document of the world bankdocuments.worldbank.org/curated/en/... · date achieved 04/29/2008...

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

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 2005 to 29% in 2011 and 25% in 2014. Equally, the

percentage of children that are stunted was reduced from 51% in 2005 to 44% in 2011

and 40% in 2014 (Table 6). These are significant improvements and the extent to which

the project may have contributed towards these improvements can be debated. What we

do know is that the project activities focused on several interventions identified in the

Lancet Nutrition Series as having high impact on nutrition and focused on the

populations (pregnant women and under-two children) expected to contribute most to

nutrition impact. CBN activities covered more than half the country’s woredas by 2014,

and the CBN program was shown to improve nutrition behaviors and to plausibly

improve stunting in the subset of the woredas where a quasi-experimental evaluation was

conducted (Mason and White, 2012).A 2014 study on the factors associated with stunting

in a district in Southern Ethiopia found that although factors such as larger families and

women in working professions were associated with higher levels of stunting in children,

so was inadequate breastfeeding, (Fikadu et al 2014) which was specifically addressed by

the project, and which improved significantly in the 4 target regions (albeit less so

nationally). And a study on the determinants of underweight children in Western Ethiopia

identified key factors to be weight at birth, breastfeeding frequency, provision of health

information (Hailemariam 2014), all of which were addressed by the project. Whilst the

project may well have impacted many of these determinants, what is also clear is that

trends in improvements in both stunting and underweight indicators were already

observed prior to the project implementation, so other factors (for example, economic

growth and increasing prosperity discussed below) may have also played a role.

Table 6: Higher level Project indicators (to which project meant to contribute) WB Project Period

2000 2005 2011 2014

Percentage of under-5 children with weight-for-age less than two standard deviations below the median of the reference population (MDG-1

51% 33% 29% 25%

10 The project seems to equate vulnerable groups with the target population (i.e. mothers and children in

remote parts of Ethiopia). Of note is that the 2014 mini DHS did not produce evidence on nutrition

outcomes of mothers, nor did it disaggregate nutrition outcomes by income quintiles or rural/urban location

which would provide for a more comprehensive definition and identification of vulnerable groups.

21

indicator)

Percentage of under-5 children with height-for-age less than two standard deviations below the median of the reference population

58% 51% 44% 40%

Source: Compiled from Central Statistical Agency 2014

The extent to which improvements in underweight children under 2 years of age

could have been attributed by the project is better indicated in the early impact

evaluation of CBN in the 4 project target regions in Ethiopia. Routine data from GMP

was transmitted to national level from villages and health posts starting in 2010, and

suggested that the trend in the first 1-2 years after CBN launch was an improvement of

about 15 percentage points in underweight prevalence, among participants. The

participation rate was estimated at about 30% (see Fig 1, below). Whereas the PAD

acknowledged that factors outside the project interventions would influence these

indicators (World Bank 2008), the joint 2012 WB/UNICEF funded external impact

evaluation, did plausibly attribute improvements of these indicators to CBN supported

under the project (Mason and White 2012).

Figure 1: Trend in Percentage of Underweight Children Under Two Years of Age in

CBN Woredas (FMOH, July 2008 - March 2014)

Source: FMOH

Finally, Maternal and Child Health indicators, indirectly targeted by the project,

also improved during the project duration (table 7). Under 5 child mortality, which the

project indirectly aimed to address at the higher level, saw a reduction from 76 per 1000

in 2010 to 64/1000 in 2013. Similarly, maternal mortality in Ethiopia was reduced from

500 in 2010 to 420 in 2013. Nutrition is only one of the many determinants of maternal

and child health, so the project and the wider community based nutrition interventions in

Ethiopia can only be partially linked to any improvements in these MDGs (which was

acknowledged in the PAD). Nonetheless, it is a powerful one, and nutrition globally is

widely linked to population health (De Onis et al 2004). Empirical evidence has

demonstrated the link between nutrition and health outcomes (WHO 2002; Barros et al

2010); 15% of the global disease burden attributed to the combined effect of

micronutrient deficiencies in children and underweights of mothers (Black et al. 2003),

between 20% of all deaths of those under 5 years of age attributed to malnutrition (Black

0

5

10

15

20

25

30

35

40

Jul-

08

Sep

-08

No

v-0

8

Jan

-09

Mar

-09

May

-09

Jul-

09

Sep

-09

No

v-0

9

Jan

-10

Mar

-10

May

-10

Jul-

10

Sep

-10

No

v-1

0

Jan

-11

Mar

-11

May

-11

Jul-

11

Sep

-11

No

v-1

1

Jan

-12

Mar

-12

May

-12

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Mar

-13

May

-13

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Mar

-14

Pe

rcen

tage

Month/year

% of children weighed with total UW % of children weighed with moderate UW

% of children weighed with severe UW

22

et al, 2008) as well as over 50% of all deaths in Sub-Saharan Africa (Chopra and

Darnton- Hill 2006).

Table 7: Improvements in MHC MDG related indicators during project Duration.

2010 2011 2012 2013

MDG4: Under 5 Child Mortality Rates/1000 76 71 68 64

MDG5 Maternal Mortality Rates/100,000 500 na na 420 Source: Compiled from World Bank II, 2014

3.2.2 Key factors that help explain the achieved impacts

The achievement of the PDO and related indicators can be attributed to the

successful implementation and relevant achievement in the following: 1)

Improvement in Community Based Nutrition and supply of key micronutrients (as

reflected in component 1), and 2) Strengthened institutional capacity to support delivery

of improved nutritional services (as reflected in component 2), and 3) factors external to

the project itself. The following discusses each in greater detail.

a) Improvement in Community Based Nutrition and Supply of key

Micronutrients (through activities funded under component 1)

The project succeeded in bringing nutrition to the community level by integrating

nutrition into the service delivery package of HEP. The project was instrumental in

funding the CBN activities, which was one of the 4 objectives of NNP. The CBN

program administrative design matched that of the wider HEP, and set up so that overall

responsibility for CBN lies with the Woreda (district) Health Office who is tasked to

provide supportive supervision and technical support to implementation (with support

from Zonal and regional Health Bureau). Under the Woreda Health office, two HEWs per

Kebele (sub-district) were tasked to provide critical nutrition services to the community.

They were supported by 10-12 VCHWs – subsequently replaced by HDA, tasked with 1)

monthly community conversations (CC) to improve feeding and other caring practices,

hygiene and sanitation, 2) home visits to follow up growth faltering of malnourished

children, 3) referral of malnourished and sick children to nearby health post for treatment,

and 4) carry out informal continuous contacts with the community. With the introduction

of the HAD (and removal of VCHWs), these tasks were fully shifted to the HEW.

Despite some delays prior to restructuring (see earlier discussion), and with TA

support from UNICEF, Community based Nutrition was successfully rolled out and

implemented in the regions with the combination of high population and high food

insecurity, namely Amhara, Oromia, SNNPR, and Tigray. Within these regions, the

program rolled out in tranches that varied in timing and size, starting with 39 pilot

woredas (districts) in 2008 (tranche 1), and subsequently 54 (tranche 2), 77 (tranche 3),

and 58 (tranche 4) more woredas in 2009, 2010, and 2011 respectively. By the time of

restructuring (2012), 238 woredas were covered by CBN, including training of 12000

HEWs and 119 000 VCHWs. By the end of the project, an impressive 80% (24000) of

23

HEWs were trained in the CBN curriculum (an intermediary indicator of the project),

which was only slightly below the envisioned target of 85%.

The nutrition training package for HEW which the project supported under CBN and

designed initially as stand-alone training (pre-and in-service) and later as part of an

integrated package of training) included: promoting improved caring practices for

children and women to prevent malnutrition (including breastfeeding); provision of

micronutrients, referral linkages to relevant child health and nutrition services, growth

monitoring, and other linkages to address the non-health causes of child malnutrition.

In order to strengthen supervision of CBN moreover, the project funded transport for

supervisors to enable them to make more frequent and timely visits to health posts. And

to strengthen the outreach needs, which was identified as an important need following

transition from VCHW to HDA, the project procured more than 28,750 bicycles and

1,600 motorcycles to provide HEWs with greater mobility and health centers access to

health posts to mitigate reduction in volunteer-provided nutrition services. In addition,

regional nutrition coordinators were recruited to strengthen overall capacity at that level.

Finally, a strong advocacy and communications strategy to support CBN activities was

developed and rolled out to reach areas beyond just the CBN target regions (e.g. for

Infant and Young Child Feeding (IYCF) and exclusive breastfeeding).

Financial and policy level support to facilitate procurement and supply of key

micronutrients contributed to the success of PDO indicators. These activities

significantly benefited both the CBN interventions supported at the community level in

the four target regions (distributed via the HEW and the VCHW and later HDAs), as well

as in other regions across the country. Aside from funding the procurement of key

micronutrients (procurement and distribution of IFA tables to pregnant women), already

the first phase of project implementation saw the adoption of legislation related to salt

iodization (adoption of salt iodization legislation was a dated covenant established by

July 2010), as well as registration of Zinc as an essential drug (another dated covenant

achieved by July 2010) both of which were hailed as a major success towards improving

micronutrient availability at all levels of the health system in Ethiopia. In the second

phase of the project, after restructuring, a number of indicators were added to help

monitor and capture outcomes related to these achievements.

The original indicators which sought an increase in the percentage of households

using iodized salt were not achieved due to the challenges discussed above (and

identified through Bank-financed analytical work) and dropped in 2012. Instead, the

project drew on the success of the adopted salt iodization legislation, and captured in the

indicators after restructuring the percentage of salt that was iodized, which showed

improvements from 0-90% (exceeding the target of 50%). Whilst this is a significant

achievement, the quality of the salt iodization has not been assessed in the absence of

independent survey data. The GOE recognizes quality to be a potential issue, and is

addressing this with various regulatory tools (with support, such as the development of a

Universal Salt Iodization Action plan etc.).

24

b) Strengthened Institutional Capacity to Support Delivery of Improved

Nutritional Services (as per the activities funded in component 2)

The project provided some support towards strengthening national level

coordination on nutrition, although inter-sectoral collaboration remained

problematic. With regards to coordination, during the first phase of implementation,

prior to restructuring, the project reflected success in establishing the national level inter-

sectoral nutrition coordination body. This was a dated covenant achieved in time by July

2009. The NNCB is composed of state ministries of the nine government NNP

implementing sectors, donors, partners, civil society organizations, academia, and the

private sector representatives. It provides policy/strategic decisions related to NNP,

allocates and approves budget for the implementation of NNP, and monitors the

implementation of NNP with key indicators and provides guidance. A National Nutrition

Technical Committee and joint FMOH and MOA technical committees were formed to

deal with technical issues such as reviewing the Health Development Army (HDA)

Agents pre-service and in-service training curriculum on nutrition, and to promote further

coordination at community level between HEWs and DAs.

Whilst the development of this coordination body was an achievement in itself, and the

objective to link the various relevant sectors and their cadres, both in terms of policies as

well as projects at community level, noble, early functioning of this body remained

somewhat challenging as the “how to” of muti-sectoral collaboration between sectors had

been inadequately defined and the Bank-financed NP was focused on the Health sector.

Multi-sectoral linkages to nutrition remained somewhat problematic as a result, and

following extensive advocacy this was ultimately addressed in a revised National

Nutrition Plan (2013-2015) which more clearly identified and spelled out the role of the

coordination body and specific responsibilities of relevant sectors/ministries.

The project made impressive gains in building nation-wide capacity to better

develop, implement and monitor nutrition interventions. Critical achievements of the

project included the training of more than 13,000 health personnel from the health center

level to the federal level in CBN, exceeding the original target of 12,000 set by the

project. In addition, and to address remaining capacity constraints related to procurement

issues, the project trained four regional finance officers and 144 project accountants at

woreda level to strengthen their skills, respectively. Federal accountant training was also

undertaken so that those trained could train woreda accountants, primarily to reduce

delays in processing funds and SOEs. The project also carried out activities originally not

tracked in the results framework, with indicators added after restructuring to better

capture achievements. This included supporting master’s level nutrition training with the

project playing a key role in 80 nutrition masters graduating by project end. In that

regard, the project assisted universities in MPH curriculum revision to make it more

nutrition friendly, and supplied text books to libraries to these universities, and financed

30 MPH candidates selected from the health sector. In addition, critical capacity building

support was provided to strengthen data collection on nutrition at the woreda level and

ensure that this was regularly transmitted to the federal level (working closely with

UNICEF). This had been somewhat of a constraint early on during implementation. At

25

project end, over 80% of woredas were providing monthly nutrition data to the FMOH

(30% more than originally planned), significantly boosting the planning and monitoring

capacity on nutrition across the country.

The project contributed towards further achievements in significantly boosting

research and knowledge generation on nutrition in Ethiopia. Such knowledge is

critical for the evidence based implementation, revision and monitoring of nutrition

interventions. Early on during implementation, a multi-stakeholder consultative

workshop in 2009 identified twelve potential thematic areas for operational research,

later reduced to 6 thematic areas, which helped kick start the operational research topics

to be funded under the project (accompanied by capacity building of the research

institutions (Universities and EHNRI). The process of determining which DP would

finance which study, and the outsourcing of selected studies involving both international

and national applicants, resulted in the Bank resources eventually financing ten studies in

lieu of the eight originally planned. Five of the ten were carried out entirely by EPHI, 5

by Ethiopian Universities, in some instances requiring EPHI direct support to complete

the work.

Table 8: Studies Funded and Produced under the Project No List of research projects Status

1. Effectiveness of organizing newly-wed women and adolescent girls through community based nutrition to improve access to, coverage and utilization of Community Based Nutrition services, Amhara region, North West Ethiopia.

completed

2. Examining Means of Reaching School and Non School Attending Adolescent Girls for Iron Supplementation in Tigray Region, Northern Ethiopia

completed

3. Effectiveness of school based health and nutrition education to improve health and dietary practices of primary school children in Jimma zone

completed

4. Evaluating the bioavailability, digestibility, and sensory acceptability of community based complementary foods

completed

5. The effect of nutrition education on child feeding practices and nutritional status

completed

6. National Iodized salt coverage in Ethiopia completed

7. National Food Consumption Survey. completed

8. Challenges and opportunities in adapting Community based Nutrition among pastoralists.

completed

9. Effective modalities to improve pregnant women’s compliance to daily iron-folate supplementation.

completed

10. Integrated refresher training (IRT) Phase one: Quality of community based nutrition of integrated refresher training and supportive supervision provided for HEWS, Amhara region. Phase two: Implementation of community based nutrition program in Ethiopia after integrated refresher training.

completed

c) The Contribution of factors external to the project

The PDO benefited from the government’s contribution and its focus on the Health

Extension Program. The government invested much of its own funding into the

development of the Health Extension Work Program (into which CBN was integrated),

26

and led the policy development on micronutrients. Government contribution towards the

components of the project covered all aspects related to the HEP and capacity building, in

particular salaries of health extension workers and human resources more generally. The

distribution of insecticide mosquito nets to the community by health extension workers is

often directly linked to improvements in under 5 mortality (Bilal et al, 2012). And the

improvements in maternal mortality is often linked to improved maternal health services.

The percentage of women for example, who received antenatal care increased from 28%

in 2005 to 34% in 2011 and 40% in 2014 (EMDHS, 2014).

Government Programs outside of health are also likely to have contributed towards

observed nutrition outcomes. Despite the challenges of engaging some of the non-

health actors (discussed before) of the state to contribute towards nutrition, some none-

health programs also could have contributed towards the observed nutrition

improvements. Notable programs were the Agricultural Extension Program (which

improved agricultural production in communities), and on the education side the National

School Health and Nutrition Strategy which promoted better nutrition practices (SHN)

(FMOH 2013). The latest 2014 DHS results moreover suggest that overall improvement

in education, for example, is an extremely important determinant of nutrition outcomes.

The PDO, moreover, benefited from parallel investments that impacted nutrition by

donors. The Bank’s SDR 18.8 m funding was always expected to be initial seed money

and spur investments from other donors. Indeed, complementary investments from

partners such as UNICEF, JICA, DFID, WFP, USAID, and CIDA (now DFATD), all

provided different levels of support to the Ethiopian health sector and its nutrition

agenda. In fact, UNICEF in particular was a key partner, which, in collaboration with the

Health Bureaus at all levels, took a leading role in launching the CBN program and in

training and providing supplies. Specifically, UNICEF provided technical assistance to

the FMOH in the areas of masters training, cascading of the training down to the kebele

level and M&E, with special reference to CBN routine data collection and processing.

Bank support linked to the IDA project in the form of a number of grants is also

likely to have contributed towards the achievement of results. One example is the

World Bank JSDF grant from 2009-2013 (US$1.8m), which was implemented as a pilot

in one region of Ethiopia, Tigray, to support the government’s effort in moving the

treatment of child severe acute malnutrition from health centers to health posts, in line

with the health extension worker program. The pilot, which produced guidance through

for example a Capacity Assessment of Health Facility Staff study, and papers on the need

for storage of Ready to Use Therapeutic Food (RUTF) at health posts), as well as training

materials (for health extension workers), led to the shift of therapeutic feeding from the

health center to the health posts (carried out by health extension workers), which is likely

to have contributed towards improvement of key nutrition indicators. Another example is

a US$ 650,000 million Global Facility for Disaster Reduction and Recovery funded

initiative (of which just over US$622,000 was disbursed) to support the rapid Social

Response Multi-Donor Trust Fund (RSD MDTF) which during the project duration

supported the improvement of the national nutrition information system and promoted

domestic production of products to treat malnutrition.

27

Finally, on a much broader level, and perhaps contributing towards the impressive

improvements in stunting and underweight, and maternal and child health

outcomes, was Ethiopia’s impressive economic performance. Throughout the first

decade of the new millennium, the government implemented an impressive fiscal policy,

that resulted in an annual growth rate of 11 percent since 2003, and a decline in poverty

from 49.5% in 2004 to 29.2 % in 2010 (FMOH 2013), which likely further helps explain

the broader nutrition and health improvements observed.

3.3 Efficiency

Rating: The Efficiency of the Project is rated Substantial both in terms of technical

design, unit ratio and cost benefit ratio, with only limited shortcomings in design and

implementation (mainly fiduciary) taken into account.

The project was characterized by strong technical efficiency. The project supported

community based interventions, coupled with a number of higher level interventions

(including policy change) that are among the most cost-effective interventions to improve

nutrition outcomes, with some of the highest cost-benefit ratios in terms of poverty

reduction and economic development.11 Critical high impact interventions were

implemented at sub-national levels, with community members securing access to those

interventions in a culturally and socially sensitive manner. The provision of transport for

supervisors (bicycles, motorcycles and vehicles procured by the project) to enable them

to make more frequent and timely visits to health posts, was a means to enhance

efficiency of community-based nutrition (CBN) services.

Nutrition activities were integrated into the work of those responsible for the

broader sub-national development, health and nutrition efforts. Existing federal and

regional management structures were utilized, and where expanded, were done with the

objective of keeping staffing at the minimum needed to achieve project objectives.

Taking into account the multi-sectoral nature of nutrition, sectoral partnerships were

fostered at policy and operational levels to strengthen cooperation between health and

agricultural staff, resulting in closer cooperation at reaching target groups in

communities. However, efforts to link projects of health, agriculture, education, water

and sanitation sectors at community level had limited traction, mostly done with small-

scale projects.

Efforts were made to engage the private sector, for example, with respect to policy

discussion and production goals for quality salt iodization, a key nutritional benefit,

following mandatory salt iodization legal covenant (IR indicator #2) . The Bank’s

Economic and Sector Work had estimated the benefits of salt iodization to be more than

80 times the costs, and was ranked as one of the three highest global interventions by the

Copenhagen Convention. The technical design was not sufficient in analyzing the salt

industry, however. While quantitative production targets were reached (at 90%

exceeding the target of 50%), quality assurance of the proper level of salt iodization was

11 See Lancet Series Maternal and Child Undernutrition (2008); “Repositioning Nutrition as Central to

Development”, World Bank 2006

28

not. The inclusion of a PDO indicator on household salt iodization in the initial results

framework was based on a superficial understanding of the structure of the salt industry

in Ethiopia, which has both large, but also many small salt producers, the latter who are

very difficult to regulate. 12

A particularly important efficiency measure is the percentage of project funds used

and whether there was a need for an extension of the closing date. Despite an

extension from January 17, 2014 to May 31, 2014, some major end-of-project

procurement items for IFA tablets remained outstanding and unresolved. Out of a total

contract amount of close to US$3m for 18 containers of IFA tablets, the supplier only

managed to ship 12 out of the 18 within the project extension time frame, with

approximately 1/3 of the total IFA quantity (6 containers) cancelled. All in all, at the end

of the project, SDR 17.3 million was actually disbursed, representing 92% of the IDA

committed funds of SDR 18.8 million. In addition, roughly another US$ 2.4million was

disbursed in linked Trust Fund grants.

With regards to the cost benefit assessment, the Project exhibited substantial

positive returns on benefit-cost (B/C) ratio and net present value (NPV), as well as

high economic rate of return. The PAD provided economic and social justifications for

a significant response to under-nutrition in the most affected areas of the country. A

benefit-cost analysis was undertaken prior to appraisal for several nutritional-related

interventions in Ethiopia as part of economic and sector work done by the World Bank. 13

It computed three main types of benefits associated with nutrition interventions, namely:

i) benefits from reducing child and maternal mortality; ii) benefits from increased

economic productivity; and iii) benefits from enhancing child ability. Each of the

interventions selected at appraisal had a benefit-cost ratio above one. The ex-ante

analysis in the PAD cited these main benefits expected from the Project, but it did not

calculate an NPV.

In the ex-post analysis, when monetized benefits for the project (under the form of saved

child and maternal lives and increased lifetime earnings from reduced stunting, anemia,

low birth weight, reduced vitamin A deficiency, and exclusive breastfeeding) are

compared to the costs for the project’s beneficiaries, the benefit to cost ratio was found to

be 4.65. In other words, for every 1$ invested by the project, $4.65 in long term

economic benefits from the project’s nutritional interventions (growth monitoring and

promotion sessions, exclusive breast feeding for children under 6 months, and increasing

utilization of key micronutrients such as vitamin A and iron and folate) can be expected

(see Annex 4). With a 5% discount rate, the net present value of the project was estimated

to be about US$ 80 million. At conventional values for the refinancing and reinvestment

12 The GOE recognizes this as a constraint and is addressing this with: a) a Universal Salt Iodization Action

Plan; b) an update Iodine Deficiency Disorder communication strategy; c) EPHI will undertake quality

control interventions at the federal level and conducting studies of households using iodized salt. 13 “Malnutrition in Ethiopia: Current Interventions, Successes, Cost-Benefit Analysis, and the Way

Forward”, Draft report, World Bank, December 2007: Published as an Africa Human Development Series

book “Combating Malnutrition in Ethiopia: An Evidence-Based Approach for Sustained Results”, by

Andrew Sunil Rajkumar, Christopher Gaukler, and Jessica Titahun, 2012

29

rates, the project also displayed a large modified internal rate of return (MIRR), namely

38 percent (see Annex 4).

The robustness of the results was tested at a higher social discount rate (10%), for

different estimates of program coverage, different fractions of the benefits attributable to

the Bank project (rather than to projects supported by partner organizations, such as

UNICEF), as well as by providing a range for the size of the impact of different

nutritional interventions on mortality and lifetime earnings suggested by the evidence.

Even under the most conservative assumptions, the values for the B/C ratio and the NPV

were 3, and US$ 44 million, respectively (see Annex 4).

The ex-post overall project B/C ratio is lower than the intervention-specific B/C ratios

cited by the PAD.14 Key contributors to the difference likely include the measurement of

benefits in the ex-post analysis.

Whereas the B/C ratios cited in the ex-ante analysis are for more narrowly targeted

nutrition-related programs, the Ethiopia Nutrition ICRR project was comprised of a

broader package of interventions (possibly interacting with one another), and had a strong

capacity building and strengthening component not present in the programs cited by the

PAD.

The ex-post results may underestimate the real benefit and efficiency of the project for

three reasons. First, even for the baseline benefit cost analysis calculations, conservative

assumptions were chosen when the evidence or project data presented a range. Second,

the analysis did not include the benefits of nutritional interventions that were likely part

of the project, but for which sufficient information to estimate program coverage was not

available. The benefits of programs that provide key micronutrients such as iodine for

pregnant women and children, or zinc and iron for children under two are likely to be

substantial, however, and could possibly even exceed the benefits of the project as

currently measured.15 Third, the analysis did not include benefits that cannot be easily

translated to monetary values, e.g. system efficiency. A program implemented by the

Bank in Ghana, focusing on similar nutritional interventions and also having a strong

institutional strengthening component had a much more similar B/C ratio (2.8) to that of

the Ethiopia Nutrition ICRR.

Although the project benefits considered in the ex-post analysis may not be

comprehensive and may not fairly represent all benefits generated by the project, they do

give a good approximation of some of the benefits that are likely to have occurred. The

results suggest that the monetized benefits greatly exceed the costs of the project,

and that, all else being considered, the Government of Ethiopia and the World Bank

are receiving positive returns on the funds invested in this project.

14 For instance, the BCR for vitamin A supplementation in Rajkumar et al. (2012) is 12.5 and that for iron

and folate supplementation in pregnant women is 8.1. 15 For instance, Rajkumar et al. (2012) estimate the benefit-cost ratios of providing iron-folate and zinc to

children between 6 and 24 months of age to be 23.79 and 2.85 respectively, and that of providing iodated

oil to pregnant women and children between 6 and 24 months to be 109.68.

30

3.4 Justification of Overall Outcome Rating

Rating: Based on the above presented data and analysis on the relevance of the project’s

objectives, design and implementation (substantial), achievement of the PDO

(substantial) and efficiency (Substantial), the overall rating of the project is

(Satisfactory)

Table 9. Summary of ratings

Criteria Rating

Relevance of Objectives/Design/Implementation Substantial

Efficacy: Achievement of Development Objectives Substantial

Efficiency Substantial

Overall Outcome Rating Satisfactory Satisfactory

3.5 Overarching Themes, Other Outcomes and Impacts

IDA has been the lead agency for nutrition in Ethiopia over more than a decade and has

demonstrated leadership in the sector by: (a) fostering partnerships that have developed

around the national nutrition program, b) mobilizing and leveraging partner support and

TA for scaling up, and c) strengthening the inter-sectoral platform for collaboration with

other sectors on nutrition.

(a) Poverty Impacts, Gender Aspects, and Social Development

During the project period, Ethiopia experienced a decline in poverty. Although the

overall improved economic performance is likely to have been the biggest factor in this,

the project did prioritize diseases of the poor (malnutrition is widely associated with

poverty) and targeted the most vulnerable - under-5 children and pregnant and lactating

women principally in poor regions with high nutritional insecurity- through the use of

pro-poor community level service delivery channels. Women’s improved access to health

care and nutrition services through the project also contributes to narrowing the gender

gap in health outcomes. Between 2010 and 2013, maternal mortality improved from 500

to 420 deaths per 100,000 population.

The interventions supported under the project and the wider NNP are likely to have

an impact on poverty reduction and social development way into the future. Nutrition inadequacy can affect the cognitive development in particular of children

(Ezzati et al. 2002; Kabubo-Mariara et al. 2009) with implications for earning potential

and thus poverty in adult life - as captured by various life course approach theories (van

de Mheen et al 1998). Targeting malnutrition early, of the mother and of children under 5

(as done by the project) is important not just from a gender and health stance, but also

from a poverty reduction and development stance.

(b) Institutional Change/Strengthening

The project has significantly contributed towards institutional strengthening and

capacity building at both the national and sub-national levels, including:

strengthening multisectoral coordination of the national nutrition agenda through the

31

establishment of a national nutrition coordination body, co-chaired by FMOH and

FMOA. EPHI research capacity was strengthened with critical laboratory equipment and

financial management capacity to handle research and evaluation tasks. Health personnel

across all levels were trained in nutrition, and MA level graduates produced with

Nutrition MAs. Within the FMOH, procurement and financial management capacity was

strengthened by funding both training and individuals. At the sub-national woreda level,

Nutrition information/surveillance, monitoring and evaluation was strengthened, as well

as capacity to carry out supervisory activities over service delivery (training supervisors).

Furthermore, the nutrition training of HEW was institutionalized (with training materials

produced), and the Bank team further provided input to the creation of Health

Development Army (to replace the CHWVs) to extend the reach of the HEW into the

community and replace the Volunteer Community Health Workers. All these institutional

strengthening activities signify the ambitions of achieving high levels of sustainability.

(c) Other Unintended Outcomes and Impacts (positive or negative)

Recent evidence suggests that health inequalities among part of the target

population, children under 5, may have actually increased during the project

period. Whilst the project may well have contributed towards overall improvements in

health and nutrition outcomes (a randomized controlled evaluation would have been

useful to generate solid results), and many of the features of the project are positively

associated with being pro-poor16, social determinants of nutrition inequalities were not

analyzed by the project, and the monitoring framework used by the project to analyze

impact, was not developed from an equity perspective as such.

Whilst the health extension worker program (into which the nutrition project was

integrated) is often associated with improvements in maternal and particularly child

health outcomes of the poor (Bilal et al 2011; Admassie et al 2009; Karim et al 2013;

Medhanyie et al 2012), research by Skaftun et al (2014) which assessed changes in

inequality between 2000 and 2011 using DHS data, found that pro-rich and regional

inequalities remained for a majority of health related indicators (albeit not nutrition

related indicators per se). By decomposing concentration indices, the research found that

while overall health outcomes increased between 2000 and 2011, socio economic

inequalities actually increased for under-five and neonatal deaths (albeit no data was

provided on under-nutrition as such).

Despite the unlikely link of the project itself in widening inequality, it is useful to

note that the wider literature on equity in health or nutrition suggests that some of

the interventions supported by the project can lead to an increase in inequalities. A

WB review of 46 recent evaluations on the impact of nutrition projects since 2000 (IEG

2010) found that while a wide range measured a positive impact on maternal and child

nutrition indicators, the review found that in many instances, mothers and children who

are better off disproportionately benefited the most. Evident was that many of these

16 Including at community level through the mobilization activities; in the community-based approach that

sought to train community volunteers to mitigate inequities related to poor access to health services; and as

well as in the selection of the most food insecure woredas in the 4 large regions

32

interventions placed great emphasis on “downstream interventions” at community level

including health promotion and advocacy. The literature says that whilst such

downstream interventions have the potential to bring about overall improvements in

health, they may be less effective at addressing inequities than so called “upstream”

interventions (Franks and Fiscella 2008; Macintyre et al 2006). Whether the downstream

interventions supported under the WB nutrition project will exacerbate inequalities in

nutrition in the longer run, or whether the upstream interventions will help address

inequities, can only be evaluated by a rigorous assessment.

3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops

A beneficiary survey was not conducted, but operational research was conducted by

EHNRI to assess the delivery of CBN (prior to the Mid Term Review), which included

qualitative assessments in CBN communities, including both participants and non-

participants, VCHWs, and HEWs. The assessments contributed to subsequent decisions

to conduct operational research on the quality of IRT, the implementation of CBN

following IRT, and on factors contributing to IFA compliance. Initially, annual CBN

review meetings were conducted at regional levels with nutrition stakeholders (with

support from the NP, as well as from UNICEF, and from the RSR trust fund), typically

from within the health sector but also included stakeholders from the Disaster Risk

Management Sector. These review meetings were particularly to improve the quality of

CBN service delivery, to review the data quality and the use of data from CBN, and to

build capacity to use these data for decision making. By the end of the project, as

coverage of CBN increased, these CBN review meetings were integrated into the routine

Regional Health Bureau annual meetings.

4. Assessment of Risk to Development Outcome

Rating: The Risk to Development Outcome is rated as Moderate

There are strong indications that the Government is continuing to seek to improve

capacity to deliver nutrition services to vulnerable populations, integrating nutrition

in other related and complementary programs, and investing in supplies and service

provider support. The Government and its DPs continue to support the NNP which the

government fully owns, and refining the mechanisms, training materials, and modus

operandi of the program. In addition to partner support, the World Bank, through its

support under the PSNP and Health MDG Program for Results, as well as proposed

follow up projects, is complementing those efforts with significant resources bearing on

nutritional status of young children, pregnant and lactating women, and adolescent girls.

The commitment of the government and partners towards the national nutrition

agenda is fuelled by significant analytical work and evidence on nutrition. The trends

in children's nutrition status reflected in the 2014 mini-DHS survey is recognized as

underscoring the worth of nutrition investments. A comprehensive micronutrient survey

to be completed later in 2015 is expected to strengthen the evidence base for nutrition

decision making. This will generate and fuel discussion around nutrition and stimulate

support.

33

On a technical level, one risk is linked to the new community level service delivery

extension model. Despite the extensive HEW presence throughout the country, and

inclusion of nutrition among the 16 HEW health packages, effectiveness of nutrition

interventions reaching the poor will nevertheless depend on how competent the new

Health Development Army cadre is in providing quality nutrition information and

support at community level. In addition, more research is needed to understand the

impact and integration of the nutrition tasks originally assigned to VCHWs onto the

already heavy workload of the HEWs.

5. Assessment of Bank and Borrower Performance

5.1 Bank Performance

(a) Bank Performance in Ensuring Quality at Entry

Rating: Moderately Satisfactory

The Bank team was comprised of staff with a range of skills and knowledge,

operational experience, nutrition technical expertise and country specific

knowledge. The development of the project benefited from the multi-partner

development of the national nutrition agenda in Ethiopia, and effectively capitalized on

the relevant knowledge and lessons learned at the time, as well as research done prior to

project finalization. The Bank team entered into discussions with the relevant

stakeholders at all levels (in particular UNICEF), had a sound relationship with the

FMOH. Overall, the Bank team took advantage of the window of opportunity to support

GOE interest in an ambitious effort, and was an important catalyst in guiding, gaining

attention and incremental resources to the National Nutrition Plan (further supporting

overall development objectives). The Bank moved swiftly and alongside the country

process from identification to development.

At the same time, a QER was not conducted for this project which could have

identified some of the initial shortcomings. A more in-depth analysis of the factors

which could influence the success of PDO objectives, and a more detailed gauge of

quantitative outcomes, would have been desirable, reducing the need for restructuring

after the mid-term review. Overall, the team could have been more aware of the difficulty

in carrying through and measuring some of the selected interventions (in particular the

poor linkage between project activities and the salt iodization PDO indicator), the range

of factors influencing timely provision of key nutrition services, service provider and

supervisory capacity gaps, monitoring and reporting, and could have carried out a more

thorough risk assessment of procurement and financial management capacity constraints,

the latter weaknesses foreseeable with significant repercussions for project performance.

(b) Quality of Supervision

Rating: Satisfactory

The project was supervised during the tenure of two Country Directors and two

Task Team Leaders. During both project execution phases, the task teams used

34

supervisory resources to great effect, including proactively accessing trust funds from

different resources (JSDF, RSR, and a GFDRR). Moreover, there were strong personal

relationships between the FMOH decision makers and the Bank team, which included

familiarity with Ethiopian Government processes, language, and local contexts, and

mutual technical respect.

Through regular supervision missions (often jointly carried out with partners) and

reliance on specialists based in the country office, the team was able to provide

guidance and inputs to the Government, and maintain ongoing dialogue with external

stakeholders. For example, revitalization of the FMOH-led nutrition technical working

group and various sub-groups to work on specific technical issues, led to complementary

evidence-based research and other undertakings supported by the Government and DPs

early on and throughout the project duration.

The task team carried out an important MTR in 2011, where some of the key

bottlenecks to implementation were adequately identified. The interim report at the

time of Mid-Term Review provided information for both NNP revision and project

restructuring, to address a number of technical and capacity related challenges and better

monitoring arrangements, all of which, after following up on these recommendations,

significantly improved implementation and disbursement thereafter.

Following the MTR and restructuring, in 2012, continuous Task Team supervision

and the addition of fiduciary staff meant that there were intensive efforts to expedite

implementation, particularly with respect to procurement. Despite almost daily contacts

and monthly follow-up meetings in the second half of the project, there were procurement

procedural matters which were not resolved in a timely manner, resulting in some IDA

(SDR 1.5 m) not disbursed.

(c) Justification of Rating for Overall Bank Performance

With both quality at entry rated as moderately satisfactory and supervision as

satisfactory, therefore the overall Bank performance rating is moderately satisfactory

(taking into account the overall challenges prevalent, particularly until the MTR).

5.2 Borrower Performance

(a) Government Performance


Government involvement and political commitment to the project was extremely

good during preparations and after approval. Conditions of effectiveness and dated

covenants (including critical policy changes) were met in a timely manner (aside from

FM), and the Government Maternal and Child Health team put in place mechanisms for

technical and management reviews, and undertook significant efforts to speed

procurement and disbursement, and strengthen accountability.

Despite the delay in the initial project advance, the FMOH was proactive in

planning and implementing the project, including designing baseline surveys, key

35

stakeholder workshops, and efforts to put in place the necessary M and E systems. This

commitment and ownership continued throughout the project life, reflected in increased

FMOH staffing at national level, appointment of regional nutrition coordinators in the

four project regions, and their active ownership and involvement.

A major problem which affected implementation across the components was

resolving procurement and FM issues hindering implementation such as the supply of

commodities identified, getting studies underway and completed, and getting financial

reports done in a timely manner. Some of these elements improved in the second phase of

the project, but procurement issues were never completely overcome. On the whole,

however, integration of the project with national strategies and other partner efforts,

development of CBN modules, operational knowledge, and monitoring systems,

contributed significantly to the national response to nutrition for children, pregnant and

lactating women and successful outcomes of the project.

(b) Implementing Agency or Agencies Performance


The Federal Ministry of Health was charged with coordinating the implementation

of the project (as it was also the lead agency for the National Nutrition Plan). It was

anticipated that the FMOH could engage the services of other agencies with specific

expertise, such as the Emergency Nutrition Coordination Unit for Emergency

Surveillance activities and the Central Statistical Agency for statistics or survey related

activities. While technical support was provided to the FMOH and by extension to PFSA,

a key procurement entity, they continued to struggle with procurement related issues and

delayed completion of procurement packages during implementation. This was the

primary cause for a project extension request, and ultimately did not result in some IFA

procurement before the closing date.

EHNRI (now EPHI) was responsible for the operational studies and the baseline,

midline, and endline. Five of the 10 studies were carried out entirely by EPHI, 5 by

Ethiopian universities, in some instances requiring EPHI direct support to complete the

work. The baseline and midline studies were done; however the endline survey has not

been completed. It was agreed the endline survey would become part of a broader

micronutrient survey financed by the Bank and other DPs. 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. Resolution of the procurement items between EPHI and UNICEF sooner

could have resulted in timely completion of the micronutrient survey and better

assessment of project performance.

At the sub-national level, the project was implemented using existing structures at

level of the community and health centers, as well as woreda and regional

authorities. Performance at woreda level and below benefited from regular review

meetings with Woreda Health Officers, regular supervision from the Bank/government

project team, as well as from the presence of partner organizations (such as UNICEF).

36

(c) Justification of Rating for Overall Borrower Performance

Both government and implementing agency performance is rated as Moderately

Satisfactory, therefore the overall rating is Moderately Satisfactory.

6. Lessons Learned

Strong Country Ownership and integration of interventions into an existing and wider

multi-sectoral agenda on nutrition and multi-partner investment strategy was key to the

success of the project. The commitment of the Government of Ethiopia to a multi-

sectoral National Nutrition Strategy and National Nutrition Plan (NNP), which it

coordinated and brought DPs into the technical and implementation aspects of the NNP,

meant there was active engagement by the key stakeholders at national level, and

financing from external sources. The project, moreover, representing the first donor

contribution in funding towards the implementation of the national plan, acted as a

catalyst to leverage funding from other sources (both the government and other donors),

particularly for CBN activities. It is important for the lead sector, in this case the Federal

Ministry of Health, to make extra effort to assure active engagement of other donors, and

for the Bank team to encourage this.

The existence of an existing institutionalized community level service delivery model,

quite unique to Ethiopia, was instrumental to the success of the project at the

community level. Ethiopia is one of the few countries globally that has developed a solid,

community level service delivery model through the development of its Health Extension

Program, which relies on Health Extension Workers (trained over a period of one year),

deployed at the health post level, to work closely with community level lay workers to

deliver basic services to the community. Unlike in many other countries, the Health

Extension workers in Ethiopia are fully integrated into the civil service, are remunerated

by the state, and part and parcel of the health service delivery model in Ethiopia. This

project benefited heavily from this existing service delivery model (implemented in the

years prior to the project and supported by various other donors), and the existing

government and donor commitment on nutrition created a perfect entry point for nutrition

support under this project. These existing structures and conditions in place during the

development and implementation thus were fairly unique, and contributed toward success

of the project. Thus, a key lesson is that even with limited funds, a project can achieve

good results when adequately linked to an existing service delivery structure and

leveraging support from partners.

Multi-sectoral coordination on nutrition is difficult, yet critical to the achievement of

the wider nutrition agenda of countries. The role of multiple sectors in addressing

malnutrition was duly recognized in the Ethiopian National Nutrition Strategy of 2008 as

well as the first National Nutrition Program (2008-2013). A national multi-sectoral

coordination body was created under the project, however seemed to have faced

difficulties in generating commitment from other Ministries. The first NNP program was

criticized for falling short of stating specific actions expected from each sector. This,

among others, led to the development of the revised NNP (2013-2015) which listed out

37

roles and responsibilities of relevant ministries/sectors and elicited signatures from each

sector to enhance accountability. Improvements in education for example are a particular

strong determinant of nutrition outcomes. Accordingly, the signatories of the revised

NNP are Ministry of Health, Ministry of Education, Ministry of Agriculture, Ministry of

Trade, Ministry of Labour and Social Affairs, Ministry of Women, Children and Youth

Affairs, Ministry of Industry, Ministry of Water and Energy and Ministry of Finance and

Economic Development. To what extent mutisectoral commitment translates into action

in Ethiopia will have to be closely monitored.

Based on the experience with the Ethiopia project, nutrition project design should

follow a number of best practices: Project design should ensure that it i) is anchored in

appropriate pro-poor, nutrition insecure choices of interventions based on sound technical

priorities fully consistent with global recommendations for scaling up nutrition and its

application to the country situation; ii) is characterized by a strong results chain; iii)

considers analyzing, addressing and tracking determinants of nutrition inequality, taking

into account that some interventions considered pro-poor can sometimes exacerbate

inequality, iv) it recognizes the importance of operational research which can be

instrumental in shaping an overall nutrition agenda, v) anticipates and ensures ability to

mitigate exogenous factors, such as new policies, restructuring or reforms which could

potentially interfere with implementation and the results chain, as well as weak fiduciary

capacity. On the latter, leaving the decision as to who will implement a project to the last

moment (as was done in this project) can be a bottleneck to this. Finally, as with any

project, Bank quality assurance and supervision tools should be utilized as best as

possible: a QER and well executed MTR (and basic restructuring) can be extremely

helpful in minimizing problems during implementation.

Finally, in moving forward, the recognition that nutrition interventions in the health

sector can address just one of the many determinants of improved nutrition outcomes

requires a coordinated effort between the CMU and various GPs (in particular

education, agriculture and health) to carry out joint planning and coordination of

complementary interventions implemented across sectors that can support the

government further improve nutrition outcomes in Ethiopia.

7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies

(b) Cofinanciers

(c) Other partners and stakeholders (e.g. NGOs/private sector/civil society)

38

Annex 1. Project Costs and Financing

(a) Project Cost by Component (in USD Million equivalent as of April 9, 2015)

Components Appraisal Estimate

(USD millions)

Actual/Latest

Estimate (USD

millions)

Percentage of

Appraisal

Supporting Service Delivery

14.0 10.96 78

Institutional Strengthening and

Capacity Building 16.0 13.10 82

Total Baseline Cost 00.0 0.00 0.00

Physical/Price Contingencies

0.0

0.00

0.00

Total Project Costs 30.00 24.06* 80.00*

Front-end fee PPF 0.00 0.00 .00

Front-end fee IBRD 0.00 0.00 .00

Total Financing Required 30.00 24.06* 80.00*

(b) Financing

Source of Funds Type of

Cofinancing

Appraisal

Estimate

(USD

millions)

Actual/Latest

Estimate

(USD

millions)

Percentage of

Appraisal

Borrower 9.60 9.60 100

IDA Grant 30.00 24.06* 80*

Rapid Social Response Program 0.65 0.62 96

JSDF grant 1.81 1.81 100

Japan Grant 0.55 0.31 57

According to Client Connection (April 9, 2015) total SDR disbursed is 92% of appraisal

estimate ($17.3 million out of SDR 18.8 million). The US$ latest estimates reflect the

large exchange rate fluctuations between SDR and US$

39

Annex 2. Outputs by Component

Component Output

Component 1: Supporting Service Delivery (CBN)

roll out of the community based nutrition package

in selected woredas including:

o promoting improved caring practices for

children and women to prevent

malnutrition

o Maternal improving referral linkages to

relevant child health and nutrition services

and other linkages to address the non-

health causes of child malnutrition

o Enhance CBN implementation capacity at

regional and woreda levels

o developing a strong advocacy and

communication strategy to support CBN

activities

In total CBN activities are implemented in 372 woredas

today

CBN package rolled out in 238 woredas in Oromia, Amhara,

SNNPR and Tigray Regions during NP implementation

period.

Baseline survey completed to provide national estimates of

change in nutrition

Population coverage in the four regions of approximately

29,750,000

Over 80% of HEWs trained in the integrated and revised

CBN curriculum

34,926 CHWV trained (by 2011)- eventually replaced by the

HDA

Routine monitoring in the four regions shows gradual

increase in the coverage and a decline of underweight

children; establishment and strengthening of CBN

monitoring system to track change in underweight through

routine data

Training Material on CBN completed and delivered through

initial and refresher trainings (and later rolled into Integrated

Refresher Trainings for HEWs)

Procurement of 28,750 bicycles and 1,600 motorcycles

completed to provide HEWs with greater mobility and health

centers access to health posts for supportive supervision

Advocacy and communications strategy developed and

implemented through FMOH (and more directly through the

Community Conversations Campaigns led by HEWs(and

initially VCHWs)

micronutrient interventions to increase appropriate

utilization of key micronutrients

IFA tablets procured and distributed to pregnant women

through antenatal care

Salt Iodization Policy Adopted supporting proclamation

200/2000 and Legislation came into force in 2011

Iodized salt production increased to 90% (up from 50%)

Vitamin A doses for children 6-59 months accessed (six-

monthly) and quarterly screening for undernourished

children through Child Health Days

Zinc registered as an essential drug and included in the

health post package

Component 2: Institutional Strengthening and Capacity

Building

Coordination mechanisms for Nutrition at Different

Levels

Establishment of a Inter-sectoral National Nutrition

Coordination Body

Coordination mechanisms at other levels created

Other Donor support leveraged under the project

40

Training and Capacity Building of Research and

Training Institutions

o Technical support team established at FMOH and the

National Nutrition Coordination body

o Federal and sub-national level staff trained on M&E and

Financial Management

o Four regional finance officers and 144 woreda project

accountants received training

o 13,000 health personnel from the health center to the federal

level, received training on CBN (up from the original target

of 12,000)

o public health sector 80 health sector professionals applied

nutrition masters graduates (up from the targeted 30))

41

Annex 3. Economic and Financial Analysis

a. Economic Analysis

The purpose of the Ethiopia Nutrition ICRR Project was to support the Government's

National Nutrition Strategy and Program by promoting critical cost-effective, technically

sound, nutritional interventions to children and women of child-bearing age, including

growth monitoring and promotion sessions, promoting exclusive breast feeding for

children under 6 months, and increasing utilization of key micronutrients such as vitamin

A and iron and folate.

Cost-benefit analysis provides a basis for assessing project efficiency by comparing the

total expected cost of each option against the total expected benefits, and examining

whether the benefits outweigh the costs, and by how much. Cost-benefit analysis,

however, may not capture all aspects of the potential development impact related to a

project because some of them cannot be easily translated to monetary values given

constrains of existing data and methodology, e.g., efficiency improvement and equity

improvement.

In order to assess project efficiency in a comprehensive manner, this economic and

financial analysis therefore both assesses overall project development impact, as well as

undertakes a cost-benefit analysis for the main nutritional-related interventions supported

by the project.

Project Development Impact

The returns to investing in nutrition are very high. Malnutrition slows economic growth

and perpetuates poverty through three main routes---direct losses in productivity from

poor physical status, indirect losses from poor cognitive function and deficits in

schooling, and losses from direct health care costs. An analysis of several countries

indicates that the overall economic costs of malnutrition run to as high as 2 to 3% of the

growth of GDP of developing countries.

The project has contributed to Ethiopia’s development through the following pathways.

First, it contributed to improving child survival and other health outcomes by

decreasing the incidence of stunting, anemia, vitamin A deficiency, and promotion of

exclusive breastfeeding for children under 6 months of age. According to WHO,

malnutrition is the underlying contributing factor in about 45 percent of all child deaths

and this can be prevented through improved nutrition practices.

Second, it generated long-term economic benefits by increasing the size of the active

and productive labor force who can potentially contribute to economic growth and

poverty elimination. With improved nutritional status, more children will survive into

adulthood and the labor force will work more productively as a result of enhanced

42

cognitive development. The most recent empirical estimates of the negative effects of

stunting on worker productivity and adult earnings range from about 10 percent a year to

as high as 20 percent per year.17 Anemia is associated with between 2.5 to 5 percent of

reduction in wages.18 Productivity losses at the individual level are estimated to be more

than 10 percent of life time earnings, which at the macro level can lead to a 2-3 percent

loss in GDP. According to estimates by Rajkumar et al. (2012), Ethiopia was estimated to

lose 3%, and respectively 2.5% of GDP between 2006 and 2016 in the absence of

interventions to remedy stunting and iron deficiency.

Third, the project significantly contributed towards institutional strengthening and

capacity building at both the national and sub-national levels. Although not quantified,

this greatly helps the country’s capacity in making evidence-based decisions and

realizing potential efficiency gains.

Fourth, the project was also associated with other benefits such as prevented

downstream losses from high use of health resources and required extra care for people

with less cognitive development as a result of childhood stunting.

The case for public intervention

Working with the public sector through this project was economically justified because:

The project focused on high impact and cost-effective nutrition interventions which are

a public good (as opposed to a private good), yielding benefits for everyone in society.

Thus, the project enabled a better use of finite resources.

The presence of positive externalities from nutritional investments through the

consumption and/or production of goods and services that would otherwise not have been

consumed. For instance, better nutrition can increase educational attainment, reduce the

spread of contagious diseases, and increase the national productivity as described above.

Addressing market failures such as undeveloped financial markets and informational

asymmetries. Although the private returns of improved nutrition are high, the constraints

imposed by poverty on poor families inhibit them from investing more resources in

children---an investment whose pay-off cannot be seen until 10 or 20 years into the future.

In addition, addressing malnutrition is often hampered by two main types of information

asymmetries: (i) mothers cannot tell when their children are becoming malnourished,

until malnutrition is severe and it might be too late (ii) good nutrition is not intuitive and

providers do not always know what food or feeding practices are best for their children or

for themselves. As a result of these information gaps, even in the absence of income

constraints children’s nutrition does not automatically improve. Given the high economic

benefits and redistributive effects of investing in nutrition, there is thus an argument for

public intervention for families and parents to get the information they need to bridge

17 Hoddinott (2003);World Bank (2006); Ross and Horton (2003); Granthan-McGregor et al. (2007) 18 Ross and Horton (1998)

43

these gaps.

Cost-Benefit Analysis

Cost-benefit analysis (CBA) is a systematic process where costs and benefits of a

program are identified, measured, and compared in monetary terms. By valuing both

costs and benefits in the same monetary terms, they can be directly compared to

determine net economic impact of a program.

The project’s population coverage provides the basis for calculating the economic

benefits arising from the nutrition-related project investments. The benefits estimated for

the CBA analysis include increased lifetime earnings, and are estimated to accrue to three

main groups of beneficiaries: children under 2 and 5 years of age benefiting from reduced

stunting, and from vitamin A deficiency, respectively; children under 6 months of age

benefiting from exclusive breastfeeding; and pregnant women and streams of newborns

benefiting from iron and folate supplementation (and thus from reduced anemia, reduced

maternal mortality, and reduced prevalence of low-birth weight). The benefits arise from

improved access to and utilization of key micronutrients such as vitamin A for children

and iron and folate for pregnant women, as well as from an increased participation in

growth monitoring and promotion sessions, and a focus on priority behaviors such as

exclusive breastfeeding for six months and adequate complementary feeding starting at 6

months with continued breastfeeding for 24 months.

When monetized, the benefits from these services were estimated to exceed the costs,

showing that the project is a sound economic investment. The analysis concludes that, at

a 5% discount rate, the net present value (NPV) of the project investments is estimated at

about US$80 million with a high B/C ratio of 4.6 (See Table A4.1). At conventional

values for the refinancing and reinvestment rates, the project also displayed a large

modified internal rate of return (MIRR), namely 38 percent.19

Table A4.1: Results summary

Description Value (US$ millions)

Present value of benefits (discounted at 5%)

19 The internal rate of return (IRR) for the Ethiopia Nutrition project is also large, exceeding 25. The IRR

calculation, however, implicitly assumes that the IRR is both the cost of financing the project, as well as

that all the benefits from the project can be re-invested at the rate of the IRR, yielding further benefits in the

next period. By contrast, the MIRR adjusts the IRR to account for the difference between re-investment

rate and investment return. Since the benefits from nutrition projects, for instance under the form of health

improvements, may not necessarily be re-investible, or are re-investible typically at a lower rate than the

IRR, the IRR will tend to overstate the true rate of return, and the MIRR will give a better estimate of

project profitability. The MIRR of 38 percent assumes that benefits are re-investible at 5 percent, and that

the refinancing rate is 8 percent (which was Ethiopia’s lending rate in 2008 as measured by the WDI). If

benefits are assumed to not be re-investible, the MIRR for the Ethiopia Nutrition Project at 8% and

respectively a 5% financing rates is 36, and respectively 33 percent.

44

Increased lifetime earnings arising from reduced stunting 44.7

Increased lifetime earnings of lives saved from Vitamin A 17.6

Increased lifetime earnings of lives saved from exclusive breastfeeding 4.0

Increased lifetime earnings from iron and folate supplementation 35.4

Present value of benefits (discounted at 5%) 101.7

Present value of costs (discounted at 5%) 21.9

Benefit-cost ratio 4.65

Net Present Value 79.9

Methodology and Assumptions of the Cost-Benefit Analysis

The methodology used in this project analysis is the standard World Bank methods for

evaluating projects where investment costs of resources used are compared with the

stream of economic benefits. This is the standard cost-benefit analysis, in which the

stream of benefits and costs are discounted to present values using a discount rate to

represent the opportunity cost of capital in the country. By investing $24.2 million in

nutrition interventions, the country did not have that amount to spend on other programs,

and thus there is an additional opportunity cost that should be recognized in the analysis.

The money spent could have been invested to earn returns. The present value of a dollar

to be received in the future is always less than 100 cents (Rhoads, 1980). In order to

incorporate this concept of time value of money, this CBA analysis uses a 5% discount

rate to convert all monetary values to their equivalent value at the beginning of the

project in 2008. The NPV is then expressed in current millions of US dollars.

Beneficiary population of the project. The incremental beneficiaries of the project are

estimated from project indicator data and include: the number of children participating in

GMP sessions (and benefiting from stunting reductions); the additional (compared to the

baseline) number of children between 6 and 59 months receiving a dose of vitamin A

every six months; the additional number of children under 6 months being exclusively

breastfed; and the additional number of pregnant women receiving iron and folate

supplementation under the project.

Benefits from increased lifetime earnings from reduced stunting. The current evidence

indicates that young children under the age of 24 months who suffer from chronic

malnutrition and are stunted (two or more standard deviations below median international

standard) would earn significantly lower incomes throughout their economically active

lives. Given that stunting is irreversible beyond the age of 2, the prevention of chronic

malnutrition increases the individual’s potential income earning capability relative to

what it would have been had she or he not suffered malnutrition at early childhood.20 For

20 Engle et al (2007); Granthan-McGregor et al (2007)

45

children who are stunted before age of 24 months, some catch up may take place, but

most stunted children will remain stunted throughout adulthood.21 Therefore, benefits of

reducing chronic malnutrition in the project areas is measured by the increased income

earning capacity of the persons whose nutritional status was improved by the project. The

most recent empirical estimates of the negative effects of stunting on worker productivity

and adult earnings range from about 10% to as high as 20%.22

The percentage of children stunted showed significant improvement during the project

period, declining from 51% in 2005, to 44% in 2011 and 40% in 2014. However, some of

these improvements had already started when the project was first implemented in 2008.

According to a joint 2012 WB/UNICEF report that attempted to separate the contribution

to the decline in stunting of the Community Based Nutrition (CBN) program supported

under the project from that of other factors (including prior trends), the reduction in

stunting attributable to the project was between by 3 to 5 percentage points each year.23

Benefits from increased lifetime earnings of lives saved from reduced vitamin A

deficiency and exclusive breastfeeding. The benefits from increased utilization of key

micronutrients such as vitamin A are large. According to the current evidence, vitamin A

supplementation reduces under 5 mortality by 20 to 24 percent. 24 For purposes of the

cost-benefit analysis, we estimate the benefits using a human capital methodology, where

benefits include the discounted future income flow received by the proportion of these

children whose lives are saved through the project investment, as they are expected

eventually to become part of the economically active population.25

A similar approach is used in the case of breastfeeding.26 The scientific literature has

confirmed the extensive nutritional benefits of exclusive breastfeeding for infants less

than 6 months old. Depending on whether exclusive breastfeeding is timely initiated on

the first day of birth, the magnitude of its negative impact on under five mortality varies

from 7.6 to 13 percent.27

Benefits from lives saved and increased lifetime earnings from iron and folate

supplementation. According to the evidence, benefits from iron and folate

supplementation are threefold: increased lifetime earnings stemming from increased

productivity; reduced maternal mortality; and increased lifetime earnings from reduced

21 Engle et al (2007); Granthan-McGregor et al (2007) 22 Granthan-McGregor et al (2007) 23 Mason and White (2012) 24 Beaton et al. (1993); Bhutta et al. (2013) 25 Human capital methodology is commonly used to estimate economic benefit related to human

development. Although there are concerns about whether all saved lives will have been employed, it is

worth noting that children saved through these program investments will enter the labor market in the

future, when job market prospects might be better given the current growth of the economy in Africa.

Furthermore, average wages also reflect unemployment, which further lessens this concern. 26 Another potential benefit of exclusive breastfeeding is the economic value of the breast milk produced

by lactating mothers. However, exclusive breastfeeding is also associated with increased nutritional intake

for the mother, and data was not available for a detailed quantification of the corresponding net benefits. 27 Rajkumar et al. (2012))

46

prevalence of low birth weight.

A similar approach to that used to estimate the benefits from stunting is used in the case

of productivity benefits from reduced anemia. Iron supplementation on anemic adults was

estimated to increase blue collar labor productivity by 5% and heavy manual labor

productivity by an additional 12% controlling for other factors.28 Scientific research

shows that there is at least 1.5% reduction in productivity for each 1% drop in iron status

below standard.29Among pregnant women, iron and folate supplementation has been

shown to reduce anemia at term by as much as 66%.30 In addition, the evidence shows

that the iron and folate supplementation decreases the prevalence of low birth weight by

13 to 20%, and that low birth weight decreases adult earnings by as much as 7.5%.31

Evidence from elsewhere (India, Philippines, Nicaragua) indicates that the productivity of

physical labor declines by 1.4% for every 1% reduction in height.32

Finally, the evidence shows that iron fortification reduces maternal mortality by 22%, and

for the purpose of this analysis we estimate these benefits from reduced maternal

mortality by using a human capital methodology, where benefits include the discounted

future income flow received by the proportion of these mothers (assumed to be 25 years

of age) whose lives are saved through the project investment.

For purposes of the CBA analysis, the following key assumptions were made:

An earnings premium of roughly 10% (for stunting avoidance), 5% (for anemia

avoidance), and 7.5 % (for low birth weight avoidance) was applied as the effect of

increased productivity.

Future wages are discounted at a relatively high discount rate of 5% per year, after

adjusting for normal mortality at each year of life. Each year of productive life is

valued as the real per capita gross domestic product (GDP, estimated to be US$222 in

2008), remaining constant throughout the benefit accrual period. Following Rajkumar

et al. (2012), the productive lifespan is defined as lasting from 15 until 53 years of

age. With this formula, the lifetime income stream of a two year old child is valued at

US$1,803, and that of a 25 year old mother is valued at $2,918.

The impact of the nutritional interventions under the project was assumed to be as

follows:

o Following Mason and White (2012), 4 percentage points reduction in stunting each

year beginning in 2009, from a baseline stunting prevalence of 50.5%.

o 24 % reduction in mortality of children between 1 and 59 months old from reduced

vitamin A deficiency. As per Ethiopia’s WHO profile, the mortality for children

between 1 month and 59 months of age was assumed to be 57% of Ethiopia’s

under 5 infant mortality rate in each year.

o 7.5% reduction in under five mortality rates each year from exclusive

28 Ross and Horton (1998) and 29 Levin et al (1993) 30 Bhutta et al. (2013) 31 Cogswell et al. (2003); Behrman, Alderman, and Hoddinott (2004).

32 Haddad and Bouis (1991)

47

breastfeeding of infants under 6 months of age.

o 22% decline in maternal mortality rates, 66% decline in anemia at term, and 19%

decline in the prevalence of low birth weight from iron and folate supplementation.

Only non-mild anemia (amounting to 45% of anemia cases) was assumed to have

negative productivity effects. The baseline anemia prevalence among pregnant

women was assumed to be 28% based on WDI data, and the baseline low birth

weight prevalence was assumed to be 13.5% based on Rajkumar et al. (2012)

Sensitivity analysis

Sensitivity analysis describes the process of establishing the extent to which the outcome

of the cost benefit analysis is sensitive to changes in the values of the input variables. It

involves recalculating the NPV based on changes made to key variables and assumptions.

To verify the robustness of the results, an uncertainty analysis was carried out to test

some key assumptions using different variable values (see Table A4.2).

Discount rate. The typical discount rate used for health program investments ranges

from 1.75-to 5%33, and to be conservative the present CBA analysis uses a 5%

discount rate. However, since recent studies suggest that discounts rates as high as

10% might be appropriate for investment programs in developing countries, the

robustness of the results was also tested using a 10% discount rate.

Statistical uncertainty. To check the robustness of the results to changes in the

magnitude of the assumed impact of the various nutritional interventions, the analysis

was also performed on the basis of the 95% confidence interval values for the size of

the impact provided in a comprehensive review of child and maternal nutritional

interventions.34 In this review, the effects of iron folate supplementation on maternal

mortality and that of breastfeeding on under five mortality were statistically

insignificant (i.e. indistinguishable from a zero effect), so in the sensitivity analysis

the magnitude of these impacts was assumed to be 0. An analysis was also performed

assuming the magnitude of the impact of the different nutritional value was equal to

the lower bound values for all the interventions where these values were available,

and zero if the effect was statistically insignificant.

Program coverage. Analyses using alternative measures of program coverage for

children benefiting from reduced stunting based on the percentage of population with

access to a basic package of nutrition services or on the basis of funds disbursed

produced similar results.

Benefit apportionment. The results were also robust (in the sense of positive returns)

to apportioning only half of the benefits from stunting and breastfeeding to the Bank

project (rather than to complementary projects supported by partner organizations,

such as UNICEF).

Table A 4.1: Sensitivity analysis

33 Helmohltz Munchen (2012) 34 Bhutta et al. (2013)

48

Analysis

Range

(value in base

scenario)

Discounte

d Benefits

(million $)

NPV

(B/C ratio)

Statistical uncertainty of estimates

Reduction in prevalence of stunting 3 - 5 ppts

(4ppt)

33.6 -

55.9

68.7-91.1

(4.1 - 5.2)

Reduction in mortality from Vitamin A

deficiency

17 - 31%

(24%)

12.5 -

22.7

74.8 - 85

(4.4 - 4.9)

Reduction in mortality from exclusive

breastfeeding

0%

(7.5%)

- 75.8

(4.5)

Benefits from iron and folate supplementation

Reduction in prevalence of anemia at term 46 - 79%

(66%)

35.4 -

49.6

84.5 - 85.2

(4.7 - 5.3)

Reduction in prevalence of low birth weight 3 - 32%

(19%)

34.8 -

35.9

83.8 - 83.9

(4.6 - 4.7)

Reduction in maternal mortality 0%

(22%)

29.1 73.6

(4.4)

Lower bound value of all estimates 65.9 44.0

(3.0)

Program coverage resulting in reduced stunting 31.6 -

44.8

66.7 - 79.9

(4.1-4.7)

Discount rate 10%

(5%)

83.2 64.9

(4.5)

Share of benefits from breastfeeding and reduced

stunting apportioned to the project

50%

(100%)

77.4 55.5

(3.5)

50

Annex 4. Bank Lending and Implementation Support/Supervision Processes

(a) Task Team members

Names Title Unit Responsibility/

Specialty

Lending

Andrew Sunil Rajkumar Senior Health Economist GHNDR Task Team Leader

Marito Garcia Lead Human Development Specialist GEDDR

Endeshaw Tadesse Senior Operations Officer GSPDR

Samuel Haile Selassie Senior Procurement Specialist GGODR

Richard Olowo Senior Procurement Specialist GCFDR

Abiy Temechew Procurement Analyst GGODR

Supervision/ICR

Andrew Sunil Rajkumar Senior Health Economist GHNDR Task Team Leader

(through ISR#5; June

23, 2010)

Adiy Admassu Temechew Procurement Analyst GGODR Procurement

management

Tafesse Freminatos Abrham Consultant GGODR

Marylou R. Bradley Operations GHNDR

Benjamin P. Loevinsohn Sector Cluster Leader GHNDR

Yuki Isogai

Aissatou Chiplaou Senior Program Assistant/Operations

Analyst

GHNDR Program Support

Ziauddin Hyder Senior Nutrition Specialist GHNDR Task Team Leader

Shimelis Woldehawariat Badisso Senior Procurement Specialist GGODR Procurement

management

Meron Tadesse Techane Financial Management Analyst GGODR Financial

management

Eleni Albejo Program Assistant AFCE3 Program Support

Eva K. Ngegba Program Assistant GHNDR Program Support

Tegist Zewdu Mekonnen E T Temporary AFCE3 Program support

Frew Tekabe E T Consultant: Nutrition Specialist GHNDR Program analysis and

support

Matthew J. Robinson Consultant GHNDR

Abiy Demissie Belay Financial Management Specialist GGODR Financial

management

Qaiser M. Khan Sector lead Economist AFCE3 Human development

Huihui Wang Economist GHNDR Health economics

Yonas Regasssa Consultant GHNDR Health economics

Andrew Sunil Rajkumar Senior Health Economist Task Team Leader

(through ISR#5; June

23, 2010)

Adiy Admassu Temechew Procurement Analyst AFTPC Procurement

management

Christopher H. Herbst Health Specialist: ICRR TTL and Lead

Author

GHNDR

Richard Seifman Consultant: ICRR Background

Research

GHNDR

51

(b) Staff Time and Cost

Stage of Project Cycle

Staff Time and Cost (Bank Budget Only)

No. of staff weeks USD Thousands (including

travel and consultant costs)

Lending

FY08 37.34 203,357.98

Total: 37.34 203,357.98

Supervision/ICR

FY09 13.88 170,354.28

FY10 80.46 229,833.65

FY11 40.99 216,475.96

FY12 11.28 112,712.96

FY13 36.16 156,715.98

FY14 26.76 146,838.17

FY15 5.81 21,194.28

Total: 215.34 1,054,125.28

52

Annex 5. Beneficiary Survey Results N/A

53

Annex 6. Stakeholder Workshop Report and Results N/A

54

Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR

I. BACKGROUND

The National Nutrition Strategy (NNS) (2008-2013) acknowledged that under-nutrition is

a multi-sectoral issue, and highlighted the need for a longer-term approach with equal

weight on food, health and care. Analyses by the World Bank (WB) and others showed

that stunting rates are high among all wealth quintiles. Furthermore, stunting and wasting

rates were similar in both food secure and food insecure woredas This underscored the

need to invest in multi-sectoral approaches to address under-nutrition, including non-food

interventions such as breastfeeding practices; infant feeding and child care practices;

hygiene, water, and sanitation; improved health services; and the status of women in

society. The NNS brought various uncoordinated nutrition programs into one

comprehensive framework.

The Government of Ethiopia (GoE) is committed to accelerating progress in nutrition,

which is reflected in the Plan for Accelerated and Sustained Development to End Poverty

(PASDEP) and also in the Growth and Transformation Plan (GTP) 2010/11 – 2014/15,

which has replaced the PASDEP as Ethiopia’s poverty reduction strategy. PASDEP

called for the implementation of the NNS, which led to the design and implementation of

the National Nutrition Program (NNP), officially launched in 2009.

The NNP, particularly through the Health Extension Program (HEP) of the Federal

Ministry of Health (FMoH) has harmonized relevant nutrition interventions targeted to

young children and pregnant and lactating women (PLW). The NNP was intended to

cover five years (2008-2013), but is currently being revised by the GoE to run until 2015

to bring it in line with the GTP, Health Sector Development Program (HSDP), and other

rolling health and development policies. The revised NNP will incorporate two recent

GOE strategies that were formulated in 2011: Strategy for Accelerated Stunting

Reduction and Strategy for Management of Moderate Malnutrition, and will seek to

catalyze multi-sectoral action and increase the focus on maternal nutrition issues.

Project Rationale: Nutrition is multi-sectoral and multidimensional in nature, is

affected by interventions and programs in several agencies and ministries in Ethiopia,

which the NNP seeks to harmonize. The Ethiopia Nutrition Project (NP) is financed by

a grant obtained from IDA and focuses on subset of nutrition activities in support of the

NNP. The total project cost for the five years project life is USD 30 million. The project

was effected in September 2008 but officially launched on June 22, 2009, commencing

with twenty-five woreds.

The NP is in line with the WB’s Ethiopia Country Assistance Strategy (CAS), which

highlights nutrition as a key element of support, due to its impact on productivity,

human development and health. The NP has been used to leverage support of other

donors for NNP implementation. The success of the NP is expected to lay the

foundation for implementation of the rest of the NNP.

55

Implementation Arrangements

The FMoH is the lead implementing agency, particularly of CBN, which is an integrated

component of HEP. The Ethiopian Health and Nutrition Research Institute (EHNRI), an

autonomous agency under FMoH, is responsible for implementation of activities,

including operational research and monitoring and evaluation.

The NNP brought several existing nutrition projects under one framework to increase

coordination and facilitate scale-up. The NNP aligns donor support in nutrition from

several development partners (DPs), including UNICEF, USAID, Irish Aid, JICA, DFID,

CIDA, the Government of Spain, WFP, MI, and the WB. The WB is extending support to

areas that are not covered by others through the NP; therefore, complementing DPs’

support to the NNP.

III. ASSESSMENT OF OUTCOMES

Relevance of Objectives, Design and Implementation

The community based nutrition (CBN) program activities were identified based on the

first component of the NNP, namely Supporting Service Delivery. At the time, CBN had

several activities within it, including, (i) monthly growth monitoring and promotion

(GMP) of children under-2; (ii) monthly community conversations and discussions on

health issues; (iii) referral linkages to health facility based services; (iv) micronutrient

deficiency control through Vitamin A supplementation and deworming; (v) IFA and

routine nutrition counselling for pregnant and pre-pregnant women; (vi) quarterly

screening for acute malnutrition at Community Health Days (CHDs);

These activities/ interventions were at the time most appropriate to overcome both acute

& chronic under-nutrition and micronutrient deficiencies amongst children under five and

(PLW) mothers. The package of interventions, even currently, are appropriate as these

address the 1000 days period. In addition, the positive aspects of implementation of the

NP was two-fold: a) system strengthening – as it was being implemented using the HEP

platform, it help build capacity/ skills of the HEW, b) this and the community

conversation also improved service coverage and assured sustainability.

During the preparation of the PIM, stakeholders were involved, such as government and

non-governmental organizations. Furthermore the local literature and necessary steps

were taken to identify evidence – based package of interventions described above. To this

end, the PIM was deemed sufficient enough which led to a successful launch. In addition,

the PIM has served as a reference document throughout the project period.

The PDOs and project components, in a way, still fit to the recently launched NNP as

well as the globally recognized 1000 days/ SUN/ 2013 Lancet Nutrition Series. Hence,

the package of interventions, mainly within component one were/ are suitable to Ethiopia.

Furthermore, some activities, such as the CHDs, have been adopted throughout the

country and are now being delivered integrated into the routine service at woreda and

community levels.

56

Some selected indicators from the project were adopted with minor modifications and

included with the HMIS.

Approaches have been changed as strategies, etc. were revised – for example the use of

VCHW was stopped and GMP is being done by HEWs; new objectives/ indicators were

added when deemed necessary – e.g. Training of regional and federal level mid-level

nutrition managers.

The implementation arrangements of both components were reasonable. Community

based nutrition and micronutrient interventions were delivered through the existing

Health system. At community level, the HEP platform was used, as nutrition was one of

the 16 packages of HEWs. This has strengthened the health system as well as the delivery

of nutrition services at community level.

Institutional strengthening – HR deployment at FMOH and RHBs to support NNP has

facilitated the implementation of the NP.

Capacity Building – there have been many in-service and pre-service trainings and

research conducted through the NP. These included CBN training for health workers and

HEWs; training of VCHW (at the beginning); training on M & E and financial

management; and Master’s level training for MOH and RHB staff.

All these have been well incorporated in existing systems and therefore have contributed

to the sustainability of the Nutrition program in Ethiopia.

Achievements of Project Development Objectives

Currently, CBN activities are implemented in 372 woredas. Mothers/caregivers with

children under two years of age are monthly weighed and counseled based on the

children nutritional status by HEWs. In March 2013, a total of 919,409 children were

weighed with an average participation rate of 44.1% and an underweight prevalence of

7%. In March 2014, there was an increase in the number of children weighed (1,144,348)

as well as in the participation rate (49.0%), with a decrease in underweight prevalence

(5%). The program has shown a consistent downward trend in underweight prevalence

over the years in CBN implementing woredas (Figure 1). This was one of the higher level

objectives of the project.

Figure 1: Trend in Percentage of Underweight Children Under Two Years of Age in

CBN Woredas (FMOH, July 2008 - March 2014)

57

The Research topics supported under the project were selected by policy & strategy

developing institution (FMOH), the research institute (EPHI/ EHNRI) and academia.

Therefore, almost all topics were targeted to address new/ old strategies, on-going

interventions as well as delivery platforms. Hence the research sub-section of the

institutional capacity building component of the NP has contributed to improving our

program(s) and interventions.

Key observations related to Implementation

On procurement

Nutrition supplies and other logistics procurements in Ethiopia have been conducted

through different channels, including both through the government procurement

mechanisms (PFSA) and from the Nutrition development partners especially UNICEF.

The quantification exercise identifies the target groups for nutrition; the type of nutrition

supplies to be forecasted, budget source for each procurement items have been identified

every year. Based on the quantification shipment order has been conducted by dividing

the quantity based on the quarterly needs. During the procurement of the above logistics

specifically related with the project, sometimes there were delays due to many reasons,

such as no objection needed from the Bank; international bidding taking longer than

anticipated, inadequate follow up from the concerned body etc. Due to the delay on

procurement the project in general was not significantly affected(CBN),but there was an

incident on Albendazole procurement delay for one year for one round (2004 EFY)

which resulted in coverage drop to 19 % nationally.

There have been logistic supply delays due to various reasons. The suppliers who want to

participate in the bidding process are required to register with Food Medicine Health

Care Administration and Control Agency (FMHACA). The requirement being this, some

suppliers apply to participate in the bid process without getting registered. The regulation

stipulates that anyone who wants to supply medicine to the country has to registered and

get acceptance by the captioned agency. The registration process also takes some time as

there are number of suppliers waiting to register. As the screening process adds up on the

time already consumed in the process mentioned above it contributes for the delay in the

procurement process. The problem arises further when a supplier does not have agent

05

10152025303540

Jul-

08

Sep

-08

No

v-0

8

Jan

-09

Mar

-09

May

-09

Jul-

09

Sep

-09

No

v-0

9

Jan

-10

Mar

-10

May

-10

Jul-

10

Sep

-10

No

v-1

0

Jan

-11

Mar

-11

May

-11

Jul-

11

Sep

-11

No

v-1

1

Jan

-12

Mar

-12

May

-12

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Mar

-13

May

-13

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Mar

-14

Pe

rcen

tage

Month/year

% of children weighed with total UW % of children weighed with moderate UW

% of children weighed with severe UW

58

here in Ethiopia, in this case the supplier has to send someone to process the registration.

The absence of an agent for a particular supplier has another delaying effect as well, it

creates a communication barrier. When there is something which has to be done through

agents like issuing warranty it may take some time. The process which is followed by the

Bank also contributes to the delay in the procurement process.

On development of Training materials for CBN

The training materials developed (for CBN plus micronutrient interventions) were well

suited for the targeted group as this enabled effective implementation of the intended

project activities. For this purpose, the materials have been modified and included within

the IRT modules for HEWs in 2012/13, hence ensuring sustainability of use and scale up.

Every two years though IRT all health extension workers were trained on nutrition which

brings major changes on health extension workers to deliver the complete packages of

community based nutrition which includes:

a) Monthly growth monitoring and promotion of under-2 children by Health extension

Workers (HEWs) to assess growth adequacy, provide nutrition education to caregivers

and identify children whose growth is faltering. This growth monitoring is intended to be

a starting point to engage the community in actions that promote child growth, including

optimal breastfeeding and complementary feeding, hand washing, hygiene, sanitation,

appropriate management of sick children, and increased use of other health services as

needed;

b) Monthly community conversations (facilitated by health development army (HDAs

and Health Extension Workers (HEWs)), which use growth monitoring results to

mobilize communities to take actions that support child growth.

c) Referral linkages: Referral of those children with severe underweight to health facility

for further check-up and response as per existing protocols (i.e. therapeutic feeding,

targeted supplementary feeding and/or treatment of health problems).

d) Micronutrient deficiency control: biannual vitamin A supplementation, de-worming,

and quarterly screening for acute malnutrition through community health days.

On Implementation Performance of different actors

The Government of Ethiopia has demonstrated its policy commitment to nutrition by

developing standalone National nutrition strategy (NNS) and its five year National

nutrition program (NNP) in 2008 and relevant guidelines, and incorporated nutrition,

especially stunting into its five year Growth and Transformation Plan (GTP). There are

also sectoral strategies and programs which create a good opportunity to mainstream

nutrition into responsible sectors, and put legislations or legal frameworks to enforce

some key nutrition interventions.

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Among these the most notable ones are: Growth and Transformation Plan (GTP),

National food security strategy, the National health sector policy and its HSDP, and the

National School Health and Nutrition strategy and its ESDP. Thus, it is the responsibility

of the line ministries or sectors to effectively mainstream the National Nutrition Strategy

and Program in their sectoral policy and programs; and implement the nutrition

interventions/programs which it is mandated in the strategies mentioned above.

The Government of Ethiopia, in collaboration with nutrition development partners, has

shown its commitment to reducing stunting at a faster rate, and signed the commitment

for food and nutrition security at the G8 meeting in 2012. Vital to the attainment of those

plans are the systems and structures to reach communities and households.

Community based service delivery platforms have been made available in health sector to

ensure decentralized and democratized public services. The Health Extension Program

(HEP) that aims at creating healthy environment as well as healthy living in an innovative

community based health care delivery system includes 16 packages where nutrition is one

of them focusing primarily on changing the behavior of the community in child feeding

and care; promotion of growth of children; screening for malnutrition and 6-59 month

children vitamin A supplementation.

The Health Extension Program (HEP) deploys two health extension workers per health

post, who together reach a population of roughly 5,000. To strengthen and accelerate

social and behavioral changes and the overall wellbeing of the population, a community

level Health development army has been established using a “one-to-five network,”

wherein out of every six households one person takes a leading role, functioning as a key

link with both health and agriculture extension workers. Five such leaders comprise a

development team. Each development team looks after 25 to 30 households. This

arrangement is contributing to Ethiopia’s sprint toward the achievement of MDGs as we

approach 2015 (MOH, 2011).

On the Coordination of FMOH of stakeholders

The FMOH, as indicated in the NNS, has been housing and managing the organizational

and management structure of NNP. However, in order to have viable linkages and

harmonization with the relevant sectors, the NNP implementation and coordination

framework has multi-sectoral implementation and coordination arrangements at the

policy and implementation level in all the decentralized administration and service

delivery levels of the country. Thus, the NNP proposes a four-tiered coordination

mechanism that is in line with the decentralized administration structure of the

government; and requires a considerable support of the partners, private sectors and

academia.

A National Nutrition Coordination Body (NNCB) and National Nutrition Technical

Committee (NNTC) were established at the Federal level to ensure effective coordination

and linkages at the national level. There has been established a similar arrangement at the

regional level with some adaptation based on the existing situation of the regions. As the

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existing woreda and Keble level administrations arrangement are multi-sectoral in nature,

the opportunity will be used to address nutrition with the leadership of the woredas health

office.

During the implementation period of the project at the beginning, NNP coordination

efforts were little due to existing changes within the public sector. In 2011/ 12, both

multi-sectoral coordination and that of Development Partners started taking shape. These

coordination systems have since been getting stronger and stronger as well as effective in

scaling up nutrition interventions. In addition, decentralization to Regional, zonal and

woreda levels has/ is taking place.

Currently, Decision makers and nutrition actors recognize that malnutrition was not

simply a health problem but was also inextricably linked to actions and conditions across

many sectors, including food and agriculture, education, economics, and environment.

They also realized that reducing malnutrition required not only dealing with proximate

causes but with underlying causes as well where the role and responsibility of other

sectors become pretty clear. The institutional and operational environment for working

multi-sectorally seems getting more promising than before. One might argue, then, that

success in working multi-sectorally in nutrition now depends more on creating a vision

and managing innovatively and on changing ways of thinking and acting across a

complex institutional landscape than on not having the basics in terms of human,

financial, technical, or even conceptual resources.

The role of multiple sectors in addressing malnutrition was duly recognized in the

Ethiopian National Nutrition Strategy of 2008 as well as the first National Nutrition

Program (2008-2013). However, the program was criticized for falling short of stating

specific actions expected from each sector. This, among others, led to the development of

the revised NNP (2013-2015) which listed out roles and responsibilities of relevant

ministries/sectors and elicited signatures from each sector to enhance accountability. The

signatories of the revised NNP are Ministry of Health, Ministry of Education, Ministry of

Agriculture, Ministry of Trade, Ministry of Labour and Social Affairs, Ministry of

Women, Children and Youth Affairs, Ministry of Industry, Ministry of Water and Energy

and Ministry of Finance and Economic Development.

There are two nutrition coordination committes at federal level; the national nutrition

coordinating body (NNCB) is the higher NNP decision making body. NNCB is

composed of state ministries of the nine government NNP implementing sectors, donors,

partners, civil society organizations, academia, and the private sector representatives.

NNCB provides policy/strategic decision related to NNP, allocate and approve budget for

the implementation of NNP, and monitor the implementation of NNP with key indicator

and provide guidance.

For the year 2006 EFY the NNCB develop TOR, annual work plan and implement the

specified activities accordingly, they meet twice a year and decide and give guidance to

the technical committees. In addition to the NNCB which mainly deals with policy issue,

there is also a National Multi-sectoral Nutrition Technical Committee that operates under

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the auspices of the NNCB. This committee was established from each sector and

organization of the NNCB. The main responsibilities of the committee are handling the

overall technical work related to the federal level NNP coordination. The technical

committee develops TOR and Annual work plan, conducts capacity building, meets more

than eight times and supports the regional committee establishments.

Similar to the national structure, all regions established RNCB and RNTC committees

after rolling out the program, some of them cascade the coordination to zonal and

woredas levels.

On Key Lessons Learned

It is possible to deliver nutrition interventions (at scale) using front-line HEWs or the

existing system, at community and all levels. This has, indirectly, strengthened the health

system. Moreover, capacity building efforts done at various levels and through-out the

country have impacted on the sustainability of the project activities. Key challenges that

were identified were: Use of volunteers to perform GMP and report data, which might

have resulted in modest attendance rate of GMP sessions in some areas, and Low Multi-

sectoral linkages to nutrition sensitive activities within community.

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Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders N/A

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Annex 9. List of Supporting Documents

Key Project Documents

"Project Appraisal Document on a Proposed Grant to the Federal Republic of

Ethiopia for a Nutrition Project" (Report No. 42171-ET) World Bank, 2008

Financing Agreement IDA Grant Number H376-ET (Nutrition Project), dated

June 13, 2008

Amendment to IDA Grant No. 376-ET (Nutrition Project) Financing Agreement,

dated July 16, 2009

Restructuring Paper on a Proposed Restructuring of the Nutrition Project

Grant:H3760-ET approved April 29, 2008 to the Federal Democratic Republic of

Ethiopia” December 16, 2013 (Report No: RES12745)

FMOH (2014) Nutrition Project: End of Project Performance Report. Federal

Ministry of Health. Addis Ababa, Ethiopia.

Program Implementation

Program Implementation Manual of the National Nutrition Program (NNP)-July

2008-June 2013, 2008 Federal Ministry of Health

Ethiopia Nutrition Project Financial Management Contribution to the

Implementation Completion Results Report, June 2014

Mid-Term Review

Aide Memoire of the Mid-Term Review Mission for the Nutrition Project

(November 21-29, 2011)

Other Project Documents

Various Aide memoires, Implementation Supervision Reports (ISR) 1-13, procurement

reports, financial management reports

Key Policies, Studies and other program related documents

“Malnutrition in Ethiopia: Current Interventions, Successes, Cost-Benefit

Analysis, and the Way Forward”, Draft report, World Bank, December 2007:

Published as an Africa Human Development Series book “Combating

Malnutrition in Ethiopia: An Evidence-Based Approach for Sustained Results”,

by Andrew Sunil Rajkumar, Christopher Gaukler, and Jessica Titahun, 2012

Ethiopian PROFILES (calculator of the consequences of nutrition) USAID, 2007

Third Health Sector Development Programme (HSDP III) and Health Extension

Program (HEP), Ethiopian Federal Ministry of Health (FMOH), 2006

National Nutrition Strategy (NSS), FMOH, 2008

National Nutrition Program (NNP), FMOH, 2008

Assessing the impact of child nutrition of the Ethiopia Community-based

Nutrition Program, UNICEF evaluation study, September 2012 Tulane

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University School of Public Health and Tropical Medicine, New Orleans,

Louisiana, USA

WHO: Guideline Use of multiple micronutrient powders for home fortification of

foods consumed by infants and children 6-23 months of age, 2011

WHO: Essential Nutrition Actions: Improving maternal-newborn-infant and

young child health and nutrition, 2013

"The Health Extension Program in Ethiopia", Universal Health Coverage Studies

Series (UNICO), Series No. 10, January 2013

“Piloting Community-Based Management of Acute Malnutrition (CMAM)

Project, Tigray Region, Ethiopia (2009-2013)” Final Evaluation”, Concern

Worldwide Ethiopia, 2014

Ethiopia 2014 Mini-Demographic and Health Survey, Central Statistical Agency,

Addis Ababa, Ethiopia, July 2014

World Bank “Directions in Development: Repositioning Nutrition As Central in

Development, A Strategy for Large-Scale Action” 2006

http://siteresources.worldbank.org/NUTRITION/Resources/281846-

113636806329/NutritionStrategy/.pdf

World Bank “What we can learn from Nutrition Impact Evaluations”, 2010

“Scaling Up Nutrition” http://scalingupnutrition.org/sun

The Lancet “Maternal and Child Nutrition Series”

http://www.thelancet.com/series/maternal-and-child-nutrition

http://scalingupnutrition.org/sun

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MAP