How WFP Supported the Mozambican

Government to Improve the National

Nutrition Rehabilitation Programme
A Case Study on Demand Generation for the
Treatment of Acute Malnutrition

January 2019
Contents

Overview ............................................................................................................. 5

Key Success Factors............................................................................................. 5

Quick Facts ......................................................................................................... 5

Country Context.................................................................................................. 6

Programme Overview ......................................................................................... 6

Getting to Success: How WFP supported the Mozambican Government to

Improve the National Nutrition Rehabilitation Programme ............................... 8

Formative research to determine the approach to demand generation ................................... 9

The involvement of community health workers in demand generation activities ………………10

Development of pamphlets to support screening and referral tailored to the context ……...11

Coordination with multi-sectoral partners and stakeholders, including government…..…….13

Interactive community radio engaging various programme stakeholders………………………….13

Challenges ....................................................................................................... 14

Summary ......................................................................................................... 14

Tables............................................................................................................... 15

Table 1: Key success factors for demand generation for acute malnutrition
treatment and recommendations for applying them in other programmatic
settings ................................................................................................................................. 15

Table 2: Challenges that surfaced during implementation of the demand

generation component of the acute malnutrition programme in Mozambique,
and possible solutions for future programming .......................................................... 16

Notes ............................................................................................................... 16

Acknowledgements ........................................................................................ 16
Introduction

In 2014, the WFP Policy, Programme, and Innovation Division initiated a project to support
Regional Bureaux and Country Offices in knowledge sharing through the documentation of a
series of technical case studies in nutrition programming. This effort was made in response to
numerous requests from across the organization for examples of how WFP is implementing
nutrition-specific and nutrition-sensitive programmes. These case studies focus on key success
factors and lessons learned, as well as challenges and potential solutions, from experiences in
each of these countries. The project also developed a template and guidance for writing
technical case studies in order to facilitate further documentation in other contexts.
The first phase of the project highlighted flour fortification in Egypt, local production of
specialized nutritious food in Pakistan, nutrition-sensitive interventions in Ecuador and the
Dominican Republic, and scaling-up nutrition interventions in Niger and Malawi. In 2017, the
Nutrition Division prioritized expanding the existing series of case studies to include examples
from Bangladesh, Cameroon, El Salvador, Rwanda and the Kyrgyz Republic. The goal in sharing
these case studies with internal and external stakeholders is to highlight important
achievements of WFP Country Offices and leverage these experiences to support nutrition
programming globally.
This initiative was made possible through the generous financial contributions of the Children’s
Investment Fund Foundation (CIFF) and Royal DSM. This case study was produced with the
financial support of the European Union. Its contents are the sole responsibility of WFP and do
not necessarily reflect the views of the European Union.
Overview
In 2017, WFP launched a programme focused on generating
demand for and increasing uptake of acute malnutrition
treatment among children under five years (CU5) and
pregnant and lactating women (PLW). This programme was
embedded within a lean season response designed to bolster
the government-led national Nutrition Rehabilitation Program
(PRN1). Formative research informed the programme design,
which emphasizes the role of community health workers
(CHWs) in demand generation and leverages community radio
to increase knowledge and awareness around acute
malnutrition and the availability of treatment. With support
from government and non-government partners, the
programme has been successfully rolled out in three
provinces – Cabo Delgado, Nampula and Zambézia – and has
produced valuable lessons that can inform the future scale-up
of demand generation efforts for acute malnutrition in
Mozambique and similar country contexts.
Key Success Factors
• Formative research to determine the approach to
demand generation
• The involvement of community health workers in
demand generation activities
• Development of pamphlets to support screening and
referral tailored to the context
• Coordination with multi-sectoral partners and
stakeholders, including government
• Interactive community radio engaging various
programme stakeholders
January 2019| National Nutrition Rehabilitation Programme in Mozambique
Quick Facts
• Among children under 5 years of age, 6% are acutely
malnourished, 15% are underweight, and 43% are
chronically malnourished.
• Anaemia affects 55% of women of reproductive age
and 70% of children under 5.
• 2.1 million people are HIV-positive; HIV prevalence is
15% among women of reproductive age.
• Within the rural population, 64% lack access to clean
water and 90% do not use improved sanitation.
In Nampula, interactive community radio has been used to
raise awareness of the signs and symptoms of moderate
acute malnutrition, and to encourage community members
to seek treatment. Messages heard on the radio are trusted
by community members, who listen to programmes in their
homes or with neighbours. Community health workers,
who support demand generation activities for acute
malnutrition treatment, participate in live radio
programmes. In addition to sharing their knowledge and
experience, CHWs also note that speaking on the radio is an
opportunity for personal and professional development;
they are proud for their friends and neighbours to hear
them speaking confidently about nutrition.
5
Country Context
Mozambique is a low-income country with a largely rural
population. The country is consistently challenged by food
deficits and ranks very low in global indices of development,
hunger and inequality. Several persistent obstacles prevent
the country from making significant progress on Sustainable
Development Goal 2 targets, including high rates of
malnutrition, economic and physical access to food,
insufficient national safety nets, and vulnerability to cyclical
climate shock which exacerbates food insecurity. Sixty
percent of the population lives in coastal areas affected by
rapid-onset disasters including regular droughts and floods.
Seventy percent of Mozambicans depend on subsistence
agriculture. Smallholder farmers, the majority of whom are
women, have limited access to credit. Rural markets are not
well integrated, and post-harvest losses are high. All of these
factors contribute to a tenuous food security situation which
negatively impacts the nutrition of vulnerable groups. The
national stunting rate for CU5 is 43 percent, which is classified
as ‘very high’ by global standards2; simultaneously, six
percent of children in this age group are wasted. Anaemia
rates are also high among women of reproductive age and
CU5 – 55 percent and 70 percent, respectively.
Programme Overview
Since 2010, WFP has supported the Ministry of Health (MoH)
in Mozambique to implement the PRN. Each year, provinces
and districts are selected based on national nutrition
assessments. WFP provides support for PRN activities to the
provinces and districts that have high prevalence of acute
malnutrition, based on data from nutrition and food security
analyses as well as available resources. Pregnant and
lactating women with signs of moderate acute malnutrition
(MAM) enrolled in the programme receive Super Cereal, and
CU5 with signs of MAM receive a ready-to-use supplementary
food (RUSF), both of which are made available by WFP and
partners in the district health centers (HCs).
In 2017, with support from the UK Department for
International Development (DFID), WFP worked with the MoH,
the Provincial Health Directorates (DPS), and the District
Services of Health, Women and Social Affairs (SDSMAS) to
design a lean season response to bolster the PRN during
times of heightened food and nutrition insecurity. In 2017,
the goal was to reach 44,000 CU5 and 19,000 PLW suffering
from MAM during the lean season. By April, the response was
set up in six provinces: Cabo Delgado, Nampula, Zambézia,
Tete, Gaza, and Sofala. Implementation in 2017 concluded in
October having reached 53,676 children and 54,083 PLW in
six months. In 2018, the lean season response was reinitiated
in March in four provinces: Cabo Delgado, Zambézia, Tete,
and Manica.
As part of this lean season response, WFP and partners
designed and implemented a demand generation
programme component to increase awareness and uptake of
acute malnutrition rehabilitation services among PLW and
CU5. The overall goal of the demand generation effort,
funded by the European Union (EU) and DFID, is to improve
coverage by increasing admission and retention of the
admitted cases in acute malnutrition treatment programmes.
Formative research conducted in 2017 informed the
development of a two-pronged approach focusing on: 1) the
involvement of community health workers (CHWs) in
screening, referral, follow-up and sensitization activities for
acute malnutrition, and; 2) the use of radio to increase
sharing of knowledge and success stories related to the
treatment of acute malnutrition.
The demand generation component is being implemented in
three of the seven provinces where WFP supported the PRN
in 2017 and 2018. Demand generation activities were rolled
out in Zambézia and Cabo Delgado in 2017, and in Nampula
in 2018 (Figure 1). In all three provinces, WFP works with
partners to support CHWs in demand generation activities at
the community level. In both Zambézia and Nampula, the
demand generation component involves community radio; in
Zambézia, the district radio broadcasts pre-recorded
messages, while in Nampula, interactive community radio is a
key component of demand generation.
Box 1. HIV and acute malnutrition in Nampula
province
In 2017, Mozambique had 130,000 adults and children newly
infected with HIV and 70,000 adult and child deaths due to
AIDS. There were 2.1 million people living with HIV, among
whom 1.2 million were accessing antiretroviral
therapy. Mozambique adopted the UNAIDS Fast-Track targets
and a phased roll-out of “test and start” in 2016 and plans to
extend antiretroviral therapy coverage to 81% of adults and
67% of children living with HIV by 2020.
Adequate dietary intake and absorption are essential for
achieving the full benefits of anti-retroviral therapy, and
evidence shows that people living with HIV who are
malnourished when they start antiretroviral therapy are two
to six times more likely to die in the first six months of
treatment than those who have a normal body mass
index3. In 2018, WFP conducted demand generation activities
in Nampula to increase uptake of PRN services for pregnant
and lactating women with HIV under the USAID PEPFAR
initiative with a dual purpose of nutrition rehabilitation and
increasing adherence to ART to support the achievement of
Mozambique’s Fast-Track targets.
6
Figure 1: Demand Generation within the National Nutrition Rehabilitation Programme in Mozambique, 2017-2018
Getting to Success:
How WFP supported the
Mozambican
Government to Improve
the National Nutrition
Rehabilitation
Programme

8
Formative research to determine the
approach to demand generation
Formative research is recommended in many contexts in
order to gather information needed to design and implement
programmes that are tailored to a specific target audience. In
Mozambique, WFP worked with the MoH and DPS to conduct
rapid formative research in 2017 to better understand how to
promote health-seeking behaviour, focusing on PLW and CU5
with acute malnutrition.
The formative research, carried out in 2017 over a period of
two weeks in Zambézia and Cabo Delgado, focused on five
key areas of enquiry: 1) perceptions around health of PLW
and CU5; 2) barriers and facilitators related to health care for
the two groups; 3) networks of trust and influence; 4) social
dynamics and communication channels, and; 5) community
mobilization as a key element of demand generation.
The research helped to clarify the factors affecting uptake of
nutrition services, and allowed programme implementers to
choose the most appropriate communication channels for
this context. The key results (Boxes 2 and 3) enabled
development of a set of recommendations to inform
programme design, leading to a two-pronged approach
focused on CHWs and community radio as key
communication channels.
Box 2. Involving fathers in community sensitization
A key finding of the formative research was that husbands
and fathers are the most influential individuals in the family.
An effort has therefore been made to involve men in commu-
nity sensitization activities to increase their knowledge of
acute malnutrition and motivate them to support their wives
and children to seek treatment.
January 2019| National Nutrition Rehabilitation Programme in Mozambique
Box 3. Key results of formative research
Barriers
• Lack of knowledge of nutrition and symptoms of poor
nutrition. Community members do not generally
regard low weight as an indicator of severity, unless
accompanied by other signs.
• Fear of adopting a new practice and/or consuming an
unfamiliar food product.
Motivational factors
• Desire for well-being of the family.
• Observing the benefits of a new practice (e.g. through
a neighbour or friend).
Networks of influence and communication channels
• The most influential figures in the family are the
husband and mother-in-law.
• At the community level, leaders and CHWs are trusted
for their advice.
• Community radio is widely accessed by most people,
either in their own home or with neighbours, and is
regarded as a trustworthy source of information.
Lessons learned from formative research to determine the
approach for demand generation
• It is crucial to understand context-specific barriers,
motivational factors and preferred communication
channels before initiating a programme.
• Dedicating time and resources to formative research
contributes to a well-designed, targeted approach to
achieving nutrition results.
9
The involvement of community health
workers in demand generation activities
In Mozambique, community health workers (CHWs) are
essential to the success of many development programmes
which are funded, designed and implemented by national and
international organizations and institutions. CHWs may work
on a variety of agriculture, health and nutrition-related
programmes, through which they receive training, supervision
and often small incentives for the time and efforts they
dedicate to the programme.
The demand generation component of the lean season
response was designed specifically to increase the number of
malnourished individuals voluntarily going to HCs for
treatment of acute malnutrition. This was achieved by
identifying CHWs and training them to engage in screening
and referral of PLWs and CU5 with acute malnutrition. CHWs
are identified among community leaders, health promoters,
teachers, traditional healers, midwives, care group mothers,
health committee members and APEs4.
Typically in Mozambique, acute malnutrition screening is
conducted by health professionals at the HCs, who measure
the MUAC5 of PLW and CU5 who have arrived at the HC for
other health needs (i.e. passive case finding). The approach of
the demand generation effort was to train and support CHWs
to conduct screening within communities, and to mobilize
those who need treatment to go to the HCs (i.e. active case
finding).
CHWs identified to support demand generation receive a two-
day training focused on acute malnutrition and the principles
of community mobilization for treatment (Box 4), facilitated
partners. CHWs also conduct sensitization activities to
increase awareness of the signs and symptoms of acute
malnutrition, and understanding of when a visit to the HC is
needed. These activities are tracked using forms which WFP
provides to the CHWs.
“Sometimes we find groups already gathered,
perhaps playing music or card games, so I take
the opportunity to conduct an activity with the
group. This approach is good, but sometimes
individual is better in case you need to convince
someone.” – CHW, Nampula
“We also do weekly meetings, to bring people
together. Mothers, children, fathers – they all
come. Sometimes we go to the school to share
messages. The students can also tell us where
there are sick children.” – CHW, Zambézia
CHWs are also responsible for follow-up, which involves a
simple investigation into the reasons why some beneficiaries
discontinue treatment (i.e. default). CHWs counsel defaulters
on the consequences of acute malnutrition and benefits of
completed treatment, and support them to resume
treatment. This activity is carried out in close collaboration
with HC staff who provide the CHWs with a list of defaulters to
enable active follow-up.
Lessons learned from the involvement of community health
workers in demand generation activities
• Empowering CHWs with the knowledge and skills
needed to engage in screening, referral, follow-up of
acute malnutrition cases and sensitization activities is
an effective way to improve health-seeking behaviour.

by WFP’s implementing partners. CHWs are given a working
kit including MUAC tapes, pamphlets (Figures 2 and 3), and
referral cards for women and children who require treatment
at the HCs.
• Training for CHWs should focus on both technical and
interpersonal communication skills, which are equally
important to generate demand for treatment.

After training, CHWs begin screening and referring individuals

suffering from acute malnutrition to HCs, receiving periodic
support and supervision visits from WFP’s implementing

Box 4. Training for CHWs focuses on:

• The signs and consequences of acute malnutrition

• Screening, referral and follow-up for PLW and CU5
with acute malnutrition, including training on use of
MUAC tapes
• Interpersonal communication techniques to support
sensitization activities
• Strategies for communicating with influential
community members about the existence of treatment
programmes
• Persuasion and influencing skills to convince
defaulters to return to the programme
• Reporting on activities using designated forms

10
Development of pamphlets to support
screening and referral tailored to the
context
Due to low levels of literacy among the CHWs, it was
necessary to develop simple materials to support their work
in screening PLW and CU5 for acute malnutrition and
referring them as needed to HCs.
WFP designed two separate pamphlets for acute malnutrition
screening and referral of CU5 and PLW using MUAC (Figures 2
and 3) which were approved by MoH for use by CHWs. The
pamphlets were made of durable, high-quality material to
avoid damage and wear-and-tear that may occur in the field.
Interviews with CHWs have shown the value of these
pamphlets as a tool to support memory of how to screen for
acute malnutrition and when to refer a PLW and/or CU5 for
treatment. CHWs also reported that the pamphlets help
mothers to understand the importance of acute malnutrition
treatment.
“I use the pamphlets and they are easy to use,
they help.” – CHW, Nampula
Staff at SDSMAS, who are responsible for training the CHWs,
have also reported that the pamphlets are essential for CHWs
to successfully conduct community screening.
January 2019| National Nutrition Rehabilitation Programme in Mozambique
“The pamphlets are practical and the CHWs
understand them. Without the pamphlets, we
would have needed five days of training.”
– SDSMAS, Nampula
Further, as SDSMAS staff members are not always
nutritionists by training, they may not have experience
measuring MUAC prior to the demand generation
programme. The pamphlets therefore help to reinforce the
technical support that SDSMAS provides to CHWs.
“I feel confident because, for example, I’m not a
nutritionist by training, so I didn’t have the
knowledge to do the screening. I needed support
to learn. The pamphlets help, they facilitate the
activity for the person doing the screening. I used
them a lot and now have them memorized.” –
SDSMAS, Nampula
Lessons learned from the development of pamphlets to
support screening and referral tailored to the context
• When designing programme materials, it is essential to
consider the local context, and in particular the
education levels of the individuals who will use the
materials.
• Simple but effective materials support the work of
WFP’s implementing partners as well as the CHWs who
are directly responsible for programme activities.
11
Figure 2. Pamphlet for Acute Malnutrition Screening and Referral of Children Under Five

Figure 3. Pamphlet for Acute Malnutrition Screening and Referral of Pregnant and Lactating Women

12
Coordination with multi-sectoral partners
and stakeholders, including government
The demand generation component has been implemented
in multiple districts across three provinces and throughout
multiple funding cycles (Figure 1). WFP has therefore worked
with a wide variety of government and non-government
partners with complementary skills to increase demand for
acute malnutrition services. In some cases, the same partners
have supported implementation of the overall lean season
response as well (e.g. World Vision in Zambézia in 2017), while
in other cases the partner’s activities are focused primarily on
demand generation.
In 2017 and 2018, WFP provided the initial training and
resources to build capacity for implementing partners to lead
the programme activities. In turn, partners were responsible
for training and supervision of CHWs. Partners further
support communication and coordination between the HCs
and the CHWs to ensure that the process of screening,
referral, treatment and follow-up of beneficiaries proceeds as
smoothly as possible. The role of staff at the HC is critical;
they are responsible for intake and diagnosis of beneficiaries
referred for acute malnutrition services, as well as
communicating with the CHWs to enable targeted follow-up if
a beneficiary discontinues treatment.
From formative research to implementation, the participation
of government partners has been critical for programme
success (Figure 4). At the national level, MoH provides
guidance to ensure the harmonization of activities and
messages, approves the material to be used by the CHWs,
and conducts meetings with the partners on a regular basis.
At the provincial level, DPS ensures the coordination of
activities to avoid interruptions in the supply of
supplementary foods at the HCs. At the district level, SDSMAS
is responsible for programme coordination, training CHWs to
screen and refer beneficiaries at the community level, and
providing periodic supervision. WFP field monitors work
closely with SDSMAS to support these activities, and also
ensure strong communication and coordination between
CHWs and health facilities.
Figure 4. Situating Demand Generation within Government
Structures
January 2019| National Nutrition Rehabilitation Programme in Mozambique
To guide implementation of demand generation activities,
WFP developed an operational plan template which SDSMAS
uses to map the needs and associated costs for each district
(e.g. for CHW trainings, working kits, and supervision visits).
The operational plans include a timeline for implementation
of activities as well as details on roles and responsibilities.
Regular meetings involving the various partners are held to
improve communication and coordination, and ensure that
programme activities are implemented according to plan.
These include an opening and closing seminar in each
province, and mid-programme meetings to discuss successes
and challenges encountered during the implementation of
demand generation activities. In Nampula, weekly meetings
occur at the district level between SDSMAS and staff of the
community radio to discuss progress and plan future
activities.
Lessons learned from coordination with multi-sectoral
partners and stakeholders, including government
• Involving national, provincial and district-level
government partners in all stages of the programme
increases buy-in and uptake.
• The complementary expertise of multi-sector partners
strengthens programme delivery.
• Coordinating activities and timelines with multiple
partners is complex but necessary to ensure efficient
and effective nutrition programmes.
Interactive community radio engaging
various programme stakeholders
Formative research revealed that radio is a key channel for
communication in many Mozambican communities.
Participants in the study reported that both provincial and
community radio are listened to every day at multiple times
(e.g. in the morning before going to the field; in the evening
around dinner time) and that messages heard on the radio
are trustworthy. Community members who do not own a
radio may join their neighbours to listen, expanding the reach
of programmes and radio spots. It was thus determined that
radio could be a successful channel for spreading knowledge
13
around acute malnutrition and increasing demand for
treatment.
In 2017, WFP developed the content for three radio spots
related to acute malnutrition which was approved by DPS in
the six provinces where WFP was supporting the PRN to be
used on provincial radio channels. In 2018, it was decided to
take a more targeted approach, working with community
radio stations to develop tailored messages and interactive
programmes. A community radio-based approach to sharing
information is also aligned with the findings of the formative
research, which showed that community radio is more
frequently listened to than provincial radio among the target
groups.
In Nampula, WFP works with IREX, a non-profit organization
with expertise in the use of creative media to spread
knowledge and enable informed decision-making. IREX
provides technical support and capacity strengthening to
seven community radio partners involved in the demand
generation effort in Nampula province. Their contributions
include direct support in the field to ensure radio program
quality, trainings for community journalists, and seminars
involving key partners to understand progress and challenges
to implementation.
Across the six districts in Nampula where demand generation
is taking place, community radio is used in various ways
(Box 5). CHWs are invited to come to the radio station to
participate in live discussions on acute malnutrition, with the
aim of increasing awareness at the community level of the
signs and consequences of acute malnutrition, and the
existence of services at the HCs. In addition to spreading
knowledge, these programmes have a great benefit for the
CHWs themselves, who have reported that the opportunity to
speak on the radio validates their work within the
communities, and gives them a sense of pride among their
friends and family.
In order to engage community members directly in the radio
programmes, the community radio staff travel outside of the
district center to visit the communities and record live
programmes. This dynamic approach brings the malnutrition
programme activities much closer to the beneficiaries, who
appreciate the opportunity to ask questions and share their
stories publically. Health center staff also participate in the
recording of radio programmes, and have acknowledged this
approach as not only an effective way of sharing information,
but also as an exercise that contributes to their own personal
and professional development.
Box 5. Ways radio is used to spread knowledge about
acute malnutrition
• Pre-recorded spots that can be used daily or weekly
• Live shows recorded at the community radio station,
featuring CHWs and HC staff
• Live shows recorded in the community, featuring
programme beneficiaries
Lessons learned from interactive community radio engaging
various programme stakeholders
• Provincial and community radio programmes can be
an effective way to spread nutrition information,
validate the work of CHWs, and foster trust among
communities.
• Engaging multiple stakeholders (e.g. CHWs, SDSMAS
staff, HC staff and beneficiaries) in interactive radio
programmes increases community ownership and
Challenges
Several key challenges have been identified during
implementation of the demand generation component of the
acute malnutrition programme. These challenges include the
difficulty of synchronizing the delivery of supplementary
foods and demand generation activities to ensure
programme quality, and the timely distribution of resources
to support all programme activities. Another challenge is that
CHWs who have low levels of education are not always
confident in their abilities to conduct screening and monitor
the programme using the designated forms. Possible
solutions to these and other challenges are presented below
in Table 2.
Summary
In Mozambique, WFP worked with the Government at all
levels to design and implement a demand generation
programme component to increase uptake of acute
malnutrition services among PLW and CU5 within a lean
season response in conjunction with the national PRN. The
approach, based on formative research, focused on the
involvement of community health workers (CHWs) in
screening, referral, follow-up and sensitization activities for
acute malnutrition, and the use of interactive community
radio to spread knowledge of acute malnutrition and increase
awareness of available treatment.
In 2018, over 2,100 CHWs have been trained in the skills
needed to screen for acute malnutrition and generate
demand for treatment among community members. These
CHWs have conducted over 9,000 sensitization activities and
screened over 16,000 individuals, more than 2,000 of whom
have been referred for acute malnutrition treatment. Nearly
500 radio activities have taken place, and commitment to
continue engaging in radio at the community and district level
is clear.
Based on the results of this successful programme, the
Government of Mozambique has shown strong support for
continuing demand generation for the treatment of acute
malnutrition. The lessons learned in this initial phase can
inform the future scale-up of efforts in Mozambique and
other countries where acute malnutrition is a persistent
challenge.
14
 Table 1: Key success factors for demand generation for acute malnutrition treatment and recommendations for
applying them in other programmatic settings
ACTIVITIES RECOMMENDATIONS
LESSONS LEARNED
Used by WFP to increase demand for For applying success factors or lessons
From programme implementation
acute malnutrition treatment learned
Success Factor: Formative research to determine the approach to demand generation

• WFP worked with provincial government
and partners to conduct formative
research in two provinces of
Mozambique to inform the design of a
new programme to increase demand
for and uptake of acute malnutrition
treatment.
• It is crucial to understand context-
specific barriers, motivational factors
and preferred communication channels
before initiating a programme.
• Dedicating time and resources to
formative research contributes to a well-
designed, targeted approach to
achieving nutrition results.
• Invest the needed resources (human
and financial) to conduct formative
research before rolling out a new
programme. This will help ensure
uptake of the approach and increase
the likelihood of achieving the desired
impact.
• Involve the target groups of the
programme as well as the stakeholders
during the formative research stage to
ensure a more effective approach.

Success Factor: The involvement of community health workers in demand generation activities

• WFP‘s partners provided training and
support to CHWs to enable them to
engage in demand generation activities
for acute malnutrition at the community
level.
• Empowering CHWs with the knowledge • In remote areas and where acute
and skills needed to engage in malnutrition is persistent, consider
screening, referral, follow-up of acute leveraging the existing CHW structure to
malnutrition cases and sensitization increase demand for and uptake of
activities is an effective way to improve acute malnutrition treatment.
health-seeking behaviour.
• Training for CHWs should focus on both
technical and interpersonal
communication skills, which are equally
important to generate demand for
treatment.

Success Factor: Development of pamphlets to support screening and referral tailored to the context

• Due to low literacy rates among the
CHWs, WFP designed simple pamphlets
for acute malnutrition screening and
referral, which were approved by the
Government before use.
• When designing programme materials,
it is essential to consider the local
context, and in particular the education
levels of the individuals who will use the
materials.
• Simple but effective materials support
the work of WFP’s implementing
partners as well as the CHWs who are
directly responsible for programme
activities.
• Develop effective communication
materials based on formative research
results which are tailored to literacy
rates, use illustrations to communicate
key messages, and represent the local
context using photos depicting the
involvement of community members.
• After the communication materials have
been used, seek feedback from
audiences and implementing partners
to understand if the materials are
effective and if any improvements can
be made.

Success Factor: Coordination with multi-sectoral partners and stakeholders, including government

• WFP engaged with the government at all
stages of the programme, from design
to implementation, and also worked
with non-government organizations
with complementary strengths to
ensure the programme could be
delivered successfully.
• WFP helped to organize and lead
regular meetings between partners to
improve communication and
coordination.
• Involving national, provincial and district
-level government partners in all stages
of the programme increases buy-in and
uptake.
• The complementary expertise of multi-
sector partners strengthens programme
delivery.
• Coordinating activities and timelines
with multiple partners is complex but
necessary to ensure efficient and
effective nutrition programmes.
• Work with the government at all levels
(national, provincial and district) to
make sure the programme is aligned
with national guidance and local
priorities and needs.
• Engage non-government partners with
complementary strengths who can add
value to the programme.
• Hold regular meetings to make sure that
the programme is running smoothly
and agree on any needed adjustments.

Success factor: Interactive community radio engaging various programme stakeholders

• Based on the findings of the formative
research, WFP identified radio as an
effective communication channel for the
demand generation effort.
• WFP worked with IREX to provide
technical support and capacity
strengthening to the community radio
partners.
• Provincial and community radio
programmes can be an effective way to
spread nutrition information, validate
the work of CHWs, and foster trust
among communities.
• Engaging multiple stakeholders (e.g.
CHWs, SDSMAS staff, HC staff, and
beneficiaries) in interactive radio
programmes increases community
ownership and uptake of the
intervention.
• Conduct needs assessment of the
community radios to understand what
support is needed to allow them to
deliver on programme objectives.
• Identify partners with the skills and
expertise required to strengthen
existing community radio programmes.
• Involve beneficiaries, CHWs, and HC
staff in dynamic and engaging live radio
programmes to promote health-seeking
behaviour.

January 2019| National Nutrition Rehabilitation Programme in Mozambique 15

 Table 2: Challenges that surfaced during implementation of the demand generation component of the acute
malnutrition programme in Mozambique, and possible solutions for future programming

Challenges Possible Solution(s)

Resources and processes in place to support activities according to schedule
• In some cases, resources and processes were not in place to
support timely delivery of all programme activities. For instance,
there were delays in beginning implementation in 2018; as a
result, the timeline was significantly shortened, reducing the
chance of impact. There were also delays in the distribution of
incentives (bars of soap) and working kits for CHWs, and in
financial resources needed for training and community radio.
Such delays can lead to misaligning of programme activities
implemented by partners, a lack of motivation to complete the
required work, and lowered trust in the organizations managing
the programme.
• Take steps to guarantee that the preparation phase provides a
solid start to programme implementation in terms of
coordination mechanisms, harmonization and synchronisation
of activities.
• Plan all programme activities and associated procurement
needs well in advance to minimize the chance of interruption to
the flow of the programme, and to maximize the chance for
achieving the desired outcomes and impact.

Synchronizing delivery of supplementary foods with demand generation

• Demand is often unpredictable, and varies across provinces and
seasons. It has thus been a challenge to synchronize the supply
of supplementary foods with increasing demand to ensure that
there is sufficient food in place for MAM treatment, which can
result in lack of trust in the programme among stakeholders.
• In order to improve programme quality, and to build trust
among partners and beneficiaries, WFP and its government
counterparts must enhance coordination to ensure that the
supply of supplementary foods is consistent and sufficient to
respond to increased demand.

Ability and confidence of CHWs to carry out all activities

• Most CHWs have a very low level of education and many are
illiterate. It is thus often a challenge for them to monitor the
programme activities (in particular screening and referral
activities) using the forms provided by WFP.
• CHWs reported that the time for the training was not sufficient
and that training should focus more on community mobilization
skills and approaches to behaviour change.
Access to services by beneficiaries
• Refresher trainings are recommended to reinforce the
knowledge and strengthen capacity of CHWs, especially for
programme monitoring. Increasing supervision from
implementing partners can also help to ensure that CHWs can
successfully carry out all programme activities.
• Develop monitoring tools that are context-appropriate and
therefore more likely to deliver results. Use illustrations as
much as possible.

• Beneficiaries and CHWs have noted the great distances they • Making supplementary food available at community level is one
must travel to reach the HCs, and the long waiting times upon option, but requires careful planning to ensure that the
arrival, as a key challenge. appropriate structures, mechanisms, and local capacity are in
place.

Notes
1 PRN is the Portuguese acronym (Programa de Reabilitação Nutricional) and will be used throughout the case study.
2 De Onis, M., et al. (2019). Prevalence thresholds for wasting, overweight and stunting in children under 5 years. Public
Health Nutrition, 22(1), 175-179.
3 WHO, UNAIDS. 2011. Technical Guidance Note for Global Fund HIV Proposals: Food and Nutrition.
4 Agentes Polivalentes Elementares, or APEs, are affiliated with the MoH and may receive a small monthly payment. Health
committees are also affiliated with MoH, though the work of their members is voluntary.
5 Mid-upper arm circumference (MUAC) is used as a measure to understand if an individual is acutely malnourished. WFP
provides treatment to women, children and other vulnerable groups who are moderately acutely malnourished, using
the cut-offs of 115 < MUAC < 125 for children. There are currently no global standards for classifying acute malnutrition
among adults and adolescents using MUAC, though research is ongoing.

ACKNOWLEDGEMENTS
European Union
Ministry of Health of Mozambique
Provincial Health Directorate of Nampula
Provincial Health Directorate of Zambézia PHOTO CREDITS:
IREX Mozambique Cover photo, page 5 (box), page 5, 6, 9, 10, 11,
WFP Mozambique Country Office back cover: Chico Carneiro

16
For more information contact:
Nutrition Division
World Food Programme
Via Cesare Giulio Viola 68/70
00148 Rome, Italy

nutrition@wfp.org
wfp.org/nutrition