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This report presents the findings for the first stage of the 1000 Most Critical Days Programme process evaluation. The National Food and Nutrition Commission (NFNC), in coordination with several donors, including the Department for International Development (DFID, developed a bundled, multisector programme called The First 1000 Most Critical Days (MCDP) in order to address Zambia’s child undernutrition. CARE, in conjunction with the NFNC, coordinates the implementation and delivery of the programme through several ministries. American Institutes for Research (AIR) was contracted by DFID Zambia in 2014 to conduct a two-year evaluation of the MCDP. The evaluation includes three components: a rapid qualitative assessment, a process evaluation, and an impact evaluation. This report presents the findings from the first process evaluation study, with a focus on implementation experiences, including communication and coordination, monitoring and reporting, financial flows, and successes and challenges in implementing each of the MCDP priority intervention areas.
In both Chipata and Mbala, we found that higher (District, WNCC) levels of actors had a good conceptual understanding of the implications of the multisectoral paradigm and co-ordinated approaches to implementation. This understanding diminished, however, further down the programme chain. Furthermore, although some coordination in activity planning and implementation (chiefly in the area of sensitisation) was under way (particularly in Mbala), this was limited by the overall slowness of activity roll-out. In terms of planning and communication, we found challenges particularly along the vertical axis, in particular between the WNCCs and their respective DNCCs: In both districts, WNCC members felt that they did not have particularly good communication with their DNCCs and that their role had been limited to simply carrying out the orders of the DNCC. We heard calls for greater ownership and autonomy. Finally, moving up a level, we note that line ministry focal points on the DNCC in Chipata reported poor communications with CARE, in which repeated requests for funding carry-over went unanswered.
Respondents we spoke to at the central, district, and ward levels indicated that monitoring processes are not being consistently or systematically carried out. Although a new, harmonised monitoring and evaluation plan was recently created, it is not yet operational. Because a unified monitoring tool for the MCDP is lacking, programme implementers improvise to extract relevant data from their respective line ministries to monitor activities. Using existing ministry registries creates an additional burden for those responsible with the task of reporting. Although the programme targets and would therefore report only on children of ages 0–2, ministry registries focus on children 0–5 years old, meaning MCDP staff must spend time extracting only the children of ages 0–2 from the registries. Furthermore, confusion over which activities are SUN- funded and which would occur without the MCDP continues to be a challenge for reporting. The lack of clarity in which activities can be attributed to the programme raises reliability problems in what is reported.
Financial processes and the flow of funds pose perhaps the most significant obstacle to MCDP implementation. There appears to be a fundamental mistrust of accountability over finances between the central, district, and ward levels, causing significant challenges in communication and coordination of financial reporting and approval procedures. Delays in funding
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disbursements pose substantial problems to implementation of several intervention activities which are time-sensitive, reducing their effectiveness. In addition, when districts need to ‘carry over’ funding from one quarter to another, the procedures necessary to request this approval cause further delays on interventions. Inconsistent funding also causes programming gaps, leading many to forget earlier activities which they may have been a part of, ultimately preventing MCDP processes from being institutionalised by implementers.
Findings highlighted many successes and ongoing challenges experienced by implementers delivering the programme’s priority interventions. In Chipata, IFA, vitamin A, and deworming activities occur regularly, and respondents noted that they have sufficient tablets to distribute. Most respondents felt that SUN funds had not significantly added to existing IFA, Vitamin A, and deworming activities, though some explained that the MCDP has been successful in routinising the activities. MCDP activities in breastfeeding also have systematised a focus on appropriate breastfeeding practices. In Chipata, a separate breastfeeding mothers’ group has been established, and sensitisation occurs frequently with pregnant women to encourage and educate them on feeding. Respondents in Mbala reported a shift in dialogue about child feeding as a result of the MCDP. Some respondents we spoke with in Chipata described a training they had received on IYCF, explaining how valuable it was, but others within the same ward revealed they had not yet had an opportunity to attend this training, highlighting perhaps inconsistent targeting efforts for trainings. Resource challenges also were mentioned by ward-level MCDP implementers, who expressed a need for additional resources, particularly for cooking demonstrations and community training activities.
Respondents provided mixed opinions on the ways in which the MCDP has added to growth- monitoring activities. Though plans exist to train growth promoters and growth monitoring volunteers, trainings have not occurred in either district as a result of funding constraints. In addition, in Chipata, insufficient growth monitoring and IMAM inputs have been provided, causing problems with conducting adequate sensitisation to malnutrition and inhibiting growth- monitoring activities. At the same time, in Chipata, implementers emphasised that because of the MCDP, they sensitise a great deal more on stunting, and pregnant and breastfeeding women consequently understand the link between malnutrition and stunting.
A number of SUN activities in dietary diversity have been completed in Chipata and Mbala. Respondents mentioned several sensitisation activities which have been integrated into regular ministry functions, as well as cooking demonstrations in Mbala, both of which target farmers and women’s groups. Respondents in Chipata reported more challenges in carrying out activities because of a lack of funding, and the trainings which have been provided were reported as too superficial. In contrast, in Mbala, the district office has conducted training and multiple cooking demonstrations, and by conducting fewer and targeted trainings they managed to distribute agricultural inputs systematically.
We also found significant variations between the districts in WASH activities, likely because Mbala is already a pilot district for a Ministry of Education and UNICEF-funded community-led total sanitation intervention. In Chipata, this intervention area largely focused on chlorination of wells and orientation of pump menders, and in Mbala activities served to reinforce previous activities done under the UNICEF CLTS project. WASH activities require substantial coordination between multiple ministries and other NGOs conducting relevant activities.
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Although it is too early to assess the success of ministerial coordination, respondents indicated that the MCDP has not been in contact with other NGOs to ensure that efforts are appropriately targeted and not duplicated.
Although community sensitisation to MCDP priority intervention areas is ongoing, the rollout of formalised nutrition messaging is still limited. The IEC materials which respondents did mention had been developed centrally and were in English, and consequently not as effective as they could have been because the target recipients of these materials do not read English. Respondents expressed a clear need for tailored messaging appropriate to the localised traditions and customs which perpetuate poor IYCF practices.
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