document of the world bank...date achieved 04/29/2008 04/02/2012 04/02/2012 05/31/2014 comments...

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

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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


4 12/19/2009 Satisfactory Moderately Satisfactory 3.05










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*



- 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



- 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

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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

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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

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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