Evaluation of Zimbabwe SPLASH

Voucher Transfer Activity

Final Report

January 2012

Submitted to:

UN World Food Programme

Zimbabwe Country Office

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Table of Contents

Table of Contents ....................................................................................................................... ii Acknowledgements .................................................................................................................. vii 1 Executive Summary ........................................................................................................... ix

1.1 Beneficiary Impacts ......................................................................................................x

1.2 Program Effectiveness ............................................................................................... xii 1.3 Conclusions ...............................................................................................................xvi 1.4 Recommendations ................................................................................................... xviii

1.4.1 Main Recommendations ................................................................................... xviii 1.4.2 Secondary Recommendations .............................................................................xix

2 Introduction ....................................................................................................................... 23

2.1 Background ................................................................................................................. 23

2.2 Scope of Evaluation .................................................................................................... 24

2.3 Methodology ............................................................................................................... 25

2.3.1 Quantitative survey methodology ......................................................................... 25

2.3.2 Qualitative methodology ...................................................................................... 26

2.3.3 Method limitations ............................................................................................... 27

2.4 Organization of the Report .......................................................................................... 27

3 Findings – Beneficiary Impact............................................................................................ 28

3.1 Demographic and Household Information ................................................................... 28

3.2 Assistance Received from SPLASH ............................................................................ 31

3.3 Benefits of food assistance .......................................................................................... 34

3.4 Expenditures ............................................................................................................... 35

3.5 Household Assets ........................................................................................................ 44

3.6 Income and Debt ......................................................................................................... 48

3.7 Food Consumption ...................................................................................................... 53

3.7.1 Number of meals per day ..................................................................................... 53

3.7.2 Food Consumption Score ..................................................................................... 55

3.8 Coping Strategies ........................................................................................................ 57

3.9 Anthropometrics and BMI ........................................................................................... 59

3.9.1 BMI using monitoring data .................................................................................. 62

3.9.2 Adherence ............................................................................................................ 64

3.9.3 Social Benefits and Side-Effects .......................................................................... 66

4 Findings - Relevance and Effectiveness of the Intervention ................................................ 66

4.1 Form of Food Assistance ............................................................................................. 67

4.1.1 Composition of ration .......................................................................................... 67

4.1.2 Quantity, duration, and quality of food assistance ................................................ 70

4.1.3 Food vs. cash ....................................................................................................... 71

4.2 The Targeting, Registration, Education and Follow-Up Process .................................. 74

4.2.1 Target Group Definition ....................................................................................... 74

4.2.2 Screening and Registration ................................................................................... 77

4.2.3 BMI measurement as criteria................................................................................ 79

4.2.4 Vulnerability screening for household rations ...................................................... 82

4.2.5 Monthly Clinic Visits ........................................................................................... 82

4.2.6 Monitoring, Discharges and Reactivations ........................................................... 83

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4.3 The Voucher and Retailer System ............................................................................... 86

4.3.1 Concept of vouchers ............................................................................................ 87

4.3.2 Issuance of vouchers ............................................................................................ 88

4.3.3 Beneficiaries: voucher redemption experience...................................................... 90

4.3.4 Retailers: Capacity and Nature and Impact of SPLASH on Business .................... 93

4.3.5 RMT: Role and Impact......................................................................................... 96

4.3.6 Clinics: Type and Impact of SPLASH Responsibilities ........................................ 98

4.4 SPLASH Approach in the Context of Zimbabwe’s Food Security and Social Welfare Sector ............................................................................................................................. 100

4.4.1 Sustainability for beneficiaries ........................................................................... 100

4.4.2 Sustainability and integration with local institutions ........................................... 102

4.5 Management Considerations ..................................................................................... 105

4.5.1 Management structure ........................................................................................ 105

4.5.2 Urban specificity of the approach ....................................................................... 107

5 Conclusions ..................................................................................................................... 108

6 Recommendations ............................................................................................................ 109

6.1 Main Recommendations ............................................................................................ 109

6.2 Secondary Recommendations.................................................................................... 110

6.2.1 Ration Composition ........................................................................................... 110

6.2.2 Targeting ........................................................................................................... 111

6.2.3 Registration and Clinic Follow-ups .................................................................... 111

6.2.4 Voucher Management ........................................................................................ 112

6.2.5 General Management and Partnerships ............................................................... 112

7 Annexes ........................................................................................................................... 114

7.1 Terms of Reference ................................................................................................... 114

7.2 Considerations for Engagement and Partnership in Community Outreach ................ 117

7.3 List of Key Informant (KI) Interviews and Focus Group Discussions (FGD) ............. 121

7.4 Quantitative Survey Questionnaire ............................................................................ 124

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List of Tables

Table 2: Percent of adults aged 18 years or more engaged in economic activity, by beneficiary status ......................................................................................................................................... 30

Table 3: Percent of adults aged 18 years or more engaged in economic activity, by sex ............. 30

Table 4: Child parental status (<18 years old), by beneficiary status .......................................... 30

Table 5: School status of children aged 6-17 years old, by beneficiary status ............................. 31

Table 6: Timing of last ration, by beneficiary status .................................................................. 32

Table 7: Number of months receiving ration before the survey, by beneficiary status ................ 32

Table 8: Number of cycles, by beneficiary status ....................................................................... 33

Table 9: Number of months between cycles, by beneficiary status ............................................. 33

Table 10: Gender of recipient and decision-maker, by beneficiary status ................................... 34

Table 11: Benefits of the SPLASH voucher system, by beneficiary status ................................. 34

Table 12: Whether or not beneficiary feels they are better off, by beneficiary status .................. 35

Table 13: Mean household monthly food expenditures, by beneficiary status (USD) ................. 36

Table 14: Percent spent on food items in previous 30 days compared to before SPLASH, by beneficiary status ...................................................................................................................... 37

Table 15: Mean non-food household expenditures, by beneficiary status (USD) ........................ 39

Table 16: Mean household monthly non-food expenditures, by beneficiary status (USD) .......... 39

Table 17: Mean household periodic non-food expenditures, by beneficiary status (USD) .......... 40

Table 18: Percent spent on monthly non-food items in previous 30 days compared to before SPLASH, by beneficiary status ................................................................................................. 41

Table 19: Percent spent on non-food periodic items in previous six months compared to before SPLASH, by beneficiary status ................................................................................................. 42

Table 20: Assets purchased since participating in SPLASH, by beneficiary status ..................... 46

Table 21: Assets sold since participating in SPLASH, by beneficiary status .............................. 47

Table 22: Would household need to sell assets if not for SPLASH, by beneficiary status........... 47

Table 23. Primary income source, by beneficiary status............................................................. 48

Table 24: External support, by beneficiary status ....................................................................... 50

Table 25: Percent change in household income, by beneficiary status ........................................ 50

Table 26: Mean household income, by beneficiary type (USD) ................................................. 52

Table 27: Percent of households borrowing money, by beneficiary status .................................. 52

Table 28: Consumption patterns for adults and children, by beneficiary status........................... 53

Table 29. Mean FCS and HDDS, by beneficiary ....................................................................... 56

Table 30: FCS category, by beneficiary type ............................................................................. 56

Table 31: Other coping strategies by beneficiary status ............................................................. 59

Table 32: Effects of cash/food on beneficiary adherence to medication, by beneficiary status.... 64

Table 33: Frequency of review and measurement, by beneficiary status .................................... 64

Table 34: Complications experienced in last 30 days, by beneficiary status ............................... 65

Table 35: Commodities received, by beneficiary status ............................................................. 67

Table 36: Receipt of other forms of assistance ........................................................................... 69

Table 37: Motivation for getting tested, by beneficiary status ...... Error! Bookmark not defined.

Table 38: Negative effects from stigma associated with being tested, by beneficiary status Error!

Bookmark not defined.

Table 39: Level of satisfaction with referral process to register in SPLASH, by beneficiary status ................................................................................................................................................. 79

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Table 40. Advantages to the SPLASH voucher system, by beneficiary status ............................ 90

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List of Figures Figure 1: Population pyramid for sampled households ............................................................... 28

Figure 2: Population pyramid, based on DHS data..................................................................... 29

Figure 3: Household food budget by food group and beneficiary status ..................................... 36

Figure 4: Percent of households owning various assets, by beneficiary status ............................ 44

Figure 5: Asset ownership – mean number owned, by beneficiary status ................................... 45

Figure 6: Mean number of income sources, by beneficiary status .............................................. 48

Figure 7: Mean per capita income 6 months ago and current, by beneficiary status .................... 51

Figure 8: Percent of households consuming various food types in the 7 days prior to the survey, by beneficiary status .................................................................................................................. 54

Figure 9: Mean coping strategies index (CSI), by beneficiary status .......................................... 57

Figure 10: Employment of coping strategies .............................................................................. 58

Figure 11. Nutritional status of households, by beneficiary status .............................................. 60

Figure 12: BMI classifications by time enrolled in program and time out of program ................ 61

Figure 14: Percent of household satisfied with commodities received ........................................ 68

Figure 15: Preference of food versus cash assistance, by beneficiary status ............................... 71

Figure 16. Reasons for preferring food, by beneficiary status .................................................... 72

Figure 17: Reasons for preferring food and cash, by beneficiary status ...................................... 73

Figure 18: Summary of Voucher Implications for SPLASH Implementing Partners and Beneficiaries ............................................................................................................................. 87

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Acknowledgements

The evaluation team wishes to thank WFP staff and partners who spent time and provided support to enable us to carry out our fieldwork and write-up. We are grateful to have had the opportunity to support the important work you are doing, on behalf of the vulnerable people of Zimbabwe. Thanks first to Felix Bamezon, WFP Country Representative, and Simon Cammelbeeck, Deputy Director, for setting up this evaluation, and to Liljana Jovceva, Programme Manager, for providing clear directions and patiently waiting for the results. Brenda Zvinorova was our competent and consistent partner in guiding the entire exercise and keeping the process moving forward, despite other demands on her time. Brenda, Tiwonge Machiwenyika and Joy Achayo played invaluable roles in managing the enumerators and setting up the tools of the research. Other WFP colleagues patiently explained their work and the national context, and contributed to our work, including: Kudzai Akino, Sherita Manyika, Tafara Ndumiyana, Hugo Rami, Herbert Matsikwa, Arthur Pagiwa, Sam Chimwaza, Robert Makasi, Bonaventure Kayinamura. Our team of researchers from the Centre for Applied Social Sciences did a stellar job – good working with you!

Qualitative researchers: Davison Muchadenyika, Shava Thokozani Quantitative enumerators: Takura Musiyarira, Heather Evelyn Mazhindu, Gift Musinake,

Tanyaradzwa Whande, Sharleen Makondo, Clemence T. Nhliziyo Their hard work and insights enriched tremendously this report, though as lead consultant, I take responsibility for any errors that may have been made. From the Government of Zimbabwe, we wish to particularly acknowledge the interest, support and sense of responsibility shown by Chris Nyadzayo, Chief Nutritionist, Dept of Nutrition, Zimbabwe Ministry of Health and Child Welfare. Julian Borcherds and Tyler Cornish of Redan Mobile Transactions helpfully provided time from their busy schedule. Many SPLASH program participants, clinic staff and retail staff took their time to help us gain a complete picture – we wouldn’t be able to do anything without your collaboration. This report has been a joint effort of Darren Hedley, lead consultant, and Suzanne Nelson, of TANGO International. Brad Sagara led the design of the quantitative research exercise and carried out analyses of the data. Prepared by:

TANGO International, Inc.

406 South 4th

Avenue

Tucson, Arizona 85701 USA

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Acronyms

AIDS Acquired Immune Deficiency Syndrome ART Antiretroviral Therapy BEAM Basic Education Assistance Module CC Christian Care CHW Community Health Worker CHS Community and Household Surveillance DAC Drug Adherence and Counselling E-vouchers Electronic Vouchers FAO Food and Agriculture Organization FCS Food Consumption Score FGD Focus Group Discussion HDDS Household Dietary Diversity Score HEPS High Energy Protein Snack HIV Human Immunodeficiency Virus HVHH Highly Vulnerable Household IRD International Relief and Development IGA Income-Generating Activities MCT Mashambanzou Care Trust MFI Microfinance Institute MMC Moderately Malnourished Children MOHCW Ministry of Health and Child Welfare MSF Médecins Sans Frontières MTZL Mobile Transactions of Zambia Limited MUAC Mid Upper-Arm Circumference NRC National Registration Card NSART Nutritional Support for Anti-retroviral Therapy OI Opportunistic Infection Clinic PDA Personal Digital Assistants PDM Post-Distribution Monitoring RFFV Response to Increase Household Food Security through Food Vouchers RMT Redan Mobile Transactions SDC Swiss Agency for Development and Cooperation SPLASH Sustainable Programme for Livelihoods and Solutions for Hunger SMS Short Message Service TB Tuberculosis UNICEF United Nations International Children’s Emergency Fund VCT Voluntary Counselling and Training WFP World Food Programme WHO World Health Organization ZIMPRO Zimbabwe Project Trust ZNASP Zimbabwe National Strategic Plan ZNNPP+ Zimbabwe National Network for People Living Positively

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1 Executive Summary

This report presents findings from an evaluation of WFP Zimbabwe’s voucher transfer pilot programme, Sustainable Programme for Livelihoods and Solutions for Hunger (SPLASH). SPLASH was an enhanced phase of the urban Nutritional Support for Anti-Retroviral Therapy (NSART) programme that provides food rations to malnourished ART and TB patients during their initial period of treatment. The pilot programme was designed as a means of enhancing implementation of the urban Nutrition Support for Anti-Retroviral Therapy (NSART) programme within the framework of PRRO 200162, Assistance for Food-Insecure Vulnerable Groups. SPLASH is a health-based safety net program focused primarily on the rehabilitation of ART/TB patients. It provides a supplementary monthly ration of 10 kg of corn-soya blend (CSB) per patient. The program secondarily focuses on vulnerable households and provides a protection ration for households deemed vulnerable consisting of 5 kg of maize meal, 1 kg of pulses, and 0.75 L of oil per person, up to a maximum of five persons. Modelled on a similar voucher initiative carried out by WFP in Zambia, the food voucher programme is, in essence, an alternative food distribution mechanism that substitutes private local retailers for traditional WFP-mediated channels of procurement, transport and storage. A household food assistance package was provided through electronic vouchers (e-vouchers), or scratch cards, that allowed disbursements of household rations to be approved and monitored online in transactions with private local retailers as an alternative to traditional transport and supply arrangements. The main goals of SPLASH, in support of the overall goals of PRRO 200162, are to: improve the well-being of chronically ill adults to achieve greater capacity for productive recovery, safeguard food access and consumption of highly vulnerable food-insecure households, and increase government and community capacities to manage and implement hunger reduction policies and approaches. As an outgrowth of NSART, the SPLASH pilot programme was managed by the local NGO, Christian Care, from August, 2010 until March, 2011. Subsequently it has been directly implemented by WFP Zimbabwe. NSART/SPLASH is a health-based safety net program. During design of the program WFP coordinated with the Zimbabwe Ministry of Health and Child Welfare (MOHCW) and the City of Harare Health Department. ART and TB patients are targeted through seven clinics (Harare Central, Parirenyatwa, Epworth, Newlands, Beatrice, Wilkins, UZCRC), the first four of which also serve as registration and voucher distribution centres. Redan Mobile Transactions (RMT) set up the voucher database and provided oversight to four retail outlets authorized for voucher redemption. The goals of the evaluation were to assess the impact of the intervention on beneficiaries’ ability to access nutritious food, determine the appropriateness of this intervention for urban beneficiaries, and examine the potential of scaling up voucher transfers as part of a longer-term social protection programme in Zimbabwe. The evaluation utilized both quantitative and qualitative methods, and was carried out by an external consultant, three WFP staff members, and a team of eight independent enumerators. There was no baseline available, thus, the study

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compared current beneficiaries with those who had formerly been beneficiaries and tracked changes in key indicators over time. The qualitative research consisted of a series of focus group discussions with current and former beneficiaries, staff at seven clinics, and interviews and observations at the four retail outlets. Key informant interviews were also conducted with government institutions, United Nations agencies, implementing partners and collaborating NGOs. The quantitative research was carried out through a household survey of a random sample of current and former beneficiaries. The questionnaire included standard questions on food and livelihood security, anthropometric measurements, and questions about beneficiary perspectives on SPLASH implementation methods. The survey faced several challenges with both groups of respondents. Current beneficiaries sampled did not appear at the clinics as expected and could not be interviewed; it later emerged that the registry which was used as the sample frame contained people who had defaulted for two or three months, and whose names were in the process of being removed. Former beneficiaries were even more difficult to track down because they don’t attend a clinic as often for their regular checkups and their medical visits may involve smaller polyclinics located throughout the city, making them logistically difficult to contact. Over 64% of former beneficiaries had received their last ration more than six months prior to the survey.

1.1 Beneficiary Impacts

Those interviewed as part of this study were broadly representative of the SPLASH beneficiaries (clients). Of the quantitative survey group, 86% were ART patients, 13% were TB patients, and 1 % were pre-ART. Thirteen percent were double orphans, 28.7 % of children were without fathers, and 5.9% were without mothers. Half of the sample had never been employed though 35 % are currently employed, including for women. Over 90 % of households reported a female as the primary household decision-maker. One impact of the monthly receipt of the rations was that households were reportedly able to redirect funds that would otherwise have been spent on the same staple foods as those received in the ration. Education is one of the areas that people spend on; school-aged children in nearly three-fourths of all respondent households are currently in school. Rent makes up the largest single non-food monthly expenditure for both current and former beneficiary households, but current beneficiaries spend more of their non-food budget than former beneficiaries on rent, transportation, electrical and other monthly bills, telephone service and household items generally. Healthcare is the second largest single expense for both groups, though current beneficiaries pay more than twice what former beneficiaries pay for healthcare. Paying down debt (i.e., repaying loans) is a relatively important non-food expenditure for households. Respondents also redirected their spending to other food items. The survey data show that current beneficiaries are spending more on cereals, tubers and bread. WFP’s post distribution monitoring findings also confirm that the savings are often used to purchase more of the basic commodities, which they say suggests that the food they receive does not take them through the month. The survey data shows no clear trends in terms of money saved through receipt of the food ration being redirected to spending on a diversity of other food items, such as fruits, vegetables, meat, eggs, fish or milk. A small group are spending more on these food groups, but

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an equal number are spending less. Thus, savings resulting from receipt of the food ration do not appear to be contributing in any significant way to diet diversity. Income is not directly influenced by the SPLASH intervention, but since the food ration is partly intended as a livelihood enhancement strategy, it is important to analyze the utilization of the food ration in the context of clients’ coping strategies. There was some evidence in FGDs of people neglecting these coping strategies and relying more on the food rations. This creates some risk that clients may find it more difficult to start up such activities again. While there may be positive aspects of being relieved from activities that are in some cases barely tolerable, it becomes that much more difficult for them to acquire assets and actually improve their economic situation on a sustainable basis. A considerable number of current beneficiaries are borrowing money to meet their immediate needs, such as food. This could expose them to the risk of struggling in order to repay loans, though that risk is partly mitigated by the fact that most loans are from friends or family members. In FGD discussions, respondents repeatedly confirmed how their food consumption had improved as a result of the program but that inevitably it became more difficult after the end of the program. The quantitative data showed a different patterns of food consumption for current and former beneficiaries. Over 57% of current beneficiaries consumed three meals/day and 38.4% consumed two meals/day. In contrast, 27.4% of former beneficiaries consumed three meals/day and 67.4% consumed two meals/day. These numbers were similar to those reported for former SPLASH beneficiaries1 in Zambia; 29.4% consumed 3 meals/day and 51.3% consumed two meals/day. Similar figures were seen for children. Almost no respondents relied on only one meal/day and thus most were able to avoid hunger lasting most of the day and that can affect energy levels. Still, ART/TB medication can be quite taxing on the body and two meals may be inadequate. The mean Food Consumption Score (FCS) was 56.5 for current beneficiaries and 39.6 for former beneficiaries, both of which are in the acceptable range. The FCS reported for SPLASH in Zambia was 46.6. However, 23.7% of current beneficiaries and 40% of former beneficiaries have borderline food consumption; 4.2% of current and 28.4% of former beneficiaries have poor food consumption. The Coping Strategy Index (CSI) was 38 for former beneficiaries and 17 for current beneficiaries (a higher number indicates a higher level of food insecurity). This compares with a CSI of 28 for SPLASH Zambia. A majority of respondents employ strategies like reducing numbers of meals, limiting portion sizes and eating less preferred foods. Nine percent of current beneficiaries and 37% of former beneficiaries at times skip entire days without eating; close to 5% of both groups at times send family members to beg. Fourteen percent of current beneficiaries and 27.4% of former beneficiaries sell assets to buy foods. An average of 14.5% of all households are reportedly engaging in transactional sex as a coping strategy, a risky strategy given that the majority of respondents are HIV positive. Even in the event they properly utilize contraceptives, the risk of infecting others is high.

1 Zambian SPLASH participants had only just finished their program, over 80% were within 6 months of discontinuation.

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The Body Mass Index (BMI) readings taken as a whole suggested an improvement in nutritional status as a result of the program, with some major qualifications. First, in comparing the two groups of survey respondents, current beneficiaries had significantly lower BMI than former beneficiaries (17.8 and 21.6, respectively; p< .001). Significantly fewer former beneficiaries experienced severe, moderate or mild thinness than current beneficiaries (p< .001). The better status of former beneficiaries is presumed to be due to all or some of the following factors: the relatively longer period of time they spent on the program, the continued impact of the food assistance on their nutritional and livelihood status, the fact that beneficiaries who improve are discharged from the program (and therefore no longer are counted among the current beneficiary group), and the likelihood that this group were less malnourished than the current group of beneficiaries. Looking at the progression of current beneficiaries during their participation in the program, some initial improvements were made and then actually appeared to have declined after the fourth month. These findings were consistent with the BMI information taken from the database of overall participants. This is probably due to the discharge of those who improve their BMI (i.e., only those with low BMI remain to be measured) and from the uneven nature of rehabilitation with ART/TB medication. The analysis was, however, limited by a lack of monthly BMI data beyond the four months. Among former beneficiaries, those out of the program for seven months or more did not appear worse off than those out for less than six months. These results suggest that while on the program clients may take variable amounts of time to improve their nutritional condition and once they have left the program appear able to maintain their weight and nutritional status for some time. Experience and reason would suggest that there might be a natural process of reversal of some of the advances made after the programme because respondents are often limited in their ability to support themselves. Such post-programme decline, however, seems to be less universal and less pronounced than expected, and may deserve further exploration. In terms of the impact of SPLASH on adherence, 83.8% of respondents stated that without food it is difficult to take ART/TB medication; the program made medicines much easier to take. Twenty-one percent of respondents reported that receipt of the ration helped them schedule monthly clinic visits involving anthropometric measurements. Though a majority of current beneficiaries made monthly visits and measurements, 13.4% reported they only had measurements taken once every two months and 6.1% indicated it was once in three months. Over 23% of respondents said they had suffered from other illnesses in the past 30 days and 7.9% of current and 1.6% of former beneficiaries reported being unable to adhere to treatment regimes while 2.7% had defaulted (interrupted for two days in a row). All things considered, this is a good rate of adherence and in FGDs, beneficiaries reiterated that the various supports were resulting in high adherence.

1.2 Program Effectiveness

The ration seems to be appropriate in terms of providing CSB for ART/TB patients and protective rations for households in which patients live. Overall levels of satisfaction with the

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commodities received are very high though there were many comments and reservations about beans and their lack of digestibility. The length of time spent on the programme may be adequate for many clients though it seems some patients do not recover sufficiently within the six month time limit, especially TB patients. The fairly easy re-activation process used in SPLASH is a good approach. With only 17% of second cycle clients among current respondents , the process is likely not too easy to enable inclusion error. A large percentage of current beneficiaries were spending more on cereals, tubers and bread – more so than on other, more protein and vitamin-rich foods. This may suggest that they have additional energetic needs not being met by the ration, but it could also be due to eating habits and a desire by beneficiaries to save, because other foods are more expensive. The use of food as opposed to cash as an intervention is firmly supported both by results of qualitative and quantitative research. The survey showed a preference for food by a majority of respondents while 27 % prefer a combination of food and cash, and less than 5% prefer cash only. The preference for food is due to the perception that it is more secure, less prone to being used for non-essential needs, and that it is an appropriate currency for sharing with others. Targeting and recruitment of malnourished ART/TB clientele was done through the network of hospitals, and particularly Opportunistic Infection clinics. These clinics gather patients from all parts of the city, irrespective of vulnerability status, with the exception of Epworth clinic in a marginalized township just outside the main city. WFP has had limited involvement with outreach activities to encourage potential beneficiaries to come forward; in the case of ART/TB patients, this would entail engaging in raising awareness and promoting voluntary testing and providing counselling. Some small-scale community health promotion activities are currently taking place but these did not figure prominently in reasons given by respondents for undergoing HIV testing. Stigma remains a significant challenge that tends to make individuals go to great lengths in avoiding disclosure, including avoiding testing or travelling far from home to receive treatment. An earlier phase of NSART involved little screening for anthropometric measures. However, the initiation of SPLASH in August, 2010 marked the beginning of this screening and it clearly entered into force in March, 2011 under WFP management. The main component of this screening was BMI testing, though MUAC measurements were taken for pregnant and lactating women. Clinic staff play a crucial role in identifying and screening particularly vulnerable and undernourished individuals. Virtually all of the clinic staff expressed their disagreement with the policy of strict screening based on low BMI, which they felt was excluding many vulnerable and malnourished patients. The recently-enforced policy had left them unable to use their clinical skills and knowledge of the individuals to recommend patients for inclusion in SPLASH. WFP staff are located at the four Voucher Distribution Points (VDP) that are the remote management centres for the SPLASH program. The online database system permits registration, screening, voucher issuance and food ration access all at one time. This reduces patients’ travel costs and waiting time considerably, and alleviates stress they may encounter at a time when they are unwell.

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Despite high numbers of patients at Beatrice and Wilkins clinics, the lack of onsite VDPs there creates challenges for patients for whom it is difficult to get to Harare and Parirenyatwa hospitals (often due to lack of transportation or simply being too sick) in order to register and receive their vouchers. Clinic staff are under tremendous pressure from large patient caseloads and are generally understaffed. Conducting measurements of patients weight creates a challenge at Parirenyatwa and Harare hospitals, where weight measurements are taken instead by the WFP officer located at the VDPs. When patients reach a BMI of 18.5 for two months in a row, or after six months, they are discharged from the program. Many respondents felt that this process had often been handled abruptly. Still, the level of satisfaction with the process of referral and registration is very high. The SPLASH supplementary feeding for pre-ART, TB and Mother and Child Health patients provides nutritional support to directly assist recovery and is also a form of incentive and condition for them to adhere to their medication. Monthly visits involved counselling and medical sessions, during which the patient’s weight should have been measured. Though these educational sessions are run almost entirely by the clinics and independently of SPLASH, the program aimed to influence programme participants by increasing their participation in nutrition and counselling sessions, and to generally promote a stronger and more effective relationship between clinics and beneficiaries. There were some problematic aspects of the cycle in terms of registered clients not appearing for monthly visits, which would mean that they would miss both their ration and possibly their medication for the month. In some cases, weight measurements are not kept in the tracker form and the discharge status not designated, which WFP explains would indicate that the beneficiary did not show up for food rations (and measurements) on that month. Thus, it was not clear how reconciliation of the records occurred between registered beneficiaries who actually show up and the vouchers that are issued. WFP states that no-shows are pulled out of the online database at the end of the month, but yet the tracker form which was used to draw the sample for the current survey contained many names of beneficiaries who apparently had not shown up for two or three months. The piloting of vouchers with retailers, particularly the establishment of the electronic voucher system, constitutes a valuable step forward for WFP. It introduced an element of improved control and instantaneous payment makes it more attractive for retailers and reduces paperwork for WFP and FIPs. The retailers proved to be effective food distributors who generally learned to deal with a low-income clientele. Quality control issues and price setting are important factors for future programmes to consider. The SPLASH experience with e-vouchers is a contribution to the discussions about optimal forms of assistance, whether food, cash, a combination or other forms. SPLASH was a food programme in the sense that it provided a voucher scratch card that was to be used for specific food items and redeemable at designated locations. However, there was more value attached to the receipt of food from a retail outlet than from a programme warehouse, as is often the case in food distribution programmes. The voucher and retailer system brings in the novel aspect of contracting retailers to procure food commodities through their normal channels, stimulating the local food market directly. Retailers take responsibility for transport and management of the food until the voucher-mediated electronic transaction allows them to disburse a ration to a client. This seems to be providing a secure means of food transfer, with no reports of theft of rations through the vouchers and more transparency for the entire process.

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Managers of traditional programs worry about managing food commodities and ensuring that they are not misused. With the voucher system, the primary control and programme quality issue becomes the tracking of vouchers, ensuring they are given to and remain in the possession of the right beneficiaries. A secondary control issue concerns beneficiaries presenting their vouchers to retailers and receiving both good service and the correct quantity and quality of commodities. For 87.2% of beneficiaries, the voucher system appears advantageous. The most common advantage mentioned is the more convenient commodity pick-up locations and times, and to some extent of the vouchers as well. Clients have a choice during the month of when they register, visit the clinic and have measurements taken, pick up the voucher, and pick up their supplies. While there are only four retailers currently contracted in SPLASH, the program does expect to expand the network. Beneficiaries also feel the arrangements are more secure, which is to their advantage. The system is also more confidential and discreet, allowing beneficiaries to purchase food items the same as anyone else, increasing their sense of dignity and avoiding the risk of stigma. Retailers involved in the programme were mostly large, established stores, which allowed them some degree of flexibility in dealing with a very large clientele and demand in the first months of the program. When the number of beneficiaries dropped suddenly, however, it was somewhat disruptive. Retailers generally spoke positively about relations with Redan Mobile Transactions (RMT) and WFP, as well as with the clients, but they expressed a lack of full awareness of program dynamics that could have a large bearing on their business, such as increases/decreases in client numbers. Network connectivity was the other major issue affecting retailers and their clients, and they suggest the need for backup arrangements. RMT is a private company which was brought into SPLASH as the food distribution service provider for SPLASH and in particularly to design the database and oversee retail operations. They learned to work effectively with WFP, Christian Care, the clinics and retailers, despite the differences of approach and organizational cultures. They forged a productive relationship with the Zambia SPLASH operations through Mobile Transactions of Zambia Limited (MTZL). Although the database was developed by MTZL in conjunction with WFP Zambia, RMT and WFP Zimbabwe have innovated several useful new features in the system, such as the different scratch bars on the vouchers that provide finer detail monitoring. In addition, the system now allows immediate registration of clients and issuance of vouchers. RMT has provided a valuable service and greatly facilitated ongoing innovations in the system, and its position in Zimbabwe will enable it to transfer benefits from SPLASH systems and approaches to other programs. The sustainability of SPLASH benefits should be considered first in terms of the durability of food and livelihood security impacts, and beneficiaries’ basic capacities to build on and make the most of their time in SPLASH. SPLASH not only provides temporary relief to vulnerable beneficiaries, it also helps them through critical phases of treatment and in many cases the benefits extend beyond the period of receiving food rations. At the most basic level, the program should help create beneficiary assets and capacity, and build the confidence of beneficiaries to cope with life after SPLASH. It is reassuring that 99% of current beneficiaries feel they are better off than they would have been had they not participated in SPLASH; it is somewhat

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disappointing that 38% of former beneficiaries feel they were not better off for having participated in SPLASH. The survey did not directly follow up this question to probe why people felt this way. Feedback from the qualitative studysuggests that for some people, despite the short-term relief of the food ration,they felt that their overall condition was not improved since the time they began the program. A second dimension of sustainability relates to the presence of other activities and programs that might help participants improve their food security situation. Experiences with sustainable livelihood activities varied widely among SPLASH participants but most stated they were unable to accrue any meaningful savings for use after discharge because of general economic hardships. The SPLASH program encouraged beneficiaries to join support groups, such as money savings groups in which members could borrow money for income generating activities. Other livelihood activities could significantly augment SPLASH’s nutrition support efforts, such as nutrition gardens promoted by ADRA in the Epworth area, and other related organizations. The institutional sustainability of SPLASH rests on the capacity and willingness of ministries, clinics, retailers and others to carry forward the model and implement lessons learned. Though there seemed to be ongoing contact between individuals within government ministries and WFP staff, information was not flowing between individuals within the government. Similarly with clinics and retailers, the foundation for communication and coordination exists, but specific gaps remain – for example the feeling by lower-level clinic staff that their views are not represented if WFP is speaking mainly to senior staff. There appears to be excellent overall coordination of WFP with other UN agencies, donors and ministries, however, such that future evolution of voucher and cash modalities are likely to be strategically carried out. WFP’s management of SPLASH has been well-conducted, both in the contracting of important pieces of work to Christian Care and RMT and in the direct involvement needed to guide the pilot phase of the program. Despite the lack of a team in WFP which works full-time on the program, activities have been properly guided and carried out on schedule. The monitoring and evaluation system has been greatly strengthened in recent months but improvements are needed to track status of beneficiaries and their monthly attendance at clinics.

1.3 Conclusions

SPLASH has helped to stabilize the food security status for approximately 18,000 malnourished ART/TB patients and enabled them to effectively initiate their treatment regimes. Through various qualitative and quantitative research methods, the evaluation team confirmed that participants benefit greatly from the programme in terms of food assistance received, their ability to adhere to medications, and the consolidated services they receive at health centres and retail outlets. The programme was managed effectively while piloting the innovative delivery and management system of electronic vouchers. These results suggest that while improvement of nutritional status in clients may vary over the length of time they are enrolled in the programme, once they have left the program they appear able to maintain their weight and nutritional status for some time. Experience and reason would suggest that there might be a natural process of reversal of some of the advances made after the

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programme because respondents are often limited in their ability to support themselves. Such post-programme decline, however, seems to be less universal and less pronounced than expected, and may deserve further exploration. Beneficiaries were able to redirect spending to important purposes such as education, health care, and other needs. Investments in business activities from savings were quite low, however. Spending on energy-rich food increased but the savings resulting from receipt of the food ration do not appear to be contributing in any significant way to diet diversity. The food assistance is instrumental in increasing adherence to medication. Levels of adherence are reasonably high and beneficiaries partly credit that to the food rations. This is a benefit that should ideally accompany ART and TB medications for all who are taking it in Zimbabwe. Issues highlighted during most FGDs and reflected in the quantitative data suggest that there is a mixed experience that needs to be taken into account when planning programs. Some SPLASH beneficiaries are what might be termed extremely food insecure, with problems severe enough that the benefits of SPLASH were outweighed by these bigger factors. Some of the indicators of this group of the sampled population are:

• Households with school aged children in which 4% never enrolled in school, while another 15% had dropped out before this school year – and this despite a widespread availability of assistance for schooling

• Single and double orphans

• Those who lack assets like beds, mobile phones, chairs, and those who sell assets

• Those who borrow money for food

• Those who employ severe coping strategies, such as selling assets or begging, and in some cases even while on the program

• Those who engage in transactional sex as a coping mechanism

This latter group raises obvious additional concerns for ART patients. On the other hand, there are beneficiaries who are somewhat better off, including those who own cell phones (about 50% of respondents) and other modest productive assets. The recent initiation of stricter targeting criteria is likely to significantly help focus scarce resources on those who are most vulnerable, though this will need to be monitored. The voucher system and its impact on the programme has been a central part of this study. Vouchers have been attracting growing attention in the past few years and garnering much interest by development agencies; WFP is piloting versions of the approach in several countries. The electronic voucher/scratch card system piloted by WFP Zimbabwe represents a unique programme delivery mechanism that positively impacted beneficiaries while providing a valuable development outcome contributing to wider learning. The voucher system approach enlists local retailers as procurement and delivery agents in an innovative public-private partnership.

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Most aspects of the program are managed well. There are challenges with the clinics that are somewhat beyond the control of the program though creative approaches could facilitate their work. The registration and voucher system was working well and involved innovations, such as easy online registration (i.e., immediate) and pushing the technology to allow for exit interviews. Unfortunately, limitations related to internet services (e.g., access, reliability) were somewhat pronounced in Zimbabwe.

1.4 Recommendations

1.4.1 Main Recommendations

Scale up vouchers while strengthening monitoring: The voucher system shows many signs of being effective for safeguarding resources, efficient in management requirements, and favourable for clients. This approach is worth applying more widely though network coverage will need to be considered carefully before undertaking any expansion of the system. Working relationships with retailers will need to be carefully negotiated as some potential retailers may be less flexible and capable than some of the large retailers that participated in the Harare pilot. Systems for tracking beneficiaries and vouchers should be strengthened in order to provide relevant information on who is enrolled in the program, who is not, and why some clients are not showing up for monthly visits according to program expectations and requirements. The link between the printing of vouchers and the list of those who show up and get weighed needs to be air-tight. Strengthen education: There are a number of areas in education that WFP should attempt to strengthen in order to maximize the programme’s positive impact on beneficiaries. Nutrition education should be reinforced as part of clinic-based counselling activities without damaging existing capacity to deliver this service. The importance of dietary diversity, which might be addressed in partnership with retailers, as well as counselling and information on the risks associated with transactional sex are both important topics that should be included in educational activities undertaken through SPLASH. Pursue sustainable options: Sustainability for beneficiaries is a huge challenge – the elephant in the room that can’t be avoided – that WFP and its partners should continue to work on while being mindful of unreasonable expectations, i.e., what can reasonably be done in the short term and with the limitations that WFP will inevitably have on any resources for such projects. Clearly, from the standpoint of the vulnerable, they need sustainable livelihood options, whether they are ART/TB patients or moderately malnourished infants. A starting point might be to include some combination of cash with food assistance, well-run savings schemes, and expansion of small-scale pilots in nutrition gardens. Partnering with other agencies should be a top priority for future phases of SPLASH and similar programs. Continue the BMI screening focus with flexibility: The recent focus on malnourished patients using BMI (and MUAC) seems to be an effective targeting filter and one that can be applied for larger scale programs to avoid inclusion error. The temptation to use the food ration as a preventive measure should be avoided if the program is to try to reach a larger percentage of ART/TB patients. However, it would be good to create space for some clinics to target potential

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beneficiaries based on wider criteria for determining malnutrition, particularly if systems are in place and wise discretion is employed. A pilot programme in a clinic such as Newlands could help to clarify the conditions, training and systems required.

1.4.2 Secondary Recommendations

Ration Composition Ensuring receipt of rations: Three percent of current beneficiaries stated they did not receive CSB and a smaller number reported not receiving other components of the ration. WFP points out that this seems odd since the CSB and voucher are given together, and that an explanation for the CSB could be that some beneficiaries are not taking it home with them. Still,any evidence of non-delivery should be treated as serious and investigated until a reasonable explanation is found. Review of the incorporation of beans in the ration: Many beneficiaries (and clinic staff) raised concerns about the digestibility of the beans being provided, thus it would be advisable to review the use of beans as part of the food ration, ideally including consultations with dieticians and with beneficiaries. An understanding should be sought as to the nature of digestibility problem that so many participants seem to have with these particular beans, and this should be used to decide whether to continue with the beans currently used. Assuming there is adequate a justification for their continued use,this justification should be made available in a user-friendly format as part of the orientation provided to beneficiaries. Balance of food and cash: The provision of food via vouchers has worked reasonably well for this context, according to beneficiaries. There is no evidence to suggest that food distribution should stop, but rather, that it should continue, especially in light of food price instability. In order to meet a variety of preferences and needs, WFP could consider a balance of food and cash assistance in future programmes to provide the security of food and the possibility of supporting livelihood activities with cash. Given beneficiaries’ concerns about the possibility of misusing cash, careful thought should be given to possible training and other support to help participants to more effectively manage and/or save their money. In addition, there may be other ways to diversify a package that will be attractive to beneficiaries, such as providing seeds and other inputs and tools. Targeting

Clarify intentions and procedures for target groups beyond ART/TB patients: There are a small number of moderately malnourished children (and mothers) included in SPLASH, in addition to the core ART/TB patients. Their limited number raises the question of of whether this target group is strategically chosen and intended for large scale coverage, or more of an ad hoc arrangement. While the selection criteria for this category may be clear, it is unclear if it is being used effectively and whether there is consistency in the information and access provided to this target group. This could lead to misunderstandings for some households with malnourished

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children who are not included. SPLASH targeting criteria and procedures should be explicit and their application among clinics made as consistent as possible.

Focus on the young: Given that youths comprise such a large percentage of ART beneficiaries, it would be of benefit to solicit input from children and youths when designing future programme approaches. Objective targeting criteria should still be used, but allowing their participation could provide insights into the best ways to implement programs, and it would strengthen the credibility of WFP programs. Future programs to consider community outreach: While the mandate of SPLASH is to target those who come into clinics to receive ART, and thereby encourage people to access clinic services, there is a possibility that vulnerable households with malnourished children and current or potential ART/TB patients are not currently coming forward to access those services. Programmes like SPLASH would be strengthened if they can be linked up – through partners like NGOs or even directly – with community volunteers and groups in identifying and encouraging these more marginalized individuals to seek medical assistance and access food assistance programs. Working with CHWs is a strategy that should be pursued, in line with national policies and systems for health volunteers. Despite the challenges inherent in managing volunteers, the effort is justified because of the potential payoff in terms of reaching isolated target group members and expanding caseloads in existing locations. It is recommended that WFP, Ministry of Health and other partners review the linkages between community outreach and clinic-based services and consider if any possibilities exist (and if it can be accommodated within the mandate of any organizations) to promote community outreach in a synergistic way alongside the clinic-based work of SPLASH. Registration and Clinic Follow-ups

Increase accessibility of registration/VDPs: The centralization of VDPs in four locations has contributed to the overall success of the pilot phase of SPLASH but it also created difficulties for large numbers of beneficiaries originating in clinics like Beatrice and Wilkins. In consultation with clients regarding their needs and preferences, WFP should experiment with the possibility of additional VDPs and fixed dates for registration in other clinics. Publicize clear information and agree on expectations about the program: Some patients expressed unawareness of the six month limit, which seemed to add to the shock and difficulty they felt when discharged. Written brochures and visible posters could help to advertise criteria, rules, expectations, and other key information about the program. Ideally patients should sign a contract governing their participation in the program that could include conditions such as monthly attendance at clinics, etc. Improving use of electronic tools for registration and monitoring: The e-vouchers offer opportunities for much better control of beneficiary lists than previous paper registration systems did, in large part because they are unified in a single and constantly updated online databaseThese databases could also be used (cautiously) to help coordinate between various assistance programmes in order to ensure households are benefitting from the most appropriate

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programme based on their needs and to direct beneficiaries into complementary programmes such as those for sustainable livelihood support. Revise vulnerability assessment: Since the vast majority of patients’ qualify for household rations, the utility of the vulnerability assessment should be reviewed. It could be seen as more of a baseline against which to measure vulnerability indicators, to complement the BMI tracking data. Voucher Management Voucher issuance: In the case of illness, patients often send family members in their place to collect their vouchers or redeem them for food rations. WFP has established procedures to accommodate such cases, but it is worth reviewing these procedures to ensure that data recording is seamless and that the procedures are understood by beneficiaries. Monitoring and explaining no-shows: High numbers of expected beneficiaries werenot showingup to collect their vouchers and rations according to WFP reports (eg. 35% during some months), and as seen during the survey (see section 4.3.2). Failure to utilize food rations provided through the programme runs the risk of diluting the benefits of such assistance for those individuals and compromises the effectiveness of the interventions. It is also important to reconcile between registered beneficiaries who actually show up and the vouchers that are issued, and to monitor this. WFP should investigate this phenomenon and attempt to address it in future SPLASH programming. General Management and Partnerships Mechanisms for beneficiary participation: Beneficiary input resulting from complaints desks or other consultation exercises is a valid way to quickly find out participant perspectives on programme benefits and effectiveness. Complaints desks that are independent from programme operations would provide a safe environment in which beneficiaries can provide honest feedback, but admittedly there may be challenges for SPLASH to set this up given the current management structures Government partnerships: Information sharing and joint discussions with government and other partners should always be a priority for WFP and is especially essential project goals include mainstreaming its approaches. WFP typically does this quite well and should take care to ensure that other management demands do not divert too much attention from this. Simple mechanisms, such as coordinating meetings or sharing circulars, are easily accomplished though poor communication within and between some government departments may require more creative approaches. Rural adaptations of the voucher approach: If WFP decided to implement an e-voucher approach in rural programmes, they should establish the necessary conditions required to ensure success of such an approach and recommendations for implementation. In view of potentially more frequent network connectivity problems and the longer distances clients might have to travel to a retail outlet, backup plans should be developed that would enable clients to obtain

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rations in the event a retailer is unable to connect to the network. Retailers involved with SPLASH have already been taking the initiative to allow clients with whom they are familiar to collect their rations during internet downtimes and to redeem their vouchers at a later date, when internet connectivity has been re-established. Clearly, this has certain implications in terms of ensuring adequate control but workaround solutions can obviously be worked out, especially in conjunction with retailers and clinics themselves.

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2 Introduction

2.1 Background

Of Zimbabwe’s 12.2 million people,21.2 million adults and children are estimated to be HIV positive. Of the 593,000 adults and children requiring ARTs, 333,000 are currently on treatment, leaving more than 250,000 in need3. Though HIV prevalence among adults (15-49 years old) has declined from 15.6% in 2007 to 13.7% in 2009,4 the Ministry of Health (MOH) estimates that 1,090 people die each week of AIDS and 18% of all those that are HIV positive suffer from malnutrition (MSF treatment data 2008). The HIV/AIDS epidemic has left numerous orphaned and vulnerable children (OVC), estimated at over 1.2 million by the Ministry of Labour and Social Services. Zimbabwe’s National Strategic Plan (ZNASP) 2006-2011 highlights the importance of nutritional support to those enrolled on ART. Political and economic uncertainty over the last ten years, including the global food price crisis, has resulted in a humanitarian crisis in Zimbabwe.5Food insecurity is widespread. Lack of income generating activities (IGA) and livelihood opportunities has resulted in the need for safety net programmes targeting the most vulnerable. A number of programs, including food distribution programs, have been operational for some time. The World Food Programme (WFP) has been providing food support to Zimbabwe since 2002. Recent changes in Zimbabwe’s economic environment, including the multi-currency policy that has stimulated imports and revitalised trade, have created an opportunity for using new mechanisms to transfer support to populations in need. In response, WFP began to implement a voucher transfer pilot in Harare in August 2010. The pilot programme, Sustainable Programme

for Livelihoods and Solutions for Hunger (SPLASH), was designed as a means of enhancing implementation of the urban Nutrition Support for Anti-Retroviral Therapy (NSART) programme within the framework of PRRO 200162, Assistance for Food-Insecure Vulnerable Groups. The goals of SPLASH are to contribute to the overall goals of PRRO 200162 and particularly:

• Improve the well-being of chronically ill adults to achieve greater capacity for productive recovery (Strategic Objective 3).

• Safeguard food access and consumption of highly vulnerable food-insecure households and support the recovery of livelihoods and access to basic services (Strategic Objective 3).

• Increase government and community capacity to manage and implement hunger reduction policies and approaches (Strategic Objective 5).

2 Country Statistical Office. 2009. 3 Murungu, J. 2011. Interview. National AIDS and TB Programme, Ministry of Health. 4 MOHCW. 2009. 5 Wydler, F and Dengu, E. 2009. Assessment of Appropriate Social Transfer Mechanisms in Zimbabwe. Consultancy Report. MTLC/GRM International, World Food Program Zimbabwe, Swiss Agency for Development and Cooperation.

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The anticipated number of beneficiaries of PRRO 200162, which is a nation-wide program running from 1 January to 31 December 2011, are to reach 60,000 ART patients, 28,000 pre-ART, and 12,000 TB patients. Thus, SPLASH would be expected to contribute to these goals though there was not a specific set of goals disaggregated for SPLASH, perhaps because it was a pilot program.

The voucher transfer mechanism was adopted due to several anticipated benefits, such as: support of existing market mechanisms; convenience and flexibility for beneficiary food collection; prevention of market distortion; improved tracking and auditable functions of food delivery; the potential of vouchers to release funds for other items; flexibility in redemption of vouchers and food, due to improved service hours and also the overall reduction in transaction costs. Modelled on a similar voucher initiative carried out by WFP in Zambia, the food voucher programme is, in essence, an alternative food distribution mechanism using e-vouchers that substitutes private local retailers for traditional WFP-mediated channels of procurement, transport and storage. As an outgrowth of NSART, the SPLASH pilot program was managed by the local NGO, Christian Care, from August, 2010 until March, 2011. Subsequently it has been directly implemented by WFP Zimbabwe. NSART/SPLASH is a health-based safety net program. During design of the program WFP coordinated with the Zimbabwe Ministry of Health and Child Welfare and the City of Harare Health Department. ART and TB patients are targeted through seven clinics (Harare Central, Parirenyatwa, Epworth, Newlands, Beatrice, Wilkins, UZCRC), of which the first four also serve as registration and voucher distribution centres. Redan Mobile Transactions (RMT) set up the voucher database and provided oversight to four retail outlets authorized for voucher redemption.

2.2 Scope of Evaluation

WFP Zimbabwe commissioned an external evaluation of the SPLASH voucher transfer pilot activity to assess the impact of the intervention on beneficiaries’ ability to access nutritious food. The evaluation was also to determine the appropriateness of this intervention for urban and rural beneficiaries, as well as to examine the potential of scaling up voucher transfers as part of a longer-term social protection programme in Zimbabwe. Based on the Terms of Reference (Annex 8.1), the objectives of the evaluation were to:

• Determine whether the voucher transfer was the most effective and efficient modality for providing assistance;

• Identify the potential for replicating the pilot program and scaling it up to complement other food assistance interventions in Zimbabwe;

• Assess the overall cost-effectiveness and impact of the SPLASH voucher transfer in meeting the stated objectives of the programme - in terms of indicators such as reduced levels of malnutrition and increased levels of food security, and increased attendance in clinics. This includes an assessment of whether the WFP-supported intervention with vouchers contributed to results observed.

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The effect of the pilot program on major cross-cutting issues of gender, partnership, and capacity development will be taken into consideration.

• Relevance: Did the transfer modality address the beneficiaries’ needs and circumstances in terms of the objectives as stated in the programme document?

• Effectiveness: Was the intervention effective in dealing with the problems identified? Could there have been another way? Was our targeting effective, did we reach the right people?

• Efficiency: Was the type of transfer utilized the most efficient use of resources?

• Impact: What has been the negative and positive impact on the beneficiaries, community, non-beneficiaries, existing markets and market forces? What was the direct impact on nutrition of NSART patients and food and livelihood security at a household level?

• Sustainability: Is the intervention sustainable? Can this be handed over to the government? Are there areas where WFP needs to involve government more? Are we using the right government structure to deliver the programme?

2.3 Methodology

Evaluation of the SPLASH voucher pilot in Zimbabwe utilized both quantitative and qualitative methods. A suitable instrument and method were designed by taking into account the key questions that WFP had regarding the programme and drawing on the tools and method used in a recent evaluation of the WFP Zambia SPLASH program. WFP Zimbabwe provided input into the questionnaire and methodology and some questions were also drawn from its tools including the Post-Distribution Monitoring and Community and Household Surveillance questionnaires. Initial interviews with key informants, particularly the Ministry of Health and Child Welfare, also helped highlight issues that the survey should address. The evaluation team consisted of an external consultant, three WFP staff members, and a team of eight experienced enumerators compiled by the consultants. A nutritionist from the Harare City Health Department accompanied the researchers in many of the field visits. The evaluators commenced with a systematic review of project documents provided by WFP, including project background, reference data, and progress reports. The study is also meant to help provide clearer data on the needs of the population and to serve as a reference point for future monitoring by WFP and other partners.

2.3.1 Quantitative survey methodology

A beneficiary household survey was conducted to enable a strong quantitative focus on beneficiary views and perceptions of changes in food consumption and expenses. The prevalence of beneficiaries was expected to be relatively small within the highly populated urban settlements, so a population-based survey was deemed inappropriate to show any impact or obtain a representative picture of beneficiaries’ views. A simple random sample was used. The sample size was calculated to get a one-time only “snapshot” of beneficiary perceptions, food security and expenses using the following equation:

n=deff�z/standard error�2 �p�(1-p)

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Where: n= sample size z=standard score corresponding to a given confidence level (z = 1.645 for the 95% confidence level) standard error = acceptable error level p=estimated proportion of the population expressing a particular characteristic is 0.5) deff=design effect

All quantitative data were collected by six locally hired consultants trained as enumerators, under the supervision of three WFP staff. The enumerators participated in a four-day training event from July 25-29 which covered survey objectives, interview techniques and field-testing of the questionnaire. The household survey was conducted during the month of August. All household data were collected on Personal Digital Assistants (PDAs) belonging to WFP Zimbabwe.

2.3.2 Qualitative methodology

The qualitative portion of the project evaluation was conducted by the external international consultant and two local qualitative enumerators, with the initial support of the WFP officer. Topical outlines were prepared for use during the focus group discussions (FGD) and key informant interviews, with the input of WFP staff. These were utilized during early interviews by the international consultant. Because the qualitative enumerators were part of the training for the quantitative enumerators, and initial FGDs were held alongside the testing of the quantitative tool. Interactions between the quantitative and qualitative teams helped to refine the approach of both. After the initial week of qualitative research, the findings and questions were reviewed, and some modifications made to probe further on key emerging findings. The full list of key informant interviews and focus group discussions is listed in Annex 8.2. Approximately 30 key informants were interviewed within WFP and at the level of ministries and city institutions, UN agencies, implementing partners and collaborating NGOs. A total of 158 individuals were interviewed in FGDs and key informant interviews at field level, including 6 groups of former beneficiaries, and 5 groups of current beneficiaries, groups of staff at seven clinics (including nurses in charge, dieticians, duty nurses, counsellors), and some additional people working in the field such as the community health workers affiliated with Edith Oppermann Clinic. Staff involved in SPLASH operations at all four retail outlets were also interviewed, and in all clinics and retail outlets, observations were made of the facilities and procedures being followed. During the extensive time in the field through the qualitative interviews and the supervision of the quantitative survey, the evaluation team also had numerous informal contacts throughout the survey with a variety of individuals involved with the programme, as well as other community members. In some cases, people with concerns about the programme had heard about the evaluation and came forward to talk to the evaluation team members. The qualitative survey topic guide is presented in Annex 8.3.

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2.3.3 Method limitations

The survey faced considerable challenges with both groups of respondents, which resulted in a longer time frame and lower number of respondents. Despite having an oversample, those current beneficiaries randomly selected from the list did not appear at the clinics nearly as early as anticipated, and even after monitoring the clinics for the entire month some could not be contacted. Former beneficiaries were even more difficult to track down because they don’t attend the clinic as often for their regular checkups, and the visits are often decentralized to smaller polyclinics around the city, so it became logistically very difficult to contact them. In addition, there was a high non-response rate with former beneficiaries, many of whom did not want to take the time for an interview.

2.4 Organization of the Report

The findings of the evaluation are presented in two sections. Section 3 relates to the programme’s impact on beneficiaries. It reviews the characteristics of the beneficiaries, discusses how they saw the value of the programme, and analyzes aspects of their livelihood and food security practices to show how the programme may have had an impact on them. Section 4 focuses on the effectiveness and relevance of the implementation modalities and process, and highlights the role of implementation partners and the impact of the programme on them. Other issues of sustainability of the impacts of the project and the applicability of the approach to rural settings are likewise addressed in this section. Conclusions and recommendations follow these findings.

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3 Findings – Beneficiary Impact

This initial section describes household characteristics of beneficiaries, and reports findings on the impact of the SPLASH program on their household income and expenditures, food consumption, anthropometrics and health status. Derived from analysis of qualitative data, beneficiary perceptions regarding the program and its impact are also reported.

3.1 Demographic and Household Information

Survey respondents were randomly selected from a sampling frame of all project beneficiaries including current beneficiaries and former beneficiaries that continue to make clinic visits for their medication and other clinic services. As indicated in Table 1, over 86% of all respondents were currently or had been receiving ART, nearly 13% were TB patients and 1% were considered Pre-ART.

Table 1: Respondents by beneficiary status

% Current Former Total

ART 84.2 88.9 86.2

TB 14.3 10.5 12.7

Pre-ART 1.5 0.5 1.1

n 266 190 456

Mean household size for current and former beneficiaries was 5.1 and 5.4, respectively. Sampled households had nearly twice as many males than females in all age groups until approximately age 50 (Figure 1). Figure 1: Population pyramid for sampled households

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 29

The age structure of the overall population in Zimbabwe is presented in Figure 2. Sampled households have considerably fewer children under five and household members in their 20s than households in the general population.

Figure 2: Population pyramid, based on DHS data

Close to one-half of all respondents were not employed at the time of the survey nor had they ever been employed (Table 2). Thirty-five percent of respondents were currently employed while nearly 16% had been at one time but were no longer employed.

12 10 8 6 4 2 0 2 4 6 8 10 12

00-04

10-14

20-24

30-34

40-44

50-54

60-64

70-74

80-84

90-94

% of survey population in age group

Ag

e g

rou

p

Male Female

18 16 14 12 10 8 6 4 2 0 2 4 6 8 10 12 14 16 18

00-04

10-14

20-24

30-34

40-44

50-54

60-64

70-74

80+

% of survey population in age group

Ag

e g

rou

p

Male Female

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 30

Table 2: Percent of adults aged 18 years or more engaged in economic activity, by beneficiary status

% Current Former Total

No/Never 48.9 49.3 49.1

Yes , currently 33.2 38.2 35.3

Yes, but no longer 17.9 12.4 15.6

n 313 225 538

When disaggregated by sex, 55.5% of female respondents were not or had never been employed compared to 41.8% of males (Table 3). Likewise, 41.4% of males were employed at the time of the survey while only 30.3% of females were.

Table 3: Percent of adults aged 18 years or more engaged in economic

activity, by sex

% Male Female Total

No/Never 41.8 55.5 49.4

Yes, currently 41.4 30.3 35.2

Yes, but no longer 16.9 14.2 15.4

n 249 310 559

Over half of all children within SPLASH beneficiary households (current and former) still had both parents living while 13 % had lost both parents (Table 4). A number of households had only one parent living; 28.7% of children were without fathers while only 5.9% were without mothers.

Table 4: Child parental status (<18 years old), by beneficiary status

% Current Former Total

Both parents alive 54.0 47.2 50.9

Father dead 25.5 32.5 28.7

Both parents dead 12.8 13.3 13.0

Mother dead 6.8 4.9 5.9

N/A 0.9 2.1 1.4

n 678 566 1,244

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 31

Of all school-aged children, one in five had either never enrolled in school or had dropped out by the time of the survey (Table 5). Three-fourths of all school-aged children are currently enrolled (81% and 67.2% for current and former beneficiaries, respectively). Only 10.5% of current beneficiaries have dropped out compared to 20% of former beneficiaries. Nearly three-fourths of all children (76.1% and 73.5% of males and females, respectively) are currently attending school. The most common reason for non-enrolment of children was lack of resources to pay school fees and other related educational expenditures, which was cited by 30.6% of current beneficiaries and 54.6% of former beneficiaries. The next most common reason was illness (2.9% of respondents). Male and female students were similarly affected. The lower enrolment for former beneficiaries is consistent with an expectation that while on the SPLASH programme, beneficiaries are more able to pay for school fees than after leaving the programme.

Table 5: School status of children aged 6-17 years old, by beneficiary status

% Current Former Total

Currently enrolled and attending pre/primary/secondary 81.0 67.2 74.6

Dropped out before this school year 10.5 20.0 14.9

Never Enrolled 2.3 6.2 4.1

Not attending - Primary/Secondary Completed 2.3 2.6 2.4

Dropped out of school this year 1.6 2.1 1.9

Currently enrolled and attending tertiary/Skills training 1.0 1.0 1.0

Enrolled but absent > 1 week in past month 1.0 0.5 0.8

N/A 0.2 0.5 0.3

n 485 421 906

3.2 Assistance Received from SPLASH

SPLASH enrolled ART and TB households in a combined programme of household food rations and nutrition education. The SPLASH strategy is to provide vouchers for essential household items, thereby freeing up money for other expenditures. The supplementary ration per patient consisted of 10 kg of corn-soya blend (CSB). An additional supplementary household ration consisted of 5 kg of maize meal, 1 kg of pulses, and 750 ml of cooking oil per person, up to a maximum of 5 household members. For purposes of this report, these will be referred to as “CSB” and “household rations” to avoid ambiguity. There was wide agreement among both current and former beneficiaries that they had received full rations (99% of all respondents) and only 2% of all households reported selling their rations.

This ration is provided for a maximum of six months after registration (i.e., one cycle) or until the beneficiary is nutritionally rehabilitated, i.e., has a BMI above 18.5 for at least two consecutive months. As TB patients typically require a longer period of medical treatment before stabilizing, they reportedly received occasional rations beyond the six month limit. Over 64% of

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 32

former beneficiaries had received their last ration more than six months prior to the survey (Table 6). Among those who were currently registered as beneficiaries, the vast majority had not missed any rations (i.e., had received their last ration in July).

Table 6: Timing of last ration, by beneficiary status

% Current Former Total

July 2011 95.8 2.6 56.6

June 2011 1.1 7.9 4.0

May 2011 0.4 7.4 3.3

April 2011 0.0 2.6 1.1

March 2011 0.8 5.8 2.9

February 2011 0.8 8.9 4.2

January 2011 0.4 12.6 5.5

December 2010 0.4 18.4 8.0

November 2010 0.4 13.7 6.0

October2010 0.0 12.1 5.1

September 2010 0.0 4.7 2.0

August 2010 0.0 3.2 1.3

n 262 190 452

A patient may be re-registered in SPLASH if he/she is considered malnourished after the first cycle and thus may receive rations for a total of more than the six month limit. Over one-third of former beneficiaries received seven or more months of food rations (Table 7). In contrast, only 5.7% of current beneficiaries received seven or more months of food rations.

Table 7: Number of months receiving ration before the survey, by

beneficiary status

% Current Former Total

1 months 1.1 0.5 0.9

2 months 12.2 6.8 10.0

3 months 24.4 20.0 22.6

4 months 22.5 8.4 16.6

5 months 21.8 6.3 15.3

6 months 12.2 23.7 17.0

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 33

7 months 2.7 3.2 2.9

8 months 1.9 5.3 3.3

8+ months 1.1 25.8 11.5

n 262 190 452

Duration of receiving rations depends on how many times a

beneficiary had been registered (number of cycles) as well as

when they began receiving rations. A majority of both

current and former beneficiaries had benefitted from only

one cycle of SPLASH (Table 8). Four percent of former

beneficiaries had been registered for three or more cycles.

Table 8: Number of cycles, by beneficiary status

% Current Former Total

One 83.0 76.3 80.2

Two 16.2 19.5 17.6

Three or more 0.8 4.2 2.2

n 259 190 449

The amount of time spent between cycles (i.e., before being re-enrolled in the SPLASH programme) may be indicative of how well patients are able to maintain their BMI through sufficient dietary intake. If beneficiaries were relapsing (i.e., BMI < 18.5), the number of second cycle beneficiaries might be expected to be higher than 16.2% for current and 19.5% for former beneficiaries.

A large proportion of former beneficiaries apparently progressed directly from one cycle to the next while current beneficiaries seemed able to spend more time off the SPLASH programme before re-enrolling (Table 9). Other factors, such as mobility, stigma, and changes to household circumstances might impact both if/whether beneficiaries re-enrol (i.e., number of cycles) or how long before they re-enrol (i.e., number of months between cycles).

Table 9: Number of months between cycles, by beneficiary status

% Current Former Total

Months 0 13.6 71.1 42.7

1 25.0 15.6 20.2

2 15.9 6.7 11.2

3 4.5 4.4 4.5

4 15.9 0.0 7.9

5 9.1 0.0 4.5

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 34

6+ 15.9 2.2 9.0

n 44 45 89

Nearly 78% of all ration recipients are female (Table 10) and most decisions over the use of food assistance are made by females (93.8%). The importance of women in decision-making related to food suggests the need to focus not only on ART/TB patients but also on the household, and particularly on women, in order to ensure optimal use of the food ration for improving household food security.

Table 10: Gender of recipient and decision-maker, by beneficiary status

% Current Former Total

Gender of recipient

Male 28.1 14.9 22.5

Female 71.9 85.1 77.5

Gender of decision maker

Male 5.0 1.6 3.6

Female 92.0 96.3 93.8

Both 3.1 2.1 2.7

n 265 190 455

3.3 Benefits of food assistance

Respondents reported globally as to the benefits provided by participation in the SPLASH programme. Both current and former beneficiaries reported improved eating as a result of the SPLASH programme (Table 11). Significantly more former beneficiaries than current beneficiaries were able to save money for other household expenses. In particular, significantly more former than current beneficiaries purchased household items.

Table 11: Benefits of the SPLASH voucher system, by beneficiary status

% Current Former Total

Able to eat better 98.5 99.5 98.9

Able to save money to use elsewhere 33.3 45.3* 38.3

n 264 190 454

How savings were used:

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 35

School fees 54.5 39.5 47.1

Purchase household items 20.5 36.0* 28.2

To purchase other types of food 28.4 16.3 22.4

Rent 20.5 23.3 21.8

Other 8.0 14.0 10.9

Medical expenses 10.2 7.0 8.6

For a business 3.4 9.3 6.3

Debt/ loan repayment 1.1 1.2 1.1

n 88 86 174

Overall, when asked if they felt they were better off as a result of participation in the SPLASH programme, approximately 84% of respondents indicated they were, while only 16.1% indicated they were not (Table 12). However, significantly more current beneficiaries than former beneficiaries felt they were better off as a result of the programme.

Table 12: Whether or not beneficiary feels they are better off, by

beneficiary status

% Current Former Total

Yes, I am better off 99.2 62.1* 83.9

No, I am not better off 0.8 37.9 16.1

n 259 182 441

* Significantly different at p < .001

3.4 Expenditures

As stated in section 3.2, the data shows that the vast majority of beneficiaries are consuming their entire ration rather than selling it. A major assumption of the programme is that because of the food ration beneficiaries can reduce or eliminate the need to spend resources on these food items and thus are able to direct those resources elsewhere. Food accounted for 56.6% of household budgets for both current and former beneficiaries (Table 13), which meets the SPLASH target of reducing food expenditure below 70% of household budgets.

There is no statistically significant difference between current and former beneficiaries in monthly household or per capita expenditures on food (Table 13). However, former beneficiaries spend significantly more than current beneficiaries on cereals, oils and legumes (provided in the food ration), which seems to reinforce the intent of the programme in terms of making limited resources available for other household needs. Additionally, current beneficiaries spend more than former beneficiaries on other diverse food items, in particular fish, meat, eggs, poultry, roots/tubers and milk.

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 36

Table 13: Mean household monthly food expenditures, by beneficiary status (USD)

Current Former Total

Mean household monthly food expenditures 55.5 58.0 56.5

Mean per capita monthly food expenditures 11.6 11.2 11.4

Cereals 8.7 15.6* 11.6

Fish/meat/eggs and poultry 12.3 8.5* 10.7

Bread 11.0 6.9* 9.3

Fruits and vegetables 8.7 8.7 8.7

Sugar/salt 6.0 4.7* 5.5

Oil/butter 1.4 7.5* 3.9

Roots and tubers 3.8 2.6* 3.3

Milk 3.5 1.6* 2.7

Legumes 0.3 2.0* 1.0

n 263 189 452

*Significantly different at p< .05. Former beneficiaries spend more than 25% of their total household food budget on cereals and more than four times as much as current beneficiaries on oil/butter (Figure 3).

Figure 3: Household food budget by food group and beneficiary status

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 37

Respondents were asked to recall their monthly expenditures before they began their participation in SPLASH and compare them with their current expenditures (i.e., in the past 30 days). Over 94% of current beneficiaries report spending more on cereal during the 30 days before the survey than they did before enrolment in the program (Table 14). This result is somewhat surprising as cereals are included as part of the ration provided by SPLASH. More than 75% of current beneficiaries reported spending more on bread currently than prior to SPLASH while nearly the same percentage of former beneficiaries report spending the same on bread. The same type of pattern emerges for pre- and post-expenses for roots and tubers; 84% of current beneficiaries report spending more during the previous 30 days while the same percentage of former beneficiaries reported no change in their spending for roots/tubers from before they enrolled in SPLASH.

For former beneficiaries overall, there were no notable changes in expenditures on food items; 68.3% to 91.4% reported their spending patterns were the same, depending on the food item. This result may be expected since by not receiving a ration they were not able to “redirect” resources to other foods.

Table 14: Percent spent on food items in previous 30 days compared to

before SPLASH, by beneficiary status

% Current Former Total

Cereals Same 4.2 68.3 31.0

More 94.3 20.1 63.3

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Current Former

% o

f h

ou

seh

old

foo

d b

ud

ge

t

Cereals Fruits and vegetables Fish/meat/eggs and poultry

Bread Sugar/salt Oil/butter

Roots and tubers Milk Legumes

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 38

Less 0.8 10.6 4.9

DNK 0.8 1.1 0.9

Fruits and vegetables

Same 52.1 81.0 64.2

More 23.2 9.5 17.5

Less 22.1 8.5 16.4

DNK 2.7 1.1 2.0

Fish/meat/eggs and poultry

Same 56.3 85.2 68.4

More 17.9 8.5 13.9

Less 21.3 5.8 14.8

DNK 4.6 0.5 2.9

Bread Same 18.6 73.9 41.7

More 76.4 16.5 51.4

Less 1.5 5.3 3.1

DNK 3.4 4.3 3.8

Sugar/salt Same 78.3 86.8 81.9

More 12.5 7.4 10.4

Less 5.7 4.8 5.3

DNK 3.4 1.1 2.4

Oil/butter Same 49.0 83.0 63.2

More 12.2 5.9 9.5

Less 33.1 8.5 22.8

DNK 5.7 2.7 4.4

Roots and tubers Same 13.3 83.5 42.6

More 84.0 13.3 54.5

Less 0.8 3.2 1.8

DNK 1.9 0.0 1.1

Milk Same 69.6 85.6 76.3

More 8.4 6.4 7.5

Less 16.3 5.9 12.0

DNK 5.7 2.1 4.2

Legumes Same 85.2 91.4 87.8

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 39

More 5.7 5.3 5.6

Less 8.4 2.7 6.0

DNK 0.8 0.5 0.7

n 263 189 452

Taken together, these data suggest that current beneficiaries are spending more than former beneficiaries on cereals, tubers and bread but that no clear trends emerge regarding how money saved through receipt of the food ration might be redirected to spending on a diversity of other food items, such as fruits, vegetables, meat, eggs, fish or milk. Most beneficiaries report spending roughly the same amounts (rather than more or less) on these food items. Thus, savings resulting from receipt of the food ration do not appear to be contributing in any significant way to diet diversity.

Current beneficiaries are spending more on non-food items than former beneficiaries (Table 15). Of the total monthly household budget, food makes up 34% and 43% of current and former beneficiaries’ respective budgets. Thus, former beneficiaries are spending more of their total household budget on food than are current beneficiaries.

Table 15: Mean non-food household expenditures, by beneficiary status (USD)

Current Former Total

Mean household non-food monthly expenditure 163.3 134.0* 151.0

Mean per capita non-food monthly expenditure 34.2 25.8* 30.7

n 264 190 454

* Significantly different at p < .05

Rent makes up the largest single non-food monthly expenditure for both current and former beneficiary households (16). Current beneficiaries spend more of their non-food budget than former beneficiaries on rent, transportation, electrical and other monthly bills, telephone service and household items generally. Former beneficiaries spend more than twice what current beneficiaries spend for milling.

Table 16: Mean household monthly non-food expenditures, by beneficiary

status (USD)

Current Former Total

Rent 32.6 25.4* 29.5

Transport 11.2 8.4* 10.0

Electricity & other bills 10.6 3.7* 7.7

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 40

Fuel 7.6 6.8 7.3

Soap & HH items 5.7 4.8* 5.3

Water bills 6.2 3.5* 5.1

Telephone 5.4 3.1* 4.4

Milling 0.6 1.5* 1.0

Alcohol & tobacco 1.2 0.4 0.9

n 264 189 453

*Significantly different at p < .05

Both current and former beneficiaries put a high premium on education as this makes up the single largest non-food periodic expense for both groups (Table 17). Healthcare is the second largest single expense for both groups, though current beneficiaries pay more than twice what former beneficiaries pay for healthcare. Paying down debt (i.e., repaying loans) is relatively important non-food expenditure for households. Beneficiaries may be taking on debt, in part, because they are more confident in their ability to repay it with savings resulting from reduced food purchases . That is, the ration and associated savings enables repayment by clients, who also feel obliged to do so.

Table 17: Mean household periodic non-food expenditures, by beneficiary status

(USD)

Current Former Total

Education 67.3 55.5 62.4

Healthcare 46.3 18.6 34.7

Debt repayment 17.6 10.6 14.7

Clothing 14.5 10.1 12.7

Funerals 10.5 5.6 8.5

Household repair/construction 6.5 10.9 8.3

Social 2.6 1.9 2.3

Equipment (tools, seeds, animals) 0.8 2.9 1.7

Hiring labour 1.8 0.4 1.2

n 264 189 453

Current and former beneficiaries reported no change in spending for all categories of monthly non-food items during the previous month compared to pre-enrolment in SPLASH with a single exception for milling (Table 18). Over 78% of current beneficiaries reported spending more for milling. Seventy-eight percent of former beneficiaries reported no change in milling

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 41

expenditures. Presumably this reflects the increased need for milling by current beneficiaries as a result of purchasing additional cereal (their monthly cereal ration consists of milled maize)

Table 18: Percent spent on monthly non-food items in previous 30 days

compared to before SPLASH, by beneficiary status

% Current Former Total

Milling Same 19.4 78.1 43.8

More 78.3 18.2 53.3

Less 0.8 1.6 1.1

DNK 1.5 2.1 1.8

Alcohol & tobacco

Same 90.1 93.1 91.4

More 4.9 5.3 5.1

DNK 4.9 1.6 3.5

Soap & HH items Same 86.3 88.8 87.3

More 5.7 4.8 5.3

Less 6.5 6.4 6.4

DNK 1.5 0.0 0.9

Transport Same 68.4 66.5 67.6

More 9.9 12.2 10.9

Less 3.8 5.9 4.7

DNK 17.9 15.4 16.9

Fuel Same 85.8 92.6 88.6

More 6.5 3.2 5.1

Less 3.1 3.2 3.1

DNK 4.6 1.1 3.1

Water bills Same 92.7 94.2 93.3

More 5.4 2.1 4.0

Less 1.2 2.6 1.8

DNK 0.8 1.1 0.9

Electricity & other bills

Same 93.1 95.8 94.2

More 5.0 1.1 3.3

Less 1.5 1.6 1.6

DNK 0.4 1.6 0.9

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 42

Telephone Same 75.4 78.8 76.8

More 5.8 6.3 6.0

Less 6.9 5.3 6.2

DNK 11.9 9.5 10.9

Rent Same 90.8 91.0 90.9

More 5.0 4.2 4.7

Less 3.4 4.8 4.0

DNK 0.8 0.0 0.4

n 263 188 451

Respondents then recalled their expenditures on those items that may not be needed on a monthly basis and can only be detected on a semi-annual timeframe. They were asked to recall the amount spent during a six-month period before they had joined the SPLASH programme and state whether during that time they spent more or less than during the present period. For most of these types of expenses, former beneficiaries spent about the same over the last six months as they did before they had been enrolled in SPLASH (Table 19). Thus, if SPLASH had any impact on periodic monthly expenditures, it does not seem to last for former beneficiaries. The pattern is substantially the same for current beneficiaries as for former beneficiaries, i.e., they report no large change in spending patterns, with a few notable differences. More than one-third of current beneficiaries report spending more on health care, while only 9.5% of former beneficiaries report spending more. Fifteen percent of current beneficiaries reported spending more on clothing compared to 7.4% of former beneficiaries. Finally, slightly more than twice as many current than former beneficiaries report spending less on education.

Table 19: Percent spent on non-food periodic items in previous six

months compared to before SPLASH, by beneficiary status

% Current Former Total

Healthcare Same 45.6 77.2 58.9

More 35.6 9.5 24.7

Less 8.0 6.3 7.3

DNK 10.7 6.9 9.1

Clothing Same 45.2 56.1 49.8

More 16.9 15.3 16.2

Less 14.9 7.4 11.8

DNK 23.0 21.2 22.2

Equipment (tools, Same 85.8 90.0 87.6

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 43

seeds, animals) More 3.8 4.7 4.2

Less 3.5 1.6 2.7

DNK 6.9 3.7 5.6

Household repair/construction

Same 87.0 88.4 87.6

More 3.8 4.2 4.0

Less 3.8 2.1 3.1

DNK 5.4 5.3 5.3

Hiring labour Same 93.1 95.8 94.2

More 0.8 2.1 1.3

Less 1.5 0.5 1.1

DNK 4.6 1.6 3.3

Debt repayment Same 61.7 66.5 63.7

More 10.7 9.0 10.0

Less 6.5 8.0 7.1

DNK 21.1 16.5 19.2

Education Same 63.6 68.1 65.5

More 14.2 17.6 15.6

Less 13.8 5.3 10.2

DNK 8.4 9.0 8.7

Social Same 79.3 90.4 84.0

More 3.8 2.1 3.1

Less 1.5 1.6 1.6

DNK 15.3 5.9 11.4

Funerals Same 60.2 69.3 64.0

More 7.3 5.3 6.4

Less 7.3 7.4 7.3

DNK 25.3 18.0 22.2

n 261 189 450

The SPLASH program was supposed to allow beneficiaries to channel money previously spent on food to other household needs, such as school fees. Others used their savings to create savings groups, typically involving about 10 members. Each member contributed US$5 per

“Before I was initiated on the programme, balancing food and non food items i.e. paying schools fees was a nightmare. However, when I joined SPLASH, things began normalizing and I would raise school fees without any hustle”.

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 44

month to a pool. Money from the monthly pool was then used to purchase, for example, cooking oil (one food item per month). This would then be shared among group members as a cushion against food insecurity.

3.5 Household Assets

Asset ownership, purchase and sales are an important gauge of the livelihood dynamics within a household. The types of assets owned provide some interesting insights into the lives of participants. Cellular telephones are owned by over 65% of respondents (Figure 4). Cell phones can be important in livelihood activities and Zimbabweans have quite economical ways of using them. A number of SPLASH participants possess such productive assets as hoes, axes, land, sewing machines, or bicycles and thus have some means to support themselves. Current beneficiaries had more livestock, land and various household items (e.g., refrigerators, sewing machines, stoves, TVs) than former beneficiaries (p < .05) . There are several different interpretations that could be made of this finding, such as a realization that malnourished SPLASH beneficiaries may not necessarily be the poorest, or that having assets doesn’t automatically result in food security.

Figure 4: Percent of households owning various assets, by beneficiary status

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0

Panga/machete

Satellite dish

Mortar/pestle

Livestock

Sickle

Bicycle

Stove

Mattress

Land

Chair

Mobile phones

% of household owning asset

Former beneficiary Current Beneficiary

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 45

Over 50% of current beneficiaries reported owning land compared with 38.8% of former beneficiaries, while 16.3% of current beneficiaries and 8.5% of former beneficiaries reported owning livestock. These differences are statistically significant at p < .05. Current beneficiaries owned significantly more land and livestock than former beneficiaries (p < .05), though the differences were small. This may be due, in part, to the fact that some current beneficiaries live in more rural areas. For example, ART patients may be more willing to travel longer distances while on SPLASH (potentially coming from outside of Harare) to obtain the food ration whereas after discharge they would seek a source of medical assistance closer to home. Rural-based beneficiaries would be more likely to own land and livestock.

Current beneficiaries own more ploughs, chairs, refrigerators, sewing machines, stoves, TVs, tables, beds, cell phones, hoes and chairs than do former beneficiaries (p< .05) though the absolute numbers are small (Figure 5). Livestock are assets that may be sold as a strategy for coping with food shortages. Chairs are another asset that could also be easily sold, while keeping one or two.

Figure 5: Asset ownership – mean number owned, by beneficiary status

It was envisaged that SPLASH participants may be able to buy assets, especially when beneficiaries are able to invest in an income-generating activity or improve on agricultural activities. Eighteen percent of beneficiaries had purchased assets since the time they started participating in SPLASH (Table 20); significantly more former beneficiaries purchased assets

0.0 0.5 1.0 1.5 2.0 2.5 3.0

Plough

Satellite dish

Solar panel/unit

Fridge

Sewing Machine

Radio

Axe

Mattress

Table

Bed

Hoe

mean number of asset owned

Former beneficiary Current Beneficiary

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 46

than current beneficiaries. However, this could be due in part to the fact that current beneficiaries are still enrolled in SPLASH and so do not have the same period of time during which assets could have been purchased since leaving the program. For those who had purchased an asset, most (63.9%) purchased a basic household asset, while 43% purchased a non-basic household asset (i.e., something that is not essential) and only 4.8% percent purchased a productive asset. Significantly more former beneficiary households (75%) purchased a basic household asset than did current beneficiary households (48.6%). For this question, productive assets were taken to include items they use to earn an income – tools such as an axe, hoe, machete, harrow, plough, or sickle. Some items would also be listed if they were used for earning an income, including bicycle, sewing machine, cell phone, car, fridge, stove, solar panel/unit. Basic need household assets included chair, table, bed, mattress, radio, mortar/pestle, pots, plates, utensils. Non-basic need household assets included TV, video, satellite dish. Nearly all (86.2%) of those individuals purchasing assets said that they would not have been able to make this purchase if they had not been on the SPLASH programme. Only 10% of all respondents reported being able to purchase assets without support from SPLASH.

Table 20: Assets purchased since participating in SPLASH, by beneficiary status

Current Former Total

% households purchasing asset 13.4 25.4* 18.4

n 262 189 451

Type of asset purchased

Basic household assets 48.6 75.0* 63.9

Non-basic household assets 48.6 39.6 43.4

Productive assets 5.7 4.2 4.8

Livestock 5.7 2.1 3.6

% beneficiaries able to make purchase without SPLASH support

9.1 10.6 10.0

n 35 48 83

Asset sales may indicate that a household is becoming increasingly desperate to meet household needs and is forced to erode their asset base in order to obtain resources to purchase food or other essential items. Over 15% of households reported selling any assets since participating in SPLASH, of which half were non-basic household assets, 42.3% were basic household assets and 14.1% were productive assets (Table 21). This suggests that beneficiaries are not so desperate as to feel the need to sell off assets, possibly due to the support of SPLASH.

However, among those that did sell assets, 32.4% reported doing so in order to purchase food for their families. Additional reasons for selling assets included school costs, medical expenses, daily and other costs of living.

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 47

Table 21: Assets sold since participating in SPLASH, by beneficiary status

Current Former Total

% households selling assets 15.8 16.0 15.8

n 260 188 448

Type of asset sold

Non-basic household assets 53.7 50.0 52.1

Basic household assets 31.7 56.7* 42.3

Productive assets 17.1 10.0 14.1

Livestock 9.8 0.0 5.6

Primary reason for asset sales

Buy food for HH 36.8 26.7 32.4

Pay school costs 13.2 26.7 19.1

Pay daily expenses 7.9 20.0 13.2

Other 15.8 10.0 13.2

Pay medical expenses 13.2 6.7 10.3

Other emergency 10.5 3.3 7.4

Pay debt 0.0 3.3 1.5

Pay for social event 2.6 0.0 1.5

Pay for funeral 0.0 3.3 1.5

n 41 30 71

* Significantly different at p = .052 Respondents who did not report selling assets were asked if they thought they would have had to sell some assets during the past year if they were not participating in SPLASH. Almost one in four responded they definitely would have had to sell an asset (Table 22) while another 32% said they may have had to sell off assets, indicating that SPLASH prevented over 50% of households from having to sell their assets to meet basic food needs.

Table 22: Would household need to sell assets if not for

SPLASH, by beneficiary status

% Current Former Total

Yes, definitely

22.0 26.1 23.7

Maybe 40.7 20.3 32.2

Probably not 14.0 24.8 18.5

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 48

Definitely not 16.8 24.8 20.2

Don’t know 6.5 3.9 5.4

n 214 153 367

3.6 Income and Debt

Income would not be expected to be directly affected by SPLASH, but it is a crucial factor that could affect respondents’ livelihoods and moderate the impact of SPLASH. Knowledge of income sources can help provide clues into the optimal design for longer-term sustainability. Current beneficiaries have significantly more (p< .001) income sources than do former beneficiaries (Figure 6).

Figure 6: Mean number of income sources, by beneficiary status

For current beneficiaries, 38.5% reported food assistance as their primary source of income (Table 23). In contrast, 34.6% of former beneficiaries reported petty trade as their primary source of income. Half as many current beneficiaries (16.8%) reported petty trade as their primary income source.

When looking at formal employment, 20.6% of current beneficiaries reported receiving salaries while only 13.3% of former beneficiaries are engaged in formal employment as their primary source of income. This may indicate that as people recuperate while enrolled in the SPLASH programme, they are more likely to return to formal employment, whereas casual labour is something they will undertake only when pressed.

Table 23. Primary income source, by beneficiary status

Current Former Total

0.0

0.5

1.0

1.5

2.0

2.5

Current Former Total

# o

f in

com

e s

ou

rce

s

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 49

Petty trade (firewood sales, etc.) 16.8 34.6 24.2

Food assistance – voucher (paper or electronic) 38.5 0.5 22.7

Formal salary/wages 20.6 13.3 17.6

Casual labour 8.4 18.6 12.7

Remittance/ gifts 2.7 12.2 6.7

Small business 3.1 5.9 4.2

Skilled trade/artisan 2.7 3.2 2.9

From rentals 2.7 3.2 2.9

Food crop production/sales 0.8 2.7 1.6

Vegetable production/sales 1.1 2.1 1.6

Other 0.4 2.1 1.1

Pension 0.8 0.0 0.4

Stone crushing and quarrying 0.4 0.5 0.4

Cash assistance 0.4 0.5 0.4

Cash crop production 0.4 0.0 0.2

Begging 0.0 0.5 0.2

n 0.4 0.0 0.2

ART patients enrolled in the SPLASH program indicated being able to work and support themselves. Much of the qualitative evidence also confirms that though participants were generally unwell before starting the program, they recuperated enough while enrolled to enable them to begin working again, a clear objective of the programme. Current beneficiaries may not have recovered sufficiently to engage in petty trade or casual labour, though this type of work is often important.

This sheds light on a trend that was also seen in Zambia’s SPLASH program, i.e., some beneficiaries discontinue livelihood activities while on the program, in part because they don’t need them. This was also discussed during FGDs. Although these livelihood activities may, in some cases, be far from ideal, they are part of the household’s coping mechanisms. If people lose momentum maintaining their livelihood activities while on the program, they may incur start-up costs once they return to these activities after exiting the SPLASH programme. Additionally, replacing income-generating activities with food rations as a primary source of income makes it difficult for households to acquire other assets and improve their overall economic and food security situations. Food assistance should not be seen as a reason to stop fending for one’s self, a concern regarding welfare in general. However, other reasons may exist for discontinuing certain coping strategies; it may simply be the case that beneficiaries are engaged in other crucial activities, such as child care.

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 50

When asked about secondary income sources, 40.3% of current beneficiaries listed food assistance as their most important source of secondary income. This is nearly the same percentage that current beneficiaries listed as their primary source of income (38.5%). The top three sources of secondary income for current beneficiaries included food assistance (40.3%), petty trade (20.2%), and remittances (10.7%) whereas the top three sources of secondary income for former beneficiaries was casual labour (30.2%), petty trade (26.7%) and remittances (18.1%). Thus, remittances are an important source of secondary income beyond petty trade, casual labour and food assistance for both current and former beneficiaries.

Significantly more current beneficiaries receive help from their friends and families than do former beneficiaries (Table 24), though more than half of all households had received some type of support from relatives or friends, including money (77.8%), food (74%), and clothing (38%). Given the relatively high levels of support received by respondents, especially for current beneficiaries, it is likely that beneficiary rations are sometimes used to assist others. Research in livelihoods has shown that informal support among people with relatively few resources is an important coping mechanism; when one receives support, one also extends support to others, when possible.

Table 24: External support, by beneficiary status

Current Former Total

% households receiving other support 62.0 47.1* 55.8

n 266 189 455

Type of support received

Money 81.7 70.5 77.8

Food 70.9 79.8 74.0

Clothing 35.8 41.6 37.8

n 165 89 254

In situations where levels of income from existing sources are relatively stagnant, the creation of new sources of income or the loss of existing sources can be a significant factor influencing livelihood and food security. During the preceding year, regular income sources had not changed for 86.2% of respondents (86.6% and 85.7% for current and former beneficiaries, respectively). For those for whom income sources had changed, the most common reason was that a family member had lost an income source (Table 25).

Table 25: Percent change in household income, by beneficiary status

% Current Former Total

% households experiencing change in regular income sources

13.4 14.3 13.8

n 261 189 450

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 51

Reason for change in income

Family member lost regular source of income

45.7 66.7 54.8

Other 34.3 11.1 24.2

Family member got a new source of income

14.3 14.8 14.5

Income earner passed away 5.7 3.7 4.8

Income earner left the household (e.g. divorce)

5.7 3.7 4.8

n 35 27 62

There are no statistically significant differences in estimated monthly household or per capita income levels between current and former beneficiaries (Figure 7). However, both current and former beneficiaries have less household income now than they did six months ago (p < .05).

Income is of course dependent on many factors, and localized factors may be as important as more global factors such as increased food prices, in determining the food security of households in a given area.

Figure 7: Mean per capita income 6 months ago and current, by beneficiary status

There were no significant differences in current mean household or per capita income between ART and TB patients (Table 26), though ART patients experienced a statistically significant (p< .001) decrease in overall income over the last six months, while TB patients did not.

0

5

10

15

20

25

30

Per capita monthly

income 6 months ago

Per capita monthly

income now

Per capita monthly

income 6 months ago

Per capita monthly

income now

Current Beneficiary Former beneficiary

me

an

pe

r ca

pit

a in

com

e

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 52

Table 26: Mean household income, by beneficiary type (USD)

% ART TB Total

Total household income 6 months ago 138.4 123.7 134.9

Current total household income 128.3* 124.2 127.2

n 295 48 347

Per capita monthly income 6 months ago 29.3 25.2 28.4

Current per capita monthly income 27.1* 25.1 26.5

n 290 48 342

* Significantly different at p < .001 Roughly one-third of respondents borrowed money in the three months prior to the survey (Table 27). Of those that reported borrowing money, the most commonly stated reason was to purchase food. Close to 20% of current beneficiaries and nearly one-third of former beneficiaries report incurring debt in order to purchase food. Few respondents (10.5%) indicated the willingness to take on debt by borrowing for small business needs, suggesting indebtedness is not something many households take on except for their most critical immediate needs.

Table 27: Percent of households borrowing money, by beneficiary status

Current Former Total

% households borrowing money 32.7 35.4 33.9

n 260 189 449

Primary reason for borrowing

To buy food 18.8 31.3 24.3

To pay for education 17.6 17.9 17.8

Other 15.3 9.0 12.5

To pay for health care 14.1 7.5 11.2

To pay rent/utilities 11.8 11.9 11.2

For business 9.4 11.9 10.5

To pay for funeral 10.6 4.5 7.9

To buy transport 2.4 4.5 3.3

To pay for social event 0.0 1.5 0.7

n 85 67 152

The disadvantage of taking out a loan is that it has to be paid back and informal credit is usually paid with very high interest rates. Thus, when food assistance prevents the need to borrow

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 53

money in order to buy food, it saves the beneficiary the cost of the food plus the cost of the interest. As for the source of the loans, the vast majority get funds from friends (92.5%) with less than 3% borrowing from either informal savings groups, lenders, or banks and other formal lending institutions. Less than 1% of respondents reported borrowing from microfinance institutions (MFIs).

The source of a loan may well affect if/when a loan gets repaid. Being in debt to a formal bank or lending institution differs from indebtedness to a family member or friend. Family and friends are more likely than a bank to be patient when repayment is slow or difficult. However, they may also be vulnerable and not be in a position to extend credit in the future or allow for lapses in payment. In some ways, it may be more important to repay debts to friends and relatives than to banks and other institutions because of the broader role they play in providing support. Of the nearly 87% of loans due for repayment at the time of the survey, nearly 32% had been repaid.

3.7 Food Consumption

One of the fundamental objectives of SPLASH was to increase and improve food consumption of beneficiaries, as measured by number of meals, Food Consumption Score (FCS) and Household Dietary Diversity Score (HDDS, or simply DDS). This section presents quantitative data regarding these important measures of project impact.

3.7.1 Number of meals per day

Increasing the number of meals consumed per day is one of the objectives of SPLASH and is often considered an important measure of food security by local residents. Repeatedly, participants in FGDs stated that they had increased the number of meals they ate because of SPLASH, though they had to cut back after SPLASH ended. On average, the number of meals consumed by current beneficiaries was statistically greater than the number eaten by former beneficiaries (Table 28). Nonetheless, the vast majority of adults (>18 years) and children in all respondent households ate two or three meals per day, providing one indication of adequate access to food for most surveyed households. The main observed difference seems to be that while enrolled in SPLASH, the majority of adults and children ate three meals/day but after the program ate only two meals/day. Approximately 30% of households shift from eating three meals/day to two.

Table 28: Consumption patterns for adults and children, by beneficiary status

% Current Former Total

Mean number of meals consumed daily by adults 2.6 2.3* 2.5

Number of meals consumed daily by adults

0 meals 0.4 0.0 0.2

1 meal 0.8 3.2 1.8

2 meals 38.4 67.4 50.6

3 meals 57.4 27.4 44.8

4+ meals 3.0 2.1 2.4

n 263 189 452

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 54

Mean number of meals consumed daily by children 2.7 2.3* 2.6

Number of meals consumed daily by children

0 meals 0.8 1.7 1.2

1 meal 0.0 2.2 1.0

2 meals 29.8 60.3 42.9

3 meals 64.3 32.4 50.6

4+ meals 5.0 3.4 4.3

n 238 178 416

*Significantly different at p < .001 One meal a day represents real hunger (food insecurity) that lasts most of the day and can be expected to affect energy levels, whereas two meals may result in discomfort for part of the day but at least some food is consumed to distribute food intake over the course of the day. While low availability of or access to food may explain taking fewer meals and thereby suggest food insecurity, it should be noted that it is also not uncommon for people with financial means to skip a meal due to lack of time, or to replace a meal with a snack. Significantly more children in current beneficiary households (3.4%) than in former beneficiary households (2.8%) consumed two daily snacks (p < .001). These patterns were similar when comparing ART and TB patients.

While two meals/day and a snack might be adequate for some individuals (and certainly better than only one meal/day), these consumption patterns may be somewhat troubling, given the increased need for calories by patients receiving ART6. In addition to an increased need for additional calories, patients undergoing treatment with anti-retroviral drugs are better able to adhere to this rigorous treatment with improved nutrition. Thus, good nutrition is critical for ART patients. Two meals a day, and no significant snacking, may not be sufficient for ART patients to maintain a level of nutritional status that diminishes the negative side-effects of the medications.

Current beneficiaries are eating more healthy foods than former beneficiaries (Figure 8). Current beneficiaries consumed significantly more HEPS, fruits, diary, poultry/eggs, roots/tubers, cereals, pulses, meat, sugar and oils than former beneficiaries (p < .05).

Figure 8: Percent of households consuming various food types in the 7 days prior to the survey, by beneficiary status

6 Gillespie S. 2006. AIDS, Poverty and Hunger: Challenges and Responses. Washington, D.C.: International Food Policy Research Institute (IFPRI).

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 55

Eighty-two percent of current beneficiaries rely on food assistance as their main source of cereals, while 67.4% of former beneficiaries purchase cereals as their primary method of acquiring them. Interestingly, in addition to food assistance, 63.7% of current beneficiaries purchase cereals as a secondary way of obtaining them. Maize, specifically, is obtained through food assistance for 95% of current beneficiaries and only 3% of former beneficiaries. Of those foods consumed by significantly more current beneficiaries than former (see Figure 8), maize, pulses, and oils are primarily obtained through food assistance for current beneficiaries but primarily purchased by former beneficiaries. According to respondent surveys, 92% of current beneficiaries obtain HEPS through food assistance while 67% of former beneficiaries produce their own.

3.7.2 Food Consumption Score

WFP guidance for the Comprehensive Food Security and Vulnerability Analysis (CFSVA)7 states that typically, FCS thresholds are set as follows: 0-21 is classified as poor food consumption, 21.5-35 as borderline, and a score of over 35 is deemed acceptable food consumption. However, in contexts where oil and sugar consumption are high in the overall population, the following thresholds are used: 0-28 as poor food consumption, 28.5-42 as borderline, and over 42 as acceptable.8 These elevated thresholds are used for the Zimbabwe study because of the prevalence of oil and sugar in the diet.

7 http://www.wfp.org/content/comprehensive-food-security-and-vulnerability-analysis-cfsva-guidelines-first-edition 8 "...in populations where consumption of sugar and/or oil is frequent among nearly all households surveyed, even when the consumption of other food groups is rare and the food score is otherwise low. In these cases if this base diet of oil and sugar is combined only with frequent

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0

HEPS

Fish

Dairy

Roots/tubers

Pulses

Maize

Oils

% of households consuming in 7 days prior to survey

Former beneficiary Current Beneficiary

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 56

The Food Consumption Score (FCS) is a key indicator for SPLASH. The overall mean FCS for SPLASH participants interviewed in this survey is 49.4 (Table 30), which is in the range of acceptable food consumption. Current beneficiaries have significantly higher FCS than former beneficiaries and TB patients have significantly higher scores than ART patients (Table 30).

Table 29. Mean FCS and HDDS, by beneficiary

Mean HDDS Mean FCS n Current 5.8 56.5 262 Former 4.5* 39.6* 190

Total 5.3 49.4 452

ART 5.2 48.5 391 TB 5.8** 56.5* 57 Total 5.3 49.4 448

* Significantly different at p < .001; ** significantly different at p < .05 The Household Dietary Diversity Score is measured by summing the number of food groups consumed over the previous 24 hours. Current beneficiaries are consuming a significantly more diverse diet, as defined by HDDS, than are former beneficiaries (Table 30). TB patients also have slightly higher, but statistically significant, dietary diversity scores than ART patients. While the food consumption profile of respondents overall is fairly good, it is of note that significantly more former beneficiaries fall in the poor and borderline categories than current beneficiaries (Table 31) and that significantly more current than former beneficiaries fall in the acceptable food consumption category. This data suggests that the project has helped raise the Food Consumption Score for program participants. Unfortunately, the FCS does not appear to be maintained very long after participants leave the program. For example, over 64% of former beneficiaries received their last ration more than six months prior to the survey. Thus, the benefits of the programme in terms of FCS begin dropping off after several months out of the program.

Table 30: FCS category, by beneficiary type

% Current Former Total

Poor food consumption 4.2 28.4* 14.4

Borderline food consumption 23.7 40.0* 30.5

(7 days) consumption of starch base, the score already arrives at 21. However, this clearly cannot be classified as even a borderline diet. For this reason the thresholds can be raised from 21 and 35 to 28 and 42 (by adding 7 to each threshold, this accounts for the daily consumption of oil and sugar which gives 7 points to the FCS)." (CFSVA Guidelines)

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 57

Acceptable food consumption 72.1 31.6* 55.1

n 728 469 1197

*Significantly different at p < .001 Food consumption profiles for ART and TB patients reveal a similar pattern in that the majority of patients are considered to have an acceptable food consumption level. However, there are no statistically significant differences between ART and TB patients for any food consumption category.

3.8 Coping Strategies

Coping strategies are the regular behavioural responses to food insecurity that people use to manage household food shortage. Measuring household use of coping strategies provides an alternative or complementary source of information on actual household food consumption.9 While coping strategies are reasonable ways to maximize the benefits from limited resources, and may be necessary in the short term, if employed over the long term, they may erode assets and capacities necessary to sustainable food security.

The Coping Strategy Index (CSI) is a proxy indicator for food insecurity, calculated by multiplying the severity score assigned to each coping strategy by the frequency the coping strategy was employed by a household from Never (x0) to Every Day (x4).10 Therefore the higher the CSI the more insecure a household is. The total possible CSI is 122.4.

Former beneficiary households had a significantly higher CSI (p< .001) than current beneficiary households (Figure 9), indicating they are experiencing greater household food insecurity. There were no differences between ART and TB patients for CSI.

Figure 9: Mean coping strategies index (CSI), by beneficiary status

9 Maxwell, D., B. Watkins, R. Wheeler & G. Collins (n.d.) Coping Strategies Index: Field

Methods Manual. CARE East Africa, WFP VAM Unit. 10 A different frequency multiplier was used for the endline survey than with the RFFV baseline, which assigned a value of one to “never”, and would therefore assign a CSI value even if the strategy was not used.

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 58

As noted in Figure 10, the most commonly employed coping strategy for all beneficiaries involved a reduction in the number of meals eaten each day (76.1 %), followed by limiting portion sizes (74.9%), and eating less preferred foods (71.6%). These coping strategies are among the least severe behaviours to employ when coping with food insecurity. More severe coping strategies are utilized by both current and former beneficiary households, though on average close to twice as many former than current beneficiary households need to rely on them.

Figure 10: Employment of coping strategies

Figure 10 reveals that 64.9% of adults in former beneficiary households are having to reduce adult consumption so children can eat, while 35% do so in current beneficiary households. Unfortunately, fully 37% of former beneficiary households are skipping entire days without

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

Current Beneficiary Former beneficiary

me

an

CS

I

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0

Harvest immature crops

Gather wild food/hunt

Send members to beg

Household members eat elsewhere

Skip entire days without eating

Buy food on credit

Rely on casual labour

Borrow food from others

Reduce adult consumption

Eat less preferred foods

Limit portion sizes

Reduce number of meals

Former beneficiary Current Beneficiary

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 59

eating, compared to less than 10% for current beneficiary households. This indicates that while most households have to deal with relatively low levels of food insecurity, others (particularly among former beneficiary households) have to employ very severe coping strategies to meet household food needs.

Food is more limited and scarce for households no longer enrolled in SPLASH. Households are rationing meals to twice a day while also reducing the portion sizes. Others are skipping meals entirely. These more severe coping strategies have profound impacts on nutritional status, generally, but affect ART patients more, as nutritional status is critical to ART adherence.

Innovative food sourcing strategies have been employed by many to augment household food supplies. Significantly more former beneficiary households revert to selling assets in order to purchase food than do current beneficiary

households (Table 32). This is supported from FGDs, where respondents reported facing increased challenges trying to provide for their basic household food and other needs after being discharged from SPLASH. On average, 14.5% of all households are reportedly engaging in transactional sex as a coping strategy. Given that the majority of respondents are HIV positive, the risk of infecting others is high, even in the event they properly utilize contraceptives. SPLASH participants undergoing treatment and counselling at clinics should also be receiving counselling and information on the risks associated with transactional sex.

Table 31: Other coping strategies by beneficiary status

% Current Former Total

% of HHs selling assets to buy food 13.9 27.4* 19.6

% of HHs that state some SPLASH participants are engaged in transactional sex to acquire food

12.0 17.9 14.5

% of HHs selling assets to pay medical expenses 6.5 4.7 5.8

% of HHs that state they are engaged in transactional sex to acquire food

3.1 2.6 2.9

n 262 190 452

* Significantly different at p < .001

3.9 Anthropometrics and BMI

The ration, along with other aspects of the programme such as nutrition education, is thought to directly reduce malnutrition by providing supplementary (CSB) and staple household foods, but also indirectly by helping the household afford, among other things, a more diverse and

“Since I have been discharged today, I am now going to work out a plan to ration and budget meals. Earlier on there was no need to budget food since I had assurance to get something the following month.”

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 60

enhanced diet. According to WHO standards11, severe thinness is characterized by BMI <16, moderate thinness as BMI 16.0-16.99, mild thinness as BMI 17.0-18.49, normal BMI as BMI 18.5-24.99, pre-obese as BMI 25.0-29.99 and obese as BMI > 30. The programme was expected to improve BMI within six months after enrolment. Qualitative research revealed strong evidence of the positive impact of the household food ration on the nutritional status of household members. To complement this, quantitative research sought to demonstrate whether that impact occurred for current and/or former beneficiaries. Overall, current beneficiaries had significantly lower BMI than former beneficiaries (17.8 and 21.6, respectively; p< .001). Significantly fewer former beneficiaries experienced severe, moderate or mild thinness than current beneficiaries (p< .001) (Figure 11). More former beneficiaries were classified as normal, pre-obese or obese than current beneficiaries (p< .001). Some current beneficiaries are expected to still be classified as malnourished, as they wouldn’t necessarily have been in the program long enough to show marked improvement in nutritional status; it is expected that others will have shown improvement. While there was no clear expectation regarding nutritional status of former beneficiaries, they might have been expected to be better off nutritionally because otherwise they could have re-enrolled in the program (i.e., if they still had BMI < 18.5).

Figure 11. Nutritional status of households, by beneficiary status

Figure 12 shows the number of current and former beneficiaries with BMI ratings based on WHO classifications of BMI12 disaggregated by the length of time in or out of the program. This figure provides some indication that the SPLASH program is indeed targeting the most vulnerable ART patients as evidenced by the fact that nearly two-thirds of current beneficiaries have a BMI of less than 18.5.

For current beneficiaries, there were no statistical differences between the length of time a beneficiary was enrolled in the program and BMI, according to Chi-square tests (Figure 12). Likewise, there were no differences in BMI among former beneficiaries regardless of the length of time since their termination in the program.

11 http://apps.who.int/bmi/index.jsp?introPage=intro_3.html 12 ibid.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Current

Beneficiary

Former

beneficiary

% o

f b

en

efi

cia

rie

s

Obese

Pre-obese

Normal

Mild thinness

Moderate thinness

Severe thinness

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 61

Figure 12: BMI classifications by time enrolled in program and time out of program

According to these data, former beneficiaries appear to be healthier, at least based on their BMI classification. These findings provide some evidence of the impact of the SPLASH program on beneficiary nutritional status, and moreover suggest that the impact can be sustained seven or more months after food assistance has ceased. Given heightened CSI and lower FCS of former beneficiaries, data suggests that this group may have reached a threshold BMI capable of weathering acute food insecurity.

As a group, former beneficiaries may have been less malnourished than current beneficiaries; according to WFP there had not been strict application of low BMI as selection criteria prior to March, 2011. However, this group was probably not particularly food secure either as the vast majority were deemed vulnerable according to the screening tool previously used.

Comparison of the observed nutritional status (as measured by BMI) of current beneficiaries with their assumed status upon registration in SPLASH also sheds light on the potential impact of SPLASH on malnutrition. As strict BMI screening was applied from March, 2011 forward, one would expect that those being registered between March and June, 2011 would have been extremely, moderately or mildly thin (i.e., BMI < 18.5). As noted in Figure 112 , however, almost 40% have normal BMI, i.e., above 18.5. This is strongly suggestive of a large change in status even within those initial months though a more rigorous comparison could be made by cross-referencing BMI at registration.

Another issue to consider regarding the observed nutritional status of current beneficiaries is that from about four months onward, some beneficiaries are discharged as they reach normal BMI (i.e., BMI above 18.5 for two consecutive months). Clients who were surveyed as current beneficiaries were by definition those who had not reached and maintained a BMI of 18.5 for two months. Current beneficiaries who had been enrolled for five or more months were those

0%10%20%30%40%50%60%70%80%90%

100%

Enrolled for 1-4

months

Enrolled for 5+

months

Out for 1-6 months Out for 7+ months

Current beneficiaries Former beneficiaries

% o

f b

en

efi

cia

rie

s

Severe thinness Moderate thinness Mild thinness

Normal Pre-obese Obese

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 62

who had not yet been discharged. Former beneficiaries would include clients who had “graduated” from SPLASH with a BMI classified as normal, as well as clients who were simply never particularly malnourished.

A number of beneficial changes in eating/dietary habits were mentioned by respondents in FGDs. Mostly notably, benefits included weight gain and changes in food consumption. For example, some participants noted improvements in their appetite and ability to eat certain foods (e.g., porridge) without suffering from digestive issues. Others indicated their diets had changed, for example, by incorporating additional foods (e.g., beans). While redeeming her voucher at OK Mbare, a client indicated, “I am now fit and I

don’t want to lie to God. I joined the programme with 40Kgs and now have 55Kgs. I will now

work to sustain my family as this is my last time as a beneficiary. Let others benefit also.”

SPLASH participants appreciated that food improved their drug intake and some have gained weight. One participant pointed out that previously he used to experience heartburn with the drugs and had no appetite but the CSB allowed him to take the drugs without associated heartburn and his appetite had improved as well.

3.9.1 BMI using monitoring data

In addition to using anthropometric data collected from a sample of SPLASH beneficiaries, the evaluation team also analyzed the same monitoring data but collected from all beneficiaries to determine the nature of the relationship between time enrolled in SPLASH and beneficiary BMI. Beneficiary data were aggregated to allow for comparisons. Possible shortcomings of the data include the fact that only four measurements were recorded (i.e., only the last four months of data before the survey was conducted were available). Additionally, BMI data was not available for former beneficiaries. Figure 13 breaks down the beneficiary BMI measurements by clinic and number of measurements.

Figure 13: Mean BMI by number of months and clinic

“Before I was on the programme two months ago, I was food insecure, shown by my weight of 30Kgs. However, at the moment I am recovering, weighing 42 kgs.”

WFP Zimbabwe SPLASH E-voucher Program Evaluation - Final Report Page 63

The findings are similar to those shown in Figure 12 in that they do not show any trend in improvement of BMI over time. Though the patterns differ somewhat between clinics, the most notable similarity between all clinics is that BMI tended to increase (p< .05) by the second measurement relative to the first measurement in all clinics except Parirenyatwa and UZCRC, and BMI at the fourth measurement had not significantly changed since the first measurement in all but two clinics; Beatrice saw a significant increase in BMI between the first and last measurement (p < .001) and UZCRC saw a significant decrease in BMI between the first and last measurements (p < .05).

Though statistical tests were not performed for changes to BMI over time (i.e., over the four measurements) between clinics due to the limitations noted above, certain trends were observed. In particular, beneficiaries appeared to show large gains in BMI after the first measurement and maintained them at the second measurement, though the gains were not as large in Parirenyatwa and UZCRC as in the other clinics. Similarly, at the fourth measurement, most clinics had large percentages of patients with BMI < 18.5. Epworth reported no beneficiaries with BMI >18.5 at the fourth measurement and less than 15% of patients at UZCRC had a BMI >18.5 at the fourth measurement. All other clinics had 20-40% of patients with BMIs >18.5.

As suggested by those familiar with the program, this trend might reflect larger numbers of beneficiaries being discharged by the fourth measurement (due to increased BMI) such that only those with BMIs lower than the graduation level (i.e., less than 18.5) remain to be measured. The recovery process that begins after a patient is initiated on ART/TB medications is not straightforward and patients often suffer side-effects that delay weight gain. It may take several months to overcome these treatment-induced setbacks or delays. Additionally, some clinics serve more rural populations, where food insecurity and livelihood patterns may result in higher overall levels of malnourished clients. Taken together, these data suggest that BMI of the

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beneficiaries still on the program may not adequately capture the impact of SPLASH, and a more nuanced picture should be sought which takes into account other indicators and the fact that some beneficiaries are discharged earlier. .

3.9.2 Adherence

For both ART and TB patients, adhering to their medical treatments is essential to recovery. Eighty-three percent of beneficiaries reported difficulty maintaining their medication schedules without food assistance from SPLASH (Table 33).

Table 32: Effects of cash/food on beneficiary adherence to medication, by beneficiary status

% Current Former Total

Without food it is difficult to take this medication, so the program made it much easier to take it

86.1 80.7 83.8

Helped me to follow regularly scheduled visits to clinic 20.1 23.0 21.3

Since I had to show that I was taking the medication in order to obtain the food ration, it forced me to take the medication

3.3 4.8 3.9

Other 1.6 2.7 2.1

n 244 187 431

Over half of all current beneficiaries (52%) are reviewed once a month at the Opportunistic Infection (OI) clinic (Table 34) while the majority of former beneficiaries (71%) come in for medical reviews once every two or three months. A similar pattern is observed for how often patients are measured; the majority of current beneficiaries (75%) are measured once a month while the majority of former beneficiaries (62%) are measured every two or three months.

Table 33: Frequency of review and measurement, by beneficiary status

% Current Former Total

Frequency of review

Twice a month 5.8 1.6 4.1

Once a month 51.9 27.3 41.8

Once in two months 26.2 33.3 29.1

Once in three months 13.8 37.7 23.7

Other 2.3 0.0 1.4

n 260 183 443

Frequency of measurement

Twice a month 3.4 2.6 3.1

Once a month 75.1 27.4 55.0

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Once in two months 13.4 26.3 18.8

Once in three months 6.1 35.8 18.6

Never 0.0 2.6 1.1

Other 1.9 5.3 3.3

n 261 190 451

Both current and former beneficiaries reported experiencing complications with their medical treatments during the last 30 days prior to the survey (Table 35), largely due to complications from other illnesses. Over 28% of former beneficiaries also reported suffering from depression.

Most beneficiaries were able to continue taking their medicines; 7.9% of current and 1.6% of former beneficiaries, respectively, reported they were not able to adhere to their medical programs.

Table 34: Complications experienced in last 30 days, by beneficiary status

% Current Former Total

Suffer from other illnesses 21.9 25.8 23.5

Depression/stress 9.1 28.4 17.1

Suffer from side effects 16.6 15.3 16.0

Loss of appetite 10.2 4.2 7.7

Did not adhere 7.9 1.6 5.3

Suffer from diarrhoea 5.7 3.7 4.8

Unable to eat 3.8 4.7 4.2

Defaulted from drugs 3.4 1.6 2.7

Other 1.1 3.7 2.2

Did not receive enough drugs 1.1 1.6 1.3

n 265 184 449

Adherence is often measured by three methods, i.e., pill count (accounting for all pills issued), direct questioning of the client, and assessing the general well being of the client (e.g., little improvement may indicate the patient is not taking his/her medicines as required). Adherence is a key priority for the Drug Adherence and Counselling (DAC) centres in the OIs. Adherence support is linked to other aspects of counselling and education. For example, Epworth Clinic carries out group sessions every morning, including discussions on:

• Nutrition management

• Early treatment of OI

• Disclosure of one’s status

• Discordant couples

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• Keeping scheduled reviews

• Discouraging alcohol and smoking

Other measures to improve adherence advocated by the centre include maintenance of a pill chart by clients and assessments conducted by the clinic when patients come for their supply of drugs. Indicators of adherence include improvements in CD4 count and weight gains.

Based on FGDs, many patients did not feel adherence was a major issue and expressed confidence in their own methods for remembering when to take their medications. Some have gone so far as to develop personal timetables. Others rely on family members to help them remember; children often serve as “tablet time tables,” reminding them to take their pills.

3.9.3 Social Benefits and Side-Effects

Overall, FGD participants thought their participation in the SPLASH program had improved their health and well being. Availability of food at home also improved relations within households. “My household was full of joy and disagreements [were] reduced significantly due

to food availability”, one household head noted. Thus it can be deduced that the programme had some positive impact on social cohesion within the family, at least for some households. The way in which SPLASH reduced disagreements and increased social cohesion was an important one. This was an unanticipated postive impact of SPLASH that only became apparent during the open-ended questioning that took place in focus group discussions and was unprompted.

The SPLASH program has in some ways incentivized care givers to provide care and treatment to ART patients. For example, an important side effect of food assistance that was confirmed with this study was the perceived increase in “value” of orphans, specifically those on ART who became SPLASH participants. Apparently, such orphans were seen, in some cases, as “prizes” for relatives who would then benefit from the household ration upon taking in the orphan.

Relatives are motivated to care for and house a SPLASH beneficiary because doing so will result in a household food ration. The assumption is that the household will make use of the ration and indeed the household ration is calculated in a way to protect the program beneficiary’s ration. It should also be noted, however, that families often provide

for/borrow from relatives. For beneficiary housholds, there may be an increased obligation to share the food basket with relatives, potentially reducing its impact on targeted beneficiaries.

4 Findings - Relevance and Effectiveness of the Intervention

This section presents an analysis and discussion of the relevance and effectiveness of the form of assistance, the implementation process, and the voucher and retailer system. It also evaluates the SPLASH approach in the context of Zimbabwe’s food security and social welfare sector, and comments on management issues. The discussion draws on both quantitative and qualitative data from the survey. In recognition that SPLASH was a pilot programme, the narrative seeks to draw out lessons that are more widely relevant.

“We could cook Sadza anytime and this greatly improved our health and there were no restrictions on quantity and time for its preparation.”

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The intervention process is broken down in order to analyze at each step whether the intervention functioned as expected, whether the beneficiaries responded as expected, and to highlight if there was anything unexpected arising at each stage.

4.1 Form of Food Assistance

4.1.1 Composition of ration

Composition of the food ration has been consistent over the life of the NSART/SPLASH project though rations for some items were adjusted (see 4.1.2). The supplementary ration consisting of 10 kg of corn-soya blend (CSB) is provided to all clients (malnourished ART/TB patients and a very small number of MCH cases). A household ration is provided to those clients who are deemed to have a high degree of household food insecurity as determined by a vulnerability screening, though the vast majority of households have been receiving household rations.

The household ration identified for use in the SPLASH programme consisted of 10 kg of maize meal per person, 1.8 kg of pulses, and 0.6 litres of oil person, up to a maximum of 5 persons. Pipeline challenges resulted in a downward adjustment in rations, which currently consists of 5 kg of mealie meal, 1 kg of pulses and 750 ml of oil.

No statistical differences were observed between current and former beneficiaries in commodities received except in the case of cooking oil (Table 36). Though the difference is small, significantly more former beneficiaries than current beneficiaries reported receiving their full allotment of cooking oil.

Table 35: Commodities received, by beneficiary status

% Current Former Total

Maize meal 98.1 100.0 98.9

Beans 98.1 100.0 98.9

Cooking oil 97.7 100.0* 98.7

CSB 97.0 99.5 98.0

n 265 190 455

* Significantly different at p < .05

It is unclear why 2-3% of current beneficiaries reported that they didn’t receive commodities. It seems unlikely they would forget receipt of a ration, and there is no apparently reason why a beneficiary would miss out on an item. Neither is it clear why CSB would be the single most “missed” commodity, as it is provided by Redan Mobile Transactions (RMT) along with the voucher before clients receive a food ration. It may be that some clients chose not to receive CSB as it was a new item and would not constitute a normal part of their diet. Although the percentage who didn’t receive commodities is very low, this is still something for which an explanation should be sought.

Overall levels of satisfaction with the commodities received was very high (Figure 14). Though approximately 12% of respondents reported not being satisfied with cooking times for oil, this is primarily an artefact of former beneficiaries responding with N/A to the survey question,

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resulting in a lower percentage with a favourable rating. Nearly 4% indicated they were not satisfied with the cooking times for beans supplied through the ration.

Figure 14: Percent of household satisfied with commodities received

Given that certain issues had arisen with delivery and acceptability of commodities, respondents were then asked whether improvements had been made. Of those that responded, 4.5% reported that improvements had not been made and 4.3% reported that they had.

The composition of the ration is determined in part by the nutritional needs of ART patients. A household ration is provided to protect the CSB from consumption by non-ART family members. There was some feedback from FG participants that if it wasn’t for the household ration, the CSB would be shared among household members and the patient would not get the expected benefit. Overall, participants expressed satisfaction with the CSB, though it was a new commodity to which they were not accustomed.

An important concern expressed by participants was whether it was more important to provide a specifically nutritious product, such as CSB, or whether any type of food was adequate. The

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Newlands Clinic director, a medical professor, indicated that ART intervention causes such an increased sense of hunger that it becomes difficult to continue on the medication unless the hunger is sated. Thus, providing nutrient-dense foods, such as CSB, maximizes the likelihood of patients adhering to their treatment interventions

Other feedback provided in FGDs involved interest by many participants for refined mealie meal, rather than the whole grain roller meal that is provided by the program. Since roller meal has nutritional benefits to these clients, the inclusion of it seems well-justified.

While respondents expressed overall satisfaction with the quality of the food ration, many FGs and clinic staff expressed some concern over the composition of the basket, specifically, in terms of the beans. Many suggested replacing the beans with dried fish (kapenta or matemba). While beans are protein-rich, inexpensive, and have a relatively long shelf-life, the retailers at times experienced difficulty in obtaining them. Equally important, it is commonly believed that beans are contributing to heart burn among recipients. In one FGD, the suggestion was made to alternate beans with other local food items, such as matemba, not only for variety but also to reduce heartburn. There were reports of beneficiaries selling beans in order to meet other family needs. In a different FGD, beneficiaries reported having reservations about the dietary balance of the ration, though in their desperation did not want to complain per se. There was some thought by nutritional and dietary specialists that the SPLASH voucher could be more balanced by including vegetables and vitamin-rich in the basket and suggested matemba (fish), madora (mopani worms) and soybeans. Still others recommended including maheu (a drink made from cereals) and milk in the food basket. Several participants even suggested adding soap to the ration.

A small percentage of both current and former beneficiaries (10.2% and 15.8%, respectively) had received other types of assistance during the previous half-year, including food assistance (Table 36) . Fully 20% of former beneficiaries reported receiving direct food assistance while only 3.7% of current beneficiaries received food assistance other than through the SPLASH program. Other types of assistance beneficiaries reporting receiving included education support (53%) and agricultural skills training (14%).

Table 36: Receipt of other forms of assistance

Current Former Total

% of HHs receiving other assistance 10.2 15.8 12.5

n 265 190 455

Type of assistance received

Direct food assistance 3.7 20.0 12.3

Clothing 7.4 0.0 3.5

Farm inputs 0.0 0.0 0.0

Loans/credit 3.7 3.3 3.5

Agricultural skills training 14.8 13.3 14.0

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Cash transfer 0.0 6.7 3.5

Other skills training 3.7 3.3 3.5

Education support 51.9 53.3 52.6

Food voucher 3.7 0.0 1.8

Other 14.8 10.0 12.3

n 27 30 57

The presence of an educational support program which benefits more than half of the clients enrolled in the SPLASH program may be important to consider, since it would imply that beneficiaries are less likely to use savings accrued as a result of the household ration; such savings would be more likely applied to other household needs. It is reassuring that beneficiaries of the SPLASH program are not simultaneously receiving significant food assistance from other sources, especially when the overall availability of such resources is quite limited compared with the number of those in need. Thus, it appears that a rational and equitable distribution of food assistance is taking place in the area. As former beneficiaries no longer receive food assistance through SPLASH, it seems reasonable they might seek assistance through other food programs.

4.1.2 Quantity, duration, and quality of food assistance

The content of maize meal in the household food ration was reduced from 10 kg to 5 kg per person in April due to resource constraints, while beans were reduced from 1.5 kg to 1 kg. The e-voucher project continued to provide 10 kg of CSB per month to malnourished ART patients (BMI < 18.5). This change resulted in some dismay and confusion for beneficiaries, who did not understand the reason for it. WFP did inform beneficiaries a month in advance, both verbally and through posters and beneficiary information slips. While a reduction in ration size is not generally likely to be greeted with enthusiasm by most beneficiaries, it may have been possible to help beneficiaries prepare somewhat more and to understood the reasons for the change. The size of the ration depends on a number of factors, most notably on whether the ration provides enough to gain weight and secondarily on whether sufficient weight gain can be achieved within six months and maintained for at least two months. The CSB supplementary ration is important for rehabilitation of patients. While the household ration is designed to “protect” a patients’ supplementary ration, it does not provide for a substantial proportion of the typical household’s needs. It was apparent from FGDs that beneficiaries credited the SPLASH program for their weight gain. Ration size is also dependent on need, i.e., whether sufficient resources exist to provide for all those who are vulnerable and other programmatic needs. Issues related to sustainability will also influence where resources should be directed. Alternatively, program goals suggest maintaining rations sufficiently high that people are more likely to convert savings accrued from reduced food expenditures into investments in sustainable livelihood activities. Any reduction in the size of the ration could have a detrimental effect on patients as current beneficiaries reported an increase in spending on cereals (as well as

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roots/tubers and breads) while on the program (see section 3.4). This might suggest that their energetic needs are not being met by the ration. In terms of duration, six months was determined to be enough to allow for initiating medications, getting over the worst side-effects of the treatment, and beginning recovery. This time period was thought by some participants to be adequate. However it was pointed out that TB has its own timeframe, different from that for ART. TB patients may be on medication for six to eight months, but at times as long as two years. Given the longer timeframe typically required for TB patients, it may be beneficial to extend food assistance for another six months. Some FGD respondents also felt that TB patients needed more food than ART patients relative to their ability to adhere to the drug regimen. A common suggestion from FGDs was to scale down the ration for those who have gained weight rather than remove them completely from the program. According to a number of health professionals this would help reduce stress-related infections at the time of discharge that result from stress related to “going off” the ration.

4.1.3 Food vs. cash

The question of food versus cash as a form of assistance has been quite topical in WFP and among many international organizations, and has been debated in Zimbabwe where both food and cash assistance have been piloted, including in WFP programs. To further explore this question, quantitative survey respondents were asked what they would prefer if they could choose between assistance in the form of food (through vouchers), cash assistance or a combination of the two. The results indicate a strong preference for food assistance only (Figure 15), with nearly 68.6% of current beneficiaries preferring food assistance over other types. Similarly, 79.4% of former beneficiaries preferred food over other types of assistance. Less than 5% of either group preferred cash only while a combination of food and cash was preferred by 27.2% of current beneficiaries and 16.9% of former beneficiaries.

Figure 15: Preference of food versus cash assistance, by beneficiary status

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Beneficiaries who prefer food to any other type of assistance were asked to state their primary, secondary and tertiary reasons for this preference. The primary reason reported by a majority of all beneficiaries (62.4%) was that receiving food was better for children and the family because cash would tend to be spent on non-essential items (Figure 16). The second most common reason reported by beneficiaries was the unpredictability of food prices (19.7% of current and 9.4% of former beneficiaries, respectively), implying that receipt of a guaranteed amount of food is more secure for them.

Figure 16. Reasons for preferring food, by beneficiary status

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When asked to give a secondary reason for preferring food assistance to cash or a combination of the two, 16.9% of all respondents indicated food is preferred because it is easier to share with family and friends and because it is managed by women (10.7% and 6.1% for current and former beneficiaries, respectively). These results were confirmed during focus group discussions. Beneficiaries clearly stated that food is a reliable form of assistance and meets their essential needs. They also felt that large cash transfers would likely be used for non-essential expenditures. Of note is the fairly large percentage who mention the importance of sharing food; it is usually assumed that cash is more transferable, yet food may be more culturally appropriate for sharing with family and friends. For respondents preferring a combination of food and cash assistance (Figure 17), 69% of current and 65.6% of former beneficiaries indicated their primary reason for preferring a combination was that it helps them meet seasonal needs more effectively and that the combination of food and cash assistance is more flexible (16.9% of current and 9.4% of former beneficiaries). Secondary reasons for preferring food and cash assistance to either type of assistance alone included more flexibility (35.9% of all respondents), improved coping ability (25.2% overall), and available cash for small businesses (12.6% overall).

Figure 17: Reasons for preferring food and cash, by beneficiary status

During FGDs, participants discussed whether they considered the food ration to be the most appropriate form of assistance. Very few preferred cash; most thought it might be “misused” or used for non-essentials items. Respondents noted high levels of misuse of cash and even the

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temptation to misuse it, the typical result of which was the household starving. One female participant commented on the likelihood that many male beneficiaries might abuse cash assistance by using it at “small houses” (ie. with “second wives” or partners) or even with friends at a beer hall. FGDs participants presented a number of other suggestions regarding assistance designed to help beneficiaries pay for other household expenses. For example, several participants in one focus group suggested alternating food with cash assistance based on the beneficiaries’ preferences in order to make it easier to meet certain expenses such as rent. However, most respondents disagreed with this idea, suggesting that food is the most basic need and should be given priority, particularly as most of them are not working. Participants in other FGDs suggested that food assistance be complemented with other social protection initiatives (e.g., Basic Education Assistance Module (BEAM) for children whose parents are on ART/TB). An important dimension of the food/cash question is the flexibility it provides in terms of choice in purchasing. The voucher provides for specific food items only and only at designated retail outlets. Therefore, it is fundamentally different from cash, which is by definition a multipurpose currency of trade. WFP Zimbabwe has also piloted a cash transfer program and one of its conclusions was that though beneficiaries often use cash to purchase food, they tend to purchase maize rather than balancing their diet by purchasing more protein-, vitamin- or mineral-rich foods. This favours providing a specific, nutritionally-balanced ration in order to ensure a minimum state of nutritional status for vulnerable populations. As noted above, it is fairly common for people to purchase relatively non-nutritious but carbohydrate-rich foods such as other cereals, tuber crops and bread with household money saved as a result of receiving a food ration. This suggests a need for nutrition education as a core activity of the program.

4.2 The Targeting, Registration, Education and Follow-Up Process

This sub-section discusses programme relevance, effectiveness and efficiency regarding targeting, registration, education and the follow-up process.

4.2.1 Target Group Definition

As SPLASH is a pilot program within the existing NSART program, geographical targeting was not much of an issue given NSARTs targeting of primarily ART and TB patients in much of Zimbabwe. The primarily urban focus of SPLASH arose from analysis that the precarious livelihood balance of already vulnerable urban populations had been upset by market forces (e.g., the global food crisis), and these factors could have continued to worsen. While priority is often given to rural areas, there is reasonable evidence to suggest focusing on urban areas is also needed. Large urban areas typically have both wealth and poverty but the numbers of poor are typically very high. HIV prevalence rates are often higher in urban areas than in rural areas. Thus, an urban focus seems reasonably justified. Issues specific to targeting Harare had more to do with identifying the most effective way of operating in the city rather than whether to operate there at all. In addition, SPLASH was a very

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small intervention compared to the Vulnerable Group Feeding program that addresses seasonal food insecurity in many of the most impoverished rural areas. In the case of Zimbabwe, the focus on urban Harare arose from a specific combination of factors. There were a high number of cases of HIV and TB in Harare, and they were likely associated with high levels of household vulnerability. As noted above, vulnerable households in cities were particularly affected by soaring global food prices in 2008-2009, which compounded the breakdown of the Zimbabwean economyof the preceding years. Targeting within the city of Harare, as in many large cities in the developing world, was far from straightforward, however. There are vulnerable individuals residing throughout Harare, including within high-income neighbourhoods. Most of the central hospitals serving ART/TB patients have city-wide coverage, albeit with referrals received from various clinics. Urban hospitals serve many patients from outside the city, particularly HIV patients as it is common for patients with HIV to avoid clinics near where they live in order to avoid being recognized and their status exposed to neighbours and friends. Epworth is perhaps the main exception to the above in that it is a distinctive, low-cost and minimally-serviced neighbourhood just outside of Harare city limits. Much of the population growth in Epworth came about when urban populations were resettled in 2006 as a part of the government’s “Operation Restore Order” that targeted informal markets and slums, and subsequently during the dollarization of the economy. Though considered part of Harare, Epworth has a separate management Board rather than being under Harare City Council. Targeting ART and TB patients for the NSART program is coherent with WFPs global policies and sharing of responsibilities among UN agencies. HIV has been an overarching threat to Zimbabwean society for several decades and had a prevalence rate of 13.7% in 2009. Direct and cross-cutting prevention and treatment programs offered by many organizations have helped to slow the spread of HIV in Zimbabwe. The need for nutritional and livelihood support as part of treatment and intervention has been increasingly recognized; strong rationale exists for providing nutritional support to ART and TB patients because good nutrition improves patients’ ability to adhere to their medication.13 An important issue related to targeting is the distinction between moderately and severely malnourished ART/TB patients and whether SPLASH is the most appropriate intervention for the latter. SPLASH beneficiaries are comprised of several types of patient: the vast majority are HIV patients being treated with ART (approximately 90%); some are on combined treatment for ART/TB; others are being treated for TB only; and still others, though in limited numbers, are maternal and child health (MCH) and/or prevention of mother to child (PMTCT) cases. There was some evidence that not all clinic staff involved are aware of the possibility of registering moderately malnourished children. There is not a clear goal articulated as part of SPLASH for targeting cases of MMC nor whether the intent is to increase their number.

13 WFP worldwide is still exploring the best way to use food assistance for HIV/AIDS patients.

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There were a number of comments from participants and partners related to the exclusion of certain target groups. Some suggested that targeting should include orphans and vulnerable children (OVC), of whom there were many in the community and who are often malnourished. They also suggested the program target pregnant and lactating mothers (PLM) irrespective of their HIV status. Others commented that groups like the hearing and speech-impaired, blind and psychiatric patients should be automatic beneficiaries of the program whether or not they are on ART/TB. There are usually good reasons for paying particular attention to the concerns of the young, not least of which is they frequently comprise a large proportion of a target population. During an FGD with children and youths on ART, they clearly expressed a feeling of being neglected by society and the donor community, and that corruption in their communities contributed to their being sidelined. This may have been a more general concern for youths and not related specifically to the SPLASH program which actually targets through clinics rather than a community-based system. FGs of children and youths also recommended the programme include activities such as vocational and life skills trainings, camps and outings. While it is not clear how much of the comments are actually related to SPLASH and much they merely reflect broader concerns that youth have, it is clear that they feel a need to have their concerns heard by government and support agencies. While defining the target group is important, the strategy for reaching them often requires additional effort on the part of national and international actors, particularly for more marginalized individuals. In the case of HIV, those most in need of treatment and intervention may be unlikely to seek it either because of the fear of disclosure and stigma or because they are unaware of programs from which they could benefit. Thus, providing assistance to those already diagnosed and undergoing treatment does not ensure that those in great need of assistance are also being targeted. Currently, the mandate of SPLASH in Zimbabwe does not include direct involvement in the outreach and recruitment of those who have not yet been tested. The national health system and other development actors are undertaking HIV awareness-raising and testing and encouraging malnourished target groups to come to clinics, at which point they can become incorporated into SPLASH. It is important to take this clinic-based focus into account when analyzing the program, and there is merit in this delineation of responsibilities. However, it is also important for WFP and partners to be aware of the “upstream” dynamics of how the potential target group can become SPLASH clients, and how their upstream experience may influence their experience once they get onto SPLASH. Also, if the number of clients has fallen in a given clinic catchment, and it is believed that there are potential target group members who are unserved within that area, then it may become a higher priority in future to try to reach those people who have not yet become registered in clinics. This should be discussed among government organizations and partner agencies to monitor whether greater efforts at community outreach becomes necessary or possible, and who would be in a position to work on this. Any possible involvement of WFP in community outreach will necessarily depend on factors such as the changing resource base and estimates of the number of potential target groups not yet tested.

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Even among those already tested, not all will be eligible for ART interventions nor prioritized for the SPLASH programme. At Epworth Clinic, MSF estimated that of some 21,000 total patients, 6,000 had been initiated on ART, and some 10% of these were on SPLASH, while another 10% could be eligible. They also estimated that there were other patients at satellite clinics who were not registering because of a lack of awareness of the program. In Parirenyatwa, staff pointed out that some who test HIV-positive do not immediately come for specialist examination and ART treatment, resulting in avoidable delays obtaining nutritional support through WFP’s SPLASH program. Obviously, there are potential target group members in the system who have not yet accessed SPLASH services. Of course, it is important to bear in mind that given the BMI criteria for SPLASH (BMI<18.5), the number of ART and TB patients who qualify may be relatively low. While there were thousands enrolled in earlier phases of NSART and SPLASH (i.e., before March, 2011), the strict application of BMI criteria beginning in March led to a significant reduction in caseload. This is positive in that food assistance is being prioritized for those who are truly malnourished. As suggested by some hospital staff, the number of cases of patients with low BMI is in fact relatively low; staff cited an average of approximately 18 individuals from a total of 300 per day.

4.2.2 Screening and Registration

Once patients have been tested and confirmed as infected with HIV or TB, they are then assessed in a clinic for their eligibility for ART medications. Eligibility for ART intervention is determined by having a CD4 count above 350, or when patients have met the indicators as set by the WHO staging system for HIV disease. Once on ART – and in some cases before – they may be referred for possible inclusion in SPLASH. Currently, this is done by the WFP field officer who ensures patients have a valid BMI measurement before initiating registration. This section describes in detail the main procedures followed while noting significant differences in practices before and after March, 2011, when WFP took over program management from Christian Care. The first point of contact a patient generally has in a clinic or hospital is the HIV testing unit or other ward that tests for HIV and TB. Testing is often done when patients access other medical services, such as ante-natal care. Many patients are referred from medical centres throughout the city, including 12 polyclinics and 12 satellite clinics. As noted by staff, most patients are quite ill when they come for testing and are often carried by relatives. Thus, it is important that treatment and nutrition support are readily available and initiated quickly. Cases of HIV and TB are referred to infectious disease clinics and units at the city’s main hospitals where they are registered with the nursing staff, consult with doctors, begin counselling, and can be put on appropriate medication. It is here that their contact with the SPLASH program begins. Screening for SPLASH is done at seven clinics in Harare: Harare Central, Parirenyatwa, Epworth, Newlands, Beatrice, Wilkins, and the University of Zimbabwe Medical School Clinical Research Centre (UZCRC). Patients are generally referred by the nursing (and counselling) staff to WFP for potential registration in SPLASH. Screening criteria include:

• BMI less than 18.5 for ART and ART/TB patients, the primary target group

• MUAC reading of 23 or less for pregnant and lactating women

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• Children 6-18 years old with a BMI 2-3 standard deviations below the reference BMI for age are eligible for SPLASH supplementary feeding; those with BMI 4 standard deviations below the reference BMI for age are eligible for Plumpy Nut where available

Clinic staff play a crucial role in identifying and screening those who are particularly vulnerable and undernourished. The screening process involves taking weight and height measurements that are entered into the patient’s log book. The patient then brings their clinic card/file (or log book) to the WFP desk where they are confirmed for registration if their BMI is under 18.5 (unless other anthropometric measurements are used). Registration is then done immediately. The high caseload and other issues at Parirenyatwa Clinic has meant staff are unable to guarantee anthropometric measurements are taken with the result that they were referring high numbers of potential SPLASH participants to WFP for screening rather than screening patients themselves. WFP staff are located at the four Voucher Distribution Points (VDP) that are the remote management centres for the SPLASH program: Harare Central, Parirenyatwa, Epworth and Newlands clinics. Patients screened at Beatrice Clinic are referred to Harare Central and patients screened at Wilkins and UZCRC are referred to Parirenyatwa. Thus, while high volumes of patients are processed at Beatrice and Wilkins, the lack of onsite VDPs there creates challenges for patients for whom it is difficult to get to Harare and Parirenyatwa hospitals (often due to lack of transportation or simply being too sick) in order to register and receive their vouchers. A substantial number of those who could qualify for the program are thought to be unable to go to a VDP because of transportation problems. After several years of management of NSART and then SPLASH by Christian Care, WFP started direct implementation of SPLASH in April, 2011 and managing registration at the four centres rather than at all seven clinics where screening is done. They were able to more strictly adhere to selection criteria and largely as a result, SPLASH registrations were substantially reduced. This translated into a smaller caseload for SPLASH. Registration is greatly facilitated through online registration and allows beneficiaries to instantly qualify to receive CSB through the VDPs and procure household rations from retailers. This has greatly reduced patients’ travel costs and waiting time, but the central challenge for clients now seems to be that they must travel to the centralized WFP registration desks and VDPs (and retail outlets). For one group of beneficiaries in Epworth, the fear of disclosure prompted them to be treated at Harare and Parirenyatwa, state hospitals distant to their homes and involving transportation costs. Despite the added costs, these patients chose to be treated there rather than at their local clinics for fear of meeting neighbours or friends. However, upon learning about SPLASH services, which they believed to be available only at Epworth, they underwent registration in Epworth and began treatment there; they would rather have had their HIV status revealed than to starve. Of note is that possible receipt of a food ration was not the primarily factor that led them to be tested but was sufficient motivation for overcoming their fear of stigma. Overall, respondents had fairly high levels of satisfaction with the process of referral and registration (Table 40). Among current beneficiaries, 74.4% are very satisfied and only 1.6% dissatisfied. Among former beneficiaries, 47.8% are very satisfied and 16.1% dissatisfied.

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Table 37: Level of satisfaction with referral process to register in

SPLASH, by beneficiary status

% Current Former Total

Very satisfied 74.4 47.8 63.3

Satisfied 24.0 36.0 29.1

Unsatisfied 1.6 16.1 7.7

n 258 186 444

This high level of satisfaction for current beneficiaries may reflect an improvement in the way that the referral and registration is handled now compared to its management prior to March, 2011. At the very least, these findings suggest there is no particular concern with the system at present. In general, it is clear that the clinics are under tremendous pressure from large patient caseloads, are generally understaffed, and with staff who work long hours for relatively low incomes. It was perceived by some survey respondents that clinics varied in their effectiveness at registering patients. In general, the private Newlands clinic and NGO-run Epworth clinic were better-equipped, followed by the large hospitals run by the Harare City Council, Beatrice and Wilkins. The state hospitals, Harare Central and Parirenyatwa, seemed to have the most congestion and most difficult conditions. These observations were broadly confirmed during FGDs.

4.2.3 BMI measurement as criteria

Anthropometric measurements have been taken as part of NSART/SPLASH from the beginning of the program though procedures and their relative importance have changed in recent months. Clinics are equipped with the appropriate instrumentation for BMI measurement, which should be officially entered into patient logbooks (referred to as OI cards) at every visit. Unfortunately, this is often not the case. There were cases reported in which BMI had not being taken or explained adequately to clients. Thus, the utility of BMI as the objective standard for entry and exit from SPLASH is compromised. Respondents in one FGD related that when they were enrolled in March, 2011, they were informed that the program would only last three months and their weights were not accurately recorded. For example, the logbook for one client showed her initial weight (recorded in March, 2011) and her weight at discharge (recorded in June, 2011) to be 45 kg. The recorded BMI of another client indicated she was still malnourished (BMI < 18.5) when discharged after three months on the program. In the earlier phases of NSART, ART and TB patients were primarily enrolled automatically, with very little emphasis on screening based on anthropometric indicators. According to the vulnerability screening done by Christian Care, the vast majority of clients were deemed vulnerable and therefore qualified for the household ration. Currently, BMI is measured to determine the patient’s eligibility to register for CSB rations. A second criteria, MUAC, is used

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in the case of pregnant and lactating mothers. As mentioned above, the strict application of BMI screening had substantially reduced the numbers of eligible clientele. Many program partners expressed concern over the extensive reliance on BMI as the factor used to determine eligibility, i.e., to include or exclude patients from the program. Health clinic staff expressed concern that other considerations, such as a comprehensive analysis (including poverty assessment and psycho-social analysis) of clients, be included in the determination of eligibility for SPLASH. Hospital staff went so far as to suggest use of clinicians at the WFP registration desk in order to conduct such assessments. Medical objections to the sole use of BMI in determining both eligibility and criteria for graduation from the program were also raised. For example, weight can vary daily and does not necessarily provide a good reflection of nutritional status on a given day. Additionally, one respondent argued that a BMI of 18.5 is low for the average African and it may therefore need to be increasedto 19 or 19.5. WFP points out however that this is the international standard set by WHO and is the national threshold set by the Government of Zimbabwe. Other suggestions included combining BMI with other assessment methods, such as door-to-door household assessments currently being used by Mashambanzou Care Trust. Part of the concern regarding BMI may be related to changes in involvement of clinic staff in determining eligibility. Before April, BMI was not the sole factor in determining eligibility; clinic staff were involved in the process. After the transition in March, 2011 to using BMI as a strict criteria for eligibility, clinic staff no longer felt their assessments were valued. Hospital and clinic staff often have personal relationships with clients and like to feel they are able to help. The introduction of strict adherence to BMI may have made them feel powerless and extraneous. Change is often difficult, particularly if “dictated from above.”Additionally, nurses who would strictly apply BMI criteria may incur the wrath of potential patients denied eligibility, particularly of patients who are friends. Some clinic staff expressed that this was a difficult position for them to be in. This change in procedure also requires ensuring that anthropometric measures are taken, though this is a requirement for medical staff whether or not an additional program required it. If the staff were not actually following this procedure, this could create an additional work burden for clinic staff. Use of a single, fairly simple indicator might prove effective and easier to use than other types of assessments. However, difficulties obtaining accurate measurements remain, particularly at Parirenyatwa. As a result, WFP staff members located at the VDP are equipped with electronic scales and are taking the only weight measurements currently being used; height still needs to be measured by clinic staff. WFP staff at other clinics also have scales, though this is partly to confirm the measurements taken by the clinics. Frontline workers are also in the unenviable position of knowing first-hand the degree of need that exists compared to available resources and the programmatic necessity of trying to make the most effective use of limited resources. From their position on the frontlines, it is difficult not to have a different perspective on approach and use of resources. For example, a Sister-in-Charge asked, “Do we have to wait for someone to get wasted so that we give her/him food.” Her perspective suggests first-hand knowledge of the likelihood a given individual is going to

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become malnourished and that by providing resources sooner than a strict eligibility requirement might allow for, such an outcome could be prevented. However, the SPLASH program is designed to intervene in cases of malnourished ART/TB patients and their vulnerable households rather than as a preventive program to reach beyond those already confirmed as being malnourished. Ultimately, WFP considers it untenable to give more discretionary power to clinic staff to qualify patients for the SPLASH program. This is a common trade-off. On the one hand it is recognized that clinic staff are well positioned to identify beneficiaries. On the other hand, such an approach could be subject to abuse, confusion and allegations of unfairness. WFP considers BMI to represent a reliable, clinical definition of malnutrition. Experienced health staff recommend a slightly different approach and suggest some medical basis for their objections. For example, the CDC states that while BMI can be used to screen for obesity or underweight, it is not a diagnostic tool. To determine whether a patient is clinically malnourished, further assessments would need to be conducted by a health care provider, including evaluations of diet, family history, etc14. This reviewer is not a nutritionist and cannot make judgments on the adequacy of assessment procedures. In view of the almost universal feedback from partners regarding BMI, however, it seems apparent that WFP Zimbabwe should at least present a clear analysis and justification for why and how it is using BMI. Additionally, the use of BMI for children with ART is potentially very problematic and fraught with misunderstanding or inconsistencies. For example, participants in one FGD perceived that some children on ART were being excluded from the program because of BMI restrictions; youths felt that the BMI requirement disadvantaged them. The literature15 discusses complications related to cut-offs for children and it is not clear that SPLASH has set up standards recognizing the complications related to growth curves, let alone adequately explained this to partners. Harmonization of standards on moderately and severely malnourished clients was a subject of concern raised by a number of respondents. Anyone with a BMI under 18.5 is now registered in SPLASH but there is not a universally-applied definition for the severely malnourished, who should receive a different nutritional regime. With no viable alternatives for treating severely malnourished patients, Plumpy Nut was prescribed as therapeutic feeding when available (especially at Epworth). Ultimately, strict application of BMI criteria is leading to an overall reduction in the number of clients registered for SPLASH. It is unclear, however, whether the number of new clients is greater than the number being discharged.

14 CDC. 2011. About BMI for children and teens. http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html#What%20is%20BMI. Accessed on Oct 24 2011. 15 See for example: Cole, T., K. Flegal, D. Nicholls, A. Jackson. 2007. Body mass index cut offs to define thinness in children and adolescents: international survey. BMJ 335:194. http://www.bmj.com/content/335/7612/194.full. Accessed Oct 24 2011.

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4.2.4 Vulnerability screening for household rations

In addition to the use of BMI criteria, WFP carefully scrutinizes its screening procedure for determining household vulnerability. Previously, Christian Care essentially confirmed that all beneficiaries should also qualify for household rations. Though some home visits were taking place to verify these vulnerability assessments, they were only done during Post-Distribution Monitoring (PDM), not prior to distribution. Additionally, though the questionnaires utilized during home visits were stored, the data was not entered into computers, which limited the potential analysis which could be done. Quantitative data clearly show that beneficiaries are not uniformly vulnerable but that at least some proportion of households are less able than others to provide for their basic needs. WFP should consider expanding its focus to reach more vulnerable households than those it is currently reaching, who may not represent the most vulnerable. Revised SPLASH procedures now include entry of BMI measurements upon registration as well as each month. This represents a potentially significant improvement in monitoring and evaluation, though it remains to be worked out how the vulnerability screening data will be used in conjunction with this.

4.2.5 Monthly Clinic Visits

The SPLASH supplementary feeding for ART, TB and pre-ART patients provides nutritional support to directly assist recovery and is also a form of incentive and condition for them to adhere to their medication. Specifically, provision of supplemental food encourages patients to attend clinics for regular checkups, receive their medications, and verification they are taking their medicines between visits. Patients generally come into the OI for medical revision on a monthly or bi-monthly basis, depending on the details of their treatment and consultation regime. WFP requires that patients’ weight measurements are taken in conjunction with the monthly issuance of CSB rations and vouchers for household rations. The packaging of food with medication and checkups reinforces health-enhancing behaviours such as adherence and combined smoothly with the disbursal of food rations via retailers. Monthly visits involved counselling and medical sessions, during which the patient’s weight should have been measured. Patients would then submit their measurements to the WFP desk in order for the information to be recorded into a tracking spreadsheet. Review of the tracking spreadsheet reveals that weight measurements were often missing, and SPLASH program staff have been probing the reasons for this Once this step was complete, clients were given a blue slip to present at the Voucher Distribution Point, where they were given a voucher and bag of CSB by a representative of Redan Mobile Transactions. Because clients are often quite sick, particularly during the first several months, and because the VDPs were often quite distant from clients’ homes, it was apparent that patients themselves were not coming to the clinic to collect their rations. Instead, it was common for other family members to come. The program had provided for such eventualities by allowing clients to visit a clinic near their homes in order to get a doctor’s note and associated weight measurements, which should then be entered into the database.

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Monthly visits also included participation in counselling sessions and nutrition classes. Some of the FGD participants and key informants spoke of the importance of understanding patients in a holistic sense, i.e., their recovery depended not only on taking medicine and consuming nutritious foods but also on gaining new knowledge and dealing with a range of psycho-social and cultural issues. SPLASH aimed to influence programme participants by increasing their participation in nutrition and counselling sessions, and to generally promote a stronger and more effective relationship between clinics and beneficiaries. An emphasis was placed on readily available and low-cost ingredients, to offset a feeling of helplessness that people often have, in which they perceive that no nutritional improvements can be made unless they are given food or money. Comments from beneficiaries at a number of clinics confirm the importance of these educational sessions. Morning nutrition sessions are held as part of the counselling sessions, where they learn about preparing food, balanced diets, traditional foods, and positive living with HIV/AIDS. These sessions help patients maintain a healthy body and to check on other possible ailments. For OI clients, dieticians schedule clinic visits twice per week, during which they offer nutrition counselling on food safety, exercise, and ailments such as diarrhoea that hinder food consumption. FGD participants viewed these morning group sessions as the central vehicle for conveying nutrition awareness and education to the community. These sessions are comprehensive and include counselling on early treatment of opportunistic infections, disclosure of one’s status, and dealing with family conflict, all with the aim of helping to prepare the clients for healthy living. Educational modules such as ART 1 and Basic 1 introduce patients to the types of drugs involved with their treatment, provide information on the interrelatedness of nutrition and drug adherence, and teach that healthy food is locally available such as tsunga (green vegetables), mufushwa (dried vegetables) and maheu (drink made from cereals).

4.2.6 Monitoring, Discharges and Reactivations

Beneficiary lists are kept by each clinic, mainly in the form of a “Splash Card” or tracker form. The information is not completely uniform, and discharges and reactivations are not consistent in that some registration desks use colour-coding without providing keys. Currently, there is no systematic way to track the number of people re-registering or to use this information for management purposes. Typically, weight and BMI are tracked though some clinics also track MUAC; age is not maintained in the database. There is not a streamlined presentation of total beneficiaries per month, discharges, or reactivations. The total number of beneficiaries is not available or maintained, though it was possible to come up with an estimate of some 18,000 total beneficiaries from August, 2010 to June, 2011. Limited human resources available to track such information during this pilot resulted in the loss of much useful data that will be critically important for future monitoring, evaluation and reporting. SPLASH clients are removed from the beneficiary list after either having “improved nutritional status” (i.e., BMI > 18.5 and weight gain for two consecutive months) or having been in the program for six months. How beneficiaries are terminated from the program impacts the overall perceived success of the SPLASH experience for the client and others. SPLASH provides an option for clients to be reactivated in the program, a feature that might require reconsideration.

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4.2.6.1 Discharges

Beneficiaries are discharged from the SPLASH program as a result of one of two developments. First, they will be discharged when their weight has increased such that their BMI is over 18.5 and they have shown a weight increase for two consecutive months. For children, youths, and pregnant and lactating mothers, the same requirements presumably prevail, i.e., they will be discharged after two consecutive months of “normal” weight measurements. Beneficiaries will automatically be discharged after six months regardless of whether their nutritional status has changed or not. FDGs and interviews frequently revealed dissatisfaction with the way in which beneficiaries were discharged from the program. To a considerable extent, this was due to the transition during the last year to a more tightly-targeted program. Due to an application of screening, there were some 5,286 beneficiaries as of August 2010, including many people who were not malnourished. Once the program began to screen by nutritional status, there was a gradual weaning out of this group such that by March, 2011 (when WFP took over direct management), all of these clients had been discharged. Since that time, the monthly caseload has been close to 2,000, with fairly consistent balancing of discharges and new registrations or re-registrations. The group of beneficiaries who had been registered at a time when anthropometric measurements were not a significant requirement would obviously find it difficult to face a stricter application of rules that caused them to lose the benefit of their food rations. For some participants, discharges appeared to be taking place without a great deal of warning or explanation; they were neither aware that discharges were based on anthropometric measurements nor that six months was the limit for enrollment. Other beneficiaries, however, understood that weight gains were the chief discharge indicator. Clearly the difference in discharge approach between Christian Care and WFP was a source of confusion and consternation. It was not apparent that WFP registration desks had a systematic approach for explaining the process to beneficiaries. In one FGD, participants were divided on whether they had been informed from the beginning of the program if and how they were going to be discharged at some point. Four respondents were adamant about being led to believe that Christian Care would provide them with food for as long as they lived. The remaining four indicated that they had been informed from the beginning they would ultimately be discharged to pave way for other patients as well. The discharge is a difficult period in which confusion on the part of some patients may interfere with others’ ability to access services. Although some beneficiaries may exaggerate their confusion with the hope of extending their duration in the program, it is in everyone’s best interest to make available information that is clear and concise, and with signed agreements in order to minimize confusion and disillusionment. An important consideration regarding the discharge process might be to include it as an integrated part of the intervention in order to help people plan and prepare for the discontinuation of food rations. Leaving the program should not constitute a shock, of which numerous beneficiaries and partners spoke. It was suggested in FGDs that clients be notified one month in advance to enable them to plan ahead. This seemed particularly important to FG participants given that SPLASH does not offer any post-program sustainability supports.

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Other issues FGD participants noted involved family dynamics. Prior to enrolment in the SPLASH program, individuals who ultimately became beneficiaries were viewed as dependent on other family members for support. Once they were enrolled and receiving food rations, they were seen as “breadwinners” and were proud to be able to tell relatives they would no longer need support. After being discharged, sometimes suddenly, they were compelled to ask for help again, prompting relatives to consider them as liars. For some, feelings related to stigma resulted from discontinuation of the ration, or at least for those not prepared or aware it would be discontinued. There were also family conflicts over food, often exacerbated by the suddenness of the discharge. Although most beneficiaries indicated awareness that the food ration was temporary, the importance of preparing people from the beginning for their ultimate discharge is highlighted by these FGDs. Some health professionals again maintained that discharge not be based on a narrowly focused indicator (as is the case for registration) but rather on a case by case basis. Individuals respond differently to ART. MSF suggested that an exchange of information and ideas around the discharge process was important. It was also suggested that the food ration could be scaled down for patients who have gained weight rather than remove them from the program completely. In particular, this might help to reduce stress-related infections at the time of discharge.

4.2.6.2 Reactivations/ Relapse

After a beneficiary has been discharged, they may become reactivated (re-registered) into the program for a second (or more) cycle. Sometimes referred to as “relapse”, reactivation recognizes that an individual may become malnourished again and as such can re-qualify for enrolment in SPLASH. WFP acknowledges that some people will not attain a satisfactory nutritional status within six months but simply requires that such cases go back through the medical referral process. This is important in terms of checking for medical complications that could be responsible for preventing an individual’s recovery, but is also probably helpful in preventing re-registrations from seeming so routine that the majority of beneficiaries would seek to re-register. There is not a fixed rule for the circumstances under which reactivations would be allowed other than the current focus on those with BMI below 18.5. There is no consistent way of monitoring the number of reactivations within the current beneficiary database. For example, it is only possible to determine that in June, Harare clinic had only 51 beneficiaries registered as reactivations compared to 654 active beneficiaries. Arguably, it might be a concern if a large proportion of beneficiaries had been reactivated because it might imply that many former beneficiaries were “relapsing” (not recovering as anticipated). It might also suggest that the benefits of SPLASH were only reaching a small group of the same individuals. According to the quantitative survey data, those who have been through the system more recently spend fewer cycles and months on SPLASH compared with those who were registered earlier. This is consistent with the renewed emphasis on malnutrition screening. As previously discussed, 16.2% of current beneficiaries were in their second cycle compared with 23.7% of former beneficiaries. In addition, 34.3% of former beneficiaries had spent seven or more months in the SPLASH program while only 7.2% of current beneficiaries had done likewise. While the two groups are not strictly comparable in a statistical sense (as the current

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beneficiaries may yet spend more months and more cycles on SPLASH), it is probably a positive sign that only 16.2% of current beneficiaries are in their second cycle. It is hard to know how this percentage might change in the coming months. On the one hand, it may rise because those who were registered early in 2011 - particularly from March onwards - were generally malnourished and may be more likely to require a second cycle than those who were registered in 2010 when malnutrition was not enforced as a criteria for registration into the programme. On the other hand, stricter application of BMI criteria for re-registration may reduce the spurious cases of inclusion and therefore lead to fewer reactivations.

4.3 The Voucher and Retailer System

As the most notable and distinctive feature of SPLASH, the voucher system is treated separately here to provide in-depth analysis of the system’s implications for the effectiveness of the programme and its impact on each partner. This section focuses on the way that the electronic voucher system specifically affected different stakeholders rather than general comments about the broad features of SPLASH.

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4.3.1 Concept of vouchers

SPLASH is in some ways a straightforward food safety-net programme for the familiar target groups of ART and TB patients, incorporating a food for nutrition and health education component; the difference between this programme and traditional assistance programmes is that rather than distribute food directly, the SPLASH program employed a voucher system and

Figure 18: Summary of Voucher Implications for SPLASH Implementing Partners and Beneficiaries World Food Programme - Larger number of contracts with smaller-volume suppliers - Suppliers are also transporters and distributors - Still procures CSB, to hand over to RMT for distribution - Less involvement in direct oversight of food distribution - Can digitally tie a cash amount to an NRC Retailers - Have large contract to deliver to a guaranteed clientele - Competition is shaped differently: potential for competition to get contract with WFP/RMT, limited competition among designated retailers - Vouchers are redeemed like cash but slightly more complicated, akin to a credit or debit card payment - Vouchers are usable for certain products only - Primary responsibility for ensuring food quality - Becomes an important “face” of the program to beneficiaries - Need to be skilled in dealing with particular needs of clientele (ART & TB patients) Clinics - Don’t carry out bulk food distribution, unlike some of the previous approaches - Potentially could do more sophisticated targeting Electronic Service Provider - It is a private company that takes responsibility for management of supply chain, indirectly by overseeing retailers - Ensures database and online system of electronic transactions Beneficiaries - After initiating treatment, can register for program and leave the clinic already with voucher and potentially CSB in hand - Pick up food at retailer in a natural setting - Dignity/empowerment associated with getting food from store - Still no choice in terms of ration - Have a choice when to pick up vouchers

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utilized local retailers. The vouchers approach is definitely new and has certain implications for the programme, to be discussed below. The elaboration of an effective management system for a new implementation modality is anything but simple; the delivery mechanism for food distribution programmes is of central importance. SPLASH was both a food programme and a cash programme. It was a food programme in the sense that it provided a voucher scratch card to be used for specific food items redeemable only at designated locations. The voucher functions as currency, i.e., as a substitute for cash. This was seen by beneficiaries as conferring a sense of status or dignity in terms of receiving food supplies from a retail outlet rather than from a clinic warehouse. Paper vouchers have been used in food assistance programs around the world for years but managers are still somewhat bound to use time-consuming control mechanisms like beneficiary lists at the time of food distribution. In contrast, the electronic vouchers allowed more timely payments and less hassle for retailers. The e-vouchers are scratch cards similar to a cell phone “talk time” card; the identifier code on the card is entered online through cell phones or laptops with internet “dongles” along with the beneficiary’s National Registration Card (NRC), uniquely linked to the e-voucher card. Once this information is as entered and the ration issued by the retailer, the payment is made instantaneously to the retailer’s RMT account and the retailer then transfers the funds to their bank account.

4.3.2 Issuance of vouchers

The food rations (including the supplementary and household rations) are transferred through the use of a commodity voucher that is a scratch card providing coded information needed to effect the online authorization of the food disbursal. Every month a single-use scratch card is given to each beneficiary at one of four Voucher Distribution Points (VDPs): Harare Central, Parirenyatwa, Epworth and Newlands Clinics. The transition to vouchers and a need for greater control over screening led to centralizing SPLASH management at these four locations from the seven previous registration points used by Christian Care in NSART. This seemed illogical to some FGD participants; they didn’t understand why VDPs were only found at state hospitals like Harare and Parirenyatwa when there are large numbers of beneficiaries at city hospitals like Beatrice. VDPs are run by RMT from containers located near the Opportunistic Infection Disease Clinics within each clinic, with the exception of Newlands, which is run by a staff member of the clinic. Having RMT perform this function separates responsibility and provides a measure of security. Patients coming in for their medical check-up and anthropometric measurements typically then proceed to the WFP registration desk where their weight is entered (weight is sometimes also taken at the registration desk). On WFP’s approval that the weight measurement is satisfactorily entered, the patient can then proceed to the VDP to receive their voucher. Along with a blue slip from WFP that shows their monthly weight has been entered, patients are required to bring their national registration card or patient ID card from the clinic as proof of identify. RMT staff at the VDP enters this ID number along with an identifier on the voucher confirming that the individual is registered to receive a voucher and then restricts that voucher to be used only by the

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designated individual. After scratching the space on the card to obtain the code for the supplementary ration, a separate RMT employee then gives out the 10 kg bag of CSB. Two minor issues were observed at the VDP. The procedure for disbursement of food rations at the VDP involves scratching and entering a code that confirms the individual may receive the household ration. This step does not seem particularly relevant at the VDP itself, as the household ration must be obtained at the retailer and not the VDP. A possible explanation could be that the individual might not be certain what ration was available to them and thus might not be sure they should go to the retailer. On the other hand, there may be advantages to limiting access to household ration information by the VDP. A second issue involves clients requesting vouchers without their designated ID card (e.g., they had left it at home). This turns out to be a fairly common occurrence and shows consideration on the part of VDP staff for clients who are unwell, have difficulties travelling to their homes and are often not living in the most stable of circumstances. However, it opens the system to abuse in which individuals other than the designated beneficiary could obtain food rations. Unfortunately, there seems to be no formal way of recording these occurrences or following up on them. Similar arrangements are probably in place for situations in which the SPLASH client is unwell, and sends someone to receive the voucher and rations in their stead, but again there should be some control on such situations. The SPLASH program regulations require that if the patient is unwell, s/he should have their weight recorded in their patient book and sent in with a doctor’s note. Aside from these minor concerns, there appeared to be no significant reports of misuse of the vouchers, other than some cases of vouchers having been lost. A few reports of voucher theft had occurred but these had not been brought in for redemption. Online registration permits screening, registration, voucher issuance and food ration access all at one time. This reduces patients’ travel costs and waiting time considerably, and alleviates stress they may encounter at a time when they are unwell. It was observed during the survey and noted in project reports that some registered beneficiaries failed to show up in a given month for their voucher and rations. The failure of current beneficiaries who were randomly selected from the beneficiary list to come to the clinics for their food rations (any time during the month) significantly reduced the survey sample size. This raises several questions, such as whether clients face significant obstacles coming to the clinics and VDPs and whether the rations and medications are insufficiently attractive motivators relative to the time and money needed to come to a clinic or VDP centre. Ultimately, it will be difficult for patients to make progress if they are not receiving their food ration each month and are potentially at risk of defaulting on their medication if they are not making regular visitations to their clinic as agreed. According to WFP progress reports, in April, 2011 WFP expected 4,598 beneficiaries where only 3,011 (65%) actually showed up at registration sites. In May the percentage was the same, with 2,933 beneficiaries out of the 4,500 expected. WFP identified several contributing factors for the no-shows, including their own strict application of the anthropometrics as selection criteria and requirement for monthly voucher receipt. In some cases, health staff at registration

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clinics (especially at Harare and Parirenyatwa) were reluctant to take anthropometric measurements for clients who had been referred from other hospitals simply because it was extra work for them. As a result, beneficiaries were sent back to their respective clinics. For example, a patient based at Wilkins Clinic could be referred to the Harare Clinic VDP where, for one reason or another, the nurses at Harare were not able to measure the client’s weight. These clients then failed to return to Wilkins in order to have their anthropometric measurements taken due to lack of money for transportation costs. Also, clients who required bi-monthly drug supplies reportedly found it difficult to get their weight measured except on the review date indicated on their cards. It may be a concern for WFP if the numbers of vouchers issued each month is significantly higher than the registered beneficiaries who actually show up for the vouchers. Having many unclaimed vouchers could be a security risk, which should be minimized whenever possible. The number of vouchers to issue has been determined through on an extrapolation from the number printed or issued in the previous month. It would be better to use actual vouchers issued rather than those printed, but this doesn’t seem to have been case in April-May (as mentioned above). During the earlier phase (with beneficiaries continuing to May 2011, for example), this projection of likely beneficiaries seems to have been challenging. The advantage of vouchers in this situation was that there is relatively little cost in overestimating beneficiary numbers, at least for the program; the potential costs accrue to the retail outlets who may find themselves overstocked, but they still are able to sell this stock to other customers. By July 2011 the number of beneficiaries registered – and for whom vouchers were issued - was much lower, close to 2000. There were still quite a few no-shows, but on a lower scale than previously. Apparently the tighter management of targeting is helping generate a more reliable projection of beneficiaries.

4.3.3 Beneficiaries: voucher redemption experience

The way that beneficiaries experience the voucher modality should be a central factor for reflection on the effectiveness of SPLASH. Respondents to the quantitative survey overwhelmingly felt that that there was an advantage to the voucher scheme (Table 41), though this opinion was slightly more prevalent among the current beneficiaries.

Table 38. Advantages to the SPLASH voucher system, by beneficiary status

% Current Former Total

% of respondents that feel there is an advantage to the SPLASH voucher system

90.3 83.0* 87.2

259 188 447

Type of advantages

Empowered to buy through local food suppliers 32.1 35.3 33.3

Flexibility of timeframe to pick up of food 61.5 52.6 57.9

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More convenient pick up points 65.8 54.5* 61.3

Reduces congestion at clinic 42.3 50.0 45.4

Flexibility on choice of food 17.9 13.5 16.2

More secure for beneficiaries 26.9 26.3 26.7

There is more confidentiality/less stigma 13.2 7.7 11.0

The arrangements are more dignified 16.7 17.9 17.2

Accuracy of ration measurements because there is no scooping involved

29.5 42.9* 34.9

n 234 156 390

*Significantly different at p< .05

Some participants perceived the vouchers to be associated with the tighter screening process initiated after WFP began managing the program. For example, former participants enrolled when Christian Care managed the program saw the voucher system as a way to systematically discharge patients from the programme. Accordingly, they considered that the previous modality was fair and asserted that food distribution conducted ward by ward (as done under the prior system) prevented congestion or long waits. Convenient pick-up points: The cost and time involved in monthly travel are important in determining the optimal arrangements for beneficiaries and should be analyzed in terms of their impact on medical checkups as well as both voucher and ration receipts. ART/TB clients are registered for medical care at either the main VDP clinics (Harare Central Clinic, Parirenyatwa, Epworth and Newlands Clinics) or at other OI clinics including Beatrice, Wilkins and UZCRC though their clinic of origin might be a smaller satellite clinic closer to their home. Their monthly checkups are handled at one of the OI clinics, where they are expected to obtain anthropometric measurements but then must go to the VDPs for vouchers and to submit their anthropometric data to the WFP desk. Feedback from participants suggested they would prefer VDPs in more locations, i.e., the seven locations. Some degree of centralization is likely necessary given the CSB and voucher distribution. While the vouchers and CSB are given out directly from the VDP containers at the four main clinics, the household ration must be accessed at participating retailers. Pick-up of the household ration is probably the most important in terms of accessibility because this ration is the heaviest and often requires clients to enlist the aid of a friend or family member or to pay for transport; during field visits, clients were observed putting the CSB bags inside smaller bags that at least some clients were able to carry. Compared to system in which household rations are distributed by clinics (however likely that might be), the voucher system adds an additional trip for beneficiaries. After making the trip to their clinic of registration and then to a VDP, beneficiaries must travel to one of the designated retailers in order to receive their household rations (e.g., OK Mbare, OK Julius Nyerere, Bonne Marche Eastlea and African Wholesalers Epworth). Retailers designated to handle SPLASH transactions are located in different sections of the city, such as in commercial areas where it may be easier for beneficiaries to arrange transport if needed. Clients

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at Epworth may obtain their food from a retailer located beside the main clinic, vastly simplifying the process for these clients. Apparently, however, as many as one-fifth of Epworth clients apparently prefer obtaining their rations at a store in Harare, where they may have other business to attend to. In the pilot phase of SPLASH, WFP (through RMT) set up four retailers with the capacity to meet the demands of the program. This model contrasts to that of the SPLASH program in Zambia that worked with many smaller retailers functioning at the neighbourhood level in order to bring food delivery closer to people’s homes. In view of their initial experiences in Zimbabwe, WFP plans to expand the retail chain further, vastly simplifying food distribution for beneficiaries. A number of beneficiaries discussed how important it was to decentralize the retail outlets to different suburbs, thereby reducing transport costs, as they often faced great difficulties carrying their food rations home due to their illness and/or transport costs. Flexibility of time to pick up food: The SPLASH voucher system provides much greater flexibility for beneficiaries in determining when to collect their food rations because the system allows them to come in any time over the course of the month to collect their voucher and provides an additional 30 days in which to redeem it. Redemption of the voucher can be done whenever the retailer is open, making it convenient for beneficiaries. In previous systems, food distribution was done on specific days at certain locations and all potential beneficiaries had to wait in crowded and stressful conditions. Even in the first few months of SPLASH voucher distribution there was a mad scramble of 5,000 beneficiaries making sure they first got their voucher and then lined up at the retailer, until they realized there was more flexibility in the system and could spread themselves out through the month according to what was most convenient to each of them. Operations at the VDPs and retailers are now seen as part of normal daily life and there is no need for queues. Clients feel less self-consciousness about receiving food assistance in an HIV-related program. The 30 day validity period gives beneficiaries flexibility as to when to “purchase” goods with their vouchers. Flexibility in receipt of vouchers and food rations is not simply for convenience. The lack of options for picking up vouchers and rations can keep beneficiaries from receiving necessary food assistance. For example, one beneficiary explained that under the previous modality he had missed the food ration twice because he had to visit his rural homeland during times allocated for food distribution. It was observed during field visits to retail outlets that beneficiaries were obliged to spend some time redeeming their vouchers. The voucher redemption process entails the electronic entry of the voucher in an office where the responsible person issues a signed paper that the beneficiary will then hand to the till operator. The client produces their National Identity Card and their name is entered into a book that s/he signs. Observations on the time required at the till indicated that the process of clearing the SPLASH card took about 10 minutes. In part, this may have been due to temporary network problems. For a number of transactions observed in one store, the timing of the transaction at the till lasted an average of just over two minutes.. The availability and variety of food items at retailers was also observed during field visits and discussed by participants in FGDs. Participants indicated that the household ration food items are

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locally available, not expensive, and generally available, except the 5 kg bags of mealie meal (mealie meal is not currently produced by most suppliers). At Bonne Marche Eastlea for example, three brands of roller (maize) meal were observed (Victoria, Red Seal and Silo), one brand of cooking oil (Sun Star), and three brands of beans (Pro Brands, Victoria, Red Seal). Among the four retailers, a number of participants mentioned that OK Julius Nyerere provided outstanding service and a wider assortment of brands. Several participants had begun collecting their food rations here because of less time spent waiting in line and better availability of different brands. Retailer interactions with beneficiaries are also important and general observations suggested they were satisfactory overall. Staff in some of the stores helped clients by collecting their groceries, pushing their trolley, and helping load bags onto bicycles. Security: SPLASH participants appreciated the effectiveness and security of the voucher system over previous modalities of direct food distribution. Under previous systems involving direct distribution for example, food could not be accounted for at times and responsible officers often corrupt. Use of sealed commercial packages offers more reliable and little possibility of scooping by those involved in delivery. In addition to how abuse of the rations might affect them personally, some beneficiaries were more generally concerned about the system working properly and for the benefit of those in need in of assistance. Many beneficiaries expressed more confidence in the voucher systems and the sense of security it provides. They see it as reducing the likelihood of corruption and theft from the system. Confidentiality and reducing stigma: While some stigma remains regarding food assistance generally, beneficiaries were more concerned about the SPLASH program being identified as for HIV positive individuals. HIV is highly stigmatized in Zimbabwe and therefore one’s status highly guarded. The voucher initiative is fundamentally discreet, as food supplies are procured by retailers as part of their regular order. Beneficiaries receive commercially packaged food items that are indistinguishable from what other customers purchase. Thus, beneficiaries are no longer seen carrying large bags of food printed with WFP, although the fact that they do carry large bags of food often makes them somewhat conspicuous. Given that they could redeem the voucher at any time during the month, beneficiaries were able to blend in and avoid being so visible. The only non-commercial package of food ration they receive is the bag of CSB. WFP procures CSB in Malawi and imports and packages it in Zimbabwe because there are no in-country sources .

4.3.4 Retailers: Capacity and Nature and Impact of SPLASH on Business

In addition to distributing vouchers instead of physical commodities, the most unique feature of SPLASH is its use of local retailers as distributors/procurers. In fact, the two are inseparably linked. Rather than considering SPLASH as piloting the voucher approach, it might be argued that it piloted the local retailer approach, with electronic vouchers as the administrative and contractual means of supporting the role of retailers. Retailers are very important to the SPLASH programme because they represent part of the human face of the program. Their role is to guarantee clients get commodities in the correct quantity and quality, to help clients in choosing brands, help them load their goods, and ensure customer satisfaction. Retailers manage and mitigate complaints from customers, help them overcome stigma and confidently learn to meet

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their needs. In this sense, retailers help empower clients. Along with the clinics, they are part of the social support to HIV/AIDS and TB patients, helping them to meet their needs and supporting their healing and recovery. Retailers were brought into the SPLASH program in July 2010 during its transition from the NSART program previously managed by Christian Care. Redan Mobile Transactions (RMT) was contracted to oversee their recruitment and set up the online transaction system (see 4.3.5). Retailers were distributed generally around Harare and clients had the choice of which outlet to use, including the option to switch outlets at any time. OK Zimbabwe is the main retailer and it is a popular household name, referred to as “the people’s shop.” It is well-stocked with all daily household requirements, are reasonably priced, and the outlets are widely distributed. As a large chain, they have considerable buying power and good inventory control systems, thus, they were typically prepared for 1-2000 beneficiaries and did not require advance notice from the SPLASH programme. They were affected, however, by shortages in Zimbabwe as a whole, such as occurred at times with beans and maize. For at least one small retailer in Harare (brought in at the request of WFP), limited supplies and the need for some forewarning of likely client numbers were of some concern. Inventory forecasts have been somewhat difficult both because clients are not restricted to using only one retailer and because client numbers have been unreliable. This particular supermarket has large floor space and is in excellent condition, but the stock volumes and lack of business activity were evident. During a period of field observations in which seven clients came through the SPLASH desk , the cash desk served only one client. The store seemed to provide a valuable and friendly service by tasking two people to assist SPLASH clients in ferrying their groceries from the shop. There seemed to be a strong bond between many SPLASH clients and shop workers; they could be seen sharing stories while redeeming their vouchers. Recruiting retailers was not straightforward. Despite the large volumes of potential sales through the programme, some retailers had difficulty imagining working with the system. Some shop owners were interested in growing their business but were conservative and nervous about change; the voucher modality involved a number of fundamental changes to existing business models. The technology seemed daunting at first, particularly for older businessmen. In other RMT projects, older businessmen had embraced the system and others who were more comfortable with the technology were brought it. Thus, it ended up being a positive learning experience. Building capacity of the retailers was an important aspect of SPLASH. A three-day workshop was provided for retail staff at the beginning of the program. The voucher system introduced challenges in terms of sales volume, number of clients, and workload. The program increased competition among retailers, which promoted improved customer care. Most retailers viewed the program positively. They felt cooperation among partners was good with RMT visiting once a week and WFP once every two months. One retailer felt that the current level of supervision and assessments by WFP and RMT was adequate; both entities interact with beneficiaries during their visits. Problem-solving was considered fine. In an example of a case of lost vouchers, the shop, RMT and the WFP desk worked together to

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deactivate the lost vouchers and issue new ones. When clients would come without their OI identification or when their vouchers indicated they had not yet redeemed their CSB, shop managers referred to RMT for assistance. The roll out of SPLASH as a new phase of NSART has created the unique situation in which a very large initial customer base was reduced to around 40% of its initial size. At the height of the program, one retail store reported US $8000 in typical SPLASH sales per week and served more than 200 clients per day. At the time of the survey, they were serving an average of 25 clients per day . Peak SPLASH sales for another store were about US$85,000; their current sales volume attributable to SPLASH is around US $18,000 per month. Clearly, this represented a challenge for smaller retailers. Feedback from larger retailers also indicated a need for more information about the likely number of vouchers that would be redeemed in any given month and the required inventory needed to accommodate those numbers. Bonne Marche Eastlea reported that SPLASH participants had unexpectedly stopped procuring their rations at the store in June, 2011; the supervisor and branch manager thought the project had ended. There were several areas in which retailers felt there could be more communication and consultation. In particular, they felt project updates would be beneficial and would help them understand the processes of discharges and scaling down, and how changes would likely impact them. Retailers were also interested in a more in-depth understanding of the program , such as how beneficiaries were selected, for example. One retailer indicated being aware only that low weight was the passport to the program and increased weight would lead to discharge. Retailers faced numerous implementation problems related to factors beyond their control. They had problems stocking the beans and ended up stocking unbranded beans from FAVCO. They often had to try and explain issues related to the programme beyond what they knew. For example, it was part of their responsibility to explain to clients the decreases in the ration size from 10 to 5 kg of mealie meal per person and from 1.5 to 1 kg of beans per person. They also faced numerous queries from clients wanting breakfast meal (refined mealie meal) and other items which are not on the WFP list. Despite these challenges, retailers generally had positive comments about their relationships with beneficiaries. In addition to the challenges resulting from declining numbers of clients and lack of sufficient programme information, retailers commonly mentioned problems accessing the internet in order to redeem vouchers. The voucher system requires that retailers scratch on the space on the card for household vouchers in order to access the code that is entered online alongside the beneficiary’s ID number. The web-based interface allows for real time updating of beneficiary base data as well as beneficiary redemption and retailer reimbursement information, which improves control and provides reporting in a timely manner to WFP. However, this function requires continuous online connectivity. Online entry can be done from a cell phone or computer connected to the internet. The computer interface is convenient and allows for rapid movement from one field to the next but access has been less reliable than cell phone network coverage. There are several service providers in Harare and services are rapidly evolving, but access has been a significant problem during the piloting of SPLASH. The preparation phase was hampered by network problems during which time customers would become impatient. The network is

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sometimes offline, which causes embarrassment to the retailer and clients. Other problems related to maintaining a computer-based system; infection of large servers by viruses often resulted in the system shutting down . These problems are exacerbated by the frequent power cuts affecting Harare. Detailed analysis of the internet problem and the way it evolved is important to a program such as SPLASH. Coverage is very spotty, intermittent, and affects all internet services, not just wireless services. Some partners were more pessimistic than WFP and RMT about the viability of services dependent on internet access. Additional discussions and brainstorming possible solutions may be required. Retailers have already begun trying to address some of the issues and had suggestions for others. For example, some clients have started to call ahead to retail staff before travelling to the store in order to check whether the network is functioning. It was suggested that backup hard copies with all the necessary details be maintained and that information could be electronically updated when the network resumes. Alternately, offline platforms such as cell phone text messages using SMS (Short Message Service) might be considered. The advantage of such platforms is that they operate more efficiently and flexibly without the bandwidth requirements of online systems currently used. The disadvantage of SMS for use in a program such as SPLASH involves its use as a mode of financial system management, which according to RMT is currently a politically difficult area to get involved with. For this reason, RMT has emphasized the online registration approach.

4.3.5 RMT: Role and Impact

This section discusses the role of Redan Mobile Transactions (RMT) as the food distribution service provider for SPLASH, particularly as its database designer and overseer of retail operations. RMT grew out of Redan Petroleum, which was formed in 2004 and has grown into a major retail gasoline and service station chain in Zimbabwe. The company diversified into finding solutions for the food industry in 2006 in response to the lack of food in markets in Zimbabwe. Their main initial intervention was to obtain food baskets that corporations could procure for their employees. RMT also developed voucher-mediated supplies in rural areas for IRD (International Relief and Development) and SDC (Swiss Agency for Development and Cooperation) projects. At that time they were using paper vouchers. Their research into the possibilities of using electronic vouchers led them to Mobile Transactions of Zambia Limited (MTZL). MTZL was setting up an electronic voucher system for WFP in Zambia and the model appeared promising to RMT. Around the same time, WFP Zimbabwe was in the process of commencing an electronic voucher system for a pilot of the NSART program in Harare called SPLASH. The SPLASH pilot in Zimbabwe was modelled on a similar WFP pilot in Zambia. RMT qualified to work with WFP as a sole-source service provider, without a tender process, since they are the only firm involved in this sector in Zimbabwe. RMT adopted MTZL’s Zambia system to set up its voucher database in Zimbabwe and has signed a formal agreement with MTZL to use its system for a fee. The operating system is provided with service support by MTZL and RMT runs the system in partnership with WFP Zimbabwe. WFP Zambia has also helped support the system setup.

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RMT was working with WFP from early 2010, in preparation for the eventual adoption of the voucher system in August 2010, at which time WFP took over management of the database from Christian Care. As the distribution service provider, RMT distributes the scratch-card voucher according to updated lists of registered beneficiaries compiled from WFP desks at each of the four clinics. RMT then procures and distributes the supplementary rations. RMT also identifies, manages and reimburses participating retailers through the online transaction system. RMT provides an integrated database for all aspects of the SPLASH cycle for use by cooperating partners, distributors, retailers and WFP. The database handles beneficiary registration, transfer allocation, transfer redemption, transfer reconciliation and transfer invoicing. Overall administration of the e-voucher system is done by WFP though RMT assures its overall functionality. The exact areas of responsibility within this relationship may not be completely clear but this is perhaps expected with such a novel business arrangement. Retailer selection and supervision was an interesting challenge for RMT. As discussed above (see 4.3.4), from a management standpoint it was advantageous to work through larger retailers with established inventories. Small retailers are usually not prepared to stock the product for beneficiaries without a guarantee that the commodity will be bought. There was effectively no evidence of poor food quality issues in Zimbabwe, likely due, in part, to retailers being well-established and reputable companies. Thus, little attention to this was required from RMT. The retailers seemed satisfied with the service provided by RMT, a proven business player in the country. WFP had no dedicated staff for SPLASH thus, it was beneficial to have a dedicated agency, i.e., RMT, tending to this sector. Although the database was developed by MTZL, RMT and WFP Zimbabwe have innovated several useful new features in the system. The vouchers are now being split between retailers and clinics, with different scratch bars that provide finer detail monitoring. The system can now break down beneficiaries in terms of ART, TB, and HVHH status. Most importantly, they have transitioned from monthly registration on excel spreadsheets administered at the country office level to on-site registration from the field-based WFP desk, allowing for immediate receipt of the first ration. WFP and RMT are also seeking new arrangements to increase the detail and utility of reporting, such as showing more activity at each retailer and VDP. As part of an ongoing global review of emerging voucher arrangements, the nature of WFP’s contract with RMT has been the subject of some consideration . Though internal to WFP, a brief mention of several of the issues raised can be mentioned here. The first regards the fee structure, which is based partly on two flat fees, one for distribution of WFP scratch cards and commodity parcels and the other for operating the system. There are also fees charged per voucher card, depending on the total number of scratch cards redeemed per month. Clearly, there are economies of scale that make the arrangement more viable with larger numbers of beneficiaries. Currently there is little guidance or consensus on the optimal way to structure fees. A review of the options for food delivery was conducted for WFP Zambia that compared traditional models with the new model of voucher/retailer/distribution service provider. It will be important to continue to discuss these issues with RMT in the months to come, with a view to arriving at mutually-beneficial arrangements. RMT has provided a valuable service and

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greatly facilitated ongoing innovations in the system, and its position in Zimbabwe will enable it to transfer benefits from SPLASH systems and approaches to other programs.

4.3.6 Clinics: Type and Impact of SPLASH Responsibilities

Traditionally, WFP programmes have been managed more closely by health facilities in that clinics are where referrals, registration and distribution occur. This creates a heavy additional workload for already overstretched staff. SPLASH was designed to eliminate this stress from clinic staff, leaving them only those functions requiring their specific expertise and that fit easily within their work. Thus, SPLASH worked with Opportunistic Infection (OI) clinics based at hospitals so that those initiating treatment for HIV and TB could be referred to the program, registered and receive their food rations. The presence of a food assistance program has purportedly increased the number of patients coming into the OI clinics and staff feel this has created additional pressure on them when they are already below a full complement of staff. Some clinic staff indicated SPLASH created extra work for them in terms of dealing with the larger numbers needing to be weighed and registered. Of course, an increase in the number of individuals getting tested and seeking follow-up medical care is one possible outcome of SPLASH. If this were the case, WFP might consider discussing the need for additional staffing with health authorities. However, findings from the quantitative survey do not provide clear evidence that beneficiaries were encouraged to be tested and seek medical treatment because of SPLASH. Thus, it is not clear that the SPLASH programme per se has increased the clinic’s workload. The weighing and calculation of BMI may be an additional burden for clinics if these were procedures they were not accustomed to providing before NSART/SPLASH. These are concrete ways of measuring patient progress, however, so there does seem to be a good argument for incorporating it into their services. Staff seemed to associate the extra work burden with the much stricter application in August, 2010 of anthropometric indicators used to screen out new registrants who were not malnourished. However, by focusing the program mainly on adult clients with BMI below 18.5 and underweight children, the overall caseload was considerably decreased, which reduced the number of clients needing to be measured each month. While the previous phase of NSART was not as demanding in terms of initial screening, anthropometric measurements were still being taken and recorded on forms that were witnessed during the evaluation. Most clinic staff also considered the exclusive focus on anthropometrics to be introducing both inclusion and exclusion errors and that some opportunity was needed for medical staff to provide their professional opinion on malnutrition status of potential clients. Their inability to provide input into this process appeared to have disempowered them compared to previous arrangements in which their recommendations were accepted. An extreme example of the importance of clinic assessments involves clinicians referring a family to the WFP desk for immediate issuance of food rations where they were subsequently refused by the desk. Within two days, the husband, wife and daughter had all passed away. Other means of testing potential beneficiaries might in some cases lead to better targeting of malnourished individuals but paradoxically it would likely lead to considerably higher workload burdens on clinical staff.

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One benefit of the voucher system was that it located food distribution outside of the health centres. This was seen by a number of partners as a major advantage because it eliminated their responsibility for food distribution, was less disruptive than if it had taken place on their premises and removed any burdens or potential problems associated with accounting for the food. Additionally, client visits were spread out through the month, distributing the workload and avoiding sudden absence of clients as well. Staff at one clinic pointed out that with direct distribution, the clinic would be empty of regular patients during those days scheduled for distribution of the food ration. By removing the logistics of physical distribution of food from clinics, they were able to focus identification of beneficiaries and monitoring their progress. This raises the question of whether there was some feature to the voucher approach that made it more feasible to undertake the stricter targeting requirements initiated in August 2010. By avoiding distribution of household rations in clinics, it was easier to single out individuals with specific anthropometric characteristics and refer them off-site to receive rations. WFP and RMT also point out that there are greater monitoring capacities inherent in the online database and that it becomes easier to avoid double-dipping, receipt of rations by unauthorized parties, and to generally track the progress of individual clients. The ability of some hospitals to handle data management activities themselves could indicate that they were capable of taking on more responsibility for targeting. This would mean that clinical staff might then be able to provide input beyond anthropometrics, such as they are requesting. With good quality and accessible record-keeping, clinician input could be included as justification for inclusion of borderline cases. Monitoring and research could be done to compare targeting approaches in terms of baseline and endline status of patients. This could be problematic for SPLASH, however, as much of the data management was handled by WFP. Even in clinics where anthropometric measurements were taken by staff, accuracy might be in question, as working conditions were often congested and rushed, and equipment may not be optimal. This was not the case at Newlands Clinic, however, which is a research-oriented clinic run by a private NGO with a relatively small caseload. Private donations help ensure the clinic has adequate equipment. Newlands has computerized their patients’ records, schedules them according to the clock, and clinicians spend considerable time with each client providing more in-depth treatment. There is little doubt that Newlands appreciates having the opportunity to provide food for 150 of their patients and the clinic itself runs the VDP and CSB distribution rather than having a WFP staff member on-site. They have no complaint about the extra workload, rather they are asking for more responsibility to utilize other clinically-based means to determine eligibility for registration. There has been some discussion of linking the Newlands Clinic computerized patient database with that of SPLASH though at the moment this has not been possible because of concerns regarding loss of control over the data and maintenance of confidentiality. Rules governing operation of SPLASH have been worked out in consultation with senior staff in the Ministry of Health and discussed during workshops involving senior clinic staff. As pointed out by some clinic staff, these consultations do not involve the junior clinic staff, who may have

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different perspectives on situations and issues they face. The evaluation team received several suggestions on ways of alleviating work loads for clinicians and making clinic visits more bearable for children. More regular consultations with clinic staff would benefit the SPLASH program in terms of their ongoing input. In addition to nurses, other important actors in the clinics are the counsellors, who often get to know patients on a more personal level and may be quite useful in helping identify prospective beneficiaries. They have not been directly involved in SPLASH, though they probably should be.

4.4 SPLASH Approach in the Context of Zimbabwe’s Food Security and Social

Welfare Sector

This section considers the wider context of food security in Harare to see how SPLASH is reinforcing and to some extent leveraging the efforts of others, and the extent to which it is contributing to sustainable benefits. As suggested by staff at Epworth clinic, WFP should be aware of what other stakeholders are doing and develop linkages to provide an integrated service to the community by which one program’s outputs can be another program’s inputs. This discussion does not involve the voucher approach per se but SPLASH as a whole.

The subject of sustainability is always important for development and relief programs, and the terms of reference for this evaluation call for the report to address programme sustainability, among other things. It is important not to exceed realistic expectations, however. For example, a number of WFP’s goals for PRRO 200162 and NSART suggest the strengthening of sustainability (see 1.2) yet the limited number of indicators used to define these goals are for very specific issues, such as BMI and FCS scores and the purchasing of food from local suppliers.

4.4.1 Sustainability for beneficiaries

The sustainability of the benefits of SPLASH should be considered in terms of the durability of food and livelihood security impacts, and beneficiaries’ basic capacities to build on and make the most of their time in SPLASH. A second level of sustainability relates to the presence of other activities and programs that might help participants improve their food security situation. As previously discussed (see Section 2) SPLASH not only provides temporary relief to vulnerable beneficiaries, it also helps them through critical phases of treatment. In many cases the benefits extend beyond the period of food rations. SPLASH was intended to be a short-term safety net intervention and FGs generally stated awareness of this (with a few exceptions). Still, many of the current beneficiaries feared losing their food ration and wished for some way to continue improving their livelihood and food security options. Former beneficiaries expressed the challenges they now faced; they have no means for continuing to sustain themselves and their families, they cannot manage on their own now that the programme has ended, and they would like to start businesses but lack resources to do so. While the programme improved food security for beneficiaries, there were considerable questions raised by participants and partners regarding long-term sustainability of these benefits. At the most basic level, the program should help create beneficiary assets and capacity, and build the confidence of “I was a cross border trader

before and ceased operations after entering the SPLASH program and its now back to the drawing board”.

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beneficiaries to cope with life after SPLASH. It is reassuring that 99% of current beneficiaries feel they are better off than they would have been had they not participated in SPLASH; it is somewhat disappointing that 38% of former beneficiaries answered that they were not better off for having benefited from SPLASH. Some participants exhibited signs of dependence syndrome; several SPLASH programme participants spoke of having closed their businesses and stopped doing piecework. Certainly, some forms of piecework can unproductive and exploitative. Women may at times be forced to work for limited incomes while sacrificing time to care for their infants and children. However, it is important that beneficiaries are motivated to help themselves wherever possible, but raises the question regarding what messages implementing partners were sending regarding self-help and sustainability. After discharge, many clients held part-time jobs, such as washing, and selling fish, groundnuts, potatoes and vegetables. SPLASH aims for the recovery of patients and their ability to return to some form of work. It appears, however, that this is happening not by design but by the simple realities of survival. Optimally, the program should prepare participants for life after SPLASH. However, there is currently no obvious place in the program to include such an orientation; counselling and education activities occur in the clinics but WFP is not currently involved in this activity. Experiences with sustainable livelihood activities varied widely among SPLASH participants but – as expected - most stated they were unable to accrue any meaningful savings for use after discharge because of general economic hardships. They benefited greatly from the programme in that money otherwise meant to purchase food was channelled to other family expenses, such as rent and school fees, but it was generally not enough to start income-generating projects. The SPLASH log frame contained no specific goals regarding savings for use in income-generating projects to improve food security,and it may be appropriate to avoid an expectation of doing so. At the same time, similar programs may be well-advised to give some thought to what may be required to enable savings for IGAs. WFP would like SPLASH interventions to do more for enhancing longer-term livelihood security. In fact, this approach has been implemented to a greater extent than in Harare with the pilot SPLASH program in Bulawayo. SPLASH’s approach encourages implementing partners to incorporate beneficiaries into existing livelihood activities, to seek opportunities to work in partnership with other programmes in the area, and to encourage self-help support groups but without additional resources. But it is important to manage expectations of stakeholders and avoid a misplaced ambition to promote sustainable IGAs in a short-term pilot project and with such a large number of beneficiaries. The SPLASH program encouraged beneficiaries to join support groups, such as money savings groups in which members could borrow money for income generating activities. Many beneficiaries found it difficult to achieve much in terms of savings mainly because of their general level of poverty. Support groups are common among ART patients in Zimbabwe as

“The main challenge is discharge from the programme after weight gains and then what’s next?”

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well as elsewhere in Africa and the Zimbabwe National Network for People living Positively (ZNNPP+) was mentioned as a way for potentially large numbers of clients to link up with some form of assistance. Still, being part of a support group may not provide very much or very effective assistance. For example, funds received by support group members from ZNNPP+ were stolen by corrupt group leaders, an experience mentioned by several other respondents. The Zimbabwe Women’s Bureau was mentioned as another source of support for revolving loan funds but partners indicated they had not been very effective. Other livelihood activities could significantly augment SPLASH’s supplementary feeding efforts with other sources of nutritious food. Such a program investment should prioritize nutrition education and awareness of people on ART/TB, which could be extended to the whole community. Community nutrition empowerment interventions would also be required, with the distribution of seeds and promotion of vegetable-growing in nutrition gardens. One such initiative, a community garden vegetable production program run by ADRA in the Epworth area, included some SPLASH ART patients, orphans and vulnerable children. ADRA also promotes small household gardening using car tires and empty bags filled with soil. They have also piloted mushroom cultivation, poultry-rearing, and training to support internal savings and loan schemes. It has some potential for expanding into other areas around the city but this will require good coordination with government and local authorities, and there is the risk of future land pressures threatening the gardens. However, care must be taken to minimize possible negative effects on local market systems and community dynamics. Thus, many types of self-help initiatives speak to the desire of SPLASH participants to expand on the programme’s benefits through improved food security, most of which involve certain obstacles and challenges that need to be considered in order to maximize the likelihood of success.

4.4.2 Sustainability and integration with local institutions

WFP seeks to maximize the positive influence that SPLASH can have on government and other programs for enhancing the nutritional and food security of chronically ill and vulnerable populations. While NSART/SPLASH has filled a critical need during a difficult time in Zimbabwe history, WFP and donors hope to build local capacity to manage this type of program in the future. While assessment of program sustainability is appropriate, it is also important to assess if/how SPLASH has been integrated into and/or supported parallel efforts in Zimbabwe. The following discussion will begin by focusing on the primary front-line agencies that served SPLASH clients: primary care hospitals in Harare that are operated by the Ministry of Health; other private/non-profit organizations; and the Opportunistic Infection clinics that are the primary centres of treatment and consultation for ART and TB patients. Unlike some programs, SPLASH Zimbabwe focused on reinforcing existing efforts provided by the medical services, where testing, counselling, treatment and care have been ongoing and increasingly enhanced over the past decade. An important collaborative initiative of the Government of Zimbabwe, the Global Fund and other agencies has been to provide ART and TB medication free of charge to

“ Everyone is selling vegetables such that it is difficult to make a profit even of one United States Dollars.”

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patients. NSART has strengthened understanding the importance of nutrition in the rehabilitation of ART/TB patients and enhanced the willingness of clinics to play a role in strengthening the food security situation of patients, particularly during the initiation of medication. Partners expressed a growing awareness of the role of nutrition security and the rights of patients to a minimum degree of support; though not necessarily solely attributable to WFP/NSART, the training and practical experience provided by the SPLASH program were likely a major factor. In order to continue playing a management role in a SPLASH-type of program, a number of challenges would need to be addressed. As staff point out, they are currently hard-pressed to provide basic services without additional responsibilities and clients, a fact easily verified by direct observation in clinics. Aligning clinic staff and management around the goals of and methodologies employed by the program (e.g., screening based on anthropometric criteria) would be necessary. Fortunately, clinics were already providing counselling and nutrition education services before SPLASH and therefore should be expected to continue independently. As a result of the numerous HIV-testing and treatment programs in Zimbabwe, there is some evidence suggesting patients are willing to be tested at and seek the services of clinics and referral centres. This suggests that strengthened relationships with clinics may help sustain these services in the future, though this is difficult to verify. Services provided by community volunteers are quite important to this relationship. The ability of volunteers to sustain these efforts will have an effect on how well clinics are able to continue providing holistic services, such as testing and counselling. Retailers represent another class of front-line providers for SPLASH clients. For them, sustainability is an issue of survival as a business, an important factor to WFP as well. SPLASH represented a sizable expansion of business for some retailers. Others were already quite large and established businesses so sustainability was less of an issue for them. For many retailers, however, involvement in the SPLASH program was their first experience working with so many of the most vulnerable members of their community. They had to learn to interact with them as equals and as valuable customers whose business they needed to attract. Both retailers and clients learned from this experience. Clients felt empowerment and diminished fear of isolation and stigma; retailers experienced clients and social relationships in a new way, with increased sensitivity for the most vulnerable. As a rule, WFP works closely with national governments to build local capacity and, as much as possible, focus on interventions that can be mainstreamed into ongoing government programmes. WFP’s main government counterpart is the Ministry of Labour and Social Welfare (MLSW), which is very supportive of WFP programmes. Monthly coordination meetings are held with them, they are able to quickly assist with any problem-solving required, and intervene as needed with other key ministries including health and agriculture. It is important to remember within the context of Zimbabwe that the government is living through an historical experience of forging two political parties that had previously been competing vigorously and that tensions remain among senior members of the parties who are trying to run a coherent organization.

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NSART had coordinated fairly closely with the Nutrition Department and the HIV/AIDS and TB department of the Ministry of Health and Child Welfare. Ministry directors took part in planning meetings during early stages of NSART and around the time of the commencement of SPLASH. They played leading roles in training provided to clinic staff. Despite obvious close involvement at the beginning, it was apparent during interviews that ministry officials were not as aware of current developments. Though there seemed to be ongoing contact between individuals within government ministries and WFP staff, information was not flowing between individuals within the government. For example, it became evident during interviews that some officials were not well informed about the program even though WFP had been involved with extensive discussions with other officials. Lack of a clear coordination mechanism ensuring adequate reporting and information exchange both within and between ministries resulted in a lack of understanding and thus, buy-in at the government level. Most of the above comments apply in some form to the health and nutrition department within the City of Harare, which also had direct responsibility over some of the referral hospitals (e.g., Beatrice and Wilkins). However, conditions were different in these hospitals in that they seemed to have better facilities and less work pressure. Program integration with these hospitals provided another layer of complexity for WFP, who appeared to be doing a relatively good job of managing. Several national programs and policies provided an overarching guidance framework for NSART and which would, at the same time, be strengthened and influenced by NSART. The Zimbabwe National HIV Strategic Plan for 2006–2010 aimed to reduce the spread of HIV and improve the quality of life for people living with HIV and the Nutrition and HIV Strategy (2009–2014) recognizes the importance of food and nutrition in HIV programme responses. Other areas of policy were not as formally developed or centralized but had potentially great importance for targeting vulnerable, chronically ill patients. Though WFP was aware of these national policies, SPLASH was not shaped by particular policy shortcomings or designed to specifically influence policy. WFP coordinates with other external cooperating partners. Among the UN agencies working in malnutrition, WFP is responsible for HIV patients, WHO has responsibility for general malnutrition, and UNICEF deals with child malnutrition. In other countries, WFP is actively involved with moderately malnourished children while UNICEF deals with severely acute malnutrition. WFP resources were currently focused more on ART issues and the SPLASH program resides within that framework. In other districts, WFP’s programmes of supplemental feeding may dovetail with UNICEF’s programs for ready-to-use therapeutic food for severely malnourished children. Though not central to SPLASH, the use of Plumpy Nut was discussed during several interviews because it was used – at least in some cases – as a form of supplementary rather than therapeutic feeding. It had also been given to malnourished adults, though ongoing issues remain related to use of Plumpy Nut, such as defining standards in connection with national protocols. WFP appears to be managing well and has excellent relations with UNICEF, the Ministry and the other agencies involved. SPLASH is set within the context of other coordinated projects in Zimbabwe. In late 2009, WFP, FAO and UNICEF commissioned a study of food and nutrition security to identify gaps

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and recommend improvements. WFP also participated in a nationwide nutrition survey led by UNICEF in early 2010. The World Bank has recently begun formulating a social-protection framework (a priority for the Government of Zimbabwe), a process in which WFP also took part. Under a cluster system, WFP leads a food assistance working group of NGOs, United Nations agencies, donors and the Government, and is active in cluster and technical groups for food security, nutrition and social protection. WFP also coordinates with others on food security and agriculture, with nutrition, child protection and education, support to internally displaced persons and returning migrants, and interventions for HIV/AIDS. In the important and innovative area of cash and voucher transfers, WFP is playing a leading role as an active member of the Cash Transfer Working Group. This forum informed the design of the voucher transfer pilot and WFP’s piloted cash transfer program in 2009-2010. WFP’s support to voucher systems will facilitate their potential adoption as modalities of assistance programs in the coming months. Electronically-mediated systems are being tried out in numerous countries and the experience in Zimbabwe will help other organizations start up quickly. By testing an e-voucher delivery mechanism at scale, WFP provided proof of concept to government and cooperating partners at all levels and has encouraged them to investigate the possibilities of using e-vouchers to deliver agricultural inputs and other commodities.

4.5 Management Considerations

4.5.1 Management structure

Early in the SPLASH pilot programme, RMT played a central role in maintenance of the SPLASH database, provision of vouchers and CSB, and oversight of retailers. Their linkage with Mobile Transactions of Zambia helped SPLASH Zimbabwe benefit from ongoing learning in Zambia’s SPLASH program, a link that allowed for the sharing of innovations in both directions. Given Zimbabwe’s history of supply interruptions, RMT’s role was also important for guaranteeing the supply chain of certain commodities. Given the involvement of so many partners at the initiation of SPLASH (e.g., WFP, numerous partners in the health sector, Christian Care , RMT ), challenges existed in establishing a clear operational structure . Partners had different world views and perspectives, difficulties communicating, and little understanding of each others’ roles and responsibilities. In order to discuss issues and derive solutions, weekly meetings were held, though these were ultimately reduced in frequency. One of the main developments occurring during implementation of SPLASH was the phasing out of Christian Care (CC) as the central manager of SPLASH. CC had partnered with WFP Zimbabwe on a number of projects in various districts and had implemented NSART in Harare prior to commencement of the SPLASH pilot programme in August, 2010. CC continued working within the new SPLASH framework until March, 2011. CC’s role was to assist medical centres with targeting, carrying out monitoring, and evaluation. In early 2011, rather than renew CC’s contract, WFP elected to directly manage the SPLASH pilot for the following reasons:·

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• Direct involvement would allow WFP to more carefully study the programme and assess the merits and demerits of its approach.

• Several key aspects of the programme were problematic for CC (e.g., strict screening for BMI) and WFP wanted to test that the programme could actually be implemented in accordance with its original design.

• WFP had staff available who could begin implementation of SPLASH around March, 2011.

The SPLASH programme seemed to have benefited from WFP’s management. WFP staff have been actively involved in program implementation and helping to enhance the monitoring and evaluation system. Screening based on anthropometric measurements has been successfully implemented, though it has its detractors within clinics. Though management of the SPLASH programme by WFP seems to have been a reasonable outcome, management by an NGO may also be possible. As WFP points out, the SPLASH program in Bulawayo is well managed by an NGO, as are other projects around the world, such as for SPLASH Zambia. The voucher system requires that NGO partners are able to focus on the fine points of targeting and leveraging parallel interventions to support sustainable livelihoods. As for WFP’s internal management arrangements during these transitions, an internal review noted that while the country office had worked collaboratively to carry out the management functions required, future roll-out would require careful definition of roles and responsibilities. There are no designated staff able to deal centrally with the particular characteristics of voucher (and cash) transfer modalities and this could be important for carrying the intervention to a larger scale. Continued coordination among the range of stakeholders involved will be important. MSF mentioned that they had participated in stakeholders’ workshops each year, which built a foundation for reviewing and planning numbers of participants, etc. Discussions with clinics about their roles in anthropometric measurements and screening should be carried to a more systematic level, involving senior staff from the Ministry of Health as well. The information management, monitoring and evaluation aspects of SPLASH have undergone considerable changes, though key features may still require enhancement. By insisting on obtaining and entering clear and accurate anthropometric data for use in targeting those who are clearly malnourished, the system obtained a reference point from which future programming could more reliably be guided. Having a clear baseline for each participant allows for tracking nutritional health status (i.e., following weight, height and MUAC) of beneficiaries over time . The whole concept of a household vulnerability assessment tool has evolved so that a more manageable tool is now in place. Data on household vulnerability is being entered into a database so that the information can be tracked, analyzed and used to compare with subsequent studies. WFP intended to conduct household verification for a certain percentage of households identified through the vulnerability assessment. The post distribution monitoring tool was also being streamlined and integrated . Though the WFP team had been aiming to conduct 35-50 assessments per month, they have not able to sustain this because of other intensive assessments. Other gaps remaining in the system (see 5.2.5) include ensuring consistency between clinics and field officers in terms of updating and labelling beneficiary databases in terms of discharges and

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reactivations. This information was not easy to obtain for the evaluation and there still seems to be uncertainty about the number of discharges, reactivations, and total beneficiaries over the life of the project

4.5.2 Urban specificity of the approach

A final question relating to the implementation modality is whether electronic vouchers could be used as a delivery model elsewhere in Zimbabwe, with retailers procuring and distributing food. The SPLASH experience in Harare provides some valuable lessons. Ongoing pilot programmes in Bulawayo and Mutare will add to the experience base. Transferability can be analyzed in terms of appropriateness and implementation modality. There are no obvious reasons why this approach would not also work in rural areas. There are malnourished ART/TB patients in rural areas; rural areas often have higher percentages of malnourished and food insecure populations than urban areas. Lower population densities in rural areas suggests beneficiaries numbers per clinic or health centre are also likely to be lower. Most rural health centres will have a lower catchment population to begin with and the number of ART patients potentially smaller as well. Patients from rural areas may be more likely to travel to more distant facilities in order to remain anonymous. The main dimensions of the SPLASH programme delivery approach needing consideration for potential use in rural areas are as follows:

• presence of retailers with adequate capacity to manage the service and procure and arrange transport of required volumes of commodities;

• cell network and/or internet connectivity in the event of connecting via computers via internet “dongles;”

• the possibility of off-line options and technologies becoming available in the country, such as use of SMS and debit cards;

• potential interest of RMT or other sub-contractors to extend services (including retail agent management) to rural areas with longer distances;

• capacity of implementing agencies (NGOs, WFP) to maintain close contact with clinics, ensure visits to check on the registration process, pick up registration books, bring vouchers, oversee all key phases of registration and distribution.

• relative proximity of health centre and retailers to one another and to population concentrations, to minimize the number of long trips clients must make.

As discussed elsewhere in the report, the development of cell phone and mobile internet networks is still not very advanced in Zimbabwe. There were numerous gaps in the coverage noted in Harare and respondents noted gaps in rural areas even on the main road to Bulawayo. Thus, conditions in more remote rural areas might present still more difficult challenges to the effective use of SPLASH approaches. A feasibility study of off-line capability using SMS or related technologies may be a prerequisite to planning possible commencement of operations in more remote rural areas.

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5 Conclusions

SPLASH has helped to stabilize the food security status for approximately 18,000 malnourished ART/TB patients and enabled them to effectively initiate their treatment regimes. Through various qualitative and quantitative research methods, the evaluation team confirmed that participants benefit greatly from the programme in terms of food assistance received, their ability to adhere to medications, and the consolidated services they receive at health centres and retail outlets. The programme was managed effectively while piloting the innovative delivery and management system of electronic vouchers. These results suggest that while improvement of nutritional status in clients may vary over the length of time they are enrolled in the programme, once they have left the program they appear able to maintain their weight and nutritional status for some time. Experience and reason would suggest that there might be a natural process of reversal of some of the advances made after the programme because respondents are often limited in their ability to support themselves. Such post-programme decline, however, seems to be less universal and less pronounced than expected, and may deserve further exploration. Beneficiaries were able to redirect spending to important purposes such as education, health care, and other needs. Investments in business activities from savings were quite low, however. Spending on energy-rich food increased but the savings resulting from receipt of the food ration do not appear to be contributing in any significant way to diet diversity. The food assistance is instrumental in increasing adherence to medication. Levels of adherence are reasonably high and beneficiaries partly credit that to the food rations. This is a benefit that should ideally accompany ART and TB medications for all who are taking it in Zimbabwe. Issues highlighted during most FGDs and reflected in the quantitative data suggest that there is a mixed experience that needs to be taken into account when planning programs. Some SPLASH beneficiaries are what might be termed extremely food insecure, with problems severe enough that the benefits of SPLASH were outweighed by these bigger factors. Some of the indicators of this group of the sampled population are:

• Households with school aged children in which 4% never enrolled in school, while another 15% had dropped out before this school year – and this despite a widespread availability of assistance for schooling

• Single and double orphans

• Those who lack assets like beds, mobile phones, chairs, and those who sell assets

• Those who borrow money for food

• Those who employ severe coping strategies, such as selling assets or begging, and in some cases even while on the program

• Those who engage in transactional sex as a coping mechanism

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This latter group raises obvious additional concerns for ART patients. On the other hand, there are beneficiaries who are somewhat better off, including those who own cell phones (about 50% of respondents) and other modest productive assets. The recent initiation of stricter targeting criteria is likely to significantly help focus scarce resources on those who are most vulnerable, though this will need to be monitored. The voucher system and its impact on the programme has been a central part of this study. Vouchers have been attracting growing attention in the past few years and garnering much interest by development agencies; WFP is piloting versions of the approach in several countries. The electronic voucher/scratch card system piloted by WFP Zimbabwe represents a unique programme delivery mechanism that positively impacted beneficiaries while providing a valuable development outcome contributing to wider learning. The voucher system approach enlists local retailers as procurement and delivery agents in an innovative public-private partnership. Most aspects of the program are managed well. There are challenges with the clinics that are somewhat beyond the control of the program though creative approaches could facilitate their work. The registration and voucher system was working well and involved innovations, such as easy online registration (i.e., immediate) and pushing the technology to allow for exit interviews. Unfortunately, limitations related to internet services (e.g., access, reliability) were somewhat pronounced in Zimbabwe.

6 Recommendations

6.1 Main Recommendations

• Scale up vouchers while strengthening monitoring: The voucher system shows many signs of being effective for safeguarding resources, efficient in management requirements, and favourable for clients. This approach is worth applying more widely though network coverage will need to be considered carefully before undertaking any expansion of the system. Working relationships with retailers will need to be carefully negotiated as some potential retailers may be less flexible and capable than some of the large retailers that participated in the Harare pilot. Systems for tracking beneficiaries and vouchers should be strengthened in order to provide relevant information on who is enrolled in the program, who is not, and why some clients are not showing up for monthly visits according to program expectations and requirements. The link between the printing of vouchers and the list of those who show up and get weighed needs to be air-tight.

• Strengthen education: There are a number of areas in education that WFP should attempt to strengthen in order to maximize the programme’s positive impact on beneficiaries. Nutrition education should be reinforced as part of clinic-based counselling activities without damaging existing capacity to deliver this service. The importance of diet diversity, which might be addressed in partnership with retailers, as well as counselling and information on the risks associated with transactional sex are both important topics that should be included in educational activities undertaken through SPLASH.

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• Pursue sustainable options: Sustainability for beneficiaries is a huge challenge – the elephant in the room that can’t be avoided – that WFP and its partners should continue to work on while being mindful of unreasonable expectations, i.e., what can reasonably be done in the short term. There is a need for opportunities to strengthen sustainable livelihood options for the vulnerable, whether they are ART/TB patients or moderately malnourished infants. A starting point might be to include some combination of cash with food assistance, well-run savings schemes, and expansion of small-scale pilots in nutrition gardens. The process for discharging patients should be planned as an integral part of the program rather than an after-thought. Partnering with other agencies should be a top priority for future phases of SPLASH and similar programs.

• Continue the BMI screening focus with flexibility: The recent focus on malnourished patients using BMI (and MUAC) seems to be an effective targeting filter and one that can be applied for larger scale programs to avoid inclusion error. The temptation to use the food ration as a preventive measure should be avoided if the program is to try to reach a larger percentage of ART/TB patients. However, it would be good to create space for some clinics to target potential beneficiaries based on wider criteria for determining malnutrition, particularly if systems are in place and wise discretion is employed. A pilot programme in a clinic such as Newlands could help to clarify the conditions, training and systems required.

6.2 Secondary Recommendations

6.2.1 Ration Composition

Ensuring receipt of rations: Three percent of current beneficiaries stated they did not receive CSB and a smaller number reported not receiving other components of the ration. Any evidence of non-delivery should be treated as serious until explained. Review of the incorporation of beans in the ration: Given the high number of comments and concerns reported by beneficiaries regarding the digestibility of beans, the use of beans as part of the food ration should be reviewed and discussed with dieticians. Results should be included in the nutrition orientation provided to beneficiaries. Balance of food and cash: The provision of food via vouchers has worked reasonably well for this context, according to beneficiaries. There is no evidence to suggest that food distribution should stop, but rather, that it should continue, especially in light of food price instability. In order to meet a variety of preferences and needs, WFP could consider a balance of food and cash assistance in future programmes to provide the security of food and the possibility of supporting livelihood activities with cash. Given beneficiaries’ concerns about the possibility of misusing cash, careful thought should be given to possible training and other support to help participants to more effectively manage and/or save their money. In addition, there may be other ways to diversify a package that will be attractive to beneficiaries, such as providing seeds and other inputs and tools.

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6.2.2 Targeting

Clarify target groups beyond ART/TB patients: There was some attempt to include moderately malnourished children in SPLASH but it was not clear whether this was a strategic choice or merely an ad hoc arrangement. SPLASH targeting criteria should be more explicit in order to avoid misunderstandings and unmet expectations. Focus on the young: Given that youths comprise such a large percentage of ART beneficiaries, it would be of benefit to solicit input from children and youths when designing future programme approaches. Emphasis on outreach with community participation: In order to reach the most vulnerable households with malnourished children and current or potential ART/TB patients, programmes like SPLASH should whenever possible seek broad participation of community volunteers and groups. Future programs by WFP and national partners should consider the possibility and possible advantages of linking with NGOs or others to strengthen community outreach. Working with CHWs is a strategy that should be pursued, along with building their capacity and strengthening national policies and systems for health volunteers. Other community groups should be brought in to help reach marginalized individuals or households who meet registration criteria.

6.2.3 Registration and Clinic Follow-ups

Increase accessibility of registration/VDPs: The centralization of VDPs in four locations has contributed to the overall success of the pilot phase of SPLASH but it also created difficulties for large numbers of beneficiaries originating in clinics like Beatrice and Wilkins. In consultation with clients regarding their needs and preferences, WFP should experiment with the possibility of additional VDPs and fixed dates for registration in other clinics. Publicize clear information and agree on expectations about the program: Some patients expressed unawareness of the six month limit, which seemed to add to the shock and difficulty they felt when discharged. Written brochures and visible posters could help to advertise criteria, rules, expectations, and other key information about the program. Ideally patients should sign a contract governing their participation in the program that could include conditions such as monthly attendance at clinics, etc. Improving use of electronic tools for registration and monitoring: The e-vouchers offer opportunities for much better control of beneficiary lists than previous paper registration systems did, in large part because they are unified in a single and constantly updated online database. Now that the basic operations of this system are in place, greater emphasis should be placed on issues like avoiding double registration (of the same NRC number) and avoiding double rations for the same household. These databases could also be used (cautiously) to help coordinate between various assistance programmes in order to ensure households are benefitting from the

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most appropriate programme based on their needs and to direct beneficiaries into complementary programmes such as those for sustainable livelihood support. Revise vulnerability assessment: Since the vast majority of patients’ households qualify for rations, the utility of the vulnerability assessment should be reviewed. It should be seen as more of a baseline against which to measure BMI and other indicators.

6.2.4 Voucher Management

Voucher issuance: In the case of illness, patients often send family members in their place to collect their vouchers or redeem them for food rations. WFP should ensure that complete procedures are in place to accommodate such cases and that they are understood by beneficiaries and partners. Monitoring and explaining no-shows: If the numbers of vouchers issued each month is significantly higher than the registered beneficiaries who actually show up for the vouchers, it indicates either that too many vouchers are produced (based on outdated registries or inaccurate extrapolations from previous months) or that beneficiaries are not showing up for their vouchers. Failure to utilize food rations provided through the programme runs the risk of diluting the benefits of such assistance for those individuals and compromises the effectiveness of the interventions, and it could be an indication of defaulting on medication as well In addition, having many unclaimed vouchers could be a security risk, which should be minimized whenever possible. WFP explains that the registry contains defaulters who have not come for vouchers for two-three months, but this important database should be updated as quickly as possible. WFP should investigate this phenomenon and attempt to address it in future SPLASH programming.

6.2.5 General Management and Partnerships

Mechanisms for beneficiary participation: Beneficiary input resulting from complaints desks or other consultation exercises is a valid way to quickly find out participant perspectives on programme benefits and effectiveness. Complaints desks that are independent from programme operations are perceived as providing a safer environment in which beneficiaries can provide honest feedback. Government partnerships: Information sharing and joint discussions with government and other partners should always be a priority for WFP and is especially essential project goals include mainstreaming its approaches. WFP typically does this quite well and should take care to ensure that other management demands do not divert too much attention from this. Simple mechanisms, such as coordinating meetings or sharing circulars, are easily accomplished though poor communication within and between some government departments may require more creative approaches.

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Rural adaptations of the voucher approach: If WFP decided to implement an e-voucher approach in rural programmes, they should establish the necessary conditions required to ensure success of such an approach and recommendations for implementation. In view of potentially more frequent network connectivity problems and the longer distances clients might have to travel to a retail outlet, backup plans should be developed that would enable clients to obtain rations in the event a retailer is unable to connect to the network. Retailers involved with SPLASH have already been taking the initiative to allow clients with whom they are familiar to collect their rations during internet downtimes and to redeem their vouchers at a later date, when internet connectivity has been re-established. Clearly, this has certain implications in terms of ensuring adequate control but workaround solutions can obviously be worked out, especially in conjunction with retailers and clinics themselves.

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7 Annexes

7.1 Terms of Reference

Zimbabwe SPLASH Voucher Transfer External Evaluation

Background

Since 2002 World Food Programme (WFP) has been providing food support to Zimbabwe. Recent changes in the economic environment, including the multi-currency policy which has stimulated imports and revitalised trade, have created an opportunity for new mechanisms to be used to transfer needed support to beneficiaries. Consequently, in August 2010 WFP started the implementation of a voucher transfer pilot in Harare targeting the urban Nutrition Support for Anti-Retroviral Therapy (NSART) activity as part of the safety net programme.

Usage of the voucher as a transfer mechanism was adopted due to several anticipated benefits, such as support of the existing market mechanisms to distribute food to selected beneficiaries, prevention of market distortion, the potential of vouchers to release funds for other items, and also the overall reduction in transaction costs which increases efficiency and effectiveness of the programme. The relative efficiency (monetary costs of input/outputs) should always go hand-in-hand and be evaluated in synergy with the effectiveness in terms of ability to achieve project goals and outcomes.

WFP is an active member of the Cash Transfer Working Group and this forum informed the design of the voucher transfer pilot.

WFP wishes to commission an external evaluation of the pilot, not only to assess the impact of the intervention on beneficiaries’ ability to access food but also to inform the Zimbabwe programme as a whole as to the appropriateness of this type of transfers and the prospects of scaling up as a longer term social protection programme.

Evaluation Objectives

• To assess the overall cost-effectiveness and impact of the SPLASH voucher transfer in meeting the programme’s stated objectives and whether or not this was the most appropriate choice of transfer modality for this programme;

• To identify the potential and conditions for replication of this modality and delivery instrument for other food assistance interventions in Zimbabwe.

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Efficiency

• Type of transfer utilised – was it the most efficient use of resources (alpha value)?

Effectiveness

• Did the transfer modality address the beneficiaries’ needs and circumstances in terms of the objectives as stated in the programme document?

• Were the roles and responsibilities of partners well defined and appropriate?

• Were the nutritional objectives realistic and to what extent were they achieved?

• Were the food basket and the value appropriate? Was the selection of brands adequate?

• Was the contractual process, the contract type issued to the private partner, and the fees structure appropriate?

• What, if any, is a more appropriate approach for future voucher transfers in Zimbabwe in urban and rural settings?

• How was the voucher received and perceived by the beneficiaries?

• How was the voucher received by the Government of Zimbabwe?

• How was the Zambian voucher model integrated in the Zimbabwean pilot? Were the technical system and the reporting adequate?

• What was the impact for individuals, community, non-beneficiaries, existing markets and market forces; special attention to be given to direct impact on nutrition of NSART patients and food and livelihood security at a household level?

• What intended or unintended impacts have occurred on the environment as a result of the operation?

• Was the M&E system robust enough to provide enough information to draw clear conclusions about the comparative advantages of the chosen transfer modality over the other possible choices?

• Did the systems put in place (both operational and IT and M&E) contribute to assuring and measuring programme quality, including setting appropriate technical standards?

• Can this delivery modality be expanded from a limited geographic and programmatic coverage to a larger scope geographic and diversified programmatic coverage?

• Links to Government strategies?

• Viability for future handover?

Evaluation outputs

• Advice for future programming.

• Final report addressing the effectiveness, efficiency, appropriateness, impact, standards and sustainability of the programme; practical recommendations for future interventions.

• Feedback workshop in Zimbabwe to key partners/stakeholders, presenting the findings and seeking feedback.

Methodology

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• Reviewing and tabulating existing data collected by WFP. Specific focus on M&E data and results / impact measurement.

• Focus group discussions/interviews with beneficiaries, non-beneficiaries, vendors and other groups.

• Formal and informal discussions with staff and other stakeholders’ including donors and Government.

• Observing people, their interactions and environment.

Timeframe and Duration

• The ideal time to begin the evaluation will be late January.

• Duration: 3 weeks: - 1 ½ week for desk-review, data collection, consultation and analysis; - 0.5 week of field work and observation; - 1 week consolidation and reporting.

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7.2 Considerations for Engagement and Partnership in Community Outreach

Future work of SPLASH (or complementary programs) may place more attention on community outreach as a means of attracting a higher percentage of the marginalized to access services at clinics; therefore, this section provides some research findings which may inform such considerations. Currently, the mandate of SPLASH in Zimbabwe does not include direct involvement in the outreach and recruitment of those who have not yet been tested. The national health system and other development actors are undertaking HIV awareness-raising and testing and encouraging malnourished target groups to come to clinics, at which point they can become incorporated into SPLASH. It is important to take this clinic-based focus into account when analyzing the program, and there is merit in the focus which WFP Zimbabwe has taken. Whether or not that mandate changes in the future, it may become helpful for WFP Zimbabwe to become more involved in the upstream community outreach aspects, either directly or through some more sharing of experiences and strategies. This strategy was taken by WFP’s SPLASH program in Zambia, which works in partnership with local NGOs to increase the efficiency of recruitment efforts. Partnering to improve targeting may represent a viable option to consider in future SPLASH programming in Zimbabwe. Testing for HIV (and TB) status is a crucial step that is difficult for many people. The majority of SPLASH respondents (74.9%) were motivated to get tested when they realized they were getting sick (Table 38). Other common reasons for getting tested included access to medical services that required testing and a positive test result for a spouse or sexual partner. Few respondents indicated they had been encouraged by volunteers (2.4%) or health clinic staff (1.8%).

Table 39: Motivation for getting tested, by beneficiary status

% Current Former Total

Realized I was getting sick 78.0 70.4 74.9

I was accessing medical services (e.g., for pregnancy) and was required to be tested

9.1 14.2 11.2

Tested voluntarily 6.8 8.4 7.5

My spouse/sexual partner was tested positive 4.5 7.4 5.7

Volunteers were encouraging community members to go for testing

1.5 3.7 2.4

Other 2.3 1.6 2.0

Health clinic staff were encouraging community members to go for testing

2.3 1.1 1.8

n 264 190 454

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There was some indication from qualitative interviews that the food ration was attractive enough to have created a pull factor for people to be tested. This was verified in the quantitative survey where 97.8% of respondents indicated they would still have been tested even without the food assistance, suggesting they were primarily motivated by other factors. Some respondents did state that they faced negative effects from stigma that might affect their willingness to undertake testing and would, therefore, prohibit their participation in SPLASH. For example, in one FGD, participants indicated knowing of others in the community who did not enrol in SPLASH because they did not want to reveal their status. Some of the negative effects of having been tested are presented in Table 38 below.

Table 40: Negative effects from stigma associated with being

tested, by beneficiary status

% Current Former Total

Loss of employment 7.5 10.6 8.8

Other 7.9 10.0 8.8

Loss of friends 4.9 9.5 6.8

Marital breakup 3.4 7.4 5.1

n 265 188 453

In addition to the more common issues related to AIDS stigma, key informant interviews discussed stigma associated with HIV status and its relationship with sexual violence. Several cases of sexual violence had resulted in HIV infection but those involved were attempting to cover it up. Thus, testing – particularly for women – takes on another dimension, in terms of women’s rights to protection from violence and their ability to access treatment and care when violence has been committed. These findings demonstrate that those who do get tested (and who have become SPLASH participants) – despite the risks inherent in testing – have not generally done so because of particularly strong promotional efforts at present. Obviously, the findings do not provide insights into the motivations of those not being tested, but there are indications that many people are avoiding testing. Analysis of DHS data from 2005-2006 found that in men and women who reported ever having had sex, 30% of women and 22% of men had been tested. Women typically accepted testing when offered (particularly in the context of ante-natal care), while men generally volunteered to be tested. The study concluded that AIDS-related stigma appears to dissuade people from HIV testing and that more work was needed to reduce the impact of AIDS-related stigma and

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encourage preventive behaviours16. Recent statements by the Minister of Health and Child Welfare suggest that much more vigorous means may soon be used to promote testing, though this remains to be confirmed17. The presence or lack of efforts by other organizations to encourage people to come forward for testing (and to provide it) can be an important determinant of the success of a program like SPLASH in reaching its target group. WFP has a smaller program of home-based care supported under the Global Fund that provides voluntary counselling and testing, and offers the youth program “Choose Life.” Additional home-based voluntary testing programs include Maoko Ane

Tsitsi (Hands of Hope) and the Midlands clinic. Community-based health promoters, such as those at the Edith Oppermann Clinic in Mbare, provide important outreach services. Supported through the Mashambansou Care Trust (MCT), “brownies” (due to their brown uniforms) conduct door-to-door assessments, identify patients for TB, ART and Pre-ART programming, and encourage testing and initiation of drug interventions. Seven clinic health promoters (out of 14) conduct home visits while five provide clinic-based counselling services. Trained in counselling, they invite clients needing counselling to their “friendship bench” where these services are provided. They also refer emergency cases to MCT caregivers for transport and treatment. Brownies are also involved in distributing food, identifying malnourished patients through house-based assessments, record-keeping of malnourished families, and referring households to NGOs (e.g., MCT, ZIMPRO) offering food or other forms of assistance. They have initiated nutrition gardens and supplied beneficiaries with seeds, fertilizers, hoes and shovels. One of the shortcomings they see in their current work with MCT is that they screen potential patients based on BMI and limit beneficiaries to 500/month, whereas they would like to reach more beneficiaries. They find it difficult to encourage patients to take ART tablets when there is no food provided at the same time and feel they would be more effective as community health workers if they had more promotional materials such as t-shirts, uniforms and pamphlets. HIV outreach efforts often also focus on malnutrition, especially in children. In Epworth, MSF has been conducting community awareness campaigns to actively identify cases of malnutrition. Such an effort was recently carried out by 37 community health workers (CHW) and eight peer educators. Peer educators provide voluntary counselling and training (VCT). CHWs use MUAC measurements to refer moderately malnourished children to WFP programs while other more severely-malnourished children are referred for medical attention. An interesting dynamic emerged from FGDs regarding current beneficiaries helping to publicize the importance of getting tested. FGD participants indicated they had been engaged by Christian

16 Sambisa W. 2008. AIDS Stigma and Uptake of HIV Testing in Zimbabwe, DHS Working Papers. Chapel Hill, NC: University of North Carolina/Measure DHS.

17 National Aids Council. 2011. Zimbabwe considers door-to-door HIV testing,

http://www.nac.org.zw/news/zimbabwe-considers-door-door-hiv-testing. Accessed on 24 October 2011.

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Care in support groups, and assisted with community awareness campaigns (e.g., the Mai Chisamba television show) encouraging people to know their HIV/AIDS status through testing. Participants disclosed their HIV status to encourage people to get tested and some did, ultimately enrolling in SPLASH. These participants felt that SPLASH was now putting more effort into assisting the new enrolees and that they themselves had been sidelined. This illustrates how beneficiaries may be hesitant to see others join the program if they perceive that this will result in increased demands on limited resources and thus, impact their own ability to remain on the program. However, this same focus group also provided suggestions on how to improve recruitment through awareness campaigns at shopping centres, publicity materials and voluntary door-to-door testing. They also suggested scaling down the food ration for patients who had gained weight rather than remove them completely, which would also help reduce stress-related infections.

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7.3 List of Key Informant (KI) Interviews and Focus Group Discussions (FGD)

Name Position Institution

Key informant Interviews

Chris Nyadzayo Chief Nutritionist Dept of Nutrition, Zimbabwe Ministry of Health and Child Welfare

Miriam M. Banda Provincial Nutritionist Dept of Nutrition, Zimbabwe Ministry of Health and Child Welfare

Dr. Joseph Murungu Deputy National ART Coordinator

AIDS and TB Programme, Zimbabwe Ministry of Health and Child Welfare

Rumbidzia Chituwu Nutritionist Harare City Health Department

Julian Borcherds Redan Mobile Transactions

Tyler Cornish Redan Mobile Transactions

Fitsum Assefa Nutrition Manager Young Children Survival and Development, UNICEF Zimbabwe

Florence Naluyinda Kitabire HIV/AIDS MNCH Manager

UNICEF Zimbabwe

Synodia Mahachi Programmes Manager Christian Care

Muramaba Tswina Country Representative MSF Zimbabwe

Professor Rudy Leuthy Clinical Director Newlands Clinic

Dr. Bethule Nyamambi Manager Newlands Clinic

Kudzanai Kasiafumbi Field Officer Newlands Clinic

Josphat Kutyauripo Nutritionist ADRA

Number and type of KI

Interviews

Location Date

1 Dietician Harare July 28

1 Sister in Charge, OI Unit Harare July 28

1 Sister in Charge, OI Unit Beatrice August 2

1 Sister in Charge, TB Unit Beatrice August 2

1 Clinical Manager, Clinical Research Center

UZCRC August 4

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1 Sister in Charge, OI Unit Wilkins August 10

1 Nutrition Specialist City of Harare August 10

1 Clinic Manager, OI Unit Epworth August 11

1 Retail staff Bonne Marche August 12

7 Counsellors Beatrice

1 Sister Parirenyatwa

Number and Type of FGDs Location Date

5 Former Beneficiaries Harare July 28

11 Staff Parirenyatwa July 29

2 Retail staff OK Julius Nyerere July 29

42 Adolescent ART (non-beneficiary)

Parirenyatwa August 1

3 Dieticians Parirenyatwa August 1

5 Former Beneficiaries Parirenyatwa August 1

3 Current Beneficiaries Beatrice August 3

6 Former Beneficiaries Wilkins August 10

2 Retail staff African Wholesalers August 11

7 Health Promoters (“Brownies”) Edith Oppermann August 12

3 Current Beneficiaries Wilkins August 12

5 Current Beneficiaries (TB) Epworth August 13

9 Current Beneficiaries Epworth August 13

7 Former Beneficiaries Epworth August 13

13 Former Beneficiaries (TB) Epworth August 13

8 Current Beneficiaries Parirenyatwa

5 Former Beneficiaries Beatrice

2 Retail staff OK Mbare August 3

3 Nutritionists Parirenyatwa

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7.4 Quantitative Survey Questionnaire

SPLASH Zimbabwe Evaluation

For programming into PDAs

Version: 16/02/2012

1 GENERAL

Interviewer name [drop-down list]

1.1 Clinic [drop-down list]

1.2 Date of Interview

1.3 Time interview started

2 PATIENT ID INFORMATION

2.1 Patient ID Number

2.2 Under which category were you registered?

ART

ART/TB

2.3 Name of suburb where residing

2.4 Does respondent have a phone (including any member of the household)?

If yes, enter the phone number

If no, go to next question

2.5 Neighbor’s phone number

2.6 Respondent’s relation to household head (Select one)

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Head

a. Head’s spouse b. Child c. Father/mother d. Other relative

2.7 What is the relationship of the respondent to the NSART client (Select one)

a. ART/TB patient b. Head of household for ART/TB patient c. Spouse of household head d. Guardian

3 HOUSEHOLD INFORMATION

For each household member, fill in the following

First Name

3.1 Relationship to household head (Select one)

a. Head of household b. Head’s spouse c. Child d. Father/mother e. Brother/sister f. Uncle/Aunt/Cousin g. Niece, Nephew, Grandchild h. Adopted/foster child i. Step child j. Grandparent k. No relation l. Other relative

3.2 Gender

a. Male b. Female

3.3 Age - In years, at last birthday (Enter 111 if don’t know)

3.4 Disability status (Select one)

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a. physically disabled b. mentally disabled c. Both d. Not disabled

3.5 Is this person currently chronically ill (ill continuously for at least past 3 months and unable to work)? Or during the past year

a. Yes b. No

3.6 Has this person been chronically ill during the past year

c. Yes d. No

3.7 Was this person engaged in any economic activities that help earn a livelihood for the household in the past 6 months? [For children 6+ years only]

(Select one)

a. Yes, currently b. Yes, but no longer c. No/Never d. n/a (eg. 5 and under)

3.8 Child parental status (for children 18 years and below)

a. Both parents alive b. Mother dead c. Father dead d. Both parents dead

3.9 School enrolment (Select one)

a. Currently enrolled and attending pre/primary/secondary b. Currently enrolled and attending tertiary/Skills training c. Not attending - Primary/Secondary Completed d. Not Attending - Completed tertiary/skills training e. Enrolled but absent > 1 week in past month f. Dropped out of school this year g. Dropped out before this school year h. Never Enrolled

>>If select a, b, c, d - skip to 3.12

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3.10 Reasons for not being in school/absence of at least one week or dropout (Select one)

a. Illness b. Work for food or money c. Help with HH work d. Care for ill household member e. Care for younger sibling f. Not interested in school g. Distance to school far h. Hunger i. Expensive/no money for school fees j. Child considered too young k. Pregnancy/marriage l. Incapable of continuing m. Other

4 EXPENDITURES

4.1 Monthly expenditure questions

Please complete the following questions, for each expenditure item, one at a time. Estimate the amount of money your household spent in the last 30 days for domestic consumption, in local currency.

a). How much money did your household spend on this item in the past 30 days? If none, write 0.

b). Before you began SPLASH, how much would you have spent on this item, compared with the past 30 days?

a. Same b. More c. Less d. Don’t know/ Don’t recall

• Cereals (maize, maize flour, rice, etc)

• Roots and tubers (Yams, potatoes, etc)

• Bread

• Legumes (beans, peas, groundnuts)

• Fruits and vegetables

• Fish/Meat/Eggs/poultry

• Oil, fat, butter

• Milk

• Sugar/salt

• Milling

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• Alcohol & Tobacco

• Soap & HH items

• Transport

• Fuel (wood, paraffin, candles, petrol/diesel etc)

• Water bills

• Electricity and other utility bills

• Telephone/Cell phone (talk time)

• House rentals (monthly)

4.2 Periodic expenditures

Please complete the following questions, for each expenditure item, one at a time. Estimate the amount of money your household spent in the last 6 months for domestic consumption, in local currency.

[For each item below, repeat the same 2 questions about expenditures]

a). How much money did your household spend on this item or service during the past 6 months? If none, write 0.

b). Before SPLASH, and before the last six months that you just mentioned, how much would you have spent on this item , compared with the last 6 months. (Select one - ie. before SPLASH, spent more than during the past 6 months, before SPLASH, spent less than during the past 6 months, etc)

a. Same b. More c. Less d. Don’t know/Don’t recall

• Medical expenses, health care

• Clothing, shoes

• Equipment, tools, seeds, animals

• Construction, house repair

• Hiring labour (not for house repair/construction)

• Debt repayment

• Education, school fees, uniform, etc

• Celebrations, social events

• Funerals

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4.3 Twelve (12) months

How has your overall expenditure pattern changed during the last twelve (12) months? (Select one)

a. Remained the same b. Increased c. Decreased

>>If select a – skip 4.4 and 4.5

>>If select b – skip 4.5

>>If select c – skip4.4

4.4 Reasons why the expenditure has increased in past 12 months? Answer Yes or No for questions (a) to (k).

a. Because of the change in my family size b. Due to loss of employment c. Due to recent gain in employment d. Due to increase in food prices e. Due to increased in school fees / education requirements f. Due to increased rentals g. Due to increased health medical expenditures h. Due to better or increased income i. Due to decrease in educational cost j. Other explain________________________________

4.5 If expenditures have decreased, please give the reasons why. Answer Yes or No for questions (a) to (k).

a. Because of the change in my family size b. Due to loss of employment c. Due to decrease in food prices d. Due to decrease in school fees / education requirements e. Due to decreased rentals f. Due to decreased health medical expenditures g. Due to reduced income h. Other explain________________________________

5 HOUSEHOLD INCOME

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5.1 What were the most important sources of income for your household during the past 1 month?

[Choose three using the codes below.]

1. Most Important 2. Second 3. Third

Responses:

a. Food crop production/sales b. Cash crop production c. Casual labor d. Begging e. Livestock production/sales f. Skilled trade/artisan g. Small business h. From rentals i. Petty trade (firewood sales, etc.) j. Pension k. Formal salary/wages l. Fishing m. Remittance/ gifts n. Vegetable production/sales o. Stone crushing and quarrying p. Brewing q. Food assistance – voucher (paper or electronic) r. Other food assistance s. Cash assistance t. Other u. No other livelihood

a. Is the primary income earner employed? Yes b. No

>> If select b – skip5.3

5.2 What main type of employment does the primary income earner have?

a. Formal employment b. Informal employment (small business or trading) c. Agriculture d. Other explain________________________________

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5.3 During the past 6 months, has your household received any of the following type of support from relatives or friends? Please answer YES or No to questions 5.4(a) to 5.4(d).

a. Money b. Food c. Clothing d. Agricultural inputs

5.4 In the past six (6) months have your regular income sources changed?

a. Yes b. No

>> Select b – skip5.6

5.5 If yes, why has your regular income sources changed? (Select all that apply)

a. Income earner passed away b. Income earner left the household (e.g. divorce) c. Family member lost regular source of income d. New income earner joined the household e. Family member got a new source of income f. Other explain________________________________ g. [leave text field for entry of response]

5.6 What was your monthly estimated household income six (6) months ago? (Enter 111 if don’t know)

5.7 What is your monthly estimated household income now? (Enter 111 if don’t know)

5.8 During the past 3 months, did you or any member of your HH borrow money?

a. Yes b. No

>> Select b – skip5.10-5.14

5.9 What was the primary reason for borrowing?

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[Choose three using the codes below.]

1. Most Important 2. Second 3. Third

Source codes:

a. To buy food b. To pay for health care c. To pay for funeral d. To pay for social event e. To pay for agricultural inputs/equipment f. To pay for education g. For business h. Other i. No other reason

[leave text field for entry of response]

5.10 From whom did you borrow? (Select one)

a. Friend/relative b. Money lender c. Bank/ formal lending institution d. Microfinance institution/ NGO e. Informal savings group

5.11 Is the debt/loan due for repayment yet?

a. Yes b. No

>>If select a– skip5.14

>>If select b – skip5.13

5.12 Have you repaid the loan yet?

a. Yes b. No

5.13 Will you be able to repay the loan?

a. Yes b. No

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>>If select b – skip5.15

5.14 If yes, how do you think you will be able to repay the loan?

a. With income from income-generating activity b. With income from formal employment c. Sale of an asset d. Remittances e. Casual labour f. Through the sale of food commodities g. Take another loan to repay h. other

6 HOUSEHOLD ASSETS

6.1 How many of the following assets are owned by you or any member of your household? If none, write 0.

• Chair

• Table

• Bed

• Mattress

• Fridge

• Stove

• Radio

• TV

• Satellite dish

• Fishing nets

• Canoes

• Axe

• Sickle

• Panga/Machete

• Knapsack Sprayer

• Mortar/pestle

• Hoe

• Scotch Cart

• Tractor

• Hand Mill

• Bicycle

• Harrow

• Plough

• Sewing machine

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• Hammer mill

• Mobile Phones

• Motor vehicle/ cycle

• Solar panel/unit

• Land

• Livestock

6.2 [Purchases of assets]: Since the time you started participating in SPLASH, did your household purchase any assets?

a. Yes b. No

>>If select a – skip6.4

>>If select b – skip6.3

6.3 What did you buy? Please answer YES or No to questions 6.3(a) to 6.3(d). [When they answer, try to probe to see what category it belongs to, and select the category]

a. Livestock b. Productive assets (items they use to earn an income – fishing nets, canoes, tools such

as axe, sickle, scotch cart, tractor, hand mill, hammer mill. For the following: Bicycle, Sewing machine, cell phone, car, fridge, stove, solar panel/unit – include them here if it was mostly used for earning an income.)

c. Basic need household assets (Chair, Table, bed, mattress, radio, mortar/pestle, pots, plates, utensils.)

d. Non-basic need household assets (TV, video, satellite dish, For the following: Bicycle, Sewing machine, cell phone, car, fridge, stove, solar panel/unit – include them here if it was not mostly used for earning and income, hence is a luxury item)

6.4 Would you have been able to make this purchase if you had not been on the SPLASH program?

a. Yes b. No

6.5 [Sales of assets]: Since the time you started participating in SPLASH, did your household sell any assets?

a. Yes b. No

>>If select yes – skip 6.8

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>>If select yes – skip 6.6, 6.7

6.6 Since the time you started participating in SPLASH, what did your household sell? Please answer YES or No to questions 6.6(a) to 6.6(d) [When they answer, try to probe to see what category it belongs to, and select the category]

a. Livestock b. Productive assets (items they use to earn an income – fishing nets, canoes, tools such

as axe, sickle, ox cart, tractor, hand mill, hammer mill. For the following: Bicycle, Sewing machine, cell phone, car, fridge, stove, solar panel/unit – include them here if it was mostly used for earning and income.)

c. Basic need household assets (Chair, Table, bed, mattress, radio, mortar/pestle, pots, plates, utensils.)

d. Non-basic need household assets (TV, video, satellite dish, For the following: Bicycle, Sewing machine, cell phone, car, fridge, stove, solar panel/unit – include them here if it was not mostly used for earning an income, hence is a luxury item or indicator of )

6.7 If yes, why? (select the first reason and the second reason)

Options

a. No longer needed b. Pay daily expenses c. Buy food for HH d. Pay medical expenses e. Other emergency f. Pay debt g. Pay for social event h. Pay for funeral i. Pay school costs j. Other k. No second reason

6.8 If you didn’t sell any assets, do you think you would have had to sell some during the past year if you were not participating in SPLASH? (Select one)

a. Yes, definitely b. Maybe c. Probably not d. Definitely not e. Don’t know

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7 HOUSEHOLD FOOD CONSUMPTION AND STOCKS

7.1 Over the past month, what were the primary and secondary sources of cereals consumed by the household? (Select one)

a. Own harvest b. Casual labor c. Borrowing d. Gift e. Purchase f. Food assistance g. Bartering h. Other

7.2 How many main meals did the adults (above 18 years) in this household eat yesterday? (Select one)

a. No meals b. 1 meal c. 2 meals d. 3 meals e. 4 meals f. More than 4 meals

7.2a How many snacks did the adults (above 18 years) in this household eat yesterday? (Select one)

a. No snack b. 1 snack c. 2 snacks d. 3 snacks e. 4 snacks f. More than 4 snacks

7.3 How many meals did the children 6 to 18 years in this household eat yesterday? If no children in the HH, Select N/A. (Select one)

a. No meals b. 1 meal c. 2 meals d. 3 meals e. 4 meals f. More than 4 meals g. N/A

7.3a How many snacks did the children 6 to 18 years in this household eat yesterday? If no children in the HH, Select N/A. (Select one)

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a. No snack b. 1 snack c. 2 snacks d. 3 snacks e. 4 snacks f. more than 4 snacks

7.4 How many meals did the children 0-5 years old in this household eat yesterday (including snacks)?

a. 1 meal b. 2 meals c. 3 meals d. 4 meals e. 5 meals f. 6 meals g. 7 meals

7.5 Has any child ever enrolled in a therapeutic feeding program (e.g. where child was fed at hospital/health centre during admission for malnutrition or fed as an out-patient using plumpy nut, RUTF, micro-nutrients etc)?

a. Yes b. No c. Don’t know

7.6 How often did the family eat from the following food groups?

a. At any time during the last 24 hours? (Answer Yes or NO) b. Number of days in the last 7 days?(Answer 0 to 7) c. What was the main source of the food? [Choose three using the codes below.]

• Maize, maize porridge

• Other cereal (rice, sorghum, millet, bead, pasta etc)

• Roots and tubers (cassava, potatoes, sweet potatoes)

• Sugar or sugar products

• Pulses: Sugar beans, soya beans, cowpeas and peas, round-nuts

• Nuts: Groundnuts and cashew nuts

• Vegetables (including relish and leaves)

• Fruits

• Beef, goat, or other red meat and pork

• Poultry and eggs

• Fish

• Oils/fats/butter

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• Milk/yogurt/other dairy

• HEPS

Source codes (Select one)

a. Own production b. Casual labour c. Borrowed d. Gift e. Purchases f. Food assistance g. Barter h. Hunting/gathering/catching

8 COPING STRATEGIES

In the past 30 days, how frequently did your household resort to using one or more of the following strategies in order to have access to food? SELECT ONE ANSWER PER STRATEGY.

a. Never b. Seldom (1-3 days/month) c. Sometimes (1-2 days/week) d. Often (3-6 days a week) e. Daily

8.1 Skip entire days without eating?

8.2 Limit portion size at mealtimes?

8.3 Reduce number of meals eaten per day?

8.4 Rely on borrowing food or on help from friends and relatives?

8.5 Rely on less expensive or less preferred foods?

8.6 Rely on purchasing/borrowing food on credit?

8.7 Gather unusual types or amounts of wild food/hunt?

8.8 Harvest immature crops (e.g. green maize)?

8.9 Rely on sending household members to eat elsewhere?

8.10 Rely on sending household members to beg?

8.11 Reduce adult consumption so that children can eat?

8.12 Rely on casual labour for food?

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8.13 Have you sold any household assets to buy food?

a. Yes b. No

8.14 Have you sold any household assets to pay for health care/medical expense?

a. Yes b. No

8.15 Do you know of any SPLASH participants who were engaging in transaction sex in order to acquire food and meet their basic needs?

8.16 Did any member of your household engage in transactional sex to acquire food?

9 TIME AND FORM OF ASSISTANCE

**

9.1 When did your HH last receive a food ration before today? (Select one)

a. July 2011 b. June 2011 c. May 2011 d. April 2011 e. Mar 2011 f. Feb 2011 g. Jan 2011 h. Dec 2010 i. Nov 2010 j. Oct 2010 k. Sep 2010 l. Aug 2010

9.2 Did you receive the following commodities and the prescribed quantities in your most recent HH ration? Please answer YES or No to questions 10.3(a) to 10.3(d).

9.3 [enter the correct quantities per household member]

a. Maize Meal (5 kg per household member)Beans (2 kg per household member) b. Cooking oil (1litre per household member) c. CSB (10 kg)

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9.4 For how many months did you receive a food ration before today? (Select one)

a. 1 months b. 2 months c. 3 months d. 4months e. 5 months f. 6 months g. 7 months h. 8 months i. More than 8 months

9.5 How many cycles have you been registered in SPLASH or NSART?

If registered more than once, answer the following

9.6 How many months between cycles were you not on SPLASH/NSART, during the past year?

9.7 What was the gender of the recipient who went and collected the last ration?

a. Male b. Female

9.8 Who in your household makes decisions on how food assistance is used?

a. Men b. Women c. Both

9.9 Did you sell or barter any food assistance from your most recent ration? Please answer YES or No to questions 10.6(a) to 10.6(d).

a. Maize Meal b. Beans c. Cooking oil

9.9.1 If yes to 10.6 what did you barter the commodities for?

10.6.1 If sold, what was the money used for?

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[this question has to be repeated for each of the 4 food items]

9.10 What level of satisfaction did you have with the following aspects of each commodity (mealie meal, pulses, vegetable oil and CSB) you received?

[Answer about each aspect, for each food item, using codes a= satisfied, b = neither satisfied nor dissatisfied, c = dissatisfied, ]

a. Taste b. Physical condition-was it mouldy, caked, moist, excessively broken,

runny/heavy/solidifies quickly c. Cooking time d. Odour e. Colour

9.11 If there were problems with the commodities at some time, were improvements made?

a. Yes b. No c. N/A

9.12 In the past 6 months, did your household receive assistance from any other organization? Please answer YES or No to questions 10.10(a) to 10.10(j)

a. Direct food assistance b. Clothing c. Farm inputs d. Loans/credit e. Agricultural skills training f. Cash transfer g. Other skills training h. Education support i. Food voucher j. Other

9.13 Which organization or program provided this assistance? (please enter the name)

10 SPLASH PROCESS

10.1 When did you get tested or diagnosed for your condition?

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10.2 What motivated you to get this test done (answer yes/no to each of the following)

Realized I was getting sick

Volunteers encouraged me

Health clinic staff encouraged me

Required to access medical services

Required for school/college/employment

Spouse/sexual partner tested positive

To get food assistance from SPLASH

If answer option above (food assistance), ask following question

10.3 Would you have been tested if there was no food assistance available?

10.4 Did you face the following problems after testing positive? (select all that apply)

Loss of employment or livelihood

Loss of friends

Marital breakup

Other - Specify:

10.5 How satisfied were you with the way that you were referred by the clinic to be registered for SPLASH?

a. Very satisfied b. Satisfied c. Unsatisfied

10.6 How satisfied were you with the way that you were registered by Christian Care /WFP?

d. Very satisfied e. Satisfied f. Unsatisfied

10.7 How satisfied were you with the process of redeeming the voucher and getting food from the retailer?

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a. Very satisfied b. Satisfied c. Unsatisfied

10.8 Did you experience any particular problems at the retailer’s shop?

a. Yes b. No

>> If select b, skip following question

10.9 If there are problems, please answer YES or No to questions 12.6(b) to 12.6(f).

b. Network problems, caused delays on one day c. Network problems, had to return another day d. Retailers were rude to us e. Fear about confidentiality and stigma f. Other: explain_______________________________

[leave text field for entry of response]

10.10 In the SPLASH program, food was provided through vouchers rather than direct distribution at the clinic. Have you ever received food assistance through direct distribution in this way?

a. Yes b. No

10.11 Are there advantages of the arrangement with vouchers?

a. Yes b. No

>>If select b, skip 12.3(a) to (g)

10.12 What advantages are there? (ask open-ended and select all that apply)

a. Feel empowered because can go into store b. Flexibility of timeframe to pick up of food c. More convenient pick up points

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d. Reduces congestion at clinic e. Flexibility on choice of foods f. More secure for beneficiaries g. There is more confidentiality/less stigma h. The arrangements are more dignified i. Accuracy of ration measurements (no scooping)

10.13 Would you say that the following are advantages of the voucher system? (please answer YES or No)

a. Feel empowered because can go into store b. Flexibility of timeframe to pick up of food c. More convenient pick up points d. Reduces congestion at clinic e. Flexibility on choice of foods f. More secure for beneficiaries g. There is more confidentiality/less stigma h. The arrangements are more dignified i. Accuracy of ration measurements (no scooping)

10.14 How many hours did you have to wait at the retailer shop to redeem your voucher and collect the food?

[Round off to nearest hour, e.g. 2 ½ hours would count as 3 hours]

a. 0-10 minutes b. 11-20 minutes c. 21-30 minutes d. 31-40 minutes e. 41-50 minutes f. 51-60 minutes g. Between 1 and 2 hours h. Between 2 and 3 hours

10.15 Do you feel it is more dignified to receive food assistance through vouchers, rather than direct distribution?

a. Yes, more dignified b. No, less dignified c. No opinion

10.16 Where would you rather pick up food from?

• At the retail outlet or at the clinic?

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• Retail outlet

• Clinic

• Either (retail outlet or clinic)

11 PREFERENCE of FOOD VS CASH

11.1 If you could choose between assistance in form of food (i.e. through vouchers), cash assistance or a combination of the two, which would you prefer?

a. food assistance only b. cash only c. combination, even if the value is still the same

>>If select a, skip 13.3, 13.4

>> If select b, skip 13.2, 13.4

>>If select c, skip 13.2, 13.3

11.2 What are the 3 main reasons you prefer food only?

Reason1

Reason2

Reason3

a. Better for children and the family because cash gets spent on non-essential items b. Difficult to steal food c. Easier to share with family/friends d. Better because it is managed by women e. Food prices are high f. Food prices are unpredictable g. Difficult to access market h. Those food items sometimes not available in market i. Other explain_______________________________

[leave text field for entry of response] j. No other reason

11.3 What are the 3 main reasons you would prefer cash only?

Reason1

Reason2

Reason3

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a. Can purchase food and other items b. Food prices are low c. Can purchase variety of foods d. Easy to transport/no costs e. Can save part of the cash f. Can be used for other expenses g. There is plenty of food for sale h. We have good access to markets i. Can purchase agricultural inputs j. Can use cash for small business k. Other explain_______________________________

[leave text field for entry of response] l. No other reason

11.4 What are the 3 main reasons you prefer a combination of food and cash?

Reason1

Reason2

Reason3

a. With both, we can meet seasonal needs b. Safer than just cash (theft) c. Can be controlled by both men and women d. Ability to cope is improved e. More flexible than just food f. Can use cash for small business g. There is confidentiality/less stigma h. Flexibility in choice of food i. Flexibility of timeframe to pick up of food j. More flexible for beneficiaries k. Other explain_______________________________

[leave text field for entry of response] l. No other reason

12 QUESTIONS RELATED TO PROGRAM MANAGEMENT and BENEFITS

12.1 In what way did the food assistance help you? Please answer YES or No to questions 14.5(a), 14.5(b).

a. Was able to eat better for some time?

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b. Was able to save money for other needs?

>> (b) If select NO, skip 14.6

12.2 If you were able to save money for other needs, what did you use the savings for? Please answer YES or No to questions 14.6(a) to 14.6(j).

a. School fees b. Medical expenses c. Social or cultural events d. Rent e. For a business f. Funeral expenses g. Debt/ loan repayment h. Purchase household items i. To purchase other types of food j. Other explain_______________________________

[leave text field for entry of response]

12.3 Do you feel you are better off after the program, better than you would have been if you hadn’t participated in the program?

a. Yes, I am better off b. No, I am not better off

12.4 Please explain your answer

[leave text field for entry of response]

13 MEDICAL QUESTIONS?? ART/TB BENEFICIARIES

13.1 How often does the client come for review or for ART services? Select the most

appropriate answer

a. Once in three months (4) b. Twice a month (1) c. Once a month d. Once in two months (3) e. Never f. Other (Specify)_______________________

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13.2 How often does the client have their anthropometric measurements taken?

a. Once in three months b. Never c. Other (Specify)_ d. Twice a month e. Once a month f. Once in two months

13.3 Did any of the following happen to the client during the last 30 days? (allow for multiple

responses)

Default is defined as a treatment interruption of two consecutive days or more while non-

adherence

Defaulted from drugs

Did not adhere to drugs why

Did not receive enough drugs from health centre (refer to Q13.1)

Suffer from side effects from drugs (nausea, vomiting, rashes) Shared with friend, neighbour or family member (2)

Loss of appetite Did not have adequate food (3)

Unable to eat Suffering from side effects (4)

Suffered from diarrhoea Lack of money to meet transport costs to the health centre (5)

Suffered from other illnesses like malaria, flu, rashes Sold drugs (6)

Depression/Stress Other___________________________(Specify) (7)

Other_____________________(Specify)

13.3.1 If client, defaulted from drugs, state the MAIN reason why

Missed the review date (1)

13.4 What effect has food/cash assistance had on the well-being of the client?

a. Weight gain b. Increased mobility c. Enhanced productivity (3) d. None directly attributed to food assistance e. Other____________________(specify)(

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13.5 Investigate clients mobility and self-sufficiency and complete table by writing a code in the final column

Normal= 1 Good= 2 Moderate= 3 Poor= 4 Very poor= 5

Mobility of ART/TB patient

Can walk 3km

Can walk 2km

Can walk 500m

Can walk around the house

Bed-Bound

Domestic chores All chores

5-6 days per week

3-4 days per week

Occasionally

Not at all

Bathing Independent

Usually independent

Needs some assistance

Needs considerable assistance

Not at all

Count

Toileting Independent

Usually independent

Needs some assistance

Needs considerable assistance

Dependent

13.6 If the program helped you to adhere to your medication, why was this case? Please answer YES or No to questions 16.3(a) to 16.3(d). [Please check respondent’s answer to question 14.4d before this question is answered.]

a. Helped me follow scheduled clinic visits b. Since taking medicine is prerequisite to get food ration c. Easier to take medicine with food d. Medicine makes me hungry, so stop taking it unless can eat e. Other explain_______________________________

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[leave text field for entry of response]

13.7 How many TB/ART clients in this household participated in SPLASH?

13.8 Please complete the table, one ART/TB client at a time. Enter all ART/TB clients who participated SPLASH in this HH.

16.5a ART/TB client’s name

16.5b Is this ART/TB client present here now?

a. Yes

b. No

>> If select no, skip 16.5(c) to (e)

16.5c ART/TB client’s weight (kg)

16.5d ART/TB client’s height (cm)

16.5e MUAC (cm)