Total country population (2001): 15 million

Project population and area: 6 million in 23 districts of two of the country's six provinces

Project Duration:1997 to present

• Visit LINKAGES/Madagascar website
• Download a complete copy of World LINKAGES/Madagascar
• Download the final report Using the Essential Nutrition Actions Approach to Improve the Nutritional Practices of Women and Children at Scale in Antananarivo and Fianarantsoa Provinces of Madagascar: Results and Trends 2000 to 2005
• Download The Story of LINKAGES AED in Madagascar, documenting the program’s major strategies from 1997-2004
• Download Journal of Human Lactation article on "Improving Breastfeeding Practices on a Broad Scale at the Community Level: Success Stories From Africa and Latin America"
• Download CHNRI Research Brief on Successfully Scaling Up Exclusive Breastfeeding: Lessons from Madagascar
• Download Cost and Effectiveness Analysis of LINKAGES' Infant and Child Feeding Program in Madagascar, prepared by Abt Associates
• Download Promoting Breastfeeding in Madagascar, a description of various media and materials used by the project
• Download the report on The Experience of Involving Members of Women’s Groups to Promote Nutrition in Madagascar
• Download counseling cards developed by LINKAGES and its country program partners

Background
In Madagascar, one in 10 children dies before reaching the first birthday; one in six dies before the age of 5. Malnutrition is an underlying cause in 54 percent of all under five deaths. Among 19 sub-Saharan African countries for which Demographic Health Survey data are available, Madagascar has the highest proportion of children under the age of three years who are stunted (low height for age). Almost half of Malagasy children in this age group suffer from malnutrition. A major cause of death and malnutrition is sub-optimal breastfeeding practices and poor complementary feeding practices with foods inadequate in quality, quantity, and/or density.

Program Design and Implementation
LINKAGES provided support to the Ministry of Health for national policy activities, particularly the establishment and coordination of an intersectoral nutrition action group of 50 organizations, known as the GAIN (Groupe d'Action Intersectoriel pour la Nutrition). Representatives of government ministries, donors, and international and national NGOs met to harmonize nutrition messages, reach consensus on micronutrient protocols, and develop a nutrition IEC and advocacy strategy.

The nutrition component of the strategy is based on Essential Nutrition Actions (ENA) that promote key nutrition behaviors at six critical health contact points: prenatal, delivery and immediate postpartum, postnatal and family planning, immunization, growth monitoring/well child, and sick child consultations. The key behaviors include the promotion of breastfeeding, complementary feeding, feeding of the sick child, and women's nutrition. In 1999 LINKAGES expanded to the district level, building a community approach on the Integrated Management of Childhood Illness (IMCI) strategy adopted by the MOH and supported by JSI, UNICEF, and WHO, as well as the BASICS I Project's communication strategy of promoting small "do-able" actions with easily recognizable health benefits.

The community approach uses interpersonal communications, capacity building, community mobilization, and mass media to promote improved breastfeeding and complementary feeding practices. BASICS I conducted formative research and developed IEC materials, enabling LINKAGES to move directly into field implementation. Training improved the capacity of health care providers and community health promoters to assist women in adopting practices to improve their children's health and their own health. Malagasy NGOs, CRS, CARE, ADRA, the MOH, and BFHI facilities participated in the training. Harmonization of promotional messages from the national to the community level and saturation of these messages has resulted in repeated delivery of consistent messages through multiple channels, including local radio broadcasts, national radio and television spots, traditional singers, and songs by pop singer Poopy, Madagascar's musical celebrity and "breastfeeding/nutrition ambassador".

Results
To assess changes in infant and young child feeding practices, LINKAGES conducted rapid assessments at program and control sites in October 2000 and October 2001, and demonstrated that breastfeeding practices can be changed quickly.