food aid quality review burkina faso effectiveness and

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Food Aid Quality Review

Burkina Faso Effectiveness and Cost-Effectiveness Study:

First Round of Results

January 31, 2018

Washington, D.C.

lgreen08

Preliminary Results

We need to “identify strategic opportunities to make global humanitarian assistance more effective and efficient, including prioritizing needs and reducing duplication and costs.”

Gregory C. Gottlieb, Acting Assistant Administrator,

Bureau For Democracy, Conflict and Humanitarian Assistance,

March 22, 2017 to Senate Committee on Foreign Relations

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Background: Improve Efficiency of Food Aid

Photo courtesy of USAID

FY2016 –Title II Food Aid

Ø ~$2 billion spent (emergency + non-emergency)

Ø 60,000 metric tons of nutrition value-added products

Ø 73,000 metric tons of vegetable oil

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Big Questions:

• Are we spending public money wisely when it comes to selecting and delivering nutritionally enhanced products?

• Are we programming products optimally for desired outcomes?

• What roles do non-food factors play in driving outcomes?

• Can we manage wasting by preventing stunting (or visa versa)?

• Are stunting and wasting episodes related in ways that food aid can address?

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Institutional Roles and Research Project Responsibilities.

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USAID

Title II Funds Donor

Tufts UniversityStudy Management

Data management and analysis

IRSSData Collection and Entry:

Field surveys and focus groupsAnthro data collected at FDPs

ACDI/VOCA

Ensure Commodity Reception/Treatment in Ouaga

Save the Children

Ensure delivery to caregivers & BCC programming

ViM Program

Food procurement and storageFood distribution at FDPs

ProgramActivitiesStudyActivities

• Introduction

–Background and overview of study design

• Results

–Effectiveness

–Cost-effectiveness

–Factors potentially influencing effectiveness

• Discussion

–What have we learned?

–What questions remain?

– Implications

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Today’s Presentation

Overview of study design

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lgreen08

Preliminary Results

Aims of the Burkina Faso Field Study

Evaluate the comparative effectiveness and cost-effectiveness of 4 food aid products in preventing stunting and wasting in children 6-24 months of age in Burkina Faso, and describe potential influencing factors.

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Study Arms:CSB+ with oil

CSWB with oil, SC+RUSF

Effectiveness: Prevention of Stunting and

Wasting

Controlling for Potential Confounders:Household & Community level characteristics

Factors Potentially Influencing

Effectiveness:Utilization of study food

Cost-Effectiveness: Cost of stunting

and wasting averted compared to CSB+ with oil

Study Design | Conceptual framework & Objectives

Study Food Contents

CSB Plus + Oil* (CSB+)

Cornmeal, whole soybeans, vitamin/mineral premix

Corn Soy Whey Blend + Oil* (CSWB)

Cornmeal, soy flour, whey protein concentrate, vitamin/mineral premix

Super Cereal Plus (SC+)

Corn, dehulled soybeans, dried skim milk powder, vitamin/mineral premix

Ready-to-Use Supplementary Food (RUSF)

Oilseeds, tree nuts, pulses, cereals, sugar, dairy protein, vegetable oil, vitamin/mineral premix

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Study Design | The 4 supplementary study foods

Monthly ration ~500 kcal/day (as delivered).

*Fortified with Vitamin A & D

Study Setting

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• Existing Title II USAID supplementary feeding program (VIM) targeting all pregnant and lactating mothers and children 6-23 months in Sanmatenga Province

• Four geographic regions randomly assigned one of four foods distributed at 48 distribution sites

CSWB

RUSF

CSB+SC+

Study Sampling

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• Target of 6,000 children, enrolled at age ~6 months (1,500 per study food arm)

• Each child measured monthly for ~18 months during the ViM program plus 3 consecutive monthly post-intervention follow-ups

• Randomly selected sub-samples for interviews and in-home observations

CSWB

RUSF

CSB+SC+

Data Collection Methods

§ Anthropometry: monthly

§ Morbidity & treatment survey: monthly

§ Socio-economic survey: enrollment & exit

§ Community questionnaire: enrollment

Effectiveness Cost-Effectiveness Influencing Factors

§ Distribution observations

§ Warehouse observations

§ Individual surveys with beneficiaries & lead mothers

§ In-home observations with beneficiaries

§ Distribution observations

§ Individual surveys with beneficiaries, lead mothers, health & nutrition promoters

§ In-home observations with beneficiaries

§ Focus Group Discussions with beneficiaries & distribution committees

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Effectiveness Results

lgreen08

Preliminary Results

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Conceptual Framework




Wasting


Factors PotentiallyInfluencing




• Compare the effectiveness of four foods as used in a real-world programmatic setting in preventing:

– Stunting (length-for-age Z-score < -2)

– Wasting (weight-for-length Z-score < -2)

• Evaluate 3-month post-intervention follow-up.

– Measurement where child’s age was between 22.9 and 23.9 months

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Objectives

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Methods | Longitudinal Data Collection

Household, SES, and community level data

collected at enrollment

~6 months of age

Monthly anthropometric data collected at each

food distribution

~18 distributions

Anthropometric data collected at 1, 2, and 3

months post food distribution

Enrollment Followed for 18 months Post-intervention follow-up

Aug. 2014 – Jul. 2015 Aug. 2014 – Sept. 2016 Feb. 2016 – Dec. 2016

• Selection of covariates based on conceptual framework• Statistical models à

– Prevalence of stunting at endline à Logistic Regression – Total number of months wasted à Negative Binomial

Regression– Mean LAZ and WLZ throughout study period à Mixed-

effects Regression– Time to first stunted and wasted measures à Cox Model

• Models fit with and without those who had an endline measurement

• Multiple imputation for missing data• Models evaluated for collinearity and influential outliers

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Methods | Data Analysis

Y=β0+βstudyfood+βindividualcharacteristics…βcommunitycharacteristics+ε

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Study Arms Similar with Regard to Programmatic Exposure and Loss-to-follow-up

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Enrollment Characteristics

CSB+

(n=1519)

CSWB

(n=1503)

SC+

(n=1564)

RUSF

(n=1526)

Age(months) 5.9± 0.8 6.6± 0.9 6.3± 0.7 6.2± 1.2

Malesex 774(51%) 779(52%) 802(51%) 755(49%)

Severely food

insecure230(15%) 201(14%) 204(13%) 209(14%)

Poorest SES 375(25%) 267(18%) 294(19%) 260(17%)

LAZ -0.72± 1.07 -0.56 ± 1.16 -0.53± 1.04 -0.58± 1.11

WLZ -0.54± 1.05 -0.58± 1.04 -0.44± 1.04 -0.59± 1.04

MUAC Z -0.46± 0.97 -0.43± 0.96 -0.31± 0.96 -0.45± 0.96

Stunted~6mos. 148(10%) 135(9%) 110(7%) 138(9%)

Wasted~6mos. 121(8%) 125(8%) 111(7%) 121(8%)

Results on Stunting Prevention

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lgreen08

Preliminary Results

The odds of stunting at endline were similar in SC+ and RUSF; twice as high in the CSWB arm

AdjustedORs à

Ref. 2.07* 1.02 1.21

*p<0.05

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LAZ declined in all arms, with greatest decline in the CSWB arm

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Non-stunted time was similar among the arms, but slightly lower in the CSWB arm

Results on Wasting Prevention

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lgreen08

Preliminary Results

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Number of monthly measures wasted were similar in the SC+ and RUSF arms, but higher in the CSWB arm

ADJUSTED NUMBER OF MONTHLY MEASURES WASTED

Ref. 1.25* 0.96 0.92

*p<0.05

AdjustedIRRs à

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WLZ trajectories are similar, with the RUSF arm showing a slower rate of decline

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Non-wasted time was similar among the arms, but slightly lower in the CSWB arm

Relationships between stunting and wasting

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lgreen08

Preliminary Results

• At Baseline (6 months)

– 13% of stunted children were also wasted

– 15% of wasted children were also stunted

• 64% of those who were stunted at endline were also wasted at least once throughout the study period

• Of those who were stunted at endline, the percentage never wasted ranged from 32-44% by study arm

• Of those who were ever stunted, 30% had their first stunted measure preceded by wasting

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Coexistence of stunting and wasting

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Percentages never wasted among those who were stunted at endline

• None of the foods prevented linear growth faltering

• Children in the CSWB arm experienced higher rates of stunting and wasting, while rates in the SC+ and RUSF arms were similar to CSB+

• Understanding these effectiveness results requires understanding factors that may influence effectiveness

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Summary points

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Factors Influencing Effectiveness

lgreen08

Preliminary Results

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Wasting






Behaviors explored:

• Sharing

• Preparation

• Consumption

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Need to understand influencing factors

– In-home observations (n=209)

– Individual interviews with beneficiary mothers (n=1,463)

– Focus Group Discussions with beneficiary mothers and distribution committees (n=48)

– Lead mother and promoter interviews (n=308)36

Qualitative Data Collection Methods

Results –

Diversion (sharing, giving away or selling ration)

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lgreen08

Preliminary Results

Ration diversion: Caregivers report diverting the ration from the intended beneficiary most often in the CSWB arm

• No selling reported in any study arm• Giving away any of the ration was rare (8-13%)• Giving away oil was also rare (7-8%)• 18-21% of people report using oil for other household cooking

68% 69%75% 74%

54%

OVERALL

(N=1,632)

CSB+

(N=415)

CSWB

(N=406)

SC+

(N=409)

RUSF

(N=401)

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Observed presence of food in households:Study foods were observed to be present in the households most often in CSB+ and least often in CSWB

Average over 4 days of observation

92%

53% 55%60%

4%

45%

25% 25%

4% 2%

20%15%

CSB+ (N=50) CSWB (N=55) SC+ (N=51) RUSF (N=53)

Study food present Study food not present Not documented

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How often the ration reportedly lasts the entire month: The ration lasts the entire month least often in the CSWB arm

35%25%

33%

57%

CSB+ CSWB SC+ RUSF

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24%

36%

25%23%

CSB+ (N=46)

CSWB (N=29)

SC+ (N=28)

RUSF (N=32)

When study food was present, HH average over 4 days of observation

Someone other than beneficiary observed eating the food: Others were observed eating the food most often in the CSWB arm

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57%71% 68%

44%

CSB+ CSWB SC+ RUSFAdjusted ORs à Ref. 1.9* 1.63* 0.60**p<0.05

Adjusted percentages of diversion: Caregivers are more likely to report diverting CSWB than the other foods

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“Even when we are getting ready to make porridge, the big brother can approach and say ‘can I have some?’. We cannot refuse so we give him a bit. Everywhere, it’s the same.”

Ration sharing quotes from focus groups:

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“They told us that if the mother eats some herself at night, the next morning she will have plenty of milk for her child.”

“It’s true that it was said that it is for the child only, but often we give some to his older brothers, that’s how it is. If we do not give it to them they will cry, so we give them a bit to calm them down and we save the rest.”

“Often the mother tastes a bit and if the big brother of the child is nearby we also give him some.”

Results - Preparation

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lgreen08

Preliminary Results

Fat content in household porridge samples: Samples indicate lower fat content than would be expected if porridge prepared according to recommendations

Intrinsic Oil

Average qty added: 7.3 g/100g 6.6 g/100g

Target quantity of added oil (FAQR)

Required fat content range for RUSF

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Contamination with E.coli:In all study arms, the majority of household water samples showed unsafe or high-risk levels of contamination with E.coli

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912 13

1013

10

1712

20 20

27

19

58 58

45

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Low risk Intermediate Risk High Risk Unsafe

Results - Consumption

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lgreen08

Preliminary Results

Form in which ration is consumed: Those in RUSF and CSB+ consume the ration most often in the recommended form

Directly from

packet93%

Mixed with other foods

5%

Other2%

RUSF (n=395)

Porridge79%

Raw20%

Other1%

SC+ (n=405)

Porridge84%

Raw1% Couscous

14%

Other1%

CSB+ (n=402)

Porridge79%

Raw1%

Couscous18%

Other2%

CSWB (n=397)

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Form in which the ration is consumed from focus group

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“Well, if I make porridge today for him and he doesn’t want it, and tomorrow again it’s the same thing, I can try to make couscous with a bit of oil to see if he’ll eat that. If he eats it once or twice, you know that the child prefers couscous to the porridge and I make that from now on all the time for him. And vice versa.”

“They told us that if the child does not like the porridge, we can simply give him the flour for him to eat raw.”

Adjusted ORs à Ref. 0.60* 1.14 1.80**p<0.05

Adjusted percentages for recommended form: Caregivers report consuming CSWB in its recommended form significantly less often than the other foods, and RUSF significantly more often

72%

61%

74%82%

CSB+ CSWB SC+ RUSF

50

38%

18%

52%

60%


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Observed consumption:Children were most often observed consuming the study food in the RUSF arm, and least often in the CSWB arm

When study food was present, HH average over 4 days of observation

• CSWB reported to be bitter by beneficiaries at the end of IDIs and to ViM staff

• Tests showed that the bitterness did not impact the safety of the food

• ViM recalled and destroyed 14 MT of bitter CSWB after organoleptic tests confirmed bitter taste

• From organoleptic tests at NC State, June 2016:

– Aftertaste: “Stale, cardboard, heat exposure, dirty”

– Aroma quality: “Cardboard, fishy”

– Higher bitterness scores than new batch of CSWB

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Anecdotal Report: Bitter taste of CSWB

Summary Points

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lgreen08

Preliminary Results

• Study foods were generally not used as intended

• Patterns of use/sharing of the study foods within the households varied by study arm

• CSWB was shared more and eaten less frequently by beneficiary child

• CSWB reported to be bitter after 8-9 months of storage time

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Summary Points

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Cost and Cost-Effectiveness

lgreen08

Preliminary Results

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4 Study Arms:CSB+ with oil



Wasting






Costing Methods

• Two Cost Lenses (for procurement and international freight):

- Study-Incurred

- Realistic

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• Two Costing Perspectives:

- Program Perspective (e.g. Product, Supply Chain, Distribution, etc)

- Caregiver Perspective (Opportunity Cost of Caregiver Time)

• Activity-based Costing Approach

• Ongoing Cost (existing program, no start-up cost)

Costing Matrix

Loss-adjusted

Average Cost per Child Reached

Average Cost per Monthly Ration

Average Cost per Metric Ton 58

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Assessing Cost-Effectiveness Across Study Arms

∆ Cost Estimates

Difference in

Average Cost per Child Reached

∆ Measured Effect

Primary Outcome for Stunting

• Difference in % Stunted at Endline

Primary Outcome for Wasting

• Difference in # of Monthly Measurements Showing Wasting

Comparative Cost-

Effectiveness

Each Arm Compared to

Reference Arm

(CSB+ with oil)

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Results on Costs: Program Perspective

Image Source: UNICEF

lgreen08

Preliminary Results

Cost/MT ($USD)Breakdown by Food Product and Supply Chain

(Realistic Procurement & Freight)

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0

500

1000

1500

2000

2500

3000

3500

4000

Oil CSB+ CSWB RUSF SC+

Storage

Reconditioning

Repacking

Inland transportation

International Freight

Food Product/Commodity

1811

1169

1532

3707

2704

Cost per Child Reached ($USD)Breakdown by Food and Other Program Cost


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0

50

100

150

200

250

300

CSB+ w/oil CSWB w/ oil RUSF SC+

Administrative & Fixed Cost

Distribution

Storage

Reconditioning

Repacking

Inland transportation

International Freight

Food Product/Commodity

122

253

223

135

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•Photo

court

esy

of U

SAID

Cost-Effectiveness Results


lgreen08

Preliminary Results

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Analysis: Excluding Lost-To-Follow-UpCSB+ w/ oil

CSWB w/ oil

RUSF SC+

Program Cost per Child Reached*Realistic Procurement & Freight

122.4 135.2 252.4 223.0

Predicted % Stunted at Endline (95%CI)

*Adjusted for baseline stunting and other confounders

20.1%

(18.0%,

22.2%)

27.5%

(25.0%,

30.0%)

20.3%

(18.3%,

22.4%)

21.9%

(20.0%,

23.9%)

Linking Cost to Effectiveness: Stunting— Average Cost per Child Reached ($USD) — % Stunted at Endline

CE Plane Graph Stunting Program Cost Study

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Less Costly

More Costly

More EffectiveLess Effective

Linking Cost to Effectiveness: Wasting— Average Cost per Child Reached ($USD)— # Monthly Measurements Showing Wasting per Child

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Analysis: Excluding Lost-To-Follow-Up

CSB+ w/ oil

CSWB w/ oil

RUSF SC+

Program Cost per Child Reached*Realistic Procurement & Freight

122.41 135.2 252.4 223.0

Predicted # Monthly Measurements Showing Wasting per Child (95%CI)*Adjusted for total number of monthly measurements received and other confounders

2.6

(2.3,3.0)

3.3

(2.8,3.7)

2.4

(2.1,2.7)

2.5

(2.2, 2.8)

CE Plane Graph Stunting Program Cost USAID

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Less Costly

More Costly

Caregiver Perspective


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lgreen08

Preliminary Results

Opportunity cost of time =

hours of time x estimated hourly wage

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Opportunity Cost of Caregiver Time

Self-reported & observed time(Mother IDI and IHO)

$0.21/hrCalculated by:• Mandated minimum

monthly wage in the formal sector: 30684 CFA

• Standard workweek of 60 hours for household workers

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Opportunity Cost of Caregiver Time per Monthly Ration

Breakdown by Caregivers’ Activity Types

$0.00

$2.00

$4.00

$6.00

$8.00

$10.00

$12.00

CSB+ w/oil CSWB w/oil RUSF SC+

Study Food Feeding

Study Food Preparation

Waiting at Distribution Site

Traveling to Distribution Site

The Impact of Adding Caregiver Opportunity Cost on Comparative Total Cost/Child by Arm

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lgreen08

Preliminary Results

$Cost/Child ReachedProgram & Caregiver Perspective


@$0.21/hr

174 152

99 179

0

50

100

150

200

250

300

350

400

450

CSB+ w/oil CSWB w/ oil

RUSF SC+

Caregiver Opportunity Cost

Total Cost to Program

72


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Less Costly

More Costly



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Less Costly

More Costly



75


Less Costly

More Costly


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Less Costly

More Costly

• Cost and cost-effectiveness analysis provides information needed in the

selection of supplementary foods.

• Cost-Effectiveness Results for stunting and wasting are similar:

– CSB+ with oil was most cost-effective

– RUSF was the most expensive from the program perspective; SC+

was most expensive from the program & caregiver perspective

– CSWB had the second lowest cost, but also lower effectiveness

• Valuing caregiver time affects relative rankings of cost-effectiveness, but

not conclusion that CSB+/oil was most cost-effective in this study.77

Summary Points

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What have we learned?

lgreen08

Preliminary Results

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• “RUTF used as part of the WHO 2013 protocol

is effective in promoting recovery from SAM

and reducing mortality.”

• “Use of RUSF to treat MAM.. has the potential to improve nutritional recovery.” [treatment]

• “Weight gain reported by studies for children given RUSF or CSB was small. There were no substantial differences in mortality rates reported for children who received RUSF compared with children in CSB groups.”

Recent Systematic Review on targeted treatment of MAM shows similar findings

Fig 5. Forest plot: Lipid-based nutrient supplement versus Specially formulated micronutrient fortified foods, outcome:

1.3 Recovery from moderate acute malnutrition.

Gera T, Pena-Rosas JP, Boy-Mena E, Sachdev HS (2017) Lipid based nutrient supplements (LNS) for treatment of children (6 months to 59 months) with moderate acute malnutrition (MAM): A systematic review. PLOS ONE 12(9): e0182096. https://doi.org/10.1371/journal.pone.0182096http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0182096

“Subset analyses

suggested higher

recovery rates with

greater amount of

calories provided.”

Fig 12. Forest plot: Lipid-based nutrient supplement versus specially formulated micronutrient fortified foods,

outcome: 1.23 Relapse after discharge.

Gera T, Pena-Rosas JP, Boy-Mena E, Sachdev HS (2017) Lipid based nutrient supplements (LNS) for treatment of children (6 months to 59 months) with moderate acute malnutrition (MAM): A systematic review. PLOS ONE 12(9): e0182096. https://doi.org/10.1371/journal.pone.0182096http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0182096

• Foods used in blanket supplementation in this context had limited effect in preventing stunting and wasting.

• Food products have to be consumed by intended index individual to have any chance of achieving intended outcome. Mostly this is not happening, regardless of product.

• Some ingredients may matter more (protein source, ASF, potassium, zinc, amino acids, etc.). But all foods performed in similar ways, so beware too much tinkering a) absent evidence of real physiological significance b) more findings on dosing.

Some things were confirmed by this study

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Growth Faltering: What, when, and can we disrupt the curve?

Victora et al. 2010 83

Hei

ght

for

age

84

WHO growth curves

v Burkina study children

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What have we learned? (i)

1. None of the foods prevented decline in LAZ over time. All foods performed comparably, but carry very different costs.

2. Most cost-effective re: defined outcome was CSB+.

3. Least cost-effective: CSWB (least often observed in-home; most shared; most often reported ‘not lasting entire month’).

4. We can’t ascribe performance to product composition. Relatively poor performance of children in the CSWB arm does NOT mean that adding WPC80 resulted in stunting.

• South Sudan (Doocy et al 2013) -

“Household food security remained poor despite ration receipt.”

• Burundi (Leroy et al 2017) –

“Positive effect on household access to food…[but minimal

impact] on household and mothers’ dietary diversity.”

• Guatemala (Ruel et al 2017) –

“Larger [family] ration led to greater participation and impacts.”

• Haiti (Donegan et al 2013) –

“Rigorous evaluations of food-assisted…programs are stymied by the ethics of randomizing recipients to a control.”

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Other PM2A evidence: food security matters

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What have we learned (from Burkina Faso)? (ii)

5. Children in CSWB arm experiencing stunting earlier (than in other arms) may suggest insufficient food intake not ameliorated by supplementary food (which was shared more).

6. Sharing/diversion of foods typical for all foods (incl. >50% RUSF); children in CSWB arm seem least likely to be consuming adequate product. [We are not seeing reports of ‘bitter taste’ of CSWB in ongoing Sierra Leone study.]

7. Quality of programming matters at least as much as quality of products being programmed. We need much more evidence of effective programming actions surrounding delivery of food aid.

8. To better understand programming requires much more attention to drivers of community participation, compliance, substitution, links among programming components, etc.

88

What have we learned? (iii)

“While WASH alone will not eliminate stunting, it does have the potential to accelerate progress on eliminating stunting as a critical component of comprehensive strategies.”

89

“There was no benefit to the integration of water, sanitation, and handwashing with nutrition.

Adherence was high in all groups and diarrhoeaprevalence was reduced in all intervention groups except water treatment.

Combined water, sanitation, and handwashing interventions provided no additive benefit over single interventions.”

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What have we learned? (iii)

8. To better understand programming requires much more attention to drivers of community participation, compliance, substitution, links among programming components, etc.

9. Broader range of outcomes need to be considered in assessing ‘growth’: cognitive function, lean mass, inflammation markets?

10. CSB+ has no dairy ingredient; the other foods studied do. We’re not able to conclude anything about the role of dairy per se in this study, but the option of continued programming of food aid (in blanket supplementation) without dairy should be discussed.

11. The role of such foods in targeted (recuperative) programming needs to be determined separately. But, the interacting etiology of stunting with wasting needs to be better understood.

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(Many) remaining questions

i. Is blanket supplementation to prevent wasting and stunting cost-effective where child intake suboptimal (food shared/diverted)?

ii. What extra/new programming options can improve performance of blanket food supplementation, regardless of product choice?

iii. No studies of blanket supplementation (including ours) show significant effectiveness in preventing wasting.

iv. Are targeted supplementary foods more effective? Separate study in Sierra Leone is asking that question.

v. What are the optimal elements of comprehensive programming?

• Huge $$$ invested in food assistance; ensuring more cost-effective programming is essential going forward.

• Investment in such research is critical to offering value-for-money to US taxpayers, and to intended beneficiaries.

• Greater impact of food aid interventions demands quality programming (design, implementation fidelity, coverage, duration, compliance), not just choice of food product.

• USG support for operations-relevant studies is key to making all-of-government actions on nutrition effective and sustained.

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Important implications

• Cost per healthy child (i.e. never stunted nor wasted)

• Cost per incremental 1cm growth/length (% point improvements)

• Multiple interactions between wasting and stunting

• Analysis of detailed 24hr food/calorie/nutrient intake of child

• Analysis of post-intervention follow-up period (outcomes)

• Analysis of in-home observations and self-reported behaviors.

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Upcoming Analytical Steps …

So please join Evidence Summit June 2018 for more…

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This work was made possible through support provided by the Office of Food For Peace, Bureau for Democracy, Conflict, and Humanitarian Assistance, U.S. Agency for International Development, under the terms of Contract No. AID-OAA-C-16-00020. The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of the U.S. Agency for International Development.

Thank you for the collaboration!

§ USAID: Funder

§ Tufts University: Beneficiary of Food For Peace/USAID grant for food aid research

§ Institut de Recherche en Sciences de la Santé (IRSS): Research implementation partner

§ ACDI/VOCA: Prime awardee implementing Title II program, Victoire sur la Malnutrition (ViM).

§ Save the Children: Sub-prime in consortium implementing the ViM program

§ Study participants from Sanmatenga Province, Burkina Faso

§ Industry partners who produce the foods. 96

food aid quality review burkina faso effectiveness and

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