AKSYON Kominotè Nan Sante Pou Ogmante Nitrisyon: Rapport Final

FINAL REPORT AKSYON KOMINOTÈ NAN SANTE POU OGMANTE NITRISYON January 2022 This document was produced for review by the United States Agency for International Development Haiti (USAID/Haiti) (DELETE THIS BLANK PAGE AFTER CREATING PDF. IT’S HERE TO MAKE FACING PAGES AND LEFT/RIGHT PAGE NUMBERS SEQUENCE CORRECTLY IN WORD. BE CAREFUL TO NOT DELETE THIS SECTION BREAK EITHER, UNTIL AFTER YOU HAVE GENERATED A FINAL PDF. IT WILL THROW OFF THE LEFT/RIGHT PAGE LAYOUT.) AKSYON FINAL REPORT AKSYON KOMINOTÈ NAN SANTE POU OGMANTE NITRISYON Contract/Agreement No. AID-521-A-16-00002 1AKSYON FINAL REPORT FONKOZE TABLE OF CONTENTS ACRONYMS 3 1.PROJECT OVERVIEW 6 1.1 CONTEXT 7 1.2 IMPACT 7 1.3 SUMMARY OF RESULTS 8 2. IMPLEMENTATION REPORT 11 2.1 COMPONENT 1.OPERATIONS TO SCREEN, TREAT AND REFER 11 2.2 COMPONENT 2. OPERATIONS TO PREVENT MALNUTRITION 19 2.3 IMPLEMENTATION CHALLENGES 26 3 . M&E 30 3.1 The ZABA experience 30 4. LESSONS LEARNED 31 4.1 PARTNERSHIP WITH THE MSPP 31 4.2 THE SFF PLATFORM 32 4.3 COMMUNITY MOBILIZATION 32 4.4 CARE AND TREATMENT 32 4.5 MALNUTRITION AS A MULTIDIMENSONAL ISSUE 33 5. FINANCIAL MANAGEMENT AND COMPLIANCE 34 6. CONCLUSION 35 ANNEXES 36 TABLES Table 1: AKSYON Impact results 7 Table 2: 2016-2021/Performance of the AKSYON project 9 Table 3. AKSYON performance vs SPHERE international program quality standard 10 Table 4. Sales of Nutrition sensitive products in communities served by AKSYON 26 FIGURES Fig.1: Percentage of U5 children suffering from acute malnutrition amongst children screened by AKSYON over the project period 11 Fig 2. Proportion of Moderate and Severe Acute Malnutrition by Sex August 2016 - September 2021 14 Fig 3: Proportion of children under 5 reached with AKSYON by age group August 2016-September 2021 15 Fig 4. Distribution of Malnourished CU5 by status at the end of project 16 Fig 5. Average savings in HTG by Center Chief 24 Fig 6. Percentage of CHEs with at risk portfolio 25 Fig 7. Evolution of expenses during the lifetime of AKSYON 34 MAPS Map 1: AKSYON's geographic scope 8 Map 2: Communes with the highest rates of malnutrition Y4 13 USAID.GOV AKSYON FINAL REPORT FONKOZE 2 ACRONYMS AGERCA -- Alliance pour la Gestion des Risques et la Continuité des Activités (Alliance for Risk Management and Business Continuity) AKSYON – AKSYON Kominotè Nan Sante pou Ogmante Nitrisyon (Community Nutrition to Increase Nutrition ANJE – Alimentation du Nourrisson et du Jeune Enfant (Infant and Young Child Nutrition) ASCP – Agent de Santé Communautaire Polyvalent (Versatile Community Health Worker) CHE – Community Health Entrepreneur CTN – Comité Technique de Nutrition (Technical Committee for Nutrition) DALY -- Disability-Adjusted Life-Year DQA – Data Quality Assessment DSO – Direction Sanitaire de l’Ouest (West Health Department) DSNO – Direction Sanitaire du Nord-Ouest (North-West Health Department) DSN – Direction sanitaire du Nord (Northern Health Department) DSNE – Direction Sanitaire du Nord-Est (North-East Health Department) DSA – Direction Sanitaire de l’Artibonite (Health Department of Artibonite) DSC – Direction sanitaire du Centre (Central Health Department) DSSE – Direction sanitaire du Sud-est (South-East Health Department) DSNi—Direction Sanitaire des Nippes (Nippes Health Department) DSS – Direction Sanitaire du Sud (South Health Department) DSGA – Direction Sanitaire de la Grande Anse (Health Department of Grande Anse) EMMP – Environmental Mitigation and Monitoring Plan GDP – Gross Domestic Product HE – Healthy Entrepreneurs HR – Human Resources ITECA – Institut de Technologie et d’Animation (Institute of Technology and Animation) 3AKSYON FINAL REPORT FONKOZE M&E – Monitoring and Evaluation MAG – Global Acute Malnutrition MAM – Moderate Acute Malnutrition MARNDR - Ministère de l’Agriculture, des Ressources Naturelles et du Développement Rural (Ministry of Agriculture, Natural Resources and Rural Development) ML – Manman Leaders - Mother Leaders MMIS – Malnutrition Management Information System MMS – Multiple Micronutrient Supplement MOU – Memorandum of Understanding MSPP – Ministère de la Santé Publique et de la Population (Ministry of Public Health and Population) MUAC – Mid-Upper Arm Circumference NR – Nonrespondents or nonresponsive to treatment NSP – Nutrition Security Program (Former USAID nutrition program) NUPAS - Non US-Organizations Pre-Award Survey PNS – Programme de Nutrition Supplémentaire (Supplemental Nutrition Program) PPI – Poverty Probability Index PTA – Programme Thérapeutique Ambulatoire (Outpatient Therapeutic Program) RUTF – Ready to Use Therapeutic Food SAM – Severe Acute Malnutrition SFF – Sèvis Finansye Fonkoze (Fonkoze Financial Services) SSQH – Services de Santé de Qualité pour Haïti (Quality Health Services for Haiti) Tx -- Treatment UCPNANu – Unité de Coordination du Programme National d’Alimentation et Nutrition (National Food and Nutrition Program Coordination Unit) UNICEF – United Nations Children’s Fund USAID.GOV AKSYON FINAL REPORT FONKOZE 4 USAID – United States Agency for International Development USG – United States Government USN – Unité de Stabilisation Nutritionnelle (Nutritional Stabilization Unit) WASH – Water, Sanitation, and Hygiene WHO – World Health Organization ZABA – Zouti Anrejistreman Benefisyè AKSYON (AKSYON Beneficiary Registration Tool) 5AKSYON FINAL REPORT FONKOZE PROJECT OVERVIEW AKSYON is a five-year program designed to decrease the number of women and children under the age of five who suffer from malnutrition in rural Haiti—reinforcing the sustainability of these gains through knowledge and skill building around nutrition, hygiene, sanitation, and food security strategies. AKSYON addresses malnutrition in rural Haiti through Fonkoze’s existing infrastructure, network, and health program. Fonkoze is the largest microfinance institution in Haiti. The 50,000 clients in its core lending program constitute a network of unprecedented scale in the country. At its heart are “Solidarity Groups” of up to five women. Twice a month, six to ten Solidarity Groups meet in “Credit Centers.” These meetings are led by an elected “Center Chief.” Critically, they serve as a reliable mechanism for education and outreach to the entire Fonkoze client network. Information is transmitted from Fonkoze’s head office in Port-au-Prince through its 45 branch offices to its 2000 credit centers, and vice versa. Solidarity group Fonkoze Foundation is leveraging this network to address the lack of reliable and affordable health products and services in rural Haiti. Boutik Sante (Community Health Store) is an innovative, potentially self-sustaining social franchising initiative. Fonkoze Foundation’s staff, including registered nurses, provide monthly trainings to representatives from each Center, many of whom are Center Chiefs, who become “Community Health Entrepreneurs” (CHEs). Registered nurses train CHEs to administer basic health screenings, deliver monthly community health education sessions during Center meetings, and explain product specifications to their clients. CHEs purchase over-the-counter health products from Fonkoze to sell in their microenterprises, establishing a Boutik Sante. AKSYON enabled Fonkoze Foundation, through its Boutik Sante Program, to deepen its malnutrition interventions. CHEs, with support from registered nurses, conduct community screening campaigns to identify cases of Severe Acute Malnutrition (SAM) and Moderate Acute Malnutrition (MAM). Each case receives appropriate care, referral, and/or follow-up, as dictated by Ministry of Health protocol. These activities were reinforced by community health and nutrition education and improving livelihoods opportunities for families affected by food and nutritional insecurity through sustainable home gardening, livestock rearing, and access to financial services. By 2021, it was planned for AKSYON to reach full-scale, with 1,800 entrepreneurs serving over two million Haitians. One of the key aspects of the Boutik Sante social enterprise is that, after initial start-up costs, it will be fully sustainable and perpetuated by the market. Upon attaining sustainability, the program will no longer need to rely on additional donor investment. Researchers from the Arnhold Institute for Global Health at the Icahn School of Medicine at Mount Sinai monitored the program’s roll-out to assess sustainability and impacts on health outcomes. The program goal was to decrease the number of women and children under age 5 who suffer from malnutrition, as measured by the following indicators: USAID.GOV AKSYON FINAL REPORT FONKOZE 6 This project lasted 5 years with a 4 month no-cost extension (August 24, 2016-December 23, 2021) and was financed fully by USAID for a total amount of USD$14,415,762.00. It was implemented in partnership with the Haitian Ministry of Health (MSPP), Sèvis Finansye FONKOZE (SFF), The Icahn School of Medicine at Mount Sinai, Di Magi Inc., Healthy Entrepreneurs, Institut de Technologie et d’Animation (ITECA), and in complementarity with Vitamin Angels (VA) and UNICEF programing. CONTEXT The AKSYON project took place during a difficult time in Haiti, during which all social and economic indicators, as well as safety and security were continuously deteriorating. In addition, the country was the scene of big destruction due to natural disasters including hurricane Matthew in 2016, hurricane Laura in 2018, various drought and flooding events, and a major earthquake in the south of the country in 2021. During this time, the proportion of households experiencing food insecurity went from 33 to 47% with a percentage of 6 to 14% households in need of emergency humanitarian assistance based on the Haiti Integrated Food Security Phase Classification analysis (IPC). In this context, we also had to face the COVID pandemic and were forced to change our established and well working processes to strategies that limited our reach but were essential to protect our staff and clients. IMPACT To document the impact of the project, our partners at the Arnhold Institute worked with local company Socio-Dig to conduct a baseline and an endline survey in regions that were considered “treatment” and regions that were a “control” group. The intervention in the latter group started during the last year of the project. The samples for baseline and endline counted respectively1174 and 1011 interviews. These surveys show that the five-year intensive efforts completed by a highly motivated team through the AKSYON project contributed to the final goal as follow: Table 1:AKSYON Impact results Indicator Chronic malnutrition rate – children aged 7 to 59 months 2016 40% 2021 19% Différence - 50% Acute malnutrition rate – children aged 7 to 59 months 24% 37% + 50% Years of life saved 11,500 7AKSYON FINAL REPORT FONKOZE The surveys show that the stunting rate has decreased by more than 50%, while the wasting rate is very high and goes beyond the alert threshold. This is very surprising, as none of the other nutrition surveys that were made during the last 2 years in the country corroborate these numbers. The sampling and survey methodology were sound, as was the quality control process used by the company, so we can only explain these differences by a sample that is too small to be representative. In addition, the survey results allowed us to compare malnutrition rates in localities where there are active CHEs and in localities that are not covered directly by the project. This comparison shows that the increase in acute malnutrition over the past 5 years is significantly higher (+13 percentage points) in areas where there were no CHE’s and where we estimate that children were not reached directly by the project. This allows us to formulate the hypothesis that households have a better resilience to shocks where the project has been active. 11,500 YEARS OF LIFE SAVED Regarding the number of years of lives of children under 5 saved, this data is the result of the standard “List” measure supported by the World Health Organization (WHO). This measurement tool calculates the number of lives saved by a completed malnutrition treatment and with the regular use of lifesaving products like antibacterial soaps to wash hands, water purifiers, Oral Rehydration Salt, and Vitamin A. SUMMARY OF RESULTS From August 2016 to December 2021, the AKSYON project implemented interventions against malnutrition at the national level, beginning with 18 regional offices where the FONKOZE foundation health program was already active and extending to 38 regional offices, covering the whole national territory through its 10 geographic departments, 143 of its 145 communes, 502 communal sections and more than 8,000 localities. The map shows in gray the areas where the Map 1: AKSYON's geographic scope USAID.GOV AKSYON FINAL REPORT FONKOZE 8 project conducted screening campaigns over the 5 years while the dots indicate the locations of CHEs. With this level of expansion, the AKSYON project was able to reach 529,207 children under 5, 49,774 pregnant women, and 36,506 community members to reinforce their capacity to fight against malnutrition and improve their nutritional habits. The main intervention for children under 5 consisted of CHEs performing screening for malnutrition with a MUAC during large gatherings they organized in their community. Micronutrients were also distributed to community members during these gatherings. Pregnant and nursing women were also screened for malnutrition during the same gatherings and received micronutrients. Lastly, CHEs shared nutrition and health information with the general population. CHEs learned this information during the monthly training sessions on nutrition and nutrition sensitive topics they received from the AKSYON nurses and shared it with their credit groups and local associations. As shown in the table below, the AKSYON team’s performance in achieving its targets is excellent; they never let their motivation decrease and stayed true to their commitment. Table 2: 2016-2021/Performance of the AKSYON project Target population Children less than 5 years old Target 482,820 Result 529,207 Performance 110% Children between 6 and 24 months old 181,448 176,066 97% Pregnant women 73,250 49,774 68% General population trained 30,000 36,506 121% The only target that has not been met is in regard to pregnant women, where we encountered less pregnant women than estimated based on the 2013 census. In addition, the latest DHS survey shows a net decrease in the fertility rate through the last years, and it is possible that the population estimations need to be reviewed at a lower rate. With this large number of persons reached through our screening interventions, we identified 11,862 children under 5 and 936 pregnant and nursing women who suffered from acute malnutrition. They were all referred to a treatment center from the national network to receive their treatment and monitored to guarantee that they complete the treatment. 9AKSYON FINAL REPORT FONKOZE For children under 5 treated for malnutrition, we present the program numbers below, and compare them to the international SPHERE indicator to assess our performance with children who utilized the treatment program. Table 3. AKSYON performance vs SPHERE* international program quality standard INDICATOR SPHERE ALARM THRESHOLD AKSYON PERFORMANCE Cure rate >75% 95% Death <3% 1.83% Drop out <15% 3.45% Relapse <5% 1.87% *The SPHERE indicators for the performance of nutrition programs uses the total of children who began treatment as their denominator The minimum sphere standards help humanitarian workers globally assess the quality of humanitarian aid. In the scope of nutrition programs, it establishes indicators to inform if programs perform at the level to which every person is rightfully entitled to. The AKSYON project shows a high performance in relation to the SPHERE standards with a very high cure rate and low levels of death, drop out, and relapse. 95% CURE RATE To complete our performance evaluation, our senior M and E consultant conducted an evaluation of the efficiency of the program, following WHO standards. She analyzed the costs of the program that are linked to the identification, referral, treatment and follow-up care of malnourished children and found that the program spent USD 114.75 per treated malnourished child under 5 years of age and USD 221.32 per avoided DALY. These results show that the AKSYON project was very efficient because the cost per avoided DALY is much lower than the GDP per capita that was at USD 1,176.76 in 2020. USD 114.75 per child fully treated USD 221.32 per year of life improved The study concluded of a very good performance compared to the WHO standards with a low mortality rate, a high number of DALY averted and a good level of cost-effectiveness when comparing the cost per DALY averted against the country GDP per capita. USAID.GOV AKSYON FINAL REPORT FONKOZE 10 IMPLEMENTATION REPORT The project was implemented through two components: the first component “to screen, refer and treat malnourished children” benefited individuals who lived with malnutrition. The goal was to identify them and ensure that they find proper treatment. The second component “to improve knowledge, skills and support to prevent malnutrition” targeted the support network (community health resources and general population) that is considered an important part of the prevention model when they improve their knowledge, share information, and adopt healthier habits. COMPONENT 1: OPERATIONS TO SCREEN, REFER AND TREAT MALNOURISHED CHILDREN Over the 5 years of AKSYON implementation, CHEs screened 529,207 children under 5 for malnutrition, of which we found 11,862 (2.24%) suffering from malnutrition. Of these children, 9,126 (1.72%) were moderately malnourished (MAM) and 2,736 (0.52%) were severely malnourished (SAM). All malnutrition cases were immediately referred to a health institution to receive proper care (see list of care and treatment health institutions in annex). Year after year, the rate of malnutrition decreased, except for year 4 during the emergence of the COVID-19 pandemic. While malnutrition numbers increased significantly during PY4 (2020), the numbers decreased again in PY5 (2021). Fig.1: Percentage of U5 children suffering from acute malnutrition amongst children screened by AKSYON over the project period 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 PY1 PY2 PY3 PY4 PY5 Malnutrition rate 11AKSYON FINAL REPORT FONKOZE If we rely on our monitoring records, we can safely say that in areas covered by AKSYON the malnutrition rate went from 4% in year 1 to 2 % in year 5, decreasing by 50%. MALNUTRITION RATE FOUND IN LOCALITIES COVERED BY AKSYON Year 1 Year 5 4.08% 2.14% During mass screening sessions, CHEs distributed a 6-month supply of multivitamins to 850 children under 5 during year 1 through our partnership with Vitamin Angels. In year 2, Vitamin Angels stopped providing the multivitamins, but continued to provide other micronutrients. Over the life of the AKSYON project, we provided 411,616 doses of albendazole and 421,124 doses of vitamin A to children under 5. In addition, 45,515 children under 2 years old received a 1-month supply of micronutrient powder received as a subvention from UNICEF. Evidence shows that Vitamin A supplementation prevents childhood blindness and increases survival rates by 27%, adding albendazole ensures the optimal absorption of nutrients. Micronutrient powders have been proven to reduce the rate of anemia that is very high in Haiti (the most recently DHS survey found a rate of 66% for children under 5). The distribution of micronutrients complements other aspects of AKSYON dedicated to identifying and treating malnourished children. Training, screening and malnutrition referrals were the primary activities anticipated in AKSYON’s original project concept. However, in working in Haiti’s rural areas, it became clear that many children would not be able to complete treatment even if they were screened and referred to the nearest treatment facility. The reality is that the most vulnerable populations live in very isolated areas and therefore often have to walk hours to reach a clinic. The minimum treatment required for a malnourished child involves three months of weekly clinic visits. This is an impossible commitment for isolated families who cannot afford transport costs and/or the loss of a workday. As a result, these children are often left to die or to develop a chronic condition that will hinder their physical and cognitive development. USAID.GOV AKSYON FINAL REPORT FONKOZE 12 To address this issue, the team worked with the MSPP to establish mobile treatment teams who meet sick children closer to their homes on a regular basis. This allows children to receive their entire treatment, as well as additional support from the project. During mobile treatment sessions, malnourished children are monitored (height and weight), their caregiver is counseled about nutrition and hygiene, and they receive a two-week supply of RUTF and additional goods such as ORS, AK-1000 (enriched flour), moringa powder, antibacterial soap, and water purification tablets. During the life of the project, the team held 202 days of mobile clinics, treating 784 children in 3 locations: the mountains of Fond-Verettes, Arcahaie, and Ganthier. Mobile Clinic In Roche Blanche MAPPING OF MALNUTRITION OVER THE LIFE OF THE PROJECT High malnutrition rates (over 5%) were found consistently in various communes during the 5 years of the project, even after rates decreased by several percentage points. The departments where malnutrition is a continuous issue are the North West, the North East, the Grande Anse and the West departments. High numbers have been found in the South and the South East, but not as consistently. During year 4, the height of COVID and the security crisis, the communes that found themselves more vulnerable to the crisis are illustrated in the map in red. Map 2: Communes with the highest rates of malnutrition Y4 13AKSYON FINAL REPORT FONKOZE MALNUTRITION BY SEX Since the beginning of the program, the rate of malnutrition in girls (2.44%) has systematically been found higher than in boys (2%). As a result, the total number of girls found with malnutrition is significantly higher than the number of boys, as summarized in the following figure: Fig 2. Proportion of Moderate and Severe Acute Malnutrition by Sex August 2016 - September 2021 GIRLS BOYS 1.89% 1.53% 0.47% MAM SAM 0.55% The data suggests that girls are consistently at higher risk than boys of developing malnutrition. The social impact team at FONKOZE implemented a qualitative study to find out if the food intake for girls was different than the boy’s food intake. Various focus groups were organized in the localities where we found the biggest differences between the two groups. After talking with parents (mothers and fathers), there was no evidence of any sexual difference in the way the children under 5 were fed. In conclusion, while we can see a difference in numbers, it is not statistically significant and there is no evidence that illustrates a difference between boy´s and girl’s feeding habits. Considering how gender norms and disparities can impact the education and future lives of girls and boys in these communities, as well as the vulnerability of their households, the AKSYON team developed a targeted gender initiative to introduce gender training into our community work, hoping that gender sensitivity will favorably influence disparities and increase resilience. USAID.GOV AKSYON FINAL REPORT FONKOZE 14 MALNUTRITION BY AGE The figure below illustrates the malnutrition vulnerability of children 6-23 months old. Even though children under 2 years old constitute only 33% of the total of children screened, they represent more than 75% of the MAM and SAM cases. This tendency had been observed year after year during the implementation of the project. Its root causes lie in weaning methods that are not always adequate and often leave children with high levels of nutrient deficiencies in quality and quantity. The AKSYON project promotes exclusive breastfeeding and offers special education on weaning strategies in communities and during home visits to vulnerable households. Mothers are coached to prepare meals that are adjusted to the children’s weaning needs. We are confident that this new knowledge will help protect their children in the future. Fig 3: Proportion of children under 5 reached with AKSYON by age group August 2016-September 2021 73% 77% 81% 33% 27% 19% CU5 SCREENED MAM SAM 6-23 months 24-59 months In addition, the project had the opportunity to host an intern who developed a recipe book for children in the weaning period. This book has been shared with mothers of malnourished children during coaching visits. FOLLOW-UP OF MALNOURISHED CHILDREN Our principles in FONKOZE demand that we always follow-up with the people we serve until they receive the full benefit of our services. While we make all possible efforts for consistent follow-up, sometimes it is difficult to stay connected as we should. During the 5 years of the project, the team identified 11,862 malnourished children under 5 and was able to follow up on 11,050 (93%) of the 15AKSYON FINAL REPORT FONKOZE sick children. 84%1 of the identified malnourished children benefited from full treatment; however, 4% did not respond and needed additional medical treatment to get better. In order to guarantee consistent follow-up, the community staff and volunteers have performed 37,355 home visits in compliance with the AKSYON follow-up protocol: each child found malnourished receives one visit immediately after the screening session and three monthly visits after treatment in which they receive nutrition and hygiene counseling as well as a support kit with livelihood products. 93% of identified malnourished children benefited from 37,355 home visits to guarantee the completion and success of the treatment protocol The distribution of all children identified during the screening campaigns is showed below: Fig 4. Distribution of Malnourished CU5 by status at the end of project Cured 84% Deceased 2% Drop out 3% Lost to follow up 7% Non responsive 4% We have been able to decrease the number of deaths and children lost to follow-up over the years, nevertheless we aim for zero deaths and 100% recovery, and we need to increase our efforts to achieve that goal. There is still lot of work to do in promoting parental compliance of treatment and understanding the severity, causes, and cures of malnutrition since. One of the main causes of noncompliance, dropout, and death is linked to parental beliefs around the supernatural origin of the sickness and/or to a lack of confidence in the medical system. Other causes include moving to another community and the effort, time, and loss of business opportunities it requires to take their child to the health center when they live very far away. 1 Note that these percentage numbers are based on our total number of children found with malnutrition while the SPHERE indicator reported in the impact section is based on the children who attended treatment. In our case, 11,862 children were found malnourished and 11.050 (93%) attended treatment. USAID.GOV AKSYON FINAL REPORT FONKOZE 16 Complications such as general edema, and the comorbidity of abdominal or respiratory infections were the leading cause of death for children under treatment. During the last couple of years, some dropouts were because of the COVID crisis where some health facilities were short staffed and/or did not have RUTF in stock. PREGNANT AND NURSING WOMEN Pregnant and nursing women have also been a focus group during AKSYON. During the project period, the project reached out to 49,774 pregnant and 35,787 nursing women who were screened for malnutrition in the intervention areas. In these groups, respectively 610 (1.22%) and 317 (0.88%) women were malnourished. They received nutrition counseling as well as prenatal vitamins, and they were referred to health centers with prenatal programs. The prenatal vitamins we distribute are a gift from Vitamin Angels. Providing supplemental nutrition in the form of a daily multiple micronutrient supplement (MMS) is an excellent way to meet the increased nutrient demands during pregnancy. Prenatal MMS help support healthy pregnancies, prevent anemia, promote fetal growth, and ensure that babies are born at a healthy birth weight. While women under 19 years old constitute almost 10% of the total number of pregnant and nursing women we screened, they represent 16% of the malnutrition cases in the group. These findings show the importance of reproductive health education for young girls, their families, and their communities to create awareness on the additional risks women face with early pregnancy and maternity. These findings reveal the necessity to begin family planning education early and to increase efforts to provide access to modern methods of contraception in isolated rural communities, especially for youth. Our team found that many health centers were not prepared to manage cases of malnourished pregnant women. Uncomfortable with the ethics of this reality, the AKSYON team decided to offer support through regular home visits and a support kit with hygiene and nutrition products. This strategy has proven successful with a recuperation rate of 64% as presented in the story below. 17AKSYON FINAL REPORT FONKOZE Taking aksyon (action) against malnutrition in Haiti Part of Fonkoze’s founding philosophy is that by supporting a woman, we’re also extending support to her entire household—enabling us to interrupt the intergenerational cycle of poverty in Haiti. When we launched the USAID AKSYON Program to combat malnutrition in Haiti, we knew that—in addition to focusing on malnourished children under 5 years old—we would also focus on malnourished pregnant and lactating mothers. Early on, we were shocked to learn that these mothers do not receive any special care in Haiti, despite malnutrition’s threat to their lives and the lives of their babies. In Haiti, 49% of women suffer from anemia and 11% are underweight (EMMUS VI). Pregnancy typically exacerbates these conditions, putting the lives of the mother and fetus at risk. Malnutrition is one of the contributing factors to Haiti’s high maternal mortality rate. As the AKSYON team began identifying malnourished pregnant and lactating mothers, one key strategy was to refer them to clinics for free prenatal care that is offered throughout Haiti. However, we were astonished to find that these prenatal care services did not provide any treatment or strategies specific to malnourished mothers; they receive the same care as all other mothers. Eager to address this situation, the AKSYON team drew on the Ministère de la Santé Publique et de la Population (MSPP or Ministry of Health) recommended strategy to use the same AK-1000 that is used for treating children with moderate malnutrition. AKSYON was already using this enriched flour to complement the diet of children Athalie Jean-François, an AKSYON Community Health Entrepreneur near Senrafayèl, explains how to use the AK-1000 enriched flour. who have recovered from malnutrition. The team decided to test AK-1000 as a recovery solution for malnourished pregnant and lactating women. During the fourth year of AKSYON, we identified 140 malnourished mothers through our screening campaigns. As part of our monthly follow-up home visits, we began providing each mother with two pounds of AK-1000 as well as water purifiers, antibacterial soap, oral rehydration solution and vegetable seeds. AKSYON’s Community Health Entrepreneurs coached mothers on strategies for improving their nutrition by using local products to improve their personal, family and household hygiene, for establishing a vegetable garden, and for increasing their self-esteem and self-care. Of the mothers with whom we worked during the first testing year, 64% recovered completely and of these, 80% had “normal” measurements related to nutrition (using mid-upper arm circumference or MUAC) within three months. Pregnant women were attending prenatal visits regularly and gave birth to healthy babies. Nursing mothers continued exclusive breastfeeding practices, whereas we know that without the program’s support, many would have ceased breastfeeding. With such strong results, we are looking for opportunities to advocate for similar support to be systematically offered to malnourished mothers in Haiti, particularly through their prenatal visits. Not only will this increase compliance with prenatal and exclusive breastfeeding guidelines, but it will also ensure that more mothers and babies experience healthy pregnancies, births, and breastfeeding practices. At Fonkoze, we know that a mother’s health is essential to enabling a strong start for her baby and we are proud to be taking innovative steps to achieve this. USAID.GOV AKSYON FINAL REPORT FONKOZE 18 This is an initiative that we would really like to analyze deeper to prove its value as a recuperation strategy for malnourished women. Screening, counseling and home visits are primarily implemented by trained CHEs, who are also Fonkoze clients. In addition, CHEs also work with existing community health resources including “Manman lidè” and ASCPs. This strategy has enabled the program to facilitate connections with other community health resources that were already trained and willing to support the fight against malnutrition in their communities. Because these resources will continue to exist beyond the timeline of the project, we will continue implementing this partnership, which contributes in part to the total project performance. COMPONENT 2: OPERATIONS TO IMPROVE KNOWLEDGE, SKILLS AND SUPPORT TO PREVENT UNDERNUTRITION AKSYON’s livelihood strategies were designed to support dietary diversity, food security and sustained positive behavior change. They were executed with several partners. NUTRITION-SENSITIVE TRAINING During the course of the project, by employing a cascading training-of-trainers strategy, 36,506 community members—primarily women—were trained on nutrition and nutrition-sensitive topics. Among the persons trained, the majority are women and members of FONKOZE. In total, 406 are members of community organizations, 383 are community members who had already been identified by former projects and were integrated in AKSYON, and 79 were ASCPs who were not attached to any project at the moment of our interventions. The program also supported the MSPP by training 82 of their staff members to reinforce staff competencies in the care and treatment of malnourished children at the health center level. Part of the training includes home gardening skills where the participants—again, mostly women—are taught to take care of a home garden where they grow nutritious produce to enrich their family’s diet. This training is unique because it involves practical lessons, through demonstrations, on growing produce. The outcomes of growing produce can be seen during follow-up visits. In total, we trained 835 CHEs in home gardening and they are using their new skills to improve their own gardens, their diet, and increasing revenue by selling compost and/or biological insecticides. AKSYON-THE LIVELIHOOD EXPERIENCE The original concept of AKSYON was designed to work in partnership with another Haitian organization committed to sustainable development. We chose to work with ITECA, an experienced organization, to test a community livelihood model based on solidarity and engagement. Below are the results of this pilot: 19AKSYON FINAL REPORT FONKOZE ITECA partnership JADEN LAVI Institut de Technologie et d’Animation (ITECA) is a Haitian organization with extensive experience providing production support to vulnerable individuals in rural areas. The participatory model was tested in the South department (Cavaillon and Les Anglais) over two years, in partnership with local authorities and grassroots community organizations. This model included support to establish and improve home gardens as well as support egg production to be used as a source of animal protein. The objective of this experiment was to find a livelihoods support model that would be replicable, scalable, and sustainable after the initial investment. In a context where the MSPP is actively promoting its concept of “Public Health Agriculture,” the Jaden Lavi model seemed like a good strategy to contribute to reducing malnutrition, by preventing it through livelihood support. Jaden Lavi included the following components: Agriculture: Implementing adapted techniques for water management, soil enrichment, and organic pest control. Income: Targeting household dietary diversity and supplementing household income. Nutrition: Promoting healthful culinary practices and nutritious dietary diversity. Over two years this pilot accomplished the following: ACTIVITY Improved home gardens RESULTS 187 Vegetable species produced 8 Individuals consuming the garden vegetables 1206 Chicken coops (holding 300 chickens) 24 Individuals consuming eggs from the units 2925 P2. A beneficiary takes care of the chickens USAID.GOV AKSYON FINAL REPORT FONKOZE 20 The activities were implemented after the following training sessions: TOPIC Vegetable production # participants 268 Soil fertility 247 Water management 100 Agribusiness management 268 Egg production 142 Environment and ecology 147 P3. Compost preparation during soil fertility training Several challenges were identified during this pilot and recommendations were made to mitigate some of them: -The lack of public policy for rural agricultural production puts all these initiatives at risk. With the drastic drop in the purchasing power due to the economic crisis and extended periods of drought, access to water, seeds and specific food for chickens becomes difficult. -The solidarity model for the chicken unit must be built on trusting relationships between co-managers. If not, it is challenging to overcome any initial difficulties and move forward in a collaborative partnership. -A single production cycle of eggs (18 months) does not yield strong profit relative to the initial investment in time and money. As such, owners looking for short-term gains tend to disengage before reinvesting in a second cycle that would have the potential for a lucrative return on investment. -In addition to increasing the availability of nutritious food in the community, there is a need to promote the consumption of nutritious foods before their commercialization, or it will not increase the nutritional status in rural areas. Conclusion: Unfortunately, because of the high cost of the intervention in relation to the number of households reached, AKSYON decided not to pursue this partnership for replication and scaling. It is not affordable at the project level and there is no evidence that it could become financially sustainable over time. However, home gardens and egg production are complementary interventions that could have a positive impact on the food and nutritional security of vulnerable populations if relative opportunities are offered. 21AKSYON FINAL REPORT FONKOZE VEGETABLE PRODUCTION TRAINING BY FONKOZE After this experience, the team did not want to abandon all livelihood activities at once and we decided to introduce only the training part on vegetal production to see if this alone would have a positive effect on family nutrition. With a specialist in agronomy in our team, we chose to test this second hypothesis in 10 of our regional branches with CHEs to see if the training portion could help reach our objective of improving the quality of the family diet and improving family revenues. In this second phase, 214 CHEs were trained during 2 sessions of 2 days where they covered, in theory and practice, the following topics: - Vegetable production - Preparation of natural insecticides - Preparation of biological compost - Environment and ecology - Management of a micro agro enterprise RESULTS Among the CHEs who were part of the pilot, 90% installed a vegetable garden at home, but only 54% were able to maintain and reproduce the garden. In the home gardens that succeeded, 61% of the families used the products for their own consumption only, increasing the quality of their diet like it was intended by the project. In addition, 26% consumed the vegetables and had enough production to sell the vegetables or the seedlings and increase their revenues. These additional revenues were used in this priority: to pay school fees, family clothing, credit, additional stock, and to increase savings. 13% of the new home gardeners shared their surplus production with their community. Seedlings to be transplanted in Trou du Nord USAID.GOV AKSYON FINAL REPORT FONKOZE 22 When preparing their home gardens, 29% of CHEs used their own biological compost, 15% prepared their own pesticides, and some even commercialized the compost and pesticides to further increase their revenues. Compost preparation in Thiotte These results show that with only a minimal investment in training (USD 33 per CHE), there can be positive impacts on the livelihoods and quality of diets for families in rural communities. This strategy should continue but will require some adjustments to maximize the results. Both the CHEs and our expert recommend the following: - Some additional coaching for their gardens - Required access to a bigger variety of seeds - Improved access to water containers for those who are far from a water source This experience is valuable, and this project should be continued in FONKOZE’s programming, and be included in other projects when possible, because of the positive effects on the health and resiliency of rural families. 23AKSYON FINAL REPORT FONKOZE SÈVIS FINANSYE FONKOZE PARTNERSHIP Sèvis Finansye Fonkoze (SFF), our financial inclusion partner, integrated a total of 35,177 new microcredit clients during the life of the project in the 38 branches where AKSYON took place. Access to financial services for these vulnerable families will lower the risk of being victimized when exposed to natural shocks as well as shocks caused by humans, as we have faced over the last five years. An analysis of SFF clients who were instrumental to the success of the project reveals a higher rate of success when supported by the project. We compared the trends of two key financial indicators between the regular Center Chiefs in SFF and the Center Chiefs who enrolled as CHEs in the AKSYON program. The CHEs received continuous training and were committed to supporting their respective communities in getting children and women screened for malnutrition, educated on nutrition, and ensuring care and treatment for sick children. Average savings is an important indicator that shows how families, and in this case the Center Chiefs, prepare for unplanned events that could jeopardize their life goals, prepare for their life development, and the development of their families. Between 2019 and 2021, we can see how despite numerous challenges, CHEs kept and increased their savings while the regular Center Chiefs had difficulties doing so. Fig 5. Average savings in HTG by Center Chief 12000 10000 8000 6000 4000 2000 0 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21 Apr-21 May-21 Jun-21 Jul-21 Aug-21 Sep-21 CHE Other Center chiefs USAID.GOV AKSYON FINAL REPORT FONKOZE 24 PAR or Portfolio At Risk shows the capacity of an SFF client to reimburse their loan. It is the proportion of the portfolio among the designated group that is at risk of not being repaid. There again, we can compare the evolution of the indicator between the CHEs and other Center Chiefs to conclude that the CHEs have developed a better capacity and commitment to repay their loan. Fig 6. Percentage of CHEs with at risk portfolio 7 6 5 4 3 2 1 0 CHE Other Center Chiefs The team truly believes that when a client participates and commits to the CHE program, it brings value to them, their family, their community, and the institution itself. 25AKSYON FINAL REPORT FONKOZE ACCESS TO NUTRITION-SENSITIVE PRODUCTS Through Boutik Sante, CHEs expand access to nutrition sensitive products for more than three million people living in communal sections where at least one CHE operated. Combined with information and education provided by CHEs, these products are important for families to avoid conditions that are linked to and/or are direct causes of malnutrition. Table 4. Sales of Nutrition sensitive products in communities served by AKSYON Nutrition-sensitive products FY1 FY2 FY3 FY4 FY5 TOTAL Antibacterial soap 60,259 55,714 27,412 14,4087 309,967 597,439 Condoms 4,734 4,385 8,948 36,553 51,722 106,342 Diapers 441,525 875,532 731,652 5,694,661 12,185,302 19,928,672 Hand sanitizer 1,241 0 0 13,948 1,037 16,226 Iodized salt 42,171 91,070 93,742 211,274 270,455 708,712 Laundry soap 62,815 38,074 54,854 125,934 160,498 442,175 SATO 85 39 88 89 0 301 Sel lavi (ORS) 5,812 6,720 11,964 16,904 23,812 65,212 Water purifiers 4,996 3,089 3,736 18,035 22,487 52,343 SOURCE: Boutik Sante sales report October 2016 - September 2021 The population consistently utilized Boutik Sante services, even with the current decrease in purchasing power and unstable prices throughout the last couple of years. Clients were grateful to have access to Boutik Sante during the periods of insecurity when most of the other products were not reaching rural areas. All of the products significantly improve the lives of the population and the ones featured in the above table (ORS, water purifiers) save lives. The full list of products is available in the annex of this report. IMPLEMENTATION CHALLENGES CARE AND TREATMENT The most important and persistent challenge faced by the program was the lack of standardization of the national care and treatment network in quality and in localization. Each department and each referral center is different, has different needs, and has a different perspective toward new or complementary providers. The team did a great job in addressing each of them appropriately and in a way that motivates all entities to work together. USAID.GOV AKSYON FINAL REPORT FONKOZE 26 The most challenging treatment issue was the logistical difficulties at the departmental MSPP level, where it takes time to plan and submit requisitions to UNICEF even though UNICEF is well-supplied. These bureaucratic delays lead to not having an inventory of essential supplies required for the care and treatment of malnourished children at the health center level. RUTF is particularly hard to acquire. The team supported the local facilities in the logistics chain by supporting local MSPP representatives with transport, communications, and the requisition process. In addition, AKSYON ensured that all children referred received adequate care and treatment, including temporarily providing supplies directly, as needed. In addition to the lack of RUTF, the care and treatment network for malnourished children does not reach the whole population, especially children that are more vulnerable and isolated. Even when AKSYON identifies these children and refers them to the nearest facility, they often abandon treatment because of the distance and time it takes to access proper care. AKSYON has responded with two activities: 1) We supported the MSPP to train health center staff, so that the centers can offer adequate services to the malnourished children. 2) We conducted mobile PTAs based on the MSPP model to bring services closer to the population in need. The following factors are a direct result of the lack of essential products being available that increase risk of death due to malnutrition: 1) Failure to respond to treatment 2) Abandoning treatment, which leads to chronic malnutrition 3) Stretching out the treatment schedule, which also increases the cost of recovery Having access to essential products is key to successfully treating malnourished children. Toward the end of the project, the high level of insecurity on the roads made this challenge even more difficult to address. Another challenge encountered by the program is the level of commitment and trust by the parents. We have found some parents are too young to face their responsibilities. Some parents have a set of taboos and beliefs regarding their child’s sickness; they did not think that the proposed treatment would work. Other parents have too many responsibilities at home to be able and take time for only one child among too many. The list goes on. For these parents, we tried to intensify the education content of the home visits, hoping to educate them through one-on-one conversations, to give their child a chance of getting better. This te