventions. Additionally, more than 4,500 community health and nutrition sites have been set up. Training was provided to health workers at over 1,080 primary health care centers to improve quality of services, in addition to equipping them with the necessary nutrition and health products and equipment.
At the community site level, services now available for children under 5 years of age, as well as pregnant and lactating women include: early pregnancy detection, home counseling and follow-up visits, nutrition education, cooking demonstrations, growth monitoring and promotion, early childhood stimulation, lipid-based nutrient supplementation (LNS), management of acute malnutrition, and detection and treatment of common childhood diseases. Basic health centers have reduced cost barriers for health services and offer free prenatal and postnatal care, assistance during childbirth, iron and folic acid supplementation, childhood vaccinations, vitamin A supplementation, integrated management of childhood illnesses, and treatment of severe malnutrition.
The FAFY Program, which initially covered seven regions in Madagascar, now extends to 13 out of the country's 23 regions. Over 2 million individuals, including 1.2 million children under 5 years of age and 440,000 pregnant women, have received health and nutrition services through this program. According to the 2021 Demographic and Health Survey (DHS), the prevalence of stunting in Madagascar decreased by nearly three percentage points from 42% to 39.8% nationally between 2018 and 2021. In the first 7 regions that started the program, the reduction was even more significant, dropping from 52.4% to 48.4% during the same period.
“The program builds upon an adaptive learning approach that is dynamic and data-driven. This expands upon the large-scale, community-based nutrition program initiated by Madagascar’s Office of Nutrition two decades ago. The design and implementation of FAFY are driven by an ambitious learning agenda, with a focus on testing and scaling up successful strategies,” explains Lisa Shireen Saldanha, Senior Nutrition Specialist at the World Bank.
In 2017, the Government of Madagascar visited Peru to learn about how that country halved stunting in seven years with support from the World Bank and brought in key lessons about targeting the supply of health services and incorporating interventions to promote demand. In Madagascar, a research initiative called the Mahay study examined the effect of expanding the community nutrition program to include preventive lipid-based nutrient supplements (LNS) and tested the feasibility of integrating early stimulation activities. South-south collaboration was a key part of the study, as the government and research teams learned from experiences in Jamaica and Bangladesh about what had worked in those contexts, and brainstormed on how to adapt it to the local context. The study demonstrated that the LNS component reduced stunting by nine percentage points, but only when supplementation began with very young children – at 6 months. These findings informed the design of FAFY, which is scaling up LNS supplementation to young children (6-18 months) in selected areas.
Chronic malnutrition has long term impacts on health and development, which hampers the natural potential of individuals and has a significant impact on human development and the economic progress of nations. The economic cost, which can consume 7 to 12% of a nation's GDP, requires immediate and decisive action. In the case of Madagascar, the impact is even more significant, with losses associated with malnutrition accounting for 14% of its GDP in 2016. Prioritizing nutrition interventions is crucial, as it can lead to substantial cognitive and economic gains, increasing future incomes by 5 to 50%.
