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Chad

Impact evaluation of WFP’s programs targeting moderate acute malnutrition in humanitarian situations in Chad, July 2018

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Summary

This study focuses on the interrelation between prevention and treatment of moderate acute malnutrition (MAM) on children aged 6–23 months. Although MAM affects an estimated 33 million children worldwide and is associated with more nutrition-related deaths than severe acute malnutrition (SAM) (IAEA 2014), the most effective way of addressing MAM is still not understood (Wegner et al. 2015).

The study took place in the Bahr el Ghazal (BEG) region of Chad. Chad is a landlocked, arid, low-income and food-deficit country, and one of the world’s poorest countries (in 2015, it ranked 185 out of 188 countries in the UNDP Human Development Index, and 73 out of 78 on the Global Hunger Index). A number of conflicts (internal and in neighboring countries) have aggravated the high levels of poverty in Chad during the last few years that have contributed to political and economic instability and poor economic development.

In 2015, about one fourth of the population in Chad were food insecure, including 6 per cent who were severely food insecure (Ministère de l’Agriculture-SISAAP et al. 2015).
The highest food insecurity rates are found in the Sahel, particularly in BEG (85.3%).
Global acute malnutrition (GAM) and SAM rates in the Sahel belt in Chad have remained consistently high. GAM rates exceed 15 per cent during the lean season (June– September) every year and during humanitarian crises, but are high in both emergency and non-emergency contexts. The yearly estimated burden of cases for SAM is close to 200,000 and 500,000 for MAM.

WFP has a number of ongoing interventions to prevent and address MAM in Chad, all including a targeted supplementary feeding program (TSFP) for children aged under five years (under-fives) and pregnant and lactating women in areas where GAM exceeds 10 per cent, and a blanket supplementary feeding program (BSFP) during the lean season in areas of high food insecurity where GAM exceeds 15 per cent.

BSFP aims to prevent a deterioration of the nutritional status of individuals identified as vulnerable through food security and nutrition assessments. TSFP aims to treat moderately malnourished individuals identified through anthropometric screening within the Ministry of Health primary healthcare system and following national MAM protocols based on standard WHO (2012) guidance (MSP-CNNTA 2014).

The study assesses the impact of WFP’s preventive intervention (BSFP) for children aged 6–23 months during the lean season on program beneficiaries' nutritional status and seeks to answer the study’s primary evaluation question: What is the difference in impact of MAM prevention (BSFP) on the incidence and prevalence of MAM in acute and protracted emergencies on children under two years of age when access to MAM treatment (TSFP) is good or poor?

The study uses quasi-experimental methods to capture the effect of BSFP on beneficiaries. Study sites were identified through a list of BSFP beneficiary villages. In order to construct a counterfactual, two study groups were identified: those who received all planned BSFP distributions (intervention group) and those who did not receive any BSFP (control group). Some 766 children were allocated to the treatment group, while 464 were in the control group and received no BSFP. An analysis of covariates (ANCOVA) approach was employed to control for unobserved child characteristics, while instrumental variables were used to test for selection bias of the program. Attrition bias was addressed using a two-stage Heckman estimator. Three main hypotheses were tested with the following results.

• Hypothesis 1: BSFP reception has a positive effect on the incidence of MAM in the target group (6–23 months).
o Findings: Statistical models provide strong evidence that the effect of receiving all planned BSFP distributions significantly reduces MAM incidence for children in the intervention group.

• Hypothesis 2: BSFP reception together with access to TSFP has a more positive impact on the incidence of MAM than reception of BSFP alone.
o Findings: (a) MAM incidence is lower in the BSFP group when access to TSFP is good (distance to health center or mobile clinic is less than two hours), and (b) BSFP is more effective among those who have poor access to TSFP.

• Hypothesis 3: BSFP reception has positive spillover effects on the incidence of MAM among siblings.
o Findings: MAM incidence for children 24–59 months is 4 percentage points lower if a younger sibling receives BSFP than if no younger sibling receives BSFP.

Heterogeneity of the effect of BSFP was tested with respect to the study variables: gender, age, number of siblings aged less than 60 months, number of income sources, main household livelihood source, water and sanitation conditions, BSFP product type, other seasonal assistance received and BSFP ration sharing patterns. A statistically significant effect was found with respect to the main livelihood source: BSFP has a significant and positive effect for those whose main livelihood source is agriculture.

Due to geographical targeting for assistance being limited and seasonal, WFP does not cover 100 per cent of the target populations. Thus, alternate funding mechanisms and earlier mobilization of resources should be established to extend geographical and individual coverage of BSFP interventions. Furthermore, starting negotiations with relevant partners earlier can improve coordination among key stakeholders.

The study highlighted that further research may be needed to better understand the particular interactions between BSFP and potential external factors that can have an impact (such as other seasonal interventions). Improved coordination with agencies can assist in producing alternative ways to manage MAM. Additionally, with the promotion and use of locally produced products, alternate routes for cost-effectiveness can be explored; especially in combination with community-based delivery approaches and increases in TSFP coverage.

The impact evaluation therefore concludes that BSFP has a positive effect on MAM incidence in children aged 6–23 months during the lean season. There is some evidence that BSFP especially protects the older age group within that range and strong evidence that BSFP protects households subject to seasonal livelihoods (agriculture and herding).
Households with more access to TSFP (closest to health center or mobile clinic) also have lower MAM incidence.