The evaluation of Suchana, a large-scale development program to prevent chronic undernutrition in north-eastern Bangladesh

摘要

Evidence of the impact of community-based nutrition programs is uncommon for two main reasons: the lack ofuntreated controls, and implementation does not account for the evaluation design. Suchana is a large-scale programto prevent malnutrition in children in Sylhet division, Bangladesh by improving the livelihoods and nutritionknowledge of poor and very poor households. Suchana is being implemented in 157 unions, the smallestadministrative unit of government, in two districts of Sylhet. Suchana will deliver a package of interventions to poorpeople in about 40 randomly selected new unions annually over 4 years, until all are covered. All beneficiaries willreceive the normal government nutrition services. For evaluation purposes the last 40 unions will act as a control forthe first 40 intervention unions. The remaining unions will receive the program but will not take part in the evaluation.A baseline survey was conducted in both intervention and control unions; it will be repeated after 3 years to estimatethe impact on the prevalence of stunted children and other indicators. This stepped wedge design has severaladvantages for both the implementation and evaluation of services, as well as some disadvantages. The units ofdelivery are randomized, which controls for other influences on outcomes; the program supports government servicedelivery systems, so it is replicable and scalable; and the program can be improved over time as lessons are learned.The main disadvantages are the difficulty of estimating the impact of each component of the program, and thegeographical distribution of unions, which increases program delivery costs. Stepped implementation allows a clusterrandomized trial to be achieved within a large-scale poverty alleviation program and phased-in and scaled-up over aperiod of time. This paper may encourage evaluators to consider how to estimate attributable impact by usingstepped implementation, which allows the counterfactual group eventually to be treated.