Implementation and Research Dr Raphael Bajay Tchumah, MPH Former CRS Chief of Party, Tubaramure Consortium

Tubaramure

Preventing Malnutrition in children under 2 years (PM2A)

• USAID/ Food for Peace response to chronic malnutrition

• Approach grounded in the results of research in Haiti between IFPRI

and World Vision in 2008

• And, evidence presented in the Lancet Series of 2008

• USAID/ Food for Peace issued an RFA in January 2009 for Burundi and

Guatemala – a single sector health RFA with a research component

2

FFP - Key components of PM2A

• The RFA explicitely required the following

– Access to quality health and nutrition services;

– Social and Behavior change on ENA, EHA

– Access to food (both local and Title II)

– Eligibility criteria was:

• Conditional transfer of foods - based on practices of one or more of the above

• Mother child unit from conception to age 2 years – 1000 days

3

RFA criteria

• In an area with few other actors

• Blanket coverage of all children eligible regardless of

household or nutritional status

• Full coverage of at least two provinces

• 10 million dollars a year for five years

4

Tubaramure’s or PM2A Burundi Results Framework

SO: Malnutrition in children under 2

years of age is prevented in Burundi

IR1: Women and children 0-59 months

access quality nutrition and health

services

IR2: Households practice appropriate

health and nutrition behavior

IR3: Eligible women & children have

increased intake of diverse foods

Implementing Tubaramure: PM2A in Burundi (July 2009- Oct 2014)

1) Awarded resources (USAID/FFP)

• USAID support over LOA – 43.1 million dollars • 27,000 MT of CSB and vegetable oil for direct distribution

and 21 MT of wheat for monetization

2) Implemented structures and networking

• 3 International NGOs: Catholic Relief Services (CRS), International Medical Corps (IMC), Food for the Hungry (FH), and one national NGO, Caritas Burundi;

• Staffing: 115 people directly involved, 2 field coordination offices, 2 warehouses, 24 distribution sites

Implementing the PM2A in Burundi- cont

3) Implemented structures and networking

• Ministry of Health: supported 11 district hospitals, 60 health centers & 1,000 CHWs

• Community of Cankuzo & Ruyigi: supported 49,555 mother-child pairs in 208 villages in more than 12 collines through 500 caregroups, involving 4,935 Lead mothers

4) Formative research to guide Care Group and SBCC work

5) Health facility assessments & support to National MOH

6) M&E system & the graduation process

7) 50,000 yellow buckets

All activities were monitored on the beneficiary card as well as on Lead mothers registers & supervision forms

Tubaramure: Final Results & Achievements

After five years of activities, CRS final evaluation confirmed that TUBARAMURE program left in Burundi (Cankuzo and Ruyigi):

• 5,000 lead mothers, in support to the Community Health system

• Strong capacities in the GoB, including revitalized health facilities & trained Health staff (increased quality of diagnostic & treatment, increased access to Prenatal & growth monitoring services, etc);

• Strong & improved behaviors on infant feeding & hygiene practices & IMCI

• Improved practices in Household dietary diversity & food consumption

• Strong orientation regarding nutrition & health systems policies in the country

• Supported National Government to adopt 1,000 Day Approach *.

• Impact and cost effectiveness to be confirmed by IFPRI.

Tubaramure: Final Results & Achievements (cont)

And if that was not enough, we partnered with IFPRI

• USAID /FANTA hired IFPRI

• Research protocols released

January 2010 – 6 months post

Tubaramure start up

• Negotiations with MOH,

communities on research arms

• Delays impacted project

activities and food distribution

10

Partnering with IFPRI – the positives

1. Open communications

– Pre-award discussion to adjust proposal to meet research needs

– Post award – joint sessions with communities and stakeholders to

explain research and the arms

Public randomisation of 60 villages for the Research purpose (T24- T18- Tnfp-

Tcontrol)

2. Shared learning

– On-going discussions based on findings to improve implementation

– Joint presentations to donor in Washington

11

Partnering with IFPRI – the positives

12

Maternal and child nutrition

FOOD

Household food security

CARE

For mothers & young children

HEALTH

Healthy environment + use of health services

? How

IFPRI: Comprehensive Study Approach

Process evaluation

? Impact study

Cost study

$?

$?

$?

Lessons Learned

1) Research design: establish research protocol & design at

RFA/Proposal periods to ensure project design and research

design are compatible

2) Orientation: Orient staff at field, country, region & HQ on all

aspects of the research to ensure all parties speak in one voice

3) Engage national government & stakeholders early: for

maximum participation & ownership of process

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Africa Latin America and Caribbean Asia

Things to do over in the partnership

1) Agree with donor about the necessary time frame for

research as the implementation was for five years, but

the reseach required time resulting in a cost extension

1) Agree on a project timeline that included the award

milestones such as baseline and final evaluation as well as

the research milestones to ensure timely attainment of

both research & required project activities

15

Process evaluation: Example of results (BCC intervention)

CRS1 & FH2 sensitize village chiefs and local people to the

Tubaramure program

LM5 deliver BCC3 lessons to BM6

BM6 receive and understand

nutrition/health care messages

Improved child health and nutrition outcomes

Improved IYCF8 and ENA9 practices

Outcomes

CRS1 hires 36 THP4

Impact

THP4 organize pregnant and lactating women into

beneficiary “care groups” of 10–12 members by

neighborhood

Beneficiary “care groups” choose their own LM5

FH2 supervisors train local THP4 on

BCC3 lessons

THP4 train LM5 on BCC3 lessons

Increased attendance at preventive health

care visits for mothers

THP4 receive and understand

nutrition/health care messages

LM5 receive, practice, and understand

nutrition/health care messages

Improved maternal health

and nutrition outcomes

CRS1 trains THP4 on seasonality

(calendar of foods) & meal preparation

(recipe manual)

LM5 train BM6 on seasonality &

meal preparation

THP4 train LM5 on seasonality &

meal preparation

BM6 receive and understand the

seasonality & meal preparation

training

Increased household dietary consumption

and/or diversity

Outputs

Increased dietary consumption and/or

diversity of child

Increased attendance at preventive health

care visits for children

Increased dietary consumption and/or diversity of mother

THPs organize LM5 into LM5 care groups of 10–12

members

FH2 develops BCC3 lesson

plans

Inputs Process

1Catholic Relief Services; 2Food for the Hungry; 3Behavior change communication; 4Tubaramure health promoter; 5Leader mother; 6Beneficiary mother; 7Essential hygiene actions; 8 Infant and young child feeding; 9 Essential nutrition actions

Improved EHA7

practices

Murakoze cane! …THANK YOU