Final Evaluation Report Evaluation of Zambia’s First 1000 Most Critical Days Programme MAY 2018 Andrew Brudevold-Newman | Paula Dias | Hannah Ring Terry Roopnaraine | David Seidenfeld | Gelson Tembo MAKING RESEARCH RELEVANT AMERICAN INSTITUTES FOR RESEARCH | AIR.ORG Final Evaluation Report Evaluation of Zambia’s First 1000 Most Critical Days Programme MAY 2018 Andrew Brudevold-Newman | Paula Dias | Hannah Ring Terry Roopnaraine | David Seidenfeld | Gelson Tembo 1000 Thomas Jefferson Street NW Washington, DC 20007-3835 202.403.5000 www.air.org Copyright © 2018 American Institutes for Research. All rights reserved. Contents Page Executive Summary .........................................................................................................................1 Introduction ....................................................................................................................................18 Background and Theory of Change ...............................................................................................19 Study Design ..................................................................................................................................23 Deviations from Original Terms of Reference ..........................................................................24 Research Questions & Development Assistance Committee Criteria .......................................24 Stakeholder Consultation ...........................................................................................................25 Poverty & Malnutrition ..............................................................................................................25 Programme Implementation & Scale Up ...................................................................................27 Programme Impact .....................................................................................................................35 Endline Quantitative Data Collection & Analysis .....................................................................37 Endline Qualitative Data Collection & Analysis .......................................................................41 Findings..........................................................................................................................................42 Nutrition and Morbidity Effects ................................................................................................59 Heterogeneous effects ................................................................................................................60 Changes in outcomes in MCDP districts ...................................................................................61 Other Qualitative Findings .........................................................................................................63 Conclusion .....................................................................................................................................67 References ......................................................................................................................................70 Annex A: Heterogeneity Analysis .................................................................................................73 Annex B: Quantitative Endline Survey 2017.................................................................................78 Annex C: 1000 Days Endline Research: Beneficiary In-Depth-Interview Guide .......................118 Annex D: 1000 Days Qualitative Endline Research Coding Outline ..........................................126 Annex E: Terms of Reference_Zambia 1000 MCDP ..................................................................128 Annex F: List of Consultees ........................................................................................................145 Annex G: Rapid Qualitative Assessment Report .........................................................................146 Annex H: First Process Evaluation Report ..................................................................................230 Annex I: Rapid Follow Up Process Evaluation Report ...............................................................285 Tables Page Table 1. PI-Specific Challenges & Recommendations ..................................................................14 Table 2. Coordination, Communication, and Structural Challenges & Recommendations ..........17 Table 3. Endline sample summary statistics ..................................................................................39 Table 4. Effects on IFA, vitamin A, and deworming.....................................................................45 Table 5. Infant and young child feeding knowledge and practices ................................................47 Table 6. Receipt of agricultural inputs ...........................................................................................49 Table 7. Consumption of nutritious and diverse foods ..................................................................50 Table 8. WASH indicators .............................................................................................................55 Table 9. Nutrition outcomes ..........................................................................................................60 Table 10. Pre-post changes in outcomes in MCDP districts ..........................................................62 Table 11: Difference-in-differences estimates for children under 1 year of age ...........................74 Table 12: Difference-in-differences estimates for girls .................................................................75 Table 13: Difference-in-differences estimates in households where mothers completed primary school ...............................................................................................................................76 Figures Page Figure 1. Timeline of MCDP Evaluation Activities ........................................................................2 Figure 2. Research Questions ..........................................................................................................3 Figure 3: Estimated programme effects ...........................................................................................9 Figure 4: Core MCDP conceptual framework ...............................................................................10 Figure 5: Antenatal care is promoted at a local clinic ...................................................................20 Figure 6: Theory of Change for the MCDP ...................................................................................22 Figure 7: Evaluation Districts in Zambia .......................................................................................23 Figure 8. Village visited during the RQA in Nthope Ward, Chipata District ................................26 Figure 9. A rural health care facility in Chipata ............................................................................37 Figure 10. Exposure to MCDP trainings within the 24 MCDP endline communities (n=595) ...........................................................................................................................................40 Figure 11. Mothers in the evaluation districts were interviewed as part of the endline qualitative data collection ..............................................................................................................42 Figure 12. Food card exercise during endline qualitative data collection. ....................................52 Figure 13. Ideal meal for pregnant women: food card responses ..................................................53 Figure 14. Ideal meal for infants: food card responses ..................................................................53 Figure 15. Mothers shared their experiences with MCDP components during qualitative interviews .......................................................................................................................................57 Figure 16. Clinic in Chipata (Kova Ward) with an MCDP information board .............................63 Abbreviations and Acronyms AIR American Institutes for Research BCC Behaviour Change Communication CLTS Community-led Total Sanitation DAC Development Assistance Committee DFID Department for International Development DNCC District Nutritional Coordinating Committee FANSER Food & Nutrition Security, Enhanced Resilience project FES Focused Ethnographic Studies FGD Focus Group Discussion GIZ Deutsche Gesellschaft für Internationale Zusammenarbeit (German Agency for International Cooperation) GMP Growth Monitoring Promoters GRZ Government of the Republic of Zambia IDI In-depth interview IEC Information Education and Communication IFA Iron and folic acid IMAM Integrated Management of Acute Malnutrition IYCF Infant and Young Child Feeding KII Key informant interview MCD Ministry of Community Development and Social Welfare MCDP First 1000 Most Critical Days Programme MDES Minimum detectable effect size M&E Monitoring & Evaluation MLGH Ministry of Local Government and Housing MoA Ministry of Agriculture, Livestock and Fisheries MoE Ministry of Education MoGE Ministry of General Education MoH Ministry of Health MUAC Mid-upper arm circumference NFNC National Food and Nutrition Commission NGO Nongovernmental organization ODF Open Defecation Free PE Process Evaluation PI Priority Intervention RQA Rapid qualitative assessment SEA Standard enumeration