Changing behaviours for better health

Ending hunger extends beyond calories. It includes good health which requires a well-rounded diet with access to fruits and vegetables, proteins, cereals, and essential nutrients.  

Launched at the UN Food System Summit in 2021, the Zero Hunger Coalition works with stakeholders in countries to develop Evidence-based and Costed Roadmaps to assist in implementing their national food system transformation pathway. To date, such roadmaps have been developed for Ethiopia, Malawi and Nigeria with current ones underway for Madagascar, Tanzania, Bangladesh and Zambia. 

In its Roadmap for Madagascar, the Zero Hunger Coalition will provide recommendations for effectives policy interventions that address malnutrition, ensure heathier diets for over 40% of the population, increase the income of small-scale farmers and enhance environmental sustainability.    

As part of its research, the Coalition has conducted an inventory of donor-funded projects currently underway in Madagascar that target nutrition, sustainability and poverty. Among these projects, the Coalition examined the outcomes from the ProSAR Food and nutrition security, Enhance resilience to food crises co-financed by the German Federal Ministry for Economic Cooperation and Development (BMZ), the Bill and Melinda Gates Foundation and implemented by the Gesellschaft für Internationale Zusammenarbeit (GIZ) in partnership with the Ministry of Agriculture and Livestock in Madagascar. The project is part of BMZ’s One World Without Hunger initiative which seeks to tackle poverty and hunger in the southeastern part of the country. 

The Head of Project for ProSAR, Jessika Löser, provided an overview of the project undertaken in the remote region of Atsimo Atsinanana with the aim of reducing chronic malnutrition among infants and women of child-bearing age in 15,000 households. While it is a project that will last 6.5 years, results at the household level have already become apparent after two years of activities. For Jessika, the success of the multisectoral programme relied on behavioral changes towards food as well as the positive impact of the so-called agents of change. 

Dietary conditions in Madagascar 

According to the World Bank, Madagascar has the fourth highest rate of chronic malnutrition in the world. Approximately 47% of children under the age of five suffer from chronic malnutrition which can lead to stunting and other developmental issues that persist into adulthood. It is estimated that malnutrition costs the country between 7-12% of GDP each year. 

The lack of dietary diversity is one reason for malnutrition. Rice, which is very poor in nutrients, is eaten three times a day and often without any accompanying protein or vegetables. The 2021 INSTAT household survey on dietary consumption patterns in Madagascar showed that cereals and starches comprise 83% of daily calories. This makes Madagascar the African country with the highest total calorie intake from rice. 

As Jessika notes, “The people in Madagascar eat a lot of rice and, through the ProSAR project, we want to diversify their diets. However, doing so requires not only agricultural production but also a change in mindset.”  

Looking to local crops 

Madagascar is rich in produce with an abundant supply of fruits and vegetables. However, these foods are not widely consumed, and, at times, some fruits can be found rotting on the ground. 

While local knowledge exists on the use of these fruits and vegetables, these plants are not usually consumed unless it is a time of duress. According to Jessika, “Traditional plants are available, but we need to convince people to eat them. However, because they are associated with hard times and poverty, it is difficult to develop a market and scale up production. In addition, these traditional crops are sometimes looked down upon as they are perceived as ‘anti-progress’.” 

As part of the ProSAR project, efforts are made to encourage the consumption of locally produced vegetables such as carrots and cabbage, legumes like Bambara ground nut, as well as vitamin-A rich orange fleshed sweet potatoes, or igname, which is a type of yam. These crops proved to be well adapted to the local climate. While farmers agreed to grow these vegetables and crops, they often sold them in markets to increase their income and purchase rice rather than consuming these nutritious products. For this reason, the ProSAR project has focused on behavioral change. 

Agents of Change 

For Jessika, changes in eating habits require accompanying information about nutrition. For this reason, the ProSAR project focuses on training and influencing by groups of neighbors. By focusing on women, ProSAR developed a supportive radio listening group to complement the care group approach and directly influence the food in plates.  

Because of the huge distances between villages in rural areas, ProSAR needed to decentralize the availability of information. As such, it adopted a multi-stage ‘cascade’ model with village promoters and mother leaders. It focused on integrating short messages as part of the daily household chores with information on topics related to nutrition, hygiene, childcare, nutrition sensitive agriculture and financial literacy.  

The results of the project have been very positive. For example, the MDDW-W (minimum dietary diversity for women) has increased from 5.6% (baseline 2020) to 20.4% (follow-up survey in 2023) for beneficiaries while it decreased to 4.9% in the control group. The IDDS (individual dietary diversity score) increased from 2.7 (2020) to 3.4 (2023) for beneficiaries and remained consistent at 2.7 for the control group (2023).  

As Jessika concludes, “We noticed that the eating habits in the target groups have changed and are becoming increasingly diverse. We have not only scaled up and increased production of nutritious products, but we have also enabled a healthier diet.”