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Impact in Action

High-Impact Nutritional Investment in Malawi for the JBJ Foundation

Identifying the most promising health sector areas in Malawi for private investment

Last Updated: April 4, 2022
In Malawi, a woman and child hold a plate of nutritious, locally grown staples.
©Thoko Chikondi/World Bank. License: CC BY NC-SA 4.0

What was the problem to be solved?

Stunting is associated with significant and lasting consequences for children and societies, including increased risk of mortality, delayed cognitive development, and reduced productivity. Malawi has made moderate progress on stunting in the last 20 years but progress has stalled in recent years, with about 41 percent of children under five in Malawi stunted in 2019.

The JBJ Foundation, a private foundation in the United States, asked Exemplars in Global Health to identify high-impact nutrition investments in Malawi. The goal of the research was to identify reasons for higher stunting rates within Malawi and interventions that would promote rapid improvements in nutrition.

What support did Exemplars in Global Health provide?

Our team and partners conducted robust research through a review of data across relevant nutritional indicators in Malawi. We explored key interventions, burden levels, trends over time, and geographic distribution of malnutrition to understand areas for improvement in Malawi relative to other Exemplar countries. In addition to reviewing quantitative data, we conducted a literature review. Based on our research findings, we developed a set of recommendations on which interventions to invest in, what geographies and populations to focus on, and why.

We worked in close collaboration with partners, including the Hospital for Sick Children in Toronto, World Bank, International Food Policy Research Institute, Dalberg, and the Copenhagen Consensus Center, to develop and validate our findings.

To conduct the assessment for Malawi, we used the evidence-based ten-step framework developed by Exemplars in Global Health over the course of studying positive outliers in stunting reduction. We identified the following three areas for high-impact investment to improve nutrition in Malawi:

  • Maternal health care and women’s empowerment: Antenatal interventions such as multiple micronutrient supplementation and balanced energy protein supplementation have strong potential to make rapid improvements in maternal and child nutrition. This will help Malawi make needed progress in improving child height-over-age Z-score, or HAZ (a measure of childhood stunting) outcomes at birth, in addition to addressing consistent risk factors around maternal health, specifically maternal body mass index – an indicator sensitive to access to a nutritionally adequate diet and health care.
  • Food insecurity: Opportunities exist to increase access to food and lower pricing through improvements in storage management. In addition, investing in the design of a more shock-resilient food system will enable it to better withstand high poverty and climate-sensitive challenges, such as flooding and droughts.
  • Equitable access to care and services: Targeted investments are needed to close equity gaps in antenatal care coverage, breastfeeding, diet diversity, and issues related to water, sanitation, and hygiene. This is especially critical in direct health sector interventions around supplementation (e.g., MMN / BEP) to avoid challenges around double burden, or both missing undernourished populations in need while worsening obesity/overweight rates in mis-targeted populations.

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Victora curves reinforce modest progress on breastfeeding, recent success in disease management and complementary feeding, and persistent challenges around maternal health and birth outcomes

Predicted HAZ Score by Child's Age

 

 
 
  1. Overlapping CI in y-intercept make it difficult to make conclusive statements, but limited to no progress on birth outcomes, suggests opportunity to prioritize maternal health / prenatal care. FBD went up significantly over this period, but ANC has remained static.
  2. Similar story with BF, with a slight flattening that suggest improvements were made here, especially around early initiation breastfeeding rates.
  3. Material improvements observed from 6–23 months of age—indicating improvements in complementary feeding practices, disease management, and/or household environments between 2010 and 2016 in particular.
 
 
 
 
 
 
 
 
 
 

Initial assessment highlighted gaps in food security, targeting inequities in access to care, and maternal health outcomes in particular.

SIGNIFICANT PROGRESS
MODERATE PROGRESS
LIMITED/NO PROGRESS
10-STEP FRAMEWORK INITIAL ASSESSMENT / GAP ANALYSIS SUMMARY
POLITICAL WILL
High-level political and donor support
  • Much of the baseline planning and multisectoral efforts and commitments have been put into place, with refreshes to robust NNPSP.

    High levels of DAH bolster modest but consistent investments in health by the Malawian government, which raises questions around sustainability.
Invest in granular data for decision making
  • Data quality has improved dramatically in recent years, but historical efforts around survey collection data highlight gaps that may make analyses over time and for specific cohorts of interest challenging – especially around mismatches among the 12-24 month cohorts.

    DHIS and other in-country real-time data collection mechanism are garnering investment and attention, and look promising but quality has been historically poor.
INDIRECT, NON-HEALTH SECTOR
Address food insecurity & reach marginalized populations
  • Food insecurity remains a persistent challenge in Malawi – and while wasting has been managed effectively, loss of produce in storage, compounded by climate-related pressures compound an already sensitive, largely small-scale subsistence-based agricultural system.

    High levels of poverty are compounded by disparities to care and drastically different household conditions.
Invest in education, especially for girls
  • Women’s median years of school completed increased from 0.4 in 1992 to 5.6 in 2016. Still, these numbers are quite low and a gap exists between men and women at the secondary level of education where females are less likely to enroll. Compounding this is a low rate of secondary enrollment and a significant drop off in GPI for secondary education
Address gender disparities & empower girls and women
  • Gender disparities extend beyond education and are reflected in composite indicators like the GII, which has Malawi at 0.62 (148 / 187), primarily driven by adolescent fertility and educational attainment (limited secondary education enrollment).
Improve living conditions, especially WASH
  • Rates of open defecation are low when compared to exemplar countries but looking at other WASH metrics from JMP (e.g. Hygiene, Sanitation, and Drinking Water) no areas meet the SDG definition for safely managed.

    Limited national level investment on WASH infrastructure is of note given the high rural population.
INDIRECT, HEALTH SECTOR
Increase access to family planning & reduce high-burden pregnancies
  • High rates of adolescent fertility (138 per 1,000 births) trending with low secondary education completion rates. While TFR has declined and birth intervals have increased, age at first birth has remained largely unchanged (~18), and among adolescents birth intervals remains short <33 months.

    Knowledge of modern contraceptive methods is high in both men and women. Usage of modern contraceptives has steadily increased in the past decades from ~22% in 2000 to ~45% in 2016, and coverage of mCPR alongside met demand paint a positive story of progress despite challenges in Malawi.
DIRECT, HEALTH SECTOR
Improve maternal nutrition & access to quality maternal and newborn outcomes
  • With a CCI score of 77% and limited geographic variation in scored coverage, there are promising developments on this front.

    Access to care, driven by urban / rural splits and wealth remain stark and often static. There are initial indications that suggest quality coverage has lagged for non-mortality related outcomes, reflected in improvements in MMR which are not mirrored in universal improvements in ANC access or birth outcomes.
Promote early & exclusive breastfeeding
  • Victora curve shows mixed results but flattening of curve in 0-6 month age group suggest improvements in breastfeeding could be at play in some of the improvements in stunting burden observed, but rates of exclusive breastfeeding have stagnated at 58%.

    DHS survey captures high rates of initiation within the first 24 hours (96%) with a median duration of exclusive feeding of 3.8 months.
Improve complementary feeding, including diet diversity & micronutrient supplementation/ fortification
  • Material improvements in the 6-23 month time period demonstrate potential improvements in dietary diversity, complementary feeding, and micronutrient status.

    Strong mandatory fortification programs in place, and high rates of Vit A. and IFA supplementation.

Our findings also demonstrated a shift in key risk factors to prioritize. Previous nutrition-sensitive investments focused on reducing poverty and improving household living conditions, but these priorities have been overtaken by high-risk factors related to maternal health and women’s empowerment. Because over half of the risk factors identified for stunting are drivers related to maternal health and women’s empowerment, maternal health care is a high priority for investment.
 
 

HOW DO WE SEE THIS DRIVING TO IMPACT?

The comprehensive analytical approach that Exemplars delivered, allowed the outputs to include context and perspectives beyond a standard diagnostic approach.

The research conducted by Exemplars in Global Health to identify high-impact areas for investment to rapidly improve nutrition in Malawi directly informs JBJ Foundation funding decisions, made in partnership with the Malawi Department of Nutrition, HIV and AIDS. Our evidence-based guidance included context and perspectives from an extensive network of academics and other experts, which provided value beyond a standard set of descriptive analyses.

More broadly, this work has the potential to provide follow-up support, such as deeper analytical engagement or support through the Exemplars Community of Experts, directly to additional stakeholders in Malawi, such as the Ministry of Health and Population and other key ministries (e.g., finance, agriculture) with influence over broader factors affecting stunting rates.
 

Interested in learning more about nutrition and stunting?

Explore our platform to learn more about stunting, understand cross-cutting lessons from Exemplar countries working to reduce stunting, or read perspectives on nutrition from our partners.

Reach out to the Exemplars in Global Health team to learn more about the work described in this article or to discuss how we can support your work.

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