Why we are still failing to measure the nutrition transition

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Does household participation in food markets increase dietary diversity? Evidence from rural Malawi

This is the final version. Available on open access from Elsevier via the DOI in this recordFood markets have been found to be, in many settings, important in shaping diets and nutritional outcomes. However, more evidence and improved metrics are needed to understand these relationships. We examined relationships between food market participation and household dietary diversity in populations of rural Malawi facing hunger and poor nutrition. We analysed, using Poisson regression, survey data from 400 households in two districts of rural Malawi in post-harvest and lean seasons of 2017/18. We also developed a new metric of food purchases to support our examination of food market participation. The findings include clear associations between food purchase diversity and household dietary diversity, and suggest households engaging more with food markets are more likely to have diversified diets and better nutrition.Drivers of Food Choice (DFC) Competitive Grants ProgramsUK Foreign, Commonwealth & Development OfficeBill & Melinda Gates Foundatio

Impact of results-based financing on effective obstetric care coverage : evidence from a quasi-experimental study in Malawi

Background: Results-based financing (RBF) describes health system approaches addressing both service quality and use. Effective coverage is a metric measuring progress towards universal health coverage (UHC). Although considered a means towards achieving UHC in settings with weak health financing modalities, the impact of RBF on effective coverage has not been explicitly studied. Methods: Malawi introduced the Results-Based Financing For Maternal and Neonatal Health (RBF4MNH) Initiative in 2013 to improve quality of maternal and newborn health services at emergency obstetric care facilities. Using a quasi-experimental design, we examined the impact of the RBF4MNH on both crude and effective coverage of pregnant women across four districts during the two years following implementation. Results: There was no effect on crude coverage. With a larger proportion of women in intervention areas receiving more effective care over time, the overall net increase in effective coverage was 7.1%-points (p = 0.07). The strongest impact on effective coverage (31.0%-point increase, p = 0.02) occurred only at lower cut-off level (60% of maximum score) of obstetric care effectiveness. Design-specific and wider health system factors likely limited the program's potential to produce stronger effects. Conclusion: The RBF4MNH improved effective coverage of pregnant women and seems to be a promising reform approach towards reaching UHC. Given the short study period, the full potential of the current RBF scheme has likely not yet been reached.Peer reviewe

Food choice responses to changes in the price of a staple crop: a discrete choice experiment of maize in rural Malawi

Price and affordability are important drivers of food choice, particularly for rural smallholder farming households in Malawi, experiencing extreme poverty, food insecurity, and lack of dietary diversity. Lowering the cost of staple crops such as maize targeted by agricultural input subsidy programmes (AISPs) may potentially increase consumption of the staple crop, but it might also lead to consumption of a more diverse range of foods. Using a discrete choice experiment, this study investigated food choice responses to changes in maize price in rural Malawi. Study participants (n = 400) were given a series of choice tasks for which they were asked to choose between food baskets with varying cost, reflecting local prices and with maize at both high and low price. Baskets contained different types of foods including maize, rice, cabbage, small-dried fish, and/or a soft drink. The data were analysed using mixed logit models including investigation of heterogenous effects based on socio-demographic characteristics, food security and actual market purchases. Individuals revealed a preference, as expected, for lower cost food baskets. Small-dried fish and cabbage were the highest valued food products. At a low cost of maize, the expected utility from a basket with maize was greater than a basket with other items, particularly among households with high- and low-food purchases, low socioeconomic status, living in Phalombe District, and experiencing food insecurity, indicating that among such populations a low price of maize will not necessarily lead to increases in dietary diversity. In contrast, among households living in Lilongwe District, with high SES and food secure, a lower maize price will not lead to a loss in dietary diversity as they prefer a basket containing non-maize products over maize. The findings suggest that achieving food security and dietary diversity may require a range of policy approaches addressing different pathways of impact as opposed to relying on subsidizing inputs for staple crop production

Perceptions of quality across the maternal care continuum in the context of a health financing intervention: Evidence from a mixed methods study in rural Malawi

Background: In 2013, Malawi with its development partners introduced a Results-Based Financing for Maternal and Newborn Health (RBF4MNH) intervention to improve the quality of maternal and newborn health-care services. Financial incentives are awarded to health facilities conditional on their performance and to women for delivering in the health facility. We assessed the effect of the RBF4MNH on quality of care from women’s perspectives. Methods: We used a mixed-method prospective sequential controlled pre- and post-test design. We conducted 3060 structured client exit interviews, 36 in-depth interviews and 29 focus group discussions (FGDs) with women and 24 in-depth interviews with health service providers between 2013 and 2015. We used difference-in-differences regression models to measure the effect of the RBF4MNH on experiences and perceived quality of care. We used qualitative data to explore the matter more in depth. Results: We did not observe a statistically significant effect of the intervention on women’s perceptions of technical care, quality of amenities and interpersonal relations. However, in the qualitative interviews, most women reported improved health service provision as a result of the intervention. RBF4MNH increased the proportion of women reporting to have received medications/treatment during childbirth. Participants in interviews expressed that drugs, equipment and supplies were readily available due to the RBF4MNH. However, women also reported instances of neglect, disrespect and verbal abuse during the process of care. Providers attributed these negative instances to an increased workload resulting from an increased number of women seeking services at RBF4MNH facilities. Conclusion: Our qualitative findings suggest improvements in the availability of drugs and supplies due to RBF4MNH. Despite the intervention, challenges in the provision of quality care persisted, especially with regard to interpersonal relations. RBF interventions may need to consider including indicators that specifically target the provision of respectful maternity care as a means to foster providers’ positive attitudes towards women in labour. In parallel, governments should consider enhancing staff and infrastructural capacity before implementing RBF

Inequities and their determinants in coverage of maternal health services in Burkina Faso

Background: Poor and marginalized segments of society often display the worst health status due to limited access to health enhancing interventions. It follows that in order to enhance the health status of entire populations, inequities in access to health care services need to be addressed as an inherent element of any effort targeting Universal Health Coverage. In line with this observation and the need to generate evidence on the equity status quo in sub-Saharan Africa, we assessed the magnitude of the inequities and their determinants in coverage of maternal health services in Burkina Faso. Methods: We assessed coverage for three basic maternal care services (at least four antenatal care visits, facility-based delivery, and at least one postnatal care visit) using data from a cross-sectional household survey including a total of 6655 mostly rural, poor women who had completed a pregnancy in the 24 months prior to the survey date. We assessed equity along the dimensions of household wealth, distance to the health facility, and literacy using both simple comparative measures and concentration indices. We also ran hierarchical random effects regression to confirm the presence or absence of inequities due to household wealth, distance, and literacy, while controlling for potential confounders. Results: Coverage of facility based delivery was high (89%), but suboptimal for at least four antenatal care visits (44%) and one postnatal care visit (53%). We detected inequities along the dimensions of household wealth, literacy and distance. Service coverage was higher among the least poor, those who were literate, and those living closer to a health facility. We detected a significant positive association between household wealth and all outcome variables, and a positive association between literacy and facility-based delivery. We detected a negative association between living farther away from the catchment facility and all outcome variables. Conclusion: Existing inequities in maternal health services in Burkina Faso are likely going to jeopardize the achievement of Universal Health Coverage. It is important that policy makers continue to strengthen and monitor the implementation of strategies that promote proportionate universalism and forge multi-sectoral approach in dealing with social determinants of inequities in maternal health services coverage

How effectively might agricultural input subsidies improve nutrition? A case study of Malawi’s Farm Input Subsidy Programme (FISP)

Agricultural input subsidy programmes (AISP) are often considered an important means of improving agricultural productivity and food security in developing countries. However, the impact of AISP on food choice and nutrition is unclear, not least because staple crops targeted tend to be calorie-dense but nutrient-poor. AISP targeting maize, for example, may increase maize production and consumption and reduce intake of nutrient-rich foods. Alternatively, a fall in maize prices may enable consumers to purchase other goods including other food items. Using mixed-methods approaches, this paper examines the impact of a prominent AISP, Malawi’s Farm Input Subsidy Program (FISP), on overall food choice. Qualitative data were collected through semi-structured interviews and focus group discussions. Quantitative data were collected through household, individual and market surveys, and a discrete-choice experiment. Hypothesised impact pathways from AISP to food choice and dietary diversity, and prior literature, suggest Malawi’s FISP could be contributing to improved dietary diversity. However, analyses from our surveys, discrete-choice experiment, interviews, and focus group discussions do not suggest any significant FISP impact on food choices and dietary diversity. Our findings suggest this lack of impact could be due to how the FISP policy is designed and implemented – but that even with changes, as with the Affordable Inputs Programme which replaced the FISP in 2020, it may still be an inefficient means of addressing dietary diversity in rural Malawi. The results highlight issues needing consideration by policymakers and the agri-nutrition community to advance discussion and research for how best to design AISP and other public policy to address malnutrition in all its forms