Perils of scaling up: Effects of expanding a nutrition programme in Madagascar (original) (raw)

Maternal & Child Nutrition

Scaling up integrated nutrition programmes from small, targeted interventions or pilot studies to large-scale government-run programmes can be challenging, with risks of changing the nature and quality of the interventions such that effectiveness is not sustained. In 1999, the Government of Madagascar introduced a nationwide, community-based, growth-monitoring and nutrition education programme, which was gradually scaled up throughout the country until 2011. Data from three nationally representative surveys, administered pre-and post-programme implementation, in participating and non-participating communities, were used to evaluate the effectiveness of the programme to reduce malnutrition in children under 5 after two phases of expansion (1999-2004 and 2004-2011). In our analyses, we compared "original" communities, who had initiated the programme during the first phase, and "new" communities, who initiated the programme during the second phase. "Original" communities demonstrated a significant effect on mean weight-forage and on the prevalence of underweight by 2004; this effect was sustained at a reduced level through 2011. In contrast, "new" communities showed no benefits for any childhood nutritional outcomes. An explanation for these findings may be that community health workers in the "new" communities reported lower motivation and less use of key messages and materials than those in the "original" communities. Frontline workers reported increased workload and irregular pay across the board during the second phase of programme expansion. Our findings underscore the risk of losing effectiveness if programme quality is not maintained during scale-up. Key factors, such as training and motivation of frontline workers, are important to address when bringing a programme to scale. KEYWORDS community-based programme, difference in differences, impact evaluation, integrated nutrition programme, scale-up 1 | INTRODUCTION Nutrition programmes must be brought to scale in low-and middleincome countries in order to achieve the global commitment to ending all forms of malnutrition (Richter et al., 2017; Ruel & Alderman, 2013). In spite of an existing knowledge base about what nutrition interventions are most effective to improve health outcomes (Bhutta et al., 2014; Black et al., 2008), there is an urgent need for cost-effective, scalable approaches that can address the entire population of children who are at risk of malnutrition and poor development. In addition to the challenge of bringing programmes and policies to scale (Bhutta,