The goal of this activity is to improve child growth, health and nutritional status, HIV-free survival of infants

and young children, and maternal nutrition, PATH/IYCN will provide technical assistance to the OPC and

the Ministry of Health to harness and strengthen the capacity of community agents and local government

structures at the community level to plan and implement integrated nutrition and HIV activities. IYCN will

provide technical assistance to condense lessons learned from the I-LIFE/WALA, BASICS and CHAM

programs, the IYCN/Bunda College IYCF study, and IYCN's similar experiences in other countries, like

Zambia and Côte d'Ivoire, to develop a comprehensive community nutrition package implemented by

Community Motivators in Malawi. IYCN will also provide assistance for the training of community

motivators and supervisors in one focus district (tentatively Mulanje), monitoring and evaluation of the

pilot implementation, and implementation planning for national scale up. Additionally, PEPFAR partners

will be supported to design and implement activities on infant feeding within the context of HIV. Initial

activities will include support to the OPC to facilitate a stakeholders' workshop to develop an IYCF

operational strategy which will identify national priorities over a specified time period and technical

approaches for addressing each of the priorities. This activity is joint-funded by MCH nutrition resources

and PEPFAR resources at a ration of 1:1.

1. PMTCT Budget Code ($300,000.00)

Project Objective 1 Activity 1: Improve enabling environment for IYCF programs Support the OPC and MoH to develop IYCF operational strategy: IYCN will conduct a series of consultative meetings with the OPC, Nutrition Department, the MoH, and key members of the IYCF Technical Working Group (TWG) to draft a national IYCF operational strategy for the implementation of the National IYCF Policy. To inform these consultations, IYCN will compile information from the recent Demographic Health Survey (DHS), the UNICEF Multiple Indicator Cluster Survey (MICS) and the Micronutrient Survey, results of studies on nutrition and IYCF, and lessons learned from the ILIFE, BASICS, and other projects and programs in Malawi and other countries in the region. These consultations will culminate in a two-day stakeholders' workshop, facilitated by IYCN, to finalize the strategy. The strategy will identify, in accordance with the national policy, priority areas and targets to support infant and young child growth and to improve nutritional status, HIV-free survival, and maternal nutrition. Activity 2: Develop operational guidelines, training curricula, job aids and IEC materials for community- based IYCF and HIV services: Guided by the priority areas and targets of the IYCF operational strategy, IYCN will work with the OPC to produce the technical supports required for operating a community-based nutrition and HIV support program. Operational guidelines and a detailed implementation plan will be developed to standardize activities at all levels of the program and guide management. Training curricula,

based on similar curricula IYCN has created for other country programs, will be produced for community motivator, supervisor, and local authority trainings. The training curricula used for lay cadres within PMTCT settings will also be reviewed and updated to reflect best practices, and if possible, combined with the training curricula being used for lay cadres within PMTC T settings so as to prevent duplication. Job aids and IEC materials will be developed in a two-stage process. First, IYCN will conduct an inventory and assessment of existing educational and counseling materials related to IYCF and HIV services. To the extent possible, IYCN will use these materials to develop standardized messages and counseling materials to support the new program, producing new materials only to fill gaps identified from the assessment of existing materials. Findings from the recently completed IYCN/Bunda College IYCF Study will inform the BCC/IEC material creation process. All materials will be context and target specific and pre-tested to ensure their suitability for communities. Activity 3: Develop and Implement a Monitoring and Evaluation Strategy: Working from and with the OPC, IYCN will oversee the monitoring of field activities. A detailed M&E plan will be developed describing indicators and targets, and emphasizing management responses based on monitoring data. Key monitoring indicators will include: coverage (contacts with caregivers and services provided); infant and young child growth and nutritional status; pregnancies and known HIV status; ARV adherence; and referrals to health, HIV and food security services. Monitoring activities will incorporate a new initiative utilizing mobile telephone text messages for timely reporting of monitoring data and quicker response time for management response. Through quarterly joint review and planning meetings IYCN will coordinate stakeholders, including the Ministry of Health, local authorities, WALA, BASICS and USAID partners to assess progress and plan activities for the next period. Activity 4: Support OPC to develop a national scale-up plan for supporting improved community-based : During the final months of the funding period, IYCN and OPC will develop a detailed implementation plan for national scale-up of the Community Motivator program, including through utilizing already existing community The plan will address human resources and training (including infrastructure for training, refresher training, and training for turnover vacancies), management, materials development, budget at national and local levels, and monitoring and evaluation.

Project Objective 2: Improve Provider Performance Activity 1: Build capacity of community nutrition and HIV motivators: IYCN will provide technical assistance to the OPC and the Ministry of Local Government to train up to 10 trainers, 300 community nutrition motivators and 30 supervisors within the first project year. [OPC will be responsible to recruit trainers, agents and supervisors.] Trainers, who will be trained first, will in turn train community motivators and supervisors with technical assistance and support from IYCN. Working in OPC- designated but peripheral training sites, IYCN will provide training materials and communications tools. OPC will manage transport, per diem, sitting fees, etc. for trainees. All training activities will rely on best practices for adult learning, with extensive practicum to build experience with IYCN developed tools for

managing program logistics (e.g., participant registers), nutritional assessment and counseling, and monitoring and supervision. Close partnership will be sought with BASICS, WALA and CHAM in a bid to increase coverage of trained community motivators—for example by including current community agents from these projects in the training. To ensure sustainability of community training programs IYCN will coordinate activities closely with institutions such as Bunda Agricultural College, Natural Resources Centre and Magomero Training College. Activity 2: Build capacity of local authority representatives: IYCN will work with the OPC to assist local government teams to develop a follow up plan which will include integration of community nutrition and HIV activities into local government plans and budget. Experience from IYCN's on going work with local government authorities in South Africa will inform this process. Activity 3: Provide support to PEPFAR partners to design and implement infant feeding within the context of HIV In addition IYCN will provide technical assistance to PEPFAR partners to design and implement activities on infant feeding within the context of HIV/PMTCT. This includes both partners implementing community-based support activities for PMTCT, such as Baylor, PACT, CHAM, and MSH, as well as partners providing facility-based support for PMTCT as part of the zonal mentoring and quality improvement initiative. Standardized approaches to supervision of IYCF activities on the facility-level will be also be developed and shared with these partners and the zonal and district health offices that they support, so that IYCN will be mainstreamed within the broader QI activities at facility level. Activity 4: Mentoring of Supervisors: Effective supportive supervision is an important factor in the success of community-based programs. In addition to producing guidance for supervision in the operational guidelines, and monitoring formats to highlight the key aspects of a supervision visit, IYCN staff will routinely accompany supervisors to mentor them in supervision techniques. To the degree that time permits, IYCN will also mentor supervisors of other lay cadres being employed in PMTCT (i.e. Baylor, M2M, MSH, PACT partners) to build their capacity to ensure that the community-based workers employed under these platforms are providing high quality support for infant and young child feeding in the context of HIV. Staff from the OPC will perform this function in later years as the project expands beyond the pilot phase. Project Objective 3: Increase community and household support Activity 1: Provide technical support for a pilot household and family centered program for nutrition and HIV support: Trained CM will be equipped to implement a package of IYCF activities which will focus on behavior change prior to the development of malnutrition rather than its detection and treatment after the fact, and on preventing HIV infection through breastfeeding. In collaboration with USAID and the OPC, IYCN will select one project district for the first year of implementation, determine coverage, and establish targets. The package will include the following: - CMs will conduct nutritional assessments of women and children and counsel women on maternal nutrition and recommended infant and young child feeding and caring practices applying interpersonal

communication, negotiation, and participatory skills using job aids. - CMs will conduct activities to enhance early identification of growth faltering (prior to the development of malnutrition). Activities will include: discussion with caregivers of growth faltering infants/children to determine current feeding practices; tailored counseling and negotiated behavior change for improved maternal diet, infant and young child feeding and caring practices; activities to reduce identified barriers to optimal nutrition practices; and home-based follow-up for mothers and children at risk. CMs also will involve traditional healers to ensure that they are providing correct messages and referring caregivers to services. - CMs will implement activities to improve complementary feeding, such as identifying local complementary foods, assessing their nutritional value, and developing recipes that can be taught to mothers through participatory food preparation sessions in the community. - CMs will guide pregnant women and caregivers to utilize HIV-related activities ensuring a standardized continuum of care for mothers, even as they move from one service type to another during pregnancy, delivery and lactation, emphasizing self-care, ARV adherence, and social support. - The package additionally will target influential community groups (males, grandmothers) to build support for program activities, and strengthen linkages with food security, sanitation, livelihood, and health programs. Local government programs such as local authority planning, agricultural extension, women and development, and education will be consulted to harness their strengths in the program. The implementation design will ensure adequate coverage for households, with no more than 20 eligible households served by a community motivator. Since effective supportive supervision is an essential element in the success of community-based programs, one supervisor will be responsible for no more than ten community motivators. Existing community local government structures will be supported to integrate the planning and implementation of these activities. Involving the local government structures will ensure that nutrition programs are managed in a more sustainable manner. The package will include: standardized behavioral change communications materials; training curricula and manuals; roles and responsibilities of local government, health and agricultural authorities; and implementation plans. GENDER PATH/IYCN will draw upon its experience working with men's groups and grandmothers' projects in other countries to develop and strengthen approaches that galvanize communities to address harmful gender norms and stigmatizing attitudes that can affect infant feeding choices and maternal nutrition. IYCN will ensure that gender concerns, including HIV-related stigma and discrimination against women and male participation, are integrated into facility and community-based activities. The aim will be to promote healthy practices and to highlight innovative approaches for engaging families and communities in transforming harmful stereotypes and stigmatizing attitudes, all of which increase vulnerability to illness and violence. IYCN will specifically ensure that training addresses the specific cultural and social barriers that female caregivers face in accessing community and government services and support for themselves and their children.