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Final Report: Southern Africa Nutrition Initiative

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Evaluation and Lessons Learned
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Executive Summary

The Southern Africa Nutrition Initiative (SANI) is a $29,487,135 CAD project to address undernutrition in women of reproductive age (15-49) and children under 5 years in Malawi, Mozambique and Zambia.
A partnership between CARE, Cuso International, Interagency Coalition on AIDS and Development (ICAD) and McGill University and the Governments and communities of implementing countries, SANI aimed to improve the nutritional status of women of reproductive age (15-49 years) and children under-5 years old. SANI was designed to align with national health and nutrition strategic priorities of Malawi, Mozambique and Zambia, and has been implemented in close collaboration with the Ministries responsible for Health, Agriculture, and Gender in each country, as well as national and district-level nutrition coordination committees (NCC and DNCC). Between June 2016 and March 2021, SANI contributed directly to the improved health of 234,000 women, children and men directly and over 498,000 individuals indirectly.

This final report covers the implementation period of the original SANI contribution agreement and project implementation plan finalized in February 2017. All activities and outputs under this initial contribution agreement were completed by March 30th, 2021, and progress towards outcomes was measured in endline studies completed between January 2020 (Malawi) and November 2020 (Zambia and Mozambique). As described in the Project Information table on pg 2., SANI was granted two costed extensions (in July 2020 and March 2021) to respond to the COVID-19 pandemic. All reporting for COVID-19 response activities, as well as financial reporting and disposal of assets, will be conducted separately in a subsequent report following the end of project activities in June 2022.

Key project achievements:

Outcome 1100 aimed to improve nutrition practices and services for women of reproductive age, boys, and girls under 5 by strengthening the delivery of community-based nutrition services at the intersection between community health and the health system. Growth Monitoring and Promotion (GMP) and Community Management of Acute Malnutrition (CMAM) programs built this link, working on the continuum of prevention of malnutrition and early detection and treatment of moderate and severe acute malnutrition. Training and support on Maternal, Infant, and Young Child Nutrition (MIYCN), CMAM, and GMP was provided to health service workers and community health workers, and Care groups were established to support families to learn about and apply gender-sensitive MIYCN practices. Interactive teaching was also done at scale through participatory education theatre and cooking demonstrations using local nutritious foods. Social Analysis and Action (SAA) dialogues encouraged families involved in the program to identify, discuss, and challenge traditional social norms and practices that affect women’s health, nutrition, and empowerment.
Endline data revealed the following increases in nutrition-specific indicators from baseline:

  • All three countries had considerable increases in rates of exclusive breastfeeding of children up to 5 months, increasing by 15-percentage points in Zambia (from 70% to 85%), 25-percentage points in Malawi (from 61% to 86%) and 17-percentage points in Mozambique (from 65% to 82%)

  • Minimum Acceptable Diet (MAD) for children 6 to 23 months increased by 24-percentage points for boys and girls in Malawi (from 7% to 31%) and in Zambia by 7-percentage points for boys (from 24% to 31%) and by 13-percentage points for girls (from 17% to 30%)

  • Knowledge of men and women on MIYCN practices improved by 6-percentage points for men (from 79% to 85%) and 4 percentage points for women in Malawi (from 90% to 94%), by 12-percentage points among women (from 59% to 71%) in Mozambique, and by 11-percentage points for women (from 81% to 92%) and 14-percentage points for men (from 72% to 86%) in Zambia.

Outcome 1200 addressed the determinants of under-nutrition with activities that influenced long-term improvements in the overall health of the population. SANI worked with communities to improve access to and availability of food by establishing climate-sensitive homestead gardens that meet the minimal acceptable dietary needs of women and boys and girls under five. Water, sanitation, and hygiene (WASH) was improved by the construction and rehabilitation of water points, the engagement of communities in Community-led Total Sanitation (CLTS) processes and water management committees (WMC). SANI made progress towards the following indicators for this outcome:

  • Minimum dietary diversity (MDD) increased among women and children in Malawi and Zambia, with a 20-percentage point increase in dietary diversity among women in Zambia (from 57% to 77%) and a 50-percentage point increase in Malawi (from 18% to 68%).

  • The number of men and women using improved drinking water sources increased by 3-percentage points in Zambia (from 29% to 32%), by 8-percentage points in Malawi (from 77% to 85%), and by 7-percentage points in Mozambique (from 66% to 73%).

  • Improvement in water treatment practices in all three countries. In Malawi, there was a 6-percentage point increase (from 25% to 31%), a 46-percentage point increase in Zambia (24% to 70%), and a 16-percentage point increase in Mozambique (from 8% to 24%).

  • Prevalence of diarrhea decreased in all three countries, by 19-percentage points in Malawi (from 54% to 35%), 4-percentage points in Zambia (from 24% to 20%), and 7-percentage points in Mozambique (from 19% to 12%).

  • Moderate and Severe Food Insecurity decreased in Malawi by 18-percentage points (from 72% to 54%), and by 9-percentage points in Mozambique (from 54% to 45%).

  • Women’s Dietary Diversity (WDD) improved by 50-percentage points in Malawi (from 18% to 68%), by 20-percentage points in Zambia (from 57% to 77%) and by 1-percentage point in Mozambique (from 21% to 22%).

Outcome 1300 took a multi-sectoral approach to ending malnutrition in Malawi, Mozambique and Zambia at multiple levels of government administration, strengthening Nutrition Coordinating Committees to plan, implement and monitor multi-sectoral nutrition programs. In Malawi, SANI focused on strengthening the capacity of already functioning District and Area Coordinating Committees to provide supported supervision and outreach, project management and monitoring. In Mozambique and Zambia SANI strengthened the Provincial Coordinating Committees and established district coordination committees. Communities were engaged in Community Scorecard processes to facilitate citizen participation in the planning, delivery, and evaluation of nutrition services at the community level. SANI contributed to the following key results under this outcome:

  • Increase in female leadership in nutrition governance, with at least 30% of DNCC members and leaders who are women in all three countries.

  • 100% of targeted districts across all 3 countries developed gender-sensitive multi-sectoral nutrition action plans.

  • Responsiveness of health service providers for gender-sensitive MIYCN and global acute malnutrition improved by 25% in Malawi, 8% in Mozambique and 7% in Zambia.

Under outcome 1400, SANI engaged the Canadian public through a public education campaign, Feed Her Future (FHF). The aim of this campaign was to engage Canadian men and women in understanding the complex relationship between gender equality and nutritional status, as well as highlight Canada’s leadership in fighting malnutrition among women and girls through SANI. The campaign launched in June 2018 and ran until August 2020. CARE and partners developed material for a variety of fora and media, including the FHF webpage, conferences and workshops, videos, infographics, and social media. These materials were based on research findings, both pre-existing and conducted as part of SANI, and stories and testimonials from people reached by the project.

  • A total of 112 campaign information products were developed, as well as 21 campaign videos featuring project participants and staff, 1 bilingual website and 4 social media channels.

  • 27 Canadian public outreach activities were conducted, engaging with 381 Canadians at farmers markets and with 404 Canadians during street outreach, an an additional 19 presentations about SANI were delivered at separate workshops and conferences in Canada.

  • Reached 2,578,243 social media impressions, 55,414 social media engagements, and saw 4,833 unique visitors to the SANI website.

Access to nutritious food is constrained by a complex intersection of poverty, gender, and community dynamics, and SANI was designed with a range of gender-specific and gender-sensitive interventions to address gender inequality. This included the promotion of male engagement and participation in MIYCN in Care groups, M2M and F2F groups, opening space to reflect and examine not only men’s knowledge and participation but also women’s autonomy, and the nutrition and health benefits of equitable decision making and sharing the work burden within the household. To shift social norms,
SANI also implemented Social Analysis and Action (SAA), a gender-specific approach for working with communities through recurring dialogue to examine, reflect and address how social and gender norms perpetuate health challenges, malnutrition and gender inequality. SANI also aimed to strengthen female participation and create spaces for women to express their rights within nutrition governance structures by promoting women’s leadership in nutrition governance committees and participation in CSC processes.

The impact of the gender equality interventions of SANI was noted through improved attitudes of women and men toward gender issues that influence nutrition practices for women of reproductive age (WRA) and boys and girls under 5. The project, in collaboration with local partners, addressed cultural norms that negatively influence family nutrition, and more men were seen to be accompanying wives and children to health facilities. In addition, SANI addressed myths surrounding nutrition through home visits and support groups and influenced men’s roles in nutrition and health within the household. By project endline, women are equipped with agricultural knowledge, have better access to more land for growing crops, to agricultural inputs like vegetable seeds and seasonal crops.

Volunteer sending

Cuso and CARE successfully deployed 35 volunteers over the course of the project, all of whom contributed their skills and time to achieving over $1.7 million in in-kind contribution to the project. An end of project survey of 12 CARE country office staff who directly worked with the volunteers or helped manage the partnership administratively found that 100% of staff valued the partnership and would recommend having volunteers on future projects, and 93% of staff felt the volunteers helped to reduce their workload. While the COVID-19 pandemic brought the final cohort of volunteers home several months earlier than planned, the volunteers continued their assignments from home in Canada and completed their scope of work in support of SANI remotely.

Twinning

As part of SANI, the Interagency Coalition on AIDS and Development (ICAD) implemented a twinning project with organizations in Canada, Malawi and Zambia to build the capacity of community-based organizations to address intersections between HIV and nutrition and improve information, education and services for women living with HIV and children living with and/or affected by HIV. Throughout the project, seven participating organizations in Canada, Malawi, and Zambia strengthened their capacity to deliver gender-equitable nutrition programs for women living with HIV, and generated important lessons learned on building nutrition programming that is responsive to the needs of people living with HIV in Malawi, Zambia, and Canada.

Overall, the SANI project directly reached a total of 233,990 people, including 125,557 women and girls and 108,433 men and boys, as well as indirectly reached 498,245 people, including 288,775 women and girls, and 209,470 men and boys.

While SANI’s theory of change and implementation strategy remained consistent through project implementation, several shifts in operating context forced SANI to adjust operational timelines and strategies. Major events included elections in Malawi and Mozambique, gassing attacks in Zambia, cyclones Idai and Kenneth in Mozambique infestation of the fall army worm, and recurrent cyclical flooding and droughts. The COVID-19 outbreak at the beginning of 2020 arrived just as the project entered a final phase, with operations having wrapped up in Malawi, and most activities coming to a finish in Mozambique and Zambia. At the same time, the social and economic pressures of the COVID pandemic pushed communities to new heights of vulnerability, threatening to reverse the progress of the SANI project. Activities were quickly adjusted, and an emergency response program rapidly launched with funding from a costed extension from GAC.

While the original activities and outputs planned under the initial program implementation plan for SANI have come to an end, CARE will continue to implement COVID-19 response activities in communities reached by SANI in Malawi, Mozambique, and Zambia through the end of June 2022 with a costed extension from GAC. This response is intended to support communities preserve the nutrition and livelihood related gains achieved during the SANI project through the COVID-19 pandemic.