Cost-benefit Analysis of Interventions to Reduce the Prevalence of Stunting in Malawi - Technical Report

The nutrition response in Malawi reflects the holistic and multi-sectoral nature of the issue. The focus of this research paper is on one aspect, namely a section of frontline workers - specifically HSAs and CDAs. The rationale for focusing on HSAs and CDAs is motivated by the intervention selection process, which was informed by the research agenda of the Malawi Priorities project. This yielded three interventions that naturally fall within the domain of HSAs and CDAs. These frontline workers form a key part of the overall healthcare system. The system operates on three levels of organization, namely: primary, secondary and tertiary. These different levels are linked to each other through an established referral system with primary and secondary level care falling under district councils. At the primary level, services are provided by health surveillance assistants (HSAs) in communities, health posts, dispensaries, maternity clinics, health centers and community hospitals. Each HSA is responsible for about 1,000 people and there are currently about 11,000 in post. HSAs mainly provide promotive and preventive health care through door-to-door visits, village clinics and mobile clinics. There remains a high level of stunting among children in Malawi – 37% in 2016, although this has declined from 47% in 2010. The primary cause of stunting is chronic undernutrition and addressing this is a challenge. Many low-income households are food insecure but this is compounded by poor infant feeding practices.