preliminary findings from a phe operations research activity in madagascar yung-ting kung, mph...

Preliminary Findings from a PHE

Operations Research Activity in

Madagascar

Yung-Ting Kung, MPH

October 5, 2007

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Household Food Security and Livelihood Concept

Rice cultivation

Anti-erosion measures

Fruit Trees

Plant nurseries

Reforestation

Off season planting

Forage Crops

Fish culture

Beekeeping

Animal husbandry

Vaccination, Diarrheal Disease, Malaria

Nutrition Safe

motherhoodReproductive health Potabl

e water

Sanitation & Hygiene

Sustainable use of natural resources

Protected ecosystems

Market garden

Income generationMicrocreditsCivil society organizations

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Community Centered P-H-E Interventions

Watershed

(Kleinau et al. presentation, May 2005)

Strategies for Working with Local Communities

Champion Community

Farmer-to- Farmer

Child-to- Community

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Partners in Sustainable Development

9 NGOs 160 Communities

8 Projects, 3 Donors3 Foundations

Government in 19 Communes6 Ministries P

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Madagascar Environmental Health Project: Two Operations Research Questions

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2. Does the sustainability and effectiveness of Integrated PHE depend on the organizational arrangement?

1. Is integrated PHE more effective and sustainable than unlinked, single-sector approaches?(synergies hypothesis)

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Program Evaluation Design Quasi-experimental design

Two groups: integration and non-integration Two household surveys: baseline 2001 and impact 2004

Integration sites: 3 organizational arrangements (4 NGOs in 3 regions) (56 communities) Type 1: Integration within 1 NGO (multidisciplinary teams) Type 2: Integration within 1 NGO (separate H & E teams) Type 3a: Integration between several NGOs Type 3b: Integration between several NGOs

Control sites: (29 communities) Single sector health or environment activities or neither


Sampling All communities self-selected to participate

(Kleinau et al, 2005)

Questionnaires Five different questionnaires

Village Household Head of household Women 15-49 Children under 5

Questionnaires developed in Malagasy and pre-tested

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Earlier Univariable Analysis

(Kleinau et al. presentation)

Dependent Variables Six population, health, environment indicators

Modern contraceptive prevalence rate Household head’s perception of food security for the

entire year Childhood (under 5 years) moderate and severe stunting Household head knowledge of soil degradation as an

effect of slash-and-burn agriculture Whether the household head has planted eucalyptus

trees Women’s community participation in village associations

All indicators are dichotomous

Difference-in-Differences (DiD) Methodology DiD estimator is defined as the difference in the mean

outcome of the treatment group after v. before treatment and the mean outcome of the control group after v. before the treatment period (Ravallion, 2005)

Both group specific and time-specific effects are controlled

for (Wooldridge, 2002)

Therefore unobservable differences between the two groups which are time invariant are controlled for

For unbiased DiD estimator, treatment cannot be related to other variables which influence the outcome (Wooldridge 2002)

Since treatment not randomized, it is essential to control for initial heterogeneity between the two groups (Ravallion 2005)

Dprobit Regression Model Used to measure the DiD

estimator since all outcomes are dichotomous

Reports the marginal effect, that is change in probability of an outcome For infinitesimal change in a

continuous variable Or for discrete change in

categorical variable Standard errors adjusted for

clustering on ID

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Baseline Characteristics: Women’s questionnaireTable 1: Women's Questionnaire relevant baseline descriptive statistics

Integration Control p-valueVariable (%/mean) (%/mean) (chi2/t-test)Dependent Variable

Modern contraceptive prevalence rate 11.67 2.39 0.000Women's community participation 29.48 30.99 0.670

Independent VariablesWomen's age 29.47 30.69 0.396Women currently married 58.81 67.52 0.022Women's education level 0.720

none 6.37 7.48primary - cannot read or write 10.20 7.81primary - can read only 59.13 68.51primary - can read and write 24.30 16.21secondary/superior

Previous live births 80.72 86.10 0.0739

Baseline Characteristics:Children’s QuestionnaireTable 2: Child's questionnaire and relevant baseline descriptive statistics


Moderate/severe childhood stunting 50.86 44.83 0.1431

Independent VariablesChild's age 1.84 2.03 0.0746Responsible's age 30.66 32.42 0.1474Child's sex 0.6427

Girl 48.56 46.75Boy 51.44 53.25

Number of children in the household 0.50431 37.73 35.062 42.71 46.753 12.83 12.994 5.63 5.195 1.10 0.00

Responsible's education 0.0279none 27.28 37.23primary - cannot read or write 10.77 6.49primary - can read only 6.40 5.19primary - can read and write 40.84 40.26secondary/superior 14.71 10.82

Responsible received health/nutrition information 69.51 61.04 0.0203Health center close by 98.02 100 0.0520Wealth Index Terciles 0.0004

First 27.61 35.40Second 31.80 38.94Third 40.59 25.66

Baseline Characteristics:Head of Household Questionnaire

Table 3: Head of Household questionnaire and relevant baseline descriptive statistics


Food security 15.60 15.13 0.8647Eucalyptus tree planting 58.22 40.00 0.0000Knowledge of soil degradation as effect of slash-and-burn 61.56 46.61 0.0001

Independent VariablesAge of head of household 43.49 45.71 0.0382Marital status (married=1) 75.16 77.96 0.3877Education level 0.0010

none 22.29 34.51primary - cannot read or write 5.33 6.67primary - can read only 5.82 4.31primary - can read and write 46.15 39.22secondary/superior 20.41 15.29

Sex of household head (female=1) 19.12 15.51 0.2155Principal activity of head of household 0.0000

Agriculture 81.79 83.27Animal Husbandry/Fishing 1.65 8.98Bee-Keeping 0.13 0.41Commerce 2.18 0.82Salaried 7.95 4.08Artisan 2.82 1.22Forest Exploitation 2.30 0.00arboriculture 0.43 0.00Gardening 0.13 0.00Other 1.22 0.62

Cultivable space 97.27 98.37 0.3376

Dprobit Model: Modern Contraceptive Prevalence Rate

Table 5a: dprobit model for modern methods CPR (2363 Observations)Variable dF/dx p-value

Year 0.0910 0.014Integration site 0.1209 0.000Program effect (Integration*year) -0.0482 0.229

Adjusted for sampling weights and clustering on id

Table 5b: dprobit model for modern methods CPR (1784 Observations)Variable dF/dx p-value

Year 0.0877 0.060Integration site 0.0897 0.030Program effect (Integration*year) -0.0447 0.373Education 0.0520 0.000Previous live births (yes=1) 0.1177 0.000Marital status (not in union=1) -0.0325 0.083Haute Matsiatra region* -0.0548 0.005Anosy Region* 0.0030 0.907Anosibe An'Ala Fivondronana** 0.0848 0.005Ambalvao Fivondronana** 0.0341 0.436Amboasary Fivondronana** -0.0977 0.008

Adjusted for covariates, sampling weights, and clustering on id*Comparison to Mangoro region**Comparison to Moramanga Fivondronana

Dprobit Model: Women’s Community Participation

Table 6a: dprobit model for Women's Participation (2363 Observations)Variable dF/dx p-value

Year -0.0546 0.201Integration site -0.0152 0.671Program effect (Integration*year) 0.0930 0.057


Table 6b: dprobit model for Women's Participation (1784 Observations)Variable dF/dx p-value

Year -0.0366 0.503Integration site -0.0006 0.990Program effect (Integration*year) 0.0573 0.350Age 0.0065 0.000Education 0.0259 0.083Previous live births (yes=1) 0.1223 0.001Marital status (Not in union=1) -0.0107 0.712Haute Matsiatra region* 0.1140 0.001Anosy Region* 0.0688 0.110Anosibe An'Ala Fivondronana** 0.2997 0.000Ambalvao Fivondronana** 0.0515 0.311Amboasary Fivondronana** 0.0829 0.193

Adjusted for covariates, sampling weights, and clustering on id*Comparison to Mangoro region**Comparison to Moramanga Fivondronana

Dprobit Model:Moderate/Severe Childhood Stunting

Table 7a: dprobit model for moderate/severe childhood stunting (2057 Observations)Variable dF/dx p-value



Table 7b: dprobit model for moderate/severe childhood stunting (1616 Observations)Variable dF/dx p-value

Year 0.0949 0.090Integration site 0.0697 0.148Program effect (Integration*year) -0.1351 0.024Child's age 0.0845 0.000Child's sex (female=1) -0.0365 0.019# children in household -0.0004 0.983Responsible's education -0.0045 0.678Responsible's age -0.0015 0.421Received info on health/nutrition (yes=1) 0.0317 0.300Health center in village -0.0163 0.730Grandmother responsible* 0.1847 0.018Aunt responsible* 0.1674 0.507Father responsible* 0.0600 0.563Other responsible* 0.3510 0.017Wealth tercile -0.0670 0.000Haute Matsiatra region** -0.0837 0.056Anosy Region** -0.2802 0.000Anosibe An'Ala Fivondronana*** -0.1460 0.009Ambalvao Fivondronana*** 0.0565 0.343Tolagnaro Fivondronana*** 0.1306 0.021

Adjusted for covariates, sampling weights, and clustering on id*Comparison to mother responsible** Comparison to Mangoro region*** Comparison to Moramanga Fivondronana

Dprobit Model: Food Security (Reported by Head of HH)

Table 8a: dprobit model for food security (2073 Observations)Variable dF/dx p-value



Table 8b: dprobit model for food security (2069 Observations)Variable dF/dx p-value

Year 0.1073 0.003Integration site 0.0013 0.971Program effect (Integration*year) -0.0440 0.297Age of household head -0.0014 0.056Marital status of household head (Not in union=1) 0.0603 0.096Education of household head 0.0038 0.600Sex of household head (Female=1) -0.0443 0.232Haute Matsiatra region* 0.1853 0.000Anosy Region* 0.0199 0.521Anosibe An'Ala Fivondronana** 0.1378 0.001Ambalvao Fivondronana** -0.1071 0.004Amboasary Fivondronana** 0.0181 0.641Principal activity of household head***

animal husbandry/fishing -0.0336 0.676Bee-keeping 0.2209 0.312Commerce 0.0041 0.963Salaried -0.0358 0.448Artisan -0.1396 0.047Forest exploitation -0.0272 0.770Other 0.0639 0.496

Adjusted for covariates, sampling weights, and clustering on id*Comparison to Mangoro region**Comparison to Moramanga Fivondronana***Comparison to agriculture as principal activity

Dprobit Model: Eucalyptus Tree Planting

Table 9a: dprobit model for eucalyptus tree planting (1872 Observations)Variable dF/dx p-value



Table 9b: dprobit model for eucalyptus tree planting (1865 Observations)Variable dF/dx p-value

Year 0.1164 0.040Integration site 0.0509 0.235Program effect (Integration*year) 0.0056 0.930Age of household head 0.0040 0.000Marital status of household head (Not in union=1) -0.0579 0.246Education of household head 0.0388 0.000Sex of household head (Female=1) -0.2290 0.000Cultivable land (yes=1) 0.1286 0.229Haute Matsiatra region* -0.1943 0.001Anosy Region* -0.1264 0.003Anosibe An'Ala Fivondronana** 0.0636 0.239Ikongo Fivondronana** -0.2600 0.000Amboasary Fivondronana** -0.3096 0.000Principal activity of household head***

animal husbandry/fishing -0.0957 0.395Commerce 0.0061 0.956Salaried 0.0374 0.559Artisan -0.1177 0.222Forest exploitation -0.0776 0.471Other -0.0238 0.229


Dprobit Model: Knowledge of Soil Degradation from slash-and-burn

Table 10a: dprobit model for knowledge of soil degradation from slash-and-burn (2288 Observations)Variable dF/dx p-value



Table 10b: dprobit model for knowledge of soil degradation from slash-and-burn (2249 Observations)Variable dF/dx p-value

Year 0.0997 0.026Integration site 0.1472 0.001Program effect (Integration*year) -0.0107 0.835Age of household head 0.0003 0.716Marital status of household head (Not in union=1) -0.0248 0.562Education of household head 0.0521 0.000Sex of household head (Female=1) -0.1300 0.006Cultivable land (yes=1) 0.1772 0.005Haute Matsiatra region* 0.0395 0.214Anosy Region* -0.1376 0.000Anosibe An'Ala Fivondronana** -0.0728 0.091Ambalvao Fivondronana** 0.1048 0.043Amboasary Fivondronana** -0.0034 0.942Principal activity of household head***

animal husbandry/fishing -0.0455 0.620Bee-Keeping 0.1639 0.533Commerce -0.0990 0.164Salaried -0.0117 0.815Artisan 0.0177 0.812Forest exploitation 0.0497 0.631Other 0.0662 0.420


Limitations to the Quasi-Experiment

Not randomized Short follow-up period

(2001-2004) Wide definition of

integration and control DiD analyses assume “time

invariant selection bias” (Ravallion, 2005)

Uncontrollable external events affecting some sites but not others

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Conclusions Results are inconclusive, especially given

some limitations in design and data 5/6 of indicators showed no program effect Integration decreased moderate/severe

childhood stunting by 13.51% More research is needed

Need to clearly define and operationalize integration and control

Missing piece: cost-effectiveness

References Kleinau, E., Randriamananjara, O., & Rosenweig, F. (2005).

Healthy People in a Healthy Environment: Impact of an Integrated Population, Health, and Environment Program in Madagascar. Washington, D.C./USAID: Environmental Health Project.

Ravallion, Martin. (2005) Evaluating Anti-Poverty Programs (06/01/2005). World Bank Policy Research Working Paper Series. Available at SSRN: http://ssrn.com/abstract=922915 (Retrieved August 23, 2007).

Wooldridge, Jeffrey. (2002). Econometric Analysis of Cross Section and Panel Data. Cambridge, MA: MIT Press.

Many thanks to Heather D’Agnes and Eckhard Kleinau for their guidance and help!

preliminary findings from a phe operations research activity in madagascar yung-ting kung, mph...

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