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height="1.2013888888888888in"}

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height="0.5506944444444445in"}

# ACRONYMS

  -------------- --- -----------------------------------------------------
  ADMARC             Agricultural Development and Marketing Corporation

  AED                Academy for Educational Development

  AIDS               Acquired immunodeficiency syndrome

  ADP                Agricultural Development Programme

  ANC                antenatal care

  BASICS             Basic Support for Institutionalizing Child Survival
                     (MSH)

  BMI                body mass index

  CAADP              Comprehensive Africa Agriculture Development Program

  CBO                community-based organization

  CCM                Community Case Management

  CDC                Centers for Disease Control

  CED                chronic energy deficiency

  CGIAR              Consultative Group for International Agricultural
                     Research

  CI                 chronically ill

  CMAM               community-based management of acute malnutrition

  CS                 Cooperating Sponsor

  CSH                Child Survival and Health

  DA                 Development Assistance

  DAP                Development Assistance Program (Title II)

  EGAT               USAID/Bureau for Economic Growth, Agriculture and
                     Trade

  ENA                Essential Nutrition Actions

  EU                 European Union

  EPI                expanded program for immunizations

  DFID               UK Department for International Development

  FANTA              Food and Nutrition Technical Assistance Project (AED)

  FAO                Food and Agricultural Organization of the United
                     Nations

  FEWS NET           Famine Early Warning System Network

  FFA                food for assets

  FFW                food for work

  GDA                Global Development Alliance

  GDP                gross domestic product

  GNI                gross national income

  GOM                Government of Malawi

  HBC                home-based care

  HIPC               Heavily Indebted Poor Country Initiative

  HIV                human immunodeficiency virus

  HSA                health surveillance assistant

  ICRISAT            International Crop Research Institute for the
                     Semi-Arid Tropics

  IEC                information, education and communication

  IEHA               Initiative to End Hunger in Africa

  IFA                iron folic acid

  IHS                Integrated Household Survey

  I-LIFE             Improving Livelihoods through Increasing Food
                     Security

  IMCI               integrated management of childhood illnesses

  IPT                intermittent preventive treatment for malaria

  ITN                insecticide treated net

  IYCF               infant and young child feeding

  M&E                monitoring and evaluation

  MCH                maternal and child health

  MDG                Millennium Development Goals

  MDHS               Malawi Demographic and Health Survey

  MGDS               Malawi Growth and Development Strategy

  MICS               Multiple Indicator Cluster Survey (UNICEF)

  MOA&FS             Ministry of Agriculture and Food Security

  MOH                Ministry of Health

  MPRS               Malawi Poverty Reduction Strategy

  MPVA               Malawi Poverty and Vulnerability Assessment

  MTE                mid-term evaluation

  MVAC               Malawi Vulnerability Assessment Committee

  MYAP               Multi-year Assistance Program

  NAC                National Aids Commission

  NASFAM             National Small Holder Farmers\' Association of Malawi

  NEC                National Economic Council

  NFRA               National Food Reserve Agency

  NGO                non-governmental organization

  NRU                nutrition rehabilitation unit

  OFDA               Office of Foreign Disaster Assistance

  OVC                orphans and vulnerable children

  PEPFAR             US President\'s Emergency Plan for AIDS Relief

  PLHIV              people living with HIV

  PMI                US President\'s Malaria Initiative

  PMTCT              prevention of mother to child transmission of HIV

  PRRO               Protracted Relief and Recovery Operation

  PVO                private voluntary organization

  PSI                Population Services International

  SAM                Severe Acute Malnutrition

  UNICEF             United Nations Children\'s Fund

  USAID              United States Agency for International Development

  USDA               United States Department of Agriculture

  USG                United States Government

  WFP                World Food Programme
  -------------- --- -----------------------------------------------------

# TABLE OF CONTENTS

[ACRONYMS i](#acronyms)

[EXECUTIVE SUMMARY 1](#executive-summary)

[1. OBJECTIVES OF THE PROGRAMMING STRATEGY
4](#objectives-of-the-programming-strategy)

[2. DEFINITION OF FOOD SECURITY 4](#definition-of-food-security)

[3. FOOD SECURITY SITUATION IN MALAWI
5](#food-security-situation-in-malawi)

[3. 1. Food Insecurity at the National Level
5](#food-insecurity-at-the-national-level)

[3.2. Geographic Distribution of Food Insecurity
9](#geographic-distribution-of-food-insecurity)

[3.2.1. Food Availability 9](#food-availability)

[3.2.2. Access to Food 12](#access-to-food)

[3.2.3. Utilization of Food 14](#utilization-of-food)

[3.2.4. Risks and Vulnerabilities 18](#risks-and-vulnerabilities)

[4. STRATEGIES AND PROGRAMS RELATED TO REDUCING FOOD INSECURITY IN
MALAWI
20](#strategies-and-programs-related-to-reducing-food-insecurity-in-malawi)

[4.1. GOM Plans, Strategies and Programs
20](#gom-plans-strategies-and-programs)

[4.2. USG Strategies and Programs 21](#usg-strategies-and-programs)

[4.2.1. Alignment with the New Foreign Assistance Framework
21](#alignment-with-the-new-foreign-assistance-framework)

[4.2.2. USAID/Malawi Strategies and Programs
25](#usaidmalawi-strategies-and-programs)

[4.2.3. USAID/Food for Peace 2006-2010 Strategic Plan
26](#usaidfood-for-peace-2006-2010-strategic-plan)

[4.2.4. The FY 2005-2009 Title II Development Assistance Program (DAP)
in Malawi
27](#the-fy-2005-2009-title-ii-development-assistance-program-dap-in-malawi)

[4.3. World Food Programme (WFP) 29](#world-food-programme-wfp)

[4.4. Other Donors 30](#other-donors)

[5. PROGRAMMING STRATEGY FOR FOOD INSECURITY IN MALAWI
31](#programming-strategy-for-food-insecurity-in-malawi)

[5.1. Role of Mission Programs funded by other accounts in Supporting
Improvements in Food Security
31](#role-of-mission-programs-funded-by-other-accounts-in-supporting-improvements-in-food-security)

[5.2. Role of the Title II Multi-Year Assistance Program (MYAP) in
Addressing Food Insecurity
31](#role-of-the-title-ii-multi-year-assistance-program-myap-in-addressing-food-insecurity)

[5.2.1. Objectives and Desired Outcomes
31](#objectives-and-desired-outcomes)

[5.2.2. Program Priorities 32](#program-priorities)

[5.2.3. Mission Management Priorities
47](#mission-management-priorities)

[5.2.4. Key Design Considerations 47](#key-design-considerations)

[5.2.5. Cross-cutting Issues 54](#cross-cutting-issues)

[6. COLLABORATION AND RESOURCE INTEGRATION
56](#collaboration-and-resource-integration)

[REFERENCES 57](#references)

[ANNEX 1: MAPS OF MALAWI 60](#annex-1-maps-of-malawi)

[ANNEX 2: LIVELIHOOD ZONES IN MALAWi
63](#annex-2-livelihood-zones-in-malawi)

[ANNEX 3: FFP STRATEGIC FRAMEWORK FOR 2006-2010
64](#annex-3-ffp-strategic-framework-for-2006-2010)

[ANNEX 4: FFP EXPANDED CONCEPTUAL FRAMEWORK FOR UNDERSTANDING FOOD
INSECURITY
65](#annex-4-ffp-expanded-conceptual-framework-for-understanding-food-insecurity)

[ANNEX 5: DESCRIPTIONS OF COMMUNITY-BASED NUTRITION PROGRAMS
66](#annex-5-descriptions-of-community-based-nutrition-programs)

[ANNEX 6: KEY CONSIDERATIONS FOR EFFECTIVE BEHAVIOR CHANGE PROGRAMMING
71](#annex-6-key-considerations-for-effective-behavior-change-programming)

[ANNEX 7: RESOURCES ON COMMUNITY-BASED PROGRAMS AND BEHAVIOR CHANGE
PROGRAMMING
72](#annex-7-resources-on-community-based-programs-and-behavior-change-programming)

[ANNEX 8: RECOMMENDATIONS FOR IMPLEMENTING GROWTH MONITORING AND
PD/HEARTH PROGRAMS
74](#annex-8-recommendations-for-implementing-growth-monitoring-and-pdhearth-programs)

[ANNEX 9: USAID HIV AND FOOD SECURITY CONCEPTUAL FRAMEWORK
76](#annex-9-usaid-hiv-and-food-security-conceptual-framework)

[ANNEX 10: FPP INFORMATION BULLETINS ON FFP INDICATORS AND REPORTING
SYSTEMS
87](#annex-10-fpp-information-bulletins-on-ffp-indicators-and-reporting-systems)

# EXECUTIVE SUMMARY

The purpose of the USAID Malawi Food Security Programming Strategy is to
provide guidance to current and potential USAID Mission partners on
designing effective food security programs for Malawi for FY2008-FY2014.

Malawi is one of the poorest countries in the world, and poverty is
widespread. Despite some improvements in food security during the 1990s,
Malawi remains food insecure with improvements needed in food
availability, access and utilization. The country is also highly
vulnerable to droughts, floods and external economic shocks, including
increases in the prices of petroleum and fertilizer and reductions in
the prices of major export crops, such as cotton, tobacco and tea. Given
the importance of agriculture and the overall lack of diversity in the
Malawian economy, these shocks can have economy-wide effects on
national-level food supplies and the level and rate of economic growth
as well as adverse effects on individual households' incomes and access
to food. The fact that almost half of the children under five are
chronically malnourished is an indicator of the magnitude of the food
security problem. It also highlights the serious implications of the
current food security situation for the country's future economic,
social and political development.

The degree of food insecurity in Malawi varies geographically depending
on the agro-ecology of specific areas, the levels of poverty and chronic
malnutrition, risks and vulnerability to shocks, particularly drought
and floods, and the prevalence of illnesses such as HIV, tuberculosis
and malaria. According to the most recent data available, the Southern
Region, which is home to almost half of the poor and has the highest
prevalence of poverty, is the most food insecure area of the country in
terms of poverty, vulnerability and access to food. Prevalence of
chronic malnutrition is also extremely high in the Southern Region, less
than a percentage point lower than the prevalence in the Central Region,
which has the highest prevalence.

The Title II program can play a positive role in this environment by
helping "*to reduce food insecurity among vulnerable populations in
Malawi*." In Malawi, this includes the poor, children under two, and
pregnant and lactating women. Given the nature of the food security
problems in Malawi, Title II programs should be designed to contribute
to improving food availability, access and utilization and to reducing
the vulnerability of the individuals, households and communities
targeted by the program.

The Malawi Food Security Programming Strategy identifies priority
outcomes and activities, which are outlined in the following box and
described in more detail in the section on "Program Priorities" (See V,
B, 2). In areas that have a high prevalence of HIV, these activities
will need to be adapted and modified to meet the special needs of
HIV-affected communities, households and individuals.

In designing their Multi-year Assistance programs (MYAPS), Title II
Cooperating Sponsors (CSs) should ensure that their programs are
targeted to the more food insecure and vulnerable regions, districts,
traditional authorities and communities within Malawi. USAID/Malawi
should guide this process by sponsoring a more detailed and updated
analysis of the food security situation by district prior to the design
of the new round of MYAPs in FY 2010. This will enable all potential
Title II CSs to work from the same data base.

To be effective at the community level, the Title II CSs need to open
their agricultural technology transfer and marketing programs to all
community members who wish to participate. To make sure these programs
meet their food security objectives, however, the CSs may also have to
adapt and modify these programs so that the more food insecure
households in the community, including those affected by HIV, are able
to participate in them. Because of the high levels of chronic
malnutrition, the health and nutrition activities should focus on
prevention by targeting all households with children under two years of
age and not just households with currently malnourished children. The
programs that involve food transfers, in contrast, need to be targeted
more narrowly to food insecure households and individuals, which will
include, but should not be limited to, HIV-affected households (See
Section V, B, 4, a).

Other key design considerations discussed in the document include:
finding the right balance between food and cash, integrating programs at
the community level, integrating HIV into the program, anticipating the
need for an emergency response, monitoring and reporting on program
performance and developing sustainability and exit strategies. As a
result of FFP's Strategic Plan, the Title II CSs are now required to pay
more attention to reducing vulnerability and risk, and this concern
needs to be reflected throughout their programs. This should start with
a risk and vulnerability assessment for each target community. This and
other cross-cutting issues \-- building local capacity, the environment
and gender equity -- are also discussed in Section V, B, 5.

Organizations that desire to partner with USAID/Malawi in food security
programming will need to explore mechanisms for collaboration and joint
programming to ensure efficient use of resources. Prospective MYAP
partners are encouraged to demonstrate how their Title II programs will
build on the comparative advantage of Title II and maximize synergies
and complementarities with other programs, including the U.S.
President's Emergency Plan for AIDS Relief (PEPFAR), and Mission and
USAID regionally- and centrally-funded projects. Prospective CSs should
also indicate how their programs align with and support GOM strategies
and programs, including the Malawi Growth and Development Strategy
(MGDS), Food Security Policy, Nutrition Policy and the Agricultural
Development Programme (ADP). []{.mark}

# 1. OBJECTIVES OF THE PROGRAMMING STRATEGY

The purpose of the USAID Malawi Food Security Programming Strategy is to
provide guidance to current and potential USAID Mission food security
partners on how to design effective food security projects for the
period FY 2008-2014 and to improve programmatic and resource
integration. The Strategy identifies the key factors contributing to
food insecurity and vulnerabilities in Malawi, using the USAID
definition of food security as a basis for describing the current food
security situation in the country, identifying who are the food
insecure, where they are located, why they are food insecure, and what
actions are necessary to reduce their food insecurity. The document also
describes the institutional context in which the USAID Malawi Food
Security Programming Strategy will be implemented, in terms of existing
United States Government (USG) and Government of Malawi (GOM) strategies
and programs. The audience for this strategy is Title II cooperating
sponsors (CSs), non-governmental organizations (NGOs), institutions,
donors, GOM entities working in food security in Malawi and USAID staff
in Malawi and Washington. The Malawi Food Security Programming Strategy
is based on a review of the literature and current data on food
insecurity in Malawi, field visits to USAID/Malawi food security partner
projects and key informant interviews with staff from USAID/Malawi,
USAID/Washington, the GOM, NGOs, and other institutions that are
stakeholders in food security programming in the country.

# 

# 2. DEFINITION OF FOOD SECURITY

In 1992, USAID's Policy Determination 19 established the following
definition for food security: *"Food security exists when all people at
all times have both physical and economic access to sufficient food to
meet their dietary needs for a productive and healthy life."*[^1] The
definition focuses on three distinct but inter-related elements, all
three of which are essential to achieving food security:

-   **Food availability**: having sufficient quantities of food from
    household production, other domestic output, commercial imports or
    food assistance,

-   **Food access**: having adequate resources to obtain appropriate
    foods for a nutritious diet, which depends on available income,
    distribution of income in the household and food prices, and

-   **Food utilization**: proper biological use of food, requiring a
    diet with sufficient energy and essential nutrients, potable water
    and adequate sanitation, as well as knowledge of food storage,
    processing, basic nutrition and child care and illness management.

This document uses the above definition of food security, with the
addition of the concepts of risk and vulnerability, [^2] as a framework
to describe the context and determinants of food insecurity in Malawi,
and the programmatic actions necessary to reduce food insecurity in the
country.

# 3. FOOD SECURITY SITUATION IN MALAWI

This section begins with an overview of food security at the national
level in Malawi. It describes the main food security problems related to
food availability, access, and utilization and the risks and
vulnerabilities that affect food security. It also discusses where these
problems are concentrated geographically in Malawi.

## ![](media/image3.wmf){width="3.348611111111111in" height="2.151388888888889in"}3. 1. Food Insecurity at the National Level

![](media/image4.wmf){width="3.3375in"
height="2.4770833333333333in"}Despite some improvements in food security
during the 1990s, primarily in food availability, Malawi remains a food
insecure country with improvements needed in food availability, access
and utilization.[^3] According to the Food and Agriculture Organization
(FAO) of the United Nations, food supplies at the country-level have
increased from 1,880 calories per person per day in 1990-92 to 2,120 in
2002-04. While this is an improvement, it is still low in comparison to
some other countries in the region.[^4]

The averages mask the year to year changes that take place in domestic
maize production, due primarily to weather conditions, and also grain
imports. During drought years, including the 1991/92 drought that
affected all of Southern Africa as well as the more localized droughts
in 1997/98, 2001/02 and 2004/05, the country had to rely on food
assistance as well as commercial imports to maintain food supplies.
These droughts had adverse effects not only on the maize crop but also
on the production of cash crops, foreign exchange earnings and the
country's capacity to import commercially.

![](media/image5.wmf){width="3.348611111111111in"
height="2.151388888888889in"}Lack of access to food due to poverty,
however, is the root cause of food insecurity in Malawi. Poverty in
Malawi is widespread and pervasive, with 52 percent of the population
estimated to be poor and 22 percent to be ultra-poor, [^5] or too poor
to be able to afford even a minimum basic diet. Equally discouraging is
the fact that the country has had little or no success in reducing
poverty in recent years, with the percent of households living in
poverty dropping by only two percentage points between 1998 and 2005.

![](media/image6.wmf){width="3.3722222222222222in"
height="2.1395833333333334in"}

This lack of progress also shows up in the FAO estimates of the numbers
and percent of the population that are undernourished.[^6] During the
first half of the 1990s, for example, the numbers and percent of the
undernourished population declined along with the increases in overall
food supplies. However, this progress has slowed in the last few years,
along with the progress in reducing poverty, with some indication that
the numbers of undernourished may actually have increased during the
last decade, from 4.1 million in 1995-97 to 4.2 million in 2002-04.

Perhaps the most serious outcome of the food insecurity problem,
however, is the high percentage of children suffering from chronic
malnutrition.[^7] Almost half of the children under five were found to
be stunted (too short-for their age) in the 2004 Demographic and Health
Survey (MDHS) [^8] (see Table 1). What is of even more concern is the
fact that data from three consecutive DHS surveys show almost no
improvement in the prevalence of stunting over the last ten years, a
situation that has serious implications for the country's future
economic, social and political development.

![](media/image8.png){width="3.875in" height="2.8125in"}

There are, however, reasons to be optimistic about the future of Malawi.
The country enjoys peace and stability. And, its recently elected
reformist government is improving fiscal management, combating
corruption, addressing the HIV epidemic and taking measures to encourage
economic growth. As a result of recent successes in improving fiscal
management, Malawi qualified for the Heavily-Indebted Poor Country
Initiative (HIPC) in 2006 and had virtually all of its external debt
cancelled. This should substantially improve Malawi's international
credit rating and reduce interest rates, while the over \$100 million
that would otherwise have been used for debt-servicing is now freed up
for more productive investments.

On the other hand, the challenges facing the country are enormous.
Malawi is a small land-locked[^9] country with one of the highest
population densities in Sub-Saharan Africa, and one of the lowest per
capita incomes in the world. In 2005, for example, its per capita income
was only \$167, less than one-third of the average for Sub-Saharan
Africa.

Over 85 percent of Malawi's 13 million people live in rural areas, where
most are engaged in rain fed agriculture, which makes them highly
vulnerable to annual variations in rainfall. This, plus the fact that
most only have access to small plots of land, means that poverty is
pervasive in the country and not just a problem for those at the bottom
of the income distribution. Social indicators are also dismal, and the
country has a long way to go to meet the Millennium Development Goals
(MDGs). The average life expectancy is only 37 years, a reflection of
the high prevalence of HIV. Malaria and tuberculosis are also
widespread. Child and maternal mortality rates are also among the
highest in the world. Only 64 percent of the population is literate,
with 60 percent of students dropping out before completing primary
school.

The country needs to grow economically in order to reduce poverty and
food insecurity and at a faster[^10] and steadier rate.[^11] To
accomplish this objective, Malawi will need to create an enabling
environment that encourages the development of the private sector and
the expansion of the country's production and export sectors. Economic
growth and poverty reduction efforts also face many other challenges,
including the need to diversify the economy, improve the quality and
quantity of infrastructure, enhance governance and reduce corruption,
improve gender equity, increase regional integration, reduce HIV
infection rates and protect the environment.

## 

## 3.2. Geographic Distribution of Food Insecurity

Malawi is divided into three regions -- the Northern Region with six
districts, the Central Region with nine and the Southern Region with
twelve.[^12] (See Annex 1, Map 1A). The degree of food insecurity in
these regions varies depending on their agro-ecology, levels of chronic
poverty and chronic malnutrition, risks and vulnerability to shocks,
particularly drought and floods, and the prevalence of illnesses such as
HIV, tuberculosis and malaria. Data on food security indicators by
region and district are presented in this section organized according to
their relationship to three major elements of food security --
availability, access and utilization -- and risk and vulnerability.

### 

### 3.2.1. Food Availability

Low agricultural productivity and limited investment in the sector,
compounded by problems of land tenure, reliance on rain, lack of rural
credit, inadequate physical infrastructure and poorly functioning
marketing institutions have resulted in the agricultural sector being
periodically unable to feed the Malawian population or to stimulate
overall economic growth. Raising agricultural productivity and
diversifying the agricultural base, including by increasing the value
added to agricultural products, is key to increasing rural incomes and
reducing the widespread food insecurity faced by Malawi's population.

Agriculture is critical to achieving food security in Malawi at the
national as well as the household level. Agriculture is the single most
important sector of the economy, employing 85 percent of the workforce
and contributing 36 percent of the country's GDP and over 80 percent of
the country's foreign exchange earnings. This means that food supplies,
at the household and the national level, depend ultimately on the
productivity of the agricultural sector, how much food is available from
domestic production and how much cash is available to purchase food when
domestic production is insufficient to meet needs. Agricultural
production is erratic, however, due to weather related shocks, drought
in particular, and lack of irrigation. This leads to periodic food
shortages, when domestic food production declines and the capacity to
import food commercially is reduced due to the decline in the volume and
value of agricultural exports. These frequent food shortages occur
despite a large natural resource base and potential water resources.

Food security is also negatively affected by the lack of diversification
in the agricultural sector. Malawi is highly dependent on maize, which
is the major food crop, and burly tobacco, which is the major cash crop.
Yields of both have been declining. Maize occupies as much as 75 percent
of the cropland and is grown by 97 percent of farmers. For most
Malawians, maize is synonymous with food and a sense of food security at
the household level. With tobacco exports being the main source of
foreign exchange, a poor tobacco harvest can also create downward
pressures on the currency, making it more expensive to import essential
goods, including petroleum, fertilizer and food. With one crop per year,
foreign exchange levels also tend to follow an annual cyclical pattern
tied to the timing of the tobacco auctions.

Food production is dominated by smallholders, and small-holder
agriculture provides a livelihood to over 2.4 million households. Small
holders also contribute about 80 percent of agricultural GDP, with
commercial farms producing the rest.[^13] Most smallholders are almost
completely dependent on agriculture for their livelihoods. Their
productivity is low, however, and, with limited irrigation, most can
only produce one crop per year. Farm sizes also are small, especially in
the south, and are declining. Three out of four farmers cultivate less
than a hectare, for example, and 40 percent of holdings are less than
one half a hectare. The result is that only a small percentage of
farmers are able to produce enough maize to last them throughout the
year, and because off-farm employment opportunities are limited, many
households experience a "hungry season" when supplies run low.[^14]

At the household level, the availability of food can be affected not
only by household and local production but also by production in other
parts of the country, commercial imports and food assistance. In Malawi,
high transportation costs[^15] plus the GOM's emphasis on maize
self-sufficiency and its interventions in maize markets, mean that poor
rural people are more dependent on their own food production and food
production in their own local communities than in other countries where
food markets function better and transportation costs are lower.

Production conditions and market opportunities vary in different parts
of the country, resulting in differences in the types of food grown and
the levels of production and market dependence. According to a recent
analysis of livelihood zones by the Malawi Vulnerability Assessment
Committee (MVAC),[^16] altitude,[^17] soils, and proximity to and size
of markets are among the more important determinants of these patterns
(See Annex 1, Map 1B). Per capita food production is generally lower and
dependence on food purchases and food obtained in exchange for labor is
higher in the southern livelihood zones than in the center or in the
north. Farmers in some areas in the southern livelihood zones can grow a
wider range of crops, which makes them less dependent on maize. On the
other hand, more land is occupied by estates in the southern zones and
individual farms are smaller, which limits farmers' options. Farmers in
the Kasungu Lilongwe Plain and Western Rumphi/Mzimba zones also produce
a variety of products, including tobacco, groundnuts and livestock but
are particularly dependent on maize as their main staple. More cassava
is produced in some livelihood zones \-- the two northern zones of
Nkhata Bay Cassava zone and Central Karonga -- which helps ensure local
food security in the event of a maize crop failure. The poor in these
livelihood zones are also more likely to be self-sufficient in food, in
part as a result of cassava's relatively low requirements for both labor
and inputs, and because many also grow bananas, rice and sweet potatoes.

Most rural people are heavily dependent on sales of crops -- tobacco,
cotton and food -- to earn cash income. Few households receive
remittances from elsewhere. This is true across livelihood zones. Some
are also able to supplement their crop sales with sales of other
products, including charcoal, firewood and grass mats, in local markets.
Tobacco is grown in the higher altitude zones in the Northern and
Central Regions of the country while cotton is grown in the lower
altitudes in the Shire Valley livelihood zones. The market for casual
labor tends to be localized, however, on the tea and sugar estates in
the Southern Region and the tobacco estates in the Central Region,[^18]
with little migration between regions. The markets for tobacco and
cotton are unpredictable and subject to international factors beyond
Malawi's control. Local markets, which are perhaps more predictable, are
stronger in the Southern and Central Regions. However, most local
markets are small, due to the small numbers and overall poverty of the
people; supply frequently exceeds demand, putting downward pressure on
prices.

Dependence on food purchases increases as one moves from the north to
the south of the country. In some districts in the Southern Region,
which contains more of the poor than the other two regions, households
may rely on the market for 30 to 40 percent of their food needs in
normal years. The Southern Region also contains the country's largest
urban population as well as its largest commercial sector. This has a
positive effect on the livelihoods of rural people in terms of the
prices they can obtain for their surplus crops and other products they
can produce and in the opportunities for casual employment. The Northern
Region, in contrast, is more sparsely populated, not very urbanized and
is isolated commercially. So, where soil conditions are favorable, a
greater proportion of the population in the Northern Regions is more or
less food self-sufficient. The Central Region contains a major urban
center and is a major producer of maize and tobacco. Here, increasing
population pressure on the land combined with low pay rates and rising
prices for inputs has meant that an estimated one in four households
normally produce only half of their grain requirement annually and must
spend what is left from their tobacco profits, after repaying debts for
inputs, on basic foods. The Central Region also contains a number of
small areas where drought is persistent.

### 

### 3.2.2. Access to Food

One of the most straightforward indicators of a population's access to
food is the percent of the population living below the poverty line.
[^19] As indicated earlier, poverty in Malawi is widespread and
pervasive, with over half the population still living in poverty in 2005
and over 22 percent classified as ultra-poor with insufficient income to
meet even their basic food needs.[^20] The existence of frequent and
widespread shocks in Malawi has also resulted in large movements of
people into and out of poverty, creating another category of people that
some analysts refer to as the transient poor. (See box on following page
for more details on the characteristics of these groups.)

Poverty in Malawi is primarily a rural problem, with over 94 percent of
the poor living in rural areas (see Table 3). It is also concentrated in
the Southern Region where almost half of the poor live. The prevalence
of poverty is higher in the Southern Region, with almost two thirds of
the population living in poverty there and almost a third living in
ultra poverty.[^21] Districts in the Southern Region are more likely to
be poor and districts in the Central Region are more likely to be better
off. Eight of the ten poorest districts are located in the Southern
Region, for example, and the three richest rural districts are all in
the Central Region (see Table 4).

The picture becomes more complicated when one looks at the distribution
of poverty by Traditional Authority (TA), a smaller administrative unit
than the district. According to the most recent poverty map, which has
been estimated using data from the 1998 census and Second Integrated
Household Survey (IHS2), the highest levels of poverty are concentrated
in the southernmost and northernmost areas of the country (See Annex 1,
Map 1 C). The Central Region has consistently lower levels of poverty,
except for two very small and isolated pockets. The greatest variations
in poverty levels are in the Northern Region, which includes some areas
with the highest concentrations of poverty as well as some of the
relatively better off areas. Substantial variations also exist within
urban areas.[^22]

With respect to gender, poverty rates are higher in female-headed
households (58 percent compared to 51 percent for male-headed
households) but in terms of numbers, more poor people live in
male-headed than female-headed households. Female-headed households are
more likely to be poor because women are less likely to engage in cash
crop production, spend less time in income generating activities, are
less likely to be employed, are paid less than men for the same
task/period, and are less likely to get access to extension services and
credit.[^23]

Due to the HIV epidemic, increasing numbers of households are headed by
women, children or the elderly (who are often left caring for orphaned
grandchildren). It is generally accepted that these households are more
vulnerable than others to both chronic poverty and to transitory shocks,
partially due to the loss of adult male labor. These households share a
common characteristic in that they are either structurally
labor-constrained, or their labor capacity has been undermined by
chronic health problems or the need to care for other sick household
members.

On the other hand, being an orphan is not consistently correlated with a
higher probability of being ultra-poor, possibly due to the purposive
placement of orphaned children in better off households in the extended
family network. Nor are households affected by chronic illnesses and HIV
likely to be poorer than other households, again possibly due to support
by the extended family and community coping strategies. In fact,
according to the Malawi Poverty and Vulnerability Assessment (MPVA),
non-poor households report higher morbidity and prevalence of chronic
illness than poor households. Data from IHS2 also indicates that the
percentage of children that is chronically malnourished is fairly
constant across income levels in rural areas. This is in contrast to
urban households, which exhibit a large drop in the prevalence of
chronic malnutrition as their wealth levels increase, from 57 percent in
the poorest quintile to 38 percent in the wealthiest quintile.[^24]

### 

### 3.2.3. Utilization of Food

The nutritional status of children less than five years of age, as
measured by either stunting (height-for-age Z score \<-2SD) or
underweight (weight-for-age Z score \< -2SD), is one of the best
indicators of food utilization and also a good indicator of the overall
level of development in a country.[^25] In Malawi, as indicated earlier,
almost half the children under five are stunted, which is significantly
above the 40 percent prevalence for stunting that WHO classifies as
being very high.[^26]

Stunting rates also vary by region and district, with the highest levels
of stunting in the Central (47 percent) and Southern Regions (46.3
percent), especially in the districts of Dedza, Machinga, Mchinji,
Mwanza, Ntcheu, Ntchisi, and Zomba, where more than 50 percent of
children under five are stunted (see Table 5 on the previous page). It
is interesting to note that, although the Central Region has the highest
stunting prevalence, it also has the highest per capita caloric
availability.[^27] The most recent data from UNICEF suggests that
stunting rates improved by almost two percentage points between 2004 and
2006, with almost a five percentage point reduction in the Central
Region.[^28] However, a great deal of improvement is still necessary,
especially in the Southern Region and in districts such as Machinga and
Blantyre, where stunting rates have increased since 2004.

Women's chronic energy deficiency (CED), as measured by Body Mass Index
(BMI), is another indicator of food insecurity. High prevalence of CED
among women may result from inadequate energy intake, which can be due
to many factors including lack of food access, anorexia due to infection
and nausea, discriminatory intra-household food distribution, and
self-sacrificing behavior.[^29] Heavy physical labor, such as water and
fuel collection or agricultural work, can also exacerbate CED. CED
increases the risk of wasting, ill health, and poor physical performance
and is associated with poor birth outcomes, including low birth weight.
CED prevalence between 10 and 19.9 percent indicates a poor nutrition
situation requiring intervention, which may include supplementation,
increased food production, education and/or behavior change. CED
prevalence between 5 and 9.9 percent signals the need for monitoring and
prevention efforts. In Malawi, the prevalence of CED among women is
highest in the Southern Region, followed by the Northern and Central
Regions (see Table 5). Of the districts for which data are available,
more than 10 percent of women in the southern districts of Machinga,
Mangochi, Mulanje and Zomba have CED, indicating the need for
intervention.

Proper child care and a diet with adequate energy and nutrients are
essential to achieving adequate food utilization. In Malawi, most
children are introduced to breastmilk early and fed on-demand, and the
percentage of children exclusively breastfed has improved dramatically
over the past 15 years. Still, according to MDHS 2004 and MICS 2006,
just over half of children under six months of age are exclusively
breastfed, leaving almost half of infants under six months of age at
high risk of illness and malnutrition during a period of rapid growth
and development. Additionally, the quality and quantity of complementary
foods and the timing of introduction of these foods are of concern. With
over 60 percent of the population's total calories coming from cereals
(up to 77 percent among the poorest), and only 40 percent of children
age 6-23 months eating even a minimum number of food groups, the lack of
dietary diversity means that most children are not getting enough of the
nutrients they need for healthy growth and development. The quantity of
food that children in this age group are eating is unclear, but less
than half of children under two are fed the minimum number of times per
day; therefore, most children probably are not consuming enough
calories.[^30]

In addition to an energy and nutrient rich diet and adequate child care,
optimal utilization, or biological use of food, requires access to
adequate health services, education, illness management, potable water
and sanitation. Almost 80 percent of women surveyed in the 2004 MDHS
reported problems in accessing health care, with access varying by
region (see Table 6). The most common challenges included accessing
transport, getting money and distance. Approximately 58 percent of
pregnant women achieve the recommended four or more antenatal care
visits, and the quality of these services varies widely. Women in urban
areas, the Northern Region and educated and wealthy women are more
likely to receive quality antenatal care. Immunization coverage of
children is also low and has been declining since 1992. In 2006, for
example, only 62 percent of children were fully vaccinated by age 12
months, compared to 82 percent in 1992. Immunization coverage is worst
in the Central Region and in Kasungu, Machinga, Mangochi, Salima and
Lilongwe districts. The Central Region also ranks lowest in terms of the
percentage of households using improved drinking water and the
percentage of households with bed nets. The four districts with the
lowest household access to improved sources of water (less than 65
percent) \-- Dedza, Dowa, Mchinji, and Ntchisi -- are also in the
Central Region. Although malaria is the leading cause of morbidity and
mortality in children under five in Malawi and is endemic throughout the
country, only 23 percent of children under five sleeps under an
insecticide treated net (ITN). The districts with the lowest ITN
coverage are: Chitipa, Dowa, Kasungu, Machinga, Nkhata Bay, Ntcheu,
Ntchisi, Rumphi, and Thyolo, all with less than 20 percent of children
sleeping under ITNs.

### 3.2.4. Risks and Vulnerabilities

A number of factors contribute to households' vulnerability to chronic
or transitory food insecurity,[^31] including shocks, such as drought,
floods, chronic or acute illness of a household member, and crop and
animal pests and disease; low income diversity; and low levels of
livelihood capacities based on measures of human, financial, physical,
natural, and social capital available to the household. Some risks, such
as illness, affect individual households while others, such as floods,
drought, pests, price changes and other political events or economic
policies, affect whole communities, TAs, districts and regions. Malawi
is also vulnerable to external economic shocks, including increases in
the prices of petroleum and fertilizers and reductions in the prices of
the major export crops, such as cotton, tobacco and tea. Given the
importance of agriculture and the overall lack of diversity in the
Malawian economy, these shocks can affect the level and rate of growth
of GDP as well as individual households' incomes.

Pervasive risks and high vulnerability to shocks are among the main
causes of persistent poverty in Malawi. According to the MPVA, the most
common shocks facing households in Malawi relate to a drop in crop
yields and an increase in the price of food, reflecting Malawi's great
dependence on rain fed agriculture and its high exposure to droughts and
floods. Over three quarters of the households interviewed during the
IHS2 during 2004/2005 stated that they had been negatively affected by
the rising price of food over the past five years, while two thirds
experienced lower crop yields due to droughts or floods. Droughts and
floods and rising food prices are also perceived as the most severe
shocks. Illness or injury to a household member is also very common,
affecting over one third of the households interviewed. The high
prevalence of shocks associated with the death of family members is also
common, reflecting, in part, the impact of the HIV epidemic. Multiple
shocks are also very common, especially in rural areas, with about 75
percent of rural households reporting more than three shocks, compared
to one third of urban households. In terms of vulnerability, however,
poor households are subject to fewer shocks because they avoid
high-risk, high return activities, but they are very susceptible to
specific shocks, crop failures in particular.

Income diversification, crop diversification and migration are the most
common strategies adopted by households to mitigate risks. Many
households, the poorer in particular, are unable to pursue these
strategies because of lack of access to capital and poorly functioning
food markets, which place a premium on the production of staple foods.
According to the MPVA, almost half the households interviewed have no
crop sales and only 30 percent sell livestock. Faced with shocks,
households first resort to increasing labor supply (21.1 percent),
cutting back on consumption (14.2 percent), spending cash savings (12.6
percent) and selling assets (10.7 percent)[^32] Borrowing or receiving
assistance is most associated with the serious illness of household
members. More than half the households interviewed reported "doing
nothing" in response to a large drop in the sales price of crops.[^33]
Shocks in the previous year are associated with decreases in durable
assets. Temporary withdrawal of children from school is another typical
coping strategy. In addition to the immediate short-term costs, these
coping mechanisms can permanently damage households' ability to engage
in productive activities.

Vulnerability to food insecurity is distributed somewhat differently
than poverty, however, with some districts with low levels of poverty
being highly vulnerable and vice versa. Much of this is related to the
level of diversification of livelihoods systems.[^34] Non-poor but
specialized districts can be more vulnerable than poor but economically
diversified districts because of the seasonality of production and
income. Vulnerability does increase from the north to the south, with
all ten of the districts in the Northern Region falling among the ten
least vulnerable districts while nine out of the ten most vulnerable
districts are in the Southern Region. In other words, while poverty and
vulnerability do not always correlate because of different risk factors,
they do converge in the Southern Region of the country.

Poverty and food insecurity in Malawi is exacerbated by the high
prevalence of HIV. According to the 2004 MDHS, 14 percent of the
population aged 15-49 is HIV positive, which places Malawi eighth in the
world in terms of the severity of its HIV epidemic.[^35] HIV
disproportionately affects the most productive age groups. The increased
mortality from AIDS, which is estimated to be responsible for about 75
percent of all deaths among the 20-49 year olds,[^36] has increased the
dependency ratio (the ratio of children and the elderly to the
economically productive). An estimated 87 thousand people are dying
annually from the disease and its associated complications, and the
number of orphans had risen from an estimated 560,000 in 1990 to
approximately 700,000 in 2005.[^37] Life expectancy in Malawi has
dropped to 37 years as a result of AIDS.[^38]

The consequences of HIV infection fall primarily on women, not only due
to their higher levels of infection but also due to social
responsibilities for family members. According to the MPVA, the HIV
prevalence is higher for women than men (13 percent compared to 10
percent). This is true at the national level, in both urban and rural
areas, in all regions and all economic groups and for most age groups.
Women also begin getting infected at a younger age, with almost four
percent of girls 15-19 years old infected compared to less than one
percent of boys in the same age group. Only among the population of
30-39 year olds do men have a higher rate of infection. Twenty percent
of men aged 30-34 are HIV positive compared to 18 percent of women, and
18 percent of men aged 35-39 are HIV positive compared to 17 percent of
women.[^39] Since HIV mostly affects people in their productive years,
older women are increasingly taking on the care giving role, even for
orphans and other vulnerable children (OVC). Beyond the role of care
giver, women may also be more vulnerable to the impact of adult deaths
if they lack title to property, either legally or as a result of
cultural tradition.[^40]

Urban areas have a much higher prevalence of HIV than rural areas (17
percent compared to 11 percent). The Southern Region has the highest
prevalence of HIV (18 percent) followed by the Northern region (8
percent) and the Central Region (7 percent). HIV prevalence is 20
percent or higher in Blantyre, Mangochi, Thyolo and Mulanje and five
percent or less in Kasungu.[^41]

# 4. STRATEGIES AND PROGRAMS RELATED TO REDUCING FOOD INSECURITY IN MALAWI

This section provides a summary of the strategies and interventions
currently used by the GOM, USAID and other development actors to address
food security in Malawi. (Further information regarding these strategies
and programs can be found in Table 7 at the end of this section.)
USAID/Malawi and its partners will complement and build upon these
approaches and interventions through activities that will be implemented
as part of the USAID Malawi Food Security Programming Strategy. Although
there are many development initiatives in the country, this document
focuses on food security initiatives.

## 4.1. GOM Plans, Strategies and Programs

The GOM has been making some progress in addressing its development and
food security problems. Until recently, GOM policies with respect to
food and agriculture have not always been consistent or implemented in a
consistent and effective manner. Factors contributing to these problems
included the "politicization of food security issues, donor
inconsistency and lack of coordination and a lack of capacity in public
and private institutions to conduct policy analysis or to monitor
implementation and impact."[^42] This situation improved dramatically in
2006 with the adoption of the Malawi Growth and Development Strategy
(MGDS), which provides the basic framework for all efforts to reduce
poverty and food insecurity in the country. The GOM indicates in the
document that it is trying to maintain a balance between the economic
and social sectors. However, the document also makes clear the GOM's
commitment to "poverty reduction through sustainable economic growth and
poverty reduction,"[^43] and it builds on the earlier Malawian Economic
Growth Strategy (MEGS), which emphasized the need to create a conducive
environment for private sector investment to stimulate the production of
goods and services and create employment opportunities. The MGDS
identifies six priority areas and five key themes (see Table 7 for more
details). Agriculture and food security is listed as the first priority,
in recognition that agricultural development will be the key to economic
growth in the country. The MGDS also identifies the prevention and
management of nutrition disorders, HIV and AIDS as its sixth priority.
Within this are goals of preventing the spread of HIV and managing
cases, ensuring the nutritional well-being of all Malawians and ensuring
that the additional nutrition needs of people living with HIV are met.

To translate the MGDS into actionable plans for 2006-2010, sector
reviews were conducted, including within the agriculture and health
ministries, to align resources to the core functional areas and improve
sector-level performance and results. These efforts led to the
reformulation of the Food Security and Nutrition policies, consolidation
of national safety-net activities into a national Social Protection
program and enabled the GOM to begin a process expected to lead to the
development of a Comprehensive Africa Agriculture Development Program
(CAADP) compact for Malawi. Work is also underway on the development of
an Agricultural Development Programme (ADP) which will focus on priority
action areas aimed at achieving the MGDS targets for the agricultural
sector. (See Table 7 for more details on these programs.)

## 4.2. USG Strategies and Programs

### 4.2.1. Alignment with the New Foreign Assistance Framework

Under the new Foreign Assistance Framework, all U.S. Government foreign
assistance spending has to be aligned with five key objectives, and
their program areas, program elements and program sub-elements. This is
true for all the Malawi Mission's funded programs as well as the current
Title II Development Assistance Program. This can be seen in Table 8,
with the USAID programs funded by other accounts focused on the
Governing Justly and Democratically, Investing in People and Economic
Growth objectives and the Title II DAP focused on the Investing in
People and Economic Growth objectives, a focus that is anticipated in
the framework itself.

### Table 7: Summary of Strategies and Programs Relevant to Achieving Food Security Objectives in Malawi

+-----------+-----+--------------------------------------------+------+
| Strateg   | Da  | Objectives and Interventions               | Res  |
| y/Program | tes |                                            | pons |
|           |     |                                            | ible |
+-----------+-----+--------------------------------------------+------+
| *G        |     |                                            |      |
| overnment |     |                                            |      |
| of Malawi |     |                                            |      |
| (GOM)*    |     |                                            |      |
+-----------+-----+--------------------------------------------+------+
| Malawi    | 200 | Five themes: (1) sustainable economic      | GOM  |
| Growth    | 6-2 | growth, (2) social protection, (3) social  |      |
| and       | 011 | development, (4) infrastructure            |      |
| De        |     | development and (5) good governance. Six   |      |
| velopment |     | priority action areas: (1) agriculture and |      |
| Strategy  |     | food security, (2) irrigation and water    |      |
| (MGDS)    |     | development, (3) transport infrastructure  |      |
|           |     | development, (4) energy generation and     |      |
|           |     | supply, (5) integrated rural development   |      |
|           |     | and (6) prevention and management of       |      |
|           |     | nutrition disorders, HIV and AIDS. Builds  |      |
|           |     | on MPRS but puts greater emphasis on       |      |
|           |     | economic growth.                           |      |
+-----------+-----+--------------------------------------------+------+
| Malawi    | 200 | Four pillars: (1) economic growth, (2)     | GOM  |
| Poverty   | 2-2 | human capital development, (3) safety nets |      |
| Reduction | 005 | and (4) governance. Put greater focus on   |      |
| Strategy  |     | reducing vulnerability through productive  |      |
| (MPRS)    |     | safety nets and disaster preparedness.     |      |
+-----------+-----+--------------------------------------------+------+
| Malawi    | 20  | Four major action areas: (1) increase      | GOM  |
| Food      | 07- | household and national food availability   |      |
| Security  |     | by stimulating household agricultural      |      |
| Policy    |     | production through irrigation, access to   |      |
|           |     | fertilizer, and better access to land; (2) |      |
|           |     | sustain access to food through improved    |      |
|           |     | rural markets infrastructure and household |      |
|           |     | purchasing power; (3) build proper         |      |
|           |     | utilization and nutrition through a        |      |
|           |     | variety of health and dietary service      |      |
|           |     | interventions and (4) stabilize food       |      |
|           |     | security through better disaster           |      |
|           |     | management, reserves, market interventions |      |
|           |     | and surveillance and food security         |      |
|           |     | information systems.                       |      |
+-----------+-----+--------------------------------------------+------+
| Malawi    | 20  | Prepared separately from the food security | GOM  |
| Nutrition | 07- | policy to ensure that nutrition would      |      |
| Policy    |     | receive adequate emphasis. Goal to improve |      |
| (Draft)   |     | nutritional status of all Malawians,       |      |
|           |     | especially pregnant and lactating women,   |      |
|           |     | children under 15 years of age, disabled   |      |
|           |     | people, and PLHIV, achieving adequate      |      |
|           |     | nutrition for all by 2015. Emphasizes six  |      |
|           |     | themes: (1) capacity building and          |      |
|           |     | promoting research and development, (2)    |      |
|           |     | prevention and treatment of micro-nutrient |      |
|           |     | deficiencies and diet-related chronic      |      |
|           |     | illness, (3) dietary diversification and   |      |
|           |     | food utilization, (4) food safety and      |      |
|           |     | quality, (5) nutritional needs of          |      |
|           |     | vulnerable groups, including PLHIV and (6) |      |
|           |     | nutrition advocacy to develop legislation  |      |
|           |     | and increase resources allocated to        |      |
|           |     | nutrition programming.                     |      |
+-----------+-----+--------------------------------------------+------+
| Malawi    | 20  | Five pillars identified in 2006: (1)       | GOM  |
| Agr       | 07- | sustainable land and water management, (2) |      |
| icultural |     | research, technology generation and        |      |
| De        |     | transfer, (3) agribusiness and market      |      |
| velopment |     | development, (4) food security and risk    |      |
| Programme |     | management, and (5) institutional          |      |
| (ADP) (In |     | development and capacity building. Working |      |
| Dev       |     | groups now in process of defining priority |      |
| elopment) |     | strategic objectives, intermediate results |      |
|           |     | and outcomes for each pillar. Tentative    |      |
|           |     | strategic objectives for the food security |      |
|           |     | pillar, as of August 2007, were increased  |      |
|           |     | food availability and stability at the     |      |
|           |     | national level and increased food access   |      |
|           |     | and improved food utilization at the       |      |
|           |     | household level.                           |      |
+-----------+-----+--------------------------------------------+------+
| Malawi    | 20  | Focuses on reducing vulnerability to food  | GOM  |
| Social    | 07- | insecurity and extreme poverty among the   |      |
| P         |     | most vulnerable population groups. This is |      |
| rotection |     | a reformulation of the previous national   |      |
| Program   |     | safety net strategies implemented from     |      |
|           |     | 2001-2006 but with a much broader and      |      |
|           |     | predictable resource commitments from the  |      |
|           |     | GOM and donors, responding to predictable  |      |
|           |     | patterns of vulnerability in the country.  |      |
|           |     | Involves community development activities  |      |
|           |     | including health care, education, water    |      |
|           |     | and sanitation, transport and household    |      |
|           |     | food security activities implemented       |      |
|           |     | through cash for work or direct cash       |      |
|           |     | transfers. The targeted input program is   |      |
|           |     | one critical component of the safety net,  |      |
|           |     | providing fertilizer and improved seed to  |      |
|           |     | many smallholder farmers.                  |      |
+-----------+-----+--------------------------------------------+------+
| Malawi    |     | Conducts rolling vulnerability assessment  | GOM/ |
| Vuln      |     | activities to: (1) determine the           |      |
| erability |     | percentage of the population in need of    | FEWS |
| A         |     | food assistance; (2) provide input to      | NET/ |
| ssessment |     | assist geographic targeting of food        |      |
| Committee |     | resources, (3) provide a description of    | WFP  |
| (MVAC)    |     | the most vulnerable populations at         |      |
|           |     | regional and community levels and (4)      |      |
|           |     | monitor changes in the food security       |      |
|           |     | situation in the country.                  |      |
+-----------+-----+--------------------------------------------+------+
| Comp      | 20  | Five focus areas: land and water           | GOM  |
| rehensive | 08- | management; rural infrastructure and       |      |
| African   |     | market access and value chain analysis;    |      |
| Agr       |     | hunger reduction, food security and        |      |
| icultural |     | nutrition; and agricultural research,      |      |
| De        |     | technology dissemination and adoption.     |      |
| velopment |     | Targets a 6 percent average annual growth  |      |
| Program   |     | rate and allocating 10 percent of national |      |
| (CAADP)   |     | budgets to the agriculture sector.         |      |
+-----------+-----+--------------------------------------------+------+
| Malawi    | 19  | The Strategic Grain Reserve established in | GOM  |
| National  | 81- | 1981 to help cope with food emergencies    |      |
| Food      |     | until times when alternative supplies      |      |
| Reserve   |     | could be mobilized. Administered by the    |      |
| Agency    |     | National Economic Council (NEC).           |      |
| (NFRA)    |     |                                            |      |
+-----------+-----+--------------------------------------------+------+
| *U.S.     |     |                                            |      |
| Go        |     |                                            |      |
| vernment* |     |                                            |      |
+-----------+-----+--------------------------------------------+------+
| USAID/FFP | 200 | Strategic Objective: *Food insecurity in   | FFP  |
| Strategic | 6-2 | vulnerable populations reduced;* IR1:      |      |
| Plan      | 010 | *Global leadership in reducing food        |      |
|           |     | insecurity enhanced* and IR2: *Title II    |      |
|           |     | program impact in the field increased,*    |      |
|           |     | through protecting and enhancing human     |      |
|           |     | capabilities, livelihood capacities and    |      |
|           |     | community resiliency and capacity to       |      |
|           |     | influence factors that affect food         |      |
|           |     | security.                                  |      |
+-----------+-----+--------------------------------------------+------+
| USA       | 200 | Focus on: *Governing Justly and            | USAI |
| ID/Malawi | 7-2 | Democratically*; *Investing In People* --  | D/Ma |
| Country   | 011 | includes a major program supporting GOM's  | lawi |
| Strategy  |     | national HIV/AIDS agenda and complementing |      |
|           |     | Global Fund interventions plus programs    |      |
|           |     | directed to malaria, tuberculosis,         |      |
|           |     | maternal and child health, family planning |      |
|           |     | and reproductive health, avian influenza,  |      |
|           |     | basic education and social assistance and  |      |
|           |     | protection; *Economic Growth\--* includes  |      |
|           |     | a focus on the agricultural enabling       |      |
|           |     | environment, agricultural sector           |      |
|           |     | productivity, financial markets and        |      |
|           |     | natural resources and biodiversity; and    |      |
|           |     | *Humanitarian Assistance \--* includes     |      |
|           |     | disaster readiness, capacity building,     |      |
|           |     | preparedness and planning.                 |      |
+-----------+-----+--------------------------------------------+------+
| USA       | 2   | Provided funds to support variety of       | USA  |
| ID/Office | 007 | programs beginning in FY2005 including to  | ID/O |
| of        |     | UNICEF for treating 20,000 malnourished    | FDA; |
| Foreign   |     | children; to CRS to support seed fair      | CRS; |
| Disaster  |     | during the 2005/06 and 2006/07             | UNI  |
| A         |     | agricultural seasons; and to the Title II  | CEF; |
| ssistance |     | Consortium to implement small scale        | I-   |
| (OFDA)    |     | irrigation projects under the              | LIFE |
|           |     | Rehabilitation Through Irrigation and      | Co   |
|           |     | Production Extension (RIPE) project.       | nsor |
|           |     |                                            | tium |
+-----------+-----+--------------------------------------------+------+
| Global    | 200 | Focus on rural income growth through       | U    |
| De        | 6-2 | partnerships between private sector, civil | SAID |
| velopment | 008 | society and government. Six GDA activities | (    |
| Alliance  |     | in 2007 including the Chia Lagoon          | Part |
| (GDA)     |     | rehabilitation project - a partnership     | ners |
|           |     | involving Wildlife Environmental Society   | hips |
|           |     | of Malawi, Nkhotakota District Assembly    | with |
|           |     | and Washington State University with       | pri  |
|           |     | technical support from Agricane. Other GDA | vate |
|           |     | activities involve community based         | sec  |
|           |     | management of natural resources --         | tor, |
|           |     | building capacity for co-management of     | GOM  |
|           |     | natural resources, and assistance for St.  | and  |
|           |     | Louis Project Peanut Butter.               | NG   |
|           |     |                                            | Os/C |
|           |     |                                            | BOs) |
+-----------+-----+--------------------------------------------+------+
| I         | 200 | Malawi becomes an IEHA country in 2008.    | U    |
| nitiative | 2-2 | The goal of IEHA is to support             | SAID |
| to End    | 012 | agricultural growth and rural incomes and  |      |
| Hunger in |     | improve livelihoods of the most            |      |
| Africa    |     | vulnerable. The IEHA focus areas for       |      |
| (IEHA)    |     | Malawi will be developed by the Mission    |      |
|           |     | through consultation with the GOM and      |      |
|           |     | other stakeholders. Expected linkages to   |      |
|           |     | be established with Title II, and CAADP.   |      |
+-----------+-----+--------------------------------------------+------+
| The       | 20  | Support to the GOM HIV/AIDS Commission.    | USG  |
| P         | 03- | Focus on prevention (behavior change, ABC, |      |
| residents |     | VCT), care (HBC, support for infected      |      |
| Emergency |     | people and affected households, and OVC).  |      |
| Plan for  |     | Emphasis on increased geographic coverage, |      |
| AIDS      |     | improved quality of services,              |      |
| Relief    |     | capacity-building and technical assistance |      |
| (PEPFAR)  |     | to the GOM. Partners include faith-based   |      |
|           |     | and community-based organizations. CDC has |      |
|           |     | provided technical and policy support to   |      |
|           |     | GOM.                                       |      |
+-----------+-----+--------------------------------------------+------+
| Global    | 20  | Support to Malawi National AIDS Commission | GO   |
| Fund to   | 03- | and MOH for HIV/AIDS (prevention and       | M/Gl |
| Fight     |     | treatment, VCT services, PMTCT, ARVs, OVC, | obal |
| AIDS,     |     | policy-making, capacity-building), malaria | Fund |
| Tub       |     | (ITNs, case management, IPT for pregnant   |      |
| erculosis |     | women, surveillance, IEC) and health       |      |
| and       |     | systems strengthening (human resources,    |      |
| Malaria   |     | infrastructure development, supplies,      |      |
|           |     | information systems, treatment, community  |      |
|           |     | programming).                              |      |
+-----------+-----+--------------------------------------------+------+
| Pr        | 20  | Reduction of malaria deaths through        | USG  |
| esident's | 07- | delivery of health services, supplies, and |      |
| Malaria   |     | medications to vulnerable groups,          |      |
| I         |     | especially pregnant women, children under  |      |
| nitiative |     | five years, and PLHIV. Four intervention   |      |
| (PMI)     |     | strategies: indoor residual spraying;      |      |
|           |     | distribution of insecticide-treated        |      |
|           |     | mosquito nets (ITNs); lifesaving drugs     |      |
|           |     | (artemisinin-based combination therapy);   |      |
|           |     | and intermittent preventive treatment      |      |
|           |     | (IPT) of malaria for pregnant women.       |      |
|           |     | Support also goes to GOM's National        |      |
|           |     | Malaria Control Program                    |      |
+-----------+-----+--------------------------------------------+------+

### 4.2.2. USAID/Malawi Strategies and Programs

USAID/Malawi's new strategy, which covers the years 2007-2011, is
designed to help promote broad-based economic growth, especially through
agricultural development; improved social services in education and
health; enhanced food security through increased and diversified
household income and carefully targeted food aid; and improved
governance through increased public and private oversight and government
accountability.

The majority of the Mission's resources will be used in the health
sector, with substantial resources being made available under the U.S.
President's Emergency Plan for AIDS Relief (PEPFAR) to fight the HIV
epidemic. The USG program, which supports the GOM's national HIV agenda,
will also complement Global Fund to Fight AIDS, Tuberculosis and Malaria
(Global Fund) Initiatives with prevention and mitigation activities
targeting high risk groups and regions. PEPFAR promotes the development
and provision of a comprehensive package of services, including
prevention, treatment and care and support. USAID-supported impact
mitigation strategies will focus on services for people living with HIV
(PLHIV), orphans and other vulnerable children (OVC) and home-based care
(HBC) initiatives. The Mission's health program also includes activities
addressing malaria, which is the number one cause of death for children
under five years of age; maternal and child health, including helping
the GOM implement its national strategy for the Integrated Management of
Childhood Illnesses (IMCI); and family planning and reproductive health.

Although the amount of DA resources available for economic growth will
be declining, this objective is still a priority for the Mission. Here
the focus is on the agricultural sector and on improving the incomes of
some of the most disadvantaged rural households. With more limited
resources, the Mission will focus on efforts to improve the agricultural
enabling environment and activities that take maximum advantage of
USAID/Washington and Africa Regional programs. An example of the former
is providing technical assistance to the Ministry of Agriculture and
Food Security (MOA&FS) to help with the development of CAADP. Examples
of the latter include the following: improving agricultural productivity
through improved technology transfer (the Mission has been supporting
partnerships between the International Agricultural Research Centers
(IARCs), GOM research facilities and private sector firms to improve
technology transfer); and promoting increased processing and value added
activities (the Mission plans to continue to use the Global Development
Alliance (GDA) program to develop innovative partnerships). The Mission
is also planning to use a Development Credit Authority (DCA)
loan-guarantee fund to encourage the development of new credit products
for farmers and micro-, small- and medium-size agro-enterprises so they
can get access to credit needed to expand product lines, modernize
plants and invest in new businesses.

### 4.2.3. USAID/Food for Peace 2006-2010 Strategic Plan

The FFP Strategic Plan is a key document for the design of Title II
programs. The definitions and concepts of food security that are laid
out in the FFP Strategic Plan, its strategic objective and intermediate
results, the underlying conceptual framework used and the target groups
identified, are all reflected in the USAID Malawi Food Security
Programming Strategy. Some of the new directions in the FFP Strategic
Plan are also reflected in the USAID Malawi Food Security Programming
Strategy, for example, the focus on food *insecurity* and the emphases
given to reducing the risks of, and vulnerability to, food insecurity
shocks (including natural, economic, social, health and political
shocks) and protecting and building human and livelihood assets. (See
Annex 3 for the FFP Strategic Framework and Annex 4 for the Expanded
Conceptual Framework for Understanding Food Insecurity, which provides
the theoretical underpinnings for the FFP Strategic Plan.)

The FFP Strategic Plan is designed to meet the needs of both the
chronically food insecure, who suffer from persistent food insecurity
over time, and the transitorily food insecure, who have a temporary
inability to meet food needs or smooth consumption levels.[^44] The
strategic objective of the FFP Strategic Plan is "*Food Insecurity in
vulnerable populations reduced,*" and its two intermediate results are:
IR 1: *Global leadership in reducing food insecurity enhanced* and IR 2:
*Title II program impact in the field increased*. Key target groups
under the FFP Strategic Plan are those populations at risk of food
insecurity because of their physiological status, socioeconomic status
or physical security, and/or people whose ability to cope has been
temporarily overcome by a shock.

In addition to enhancing the capabilities of vulnerable individuals,
households and communities, the FFP Strategic Plan focuses on building
the capacity of partners in the field in order to increase the impact
and sustainability of food security programming. The Plan includes
activities to improve the measurement of Title II impact, particularly
the impact of the program on achievement of the Millennium Development
Goals (MDG) to reduce the prevalence of underweight children under five,
and to improve food access and community coping capacity. The FFP
Strategic Plan also aims to expand knowledge and sharing of what works
and why and use this knowledge to influence policy and improve program
impact.

### 4.2.4. The FY 2005-2009 Title II Development Assistance Program (DAP) in Malawi

The current Title II DAP in Malawi is a five-year, \$70 million program
known as I-LIFE, which stands for "Improving livelihoods through
increasing food security." The program is being implemented by a
consortium of seven CSs in seven districts in southern and central
Malawi. The consortium has two co-leads -- the Catholic Relief Services
(CRS), which is the grant holder, and CARE. The other partners are
Africare, Emmanuel International (EI), Save the Children US, the
Salvation Army (TSA) and World Vision (WV).[^45] I-LIFE was designed to
address food availability, access and utilization through activities
focused on agricultural production and marketing, and health and
nutrition with a goal of reducing food insecurity among households and
communities in rural Malawi. These activities were envisioned as part of
a broader livelihoods strategy that recognizes the importance of
strengthening civil society and governance as part of a food security
strategy.

The majority of I-LIFE's resources have been directed to its livelihoods
objective. I-LIFE has been using a Farmer Field School model to promote
the use of improved agricultural practices; promoting the development of
farmers groups to market in bulk; improving access to seeds and
fertilizers, including through seed banks and seed fairs; promoting the
development of village-level savings and loan groups; and, with Office
of Foreign Disaster Assistance (OFDA) funds, supporting the development
of small-scale irrigation systems. Direct food distribution is being
used in food-for-work programs to improve rural infrastructure, feeder
roads in particular. Under the health and nutrition objective, much of
the focus has been on the rehabilitation of underweight children,
including through the use of the Positive Deviance/Hearth model. This
model identifies positive practices that mothers with healthy children
in the same community are using to feed and care for their children and
motivates other mothers to adopt these practices during "hearth
sessions" in which children are fed a special recuperative meal prepared
by their caregivers. The I-LIFE health and nutrition objective also
includes a major HIV effort, which includes direct food assistance for
families caring for the chronically ill and/or OVC, training for HBC
volunteers and the dissemination of HIV prevention messages. A third
component has been focusing on increasing the capacity of districts and
community-based organizations (CBOs) to provide leadership and services
to the agricultural and health and nutrition components of the programs.

The I-LIFE Mid-term Evaluation (MTE), which was undertaken in the spring
of 2007, singled out the small-scale irrigation and village savings and
loan activities as the two most important activities being implemented
under the agriculture objective and the most likely to have significant
impacts on the incomes and food security of thousands of households in
the target areas. [^46] Changes were recommended including that the
partners discontinue the free distribution of seeds, the promotion of
seed banks and the use of the Farmers Field School Model to disseminate
new agricultural technologies and practices. The partners will need to
continue to undertake demonstration trials to test new technologies and
practices, but these demonstrations, the MTE concluded "should be
focused on themes directly related to increasing the productivity of
commodities identified by marketing research to have real potential for
commercialization." In the health and nutrition area, the MTE endorsed
the new Care Group Model being tested, recommending that it be more
widely promoted and scaled-up throughout the consortium, and endorsed
I-LIFE plans to put more emphasis on pregnant and lactating women and
children under two years of age. It also endorsed I-LIFE plans to move
the home garden activities out of the agricultural productivity program
and to begin to promote them to the "most vulnerable" through the new
Care Groups. The MTE also recommended that I-LIFE make several
modifications to its direct food distribution program: (1) limiting food
distribution to areas where its other programs are underway, so that
these programs will be mutually reinforcing, as was originally
anticipated, (2) making sure that they are targeting the most food
insecure households, incorporating a simple food security assessment
along with the other eligibility criteria, and (3) completing the
targeting, graduation and exit strategies, and standardizing their
implementation across the consortium.

## 4.3. World Food Programme (WFP)

World Food Programme (WFP) activities form an integral part of efforts
to reduce food insecurity in Malawi, providing food resources during
emergencies and encouraging development by supporting agriculture-,
education-, health- and nutrition-related projects. The new country plan
for Malawi (2008-2011), similar to the current one, will focus on food
for education, using resources made available under the U.S. Department
of Agriculture's (USDA) McGovern/Dole program.

WFP is also implementing two Protracted Relief and Recovery Operations
(PRRO) in Malawi. One is a regional program, which provides assistance
to populations in Southern Africa that are vulnerable to food insecurity
and the impacts of HIV. This PRRO was originally designed to run from
2005 though 2007 and to cover Lesotho, Malawi,

Mozambique, Namibia, Swaziland, and Zambia. Zimbabwe has been added to
the PRRO, and it has been extended to April 2008. The Malawi portion of
the PRRO provides food for use in supplementary feeding and
food-for-assets programs. These programs help beneficiaries cope with
food shortages and strengthen community resiliency to shocks through the
creation of assets such as village feeder roads and water harvesting
structures. The PRRO also provides food rations through MCH clinics to
the chronically ill to reduce the impact of HIV on their households and
for the nutritional rehabilitation of children through the Ministry of
Health (MOH) and the Christian Hospital Association of Malawi. The
second PRRO, which runs from 2007 to 2009, provides food rations to
refugees living in two camps and a transit shelter and food for assets
for members of the communities hosting the camps.

## 4.4. Other Donors

The international donor community has been playing a significant role in
Malawi, in part by financing a major portion of the GOM's development
budget (over 80 percent in 2004/2005, for example).[^47] The United
Kingdom, which is the largest bilateral donor, is now focusing on social
protection and within the agricultural sector on providing support to a
large fertilizer and seed subsidy program. The European Union (EU) has a
large program focusing on food security and agriculture, with a focus on
larger farmers and infrastructure development. The World Bank's
activities in agriculture focus on developing a land market, resettling
smallholders on land bought from the estate sector, irrigation system
rehabilitation and infrastructure development. The Bank also supports
Agricultural Development and Marketing Corporation (ADMARC) reforms and
is working with the National Small Holder Farmers\' Association of
Malawi (NASFAM) on cereal banks, a warehouse receipts program and the
agricultural commodity exchange.

The donor community has not always been consistent on key policy issues,
such as subsidies, and donors were having frequent disagreements among
themselves and with the GOM. Dialogue between the GOM and the donors has
improved recently, however, and donors are working together more
effectively to harmonize policies and coordinate development
programming.[^48] However, donors still tend to split into two groups
with respect to the best approaches for tackling the country's food
security problems. One group, which includes the World Bank, EU and
USAID/Malawi, tends to favor market-based solutions to food insecurity
and chronic poverty. In broad terms, these donors emphasize the need to
develop agribusinesses and private sector-led rural input, output,
finance and credit markets; promote export-led agricultural growth; and
create more investment incentives by improving legal/regulatory
policies. The second group, which includes the United Kingdom's
Department for International Development (DFID), the Norwegian
International Development (NORAD) Program and civil society
organizations, takes the view that Malawi is a fragile, disaster prone,
land-locked country and a young democracy in a volatile region. These
donors tend to emphasize the importance of increasing smallholder food
production, maintaining a national food reserve, supporting input
distribution programs, and converting the national safety net program
into a long-term, predictable social protection program.

These views are also reflected in how food security issues are being
handled within the GOM, with the responsibility now being divided
between two ministries \-- the Ministry of Agriculture and Food Security
and the Ministry of Poverty and Disaster Preparedness and Management.
The responsibility for coordinating the activities of these two
ministries has been given to the National Food Security Task Force,
which is located in the MOA&FS. However, a number of activities are
still coordinated through the National Economic Council (NEC) and the
Nutrition and HIV/AIDS units in the Office of the President and Cabinet.

# 5. PROGRAMMING STRATEGY FOR FOOD INSECURITY IN MALAWI

## 5.1. Role of Mission Programs Funded by Other Accounts in Supporting Improvements in Food Security

Mission programs that support rapid growth of incomes in rural areas and
improvements in the health conditions of the Malawian population will
continue to help improve the food security conditions in the country,
contributing to improving food availability, access and utilization.
Mission programs funded by other accounts cover a greater number of
program areas and elements than the Title II DAPs (see Table 8). Many of
these programs also have a national-level focus, which is an area where
the USAID Mission has an advantage in comparison to the Title II CSs,
which are most effective at a more local level. The Mission also has an
important role to play in helping improve the enabling environment in
the country, which is one of the key contributing results recognized in
the FFP Strategic Plan (see Annex 3). Mission activities, by assisting
the GOM with the development of the CAADP and linking with USG Southern
Africa regional programs supporting improvements in trade and
investment, for example, will contribute to increased food availability
and access as well as the Mission's Economic Growth objective.
Similarly, Mission programs funded by other accounts, by helping the MOH
improve health policy and roll out the IMCI program, will contribute to
improved food utilization and its Investing in People objective. Other
Mission activities contribute more directly to improvements in food
security, some of which the Title II program can benefit from directly.
These include activities supporting improvements in food availability
(partnerships with the International Agricultural Research Centers) and
utilization (improvements in the quality and delivery of health
services, for example, and making funds available for HIV/AIDS
prevention, treatment and care and support services).

## 5.2. Role of the Title II Multi-Year Assistance Program (MYAP) in Addressing Food Insecurity

### 5.2.1. Objectives and Desired Outcomes 

The overall strategic objective for the multi-year Title II program in
Malawi should be "*to reduce food insecurity among vulnerable rural
populations in Malawi*." In Malawi, this includes the poor, who by
definition do not have sufficient income to purchase an adequate diet
and other basic necessities, children under two, and pregnant and
lactating women. (Also see following section on targeting for a further
discussion of the priority vulnerable groups and how they will be
targeted.) This formulation puts the emphasis where it should be -- on
those populations in the country that are already food insecure or
vulnerable to food insecurity. It is also consistent with the strategic
objective that has been adopted by FFP for the period 2006-2010 (see FFP
Strategic Framework in Annex 3).

The Title II programs should be designed to contribute to improving food
availability, access and utilization and to reducing the vulnerability
of the individuals, households and communities targeted by the program.
Availability, access and utilization are the three elements necessary to
achieving food security, which are identified in USAID's definition of
food security, and all three are important in the Malawian context. The
concepts of risk and vulnerability were added to the "Expanded
Conceptual Framework for Understanding Food Insecurity" which underlies
FFP's Strategic Plan (See Annex 4) and are also essential to addressing
food insecurity in Malawi.

Program success at the impact level should be measured in terms of
reducing child malnutrition (both height-for-age and weight-for-age in
children under five years of age). This is a measure of the success of
the entire program as well as activities directed more specifically to
improving the health and nutritional status of program beneficiaries.
Since the Malawi program will also need to have a food access dimension,
the Title II CSs will also have to track changes in measures of
household consumption (number of months of adequate food provisioning
and a household dietary diversity score). (More specific information on
FFP's indicators and reporting systems can be found in Annex 10.)

### 5.2.2. Program Priorities

The Title II program in Malawi should give priority to activities
expected to:

-   Increase agricultural productivity and rural household incomes

-   Reduce chronic malnutrition among children under five

-   Increase the effectiveness of the Title II contributions to the
    Malawian Social Protection Program

Where the Malawi Title II program is operating in areas that have a high
prevalence of HIV, activities will need to be adapted and modified to
meet the special needs of communities experiencing a high prevalence of
HIV and of the HIV-affected households and individuals living within
them. (See following sections on "Increasing the Effectiveness of the
Title II Contribution to the Malawian Safety Net Program" and
"Integrating HIV into the Title II Program" for further discussion.)

Priority activities within each of these three outcome areas
(agriculture, chronic malnutrition, social protection) are identified
and discussed below. These priorities reflect the various assessments of
the extent and nature of the food security problems in Malawi and the
priorities and focus of the GOM, USAID/Malawi and FFP, discussed in
previous sections. They also build on the knowledge and experience that
the current Title II partners have gained during the first half of the
current Title II Development Assistance Program (DAP). Some of the
activities identified reflect recommendations for reorienting key
components of the current program, some changes to which are already
underway. Other activities reflect the need to address problem areas
that are emerging as serious constraints to further progress toward the
overall objective of reducing food insecurity.

#### 5.2.2.a. Increasing Agricultural Productivity and Rural Household Incomes

To improve food availability and access within the Malawian context,
priority needs to be given to activities designed to improve
agricultural productivity and increase rural household incomes. Poverty
is the root cause of food insecurity in Malawi, and the vast majority of
the population depends on agriculture for their livelihoods. The current
Title II program has focused on transferring improved agricultural
practices and technologies, a focus which needs to be continued but with
important modifications discussed below.[^49] Much greater priority
needs to be given to markets and market demand and to increasing and
improving market linkages. The irrigation activities that were initiated
with funds from OFDA need to be brought under the auspices of the Title
II program and given higher priority. Food-for-work activities focused
on increasing productive assets in target communities, which are
discussed in a following section, also will contribute to this
objective. To achieve impact, both now and in future programs, Title II
CSs also will need to be able to access capable technical expertise in
key areas, including marketing and business management and development,
agronomy, micro-finance and civil engineering, from their own staff,
through partnerships with other USAID/Malawi projects or other
organizations, and/or through short-term consultants.

##### Increasing and Improving Market Linkages

To be successful in helping farmers increase their incomes, the Title II
program has to be market driven, and farmers need to be helped to think
more about market opportunities and profitability. Implementing a
market-led strategy in Malawi will not be easy. The country's domestic
market is relatively small due to the small size and poverty of its
population, and getting products to markets is difficult due to poor
infrastructure and high transport costs. The private sector in Malawi is
also small and relatively undeveloped. Still, focusing on market
opportunities, analyzing and working on value chains and facilitating
links with the private sector can produce results.

Assessing market opportunities for products that the Title II client
farmer groups may be able to supply should be one of the first steps
taken in developing a program and it should be an on-going process. The
focus should be on higher value products for which there is a growing
demand. Title II CSs need to think beyond sales in the local or even
national market, and begin to think also of regional and international
marketing opportunities. Trying to sell larger quantities of products
into small, slow-growing markets such as those in Malawi, can easily
lead to depressed prices and reduced profits. A strong case can also be
made for beginning to think beyond crops. There is a substantial unmet
demand for the locally produced fish, for example, as a result of the
decline in catches from Lake Malawi, and fish farming is a potential
activity for at least some of the Title II client farmers.

Organizing farmers into groups makes it easier to transfer information
to client farmers on marketing and should help them achieve some
economies of scale in marketing their production. However, much more can
and needs to be done to help farmers identify and better link to
markets, especially for products that are higher in value and face a
growing demand. Activities that have been successful elsewhere have
included helping farmer clients identify promising markets and develop
information on the specific needs of these markets with respect to
varieties, quality, packaging, etc. and facilitating linkages with
buyers, including facilitating the development of new types of
arrangements that give farmers more security, such as contract farming.
Viewing marketing primarily as a way to dispose of surplus production
will never succeed in helping raise the Title II client groups out of
poverty.

Analyzing the value chains for promising products is also priority. This
is important, not only to identify potential buyers, but also as a means
of identifying key constraints and the steps that the Title II CSs and
other actors will need to take to address these constraints to moving
products from producers to the ultimate consumers. These types of
activities need to be part of the Title II CSs marketing strategy and
given high priority.

[Transferring improved agricultural practices and
technologies]{.underline}

Agricultural productivity is low in Malawi, and small farmers need
access to information about more productive farming practices and
introduction to new crops and more productive crop varieties. Title II
CSs can provide this type of assistance, but to be effective in raising
farmers' incomes, the technology packages being extended need to focus
on crops for which there are real and preferably growing markets.[^50]
The CSs may have to test the packages they decide to promote to make
sure they are adapted to specific localities, and they will have to
develop and disseminate clear messages about their use. In areas where
farmers are dependent on rain-fed agriculture, priority needs to be
given to testing and extending conservation agricultural techniques,
which are proving valuable in other programs in Malawi and neighboring
countries. And, in areas where irrigation is being introduced (see
following section), priority also needs to be given to identifying and
extending best practices for farming under irrigated conditions.

With an expansion of the area under irrigation, more priority can be
given to crops, such as rice and winter vegetables, that have promising
markets but need irrigation. In areas with irrigation potential, it
makes more sense to focus on irrigated vegetables for sale than on home
gardens. These programs offer more promise in terms of generating
incomes as well as improving household diets[^51] than home gardens,
which have been occupying agricultural extension staff time. Home
gardens, if they are to be pursued, should be integrated into the
community health programs, as was also recommended by the MTE.

Title II CSs may also want to consider experimenting with activities
related to small-scale livestock, including by building on other
USAID/Malawi projects. Small farmers in the target areas are familiar
with small-scale livestock, although the numbers of animals have
declined in recent years as households have had to spend down their
assets in response to reduced crop production or crop failures. Still,
one of the first things that most farmers do when they get a little
additional money is buy small-scale livestock; this is an important part
of their risk management strategies. The CSs should avoid distributing
animals. This will interfere in local markets and farmers are willing to
buy them. Farmers, however, could use help in keeping their animals
healthy. Programs that train community members as veterinarian
assistants and then help them set themselves up in their communities as
micro entrepreneurs charging for services provided, including
vaccinations, for example, have worked well in other poor rural
communities and might also be appropriate in Malawi. Assistance in
improving animal feeding practices might also be effective, but only if
undertaken as part of a program that addresses the other constraints in
the market chain for these animals.

The Title II CSs need to work with groups of farmers in order to achieve
economies of scale in information transmission. However, informal groups
seem to work as well as more formal ones in many places. That is, one
does not seem to have to spend a lot of time up front on group
organization or formalizing farmers' groups in order for them to
function effectively as a means for transferring information and
technology. [^52] This suggests that what is needed in Malawi is a
pragmatic approach to working with farmers that builds on the approaches
that they are already used to, which include demonstration trials using
contact farmers and/or collective fields. Effective use also needs to be
made of lead farmers, the early adopters who understand farming as a
business, finding effective ways to use these new leaders within the
traditional leadership structure.[^53] As CSs expand their work with
value chains, more opportunities may also open up for involving other
actors in the value chain, including input suppliers and buyers, as
suppliers of information and technical assistance to their farmer
clients, a potentially more sustainable approach to information
transfer.

For these technology transfer activities to be sustainable, the Title II
program has to work within the market system, including by helping
farmers make links with private sector input suppliers, and avoiding
subsidizing the distribution of inputs.[^54] Since farmers will not
continue to use the new technologies and practices unless they are
profitable, the Title II CSs will also have to give priority to
understanding the economic costs and benefits of the activities they are
promoting and insuring that their staff as well as their farmer clients
understand the economics of these programs and become more
entrepreneurial in their outlook.

[Increasing Access to Water and Improving Water Management]{.underline}

The majority of Malawi's farmers are dependent on rainfall. And, the
environments in which they live are prone to drought. These are two of
the key constraints Malawian farmers face, including the food insecure
households that are being targeted by the Title II program, in trying to
increase their agricultural production and household incomes.
Programming options to help farmers face these challenges include
introducing drought resistant crop varieties, conservation farming
practices and small-scale irrigation.

More drought-resistant crop varieties, when available, and conservation
farming practices are attractive as a means for helping farmers reduce
risk. Conservation farming practices, which have the added benefit of
improving the quality of the soil and increasing its capacity to retain
moisture, are being experimented with in Malawi, including by other
USAID partners. The potential and desirability of adapting conservation
farming practices to a labor-constrained environment also need to be
assessed. Some of the practices being promoted seem to require less
labor (eliminating the need for ridging fields, for example), which
could make them more suitable for labor-constrained households,
especially for those with chronically ill members.

Several members of the current Title II consortium are using funds from
OFDA to help their client farmers construct and operate small-scale
irrigation facilities. These types of activities need to become an
integral part of the Title II program and be given priority, both in the
short and over the longer term. Improving farmers' access to water for
irrigation can make a tremendous difference to the lives of rural
households, reducing their vulnerability to drought, expanding the
number of harvests and making the adoption of new crops and agricultural
practices more feasible, as small-scale irrigation programs elsewhere in
the world have learned. This is a GOM priority and water harvesting and
small-scale irrigation are recognized as key instruments for reducing
poverty and vulnerability in the MGDS. Expanding irrigation is
particularly important in the Southern Region, which is the most densely
populated and food insecure area of the country but which also has
considerable water resources available for exploitation.

Under the current program, priority needs to be given to completing the
coverage of sites that have already been started with OFDA funding.
Priority also needs to be given to helping build the capacity of the
water management committees, because the sustainability of these systems
depends on user groups being able to operate and maintain them on their
own.[^55] In the future, greater priority will need to be given to
developing these committees at the beginning and to identifying and
finding ways to deal with potential land tenure problems to avoid
serious water user conflicts later on. Farmers will be able to add to
their incomes just by increasing the numbers of harvests per year. To
achieve full value from the new irrigation, however, the program will
also need to give more attention to identifying and extending best
practices with respect to farming under irrigated conditions, as was
discussed in the previous section on improved agricultural practices.
Options should also be explored for encouraging the private sector to
begin selling irrigation equipment suitable for small-scale systems
(e.g., treadle pumps and drop kits).

[Promoting Increased Village-Level Savings and Investment]{.underline}

The current Title II program is promoting the development of village
savings and loan (VS&L) groups. This is an unusual and innovative
activity and needs to be strengthened and better integrated into the
overall program. The original reason for forming these groups was to
enable groups of women, female-headed households in particular, to
increase their access to financial services and non-agricultural income
generating opportunities. The idea was to bring poor rural women
together and see if they would be able to contribute small amounts of
money on a regular basis into a capital fund, which then could be loaned
out to members to meet consumption needs, invest in small economic
activities and use as collateral for micro-finance institutions.[^56]
The MTE concluded that the VS&L program is one of the most important
activities being undertaken under the current program, because it helps
households create the capital they need to take advantage of new and
different economic opportunities in agricultural production and
processing. Although many of the groups are still weak, the more mature
ones, according to the MTE, have already been having a very positive
impact on their members' lives (enabling them to buy fertilizers and
seeds, process products for sale in the market, pay school fees and
improve their houses) as well as in their communities more generally.

Priority needs to be given to this activity both now and in the next
round of programs. Many groups need to be strengthened, and even the
more mature ones need to be given more training in finance and business
management. Most of the money that is being saved is being used to pay
for agricultural production inputs and for consumption purposes, but the
potential exists for at least some of this capital to be used for
investing in promising business opportunities, including those that are
generated under other Title II project activities. However, these groups
will also need additional business training to increase their capacity
to identify and assess business opportunities and make wiser investment
decisions, as individual as well as group investors. Issues with respect
to linking the more mature groups with microfinance institutions also
need to be resolved.

#### 5.2.2.b. Reducing Chronic Malnutrition Among Children Under Five

With almost half of pre-school children in Malawi stunted, reducing
chronic malnutrition among children under five must be the overarching
health and nutrition goal for the Malawi Food Security Programming
Strategy. To achieve this goal, preventive nutrition programming should
be focused primarily on children from the fetal stage through age two.
This is the period of most rapid growth, during which children are at
highest risk for nutritional deficiencies that can impair their physical
growth and cognitive development. This pattern holds true in Malawi,
where the prevalence of malnutrition increases dramatically from ages 6
to 18 months and then levels off and remains steady through five years
of age. Nutritional deficits occurring during this period of infancy and
early childhood affect health, learning and productivity in the
long-term, and losses are often irreversible after age two. However, the
rapid growth taking place from conception to age two also creates a
period of opportunity, because children in this age range are most
responsive to interventions that improve their nutritional status,
growth and development. As the time of both greatest nutritional risk
and greatest opportunity for growth, focusing Title II health and
nutrition activities on children under the age of two and pregnant and
lactating women is the strategy most likely to reduce chronic
malnutrition in pre-school aged children in Malawi.

Community-based health and nutrition programming to improve infant and
young child feeding practices, improve hygiene and sanitation, reduce
illness in young children, and improve maternal nutritional status is
the recommended strategy to reduce the extremely high prevalence of
stunting in Malawi. In addition, appropriate referral mechanisms should
be incorporated into any community-based program to ensure that children
with severe acute malnutrition, HIV or other complicated conditions
receive the treatment and support they need.

To increase access to health and nutrition services for the rural poor,
programs should operate at the community level, working closely with
members of the community and drawing on their experiences and skills. In
addition, all organizations implementing a health and nutrition program
will need to have qualified staff with expertise in maternal and child
nutrition. (Further information relevant to this section can be found in
Annexes 5 through 8. Annex 5 contains descriptions of several types of
community-based programs. Annex 6 includes a discussion of principles of
behavior change programming and Annex 7, a list of resources available
on community-based programs and behavior change programming. Annex 8
provides recommendations for implementing Growth Monitoring and
PD/Hearth programs, including in Malawi.)

Whenever possible, community-based programs should link with
district-level and other GOM initiatives as well as other USAID-funded
health and nutrition activities that seek to improve the health and
nutrition of women and children. These include the GOM initiative
promoting the "six food groups," GOM/UNICEF plans to implement the
Essential Nutrition Actions (ENA) framework, the Accelerated Child
Survival and Development Program (ACSD), and the Ending Child Hunger and
Undernutrition Initiative (ECHUI). A National Nutrition Policy is also
pending legislative approval. BASICS,[^57] with funding from
USAID/Malawi, also will begin health and nutrition programming in seven
districts in the fall of 2007, incorporating Integrated Management of
Childhood Illness (IMCI) and Community IMCI (C-IMCI), Community-based
Growth Promotion, Community Case Management (CCM), and Community-based
Therapeutic Care (CTC). The Title II Program should also seek linkages
with any program providing testing, treatment, and care and support for
women and children with HIV and other support services for OVC. (See Box
for some of the other complementary programs funded by the USG and other
donors.)

[Improving Infant and Young Child Feeding (IYCF) Practices]{.underline}

Programs seeking to reduce malnutrition in Malawian children under five
must address child feeding practices, including promotion of exclusive
breastfeeding and optimal infant and young child feeding (IYCF) through
two years of age. Community-based behavior change interventions and
accompanying information, education and communications (IEC) materials
that promote optimal feeding practices by targeting caregivers and
household decision-makers should be designed based on formative research
that identifies constraints and opportunities for behavior change within
the communities. In addition, any education, counseling, or behavior
change programming and materials should be adapted to provide guidance
on the nutritional needs of HIV-infected children. In communities with
high HIV-prevalence, the WHO consensus statement on infant feeding
should be followed, [^58] and the Title II program should link with any
programs providing prevention of mother-to-child transmission (PMTCT) of
HIV or nutritional care and support for HIV-infected children.

In Malawi, as discussed previously, certain optimal breastfeeding
practices, such as early introduction of breastfeeding and feeding
on-demand are used by a high percentage of mothers. However, just over
50 percent of children under 6 months are exclusively breastfed, putting
almost half of children at risk for illness, poor growth and
malnutrition. Promotion of exclusive breastfeeding, while also
reinforcing the many good breastfeeding behaviors that caregivers are
practicing, is a top priority in Malawi, especially given the high
prevalence of HIV.

Children six months to two years old should continue to breastfeed and
also be given complementary food according to the guidelines established
in WHO's Guiding Principles for Complementary Feeding of the Breastfed
Child (similar guidelines exist for non-breastfed children).[^59] As
discussed in the section on food utilization in Malawi, there is a great
need to improve complementary feeding practices, including quantity and
quality of food and the timeliness of introduction. It is of particular
importance to ensure that children are being fed sufficient amounts of
protein and nutrient dense complementary foods, including animal
products and vitamin-A rich fruits and vegetables in addition to
*nsima*,[^60] while also continuing to breastfeed until they are at
least two years old. CSs may also promote fortified foods (where
available and accessible) to improve the quality of children's diets,
and coordinate with UNICEF and the GOM to ensure that all children in
Title II program areas receive deworming and micronutrient
supplementation.

Improving IYCF practices will require the Title II CSs to conduct
formative research to develop a comprehensive behavior change strategy
that can be tailored to each community and targeted to caregivers and
decision-makers at all appropriate contact points. Formative research to
understand child feeding practices should explore the volume, variety
and consistency of food given to children in addition to how mothers
feed and care for their children (e.g. active or passive feeding, from a
separate bowl or shared). CSs need to identify priority behaviors,
understand current practices, determine which behaviors caregivers are
willing and able to change, determine constraints that may prevent
adoption and decide how best to provide support to those adopting new
behaviors. When conducting behavior change programs, Title II CSs should
ensure that any services promoted by the program are available to
program participants. If products, such as ITNs, or services, such as
micronutrient supplementation, are unavailable in the community, CSs
should coordinate with the MOH, UNICEF, other donors and stakeholders to
make these complementary services available. (Annexes 6 and 7 contain a
discussion of behavior change principles and a list of programming
resources.)

Title II programs can identify practical and innovative ways to improve
feeding practices and implement the health and nutrition policies and
guidance of the GOM and USAID. Potential Title II activities include
presenting the six food groups in a meaningful way that is useful for
families that have limited choices and education; working with
communities to identify specific, achievable ways for them to increase
the quantity of food consumed by young children; and collaborating to
add growth promotion and nutritional counseling to the current growth
monitoring program. Other potential program activities to support the
nutritional needs of children include promoting household gardens for
dietary diversity, training mothers in gardening (currently being done
at Nutritional Rehabilitation Units (NRUs)) and training in
household-level food preparation, preservation, processing and storage.
Several of these activities are currently being undertaken in Malawi.
Title II CSs should investigate and identify the most promising
approaches. Collaborating with UNICEF to implement the ENA package that
has been developed in Malawi and adopting other community-based
approaches, such as the Care Group model or the community-based growth
promotion model, are all potential ways to deliver these program
activities and improve community practices. Annexes 5, 6 and 8 contain
further discussion of community-based nutrition programs.

[]{.mark}

[Reducing Prevalence of Childhood Illness]{.underline}

Title II programming in Malawi should strengthen community-based
maternal and child health programming to increase access to treatment
for common child illnesses, especially malaria, pneumonia, diarrhea and
malnutrition, and to promote behavior change to prevent these illnesses.
It is essential that Title II programs link with any C-IMCI or CCM
programs operating in their areas. Additionally, in areas where
prevalence of HIV among children is high, appropriate referral
mechanisms to prevention, treatment and care and support programs should
be in place to complement nutritional support provided by the Title II
program.

High rates of common childhood illnesses in Malawi, including pneumonia,
diarrhea, and malaria, likely contribute to the high rates of
malnutrition seen in pre-school children. According to MDHS 2004 data,
prevalence of all three of these illnesses peaks in the 6-23 month age
range, the same age range in which malnutrition rates are climbing. To
prevent death, increased severity of illness, risk of complications,
disability and associated malnutrition, it is important that children
receive prompt and appropriate treatment. However, access to health
services is limited, with almost 80 percent of women claiming they face
challenges accessing health care because of distance, cost of care and
cost of transport, among other constraints.[^61] Community-based health
programming, such as CCM, will help increase access to healthcare, with
health surveillance assistants (HSAs), other community health workers or
trained volunteers providing treatment for common illnesses and referral
for complicated cases. This will also be a contact point to provide
support for promoting key care practices at the community level and
educating caregivers to recognize when a child needs medical care. CCM
programs will be implemented with support from BASICS in the southern
districts of Phalombe, Mangochi, Zomba, Chikwawa and Nsanje.

To prevent and treat illness, Title II programs should link with and
support other GOM and USG programs offered in the district or TAs.
Additionally, USAID/Malawi efforts to strengthen the health sector in
Malawi, especially in districts where they can link with community-based
Title II programming, will enhance results of Title II program
investments. Leveraging support from or linking to programs that focus
on reducing childhood illness, such as those supported by PEPFAR, the
Global Fund for AIDS, Tuberculosis and Malaria, and the President's
Malaria Initiative (PMI) will be essential to strengthening support for
vulnerable children in Title II communities.

[Improving Hygiene and Sanitation Practices]{.underline}

Rates of diarrheal disease are high in Malawi, especially in the 6-23
month age range. Data from MDHS 2004 and the MPVA indicate that
households in Malawi with better sanitation and protected water sources
have a lower prevalence of diarrheal disease and stunting than those
with poor sanitation. Building on the successes achieved by the current
Title II program, improving hygiene and sanitation practices and
structures should be a priority in future food security programs in
Malawi. Specific areas of focus should include behavior change for hand
washing (with soap), proper disposal of waste, safe preparation and
storage of food (especially foods for young children), point of use
water treatment, safe storage of water and helping communities access
clean water sources and construct sanitation structures, as needed.
Opportunities for collaboration to improve hygiene and sanitation
include Population Services International (PSI) Malawi's social
marketing of point-of-use water treatment (Water Guard). Title II CSs
could explore links with PSI to ensure the product is available in
program areas or promote the product's use among program participants.

[Improving Maternal Nutrition]{.underline}

Because stunting begins as early as the fetal stage, ensuring good
health and nutritional status of the mother, especially during
pregnancy, is vital to reducing malnutrition among young children.
Promoting women's nutrition, including anemia prevention, should be a
priority in food security programming in Malawi.

According to MDHS 2004, eleven percent of women in southern Malawi have
Chronic Energy Deficiency (CED). And, over 44 percent of women of
reproductive age and more than 47 percent of pregnant women in Malawi
are anemic. CED may be caused by insufficient food intake, illness, or
hard labor and increases women's risk of illness and delivering low
birth weight babies. Anemia is often caused by insufficient intake of
iron, poor absorption of iron, malaria, worm infestation, or infectious
disease. It increases the risk of premature delivery, low birth weight,
death for both the mother and her baby during delivery and impaired
cognitive development in the fetus. In addition, babies of anemic
mothers are more likely to be anemic themselves and face challenges to
growth and development.

Interventions to combat CED include food supplementation, increased food
production, nutritional education, and behavior change. To prevent
anemia in pregnant women, iron/folic acid (IFA) supplementation and
intermittent preventive treatment (IPT) for malaria are recommended
actions that are included in GOM policy. A woman should receive IPT and
IFA supplementation during routine antenatal care. Although 80 percent
of women report receiving IFA supplements during antenatal care, only 18
percent report taking the supplements for the minimum recommended 90
days.

While the GOM health services and PMI are providing the IPT and IFA,
community-based programs should encourage attendance at antenatal care,
and promote IFA supplements, helping women to take them for the
minimum-recommended 90 days. Formative research that explores women's
dietary practices, intra-household food distribution, food access, and
perceptions of antenatal care and health facilities and also identifies
barriers, constraints and opportunities for promoting women's nutrition
and anemia prevention can help programmers identify ways to best
encourage adequate maternal health and nutrition.

[Linking with Programs Focused on the Management of Acutely Malnourished
Children]{.underline}

The GOM has adopted a plan to roll out Community-based Management of
Acute Malnutrition (CMAM), formerly known as Community-based Therapeutic
Care (CTC). This program is targeted at children with severe acute
malnutrition (SAM),[^62] which represents about 0.5 percent of children
under five in Malawi. Levels of SAM can fluctuate quickly, however, and
children with SAM are at high risk of death and must be treated promptly
and according to specific clinical protocols. Until recently, management
of SAM cases only took place in NRUs at hospitals. Now, using CMAM
protocols, it is possible to rehabilitate many cases in the community,
avoiding an inpatient hospital stay. The GOM is planning to implement
CMAM nationwide. Title II programs, while maintaining their focus on
reduction of chronic malnutrition, should link with CMAM programs and be
prepared to refer SAM cases to them and provide support, as needed.

Additionally, HIV appears to be a contributing factor to complications
requiring inpatient care for many children with SAM. Studies done in
Malawi have demonstrated that HIV-positive children with SAM respond to
outpatient care, but at a lower rate than children who are HIV-negative,
and also have a significantly higher rate of relapse into moderate acute
malnutrition. Because of the high risk of relapse, HIV-positive children
with SAM should be carefully monitored over a longer period than
children who are not HIV-positive.[^63] Title II programs should remain
abreast of any developments that will guide them in providing
nutritional support to HIV-positive children in their program areas.

#### 5.2.2.c. Increasing the Effectiveness of the Title II Contribution to the Malawian Safety Net Program

Social protection is an important issue on the agenda of the GOM, the
donors and the NGOs, and the amount of resources being devoted to social
protection and safety nets is quite large. During the period 2003-2006,
for example, almost \$150 million was spent per year on average for this
purpose, including emergency aid and disaster response.[^64] To date,
the majority of these resources have been made available for short-tem
relief or emergency responses. The GOM, on the other hand, would like to
move away from safety net programs that help food insecure households
during crises to longer-term, more predictable programming for social
protection.

Under the current Title II program, food is being provided as an income
supplement to needy households in exchange for work (food for work) and
as a ration distributed to vulnerable households. These uses of food are
appropriate and should be continued. Both of these programs are
consistent with the development focus of the Malawi Title II program,
and both contribute to the GOM's priority, which is "the longer-term
developmental social protection that seeks to enable/smooth consumption
and both protect and promote assets."[^65] These activities could be
improved, however, by putting a greater emphasis on increasing the
productive assets available to communities through food-for-work, and
improving the targeting of the ration program to the food insecure.

[Focusing Food-for-Work Activities on the Development of Community
Assets]{.underline}

Food for work activities should be designed and implemented in ways that
support the broader objectives of the Title II program, contributing to
improvements in productivity and access and to reductions in
vulnerability. This means giving priority to the development of
productive assets at the community level. A variety of public works can
meet these objectives, including building and repairing roads, water
reservoirs and small-scale irrigation systems, and the construction of a
variety of soil and water conservation structures on community land.
Specific activities need to be identified in dialogue with communities
to obtain their support, recognizing that communities are more likely to
contribute to and maintain assets they recognize as having an economic
value to them.

When the emphasis is on creating assets, rather than the generation of
temporary employment, issues of quality and sustainability become more
important. This could require Title II CSs to make adjustments in their
staffing, adding more engineers, for example, and improving supervision.
Enhancing sustainability also requires making sure that appropriate
environmental mitigation measures are incorporated into the design and
implementation of the infrastructure and that sufficient time and
attention is paid to building local commitment and capacity to maintain
whatever is built.

Although Title II food has been used successfully in numerous countries
to develop feeder roads, road projects have had a checkered history in
Malawi. Food for work might also be an appropriate mechanism to support
the further development of irrigation infrastructure, although many of
the small-scale irrigation systems that are being developed by the
current Title II CSs with OFDA resources are being developed in the
absence of food for work. The CSs are providing the purchased inputs,
such as cement, PVC pipe and pumps, and the beneficiaries are
contributing their labor. This is preferable in the case of smaller
systems where participants are able to directly capture the economic
benefits of their own work, from digging feeding canals to their own
plots, for example. On the other hand, food for work could be
appropriate to support the construction of over-night storage tanks
and/or longer diversion canals that benefit larger groups of people.

Food for work could also be used to support the undertaking of
environmental protection measures such as stream protection, terraces,
gully plugs, check dams, vegetative barriers and other soil and water
conservation structures and plantings. To enhance the likelihood of
sustainability, these types of structures and plantings should be
limited to the protection of economic assets that are important to
communities, such as sources of water for irrigation and household uses
and valued feeder roads. To have the intended effect, for example, to
conserve soil and water, these types of structures and plantings have to
be located close together and constructed in sufficient numbers so that
they will be able to have a an effect at a landscape level, i.e. on a
hillside, a gully, a micro-watershed. If these types of structures and
plantings are not implemented in a contiguous area, their impact will be
limited and community members will have little incentive to continue to
maintain them in the absence of food. When this happens, the
contribution to assets dimension of the program disappears. The program
generates short-term employment but little else.

Food-for-work programs also have to be careful to avoid creating
perverse economic incentives and having adverse effects on local labor
and product markets. This is always difficult, and perhaps even more so
in Malawi. The timing of the work can be important, for example, and may
place practical limits on the size of a food-for-work program that can
be implemented, which may be the case in Malawi. Road construction
cannot be done in the rainy season, for example, and the work should not
be undertaken during the times when farmers need to be working in their
fields, even when some of these activities could be undertaken during
the so-called "hungry months." The poor rural households in Malawi, who
are the target group, are heavily dependent on agriculture as their main
(often only) source of income, and they need to have the time to invest
in their own assets and livelihoods to ensure longer-term survival. One
also needs to be careful in setting the ration, keeping its value below
the prevailing wage rate to avoid having the program interfere with the
functioning of local labor markets. Normally, one should also avoid
using food to reward farmers for undertaking activities on their own
land from which they would be expected to receive direct economic
benefits. This includes various land preparation activities, planting
fruit trees around their houses and making individual compost pits.
Using food can make an activity profitable for farmers to undertake in
the short-run, as long as the food is available. But if activities are
not profitable in the absence of food, farmers will not continue them or
continue to maintain structures once the food is no longer available.
Using food to promote the adoption of activities that are not economic
in the absence of food has another disadvantage in that it can also
divert people's time and attention from other potentially profitable
activities. The economics are similar with respect to community
infrastructure. If people do not gain economic benefits from a new road
or a series of terraces, for example, they are not likely to make an
effort to maintain this infrastructure in the absence of additional food
for work. [^66] The Title II CSs also need to be aware that some types
of food-for-work activities that have been used effectively in emergency
environments, when markets were likely in disarray, may no longer be
appropriate once production levels have been restored and markets have
returned to more normal conditions.

[Targeting the Ration Program to the Most Vulnerable and Linking It to
Other Complementary Activities]{.underline}

The value of the ration program is that it can reach an important
population that the food-for-work programs may not be able to reach.
This includes the more vulnerable households, especially those with
labor constraints that make it difficult for them to participate in the
food-for-work programs. To meet the development objectives of the GOM
and the Title II program, these rations should be viewed as a time
limited transfer, with the idea that the recipients will use the time
period to take advantage of the other food security activities that are
being made available under the Title II program to improve their
situations economically and eventually graduate from the ration. This
ration should be available to the most vulnerable. This is likely to
include PLHIV and HIV-affected households in the target areas. However,
as the MPVA analysis of the IHSA data indicates, being chronically ill
or an orphan (proxies for HIV) is not synonymous with being poor. So
targeting guidelines need to be developed and implemented that help the
CSs identify the truly food insecure. To increase the likelihood of
having a developmental impact, direct distribution of food should be
limited to the same communities where other Title II program activities
are being implemented. Plus, the CSs need to develop strong linkages
between their ration program and the other food security activities
being implemented in the same communities.

I-LIFE has been providing rations to families caring for the chronically
ill and OVC in their target areas from the beginning of the DAP.
According to the MTE, targeting guidelines and graduation criteria have
been drafted. However, the MTE also notes that Title II CSs are
distributing food in areas that are not recipients of their other food
security programming, a food security assessment is not being used in
the beneficiary selection process and the draft graduation and exit
criteria are not being consistently used even within the same CS. The
MTE recommended that the Title II CSs stop distributing rations in
communities that are not also recipients of their other activities and
that they improve the targeting of their programs at the community
level, by adopting a simple food security assessment tool perhaps, to
ensure that food insecure households are benefiting from the program.
The MTE also recommended that the consortium finalize its criteria for
targeting and graduating individuals/households from the program and put
them in place across the consortium.

Differences will still exist between the Title II program and other
similar programs. So discussions also need to take place with the GOM
and the WFP about the various targeting and graduation criteria being
used in the country and the need for more standardization.

### 5.2.3. Mission Management Priorities

USAID/Malawi has a relatively small staff with limited Title II program
experience and it would like to minimize the amount of time and effort
that will be required of its staff to manage the Title II program. The
Mission would also like to increase the synergies between the Title II
program and Mission programs funded by other accounts. This could
include taking advantage of the considerable resources available to
Malawi for HIV programming and expanding the reach and impact of the
reduced DA funding for economic growth.

### 5.2.4. Key Design Considerations

#### 5.2.4.a. Targeting the Program Geographically

The Title II program should be targeted to the regions and districts in
the country that are the most food insecure. According to the most
recent data available, the Southern Region is the most food insecure
area of the country in terms of poverty or access to food. As indicated
earlier, almost half the poor live in the Southern Region and the
prevalence of poverty is highest there. Eight out of the ten poorest
districts are also located in this region. The Southern Region is also
the region where poverty and vulnerability coincide. Rates of chronic
malnutrition are highest in the Central Region, but, according to the
UNICEF estimates for 2006, the difference is less than a percentage
point and three of the districts with percentages of chronically
malnourished children above 50 percent are located in the Southern
Region and four in the Central Region.

To provide more detailed guidance on how the next round of Title II
programs should be targeted geographically, a more detailed and up-dated
analysis of the food security situation by district[^67] needs to be
undertaken prior to the design of the new round of Title II programs.
This is needed to ensure that the new programs are targeted to the more
food insecure and vulnerable areas of the country. This assessment
should be done under the auspices of the USAID/Mission so that all
potential CSs will be working from the same data base. The current
consortium of implementers selected the seven districts where they are
working based on an assessment using five indicators of food insecurity
and vulnerability -- chronic malnutrition, HIV, poverty, food needs and
female literacy rates. This assessment needs to be up-dated, however,
especially given the many changes that have occurred in the country in
the almost ten years that have passed since some of the data that was
used in making this assessment were collected.[^68]

Within their major areas of operation, the Title II CSs will have to
make further decisions about which TAs and communities to work in. These
decisions will be unique to individual CSs, but should also be
evidenced-based, using data collected through surveys and/or rapid
assessments and indicators that are known to correlate with food
insecurity and vulnerability.

#### 5.2.4.b. Targeting Programs in the Community to Vulnerable Households and Individuals

To be effective, given the nature of Malawian culture and community
dynamics, the agricultural technology transfer and marketing programs
will need to be open to all community members who wish to participate.
To make sure that these programs meet their food security objectives,
however, the Title II CSs may also have to adapt and modify these
programs so that the more food insecure households in the community are
definitely able to participate in them. This should be done in ways that
ensure that all types of food insecure households are able to
participate, not just those affected by HIV.

All households with children under two years of age and pregnant and
lactating women (i.e., areas C+D+E+F, below) also need to be given
priority, because of the long-term negative effects of chronic child
malnutrition and the fact that almost half of the children under five in
Malawi are chronically malnourished. To prevent chronic malnutrition,
all households with children under two should be targeted by the health
and nutrition programs described in the previous section under program
priorities and not just households with children who are already
malnourished, as was the case during the first two years of the current
Title II program. Title II programs must include households with
children under two that are not food insecure (areas E+F in the below
diagram). This is because significant numbers of non-poor households
also have stunted children and failing to address their problems has
equally high long-term costs to these children, their families, their
communities and the country as a whole

The programs that involve food transfers, in contrast, need to be
directly targeted to the food insecure households and individuals (areas
A+B+C+D). Food-for-work programs should be self-targeting to the poor
and food insecure by setting the value of the ration below the
prevailing wage rate in rural areas. The direct distribution rations
should also be going to food insecure households and individuals in the
communities in which the program is working. However, the common
practice at present is to use one indicator \-- households with orphans
and/or chronically ill persons (proxies for HIV-affected households) --
as a proxy indicator for food insecurity. The problem is that not all
households that have been affected by HIV are also food insecure. In
other words, the rations should be targeted to HIV-affected households
that are also food insecure (i.e. areas B+C in the following diagram)
and not to all HIV-affected households (areas B+C+F+G). Other households
such as ultra-poor households headed by females or very young or old
persons, larger households and especially households with more young
children and dependents, households with low levels of education and
with little or no land and few assets may be equally deserving of a
ration.

#### 5.2.4.c. Finding the Right Balance Between Food and Cash

To enhance program effectiveness, the Title II program will need to find
the right balance between food and cash. The Title II program is the
largest source of USG resources available to focus on food security
problems, and its main resource is food. Under its current Strategic
Plan, FFP expects the direct distribution of food to play an important
role in non-emergency as well as emergency programs.

The current Title II program in Malawi has a relatively high percentage
of total resources being used in the form of food. This was appropriate
at the beginning of the program when the country was just emerging from
a drought and food supplies at the country level were insufficient to
meet minimum needs. Now, after several years of good rains and
successful harvests, lack of access on the part of the poor, rather than
lack of availability has reemerged as the root cause of food insecurity
in the country. This means that more cash is needed now to pay for the
expertise, technical assistance and training that are required to ensure
that the program will have a measurable and sustainable impact on the
underlying causes of poverty and malnutrition in the target areas over
the longer term. These several years of good harvests have also resulted
in concerns being raised about the relatively large amounts of imported
food that are still being distributed in the country.

The balance between monetization and direct distribution proposed in a
MYAP needs to be based on best estimates of future conditions available
at the time of the design. However, in light of the small size of the
Malawian markets and the volatility in domestic production, the Title II
CSs also need to be given the flexibility to make appropriate
adjustments in the amounts of food to be monetized and distributed each
year, based on more up-to-date estimates of local needs. The food
transfers that are being made under the current program are helping poor
vulnerable households. However, direct distribution programs can have
adverse affects on local production and marketing, as can monetization
programs. There is room in the Malawian market for more monetization of
the appropriate commodities. However, the small size of the market is
also a real constraint. Other monetization programs, including USDA's
Food for Progress, could also limit the size of the Title II
monetization. Closer coordination between FFP, USAID/Malawi and USDA's
Foreign Agricultural Service could help avoid potential problems.

#### 5.2.4.d. Integrating Programs at the Community Level

The Title II activities need to be integrated at the community level to
create synergies and increase impact. I-LIFE is working to ensure that
the most vulnerable in its target areas have access to activities in
each of its major programs areas, including activities relating to
agriculture, marketing, health, nutrition and HIV. This emphasis on
integration needs to be continued in the current and next round of
programs and intensified, including by strengthening the linkages among
individual activities. For program integration to pay off, however, the
core program activities themselves need to be meeting real needs,
technically sound and functioning well.

#### 5.2.4.e. Integrating HIV Into the Program

When Title II programs operate in areas that have a high prevalence of
HIV, they need to be designed to explicitly address the constraints that
PLHIV and HIV-affected households face. Adding a HIV dimension to Title
II programs should not change their overall nature, however. Their
target groups should still be the food insecure and their core
objectives should continue to be to reduce food insecurity through
improved availability, access and/or utilization of food and reduced
vulnerability.

With its access to food resources, the Title II program is positioned to
make a unique contribution to programs dealing with the most food
insecure, HIV-affected households. In Malawi this is taking the form of
a time limited ration which is being provided to families taking care of
the chronically ill and orphans (the proxies being used to identify
families affected by HIV). The rationale for this ration is that it will
enable families affected by HIV and other chronic diseases to
participate in the other activities being provided under the Title II
program, the agricultural and income generation programs in particular,
and to use the time and knowledge gained to rebuild their assets and
improve their food security. This is a good use of these resources and
should be continued but the targeting should be modified to include
non-HIV-affected food insecure households and exclude non-food insecure
HIV-affected households, as is discussed in the previous section on
targeting.

To be effective, the programs will also need to address the specific
prevention, treatment and care and support needs of HIV-affected
households and individuals. In some cases, Title II CSs may be able to
contribute to this directly (e.g., integrating prevention messages into
other BCC efforts), and in other cases the best approach will be to
focus on establishing linkages with HIV service providers (e.g.
anti-retroviral treatment). If these needs are not addressed, HIV is
likely to further worsen the food security situation, and the food
security objectives of the program are unlikely to be met. Most of the
current partners are involved in other HIV programming, including the
implementation of HBC programs, and they are using this experience to
help them provide these services as part of their Title II programming.
There is no guarantee that this situation will continue into the next
round of programs, however. That is, some or all of the future Title II
CSs may not have the same level of experience that the current
implementers have. In this event, it will be necessary for these Title
II CSs to emphasize strong coordination, partnerships and the
development of referral mechanisms and collaborative planning with other
service providers.

In other words, the Title II food assistance should be used to support
comprehensive and holistic programming so that objectives for both food
security and HIV prevention, treatment, care and support are achieved.
However, in the event that a Title II CS wants to address the specific
prevention, treatment and care and support needs of the HIV-affected
households and individuals, it will also need to make provisions in its
MYAP for non-Title II financing or link with other programs to cover
much of the costs of providing these other complementary activities.
Although Malawi is a non-focus PEPFAR country, it is still scheduled to
receive \$15 to \$20 million a year to finance a variety of non-food HIV
activities. The Title II ration by itself represents a significant
contribution to the HIV problem in Malawi. However, there are many other
urgent uses for Title II cash resources, including to finance some of
the activities identified previously that could help reduce the numbers
of chronically malnourished children in the country.

Further information on the rationale and framework for coordinating
Title II and PEPFAR activities can be found in a September 2007 document
entitled "USAID P.L 480 Title II Food Aid Programs and the President's
Emergency Plan for AIDS Relief: HIV and Food Security Conceptual
Framework" (See Appendix 9) and the HIV/AIDS section of FFP's "Policies
and Proposal Guideline for FY 2008.[^69] However, it should be kept in
mind that not all of the recommendations for integrating the two
programs are appropriate for every context. For a highly rural country
like Malawi, for example, it is not advisable to move food aid resources
to urban/peri-urban programming.

#### 5.2.4.f. Anticipating the Need for an Emergency Response

In recent years, erratic rainfall patterns have led to much volatility
in Malawi's maize harvests and food security situation. This points to
the likelihood that some areas in Malawi will at some point suffer from
a serious weather-induced crop failure. This means that all potential
Title II CSs should assess the likelihood of erratic rainfall, droughts
and other potential emergencies in the areas in which they propose to
work. This assessment should be included in their proposals along with a
discussion of the nature and timing of the steps they would take to deal
with particular emergencies in the event they occur.

Possible mechanisms for responding include: (1) adjusting program
activities; (2) diverting up to 10 percent of in-country Title II
commodities from their MYAPs for emergency use;[^70] (3) partnering with
WFP to address emergency caseload need; or (4) requesting FFP to
supplement their programs with additional emergency Title II resources.
Given the high likelihood that title II program communities will suffer
shocks during the life of a MYAP, this third option should be achieved
by including an emergency response component in new MYAPs, which could
be implemented if and when specific emergency indicators also identified
in their MYAPs are triggered.[^71]

If a new emergency is widespread across the country, rather than
localized in the CS's operational areas, FFP and the Mission encourage
the CS's to work through WFP to respond to emergencies outside of the
MYAPs, as they have done in the past. The WFP has the capacity to work
country-wide, unlike the Title II development programs, whose
geographical focus will be more limited to the areas of the country that
have the highest prevalence of chronic food insecurity. This strategy
will facilitate a more coherent response that is better able to target
and equitably prioritize resources to areas of greatest need. Since it
is also likely that the WFP will want to work with one or more of the
Title II CS in mounting an emergency response, the Title II CSs and the
WFP should consult on a regular basis on the results of the
vulnerability assessments and the necessity for and types of responses
that might be needed and how they would be coordinated and managed.

#### 5.2.4.g. Monitoring and Reporting on Program Performance

Developing an effective monitoring and reporting system that is
responsive to internal management needs as well as the various reporting
requirements of FFP, the Mission and the State Department will be a real
challenge. To help clarify its requirements, FFP issued two information
bulletins in August 2007 (see Annex 10). The first bulletin \[FFPIB
07-01 (updated)\] describes the five sets of reporting requirements that
are applicable to all MYAPs. These include: (1) CS program indicators,
(2) FFP/ Washington's Performance Management Plan (PMP) indicators, (3)
USAID Mission indicators, (4) "F" indicators, i.e. indicators required
by the Director of U.S. Foreign Assistance under the new U.S. Strategic
Framework for Foreign Assistance, and (5) IEHA indicators.[^72] The
second bulletin (FFPIB 07-02) lays out new reporting requirements
designed to enable FFP to better track progress toward the objective and
intermediate results identified in its 2006-2010 Strategic Plan. All
Title II CSs will need to follow this new guidance in developing and
implementing their new MYAPs.

#### 5.2.4.h. Developing Sustainability and Exit Strategies

The Title II program needs to give priority to sustainability issues and
to developing criteria to help the Title II CSs determine when
individuals can be transitioned out of the safety net programs and when
their programs can exit specific communities. In developing their
approaches to sustainability, the Title II CSs will need to distinguish
between the sustainability of the behavior changes and the technologies
that they are promoting, and the sustainability of the institutional
mechanisms they are using to deliver their programs. The Title II CSs
also need to understand the different factors that drive sustainability
in the public and private sectors, and recognize the importance of
economic returns driving the latter. Given past history in Malawi, the
Title II CSs need to take particular care not to resort to approaches,
such as the free distribution of inputs and similar approaches that will
create disincentive effects to private sector participation.

### Cross-cutting Issues

#### 5.2.5.a. Risk and Vulnerability

Under FFP's Strategic Plan, the Title II CSs are required to pay more
attention to reducing vulnerability and risk. Vulnerability means that
food security can be lost as well as gained, as a result of shocks that
affect the many (e.g., droughts and floods) or shocks that affect the
individual (being infected with HIV or the death of the household head).
Risks such as these are common in the food insecure areas where the
Title II programs are working. So, the Title II CSs will need to give
particular attention to integrating activities that will help prevent
and mitigate these risks throughout their programs. This should start
with a risk and vulnerability assessment for each target community.
Types of activities can range from the introduction of drought-resistant
crop varieties and improved technologies for storing crops to building
the capacities of communities so that they are better able to respond
and reduce the damage caused by shocks. In Malawi, expanding access to
irrigation can be one of the most effective ways not only to increase
agricultural productivity and rural incomes but also to enable farmers
to better manage the risks that are inherent in rain-fed agriculture.
Food-for-work programs can also be used to create physical
infrastructure, such as bunds to help control water flow and water
retention and soil conservation structures, which will also help
communities reduce their vulnerability to floods and droughts.

#### 5.2.5.b. Building Local Capacity

Capacity strengthening, of local partners and local governments as well
as the MOH and MOA&FS field staff, is a high priority need for ensuring
that the food security objectives of the Title II program are achieved.
Capacity strengthening initiatives should be designed to ensure the
sustainability of food security initiatives through strengthening the
analytical and managerial capacities of these stakeholders, as well as
that of community and household leaders. Capacity strengthening also
includes activities designed to strengthen communities' capacities to
organize, plan and represent their interests in broader fora. The Title
II CSs also need to focus on strengthening the capacities of their own
staff and volunteers, providing them with on-going training and
frequent, supportive supervision in which the supervisor provides
constructive feedback to improve staff performance and enhance learning.
Capacity-building should be integrated into the design of all food
security program activities, rather than existing as a stand-alone
objective of the program. The Title II CSs also have a role to play as
important stakeholders in assisting and supporting the GOM with the
development and implementation of its food security-related policies and
programs, bringing their own unique field-based knowledge and experience
into the dialogue process that the GOM has established.

#### 5.2.5.c. Environment

The quality of natural resources and people's equitable access to them
are issues critical to the success of poverty reduction and food
security interventions in Malawi. The Title II food security programs
must also integrate the sustainable use of natural resources into their
interventions to support agriculture-based livelihoods, rural income
strategies, disaster prevention, preparedness and resilience building.
During the time frame encompassed by this programming strategy, this
means giving priority to the assessment and promotion of conservation
agricultural technologies, where appropriate, and insuring that
environmental mitigation measures are incorporated into all relevant
activities, especially those involving the construction of roads and
irrigation infrastructure.

#### 5.2.5.d. Gender Equity

The MGDS recognizes that there are large disparities between men and
women, with women being marginalized both socially and economically and
"unable to effectively contribute to the social, economic and political
development of Malawi." Women face problems in accessing productive
resources, development opportunities and decision making, and this has
adverse consequences for the country's economic growth and development.
The MGDS also identifies social/cultural factors, limited access to
means of production and limited participation in social and economic
activities as the main challenges to reducing these disparities.
Although current USAID food security programs have addressed issues of
gender equity, the principles of gender equity need to be integrated
more explicitly and proactively into all food security programs.

# 6. COLLABORATION AND RESOURCE INTEGRATION

Organizations that desire to partner with USAID/Malawi in food security
programming will need to explore mechanisms for collaboration and joint
programming to ensure efficient use of resources. Prospective MYAP
partners also are encouraged to demonstrate how their Title II programs
build on the comparative advantage of Title II and maximize synergies
and complementarities with other programs, including Mission and USAID
regional and centrally funded projects.[^73]

Prospective CSs proposing to work in food insecure areas highly affected
by HIV are encouraged to consult with PEPFAR to discuss possible
collaboration and resource integration. In cases where integration of
resources is possible, prospective partners are encouraged to work
closely with PEPFAR to ensure integration of livelihood promotion with
social protection activities for food insecure families affected by HIV.

Prospective CSs should also indicate how their programs align with and
support GOM strategies and programs. This includes the MGDS, the Food
Security and Nutrition Policies and the ADP.

All prospective partners in food security programming are encouraged to
demonstrate collaboration and integration of resources with the private
sector, given the importance of the private sector and its essential
role in the development of the agricultural sector.

Prospective partners are also encouraged to consider working together in
consortia.

###  

# REFERENCES

African Development Bank. "Malawi Country Strategy Paper, 1005-09,"
Country Operations Department, North, East & South (ONCF), September
2005.

Benson, Todd. "Insights from Poverty Maps for Development and Food
Relief Program Targeting: An Application to Malawi," Food Consumption
and Nutrition Division (FCND Discussion Paper \# 205, International Food
Policy Research Institute (IFPRI), Washington, D.C., April 2006.

Catholic Relief Services (CRS). "Improving Livelihoods Through
Increasing Food Security (I-LIFE) 2005-2009," A Development Assistance
Proposal Submitted to USAID/FFP, April 2004.

Catholic Relief Services (CRS). "I-LIFE First Quarterly Report for FY
2007," A report prepared by the I-Life Project Management Unit for
USAID/FFP, Lilongwe, Malawi.

Catholic Relief Services (CRS). "I-LIFE Results Report for FY 2005," A
report prepared by the I-Life Project Management Unit for USAID/FFP,
Lilongwe, Malawi, November 1, 2005.

Colllier, Paul. "The Bottom Billion: Why the Poorest Countries Are
Failing and What Can Be Done About It," New York: Oxford University
Press, 2007.

Devereux, Stephen, et.al. "Vulnerability and Social Protection in
Malawi," Discussion Paper \# 387, Institute of Development Studies,
January 2007.

Hobgood, Tom, et.al. "USAID's Activities on Agriculture and Food
Security in Malawi: Report of an Internal Assessment Team," A report
prepared for USAID/Malawi (Fourth Consolidated Draft), Washington, D.C.,
November 2006.

Imperial College London, Wadonda Consult, Michigan State University and
Overseas Development Institute. "Evaluation of the 2006/7 Agricultural
Input Supply Programme, Malawi." A report prepared for the Ministry of
Agriculture and Food Security, March 2007.

Jere, Paul. "The Impact of Food Aid on Food Markets and Food Security in
Malawi," Discussion Paper No.45, Regional Network for Equity in Health
in Southern Africa (EQUINET), Lilongwe, Malawi, April 2007.

Lynam, John K. "Scaling Up, Out and Beyond: Approaches to Technology
Dissemination in Africa," August 2006.

Lynam, John K. and Were Omano, "Consolidating Agricultural Extension in
East Africa."

Malawi National Statistics Office (NSO) and ORC Macro. "Demographic and
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[www.measuredhs.com](http://www.measuredhs.com/)

Malawi National Statistics Office (NSO) and UNICEF Malawi. "Malawi
Multiple Indicator Cluster Survey, 2006," Preliminary report, 2007.

Malawi National Vulnerability Assessment Committee (MNVAC). "Malawi
Baseline Livelihood Profiles, Version 1," A report prepared in
collaboration with the SADC FANR Vulnerability Assessment Committee,
September 2005.

Remancus, Sandra, Penelope Nestel and Leslie Elder. "Women's Nutrition
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Project, Washington, DC, forthcoming.

Nin Pratt, Alejandro and Xinshen Diao. "Exploring Growth Linkages and
Market Opportunities for Agriculture in Southern Africa," Development
Strategy and Governance Division Discussion Paper No. 42, International
Food Policy Research Institute (IFPRI), Washington, D.C., September
2006.

President's Malaria Initiative (PMI). "Country Profile for Malawi,"
February 2007 <http://www.fightmalaria.gov/countries/malawi_profile.pdf>

Republic of Malawi. "Food Security Policy," Prepared by the Ministry of
Agriculture and Food Security, August 2006.

Republic of Malawi. "Malawi Growth and Development Strategy," Lilongwe,
Malawi. 2006.

Republic of Malawi. "National Nutrition Policy," Prepared by the
Department of Nutrition, HIV/AIDS for the Office of the President and
Cabinet, Lilongwe, Malawi, January 2007.

Republic of Malawi. "National Nutrition Programme," Prepared by the
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Republic of Malawi. "Nutrition, HIV and AIDS Business Strategy,"
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the President and Cabinet, Lilongwe, Malawi.

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and Cabinet, Lilongwe, Malawi.

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# ANNEX 1: MAPS OF MALAWI

## Map 1 A: Political Districts

![](media/image10.png){width="5.919444444444444in"
height="7.741666666666666in"}

## Map 1 B: National Livelihood Zones

![](media/image11.wmf){width="5.9118055555555555in"
height="6.101388888888889in"}

Source: MVAC. Malawi Baseline Livelihood Profiles, September 2005.

## Map 1 C: Poverty Head Count at Traditional Authority Level

![](media/image12.wmf){width="5.822916666666667in"
height="6.395833333333333in"}

Source: GOM/World Bank, Malawi Poverty and Vulnerability Assessment,
June 2006

(Based on NSO 1998 Census and IHS2 2005)

# ANNEX 2: LIVELIHOOD ZONES IN MALAWi

+--------------+-------------------------------------------------------+
| **Livelihood | **Description of Typical Food Economy Practices**     |
| Zone**       |                                                       |
+--------------+-------------------------------------------------------+
| Central      | Good maize/cassava base for food and cash, even for   |
| Karonga      | poor. Much ganyu done by migrant labor. Less          |
|              | dependent on maize than other northern zones.         |
|              | Livestock holdings, especially of cattle are high by  |
|              | national standards. Livestock comparatively           |
|              | important. The poor depend on ganyu and self          |
|              | employment (firewood and mat making etc)              |
+--------------+-------------------------------------------------------+
| Western      | People highly maize dependent but do not produce      |
| R            | surplus. Tobacco sales crucial for poor as well as    |
| umphi/Mzimba | others. The zone produces just enough to feed itself  |
|              | in an average year. Collection of wild foods from     |
|              | Nyika National Park and Vwaza Game Reserve. Drought   |
|              | hazard area.                                          |
+--------------+-------------------------------------------------------+
| Mzimba self  | Diversified zone with food and income generated from  |
| sufficient   | a variety of sources. The zone produces just about    |
|              | enough to feed itself in an average year. High maize  |
|              | yields and cassava assure zonal food security, with   |
|              | tobacco as main cash crop. Cattle ownership 1-15 for  |
|              | the wealth groups. But the poor still depend on       |
|              | ganyu.                                                |
+--------------+-------------------------------------------------------+
| Nkhata-Bay   | High rainfall but very poor soils mean unique cassava |
| Cassava zone | dominance but food deficit. The zone is food rich but |
|              | cash poor. There are limited sources of income apart  |
|              | for crop sales. Maize, rice, cassava and bananas      |
|              | grown in addition to cassava. Low prices for staples. |
|              | The poor rely heavily on migrating for ganyu.         |
+--------------+-------------------------------------------------------+
| Kasungu and  | Surplus maize is second only to tobacco as cash crop. |
| Lilongwe     | The zone produces surplus of food, maize, groundnuts, |
| Plain        | sweet potatoes and soya beans. Surplus comes from the |
|              | 20% well off farmers. Tobacco is the main cash crop   |
|              | generating 65-85% of income for all categories. Some  |
|              | poor farmers are shifting from tobacco to groundnuts. |
|              | But land pressure makes poor highly ganyu-dependent.  |
|              | Drought hazard.                                       |
+--------------+-------------------------------------------------------+
| Southern     | Fishing dominates the economy. Crop production is     |
| Lakeshore    | also important but is insufficient to cover local     |
|              | food requirements, in ganyu for poor as well as fish  |
|              | sales for others. But cropping is important. Major    |
|              | crops maize and sweet potatoes.                       |
+--------------+-------------------------------------------------------+
| Shire        | Country's densest population but largely self         |
| highlands    | sufficient in grain. Smallest landholdings; Income    |
|              | generating opportunities are referred. Crop           |
|              | production is undiversified supplemented by cassava.  |
|              | For cash, the well off sell crops. The poor and less  |
|              | poor do ganyu and trade.                              |
+--------------+-------------------------------------------------------+
| Middle Shire | Relatively dry area with modest grain crops; winter   |
| Valley       | crops and fishing along Shire River. The poor sell    |
|              | cash crops especially green maize and vegetables and  |
|              | look for ganyu.                                       |
+--------------+-------------------------------------------------------+
| Phalombe     | Weak production zone for the staple maize, with cash  |
| Plain        | from rice, tobacco and fish. The poor and less poor   |
|              | do farming/estate ganyu contracts. There are poor     |
| Lake Chilwa  | road network and proneness to dry spells.             |
+--------------+-------------------------------------------------------+
| Thyolo       | Very small landholdings mean poor and less poor       |
| Mulanje Tea  | people work on tea estates and elsewhere maintain a   |
| Estates      | living. Low estate wages and poor access to land a    |
|              | cause for food insecurity. Government resettlement    |
|              | plan for the poor being debated.                      |
+--------------+-------------------------------------------------------+
| Lower Shire  | Hot dry lowlands. Maize dominates for cash as well as |
| Valley       | food. Seasonal employment on sugar estate.            |
|              | Smallholder tea production and small scale irrigation |
|              | being developed for the poor but still small          |
|              | coverage.                                             |
+--------------+-------------------------------------------------------+

Source: MNVAC, "Malawi Baseline Livelihood Profiles, September 2005.

# ANNEX 3: FFP STRATEGIC FRAMEWORK FOR 2006-2010

![](media/image13.wmf){width="6.625694444444444in"
height="4.9743055555555555in"}

# ANNEX 4: FFP EXPANDED CONCEPTUAL FRAMEWORK FOR UNDERSTANDING FOOD INSECURITY

![](media/image14.png){width="7.406944444444444in"
height="5.997916666666667in"}

# ANNEX 5: DESCRIPTIONS OF COMMUNITY-BASED NUTRITION PROGRAMS

+----------+--------------+-------------+--------------+--------------+
| **N      | **Community  | **Community | *            | **Care       |
| utrition | Based Growth | Integrated  | *PD/Hearth** | Groups**     |
| P        | Promotion    | Management  |              |              |
| rogram** | (CBGP)**     | of          |              |              |
|          |              | Childhood   |              |              |
|          |              | Illness**   |              |              |
|          |              |             |              |              |
|          |              | *           |              |              |
|          |              | *(C-IMCI)** |              |              |
+==========+==============+=============+==============+==============+
| **Descr  | Com          | Comm        | Com          | Com          |
| iption** | munity-based | unity-based | munity-based | munity-based |
|          | program to   | program to  | program to   | program for  |
|          | prevent      | address     | sustainably  | improving    |
|          | malnutrition | ma          | rehabilitate | coverage and |
|          | and improve  | lnutrition, | underweight  | behavior     |
|          | child growth | measles,    | children. In | change       |
|          | through      | malaria,    | 12 day       | through      |
|          | monthly      | pneumonia,  | intensive    | building     |
|          | monitoring   | and         | behavior     | teams of     |
|          | of adequate  | diarrhea.   | change       | women who    |
|          | child weight | Four key    | program,     | individually |
|          | gain,        | elements    | volunteers   | represent,   |
|          | one-on-one   | are:        | and          | serve and    |
|          | counseling   | facilit     | caregivers   | promote      |
|          | and          | y/community | prepare and  | health among |
|          | negotiation  | linkages;   | feed a       | women in     |
|          | for behavior | care and    | recuperative | 10-15        |
|          | change, home | information | meal of      | households   |
|          | visits, and  | at the      | locally      | in their     |
|          | integration  | community   | available    | community.   |
|          | with other   | level;      | foods, and   | The leaders  |
|          | health       | promotion   | learn and    | form a Care  |
|          | services.    | of16 key    | practice     | Group that   |
|          | Action is    | family      | affordable,  | meets weekly |
|          | taken before | practices;  | acceptable,  | or bi-weekly |
|          | a child      | c           | effective    | and is       |
|          | becomes      | oordination | and          | trained by a |
|          | m            | with other  | sustainable  | paid         |
|          | alnourished. | sectors     | care         | facilitator. |
|          |              |             | practices    | These Care   |
|          |              |             | identified   | Group        |
|          |              |             | in families  | members      |
|          |              |             | of healthy   | visit the    |
|          |              |             | children in  | women for    |
|          |              |             | the          | whom they    |
|          |              |             | community.   | are          |
|          |              |             | It requires  | responsible, |
|          |              |             | that a       | offering     |
|          |              |             | growth       | support,     |
|          |              |             | monitoring   | guidance and |
|          |              |             | program be   | education to |
|          |              |             | operating in | promote      |
|          |              |             | the same     | behavior     |
|          |              |             | community.   | change.      |
+----------+--------------+-------------+--------------+--------------+
| **Obj    | -   Improve  | -   Reduce  | -            | -   Improve  |
| ective** |     child    |             | Rehabilitate |     coverage |
|          |     growth   |   morbidity |              |     of       |
|          |              |     and     | malnourished |     health   |
|          | -   Prevent  |             |     children |     programs |
|          |              |   mortality |              |              |
|          | malnutrition |     of      | -   Sustain  | -            |
|          |              |             |              |  Sustainable |
|          |              |    children |  nutritional |     behavior |
|          |              |     under 5 |     status   |     change   |
|          |              |             |              |              |
|          |              | -   Address | ```{=html}   |              |
|          |              |     ma      | <!-- -->     |              |
|          |              | lnutrition, | ```          |              |
|          |              |             | -   Prevent  |              |
|          |              |    malaria, |              |              |
|          |              |             | malnutrition |              |
|          |              |  pneumonia, |     among    |              |
|          |              |             |     other    |              |
|          |              |   diarrhea, |     children |              |
|          |              |     measles |              |              |
+----------+--------------+-------------+--------------+--------------+
| **Target | -   Children | -           | -   Children | -   Mothers  |
| Group**  |     0-24     |    Children |              |     of       |
|          |     months   |     0-59    |   6-36months |     children |
|          |              |     months  |              |     0-59     |
|          |              |             |              |     months   |
+----------+--------------+-------------+--------------+--------------+
| **Unique | -   Uses     | -           | -   Com      | -   Trained  |
| a        |     trained  |  Integrated | munity-level |     "leader  |
| spects** |     commun   |             |     re       |     mother"  |
|          | ity-selected |    approach | habilitation |              |
|          |              |     focuses |              |   volunteers |
|          |   volunteers |     on      | -   Uses     |     provide  |
|          |              |     whole   |     locally  |     support  |
|          | -   Closely  |     child,  |              |     to other |
|          |     tied to  |     not     |    available |     mothers  |
|          |     ev       |     disease |     foods    |              |
|          | idence-based |             |     and      | -   Small    |
|          |     i        | -           |              |     number   |
|          | nterventions |   Community |    practices |     of paid  |
|          |              |     level   |              |     staff    |
|          | -   Uses     |             | -   Engages  |     reach    |
|          |              |  prevention |              |     large    |
|          |    "adequate |     &       |    community |              |
|          |     weight   |             |     in       |   population |
|          |     gain" as |   treatment |              |     (through |
|          |     early    |             |   addressing |     leader   |
|          |              | -   Linked  |              |     mothers) |
|          |    indicator |     with    | malnutrition |              |
|          |     of       |     health  |              | -   Peers    |
|          |              |             | -            |     support  |
|          | malnutrition |  facilities |   Prevention |              |
|          |              |             |              | -   Can      |
|          | -   Referral | -   Evi     |    component |     support  |
|          |     and      | dence-based |              |     other    |
|          |     coun     |             | -            |     health   |
|          | ter-referral |   protocols |    Follow-up |              |
|          |     system   |     for     |     home     |  initiatives |
|          |     with     |             |     visits   |              |
|          |     health   |  prevention |              |              |
|          |     p        |     and     | -            |              |
|          | osts/centers |             |    Intensive |              |
|          |              |   treatment |     behavior |              |
|          | -            |             |     change   |              |
|          |  Counseling, | -           |              |              |
|          |              |   Addresses |              |              |
|          |  negotiation |     r       |              |              |
|          |              | elationship |              |              |
|          | -            |     among   |              |              |
|          | Supervision, |             |              |              |
|          |     home     |   illnesses |              |              |
|          |     visits   |             |              |              |
|          |              |             |              |              |
|          | -   Active   |             |              |              |
|          |              |             |              |              |
|          |    community |             |              |              |
|          |              |             |              |              |
|          |  involvement |             |              |              |
|          |     in       |             |              |              |
|          |     pro      |             |              |              |
|          | blem-solving |             |              |              |
|          |     &        |             |              |              |
|          |     planning |             |              |              |
+----------+--------------+-------------+--------------+--------------+
| **       | -   Useful   | -   Mostly  | -   PD       | -   Need a   |
| Consider |     in       |     applied |     inquiry  |              |
| ations** |     linking  |     to      |     done in  |   sufficient |
|          |     health   |             |     every    |              |
|          |     and      |    children |              |    volunteer |
|          |              |     who     |    community |     pool     |
|          |    nutrition |     present |              |              |
|          |     i        |     with    | -            | -            |
|          | nterventions |     illness |   Caregivers |   Households |
|          |              |             |     must     |     should   |
|          | -   Needs    | -           |              |     be close |
|          |     large    |   Nutrition |   contribute |     enough   |
|          |     network  |             |     food     |     together |
|          |     of       |   component |              |     so that  |
|          |     com      |     often   | (challenging |              |
|          | munity-based |     needs   |     in food  |   volunteers |
|          |     workers  |     st      |     insecure |     can walk |
|          |     or       | rengthening |     e        |     between  |
|          |              |             | nvironments) |     them and |
|          |   volunteers | -           |              |     to       |
|          |     (2-3     | Involvement | -   30% or   |     meetings |
|          |              |     and     |     more     |              |
|          |    community |             |     children | -   Time     |
|          |     workers  |  commitment |     in the   |              |
|          |     per 20   |     of the  |              |    available |
|          |              |     health  |    community |     -- do    |
|          |    children) |     sector  |     should   |     women    |
|          |              |     needed  |     be       |     have 5   |
|          | -            |             |     WAZ\<-2  |     hours    |
|          |   Supportive |             |              |     per week |
|          |     and      |             | -   Monthly  |     to       |
|          |     quality  |             |     growth   |              |
|          |              |             |              |   volunteer? |
|          |   monitoring |             |   monitoring |              |
|          |     and      |             |     required | -   Long     |
|          |              |             |              |     start-up |
|          |  supervision |             | -   Resource |     time --  |
|          |              |             |              |     project  |
|          |    essential |             |   intensive, |     should   |
|          |              |             |     requires |     be of    |
|          | -   Quality  |             |              |     4-5 year |
|          |     of       |             |   commitment |     duration |
|          |              |             |              |              |
|          |   counseling |             |  (follow-up, | -            |
|          |              |             |              |  Supervisor: |
|          |    important |             | supervision) |     promoter |
|          |              |             |              |     should   |
|          | -            |             | -   Homes    |     be 1:5   |
|          |    Community |             |     should   |              |
|          |     p        |             |     be close |              |
|          | articipation |             |     together |              |
|          |     in       |             |              |              |
|          |              |             | -   Requires |              |
|          |    planning, |             |     access   |              |
|          |     p        |             |     to basic |              |
|          | articipation |             |     c        |              |
|          |     required |             | omplementary |              |
|          |              |             |     health   |              |
|          | -   Requires |             |     services |              |
|          |     access   |             |     (i       |              |
|          |     to basic |             | mmunization, |              |
|          |     c        |             |              |              |
|          | omplementary |             |   deworming, |              |
|          |     health   |             |     mic      |              |
|          |     services |             | ronutrients) |              |
|          |     (i       |             |              |              |
|          | mmunization, |             |              |              |
|          |              |             |              |              |
|          |   deworming, |             |              |              |
|          |     mic      |             |              |              |
|          | ronutrients) |             |              |              |
+----------+--------------+-------------+--------------+--------------+
| **Compl  | -   Any      | -   Any     | -   CBGP     | -   Any      |
| ementary |     com      |     comm    |              |     com      |
| to:**    | munity-based | unity-based | -   IMCI     | munity-based |
|          |     program  |     program |              |              |
|          |              |             | -   Support  | intervention |
|          |              |             |     Groups   |              |
+----------+--------------+-------------+--------------+--------------+
| **E      | -            | -   All ENA | -   IYCF,    | -            |
| ssential |  Appropriate |             |     feeding  |  Appropriate |
| N        |     contact  |    messages |     of the   |     contact  |
| utrition |     for all  |     are     |     sick     |     for all  |
| Action   |     ENA      |     part of |     child,   |     ENA      |
| M        |     messages |     IMCI    |              |     messages |
| essages/ |              |     key     |   deworming, |              |
| services |              |     family  |     mi       |              |
| to be    |              |             | cronutrients |              |
| del      |              |   practices |              |              |
| ivered** |              |             |              |              |
+----------+--------------+-------------+--------------+--------------+

+---------+-------------------+------------------+-------------------+
| **Nu    | **Community-based | **Support Groups | **Child Health    |
| trition | Therapeutic Care  | (mothers/        | Weeks/Days**      |
| Pr      | (CTC)**           | grandmothers,    |                   |
| ogram** |                   | etc)**           |                   |
+---------+-------------------+------------------+-------------------+
| *       | A community-based | A way in which   | Occurs every 6    |
| *Descri | approach for      | mothers can      | months to deliver |
| ption** | managing cases of | learn from each  | vitamin A         |
|         | severe acute      | other, health    | supplements and   |
|         | malnutrition      | care providers,  | other preventive  |
|         | (SAM) (WHZ \<-3,  | or members of    | health services   |
|         | MUAC \<110 mm,    | the community    | to children at    |
|         | edema). Actively  | about optimal    | the community     |
|         | seeks SAM cases   | child care and   | level. In         |
|         | through MUAC      | feeding          | addition to       |
|         | screening. Using  | practices. This  | vitamin A,        |
|         | Ready to Use      | is a             | services have     |
|         | Therapeutic Food  | comfortable,     | included:         |
|         | (RUTF), CTC       | supportive, and  | catch-up          |
|         | treats the        | respectful       | immunization,     |
|         | majority of SAM   | environment. May | providing         |
|         | cases at home     | be mother to     | iron/folic acid   |
|         | instead of        | mother,          | to pregnant       |
|         | Therapeutic       | facilitated by a | women, iodized    |
|         | Feeding Centers.  | health care      | salt testing,     |
|         | SAM cases with    | provider or      | re-dipping ITNs,  |
|         | complications are | other community  | promotion of      |
|         | referred to       | member.          | infant and young  |
|         | facilities for    |                  | child nutrition.  |
|         | stabilization     |                  |                   |
|         | before released   |                  |                   |
|         | to outpatient     |                  |                   |
|         | care. GAM (WHZ    |                  |                   |
|         | \<-2 \>-3, MUAC   |                  |                   |
|         | \< 125 mm \>110   |                  |                   |
|         | mm) cases are     |                  |                   |
|         | treated with      |                  |                   |
|         | supplementary     |                  |                   |
|         | feeding or other  |                  |                   |
|         | community         |                  |                   |
|         | rehabilitation    |                  |                   |
|         | program, if       |                  |                   |
|         | available.        |                  |                   |
+---------+-------------------+------------------+-------------------+
| **Obje  | -   To treat SAM  | -   To promote   | -   Increase      |
| ctive** |     in the        |     optimal      |     coverage of   |
|         |     community     |     child care   |     vitamin A     |
|         |                   |     and feeding  |                   |
|         | -   Improve       |     behaviors    |   supplementation |
|         |     survival      |                  |                   |
|         |     rates of      |                  | -   Increase      |
|         |     children with |                  |     coverage of   |
|         |     SAM           |                  |     other         |
|         |                   |                  |     nutrition     |
|         |                   |                  |     interventions |
+---------+-------------------+------------------+-------------------+
| *       | Children 6-59     | Mothers of young | -   Children 0-59 |
| *Target | months            | children (\<2,   |     months        |
| group** |                   | \<3 or \<        |                   |
|         |                   | 5years)          |                   |
+---------+-------------------+------------------+-------------------+
| *       | -                 | -   Safe         | -   High coverage |
| *Unique |   Community-based |     environment  |     rates         |
| As      |     approach for  |     for mothers  |                   |
| pects** |     treating      |     to learn and | -   Feasible in   |
|         |     acute         |     share        |     diverse       |
|         |     malnutrition  |                  |     settings      |
|         |                   | -   Requires     |                   |
|         | -   RUTF          |     minimal      | -   Community     |
|         |                   |     outside      |     census and    |
|         |                   |     resources    |     social        |
|         |                   |                  |     mobilization  |
+---------+-------------------+------------------+-------------------+
| **Co    | -   RUTF supply   | -   Group leader | -   Best suited   |
| nsidera |     must be       |     must have    |     for areas     |
| tions** |     secured       |     strong       |     with high     |
|         |                   |     facilitation |     prevalence of |
|         | -   Requires      |     skills       |     vitamin A     |
|         |     trained       |                  |     deficiency    |
|         |     clinical      | -   Training may |                   |
|         |     staff to      |     be necessary | -   Require       |
|         |     classify and  |                  |     coordination  |
|         |     treat cases   | -   Variation in |     with district |
|         |                   |     methodology  |     health plan   |
|         | -   Most          |     from very    |                   |
|         |     frequently    |     interactive  | -   Assure        |
|         |     used in       |     to lecture   |     adequate      |
|         |     emergencies   |     driven       |     supply        |
|         |     --            |                  |                   |
|         |     integration   | -   Can link     | -   Volunteers    |
|         |     into health   |     into the     |     and           |
|         |     systems       |     non-health   |     supervisors   |
|         |     occurring in  |     sector       |     need to be    |
|         |     some places   |                  |     trained       |
|         |                   |                  |                   |
|         |                   |                  | -   Substantial   |
|         |                   |                  |     social        |
|         |                   |                  |     mobilization  |
|         |                   |                  |                   |
|         |                   |                  | -   Follow-       |
|         |                   |                  | up/record-keeping |
|         |                   |                  |     important     |
|         |                   |                  |                   |
|         |                   |                  | -   Part of a     |
|         |                   |                  |     larger        |
|         |                   |                  |     nutrition     |
|         |                   |                  |     strategy      |
+---------+-------------------+------------------+-------------------+
| *       | -   CBGP, IMCI,   | -   CBGP, IMCI,  | -   CBGP, IMCI    |
| *Comple |     maybe         |     PD/Hearth    |                   |
| mentary |     PD/Hearth     |                  |                   |
| to**    |                   |                  |                   |
+---------+-------------------+------------------+-------------------+
| **Es    | -   Infant and    | -   All ENA      | -   Vitamin A     |
| sential |     young child   |     messages,    |                   |
| Nu      |     feeding,      |     including    |   supplementation |
| trition |     feeding of    |     women's      |                   |
| Ac      |     the sick      |     nutrition    | -   Other         |
| tions/M |     child, some   |                  |     micronutrient |
| essages |     micronutrient |                  |     and IYCF      |
| to be   |     messages      |                  |     messages      |
| deliv   |                   |                  |                   |
| ered.** |                   |                  |                   |
+---------+-------------------+------------------+-------------------+

# ANNEX 6: KEY CONSIDERATIONS FOR EFFECTIVE BEHAVIOR CHANGE PROGRAMMING

To achieve effective behavior change, a comprehensive strategy should be
in place that targets the appropriate people with a feasible change to
behavior. The strategy should also address support for overcoming
constraints to practicing that behavior with appropriate program
activities. The community should be a partner in the behavior change
process from the beginning.

A key first step in behavior change programming is to conduct formative
research to understand current behaviors and gaps, as well as
constraints, incentives and opportunities for behavior change that will
support the program's objectives. This research should identify optimal
behaviors to promote and determine best interventions for promoting them
(e.g., training, outreach, mass communication, policy change, support
services). It is important at this stage to identify behaviors that are
effective in achieving program objectives and are feasible in the
context of the communities in which the program is working. For example,
if the program is encouraging children to sleep under insecticide
treated nets (ITNs), ITNs should be accessible in that community.

Materials that support and reinforce behavior change messages should be
developed, tested and available everywhere that community-based
nutrition and health activities take place. Clear, simple and consistent
messages should be delivered at as many contact points as possible, in
addition to key health contact points. Other potential venues for
delivering messages include agriculture, education and income generation
programs. Messages should be targeted to the person whose behavior the
program seeks to change. This may include mothers, fathers, caregivers
or other household decision-makers. It is also important to target
appropriate messages to support persons such as community leaders,
grandmothers and others who influence community and household behaviors.
In Malawi, there are policies and educational curricula for certain
nutrition priorities (such as the six food groups), but very few IEC
materials are available at health facilities and community program sites
to provide guidance to caregivers on how to incorporate the six food
groups into their families' diets. This is an enormous missed
opportunity that Title II programs should address in any community in
which they are doing community-based health and nutrition programming.

Many tools have been developed to guide programmers through the
step-by-step process of designing and implementing behavior change
programs. Several are listed in annex 7.

# 

# 

# ANNEX 7: RESOURCES ON COMMUNITY-BASED PROGRAMS AND BEHAVIOR CHANGE PROGRAMMING 

## Community-based Nutrition Programs:

PVO Child Survival and Health Grants Program. *Nutrition Technical
Reference Materials*.

> <http://www.childsurvival.com/documents/trms/tech.cfm>

Community-based Growth Promotion:

Griffiths, Marcia, Kate Dickin and Michael Favin (1996). *Promoting the
Growth of Children: What Works.* Tool #4. The World Bank Nutrition
Toolkit, The World Bank.

> <http://siteresources.worldbank.org/NUTRITION/Resources/Tool4-Frontmat.pdf>

C-IMCI:

CORE (2001). *Reaching Communities for Child Health and Nutrition: A
Framework for Household and Community IMCI.*
<http://www.coregroup.org/working_groups/c_imci_full_english.pdf>

PD/Hearth:

Core (2003). *Positive Deviance/Hearth: A resource guide for sustainably
rehabilitating malnourished children.*

> <http://www.coregroup.org/working_groups/pd_hearth.cfm>

Core (2005). *Positive Deviance/Hearth: Essential Elements*. A resource
guide for sustainably rehabilitating malnourished children (addendum)

> [http://www.coregroup.org/working_groups/PD
> Hearth_Addendum_Aug_2005.pdf](http://www.coregroup.org/working_groups/PD Hearth_Addendum_Aug_2005.pdf)

Care Groups:

World Relief and Core (2005). *The Care Group Difference: A guide to
mobilizing community-based volunteer health educators.*

<http://www.coregroup.org/diffusion/Care_Manual.pdf>

CTC:

Valid International (2006). *Community-based Therapeutic Care: A Field
Manual*

<http://www.fantaproject.org/ctc/manual2006.shtml>

(A trainer's manual is forthcoming)

Support Groups:

Linkages (2003). *Mother-to-Mother Support Group Methodology and Infant
Feeding: Training of Trainers*

<http://www.linkagesproject.org/publications/index.php?detail=51>

## Behavior Change:

Child Survival and Health Grants Program (2005). *Behavior Change
Interventions Technical Reference Materials.*

<http://www.childsurvival.com/documents/trms/xcut.cfm>

Core and AED. *Applying the BEHAVE Framework. Workshop Guide.*

[http://www.coregroup.org/working%5Fgroups/behave_guide.cfm](http://www.coregroup.org/working_groups/behave_guide.cfm)

The Core Group. Social and Behavior Change Working Group.

[http://www.coregroup.org/working%5Fgroups/behavior.cfm](http://www.coregroup.org/working_groups/behavior.cfm)

Emory University; Nutrition Research Institute, Peru; National Institute
of Public Health, Mexico; PAHO (2003). *ProPAN: Process for the
Promotion of Child Feeding.*

<http://www.paho.org/English/AD/FCH/NU/ProPAN-index.htm>

## Formative Research:

Dicken, K and M. Griffiths. *Designing by Dialogue: A Program Planners'
Guide to Consultative Research for Improving Young Child Feeding*

<http://www.eldis.org/go/display/?id=27958&type=Document>

Food for the Hungry International. *How to Conduct Barrier Analysis.*
<http://barrieranalysis.fhi.net/how_to/how_to_conduct_barrier_analysis.htm>

# ANNEX 8: RECOMMENDATIONS FOR IMPLEMENTING GROWTH MONITORING AND PD/HEARTH PROGRAMS

Community-based programming allows a project to maximize coverage and
access of available health and nutrition services and is a key strategy
to achieving a reduction in malnutrition. Growth Monitoring and
PD/Hearth are two well-known community-based health and nutrition
programs that are frequently implemented worldwide and are currently
operating in Malawi. When implemented optimally, these have great
potential to improve the nutritional status of children under two.
However, sub-optimal implementation results in wasted resources and
limited effectiveness. A discussion of factors that must be kept in mind
when implementing Growth Monitoring and PD/Hearth follows. Annex 5
contains summaries of these and other community-based programs.

**Growth Monitoring**, as it is currently implemented in Malawi, is
insufficient to address the high rates of chronic child malnutrition and
will likely have little to no impact on prevalence of stunting. The
program has poor attendance, especially after children reach 12 months,
is overly focused on weighing and charting children (with mixed levels
of accuracy) rather than the health and growth of the children, and uses
static nutritional status as a trigger for action rather than adequate
growth. Title II CSs working in this area need to address the limited
understanding of child growth, limited counseling of the mother, and
intervene before children are identified as malnourished. Title II CSs
should also focus on opportunities for promoting growth of children
during and after the Growth Monitoring sessions, and using the data on
the growth cards to engage mothers and support messages related to IYCF
actions. Title II CSs that are working in communities that have GOM
Growth Monitoring programs should seek ways to link their community
activities with these programs, encouraging participation, training and
supporting the Health Surveillance Assistant (HSA), and using the
information on the growth cards to counsel mothers. This could be done
through establishing a growth promotion program as a complement to the
Growth Monitoring, through Care Groups, through mother support groups or
another appropriate community level program.

**PD/Hearth** is a popular community-based nutrition program throughout
the world. Its use of local foods, of solutions found within the
community, the rapid observable recuperation of children, and the
powerful behavior change component make it a very powerful tool to
sustainably rehabilitate children. It has been the central nutrition
program in the current Title II program in Malawi and is popular in
communities. However, implementing PD/Hearth must be done with caution,
because it is very resource intensive and is not the optimal choice for
every community. There are several key criteria that should be in place
for PD/Hearth to be successful, and several essential program elements
that cannot be adapted, modified or disregarded. In Malawi, only one
district (Dedza) approaches the required 30 percent prevalence of
underweight that is a key criterion for cost-efficiency. Within
districts, there are likely communities that do reach 30 percent, and
PD/Hearth may be effective in those locations, assuming other criteria
are met. There are several challenges to the success of PD/Hearth in
Malawi, including a poorly functioning Growth Monitoring system, and
that some communities may be too food insecure to benefit from the
intensive behavior change component (i.e. they cannot access enough food
or a diverse enough diet). If criteria are met, and a Title II program
chooses to move forward with PD/Hearth in its communities, it must
conduct a PD inquiry in every community, be sure that the Hearth menus
are a nutrient-dense recuperative supplemental meal that meets a minimum
standard, actively involve caregivers in the Hearth session, have
mothers serve as community volunteers to conduct and host the sessions,
ensure regular follow-up and referral, and conduct the sessions with a
maximum of ten caregivers per session. Several of these essential
elements have been modified in current Malawi PD/Hearth programming to a
point that the program may be ineffective. If the challenges are
addressed and high quality technical assistance is made available to
establish optimal programs, then PD/Hearth would be an appropriate
intervention in certain communities.

# ANNEX 9: USAID HIV AND FOOD SECURITY CONCEPTUAL FRAMEWORK

![](media/image15.jpeg){width="3.0208333333333335in"
height="1.1770833333333333in"}

![](media/image16.jpeg){width="3.375in" height="0.85in"}

> **USAID P.L. 480 Title II FOOD Aid Programs and**
>
> **The president'S Emergency Plan for AIDS Relief: HIV and FOOD
> SECURITY CONCEPTual Framework**

**USAID Bureau for Democracy, Conflict & Humanitarian Assistance, Office
of Food for Peace and the U.S. President's Emergency Plan for AIDS
Relief**

**September 2007**

**HIV AND FOOD SECURITY CONCEPTUAL FRAMEWORK**

USAID Bureau for Democracy, Conflict & Humanitarian Assistance, Office
of Food for Peace and the U.S. President's Emergency Plan for AIDS
Relief

# 

I.  **Introduction**

This paper describes the rationale for and proposed approach to
developing and implementing an HIV and Food Security Conceptual
Framework for coordination of activities between the President's
Emergency Plan for AIDS Relief (PEPFAR) and the USAID Office of Food for
Peace (FFP). The Conceptual Framework will establish and facilitate a
programmatic continuum to address the nutrition, dietary supplementation
and food security needs of HIV-infected and -affected populations. This
Conceptual Framework will address the mutual objectives of FFP and
PEPFAR.

In many countries, there is a complex interface between chronic food
insecurity and HIV. The infection itself affects metabolism and causes
wasting, especially in more advanced stages and in the absence of
anti-retroviral therapy (ART). For the past four years, nongovernmental
organizations (NGOs) and the World Food Program (WFP) that have been
implementing P.L. 480 Title II (otherwise known as Food for Peace)
emergency and non-emergency programs have not necessarily worked closely
with PEPFAR, nor have resources been programmed systematically in
conjunction with PEPFAR to address the food needs of PEPFAR
beneficiaries and their communities. Recognition of this situation has
highlighted a significant potential for broadening synergies to
strengthen the U.S. Government's (USG) response to HIV-related
nutrition, food and food security needs in countries where FFP emergency
and non-emergency food aid programs and PEPFAR both operate.

In 2005, the U.S. Congress called on the Office of the Global AIDS
Coordinator (OGAC) at the U.S. Department of State to take the lead in
developing and implementing a USG interagency strategy to address the
food and nutrition needs of people living with HIV (PLHIV). Submitted to
Congress in May 2006, the *Report on Food and Nutrition for People
Living with HIV* builds on the respective comparative advantages of the
USG agencies working in HIV, nutrition, food assistance, agriculture and
livelihood assistance in order to benefit individuals, families and
communities affected by HIV. The Report has led to greater clarity on
how PEPFAR and FFP, as well as other USG agencies, international
partners and host countries can better collaborate to strengthen
nutrition and food interventions for individuals and communities
affected by HIV and reduce any remaining programming gaps. By
formalizing and expanding the basis for collaboration, a P.L. 480 Title
II/ PEPFAR HIV and Food Security Conceptual Framework will ensure that
more effective and comprehensive programs are implemented. By continuing
to draw upon the technical expertise and resources of both FFP and
PEPFAR, the goals of meeting the nutrition, food and food security needs
of individuals, households and communities affected by HIV, while
strengthening HIV prevention, care, support and treatment, will be
better achieved.

**Impacts of the HIV Pandemic**

HIV imposes a series of dynamic shocks on livelihoods and food security,
and these cannot be addressed in the same way as droughts and other
natural disasters. As was noted in a collaborative World Food Program
(WFP) and International Food Policy Research Institute (IFPRI) paper for
the 2001 UN Standing Committee on Nutrition Meeting: *HIV/AIDS Food and
Nutrition Security: Impacts and Actions* held in Nairobi, Kenya, the
impact of HIV is felt through individual, household, community, national
and regional levels because of the loss of human, financial, physical,
social and political capital. These impacts include:

i.  **Human capital:** HIV decreases the productivity of household labor
    due to sickness and HIV-related opportunistic infections.
    Additionally, infected individuals die prematurely, resulting in
    lost productivity. The labor pool is further diminished as healthy
    individuals have to care for those infected and attend the funerals
    for those who have died. Children in particular suffer from the
    emotional and psychological pain of the loss of parents. They are
    often displaced and forced to leave school early, resulting in lower
    levels of education. Because of the premature deaths of adult
    workers, there is a loss of indigenous knowledge transfer between
    generations. According to the Food and Agriculture Organization's
    2005 *Focus Report on HIV*, more than seven million farmers have
    died and an additional 16 million are likely to die over the next
    two decades in 25 Sub-Saharan countries.

ii. **Financial capital:** Medical costs and funerals are a major
    financial burden. HIV-affected households are often forced to sell
    assets or increase their burden of debt to pay HIV-related costs.
    Thus, affected households risk facing difficulties in getting loans
    from banks. The poor usually rely on informal money-lenders, often
    at very high interest rates. Infected and affected adults may lose
    employment as a consequence of illness or because of pressures of
    caring for the sick, leading to depletion of financial capital and,
    sometimes, to destitution.

iii. **Physical capital:** Land is often sold to pay for medical and
     funeral expenses. Land inheritance patterns can make widows more
     vulnerable to becoming homeless and similarly disinherit their
     children. In agriculture, less labor-intensive,
     livelihood-sustaining ways of farming land are required, resulting
     in reduced crop value and dietary diversity. Affected households
     are forced to sell productive assets and livestock and the loss of
     productive traction animals further reduces agricultural output.
     Loss of employment may also lead to sale of assets.

iv. **Social capital:** With rising HIV prevalence rates, social
    networks within communities fragment, as an increasing number of
    households and individuals become affected by the disease and cannot
    provide support to other families in the community. At the national
    level, the capacity of government and social institutions to provide
    formal safety nets and support to HIV-affected people decreases with
    the progression of the epidemic, because of increasing costs and
    diminished revenues due to illness or death of populations in
    productive age groups.

v.  **Political capital:** Political participation of HIV-affected
    family members is constrained due to the burden of illness and the
    diversion of time to tasks related to survival. Additionally,
    HIV-affected families are often deliberately excluded from the
    political process due to stigma and discrimination.

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II. **Background**

**FFP Policies and Programs Addressing HIV**

HIV-infected and -affected populations often cite food as one of their
greatest needs. In response, FFP has addressed the food security needs
of these groups since 1999. These efforts began with the Leadership and
Investment in Fighting an Epidemic (LIFE) Initiative, which provided
food assistance and other support to PLHIV and orphans and vulnerable
children (OVC) in four countries: Kenya, Malawi, Rwanda and Uganda.
Between FY 2002 and FY 2004, FFP invested approximately \$14,000,000 in
the LIFE Initiative and provided supplementary feeding for more than
118,000 children and family members affected by HIV.    

By 2006, FFP NGO programs with HIV components had expanded to Benin,
Burkina Faso, Central African Republic, Dominican Republic,
Ethiopia, The Gambia, Ghana, Guinea, Haiti, Indonesia, Kenya, Lesotho,
Malawi, Mozambique, Romania, Rwanda, Senegal, Sierra Leone, South
Africa, Uganda, Zambia and Zimbabwe. The programs included more than
\$50,000,000 in FY 2006 for prevention, care and support, vulnerable
group feeding, education and food security-enhancing activities for
one-half million HIV-infected and -affected beneficiaries. Over 30,000
MT of food aid for vulnerable group feeding was distributed as take-home
rations under Food-for-Work (FFW), Food-for-Assets and general relief
activities. In fact, most USG food resources directed to support
HIV-affected communities and individuals are currently allocated through
P.L. 480 Title II FFP programs.

As a result of partners' experiences with mitigation of HIV impacts on
food-insecure families, Food for Peace developed guidance in 2004 for
both emergency and non-emergency programs on HIV and food insecurity.
The guidance seeks to ensure that, where appropriate, partners take HIV
into account when analyzing food insecurity and include HIV in their
mapping of food insecurity. They are encouraged to develop tools and
programming designs that ensure that targeted resources are provided
only for *food-insecure* HIV-affected families. These resources should
also facilitate collaboration between food security programs and HIV
programs. According to the guidance, food may be programmed for related,
coordinated food security activities that wrap around nutritional care
and support, as an incentive to participating in program activities and
as a safety net or income transfer. Ration size and composition are to
correspond to the objectives of the program. Food utilization issues
should receive adequate attention. In addition, partners are required to
present clear, realistic and sustainable eligibility and graduation
criteria, as well as appropriate and adequate monitoring and evaluation
of the activities.

Most of this assistance has been targeted at HIV-affected food-insecure
households through community-level mechanisms, such as home-based care
(HBC) networks, PLHIV associations and the use of village health
committees and/or village elders. Generally, this aid has not been
targeted at HIV-infected individuals in clinical settings---with the
exception of some of the more recent WFP programs ─ nor have the
resources necessarily been programmed in conjunction with PEPFAR
programs to maximize program synergies. One of the main reasons for this
is that P.L. 480 Title II programs are mandated to focus on areas with
the highest food insecurity prevalence, which tend to be rural, whereas
the majority of HIV clinical treatment, care and support services tend
to be clustered in urban areas, where HIV prevalence is higher. Thus, it
has become clear, especially to HIV service providers, that urban and
peri-urban food insecurity among HIV-affected individuals, households,
and their communities has largely been neglected and requires
alternative targeting strategies by Title II and other food security and
livelihoods assistance programs.

**PEPFAR's Approach to Supporting Food and Nutrition Needs**

PEPFAR is the largest public health initiative focused on a single
disease in history. Initiated in January 2003, PEPFAR coordinates and
funds HIV/AIDS activities aimed at providing comprehensive and
integrated prevention, treatment, care and support services. PEPFAR
supports programs worldwide, and focuses its efforts on 15 heavily
impacted countries in Africa, Asia and the Caribbean: Botswana, Côte
d\'Ivoire, Ethiopia , Guyana, Haiti, Kenya , Mozambique, Namibia,
Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam and Zambia. The
goals for these countries, known at the "2/7/10 goals" are to support,
in an accountable and sustainable way:

-   [Prevention](http://www.pepfar.gov/about/c19387.htm) of 7 million
    new HIV infections

-   [Treatment](http://www.pepfar.gov/about/c19384.htm) of 2 million
    HIV-infected people

-   [Care](http://www.pepfar.gov/about/c19386.htm) for 10 million people
    infected and affected by HIV/AIDS, including orphans and vulnerable
    children

Based on the May 2006 *Report on Food and Nutrition for People Living
with HIV/AIDS* presented to Congress, PEPFAR released field guidance in
September 2006 in order to further inform country-level programs. A
central precept of the PEPFAR guidance is to leverage other partners for
broad support for the provision of food and livelihood assistance to
vulnerable families while targeting PEPFAR resources to specific
priority target groups. PEPFAR priorities include meeting the
nutritional needs of HIV-positive pregnant and lactating women (P & L
♀), orphans and vulnerable children born to HIV-positive parents, and
HIV patients in care and treatment programs, especially those who are
severely malnourished at entry. The following are illustrative examples
of the types of food and nutrition interventions that contribute to
achievement of the 2/7/10 goals, as stated in the 2006 Report:

-   Development and/or adaptation of food and nutrition policies and
    guidelines;

-   Nutritional assessment and counseling, including hygiene and
    sanitation education, maternal nutrition, and safe infant and young
    child feeding related to prevention of mother-to-child transmission
    (PMTCT);

-   Therapeutic and supplementary feeding that is well-targeted to the
    priority groups noted above;

-   Micronutrient supplementation, where adequate intake of
    micronutrients is not being addressed through a diverse diet,
    including fortified foods;

-   Replacement (weaning) feeding and support, within the context of WHO
    and national PMTCT and infant feeding guidelines; and

-   Linking Emergency Plan programs to food assistance, food security
    and livelihood programs.

While PEPFAR remains focused on supporting food and nutrition
interventions in limited, priority circumstances, its strategy also
strongly promotes and fosters linkages to food security and livelihood
assistance activities. These include, for example, improved agricultural
practices, and skills training and microcredit programs supported by
other donors and USG entities, including FFP, to avoid dependency and
address chronic individual and family food needs. Models of innovative
sustainable approaches that link HIV/AIDS care and treatment can be
found in many PEPFAR programs. One notable model is partnerships in
Kenya through the AMPATH program that links clinical care and treatment
with food production and distribution programs as well as small business
development. FFP is also a partner in sustainable approaches in
countries where programs overlap. Partnering with the private sector,
the PVO and NGO community and relevant USG and other international
partner agencies to strengthen these linkages is a key PEPFAR priority.
One of the past challenges with establishing specific FFP linkages
however, has been differences in the geographical targeting of the two
programs, combined with FFP's approach of identifying vulnerable
households within food-insecure communities versus the PEPFAR focus on
HIV-infected and -affected individuals. The Food Security Conceptual
Framework outlined below seeks to address this challenge.

III. **Toward a New Title II- PEPFAR HIV Food Security Conceptual
     Framework**

While opportunities for closer collaboration between P.L. 480 Title II
and PEPFAR programs have begun to emerge, some programming challenges
have prevented a more seamless continuum of support. For example, as
previously mentioned, the focus of P.L. 480 Title II programs on areas
with the highest levels of food insecurity, which tend to be rural,
often differ from those areas that have the highest HIV prevalence,
which tend to be urban and peri-urban. Also, P.L. 480 Title II uses
community-level mechanisms for targeting food-insecure households,
rather than targeting through clinics or HIV service delivery sites.
P.L. 480 Title II programs are also awarded through a Washington-based
process while PEPFAR funding is determined at the country level. Table 1
illustrates the different focal points, targeting strategies and inputs
of Title II and PEPFAR food support in the HIV context.

**Table 1: Food Support in the HIV Context**

+----------+------------+-------------+-------------+-----------------+
|          | **Title    | **PEPFAR**  |             |                 |
|          | II**       |             |             |                 |
+==========+============+=============+=============+=================+
| *        | Households | PLHIV       |             | HIV+ P & L ♀    |
| *Benefic |            |             |             |                 |
| iaries** |            |             |             | OVC             |
+----------+------------+-------------+-------------+-----------------+
| **Point  | Community  | Hospital,   |             | Community,      |
| of       |            | Clinic,     |             | Hospital,       |
| Entry**  |            | Community,  |             | Clinic          |
+----------+------------+-------------+-------------+-----------------+
| **       | Food       | Clinical    |             | Any nutritional |
| Criteria | Insecurity | M           |             |                 |
| for      |            | alnutrition |             | status          |
| Entry**  |            |             |             |                 |
+----------+------------+-------------+-------------+-----------------+
|          |            | Severely    | Mild and    |                 |
|          |            | m           | Moderately  |                 |
|          |            | alnourished | m           |                 |
|          |            | adults      | alnourished |                 |
|          |            |             | adults      |                 |
+----------+------------+-------------+-------------+-----------------+
| **Asse   | Household  | Nutritional | Nutritional | P & L ♀: HIV    |
| ssment** | Food       | Assessment  | Assessment  | Status,         |
|          | Security   | and         | and         | OVC:HIV-        |
| **Tool** |            | counseling  |             | af              |
|          |            |             | counseling  | fected/infected |
|          |            |             |             | (i.e. any       |
|          |            |             |             | nutritional     |
|          |            |             |             | status)         |
+----------+------------+-------------+-------------+-----------------+
| **N      | Food aid   | Therapeutic | Su          | Basic Food      |
| utrition | co         | foods;      | pplementary |                 |
| S        | mmodities, | Mi          | food if     | Commodities,    |
| upport** |            | cronutrient | severely    |                 |
|          | Su         | supplements | m           | Therapeutic or  |
|          | pplemental |             | alnourished | Supplemental    |
|          | foods      |             | at entry;   | foods           |
|          |            |             |             |                 |
|          |            |             | Mi          | Micronutrient   |
|          |            |             | cronutrient | supplements     |
|          |            |             | supplements |                 |
+----------+------------+-------------+-------------+-----------------+
| **Types  | Fortified  | F-100,      | Fortified   | Fortified       |
| of       | and        | F-75, and   | and blended | blended foods   |
| food**   | blended    | r           | foods and   |                 |
|          | foods      | eady-to-use | RUTF in     |                 |
|          | legumes,   | therapeutic | pilot study |                 |
|          | oil        | foods       | areas       |                 |
|          |            | (RUTF)      |             |                 |
+----------+------------+-------------+-------------+-----------------+

Table 2 shows the allowable coverage for the direct distribution of food
for various HIV-infected and --affected target groups under P.L. 480
Title II and PEPFAR. The table illustrates that while the allowable
coverage under these two programs is extensive, in practice, even when
all of the interventions described below are being implemented, there
could be gaps in coverage.

**Table 2: Allowable Coverage by Direct Food Distribution and Livelihood
Support by Target Group and Funding Source**

+------------------+--------------+-----------------+-----------------+
| **Target Group** | *            | **PEPFAR**      | **Title II**    |
|                  | *HIV-Related |                 |                 |
|                  | Goal**       |                 |                 |
+==================+==============+=================+=================+
| Severely         | Treatment    | Therapeutic     | Supplemental    |
| malnourished ART |              | Feeding         | feeding for     |
| & pre-ART        | Care &       |                 | food insecure   |
| clients          | Support      | Supplemental    | HH & improved   |
|                  |              | Feeding         | sustainable     |
|                  |              |                 | livelihoods for |
|                  |              | Select support  | food-insecure   |
|                  |              | for livelihoods | (FIN) families  |
|                  |              | (improved       |                 |
|                  |              | sustainable     |                 |
|                  |              | agricultural    |                 |
|                  |              | practices,      |                 |
|                  |              | microfinance    |                 |
|                  |              | etc.)           |                 |
+------------------+--------------+-----------------+-----------------+
| Food insecure or | Treatment    | N/A (some       | Supplemental    |
| moderately       |              | clinic-based    | feeding         |
| malnourished ART | Care &       | supplemental    |                 |
| & pre-ART        | Support      | feeding in      | Improved        |
| clients          |              | pilot study     | sustainable     |
|                  |              | areas only)     | livelihoods for |
|                  |              |                 | FIN families    |
|                  |              | Select support  |                 |
|                  |              | for livelihoods |                 |
|                  |              | (improved       |                 |
|                  |              | sustainable     |                 |
|                  |              | agricultural    |                 |
|                  |              | practices,      |                 |
|                  |              | microfinance    |                 |
|                  |              | etc.)           |                 |
+------------------+--------------+-----------------+-----------------+
| HIV+             | Care &       | Supplemental    | Supplemental    |
| pr               | Support      | Feeding         | Feeding for FIN |
| egnant/lactating |              |                 |                 |
| women            |              | Select support  | Improved        |
|                  |              | for livelihoods | sustainable     |
|                  |              | (improved       | livelihoods for |
|                  |              | sustainable     | FIN             |
|                  |              | agricultural    |                 |
|                  |              | practices,      |                 |
|                  |              | microfinance    |                 |
|                  |              | etc.)           |                 |
+------------------+--------------+-----------------+-----------------+
| OVC \< 2         | Care &       | Replacement     | Supplemental    |
|                  | Support      | Feeding         | Feeding         |
|                  |              |                 |                 |
|                  |              | Supplemental    | Improved        |
|                  |              | Feeding         | sustainable     |
|                  |              |                 | livelihoods for |
|                  |              | Select support  | FIN             |
|                  |              | for caretakers' |                 |
|                  |              | livelihoods     |                 |
|                  |              | (improved       |                 |
|                  |              | agricultural    |                 |
|                  |              | practices,      |                 |
|                  |              | microfinance    |                 |
|                  |              | etc.)           |                 |
+------------------+--------------+-----------------+-----------------+
| OVC 2-5 years    | Care &       | Supplemental    | Supplemental    |
|                  | Support      | Feeding         | Feeding         |
|                  |              |                 |                 |
|                  |              | Select support  | Improved        |
|                  |              | for caretakers' | sustainable     |
|                  |              | livelihoods     | livelihoods for |
|                  |              | (improved       | FIN caretakers  |
|                  |              | sustainable     |                 |
|                  |              | agricultural    |                 |
|                  |              | practices,      |                 |
|                  |              | microfinance    |                 |
|                  |              | etc.)           |                 |
+------------------+--------------+-----------------+-----------------+
| OVC primary      | Care &       | Supplemental    | Supplemental    |
| school-age       | Support      | Feeding         | Feeding         |
|                  |              |                 |                 |
|                  |              | Select support  | Food for        |
|                  |              | for livelihoods | Education       |
|                  |              | (improved       | (including      |
|                  |              | agricultural    | take-home       |
|                  |              | practices,      | rations)        |
|                  |              | microfinance    |                 |
|                  |              | etc.)           | Improved        |
|                  |              |                 | sustainable     |
|                  |              |                 | livelihoods for |
|                  |              |                 | FIN caretakers  |
+------------------+--------------+-----------------+-----------------+
| OVC secondary    | Care &       | Supplemental    | Supplemental    |
| school-age       | Support      | Feeding         | Feeding         |
|                  |              |                 |                 |
|                  | Prevention   | Select support  | Food for        |
|                  |              | for caretakers' | Education       |
|                  |              | livelihoods     | (including      |
|                  |              | (improved       | take-home       |
|                  |              | sustainable     | rations)        |
|                  |              | agricultural    |                 |
|                  |              | practices,      | Food for        |
|                  |              | microfinance    | Training        |
|                  |              | etc.)           |                 |
|                  |              |                 | Improved        |
|                  |              |                 | sustainable     |
|                  |              |                 | livelihoods for |
|                  |              |                 | FIN             |
+------------------+--------------+-----------------+-----------------+
| Food-insecure    | Prevention   | N/A             | Supplemental    |
| HIV negative     |              |                 | Feeding         |
| household        | Mitigation   |                 |                 |
| members in HIV   |              |                 | Food for        |
| affected         |              |                 | Education       |
| communities      |              |                 |                 |
|                  |              |                 | Food for        |
|                  |              |                 | Training        |
|                  |              |                 |                 |
|                  |              |                 | Food for Work   |
|                  |              |                 |                 |
|                  |              |                 | Improved        |
|                  |              |                 | sustainable     |
|                  |              |                 | livelihoods     |
+------------------+--------------+-----------------+-----------------+
| Food-insecure,   | Prevention   | N/A             | Food for        |
| high-risk        |              |                 | Education       |
| groups: female   | Mitigation   |                 |                 |
| headed HH,       |              |                 | Food for        |
| child-headed HH, |              |                 | Training        |
| HH with high     |              |                 |                 |
| dependency       |              |                 | Food for Work   |
| ratios           |              |                 |                 |
|                  |              |                 | Improved        |
|                  |              |                 | sustainable     |
|                  |              |                 | livelihoods     |
+------------------+--------------+-----------------+-----------------+

Beyond harmonized targeting and coordination of PEPFAR and FFP support
to address the immediate needs of individuals and families for food
assistance, a commitment is needed by the USG, international agencies,
governments and the NGO community to strengthen the long-term capacity
of HIV-affected families to provide for their own basic food and other
needs. Thus, a number of program modifications are necessary to provide
more complete coverage for HIV-infected and -affected target groups
through P.L. 480 Title II and PEPFAR programming, including:

1.  Reducing the geographic disparity between food aid and HIV program
    targeting, by expanding the focus of FFP resources to include food
    insecurity within urban and peri-urban areas.

2.  Strengthening the use of clinics, PMTCT sites and other HIV service
    delivery sites for the targeting of PLHIV and their households for
    food aid to address household food insecurity.

3.  Improving the ability of community-based P.L. 480 Title II programs
    to link with and refer beneficiaries for HIV services, such as VCT,
    ART, PMTCT and palliative care, including nutritional support.

4.  Improving the ability of HIV clinical services to link with and
    refer food-insecure beneficiaries to community food security, food
    aid and livelihood assistance programs.

5.  Increasing FFP support for institutions, community organizations and
    families providing services and support to food-insecure OVCs,
    including orphanages, training centers and programs for street
    children, which tend to be more urban and peri-urban based.

6.  Strengthening prevention programs among food-insecure high risk
    populations such as female and child-headed households, families
    with high dependency ratios, etc.

7.  Improving monitoring and evaluation, including the utilization of
    shared indicators and reporting systems.

8.  Strengthening the capacity of all individuals and families receiving
    nutrition and food support to sustainably address their long-term
    food needs through improved food production, employment and other
    vocational and livelihood assistance.

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IV. **The Legal and Statutory Frameworks**

PEPFAR and P.L. 480 Title II programs operate under separate authorities
for acquisition of both services and commodities. To realize the most
efficient and effective food security and nutritional support programs
using resources from both, PEPFAR and FFP can explore a variety of
funding options. These may include coordinated country PEPFAR and FFP
operation and budget plans and either "hybrid" agreements or a central
mechanism that would allow PEPFAR funds to be added to individual FFP
agreements with PVO cooperating sponsors to conduct appropriate HIV/AIDS
activities.

V.  **Next Steps**

The Conceptual Framework will be implemented in FY 2008. Both PEPFAR and
FFP have already strengthened guidance language for proposal
submissions: PEPFAR for Country Operations Plans and FFP for its
Multi-Year Assistance Programs (MYAP). There are several additional
actions that have been identified as next steps. The FFP HIV Policy
Working Group, in collaboration with the PEPFAR Food and Nutrition
Technical Working Group (F&N TWG), should continue to support the
implementation of these steps, including:

**1. Stakeholder discussions:** FFP, in collaboration with PEPFAR, will
take the lead to share ideas and seek to develop a consensus, through
discussions within the USG and with outside stakeholders, on how P.L.
480 Title II and PEPFAR can improve programmatic collaboration. FFP, in
collaboration with PEPFAR, will also reach out to USAID Missions, and
host country food and nutrition working groups to include them in this
process.

**2. Formation of FFP procurement task force:** Led by FFP's Policy and
Technical Division (PTD), this group will work closely with PEPFAR to
identify technical and programmatic parameters to achieve the objectives
of both groups and develop an appropriate award process to facilitate
tandem programming of P.L. 480 Title II funding in support of PEPFAR
programs, as well as an examination of options to use Title II
mechanisms for PEPFAR funds. This process will further ensure close
collaboration with in-country teams, an optimal geographic focus and
that the communities identified represent priority beneficiary groups.

**3. Development of the program module:** At the end of the procurement
exercise, the Procurement Task Force should be able to present options
for model program formats explaining programmatic/technical approaches,
and possible funding and procurement configurations to the FFP and
PEPFAR Directors for their approval.

**4. Inventory of policies and guidelines for funding of initiative
proposals:** The Task Force will work with P.L. 480 Title II managers,
Missions, and host country food and nutrition working groups, to develop
written guidance on key criteria for the funding of future proposals.

**5. Mapping of Current Title II and PEPFAR programs:** Gaining a
clearer idea of where existing Title II and PEPFAR programs are being
implemented in each country is an essential starting point. This
exercise is underway. This information will allow the joint Washington
and country working groups to identify priority areas, gaps, and develop
a clearer vision of coverage needs. It will also increase synergies of
existing P.L. 480 Title II and PEPFAR programs already underway when the
information is shared.

**6. Determination of standardized eligibility and exit criteria:** As
with existing P.L. 480 Title II programs, food aid support to PEPFAR
beneficiaries and their families would be based on levels of food
insecurity as well as nutritional status, with clear eligibility and
exit criteria. Discussions with other stakeholders are needed to
determine optimal vulnerability, eligibility and exit criteria to inform
the development of guidelines for the program participation of future
beneficiaries.

**7. Assessing urban and peri-urban food insecurity in PEPFAR
countries:** P.L. 480 Title II implementing partners have extensive
experience with vulnerability assessments. It will be important to
gather food insecurity data from urban and peri-urban areas in the
countries selected to be able to further define eligibility and exit
criteria, priority target groups, rations, program design and monitoring
and evaluation plans. In addition, further thought is needed on the
additional program linkages for PLHIV who have successfully "graduated"
from food support, are healthier, but have no source of income. PEPFAR
and FFP will begin discussions with Missions, other USAID offices and
implementing partners to create program links where possible.

**8.** **Strengthening monitoring and evaluation**: There is a need for
more accurate tracking and reporting on beneficiaries from both
programs. This process would use standard indicators that both identify
numbers of people served with funding from either program as well as
better account for dollars leveraged. A common set of indicators need to
be identified or developed and agreed upon.

**9. Development of a timetable**: The FFP HIV Policy Working Group
together with the PEPFAR F& N TWG representatives will develop a
timetable for the steps necessary for successful implementation of the
Conceptual Framework during FY 2008.

#  

# ANNEX 10: FPP INFORMATION BULLETINS ON FFP INDICATORS AND REPORTING SYSTEMS

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[^1]: USAID, "Policy Determination 19, Definition of Food Security,"
    April 13, 1992, p 1.

[^2]: The concept of risk, which is implicit in the USAID definition of
    food security, was added to the conceptual framework that underlies
    the Office of Food for Peace (FFP) Strategic Plan for 2006-1010 as a
    fourth pillar (See Annex 4). The concept of vulnerability is also
    addressed in the FFP Strategic Plan in the sense that food security
    can be lost as well as gained and is defined as the inability to
    manage risk. USAID/FFP, "Strategic Plan," p. 20.

[^3]: According to FAO ("State of Food and Agriculture," 2006), Malawi
    is classified as having one of the highest levels of
    undernourishment in the world. FFP has also included Malawi in its
    list of 15 most food insecure countries based on its high levels of
    chronic undernutrition, poverty and undernourishment.

[^4]: For example, South Africa had an estimated 2,980 calories per
    person per day available for human consumption in 2002-2004.

[^5]: The data on poverty used in this document comes from two
    integrated household surveys -- IHS1 which was conducted by the
    National Statistics Office (NSO) in 1998 and IHS2, which was
    conducted in 2004/05. Poor households are defined as individuals
    with incomes below the level needed to purchase a minimum necessary
    diet and critical non-food needs. These poverty lines were
    calculated using household consumption expenditures as a proxy for
    income.

[^6]: This FAO-developed indicator measures the extent to which the
    total amount of food energy available in a country is below the
    minimum required for maintaining a healthy life and carrying out
    light physical activity. It is calculated based on estimates of the
    per capita dietary energy supply available in a country, assumptions
    about the distribution of food supplies across households, and a
    minimum energy requirement threshold.

[^7]: Children's nutritional status is a good indicator of food access
    and utilization, as well as being an important element of human
    development in its own right. Height-for-age is the best indicator
    of whether malnutrition is a chronic problem because it indicates
    past growth failure, reflects long-term factors such as chronic
    insufficient protein and energy intake, frequent infection and
    sustained inappropriate feeding practices and is not sensitive to
    short-term changes.

[^8]: Chronic malnutrition, stunting and low height-for-age are three
    terms that are used in this document to refer to this problem.

[^9]: Recent analyses, including by Jeffrey Sachs, suggests that being
    landlocked can reduce a country's economic growth rate by around a
    half a percentage point. Being land-locked affects countries' access
    to international markets, for example, by making them dependent on
    the transport infrastructure and policy decisions of their coastal
    neighbors. Collier, "The Bottom Billion," pp. 53-63.

[^10]: The African Development Bank estimates that Malawi will have to
    generate real growth in GDP on the order of 6 percent per year in
    order to make an impact on reducing poverty. African Development
    Bank, "Malawi Country Strategy Paper, 2005-09," September 2005, p.
    vi.

[^11]: The rate of growth in GDP also tends to be highly variable in
    Malawi as a result of the country's continued dependence on the
    agricultural sector (See further discussion in the section on food
    availability), which in turn is highly susceptible to changes in
    weather, drought and floods in particular.

[^12]: The districts included in the Northern Region are Chitipa,
    Karonga, Mzimba, Nkhata-Bay, Rumphi, and Likoma Island; the
    districts in the Central Region are Dedza, Dowa, Kasungu, Lilongwe,
    Mchinji, Nkhotakota, Ntchisi, Ntcheu and Salima; and the districts
    in the Southern Region are Balaka, Blantyre, Chikwawa, Chiradzulu,
    Machinga, Mangochi, Mulanje, Mwanza, Nsanje, Phalombe, Thyolo and
    Zomba.

[^13]: Total cultivated area in the beginning of the 21^st^ century
    averaged about 2.7 million hectares, of which from 1 to 1.1 million
    hectares are held in some 30,000 estates with average farm size
    ranging from 10 to 500 hectares. The remaining approximately 1.7
    million hectares are cultivated by small holders with farm sizes
    averaging around 1 hectare. World Bank, "Malawi Country Economic
    Memorandum, Policies for Accelerating Growth," June 2004, p. 37.

[^14]: According estimates by the Malawi Vulnerability Assessment
    Committee (MVAC), roughly one third of the population in the
    livelihood zones analyzed is in perpetual food production deficit
    and has to rely on local agricultural labor (*ganyu*) for between
    two and six months each year. MVAC, "Malawi Baseline Livelihood
    Profiles," 2005.

[^15]: Poor road infrastructure in Mozambique as well as Malawi
    increases the price of petroleum in Malawi and both contribute to
    the high costs of transporting goods to and within the country.

[^16]: MVAC, 2005. Also see Annex 2 for more details on the individual
    livelihood zones.

[^17]: Higher altitudes in Malawi, as in the other Rift Valley
    countries, tend to mean higher rainfall and better cropping
    potential. MVAC, 2005.

[^18]: Casual labor is an important coping mechanism. However, casual
    labor is not always available during the hungry season, especially
    during the last two months. And, when it is available, it sometimes
    results in poor households having to delay planting their maize
    gardens by three to four weeks, which increases the risk of crop
    failure, and to defer weeding, which can reduce crop yields.

[^19]: USAID, "Food for Peace Strategic Plan for 2006-2009," p. 89.

[^20]: IHS2, 2005/06; also GOM/World Bank, "Malawian Poverty and
    Vulnerability Assessment (MPVA)," 2006.

[^21]: MPVA, 2006, p. 10.

[^22]: Ibid. pp. 7-8.

[^23]: Much of the discussion in this and the following two paragraphs
    is based on the IHS2 and the MPVA, 2006.

[^24]: MPVA, p.95.

[^25]: USAID, "Food for Peace Strategic Plan 2006-2010," p.89.

[^26]: WHO Technical Report Series. "Physical Status: The use and
    interpretation of anthropometry," 1995, p. 208-212.

[^27]: MPVA, pp.79-80.

[^28]: DHS and UNICEF MICS. These organizations coordinate their work to
    ensure maximum country coverage and comparability of surveys.
    <http://www.childinfo.org/mics/mics3/index.php>

[^29]: Remancus et al., "Women's Nutrition Indicator Guide,"
    forthcoming, p. 61

[^30]: Mukuria, Altrena G., Monica T. Kothari, and Noureddine
    Abderrahim, "Infant and Young Child Feeding Updates," Calverton,
    Maryland, 2006: ORC Macro.

[^31]: Chronic food insecurity is the state of being vulnerable to food
    insecurity that persists over time, while transitory food insecurity
    is a temporary inability to meet food needs or smooth consumption
    levels.

[^32]: MPVA, p. 76.

[^33]: Ibid.

[^34]: Slater, "Social Protection in Malawi," pp.10-12.

[^35]: NSO and ORC Macro 2005.

[^36]: NAC2003.

[^37]: 2004/05 Integrated Household Survey (HIS)

[^38]: MPVA, 2006 (citing CDC 2004).

[^39]: MDHS, 2004

[^40]: MPVA, 2006.

[^41]: MDHS, 2004.

[^42]: Hobgood, "USAID Activities on Agriculture and Food Security in
    Malawi," 2006, p. 6.

[^43]: GOM, "Malawi Growth and Development Strategy (MGDS)," 2005.

[^44]: "Smoothing" refers to any actions to even out or stabilize
    fluctuations in food consumption.

[^45]: During the drought years in the early 1990s, these same CSs had
    been working together in an emergency program known as C-SAFE. The
    I-LIFE consortium was developed in recognition of the need to
    transition from an emergency to a development program in the
    aftermath of the drought.

[^46]: Swanson, "I-LIFE Mid-term Evaluation," 2007.

[^47]: Hobgood, p.6.

[^48]: Ibid.

[^49]: Many of the modifications discussed in the following sections had
    already been identified by the I-LIFE consortium and changes were
    underway at the time of the Mid-term Evaluation (MTE), and others
    were recommended by the MTE.

[^50]: Although not labeled as a diversification strategy, the
    combination of a market-led approach, the expansion of land under
    irrigation and an increased emphasis on entrepreneurship and
    investment should result in greater diversification of income
    sources in the target areas.

[^51]: Experience in a number of places in the world has shown that
    programs promoting vegetables for sale can also have a beneficial
    impact on household diets, with households also increasing their
    consumption of the vegetables that they are producing

[^52]: Experience in a number of places in the world has also shown that
    farmers are more interested ion getting organized once they see some
    real concrete benefits from a program and begin to see how further
    organization can help them expand and sustain these benefits. This
    motivates farmers much more than the theoretical arguments about the
    benefits of producers' organizations.

[^53]: The current Title II program tried to use the Farmer Field School
    model initially but decided that the results were not worth the
    amount of time and effort required on the part of its field and
    supervisory staff to implement it properly. The MTE agreed that this
    model was too complicated and recommended that I-LIFE focus on
    demonstration trials working with and through lead farmers. The MTE
    also recommended that I-LIFE focus its demonstrations on key project
    interventions, including those related to small-scale irrigation and
    commercial farming.

[^54]: The priority given to the free distribution of seed in the first
    years of the current program may have made sense under drought
    conditions and to organizations that were more used to working in an
    emergency environment. However, as is also stressed in the MTE, this
    is not an appropriate strategy for a development program because it
    distorts economic incentives, encouraging farmers to adopt practices
    that may not be profitable for them in the absence of the subsidies
    and discouraging private businesses from participating in these
    markets. In this case, the free distribution of seeds had the added
    disadvantage of diverting the time and attention of Title II
    extension staff from their primary information extension
    responsibilities, as also noted by the MTE.

[^55]: Effective group formation is essential when it comes to managing
    small-scale water systems, for both home use and irrigation. Water
    is a common resource and needs to be managed as such. Since, these
    systems are small, national and local governments are usually not
    willing or able to operate and maintain them. So the beneficiaries
    will have to, as a group, since individual households/farmers will
    not be able to manage these systems working individually.

[^56]: In Malawi, these groups also include men, although women still
    predominate. Loans are also being made to non-members, and the model
    is being replicated by other groups, including many of the
    production and marketing groups that are being promoted under the
    auspices of the overall I-LIFE program.

[^57]: BASICS, which stands for Basic Support for Institutionalizing
    Child Survival, is a USAID-funded project implemented by Management
    Sciences for Health (MSH).

[^58]: WHO Consensus Statement, "WHO HIV and Infant Feeding Technical
    Consultation," October 25-27, 2006.

    <http://www.who.int/child>-adolescent-health/New_Publications/NUTRITION/consensus_statement.pdf

[^59]: The "Guiding Principles for Complementary Feeding of the
    Breastfed Child" can be found at:
    <http://www.who.int/nutrition/publications/guiding_principles_compfeeding_breastfed.pdf>.
    The "Guiding Principles for Feeding Non-breastfed Children 6-24
    months" can be found at:
    http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/ISBN_92_4_159343_1.pdf.

[^60]: Nsima is stiff porridge made from maize flour and water and is
    the staple food in Malawi.

[^61]: MDHS, 2004.

[^62]: Severe Acute Malnutrition (SAM) is indicated in a child whose
    weight is less than 70 percent of the median weight expected for
    his/her height or is 3 standard deviations or more below the median
    weight expected for his/her height., or whose mid-upper arm
    circumference is less than 110 mm, or who has pitting edema in both
    feet. A child with SAM is at high risk of death.

[^63]: Collins, S, N Dent, P Binns, P Bahwere, K Sadler, A. Hallam.
    "Management of Severe Acute Malnutrition in Children," *The Lancet*
    2006; 368: 1992-2000.

[^64]: Slater and Tsoka, "Social Protection in Malawi," April 2007, p.
    vii.

[^65]: Ibid, p. xi.

[^66]: The MTE recommended discontinuing using food for work to develop
    seed storage facilities. Using food for work to build other storage
    facilities is also problematic for a variety of reasons, including
    that there are better alternatives that involve making use of the
    private sector. Instead of using food for work to support community
    nurseries, an approach that has had very mixed results, the CSs
    might want to consider a more market-based approach that focuses on
    helping farmers, as individuals or in groups, develop the capacity
    to supply seedlings to their programs on a commercial basis.

[^67]: This could also be done by TA if the new data from the 2008
    Census is available.

[^68]: If one looks at the most recent poverty data, the current program
    is working in only one of the poorest ten districts (Thyolo) and in
    two of the richest ten districts (Ntchisi and Lilongwe Rural), with
    the remaining five falling into the middle ten. The ranking of
    districts by degree of poverty using the most recent poverty data
    also is very different than the rankings that were used as a basis
    for the current targeting, which were calculated using the 1998 data
    from the National Statistical Office Atlas of Social Statistics.

[^69]: USAID/FFP, "Title II Program Policies and Proposal Guidelines for
    Fiscal Year 2008," (DRAFT) dated August 8, 2007.

[^70]: A CS needs to get USAID Mission or Diplomatic Post approval to
    divert 10 percent of in-country commodities for emergency uses. If a
    CS wants to divert more than 10 percent for emergency needs and/or
    would like FFP to replace the commodities that have been diverted,
    it needs to get FFP authorization, and this authorization needs to
    be received prior to the transfer of any additional commodities and
    funding. USAID Missions cannot authorize the transfer of monetized
    proceeds, ITSH or Section 202(e) for emergency uses, unless this
    step has been approved by the FFP Director in an amendment to the
    approved program.

[^71]: This option is spelled out in more detail in FFP's "Title II
    Program Policies and Proposal Guidelines for Fiscal Year 2008,"
    (DRAFT) dated August 8, 2007.

[^72]: Note: FFPIB 07-01 (updated) was released on October 5, 2007 as an
    update to FFPIB 07-01 (August 8, 2007. The updated version includes
    IEHA indicators, in addition to the other reporting requirements.
    Since Malawi will become an IEHA country in 2008, CSs should consult
    with the USAID Malawi Mission about IEHA indicators to include in
    their reporting systems.

[^73]: The FFP "Title II Program Policies and Proposal Guidelines for
    Fiscal Year 2008," (DRAFT) provide more detailed guidance on the
    types of coordination and synergies that it expects with respect to
    a number of programs and technical areas, including the GDA,
    HIV/AIDS, CAADP and the Millennium Challenge Corporation (MCC).