document of the world bank...date achieved 04/29/2008 04/02/2012 04/02/2012 05/31/2014 comments...
TRANSCRIPT
-
Document of
The World Bank
Report No: ICR00003201
IMPLEMENTATION COMPLETION AND RESULTS REPORT
(IDA-H3760)
ON A
GRANT
IN THE AMOUNT OF SDR 18.8 MILLION
(US$ 30 MILLION EQUIVALENT)
TO THE
FEDERAL DEMOCRATIC REPUBLIC OF ETHIOPIA
FOR A
NUTRITION PROJECT
April 15, 2015
Health, Nutrition and Population Global Practice (GHNDR)
Eastern and Southern Africa
Africa Region
Pub
lic D
iscl
osur
e A
utho
rized
Pub
lic D
iscl
osur
e A
utho
rized
Pub
lic D
iscl
osur
e A
utho
rized
Pub
lic D
iscl
osur
e A
utho
rized
Pub
lic D
iscl
osur
e A
utho
rized
Pub
lic D
iscl
osur
e A
utho
rized
Pub
lic D
iscl
osur
e A
utho
rized
Pub
lic D
iscl
osur
e A
utho
rized
-
-ii-
CURRENCY EQUIVALENTS
(Exchange Rate Effective March 27, 2008)
Currency Unit = Ethiopia Birr
US$ 1.00 = Ethiopia Birr (ETB) 9.36
FISCAL YEAR
July 8-July 7
ABBREVIATIONS AND ACRONYMS
BF Breast Feeding
BMI Body Mass Index
BPR Business Process Re-engineering
CBN Community-Based Nutrition
CF Complementary Feeding
CHD/EOS Child Health Days/Enhanced Outreach Strategy
CPS Country Partnership Strategy
CMAM Community-Based Management of Acute Malnutrition
CSA Central Statistics agency
DA Development Agent
DALY Disability-Adjusted Life Years
DHS Demographic and Health Survey
DP Development Partner
EDHS Ethiopia Demographic and Health Survey
EHNRI Ethiopia Health and Nutrition Institute
EPHI Ethiopia Public Health Institute
FMOH Federal Ministry of Health
GMP Growth Monitoring and Promotion
HABP Household Asset Building Program
HAZ Height-for-Age Z Score
HDA Health Development Army
HEP Health Extension Program
HEW Health Extension Worker
HMIS Health Management Information System
IDA Iron Deficiency Anemia
IDD Iodine Deficiency Disorder
IFA Iron Folic Acid
IFR Interim Financial Report
IRT Integrated Refresher Training
ISS Integrated Supportive Supervision
IYCF Infant and Young Child Feeding
NNP National Nutrition Plan
-
-iii-
NNS National Nutrition Strategy
PASDEP Plan for Accelerated and Sustained Development to End Poverty
PBS Protection of Basic Services Program
PFSA Pharmaceutical Fund and Supply Agency
PPT Government Project Preparation Team
PSNP Productive Safety Net Program
P4R Program for Results
RUTF Ready to Use Therapeutic Food
SCF Save the Children Federation
SNNPR Southern Nations, nationalities, and Peoples' Region
Vice President: Makhtar Diop
Country Director: Guang Zhe Chen
Sector Manager: Abdo S. Yazbeck
Project Team Leader: Ziauddin Hyder
ICR Team Leader: Christopher H. Herbst
-
-iv-
ETHIOPIA
NUTRITION PROJECT (P106228)
CONTENTS
Data Sheet
A. Basic Information .......................................................................................................... vi B. Key Dates ...................................................................................................................... vi C. Ratings Summary .......................................................................................................... vi D. Sector and Theme Codes .............................................................................................. vii
E. Bank Staff ..................................................................................................................... vii
F. Results Framework Analysis ........................................................................................ vii
G. Ratings of Project Performance in ISRs ....................................................................... xi H. Restructuring (if any) .................................................................................................... xi I. Disbursement Profile xii
1. Project Context, Development Objectives and Design .............................................. 1 1.1 Context at Appraisal ............................................................................................. 1
1.2 Original Project Development Objectives (PDO) and Key Indicators ................. 3
1.3 Revised PDO (as approved by original approving authority) and Key Indicators,
and reasons/justification.............................................................................................. 4
1.4 Main Beneficiaries, ............................................................................................... 5
1.5 Original Components (as approved) ..................................................................... 5
1.6 Revised Components ............................................................................................ 7
1.7 Other significant changes ...................................................................................... 7
2. Key Factors Affecting Implementation and Outcomes ............................................. 7 2.1 Project Preparation, Design and Quality at Entry ................................................. 7
2.2 Implementation ................................................................................................... 10
2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization .... 13
2.4 Safeguard and Fiduciary Compliance ................................................................. 15
2.5 Post-completion Operation/Next Phase .............................................................. 15
3. Assessment of Outcomes............................................................................................. 17
3.1 Relevance of Objectives, Design and Implementation ....................................... 17
3.2 Achievement of Project Development Objectives .............................................. 18
3.3 Efficiency ............................................................................................................ 27
3.4 Justification of Overall Outcome Rating ............................................................ 30
3.5 Overarching Themes, Other Outcomes and Impacts .......................................... 30
-
-v-
3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops ... 32
4. Assessment of Risk to Development Outcome .......................................................... 32
5. Assessment of Bank and Borrower Performance .................................................... 33 5.1 Bank Performance ............................................................................................... 33
5.2 Borrower Performance ........................................................................................ 34
6. Lessons Learned .......................................................................................................... 36 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners ....... 37 Annex 1. Project Costs and Financing .............................................................................. 38
(a) Project Cost by Component (in USD Million equivalent as of April 9, 2015) ... 38
(b) Financing ............................................................................................................. 38
Annex 2. Outputs by Component...................................................................................... 39 Annex 3. Economic and Financial Analysis ..................................................................... 41
Annex 4. Bank Lending and Implementation Support/Supervision Processes ................. 50
(a) Task Team members............................................................................................ 50
(b) Staff Time and Cost............................................................................................. 51
Annex 5. Beneficiary Survey Results ............................................................................... 52 Annex 6. Stakeholder Workshop Report and Results ....................................................... 53 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR ......................... 54 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders ........................... 62 Annex 9. List of Supporting Documents .......................................................................... 63
-
-vi-
A. Basic Information
Country: Ethiopia Project Name: Ethiopia Nutrition
(FY08)
Project ID: P106228 L/C/TF Number(s): IDA-H3760,TF-
10247,TF-93946
ICR Date: 04/08/2015 ICR Type: Core ICR
Lending Instrument: SIL Borrower:
FEDERAL
DEMOCRATIC REP.
OF ETHIOPIA
Original Total
Commitment: SDR 18.8M Disbursed Amount: SDR 17.3M
Revised Amount: SDR18.8M
Environmental Category: C
Implementing Agencies:
Federal Ministry of Health, Ethiopia
Cofinanciers and Other External Partners:
B. Key Dates
Process Date Process Original Date Revised / Actual
Date(s)
Concept Review: 09/27/2007 Effectiveness: 09/10/2008 09/10/2008
Appraisal: 02/26/2008 Restructuring(s): 12/16/2013
04/02/2012
Approval: 04/29/2008 Mid-term Review: 11/21/2011 11/29/2011
Closing: 01/07/2014 05/31/2014
C. Ratings Summary
C.1 Performance Rating by ICR
Outcomes: Satisfactory
Risk to Development Outcome: Moderate
Bank Performance: Moderately Satisfactory
Borrower Performance: Moderately Satisfactory
C.2 Detailed Ratings of Bank and Borrower Performance (by ICR)
Bank Ratings Borrower Ratings
Quality at Entry: Moderately Satisfactory Government: Moderately Satisfactory
Quality of Supervision: Satisfactory Implementing
Agency/Agencies: Moderately Satisfactory
Overall Bank
Performance: Moderately Satisfactory
Overall Borrower
Performance: Moderately Satisfactory
-
-vii-
C.3 Quality at Entry and Implementation Performance Indicators
Implementation
Performance Indicators
QAG Assessments
(if any) Rating
Potential Problem Project
at any time (Yes/No): No
Quality at Entry
(QEA): None
Problem Project at any
time (Yes/No): No
Quality of
Supervision (QSA): None
DO rating before
Closing/Inactive status: Satisfactory
D. Sector and Theme Codes
Original Actual
Sector Code (as % of total Bank financing)
Central government administration 36 36
Health 57 57
Sub-national government administration 7 7
Theme Code (as % of total Bank financing)
Child health 25 25
Health system performance 25 25
Nutrition and food security 50 50
E. Bank Staff
Positions At ICR At Approval
Vice President: Makhtar Diop Obiageli Katryn Ezekwesili
Country Director: Guang Zhe Chen Kenichi Ohashi
Practice
Manager/Manager: Olusoji O. Adeyi John A. Elder
Project Team Leader: Ziauddin Hyder Andrew Sunil Rajkumar
ICR Team Leader: Christopher H. Herbst
ICR Primary Author: Richard M. Seifman
F. Results Framework Analysis
Project Development Objectives (from Project Appraisal Document)
To improve child and maternal care behavior, and increase utilization of key
micronutrients, in order to contribute to improving the nutritional status of vulnerable
groups.
-
-viii-
Revised Project Development Objectives (as approved by original approving authority)
No Changes to the PDO were made
(a) PDO Indicator(s)
Indicator Baseline Value
Original Target
Values (from
approval
documents)
Formally
Revised
Target
Values
Actual Value
Achieved at
Completion or
Target Years
Indicator 1 : Percentage of infants aged 0-5 months exclusively breastfed.
Value
quantitative or
Qualitative)
51% (49% in PAD)
At least 5% above
baseline value or
56%
56% 52%
Date achieved 03/29/2008 04/02/2012 04/02/2012 05/31/2014
Comments
(incl. %
achievement)
Target not achieved. Original 2005 Baseline data value updated with 2009 data,
and end-line target adjusted, at time of restructuring. Actual values based on
2013 National Nutrition Survey with no additional data available from 2014
Mini-DHS Survey. At the same time, it should be noted that these are national
level data, and an external evaluation carried out by Tulane in CBN woredas
only, which received much of the focus of this project, showed an increase in
tranche 2 to nearly 90% (an increase much higher than observed at national level
increase above).
Indicator 2 : Percentage of households using adequately iodized salt.
Value
quantitative or
Qualitative)
Date achieved
Comments
(incl. %
achievement)
Dropped at time of restructuring.
Indicator 3 : Percentage of pregnant women receiving iron and folate supplementation
Value
quantitative or
Qualitative)
17% 25% 25% 89%
Date achieved 10/01/2009 04/02/2012 04/02/2012 05/31/2014
Comments
(incl. %
achievement)
Target significantly exceeded. Baseline value updated with 2009 data and end-
line target adjusted accordingly at time of restructuring. The DHS shows a more
modest increase, a two-fold increase in iron tablet consumption among rural
women in the last three years from 15% in 2011 to 34%. Data based on
Ethiopia Mini-Demographic and Health Survey 2014, pp 42-43)
Indicator 4 : Percentage of children 0-23 months participating in monthly GMP sessions
Value
quantitative or
Qualitative)
0.00 40% 40% 42%
Date achieved 04/29/2008 04/02/2012 04/02/2012 05/31/2014
Comments Target exceeded. Indicator added at time of restructuring.. Data based on routine
-
-ix-
(incl. %
achievement)
CBN data from the FMOH.
Indicator 5 : Number of people with access to a basic package of nutrition services
(CBN).
Value
quantitative or
Qualitative)
0 44,125,000 44,125,000 55,800,000
Date achieved 04/29/2008 04/02/2012 04/02/2012 05/31/2014
Comments
(incl. %
achievement)
Target significantly exceeded. Indicator refined at re-structuring from "people
with Access to a basic package of health, nutrition or population services". Data
based on routine FMOH CBN data.
Indicator 6 : Number and percentage of children aged 6-59 months receiving a dose of
vitamin A every six months.
Value
quantitative or
Qualitative)
10,200,000 11,300,000 11,300,000 12,159,933
Date achieved 04/02/2012 04/02/2012 04/02/2012 04/02/2012
Comments
(incl. %
achievement)
Target exceeded. Indicator refined at restructuring from "Children Receiving a
dose of Vitamin A". Data based on routine CHD/EOS reports.
(b) Intermediate Outcome Indicator(s)
Indicator Baseline Value
Original Target
Values (from
approval
documents)
Formally
Revised
Target Values
Actual Value
Achieved at
Completion or
Target Years
Indicator 1 : Percentage out of target based on 30,000 Health Extension Workers
(HEWs) trained on a revised curriculum
Value
(quantitative
or Qualitative)
0.0 85% 85% 80%
Date achieved 04/29/2008 04/02/2012 04/02/2012 05/31/2014
Comments
(incl. %
achievement)
Partially achieved. Data based on FMOH Policy and Planning Directorate
information, HMIS and annual NNP reports.
Indicator 2 : Universal Salt Iodization policy adopted and in force (supporting
Proclamation 200/2000).
Value
(quantitative
or Qualitative)
Not yet achieved Achieved Achieved Achieved
Date achieved 04/29/2008 04/02/2012 04/02/2012 05/31/2014
Comments
(incl. %
achievement)
Target achieved. Legislation adopted and came into force in 2011.
Indicator 3 : Percentage of iodization machines functioning out of 60 planned.
Value
(quantitative Not achieved Not achieved Not achieved Not achieved
-
-x-
or Qualitative)
Date achieved 04/02/2012 04/02/2012 04/02/2012 04/02/2012
Comments
(incl. %
achievement)
Dropped at restructuring.
Indicator 4 : Establishment of inter-sectoral National Nutrition Coordination Body.
Value
(quantitative
or Qualitative)
Not yet achieved Achieved Achieved Achieved
Date achieved 04/02/2012 04/02/2012 04/02/2012 05/31/2014
Comments
(incl. %
achievement)
Target met. Data reflected in terms of reference, in annual NNP program reports
Indicator 5 : Number and percentage of Health personnel (health center to federal level)
receiving training on CBN).
Value
(quantitative
or Qualitative)
0.00 12,000 12,000 13,000.00
Date achieved 04/29/2008 04/02/2012 04/02/2012 05/31/2014
Comments
(incl. %
achievement)
Target exceeded. Data based on FMOH routine reports.
Indicator 6 : Percentage of national salt production iodized in previous year.
Value
(quantitative
or Qualitative)
0.00 50% 50% 90%
Date achieved 04/29/2008 04/02/2012 04/02/2012 05/31/2014
Comments
(incl. %
achievement)
Target exceeded. Added at time of restructuring. Data based on FMOH routine
reports and HSDP IV annual performance reports.
Indicator 7 : Percentage of CBN woredas providing monthly nutrition data to federal
level.
Value
(quantitative
or Qualitative)
0.00 50% 50% 80%
Date achieved 04/29/2008 04/02/2012 04/02/2012 01/07/2014
Comments
(incl. %
achievement)
Target Exceeded. Revised at restructuring from" percentage of nutritional
surveillance sites operating and providing periodic data, out of a target of 20, to
be achieved by project completion". Data based on FMOH administrative
reports.
Indicator 8 : Percentage of NNP operational research studies completed and disseminated
Value
(quantitative
or Qualitative)
0.00 8 8 10
Date achieved 04/29/2008 04/02/2012 04/02/2012 04/02/2012
Comments
(incl. %
achievement)
Target exceeded. Refined at restructuring from" percentage of operational
research studies contracted out of a target of 8 to be achieved by project
completion". Data based on FMOH administrative reports
-
-xi-
Indicator 9 : Percentage of health personnel trained to masters level in nutrition ( target
of 30)
Value
(quantitative
or Qualitative)
0 80 80 100%
Date achieved 04/29/2008 04/02/2012 04/02/2012 05/31/2014
Comments
(incl. %
achievement)
Target exceeded. Indicator added at time of restructuring. Data based on FMOH
administrative reports
Indicator 10 : Zinc registered as essential drug and included in Health Post package
Value
(quantitative
or Qualitative)
Not yet achieved Not Achieved Not Achieved Achieved
Date achieved 04/02/2012 04/02/2012 04/02/2012 04/02/2012
Comments
(incl. %
achievement)
Target achieved. Data based on FMOH administrative reports.
G. Ratings of Project Performance in ISRs
No. Date ISR
Archived DO IP
Actual
Disbursements
(USD millions)
1 06/20/2008 Moderately Satisfactory Moderately Satisfactory 0.00
2 12/27/2008 Satisfactory Satisfactory 3.00
3 06/29/2009 Satisfactory Satisfactory 3.00
4 12/19/2009 Satisfactory Moderately Satisfactory 3.05
5 06/23/2010 Moderately Satisfactory Moderately Satisfactory 3.56
6 03/26/2011 Moderately Satisfactory Moderately Satisfactory 7.18
7 09/13/2011 Satisfactory Satisfactory 9.20
8 03/31/2012 Satisfactory Satisfactory 15.37
9 05/19/2012 Satisfactory Satisfactory 15.80
10 01/15/2013 Satisfactory Satisfactory 17.62
11 06/18/2013 Satisfactory Satisfactory 18.57
12 01/04/2014 Satisfactory Moderately Satisfactory 23.37
13 05/28/2014 Satisfactory Moderately Satisfactory 24.55
H. Restructuring (if any)
The project was restructured on April 2, 2012 to refine the Results Framework, some
Indicators, and baselines. It was restructured again December 16, 2013, to extend the
Grant Closing Date by 5 months from January 07, 2014 to May 31, 2014.
-
-xii-
I. Disbursement Profile
-
1
1. Project Context, Development Objectives and Design
1.1 Context at Appraisal
At the time of appraisal in 2008, Ethiopia had GDP growth averaging an impressive
6.4% annually, however further growth was held back by a number of important
bottlenecks. As an economy significantly dependent on the agriculture sector, high
population growth rates contributed to a decline in farm sizes, with climate variability in
rainfall correlated to lower household income and consumption (Poverty Assessment,
World Bank, 2005). Health risks - including malaria and HIV/AIDS - exacerbated the
vulnerability of the poor, driving thousands into poverty traps.
An underlying problem in Ethiopia was the high rate of malnutrition, with
micronutrient deficiencies some of the most prevalent disorders. As correctly
identified in the PAD, high prevalence of malnutrition, referring to under-nutrition, or
deficiency of nutrition (as opposed to over-nutrition), was a key problem. The 2005 DHS
data at the time found that alongside unacceptable maternal and child mortality rates,
Ethiopia had the second highest rate of malnutrition in Sub-Saharan Africa, with about
47% of children under 5 stunted, 11% wasted, 38% underweight and 27% of women
chronically malnourished, with a Body Mass index (BMI) of less than 18.5. About half of
all child deaths were estimated to have arisen from malnutrition (Central Statistical
Agency 2005). A key form of malnutrition were micronutrient deficiencies, specifically,
iron deficiency anemia (IDA), vitamin A deficiency (VAD), and iodine deficiency
disorder (IDD). IDA was recognized as having affected 54% of children under 5 and
27% of women (Central Statistical Agency 2005). As to breastfeeding, only one in three
children aged 4-5 months was exclusively breastfed, and many children aged 6-9 months
not breastfed at all resulting in an estimated 18% of all infant deaths, and 7.5 % of under
5 mortality, annually, caused by poor breastfeeding behavior.
The PAD rightfully linked the high levels of malnutrition as a threat to national
health objectives and economic growth. Nutrition is one of the key determinants of
health, with malnutrition increasing the susceptibility and vulnerability of individuals to
disease (WHO 2002; Barros et al, 2010). Furthermore, globally there is a well-
established link between health, nutrition and education and economic growth .Whereas
economic growth can help lift people out of poverty and improve their access to some of
the determinants of health and nutrition, inadequate health and nutrition have been
closely linked globally to deterioration of individual cognitive ability, productivity and
labor market outcomes, and ultimately economic growth. At the time of project appraisal,
it was estimated that Ethiopia would lose approximately 2.5% of GDP between 2006 and
2016 in the absence of interventions to remedy stunting and iron deficiency (Rajkumar et
al, 2012).
The Bank Project tapped into strong political commitment and a corresponding
policy cycle that aimed to address malnutrition in Ethiopia. Following the
formulation of a National Nutrition Strategy (NNS) in 2005, the government launched the
-
2
Accelerated and Sustained Development to End Poverty (PASDEP) Plan (2005-2010)
which called for the implementation of a multi-sectoral nutrition strategy to achieve the
MDG 1 goal of halving poverty and hunger by 2015 (Taylor 2012). This was followed by
the launch of the National Nutrition Program (NNP) in 2008, with the aim of
harmonizing and implementing multi-sectoral nutrition interventions and strengthening
service delivery and institutions for nutrition during 2008 - 2013 (FMOH 2008). The
Government's commitment to accelerating progress in nutrition was furthermore reflected
in its major development plans including the Growth and Transformation Plan (GTP) and
fourth Health Sector Development Program (HSDP IV). In line with these planning
documents, the PAD rightfully argued that the high prevalence of malnutrition was seen
as a key contributor to high infant and maternal mortality rates and considered a threat to
the achievement of MDGs and maintenance of sustained economic growth in Ethiopia.
The Bank project positioned itself as a self-contained project focusing on more
narrow nutrition objectives within the wider multi-sectoral National Nutrition
Program (2008-2013). By 2007, a draft “Detailed Program Proposal” of the NNP existed
and served as the base document for developing the World Bank project design, including
implementation and financing plans. In consultation with the government and partners,
the agreed upon objective of the Bank Project was to "improve child and maternal care
behaviour, and increase utilization of key micronutrients, in order to contribute to
improving the nutritional status of vulnerable groups". Higher level objectives that the
project was hoped to contribute to included improvement of the nutritional status of
vulnerable groups, especially young children and pregnant women, as well as overall
maternal and child health outcomes, and ultimately removal of important barriers to
overall economic growth.
The project was designed to support a combination of community and national level
interventions to achieve its objectives. A primary focus was on funding interventions
and activities that would bring nutrition services closer to the community, largely by
strengthening community capacity and integrating nutrition interventions into the
government’s existing flagship Health Extension Program (HEP), a community level
health service delivery model, heavily supported and funded by the government, intended
to reach remote populations across Ethiopia. By 2008, this innovative and much lauded
program had already trained and deployed up to 30,000 female health extension workers
(HEWs) to deliver basic preventive and curative health services at health post level
across remote communities in Ethiopia. However, nutrition related competencies
remained underdeveloped (for more information on the HEP, read Bilal et al, 2011). In
addition to supporting community based nutrition (CBN) in 4 regions across Ethiopia,
including the provision of micronutrients, the project also intended to (and managed to)
leverage interest and funding from other donors for nutrition and nationwide scale up,
and strengthen coordination, implementation and research capacity on nutrition at various
levels.
Overall project implementation was led by the Federal Ministry of Health (FMOH) and by extension, the Pharmaceuticals Fund and Supply Agency (PFSA), the key
procurement entity. Ethiopian Health and Nutrition Research Institute (EHNRI), an
-
3
autonomous agency, was responsible to implement the project financed research related
activities. There was no Project Implementation Unit (PIU); however focused technical
assistance (TA) was provided in conjunction with short to long term capacity building
efforts in the health sector to build project management capacity. At the sub-national
level, the implementation was led by the Regional Health Bureaus (with support from
regional NNP coordinators financed under the project) as well as the District Health
Offices (Called Woreda Health Offices), and as the project progressed, by health sector
staff trained in two-year sandwich Masters Course in nutrition (financed by the project).
At the level of service delivery, implementation was led by HEWs (initially supported in
their nutrition tasks by volunteer community health workers (VCHWs), and subsequently
the Health Development Army (HDA)) under the government’s flagship Health
Extension Program (HEP). More detail on these service delivery agents is provided
throughout the report below.
The rationale for the Bank to support Ethiopia on nutrition was high. The Bank was
engaged in the formulation of the National Nutrition Plan, responding to requests from
the Government for technical assistance and financial resources. Moreover, the Bank was
involved in a wide range of activities, multi-donor operations, and sectors (agriculture,
water, education), much of it over an extended period, and had demonstrated leadership
in important and complex productive safety nets such as the Productive Safety Net
Program (PSNP) and in providing basic services, as well as its involvement with the
Ethiopia International Health Partnership Compact (August 2008). Its engagement was
seen as needed by both the Government and development partners (DPs). Many DPs saw
the Bank as a catalyst for their participation, and as providing greater assurance of the
likelihood the harmonizing and integrated approach put forward by the NNP
implementation, would be carried forward. The Bank’s Nutrition Project, fully aligned
with the national plan, constituted a major contribution to the NNP.
The project remained fully relevant with the most recent Country Partnership
Strategy (CPS 2012-2017) which emphasized increasing resilience and reducing
vulnerability. The CPS is well tied to the Government's Growth and Transformation
Plan and particularly in areas of strong Government ownership. Pillar Two of the CPS
aims to enhance resilience and reduce vulnerabilities by improving delivery of social
services and developing a comprehensive approach to social protection and risk
management. An important outcome sought by the CPS is increasing access to quality
health and education services, and these are closely linked to nutrition. The objective of
the Nutrition Project was consistent with good governance in that it focused on improved
public service management and responsiveness; enhanced community participation; and
better public service (health sector) financial and procurement management, and
accountability.
1.2 Original Project Development Objectives (PDO) and Key Indicators
The Project Development Objective (PDO) was to "improve child and maternal care
behavior, and increase utilization of key micronutrients, in order to contribute to
improving the nutritional status of vulnerable groups". This was to be primarily achieved
by equipping and supervising front line Health Extension Workers (HEWs), already
-
4
deployed throughout Ethiopia, with new nutrition outreach skills and competencies, and
mobilize Volunteer Community Health Workers (VCHWs), done specifically under the
project, to support HEWs in their nutrition outreach activities. These Community Based
Nutrition (CBN) interventions (carried out, incrementally, in 4 regions), which also
focused on distributing key micronutrients, would be complemented by supporting social
advocacy and communications campaigns on nutrition (through community
conversations carried out by HEWs and VCHWs)-, as well as strengthening overall
coordination, management and research capacity on nutrition more generally at various
levels. The support provided under the project was expected to leverage additional donor
support (and that from other sectors) towards the NNP and lead to improvements in a
number of intermediary and project outcome indicators (Table 1), in addition to higher
level nutrition objectives discussed below.
Table 1: Original indicators of the WB nutrition project
1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and
reasons/justification
Whilst the PDO was not changed, the project indicators were revised during the
project duration to be more logically linked to the PDO and allow more rigorous and
timely monitoring of the project. The June 2011 supervision mission reviewed the
original indicators and assessed available data sources. During the Mid-Term Review
(MTR) mission (November 21-29, 2011) a review of the proposed revised results
framework was done and finalized1. The project was formally restructured in 2012 to
respond to a GOE request to revise the indicators going forward. One new PDO indicator
Project Outcome Indicators
- Percentage of infants aged 0-5 months exclusively breast fed
- Percentage of households using adequately iodized salt
- Percentage of pregnant women receiving iron and folate supplementation
- People with Access to a Basic package of health, nutrition or population services
- Children Receiving a dose of Vitamin A
Intermediary Results Indicators
- Health Extension Workers trained on revised curriculum: percentage out of a target of 30,000 to be
achieved by project completion
- Percentage of iodization machines functioning out of 60 planned
- Universal Salt Iodization policy adopted and put in force, supporting proclamation 200/2000
- Zinc registered as essential drug and included in Health Post Package
- Percentage of nutritional surveillance sites operating and providing periodic data, out of a target of 20
to be achieved by project completion
- Percentage of operational research studies contracted out of a target of 20 to be achieved by project
completion
- Establishment of Inter-sectoral Nutrition Coordination Body
-
5
was added (GMP sessions) with the existing iodized salt indicator removed2, with other
PDO indicators definitions refined. As for the Intermediary Indicators, two new
indicators were included (health personnel receiving training in CBN and masters level
training in nutrition) and others were refined in their specificity (see datasheet comments
for details). For all indicators, where possible, values were updated using more recent
nationally representative data, data from the 2009 National Nutrition Survey. Table 2
provides details on the indicators following restructuring.
Table 2: Revised/expanded indicators of the WB nutrition project
1.4 Main Beneficiaries,
The primary target beneficiaries were under-5 children and pregnant and lactating
women principally in food insecure regions with high malnutrition rates, with
particular emphasis on improvements in MDGs 1 (eradicate extreme poverty and
hunger), MDG 4 (reduce Child Mortality), and MDG 5 (reduce Maternal Mortality). The
Community Based Nutrition aspect of the project was designed to target beneficiaries in a
phased approach in four diverse and highly food insecure regions (Amhara, Oromia,
SNNPR, Tigray) before going nationally. Secondary beneficiaries were institutions
involved in the implementation of the project and wider nutrition agenda whose capacity
was built to help reach the primary targets. They included FMOH, EHNRI, Regional
Health Bureaus, Woreda Health Offices and at the level of service delivery, HEWs under
the government’s flagship HEP, whose competencies in implementing and monitoring
CBN activities were upgraded.
1.5 Original Components (as approved)
2 This was done because there was a limited link between project inputs and salt iodization and thus
"Universal Salt Iodization coverage" was not considered a good PDO indicator.
Project Outcome Indicators*
- Percentage of infants aged 0-5 months exclusively breast fed
- Percentage of pregnant women receiving iron and folate supplementation
- Number of people with access to basic package of nutrition services (CBN), % female
- Number and percentage of children 6-59 months receiving a dose of Vitamin A every 6 months
- Percentage of Children 0-23 months participating in monthly GMP sessions
Intermediary Results Indicators
- Number and percentage of Health Extension Workers (HEWs) trained on CBN curriculum
- Percentage of national salt production iodized in previous year
- Universal Salt Iodization policy adopted and put in force, supporting proclamation 200/2000
- Zinc registered as essential drug and included in Health Post Package
- Percentage of CBN woredas providing monthly nutrition data to federal level
- Percentage of operational research studies contracted out of a target of 10 to be achieved by project
completion (out of target 10)
- Establishment of Inter-sectoral Nutrition Coordination Body
- Number and percentage of health personnel (health center to federal level) receiving training on CBN
- Percentage of persons in the health sector trained to masters level in nutrition (of a target of 30)
-
6
The project development objective and related indicators were expected to be achieved
through the implementation of activities specified in 2 components, summarized as:
Component 1: Supporting Service Delivery (US$14m IDA and US$4.3 from GOE). This component provided support to i) strengthen CBN and wider health services under
the HEP outreach program, through capacity enhancement of HEWs and their
supervisors, and mobilization of Volunteer Community Health Workers (VCHWs) to
support them in nutrition related outreach activities, and ii) provision of micronutrients to
the target population through regulatory interventions and support towards procurement,
delivery and utilization of key micronutrients, especially iodine, iron, zinc, and vitamin
A.
Component 2: Institutional Strengthening and Capacity Building (US$16m and $4.3
from GOE). This second component provided support to i) strengthen coordination and
capacity for nutrition, in particular the setting up of a national coordination mechanisms
for nutrition; strengthening human resources for nutrition including researchers and
nutrition managers at various levels, and supporting capacity building of institutions to
implement nutrition interventions; ; ii) support national advocacy and social mobilization
messages on nutrition to a) build country ownership around nutrition and b) disseminate
nutrition messages in the media, and c) complement practices of HEWs and VCHWs in
promoting caring practices. Finally iii) support towards operational research, surveillance
and monitoring on nutrition, including building on existing data structures, overall
monitoring and evaluation for the NNP and relevant operational research for the NNP.
The causal linkages between components and the intermediary, PDO and higher
level indicators are illustrated in table 3 below, reflecting the results framework with
the post 2012 restructured indicators.
Table 3: Linkages between higher level objectives, PDO indicators, Intermediary
indicators and components
Higher Level Objectives Higher Level Objective indicators1
To improve the nutritional status of
vulnerable groups, especially
young children and pregnant
women
- Percentage of under-5 children with weight-for-age less than two
standard deviations below the median of the reference population (MDG-
1 indicator)
- Percentage of under-5 children with height-for-age less than two standard
deviations below the median of the reference population
Project Development Objective
(PDO)
Project Outcome Indicators
To improve child and maternal
care behavior, and increase
utilization of key micronutrients, in
order to contribute to improving
the nutritional status of vulnerable
groups
- Percentage of infants aged 0-5 months exclusively breast fed
- Percentage of pregnant women receiving iron and folate supplementation
- Number of people with access to basic package of nutrition services
(CBN), % female
- Number and percentage of children 6-59 months receiving a dose of
Vitamin A every 6 months
- Percentage of Children 0-23 months participating in monthly GMP
sessions
Intermediate Results Results Indicators for Each Component
-
7
1.6 Revised Components
No new Components were added
1.7 Other significant changes
N/A
2. Key Factors Affecting Implementation and Outcomes
2.1 Project Preparation, Design and Quality at Entry
There was intensive and high quality technical preparation of the project, both on
the Government's side with EHNRI nutrition research coupled with Bank supported
detailed analysis, and significant interaction in terms of developing the NNP.
The preparation of the Bank project was closely linked to preparation of the wider
NNP. Project identification and preparation, which began in earnest following the project
concept note review held in September 2007, was informed and benefitted from a wider
government and multi-partner team formed that same year to determine national level
nutrition objectives, components and activities, financing priorities and implementation
arrangements. Many of the specific details of the proposed structure of the wider
Ethiopia NNP and alongside it, the fully consistent Bank project, were established during
a Joint Partner Pre-Appraisal Mission held in October 2007 (Aide Memoire, 8-31
October, 2007).
The project preparation was swift, and whilst there was no formal Quality- at –
Entry Review, the technical design was endorsed at the decision meeting held in
February 2008. Throughout the preparation and appraisal period until board approval on
April 29, 2008, the Bank team continued to consult and benefit from global expertise and
a new found momentum to tackle nutrition in Ethiopia, exemplified for example by a
Component 1: Supporting Service Delivery
To enhance delivery of key
nutrition services, in terms of
quantity and quality, through
community-based nutrition
interventions and supply of key
micronutrients
- Number and percentage of health extension workers trained in CBN
curriculum
- Universal Salt Iodization policy adopted and put in force, supporting
Proclamation 200/2000;
- Zinc registered as an essential drug and included in the health post
package
- Percentage of national salt production iodized in previous year
Component 2: Institutional Strengthening and Capacity Building
To strengthen institutional capacity
to support delivery of improved
nutritional services
- Establishment of inter-sectoral National Nutrition Coordination Body
- Number and percentage of health personnel (health center to federal
level) receiving training in CBN
- Percentage of CNB woredas providing monthly nutrition data to federal
level
- Percentage of NNP operational research studies completed and
disseminated
- Percentage of health personnel trained to masters level in nutrition
-
8
high level nutrition workshop held in 2008 linked to the Lancet journal series on nutrition
(Ethiopia was chosen as one of five countries in which the series was launched).
The project was largely designed around a solid evidence base on the status and
causes of malnutrition. Much of the evidence base was informed by an earlier
unpublished version of a nutrition study task led by the then Project TTL (eventually
published as Rajkumar et al 2011). As such, the determinants of malnutrition were
correctly recognized to be multi- sectoral in nature, linked to factors beyond food
security. Whilst the PAD drew on a solid external evidence base (including the numerous
documents that informed the NNP and NNS), it could nevertheless have benefited from
showing how the more narrow interventions that were to be supported and funded under
the project were anchored into the overall determinants and parallel interventions
impacting (mal) nutrition in Ethiopia. Not doing this may have contributed to the
selection of a set of indicators that had to be revised during subsequent restructuring
(largely to better capture impact, as discussed below), and has made it more difficult to
make the clear attribution of funded project interventions from interventions funded by
others.
The selected interventions supported under the project were generally based on
global best practice. Embedding micronutrient supplementation within an integrative
public health and nutrition strategy at community level, for example, is known to
maximize the potential for success (Thompson and Amoroso 2011). And recent reviews
on the impact of broader demand and supply side interventions at the community and
individual level have shown them to be successful, when they are coupled with wider
regulatory interventions, social advocacy and mobilization, and reinforced by
complementary capacity building interventions at all levels (see UNICEF 2014; IEG
2010). These best practices were largely adopted in project design.
Project design focused on entry points and best practices associated with targeting
the poor. Whereas the PAD could have benefited from a brief review of the evidence of
social determinants of malnutrition inequities in Ethiopia, to more systematically identify
and target nutrition inequalities, pro-poor design features included 1) a focus on high
risk and vulnerable groups (mothers and children), 2) prioritizing diseases of the poor
(the poor are disproportionately affected by malnutrition), 3) strengthening individuals
(the project promoted knowledge on nutritional practice), 4) strengthening communities
(the project used community level actors to strengthen social cohesion), 5) improving
living and working conditions (the project improved access to better nutrition care), 6)
complementing individual level interventions with macro level policies (the project
supported regulatory interventions on micronutrients), and 7) deploying or improving
services where the poor live (the project focused on poor regions) and 8) employing
appropriate delivery channels” (the project made use of health extension workers at
community level) (Whitehead 2007; Barros et al, 2010).
Additional notable strengths of project design included: i) drawing on strong political
and partner commitment for nutrition and community based service delivery; ii) logical
organization into two simple components, and a results chain with indicators plausibly
connecting the development objective with the planned activities/inputs, outputs,
-
9
processes, and outcomes (albeit this was improved significantly after restructuring in
2012); iii) embedding the CBN activities of the project within an existing, innovative
community level service delivery program (i.e. the community level Health Extension
Program); iv) the use of existing institutions, and flexibility to accommodate new
structures for implementation at community, kebele, woreda and federal levels; v) roll
out of the CBN interventions in a phased approach in diverse and highly food insecure
rural districts within four regions (Amhara, Oromia, SNNPR, Tigray); vi) utilizing
strong partnerships (and collaboration) with other development partners engaged in
Ethiopian nutrition efforts, particularly with UNICEF; vii) developing a sound Project
Implementation Manual, with support of an external consultant hired with a PHRD grant,
which provided a good basis for project execution and was used extensively throughout.
The design, moreover, anticipated and identified mitigation towards potential risks
that could negatively impact project outcomes. The emphasis was crucially placed on
coordination and implementation requirements, identified to be as particular risks to the
achievement of the development objectives, if the appropriate mitigation measures were
not implemented. They included:
(a) Inter-Ministerial commitment, linkages and coordination- Nutrition requires effective
links with sectors that affect or are affected by nutrition. The principal mitigation
measure was the commitment to establish and support a high-level national coordinating
body, to be actively supported by Ministries beyond just MOH.
(b)Intra-health sector coordination-There are numerous units and agencies within the
FMOH, with different program specific objectives other than nutrition. To overcome
possible difficulties, the project would look to active engagement of the Minister, to
whom the units and agencies are accountable, and Ministerial commitment to play a
strong supervisory and coordination role.
(c)Need for reporting from multiple implementers-Concerns were expressed that
reporting from various implementers, at the various levels, would not be timely,
complete, and relevant. The primary mitigating measure was to task EHNRI with overall
responsibility for monitoring and evaluation of the NNP and Bank project.
(d)Donor coordination -With multiple development partners engaged in nutrition,
harmonization and coordination issues are challenging. Mitigation measures were to look
to the FMOH to proactively coordinate donor participation and response for activities
related to the NNP, including the Bank project.
Some of the design shortcomings at entry, which affected implementation and were
partly rectified after restructuring in 2012 included: insufficient awareness in the
initial design on the complexity involved in iodized salt production, particularly with
regard to its political economy, in addition to quality and the difficulty in assuring
standardized iodine dosage with small producers (hence the subsequent removal of
associated indicators during restructuring). More scrutiny could have been placed on the
development of the results framework more generally: Project restructuring in 2012 had
-
10
to be carried out to better link PDIs with IOIs, in addition to building on better data
sources. Perhaps a key weakness at appraisal was insufficient identification of weak
fiduciary and M&E capacity as a key risk. The fact that the PAD did not sufficiently flag
such risks could be linked to the fact that from the outset, what was not well defined was
where to house the program and responsibility for its implementation, with ultimately
much later agreement that it should be the FMOH. In any case, greater analysis and
assessment of risks and identification of solid mitigation of challenges early would have
improved project execution.
2.2 Implementation
The project was financed by an IDA grant of SDR 18.8 million (US$ 30 million
equivalent) with a Government contribution of US$9.6million. Over the course of the
project two Trust Fund grants were linked to the project, a US$ 1.81million recipient
executed Japanese Social Development Fund Grant, and a US$ 650,000 grant towards the
Rapid Social Response Multi-Donor Trust Fund (RSD MDTF). Their role in contributing
towards the PDO is discussed in section 3.2 of this ICR.
The project was approved by the Board in April 2008 and became effective in
September 2008 with conditions of effectiveness and dated covenants largely achieved
as planned. Conditions of effectiveness included assignment of a financial specialist for
the FMOH, adoption of a Program Implementation Manual, and project procurement
specialists for the PFSA and EHNRI. Dated covenants included establishment by July
2009 of a National Nutrition Coordinating Body, recruitment by October 2008 of an
external auditor for the Project, evidence of adoption and implementation of universal
salt iodization regulations by July 2010, and registration of zinc as an essential drug by
July 2010.
Despite effectiveness declared in September 2008, the actual launch of the project
was delayed significantly due to factors extrinsic to the project itself. The project
launch did not occur until 9 months later until June 2009, which was largely attributed to
the Ethiopian Government-wide “Business Process Reform” process, a wide ranging
public sector reform effort designed to bring about efficiencies in the public sector over
an extensive period, which affected and delayed many parts of the government and the
Bank portfolio. The BPR affected project launch because it was hard to secure the
presence of higher level government officials during this period and because it involved
restructuring of relevant structures and responsibilities of certain agencies within the
government (e.g. EHNRI, FMOH). Whilst the project launch was put on hold during this
process, the project team continued to benefit from donor support towards the
development and refinement of the PIM and of the broader NNP (in which the Bank
project was anchored), initiation of the baseline survey process, and key steps were taken
to enhance project execution readiness, including for example the selection of operational
research topics to be supported under the project. Thus, the principal cause of the delay in
Bank project start-up was extrinsic to the project itself, while the Government and other
DPs proceeded with the execution of the NNP.
-
11
Furthermore, an issue extraneous to the nutrition project, namely the existence of
unaccounted advances in other projects in the Ethiopia portfolio, meant that the initial,
agreed Withdrawal Application disbursement for the project Special Account was
delayed for several months, hamstringing project start up and impacting performance.
Following launch in June 2009, the first phase of service delivery to 238 woredas
proceeded largely as designed3. Project-financed training and procurement for CBN
under the NNP was linked to complementary UNICEF-financed technical assistance to
FMOH in the development of training materials and training of master trainers for
cascading training to community level and UNICEF procurement of items known to be
complicated to procure (e.g. weighing scales). In this initial implementation phase,
VCHWs and HEWs in project areas received CBN specific training and refresher training
under the project (VCHWs were originally assigned under the project to work with
HEWs to deliver two major activities under CBN notably GMP and Community
Conversations (CC), each responsible for 30-50 households – under HEW’s supervision).
From the end of 2010 onwards, the project experienced disruptions and delays in
carrying out CBN activities due to a training-related policy shift, again extrinsic to
the project itself. The FMOH dropped CBN specific training and instead developed
Integrated Refresher Training (IRT) for HEWs, which included 4 broader modules one of
which included CBN. Consequently, HEW refresher training was disrupted and with it
project implementation. Around the same time, a second policy shift affected CBN
activities, as FMOH national policy replaced the VCHW with “Health Development
Army (HDA)” volunteers, who were assigned to carry out mobilization and promotional
activities within the community (not specific to nutrition), with GMP and CC transferred
fully to the HEW. Training of the new HDAs was less focused on nutrition, and CBN
service delivery, specifically GMP and CC, were severely affected in some areas where
the transition from VCHW to HAD and HEW took longer than expected4. These policy
changes slowed and disrupted implementation.
Other challenges during implementation could be linked more directly to the
project, and related to some of the intended micronutrient interventions, also under
component 1. During the first phase of implementation, it became evident that the
targeted levels of household provision of adequately iodized salt was an unrealistic goal,
given the nature of the Ethiopian salt industry with many small producers in a politically
complex region with extreme weather, poor infrastructure (water, electricity, roads), and
the absence of a means to assure compliance to centrally mandated legislation. While
3 By June 2011, 11,900 Health Extension Workers (HEWs) and 90,000 Voluntary Community Health
Workers (VCHWs) were trained on CBN, (GMP) coverage increased to 60% with 1.08 million out of 1.8
million under-2 children participating in GMP sessions, and 65% of VCHWs were submitting monthly
CBN reports to HEWs 4 Moving to an HDA system took time to establish with some regions doing so quickly and others not.
Furthermore, the HDA were trained in an integrated package that diluted the nutrition messaging.
Combined with the shifting of responsibilities to HEWs, this reduced the “dose” of nutrition activities at
community level.
-
12
efforts continued to build on the approved salt iodization policy and pursue increases in
quality salt iodization (reflected in new intermediary indicators added after 2012), it was
evident early on that household coverage of iodized salt was beyond the project to
achieve given the financed activities (and the original PDO indicator on that was
dropped). Implementation of other aspects of micronutrient interventions in this
component were successful, as the targets for community-based Vitamin A
Supplementation were routinely exceeded and uptake of IFA among pregnant women
increased over the project period.
A particular concern, moreover, were FM issues and procurement delays
particularly with the FMOH and by extension with a key procurement entity, the
Pharmaceuticals Fund and Supply Agency (PFSA) and to some degree with ENHRI.
Procurement processes were cumbersome, took time to complete, and resulted in delays
in getting goods to the end-users, such as iron folate or vehicles, or selecting institutions
to produce studies. A procurement plan had been adopted but the implementing entities,
namely PFSA, EHNRI, and FMOH had limited experience with Bank procurement
procedures, and were slow in processing procurement requests despite additional
technical assistance to facilitate. With respect to financial management, in the first phase
of the project, there were key budgeting, internal controls and financial reporting and
external auditing issues that were identified as warranting improvement, with an action
plan for improvement developed in 2011 (during the MTR). Funds flow was slow, with
delays and or lags in disbursement.
A Joint Mid-Term Review in November 2011 sought to identify and address a
number of challenges, including: weaknesses in federal and regional level staff
particularly with regards to financial management and procurement (development of an
FM action plan with agreed actions contained in the Annex of the MTR); strengthening
integrated refresher training (IRT) in light of the policy shift on training5, responding
to/mitigating the adverse effects as a result of replacement of VCHW by a new Health
Development Army cadre on CBN nutrition services6; revising the results framework to
align it more closely with project activities, including elimination of the universal salt
iodization objective as unrealistic; speed up progress in implementing M&E activities;
foster recognition of the need for, and recommendations to generate multi-sectoral
commitment, including Ministry commitment to their respective roles in stunting
reduction (given the slow advancements in that regard of the multi-sectoral nutrition
coordination committee), and in particular MOA/FMOH collaboration at national and
community/kebele level. All in all, the interim report at the time of Mid-Term Review
5 Critical to the success of the approach was HEW and VCHW competency and quality of counseling,
which was dependent on training, refresher training, and supervision. After VCHWs were replaced by
HAD, the HEWs training became even more critical, but CBN was integrated into HEW IRT, with limited
time devoted to it. Recognition of the need to improve skill levels was raised by a Bank financed EHNRI
study which did a candid analysis of pre- and post-refresher training skills, and resulted in an ongoing
effort to develop "Blended Training Materials for Nutrition" which remains a work in progress. 6 While each HDA was assigned to mobilize 5 households, they were not given permission to deliver any
service. Instead, HEWs were asked to carry out GMP which added significantly to their workload.
-
13
provided information for both NNP revision and project restructuring, and led to an
action plan to address them.
The task team and the FMOH were proactive in addressing the challenges
experienced during the first half of the project, particularly after the MTR. Formally
restructuring the project in 2012 helped to more logically link and redefine project and
intermediary indicators and targets, and improved the data available for decision-making.
With regards to procurement, notable steps were taken including: carrying out continuous
revisions of procurement plans, procurement training for PFSA staff; and implementation
of recommendations to hire a procurement officer in the FMOH (eventually done post
2012). To improve financial management, the FMOH hired nutrition coordinators to
work at regional level in project regions; financial capacity building was completed at the
woreda level (training for financial managers in 144 woredas); Federal level accountant
training was also undertaken to cascade training to woreda accountants; and TA was
recruited to support FM.
Following the MTR and subsequent restructuring, there was progress with
implementation of components and procurement of some activities improved. Financial management also improved reflected in the quick settlement of SOEs, including
outstanding balances at regions and implementing agencies. Disbursement shows a slow
start with improvements only beginning in the first quarter of 2011, increasing from 10%
($3 million) in December 2009, to 50% ($15 million) by March 2012. The disbursement
pattern, which improved more significantly only in 2011 following the MTR, reflects the
above discussed extrinsic and intrinsic factors which hampered early implementation
progress. Whilst overall implementation and disbursement improved after 2011, the
procurement of some micronutrients, and in particular iron folate tablets remained
problematic throughout project execution, primarily due to delays within PFSA, as there
are additional registration processes required for “medical” suppliers, and FMOH
determined that IFA supplements be treated as medical supplies. By the time the project
closed, SDR 17.3 million was disbursed (92% of the original allocation of SDR 18.8
million).
2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization
The project was formally restructured on April 11, 2012. Design and implementation
issues resulted in the need to change one Project Development Objective (PDO)
indicator, update baseline values of the PDO indicators (with data from the NP-financed
NNP baseline survey, accordingly changing end-line targets), and fine tune some IOIs to
more logically link them to the PDO, and permit their regular and more targeted
monitoring. At restructuring, one PDO indicator was dropped (salt iodization) and one
added (GMP). As for the Intermediary Indicators, 2 new indicators were added, 5
indicators made more specific, and 3 indicators remained the same. The indicators were
fine-tuned with the wider government and multi-partner discussions during preparation
and subsequent implementation, with the revision aligned with the revised NNP
framework.
-
14
Project monitoring, which relied largely on the HMIS system, was initially
challenging but improved significantly as the project progressed. The monitoring and
evaluation data used by the project to monitor and evaluate progress depended on two
major systems: 1) the national Health Monitoring Information System (HMIS) which did
not initially include nutrition indicators but was revised under the project to include
Growth Monitoring and Promotion; and 2) CBN data collection carried out at woreda
level on a monthly basis flowing to Regional Health Bureaus (RHB) and national level.
Initial challenges to obtain woreda level nutrition data at the federal level (in the HMIS)
were addressed during restructuring in 2012, which added an intermediary indicator to
ensure woredas were providing monthly nutrition data to the federal level. By the end of
the project, the flow of nutrition data from the woredas to the national level, as well as
perceived quality of this data, improved significantly, with over 80% of woredas
providing monthly nutrition data to the MOH.
The project also supported an independent impact evaluation of CBN activities in
collaboration with UNICEF. Surveys were carried out by local partners Addis
Continental and Mela, with analyses conducted by Tulane University. This was a
unique feature supported by the project in collaboration with UNICEF. The report,
finalized in September 2012 was disseminated also via a BBL at the Bank, and the
assessment showed impressive progress towards improved nutrition outcomes in the 4
target regions where CBN was supported, and in particular the reduction of stunting. The
key findings of this study are highlighted below, in section 3.2 of this ICR.
In addition, the project provided support towards EHNRI under component 2
towards operational research studies on nutrition. A multi-stakeholder consultative
workshop held in 2009 identified twelve potential thematic areas for operational research,
later reduced to six thematic areas. Eight out of the originally planned 10 studies were
carried out during the project (the initial 10 study target had been reduced to 8 by
EHNRI), with findings used by the government to understand and discuss project
performance, guide implementation and inform the new NNP. For example, a study of
iron supplementation coverage at health centers and health posts showed very low
coverage, and led to subsequent remedial action, the review of IRT identified gaps in
HEW training on nutrition and identified priority areas for revision.
Finally, EHNRI (now EPHI) was responsible for the baseline, midline, and end-line
survey. The baseline and midline studies were done (and results disseminated through
national workshops); however the endline survey has not been completed. It was agreed
the endline survey would become part of a broader micronutrient survey financed by DPs
(primarily UNICEF). While plans for the survey were completed well within the
anticipated closing date of the project, procurement constraints beyond the control of
EPHI and the FMOH, prevented commencement of the MN survey. UNICEF has
acknowledged that the delay has been with their procurement of a number of supplies,
including data collection supplies, which were to be provided by UNICEF. The end-line
survey was to be in lieu of a separate Bank financed end-line survey for project
purposes, which would have been repetitive and costly to have done as a stand-alone
effort. Resolution of procurement items between EPHI and UNICEF sooner could have
-
15
resulted in timely completion of the micronutrient survey and better assessment of project
performance (end-line results reporting).
2.4 Safeguard and Fiduciary Compliance
Safeguards: The project was classified as a Category C project and no negative
environmental impact was either identified or occurred during project implementation.
Financial management and disbursement: Project appraisal had identified low fiduciary
capacity as one potential risk to the achievement of proposed development objective.
Whilst initial fiduciary compliance was problematic, there are indications that this
improved during the latter half of the project. In the first phase of the project, there
were key budgeting, internal controls and financial reporting and external auditing issues
that were identified as warranting improvement, with an action plan for improvement
developed in 2011 (contained in the Annex of the MTR). Many of the recommendations
were adopted including the use of project financing to enhance training of regional
financial officers and woreda project accountants. Other recommendations, including
improving the quality of regional and sub-regional budget monitoring and reporting, and
internal audit unit capacity, will require continuous future attention. An in-depth
Financial Management Supervision Report in March 20147 provided assurance of
adequate financial management under the project. The report focused on assessing the
status and adequacy of the Project's financial management arrangements and compliance
with legal covenants related to financial management. The mission reviewed budgeting,
accounting, internal controls, funds flow, financial reporting, and external auditing. It
concluded that there was reasonable adequacy that the FM system in place provided the
necessary assurance that Bank grant proceeds were used for the intended purposes and
reports produced can be relied on to have monitored Project activities.
As identified previously, disbursement was slow during the first 2 years of the
project, and at least partly attributed to procurement related challenges. Despite
some improvements after 2011, procurement was a major issue throughout the project
life. A recommendation to recruit a procurement officer to handle and oversee
procurement activities of the project was pursued after considerable delay and located at
the FMOH. Procurement plans were developed and continuously revised for goods
(micronutrients, vehicles and motorcycles, furniture, educational materials, laboratory
equipment, printing of manuals and workshop training materials, IT equipment), as well
as multiple consultancy service assignments and positions for FMOH and EHNRI, but
remained a major constraint for proper implementation of the project.
2.5 Post-completion Operation/Next Phase
7 Financial Management Supervision Report [October 2013 to March 2014]. Ethiopia Nutrition Project,
World Bank Ethiopia, March 2014
-
16
The project was instrumental in triggering donor attention to nutrition and as a
result leveraged interest and additional resources to support the implementation of
the NNP. Throughout the project duration, the Bank provided overall leadership in the
national scaling up of nutrition movement amongst donors, and played a key role in
strengthening nutrition coordination partnerships including via carrying out bi-annual
NNP joint supervision missions. The Bank team was also actively involved in supporting
the government to implement nutrition interventions not directly linked to the project
(that would nonetheless impact higher level project objectives), including the roll out of
the national food fortification program.
Building on the work done under the project and the NNP, the Government's next
Health Sector Development Program (V) will have nutrition indicators, with the
likely inclusion of stunting, breast feeding and complementary feeding, GMP,
micronutrient supplementation, management of acute malnutrition. Currently the HMIS
collects data on under 3 year old children while the focus of the SUN approach and CBN
is on children under age 2 years; how this disparity will be dealt with, either by
modification of the HMIS or separate but complementary nutrition data collection, is not
determined.
The Government partners are continuing to support the NNP, continuously refining
the mechanisms, training materials, and modus operandi. The second phase of the
national nutrition program is detailed in a 2013 FMOH document “National Nutrition
Program, June 2013-June 2015”8. Part of the NNP continues to be supported under the
Productive Safety Net Program (PSNP) and the Health Millennium Development Goals
Program-for-Results Project (Health PforR), with significant resources bearing on
nutrition related interventions in both projects.
Moving forward, the Bank is supportive of continued support for nutrition activities in
the country and is discussing the possibility of additional financing (AF) for the Health
Millennium Development Goals Program-for-Results Project (Health PforR). The
additional financing could build on this first nutrition operation with focus on high
impact targeted nutrition specific interventions and significantly enhance HSDP IV’s
maternal and child health results. In the meantime, the Bank team will continue engaging
the Government on nutrition issues through analytical work based on the latest DHS data
and other data sources, focusing on the sizeable nutrition outcome gaps between different
income groups.
8 FMOH (2013) National Nutrition Program, June 2013-June 2015. Federal Ministry of Health, Addis
Ababa, Ethiopia. Accessed: www. unicef.org/ethiopia/National_Nutrition_Programme.pdf
-
17
3. Assessment of Outcomes
3.1 Relevance of Objectives, Design and Implementation
Rating: The relevance of the project’s development objective, design and
implementation is substantial.
The relevance of the objectives: The PDO remains extremely relevant for Ethiopia, in that malnutrition continues to be a key bottleneck to economic growth and prosperity.
It remains relevant for Ethiopia, fully supporting (and in line with) the NNS and both the
first and second phases of NNP with the aim to shift the country from a focus on
emergency response to an evidence-based preventive/promotive approach to improving
nutrition, and harmonize various independent nutrition programs, interventions and
activities, into one integrated program overseen by the Government. The NNS and NNP
remain highly relevant to Ethiopia’s efforts to reduce poverty, improve nutrition and
health, and remove bottlenecks to economic growth. The PDO also remains relevant to
Bank priorities and development objectives including progressing towards the twin goals
of the World Bank Group, and contribute to 1) end extreme poverty and 2) promote
shared prosperity of the bottom 40%. The PDO is in alignment with the basic objectives
of the PRSP and the Country Partnership Strategy.
The relevance of the design: The design of the project continues to be relevant to
achieving Ethiopia’s development objectives, and the Bank’s mandate to support poverty
reduction and foster economic growth. Despite the early design issues addressed during
the 2012 MTR, overall, the project design focused on a number of good practices that
continue to be relevant today (and to the achievement of the objective). These include: i)
drawing on global expertise and a solid evidence base to develop technical interventions;
ii) focusing on the vulnerable and entry points associated with reaching the poor; iii)
drawing on strong political and partner commitment; iv) embedding the project within an
existing national nutrition program and a functioning well designed community level
service delivery program; v) using existing institutions, and flexibility to accommodate
new structures for implementation at community, kebele, woreda and federal levels; vi)
focusing on a combination of community level with higher level interventions; and vii)
roll out some of the CBN interventions in a phased approach. The relevance of these
strong features were fully recognized by the Lancet Series on Maternal and Child
Nutrition of June 6, 2013.
The relevance of implementation: The project was implemented overall by the FMOH,
and by extension, the Pharmaceutical Fund and Supply Agency (PHSA) and the
Ethiopian Health and Nutrition Research Institute (EHNRI). Per best practice and the
decentralized institutional arrangement of the health system, at the sub-national level
implementation was led by the Regional Health Bureaus as well as Woreda Health
Offices and at the level of service delivery by health extension workers (HEWs), the
health development army (following on from the VCHWs), and supervisors - under the
government’s flagship Health Extension Program (HEP). The capacities of all these
bodies, which implemented the project according to good practice from the community
level upwards, were reinforced throughout the duration of the project. Implementation of
-
18
the research activities by the national research organization EHNRI remained relevant. At
the same time, disbursement was relatively slow during the first two years of the project,
reflecting implementation challenges as well as the lack of experience, and bureaucratic
processes, related to procurement and FM, which particularly occurred early on during
the project. Issues with M&E also characterized the first phase of the project. Much was
addressed prior to and during the MTR, and subsequent restructuring, however
challenges remained particularly on procurement.
3.2 Achievement of Project Development Objectives
Rating: Project efficacy is rated substantial.
The PDO which was to “improve child and maternal care behavior and increase
utilization of key micronutrients, in order to contribute to improving the nutritional status
of vulnerable groups” is rated substantial overall, as measured against the original targets
and those following project restructuring in 2012. The project has made an impressive
contribution towards improving child and maternal care behavior and increasing the
utilization of key micronutrients and improving the nutritional status of vulnerable
groups. In addition, the project has contributed to strengthening institutional capacity to
support delivery of improved nutritional services and towards boosting research and
knowledge generation on nutrition in Ethiopia. Aside from achieving most of the PDO
and intermediary indicators, some higher level nutrition and health objectives also
improved during the duration of the project. The efficacy rating is based on the following
main results outlined below.
3.2.1 Evidence on the Achievements of the Project Development Objective
a) Improvements in Child and Maternal Care Practices and Increased Utilization
of key Micronutrients:
This is particularly reflected in the impressive achievement of the PDO indicators added
after restructuring in 2012 (to better capture results of project activities). Improvements
in these indicators (often exceeding the target values) show that today more than 55m
people have access to a basic package of nutrition services (up from 0 persons prior to the
project) and 42 % of children 0-23 months being routinely weighed and monitored, by
Health Extension Workers (HEWs), a starting point to engage the community in actions
that promote child growth including optimal breastfeeding and complementary feeding.
In addition, 2 million more children receive a dose of vitamin A every 6 months, and the
same amount are screened quarterly for acute malnutrition through community health
days. The percentage of pregnant women receiving iron and folate supplementation
increased from 17% to 89% during the project duration, and the percentage of infants
exclusively breastfed increased by about 1% over the duration of the Project (albeit this
indicator reflects national level data – an external evaluation carried out by Tulane in
CBN woredas only, which received much of the focus of this project and is discussed
below– revealed much better improvements). Addressing household provision of
adequately iodized salt (an indicator dropped in 2012) was an unrealistic goal, given the
-
19
nature of the salt industry with many small producers and the absence of a means to
assure compliance. Instead, headway was made related to the approved salt iodization
policy and overall increases in quality salt iodization (reflected in the intermediary
indicators).
Table 5: PDO Level Indicators: Aims and actual achievements at completion
PDO Indicators Base line Value
Original Target Values (from approval documents)
Actual Value Achieved at Completion or Target Years
Indicator
Percentage of people with access to a basic package of nutrition services (CBN)
0 44,125,000 55,800,000 Refined at time of Restructuring
Percentage of children 0-23 months participating in monthly GMP sessions
0 40% 42% New at time of Restructuring
Percentage of infants aged 0-5 months exclusively breast fed9
51% (49% in PAD)
56% 52% Original Indicator
Percentage of pregnant women receiving iron and folate supplementation
17% 25% 89% Original Indicator
Number and percentage of children receiving a dose of vitamin A every 6 months
10,200,000 11,300,000 12,159,933 Refined at time of Restructuring
Percentage of households using adequately iodized salts
Na Na na Dropped at time of Restructuring
Sources: Compiled from final ISR March 2014.
The impressive national level results are reinforced by the findings of an impact
evaluation of the CBN interventions in the four target regions a few years into the
project. The impact evaluation, which was coordinated by Tulane and jointly funded by
the project and UNICEF, carried out four evaluation sample surveys of CBN between
2009 and 2011 in Tranches 2 and 3 of successive scale up of the CBN interventions. The
surveys covered about 120 randomly selected clusters each in the four target regions, and
had re-sampling of households from the same clusters at endline. Findings from the
surveys reported significant increases in households reporting receiving nutrition
information from HEW or VCHWs and participating in community-based nutrition
activities such as Community Conversations and child weighing. The evaluation found
significant changes in maternal and child nutrition care practices targeted by the project,
including infant and young child feeding (IYCF) practices (using WHO indicators):
Exclusive breastfeeding under 6 months, already high in CBN woredas, increased in
tranche 2 to nearly 90% (an increase much higher than observed at national level increase
9 This indicator reflects national level data only – an external evaluation 2 years into the project, carried out
by Tulane in CBN woredas only, which received much of the focus of this project and is discussed below–
revealed much better improvements
-
20
above). Dietary diversity at 6-23 months increased significantly, as did the minimal
acceptable diet-reaching around 40-50%. Poor dietary practices, such as providing less
food to children with diarrhea and eating less during pregnancy, were also significantly
reduced. Use of antenatal care increased as did women taking iron-folate during
pregnancy from 30 to 50%.
b) Improvements in Nutritional Status of Vulnerable Groups10:
During the duration of the project, two important higher level Protein Energy
Malnutrition (PEM) outcome indicators at national level improved: stunting and
underweight (an MDG indicator). National level data compiled from the Central
Statistical Agency (DHS 2014) reported that the percentage of children underweight in
Ethiopia was reduced from 33% in 200