Evidence is scant that a reduction in malnutrition can be sustained over the long term using community nutrition programs operated on a national scale in developing countries.  Although growing a program to increase coverage is important for shifting the distribution of malnutrition in a population, it risks changing the nature and quality of the intervention such that the effectiveness of the program is reduced or lost.  The purpose of this evaluation is to determine whether early benefits to nutritional outcomes in 2004 from a nutrition program in Madagascar were sustained in 2011 after a period of program expansion.

In 1999, the Government of Madagascar rolled out a national, community-based growth monitoring and nutrition education program.  Data from three nationally representative anthropometrics surveys, administered pre and post program implementation, in participating and non-participating communities, are used to evaluate the effectiveness of the program on reducing malnutrition in children less than 5 years of age.  

Communities that initiated the program in 1999 evidenced a small but significant effect on mean weight-for-age by 2004, but this effect was not sustained to the same level through 2011.   Early evidence that the program improved mean height-for-age was eliminated by 2011. Communities that adopted the program after 2004 showed no evidence of benefit to any nutritional outcomes in children.  As compared to the “early” communities, nutrition workers in the “new” communities reported less use of key messages and materials and participants demonstrated poorer understanding of good hygiene and feeding practices.

The results show that expanding a program can jeopardize the effectiveness of the program if intensity, quality, or processes are not maintained.  Key factors, such as increased population pressure and workloads, are important to consider when bringing a program to scale.