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# Impact of Feed the Future initiative on nutrition in children aged less than 5 years in sub-Saharan Africa: difference-in-differences analysis

BMJ 2019; 367 (Published 11 December 2019) Cite this as: BMJ 2019;367:l6540
1. Theresa Ryckman, PhD candidate1,
2. Margaret Robinson, medical student2,
3. Courtney Pedersen, medical student2,
4. Jay Bhattacharya, professor of medicine1 3,
5. Eran Bendavid, associate professor of medicine1 4
1. 1Center for Health Policy and the Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
2. 2Stanford University School of Medicine, Stanford, CA 94305, USA
3. 3National Bureau of Economic Research, Cambridge, MA, USA
4. 4Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
1. Correspondence to: T Ryckman ryckmant{at}stanford.edu (or @rycktessman on Twitter)
• Accepted 7 November 2019

## Abstract

Objective To evaluate the impact of the US government’s Feed the Future initiative on nutrition outcomes in children younger than 5 years in sub-Saharan Africa.

Design Difference-in-differences quasi-experimental approach.

Setting Households in 33 low and lower middle income countries in sub-Saharan Africa.

Population 883 309 children aged less than 5 years with weight, height, and age recorded in 118 surveys conducted in 33 countries between 2000 and 2017: 388 052 children were from Feed the Future countries and 495 257 were from non-Feed the Future countries.

Main outcome measures A difference-in-differences approach was used to compare outcomes among children in intervention countries after implementation of the initiative with children before its introduction and children in non-intervention countries, controlling for relevant covariates, time invariant national differences, and time trends. The primary outcome was stunting (height for age >2 standard deviations below a reference median), a key indicator of undernutrition in children. Secondary outcomes were wasting (low weight for height) and underweight (low weight for age).

Results Across all years and countries, 38.3% of children in the study sample were stunted, 8.9% showed wasting, and 21.3% were underweight. In the first six years of Feed the Future’s implementation, children in 12 countries with the initiative exhibited a 3.9 percentage point (95% confidence interval 2.4 to 5.5) greater decline in stunting, a 1.1 percentage point (0.1 to 2.1) greater decline in wasting, and a 2.8 percentage point (1.6 to 4.0) greater decline in underweight levels compared with children in 21 countries without the initiative and compared with trends in undernutrition before Feed the Future was launched. These decreases translate to around two million fewer stunted and underweight children aged less than 5 years and around a half million fewer children with wasting. For context, about 22 million children were stunted, 11 million children were underweight, and four million children were wasted in the Feed the Future countries at baseline.

Conclusions Feed the Future’s activities were closely linked to notable improvements in stunting and underweight levels and moderate improvements in wasting in children younger than 5 years. These findings highlight the effectiveness of this large, country tailored initiative focused on agriculture and food security and have important implications for the future of this and other nutrition interventions worldwide.

## Introduction

Undernutrition is the single greatest risk factor for child morbidity and mortality globally,1 underlying 56% of all deaths in children younger than 5 years and accounting for more than 8000 deaths each day in 2017.1 In 2016, 32% of children younger than 5 years living in sub-Saharan Africa were chronically undernourished, or stunted (low height for age), and 8% were acutely undernourished, or wasted (low weight for height).2 Undernutrition in childhood is strongly linked with diminished physical and cognitive development and lower lifetime earning potential.345

Although the direct causes of undernutrition include insufficient dietary intake, illness, and malabsorption of energy and micronutrients, previous work has identified links between nutritional status and food security, socioeconomic status, and women’s decision making power (so called nutrition sensitive factors).678910 Over the past several decades, health interventions targeting undernutrition have moved away from nutrition sensitive sectors, particularly agriculture, toward nutrition specific programs that focus on energy intake, breast feeding, and micronutrients.11 Nutrition specific interventions have been shown to lead to improvements in growth in children12 but in isolation might be insufficient to reduce stunting.13 A 2013 review concluded that nutrition specific approaches, even at 90% coverage, need to be paired with nutrition sensitive programs to reduce current burdens by more than 20%.12

### Country selection and identification strategy

Because our study is observational, we carefully consider the possibility that unobserved time varying factors could confound our observed effects. The assumption that pre-Feed the Future trends in nutrition would continue in the absence of Feed the Future is not directly testable. The US government presumably selected countries based on need and capacity, but we do not observe differential trends in undernutrition in the years leading up to its implementation. Still, we account for time invariant and pre-existing differences among countries, and we control for the US government’s stated selection criteria (eg, governance) and other potential time varying confounders as much as possible. We also identify accentuated effects in populations more exposed to Feed the Future by restricting analyses to rural areas, high coverage countries, and children younger than 2 years, increasing the likelihood that we are measuring the effects of the initiative, not unobserved confounders.

Our analytical approach would be threatened only if changes starting in 2012 in primarily Feed the Future countries led to improvements in nutrition but were uncorrelated with regression covariates. We identified a major funding increase to several Feed the Future countries from the Canadian government around 2012 but found that the impact in these countries was not driving our results (appendix eTable 12 and methods). We identified no other initiatives of the same scope, time, and locations, or other drivers (eg, weather events, conflicts) unique to Feed the Future countries starting around 2012, other than the initiative itself. However, we remain cautious in attributing all of the observed nutritional improvements to Feed the Future; as with any observational analysis we cannot completely rule out the possibility that other factors might have also played a role.

### Strengths and limitations of this study

Feed the Future is generally administered to a set of subnational regions (zones of influence) in each country. Our analysis was conducted at the national level because precise locations of zones of influence are not always available or have changed since the initiative’s start, and many surveys do not contain detailed data on location. Our regressions thus average effects across treated and untreated areas within focus countries, implying we may underestimate the true effect of Feed the Future on the specific areas where it operates. The estimated reduction in stunting associated with Feed the Future becomes more pronounced when we focus the analysis on Feed the Future countries with greater subnational coverage. This estimate may more closely approximate the initiative’s treatment effect on the treated.

Our analysis is weighted such that large countries have more impact on results, therefore nutrition levels might not be improving in all Feed the Future countries. For instance, we observed stable or flatline trends in Ghana and Uganda (appendix eFigure 2). Though these descriptive analyses are not adjusted for relevant covariates, they do point to the potential for heterogeneous effects across Feed the Future countries and programs. Furthermore, Feed the Future intervened in countries where less than 40% of stunted children in sub-Saharan Africa reside, was active in only parts of these countries, and operated in only five of the 10 sub-Saharan African countries with the highest prevalence for stunting. It remains to be seen whether Feed the Future’s approach would be equally effective in other countries with different burdens, weaker institutions, or less governmental commitment.

Our findings are a substantial addition to the current evidence base on the impact of large scale nutrition initiatives. The US government’s 2016 evaluation of Feed the Future acknowledges that it is “difficult to understand the degree to which ZOI [zones of influence]-wide changes in impact level indicators for poverty and nutrition were driven by Feed the Future interventions or broader long-term trends.”21 We estimate that Feed the Future has prevented 2.2 million children from becoming stunted, whereas the US government evaluation estimates 3.4 million. This difference could be due to the US government evaluation’s lack of a counterfactual comparison but is also partly explained by our focus on only countries in sub-Saharan Africa. If we inflate our estimate by the number of stunted children in all Feed the Future focus countries, our estimate is closer to that of the US government, although this assumes that the impact was similar in non-sub-Saharan Africa countries.

Studies have shown the importance of addressing the indirect determinants of poor nutrition,67810 but to date there has been a lack of large scale, robust analyses evaluating multisectoral initiatives such as Feed the Future that focus on these determinants.10 Most evaluations of nutrition programs focus on interventions implemented in one or two countries at most.134950 Feed the Future’s rollout across several countries offers an ideal natural experiment to infer the effectiveness of a large multifaceted approach at scale. We analyze the impact of Feed the Future using large datasets from two publicly available sources, allowing for future replication, that cover hundreds of thousands of children in more than 30 countries. Our design controls for pre-Feed the Future trends in outcomes, time variant confounders, and Feed the Future’s stated selection criteria to isolate improvements in nutrition uniquely associated with the program. We conduct extensive sensitivity analyses that further verify the robustness of our findings.

### Conclusions and policy implications

Evaluations of large donor funded initiatives such as Feed the Future are often conducted with considerable donor involvement. A recent editorial stressed the increasing importance of conducting independent evaluations of such programs.51 Prospectively designed independent evaluations could advance the value of programs and should include better measures of exposure, standardized intermediate and primary outcomes, thoughtful selection of counterfactual populations, sample size calculations that allow for measurement of average and heterogeneous effects, and engagement of beneficiaries (eg, households) to assess both quantitatively and qualitatively how programs succeeded and how they could improve.5152

Our results are consistent with the hypothesis that the average child residing in a Feed the Future focus country is less likely to be undernourished than he or she would have been in the absence of the initiative. Feed the Future is now concentrating its activities on a smaller set of eight focus countries in sub-Saharan Africa. Though our findings indicate initial and increasing progress, it will be several years before we know whether the initiative’s efforts were sustainable in either set of countries. Although a 3.9 percentage point decrease in stunting (and a 1.2 percentage point annual decrease) across several countries is noteworthy, many countries face stunting levels above 30%. The United Nation’s Sustainable Development Goals include reducing stunting by 40% and wasting to less than 5% by 2025.5354 Based on our analysis, Feed the Future may be making a noticeable difference, but its impact alone will not be enough to meet these targets. While we show the promise of an approach such as Feed the Future, addressing the complexities of undernutrition in the long term will require sustained effort across multiple sectors for years to come.

#### What is already known on this topic

• Prevalence of child undernutrition in low and middle income countries has remained consistently high, even as other measures of child health have improved

• Debate is ongoing about the relative effectiveness of programs that address underlying determinants of undernutrition versus those that focus on nutrition directly

• Feed the Future, an agriculture and nutrition assistance initiative, has been in operation since 2011 and focuses on many of these underlying determinants; however, robust evidence on the program’s effectiveness in reducing stunting is sparse

• The Feed the Future initiative was associated with meaningful improvements in nutrition outcomes in children younger than 5 years of age

• Adjusted stunting prevalence decreased 3.9 percentage points more in Feed the Future countries than non-Feed the Future countries, translating into 2.2 million fewer children stunted

• This analysis supports the value of a multisectoral approach, including a focus on agriculture and food security, to improve nutrition in children

## Acknowledgments

This material is based on work supported by the National Science Foundation graduate research fellowship program (grant No DGE-1656518). Any opinions, findings, and conclusions or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of the National Science Foundation.

We thank Kiersten Johnson, monitoring and evaluation advisor at the United States Agency for International Development’s Bureau for Food Security, who provided clarifications on the structure and early implementation of Feed the Future.

## Footnotes

• Contributors: EB and TR were involved in initial conceptualization and methodology development. TR and MR cleaned, curated, and analyzed the data. CP, MR, and TR contributed to the first draft of the manuscript. EB, JB, TR, MR, and CP contributed to study design, interpretation of results, development of visualizations, writing, and initial editing. EB and JB were involved in validation of results and conclusions and act as guarantors of the study. All authors have read and approved the final draft of the manuscript. All authors had access to all data in the study and had final responsibility for the decision to submit for publication. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

• Funding: This study received no specific funding.

• Competing interests: All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/coi_disclosure.pdf and declare: EB receives funding from the Doris Duke Charitable Foundation and the National Institute for Allergy and Infectious Diseases; JB was partially supported by the US National Institute on Aging through the Stanford Center for Demography and Economics of Health and Aging (grant No P20-AG17253); TR receives support for her PhD research as a National Science Foundation graduate research fellow and Stanford graduate fellow in science and engineering; no support from any organization specifically for the submitted work, no financial relationships with any organizations that might have an interest in the submitted work in the previous three years, and no other relationships or activities that could appear to have influenced the submitted work. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

• Ethical approval: Not required.

• Data sharing: All data used in the analysis are available through the Demographic and Health Surveys and Multiple Indicator Cluster Surveys websites for academic researchers.

• The lead author (TR) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.