Perils of scaling up: Effects of expanding a nutrition programme in Madagascar

Abstract

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-for-age 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.

Figure 1

Line graphs for the proportion of (a) underweight and (b) stunting among children under 5 years by survey year for each of the four site types (“original,” “new,” “never,” and “closed”). Included under each line graph is a table of the raw mean underweight or stunting proportion with standard deviation (SD), total number of children by site type (n), and number of sites by site type.

Figure 2

Working conditions of community health workers (CHWs) in 2004 and 2011. The figure shows that all programme communities (“original” and “new” combined) experienced increased workload of CHWs between 2004 and 2011, including increases in population pressure (e.g., more children and mothers in the site census), inconsistently paid salary, reliance on other sources of income, and involvement in commune and community health programmes.