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Document of The World Bank

Report No:ICR0000336

IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-34030, ITAL-24927)

ON A

CREDIT

IN THE AMOUNT OF SDR 29 MILLION (US$ 40 MILLION EQUIVALENT)

TO THE

GOVERNMENT OF ERITREA

FOR A

INTEGRATED EARLY CHILDHOOD DEVELOPMENT PROJECT

May 31, 2007

Human Development 1 Country Department 6 Africa Region

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CURRENCY EQUIVALENTS

Exchange Rate Effective for year 2007

Currency Unit = Nakfa (Nf)

15.00 Nakfa = US$ 1.00

FISCAL YEAR: January 1st – December 31st.

ABBREVIATIONS AND ACRONYMS

ARI Acute Respiratory Infection. BCC Behavior Change Communication C-GMP Community-Growth Monitoring Program C-IMCI Community-Integrated Management of Childhood Illness CAS Country Assistance Strategy CCG Community Caregiver CFR Case Fatality Rate CHW Community Health Worker CNSP Children in Need of Special Protection CPPR Country Portfolio Performance Review ECD Early Childhood Development ECE Early Childhood Education EDHS Eritrea Demographic and Health Survey EENT Eye, Ear, Nose and Throat EPI Expanded Program on Immunization FMR Financial Monitoring Report GOE Government of Eritrea GMP Growth Monitoring Promoters HAMSET HIV/AIDS; Malaria; Sexually Transmitted Diseases; Tuberculosis HDNED Human Development Network- Education Cluster HFA Health Facility Assessment HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency

Syndrome HH Household IBRD International Bank for Reconstruction and Development ICR Implementation Completion Report IDA International Development Association IECDP Integrated Early Childhood Development Project IMCI Integrated Management of Childhood Illnesses IMR Infant Mortality Rate ISN Interim Strategy Note KABP Knowledge, Attitude, Beliefs and Practices KG Kindergarten

M&E Monitoring and Evaluation MF Ministry of Fisheries MoA Ministry of Agriculture MoE Ministry of Education MoH Ministry of Health MoLG Ministry of Local Government MoLHW Ministry of Labor and Human Welfare MTR Mid-Term Review NRS Northern Red Sea Zoba NSS Nutrition Surveillance System SRS Southern Red Sea Zoba UNICEF United Nations Children’s Fund USAID United States Agency for International Development VHC Village Health Counselors VWG Village Working Group WFP World Food Program WHO World Health Organization WB World Bank

Vice President: Obiageli Katryn Ezekwesili Country Director: Colin Bruce

Sector Manager: Dzingai B. Mutumbuka Project Team Leader: Christopher D. Walker

ICR Team Leader: Carla Bertoncino

ERITREA INTEGRATED EARLY CHILDHOOD DEVELOPMENT PROJECT

CONTENTS

Data Sheet A. Basic Information B. Key Dates C. Ratings Summary D. Sector and Theme Codes E. Bank Staff F. Results Framework Analysis G. Ratings of Project Performance in ISRs H. Restructuring I. Disbursement Graph

1. Project Context, Development Objectives and Design............................................... 12. Key Factors Affecting Implementation and Outcomes .............................................. 73. Assessment of Outcomes .......................................................................................... 104. Assessment of Risk to Development Outcome......................................................... 215. Assessment of Bank and Borrower Performance ..................................................... 226. Lessons Learned ....................................................................................................... 247. Comments on Issues Raised by Borrower/Implementing Agencies/Partners ........ 245Annex 1. Project Costs and Financing.......................................................................... 26Annex 2. Outputs by Component ................................................................................. 28Annex 3. Economic and Financial Analysis................................................................. 34Annex 4. Bank Lending and Implementation Support/Supervision Processes ............ 36Annex 5. Beneficiary Survey Results ......................................................................... 378Annex 6. Stakeholder Workshop Report and Results................................................... 39Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR..................... 40Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders....................... 41Annex 9. List of Supporting Documents ...................................................................... 42

MAP

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A. Basic Information Country: Eritrea Project Name:

Integrated Early Childhood Development Project

Project ID: P068463 L/C/TF Number(s): IDA-34030,ITAL-24927

ICR Date: 10/01/2007 ICR Type: Core ICR

Lending Instrument: SIL Borrower: GOVERNMENT OF ERITREA

Original Total Commitment:

XDR 29.0M Disbursed Amount: XDR 28.1M

Environmental Category: C Implementing Agencies: Ministry of Education Cofinanciers and Other External Partners: italian cooperation B. Key Dates

Process Date Process Original Date Revised / Actual Date(s)

Concept Review: 10/26/1999 Effectiveness: 09/27/2000 09/27/2000 Appraisal: 01/24/2000 Restructuring(s): Approval: 07/27/2000 Mid-term Review: 01/19/2004 Closing: 12/31/2005 03/31/2007 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Satisfactory Risk to Development Outcome: Substantial Bank Performance: Satisfactory Borrower Performance: 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: Satisfactory

Overall Bank Performance: Satisfactory Overall Borrower

Performance: Satisfactory

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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):

Yes Quality of Supervision (QSA):

None

DO rating before Closing/Inactive status:

Moderately Satisfactory

D. Sector and Theme Codes

Original Actual Sector Code (as % of total Bank financing) General public administration sector 4 4 Health 35 35 Other social services 25 25 Pre-primary education 23 31 Primary education 13 5

Theme Code (Primary/Secondary) Child health Primary Primary Education for all Secondary Primary Improving labor markets Secondary Secondary Nutrition and food security Primary Primary Social safety nets Secondary Primary E. Bank Staff

Positions At ICR At Approval Vice President: Obiageli Katryn Ezekwesili callisto madavo Country Director: Colin Bruce oey meesook Sector Manager: Dzingai B. Mutumbuka van adams Project Team Leader: Christopher D. Walker Marito H. Garcia ICR Team Leader: Carla Bertoncino ICR Primary Author: Peter A. Gaius-Obaseki F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The objectives of the project are:

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(i) to promote healthy growth and development of children under six years of age; (ii) to expand access to, and improve the quality of, services that address the basic needs of young children; (iii) to support orphans and children facing especially difficult circumstances; (iv) to improve health and nutrition of children in primary schools. Revised Project Development Objectives (as approved by original approving authority) (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 : case fatality rate (CFR) in <6 children from the combined 5 major causes: malaria, ARI, diarrhea, measles, and anemia + malnutrition in project areas.

Value quantitative or Qualitative)

CFR: malaria (2.5%); ARI (3.3%); diarrhea (4.5%); measles (0%); malnutrition (10.3%); and combined rate (5.15%). Data sou rce: Ministry of Health, HMIS

Reduction of 20% of all types of CFR

Malaria (1.5%); ARI (1.5%); diarrhea (1.8%); measles (0%); malnutrition (4.8%); and combined rate (2.4%). Data source: Ministry of Health, HMIS

Date achieved 12/29/2000 10/31/2006 10/31/2006 Comments (incl. % achievement)

Cumulative 53.4% reduction in CFR for malaria,measles,malnutrition,ARI and diarrhea.

Indicator 2 : % of underweight (weight for age) children under 6 years of age in project areas (see PDO rating explanation for the reason why this indicator needs to be revised)


39.2% Reduction by 20% 41.7%


6.4% Increase.

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Indicator 3 : repetition and dropout rates from primary grade 1 to grade 2 in project areas


25.97% repetition rate and 13.7% dropout rates from grade 1 to grade 2.

15% decrease in repetition rate and 20% decrease in drop out rate

18.24% and 8.79% for repetition and drop-out respectively.


29.77% drop in repetition rates and 35.84% drop in dropout rates

Indicator 4 : Successful reunification of orphans with nearest relative(s) Value quantitative or Qualitative)

zero orphans through the project 32,000 31,556


98.7% achievement

(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 : % of health workers trained in IMCI case management by ECD project Value (quantitative or Qualitative)

None 150 1096 Health workers


631% achievement

Indicator 2 : % of facilities stocked with essential IMCI drugs through project. Value (quantitative or Qualitative)

None 100%

Date achieved 04/29/2000 12/31/2006 Comments (incl. % achievement)

Values not available at time of ICR.

Indicator 3 : Number of mothers training in food security and nutrition through the Ministry of Agriculture training program, with support from the Ministry of Health through the ECD project.

Value (quantitative or Qualitative)

13,374 trained mothers N.A.

8,667 mothers trained through project

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Indicator 4 : Cumulative enrolment in Kindergartens and Child Care Givers

Value (quantitative or Qualitative)

12,436

31,000 and 50,000 respectively (see IP rating explanation)

31,653 and 50,425 respectively


102.1% and 100.9% respectively

Indicator 5 : Number of social workers trained Value (quantitative or Qualitative)

zero through the project 90 (see IP rating explanation) 36


60% achievement

G. Ratings of Project Performance in ISRs

No. Date ISR Archived DO IP

Actual Disbursements (USD millions)

1 10/14/2000 Satisfactory Satisfactory 0.00 2 01/08/2001 Satisfactory Satisfactory 1.00 3 06/21/2001 Satisfactory Satisfactory 1.67 4 12/21/2001 Satisfactory Satisfactory 3.46 5 04/29/2002 Satisfactory Satisfactory 4.99 6 09/17/2002 Satisfactory Satisfactory 6.17 7 01/16/2003 Satisfactory Satisfactory 6.31 8 07/23/2003 Satisfactory Satisfactory 7.31 9 12/01/2003 Satisfactory Unsatisfactory 10.14

10 05/12/2004 Satisfactory Unsatisfactory 15.27 11 11/17/2004 Satisfactory Unsatisfactory 20.90 12 01/06/2005 Satisfactory Unsatisfactory 22.40 13 05/05/2005 Moderately Satisfactory Moderately Satisfactory 26.73 14 12/19/2005 Moderately Satisfactory Moderately Satisfactory 33.33 15 04/07/2006 Moderately Satisfactory Satisfactory 35.89 16 10/30/2006 Moderately Satisfactory Satisfactory 39.98 17 03/29/2007 Satisfactory Satisfactory 41.64

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H. Restructuring (if any) Not Applicable

I. Disbursement Profile

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1. Project Context, Development Objectives and Design (This section is descriptive, taken from other documents, e.g., PAD/ISR, not evaluative)

1.1 Context at Appraisal (Brief summary of country and sector background, rationale for Bank assistance)

Over the period between Independence (1992) and the identification and design of the Eritrea Integrated Early Childhood Development Project (from now on “the Project”) in 1999/2000, Eritrea’s economy was growing rapidly with annual GDP growth rate averaging 5.4 percent. The gross primary school enrolment rate increased from 36.3% to 64%, access to health services doubled from 30%, the Expanded Programme on Immunization (EPI) coverage increased by 125%, and basic social infrastructure was rehabilitated. The government was focused on building the foundations for long-term growth and development. Within that context, a set of policies aimed at strengthening the country’s human resources was formulated. However, the resumption of the armed conflict with Ethiopia in May 1998 seriously undermined Eritrea’s chances of economic and social success. By the time the hostilities ceased, in June 2000, the war had caused: (i) some US$600 million damage in property including the destruction of US$225 million in livestock and 55,000 homes; (ii) the disruption of the agriculture cycle in the country’s most productive region causing national food production to drop by as much as 60%; and (iii) one third of the population to be without water, sanitation or shelter.

The War and its aftermath had severe effects on the nation’s children, especially since over 70% of the population comprise of children and women of child-bearing age. The health status declined with malaria, Acute Respiratory Infection (ARI) and diarrhea being the primary causes of mortality and morbidity in children under 5 years. Infant and under 5 mortality rates were 72 and 135 per 1000 respectively in 2000. The nutritional status was also poor with 10% of children wasted, 66% stunted and 41% underweight. It is in this context that the Project and the Eritrea Interim Support Strategy (ISN, 2000) were conceived.

The ISN prioritized the development of the human resource base of the country. In particular, the Government of Eritrea (GoE) recognized the importance of investing in young children’s growth and development within its macroeconomic policy framework. It underscored the importance of mother and child services and the need to provide children with legal and social protection. A series of initiatives were already being implemented, providing a platform for the Project to build upon:

• The Ministry of Agriculture (MoA) in collaboration with the Ministry of Health (MoH) had developed a food security strategy supporting interventions that included increasing agricultural and livestock production, financial support to farmers through a credit window, and training for selected income generating activities for households. Guidelines for the implementation of the strategy were also prepared which incorporated Public Health Centers (PHC), Expanded Program on Immunization (EPI)-plus and Integrated Management of Childhood Illnesses (IMCI).

• The MoE drafted a policy on Early Childhood Education (ECE) in 1995 which, among other things, promoted diversified forms of ECE delivery through formal and non-formal methods including Kindergartens (KGs) and Community Caregivers (CCGs) and provided guidelines on setting up and managing day-care centers.

• The GoE, through the Ministry of Labor and Human Welfare (MoLHW), had a firm policy seeking to phase out the institutionalization of orphans while promoting their re-

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integration with extended families. At that time, the MoLHW had re-integrated 14,000 children over the previous six years.

In spite of these efforts, significant challenges remained: a very limited supply of early childhood programs, ECE activities only available in urban areas, a mere 2% of 5-6 year olds enrolled in KGs, and a high number of orphans (90,000) due to the war. These became the areas of intervention for the Project. A majority of the interventions that were envisaged were ongoing and had been tested. Thus the Project was multi-sectoral and decentralized, and was developed to increase coverage and foster the institutional integration of the ministries involved. These latter were initially six: Ministry of Agriculture (MoA), Ministry of Education (MoE), Ministry of Health (MoH), Ministry of Fisheries (MF), Ministry of Local Government (MoLG) and the Ministry of Labor and Human Welfare (MoLHW). However, the Project was actually implemented by four ministries as the MoA absorbed the MF and, for the Project’s purposes, the Ministry of National Development (MOND) took over the MoLG’s functions.

The Project was financed with resources provided by IDA, the GoE, and the Italian Cooperation. The Italian Cooperation contributed to the Project through a trust fund allocation of US$5 million. The agency first expressed its interest during the pre-appraisal phase and remained engaged throughout the life of the Project, including after the trust fund closed at the end of 2004. This ICR also serves as the Implementation Completion Memorandum for the Italian Trust Fund. Strong technical assistance ties were established from the beginning with World Health Organization (WHO), United States Agency for International Development (USAID), United Nations Children’s Fund (UNICEF) and the Partnership for Child Development (UK).

1.2 Original Project Development Objectives (PDO) and Key Indicators (as approved) The objectives of the Project are: (i) to promote healthy growth and development of children under six years of age; (ii) to expand access to, and improve the quality of, services that address the basic needs of young children; (iii) to support orphans and children facing especially difficult circumstances; and (iv) to improve health and nutrition of children in primary schools. The PDOs are summarized in Table 1. Table 1. PDO Indicators and Targets Component Indicator Target Child Health Combined Case Fatality Rates

(CFR) 20% reduction

Child and maternal nutrition. Prevalence of underweight children less than 6 years of age.

20% reduction

Early Childhood care and education. Repetition and Dropout rates between grades 1 and 2.

20% reduction

Support for Children in need of special protection measures.

Reunification of orphans with close relatives.

32,000 orphans

1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification

There were no revisions to the PDOs.

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The original indicator for malnutrition was changed to monitor the prevalence of children under three years from the earlier indicator that monitored children under six years. Had the Growth Monitoring and Promotion (GMP) program become operational very early in the life of the Project, it would have been possible for it to have an impact on children older than threei. However, on realizing that the implementation had been irrevocably delayed, the current Project team decided that for any impact to be measurable, the indicator had to be modified to focus on children under three.

1.4 Main Beneficiaries

Children were the primary beneficiaries, with a focus on 6 years olds and younger. The secondary beneficiaries of the Project were mothers, caregivers, teachers, agricultural extension workers, social workers and health workers. The Project was implemented in all the six zobas (regions) in the country, and in a subset of the 59 sub-zobas (sub-regions), where it reached 588 villages out of a total of 2,606.

1.5 Original Components (as approved) Component 1 Improving Child Health (US$10.5 million) The objective of this component was to reduce childhood morbidity and mortality by improving case management and preventive skills of health staff and empowering communities and caregivers to improve family/child health care practices. Interventions included: Improving skills of health workers and caregivers; improving the health system; improving family and community practices; environmental health interventions; school health interventions; improving Information Education and Communication (IEC) for behavioral change; and supervision, support, monitoring, evaluation and research. The inputs for this component were:

• National strategic guidelines for school based delivery of health and nutrition and operations manual.

• Implementation workshops at zoba level. • Training of health workers and teaching staff in case management and implementation

support for community Integrated Management of Childhood Illnesses (C-IMCI). • Training of Community Health Workers (CHWs) and Volunteer Health Counselors

(VHCs) in C-IMCI. • Training of 101 health workers and 15 for implementation support of the community

level activities. • Drugs and medical equipment for the health facilities. • Equipment and training, at health facility and school level, for Participatory Hygiene and

Sanitation Transformation (PHAST).

i It is worth noting that underweight for age is not a suitable indicator of malnutrition for children older than three.

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• Other equipment for health facilities (36 laundry machines, 8 generators, 30 health facility kitchen stoves, beds, blankets, bed sheets and chairs).

Component 2 Improving Child and Maternal Nutrition (US$4.6 million)

The objective of this component was to improve the nutritional status of children under 6 years, and pregnant and nursing mothers. Interventions included:

Building capacities of families and communities for growth monitoring and promotion; reducing micro and macro-nutrient deficiency by vitamin A and iron supplementation; interventions to improve food security especially for children in the target population; and building capacity within ministries to implement the nutrition component.

The inputs for this component were:

• Sensitization of families and communities for the GMP program. • Development and distribution of a manual, counseling cards, registers, growth cards,

referral sheet and minimum expected weight gain to all GMP volunteers. • Intensive practical training of the GMP volunteers on basic nutrition, principles and

objectives of the GMP, weighing, plotting, interpreting growth patterns, counseling mothers, how to organize sessions and what to do about children who require special care. Refresher training to GMP promoters was also provided.

• Basic GMP training for mothers, health workers, sub-zoba (sub-regional) home agents (MoA) as well as GMP coordinators.

• Food security inputs: water pumps, chicks, smokeless stoves. • Training of mothers for improved food security at the household level.

Component 3 Improving Early Childhood Education (ECE) and Care (US$11.8 million)

The objective of this component was to:

Improve access to and quality of ECE; improve primary school health environment; and enhance institutional capacity of all administrative levels, especially that of communities, to undertake childcare, ECE and effectively supervise and monitor ECE activities.


• Development of policy and procedural guidelines. • Development and printing of curriculum materials. • Training of kindergarten teachers, assistant kindergarten teachers, community caregivers,

directors, supervisors and resource centre coordinators has taken place. • Construction of, and equipment for kindergartens (KGs) and ECE Resource Centers • Establishment of community caregivers (CCGs) in rural areas • Research studies conducted and properly utilized

Component 4 Support for Children in Need of Special Protection Measures (US$11.7 million)

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The objective of this component was to strengthen the traditional safety nets for child care and protection through community-based reintegration and psycho-social support for orphans. It specifically sought to:

Reintegrate 32,000 orphans - including disabled, displaced and expelled orphans as well abandoned street children; minimize the long-term social and psychological problems of Eritrean orphans; strengthen the ability of families to cope financially by means of income-generating programs; increase awareness of communities about the need for community based interventions for orphans and to encourage and strengthen community-based initiatives to support these orphans; build the capacity of personnel at the national, regional and community levels involved in offering services, with special emphasis on the recruitment of appropriate personnel at the community level; and improve program supervision, monitoring and evaluation.


• Grants to reunified households for income generating activities. • Equipment for the MoLHW office at the zoba level. • Two skilled personnel employed at the children play material and production center

workshop. • Development and distribution of the orphan children reintegration and reunification

manual. • Training of middle level social workers on the resource manual. • Development and distribution of the Group home Mother’s manual. • One Project officer at the MoLHW headquarters to help in the Implementation and

follow up of the entire ministry activities funded under ECD Component 5 Project Management, Evaluation and Strategic Communications (US$5.45 million)

The objective of this component was to support the overall management of the multi-sectoral program and the cross-cutting activities. Its subcomponents were:

The Project Management Team (PMT) for overall project management and coordination, including planning, budgeting, procurement and financial management, and M&E; advocacy and awareness for ECD issues to be achieved through advocacy and sensitization campaigns; an Innovation Fund to support new activities that are developed at the community, sub-regional, and regional levels; and integrated ECD program evaluation/surveys and research.

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Figure 1 The Project’s organizational chart

Policy Steering Committee (PSC): highest decision making body for the Project, which consisted of ministers from all the involved ministries and was chaired by the MoE. Technical Steering Committee (TSC): national and zoba, consisted of the technical heads of each participant ministry. Working groups: Zoba, sub-zoba and village, consisted of line-ministry and community representatives at each of these levels. Project Management Team (PMT): comprised full time employees and was responsible for overall coordination as well as national level activities and was headed by a coordinator.

1.6 Revised Components

None of the components were formally revised.

1.7 Other significant changes

Scope:

The planned expansion of the coverage of the nutrition component was not carried out in recognition of limited implementation capacity as illustrated by the considerable delays in material development and training that were pre-requisites for the introduction of GMP in all

Policy Steering Committee (Ministers)

Project Management Team

Zoba Working Group Zoba Technical Steering Committee

Sub-zoba Working Group

Village Working Group

National Technical Steering Committee

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zobas. This decision, taken at the MTR, was one of the risk mitigating measures outlined in the PAD.

Implementation arrangements and schedule:

Effectiveness, originally planned for June 2000, was delayed into September 2000 due to the intensification of the war in May 2000.

In 2002, the MoE assumed leadership of both the PSC and the TSC from the MoLG. This was cordially agreed to at both senior Committees.

In 2003 the representation from each implementing ministry in the TSC was upgraded to the Director General level.

The therapeutic feeding activity of the nutrition component was taken over by UNICEF and the savings realized from this in the Project were used to train more GMP promoters.

Funding allocations:

Due to the sharp increase in the cost of building the KGs, the allocation for civil works increased from the original US$9.2 million to US$13.9 million, with corresponding decreases in the allocations for consultants, training and operating expenses.

Also, due to inflation, income generating grants were increased from Nf 6,000 to Nf 10,000.

US$900,000 was reallocated within the nutrition component for distribution of DMK (supplementary feeding rations) during a food security emergency in 2003. However, this intervention encountered logistical difficulties resulting in substantial under spending and delays in distribution. Finally the GoE and the Bank agreed to use the balance (US$700,000) to provide high energy biscuits to children in KGs.

2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry

The three most positive factors were that (i) the PDO and the components were well aligned both with the developmental priorities of Eritrea and the ISN, in particular the support for the holistic development of children and the development of the human resource base of the country respectively; (ii) several of the Project activities built on the government’s prior engagement in the participant sectors, e.g. re-integration of orphans with relatives, thus augmenting the efforts of the government while introducing new interventions, e.g. the GMP and its integration with community-IMCI (C-IMCI); and (iii) the deep commitment of the GoE. A negative factor was the choice of project design which was too complex for the environment and which was prepared in three months. The choice of project design was influenced by: (i) the great enthusiasm generated during the early successful years of independence; and (ii) the expectation that the war would not last long.

As to taking into account lessons learnt from previous operations, this was the first social sector engagement in Eritrea and hence there was scarce operational experience on the ground to draw from. The Project design, however, was based on international experience from the integrated approach to ECD, especially from South Asia. Considering the particularly acute food insecurity that characterized Eritrea at the time, the design probably should have put more emphasis on food security rather than GMP. This issue will be discussed in section 3.1 as part of the assessment of the relevance of the Project design.

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Integrated approach: The Project embraced the GoE’s priority of providing an integrated package of interventions necessary for childhood development. This it did by providing a platform through which the GoE’s ongoing individual line ministry ECD interventions could be jointly implemented with some innovations, e.g. GMP. Community involvement: Including a partnership with the major Community Based Organizations i.e National Union of Eritrean Women (NUEW) and the National Union of Eritrean Youth (NUEY) in the Project design led to a very high level of community involvement, especially during the last two years of the Project Ambitious PDO targets for three main reasons: (i) The Bank had no previous Social Sector involvement in Eritrea, hence there were no direct precedents to learn from; (ii) Eritrea had just emerged from a protracted war which had caused severe internal displacement; and (iii) Capacity, as noted in the PAD, was markedly low and subsequent events showed that it needed significantly more attention than was originally planned. Even if the Project’s interventions could reach the communities immediately after effectiveness, the Project period was too short for the integrated ECD (GMP, ECE, and other Project activities) to have an impact on children of primary school age. Cognitive development in particular would take even longer to manifest than higher school entry and retention. The Project performed well in spite of this because of a high level of commitment by the GoE and the extraordinary level of coordination with the other development partners. Underestimation of risks: Although several critical risks were identified during the Project design process, some were underestimated, particularly the inadequate capacity to implement a coordinated IECD strategy throughout the country and the unclear definition of roles and responsibilities among all administrative levels. Expedited Project preparation: While preparing such a complex Project in three months is commendable, it affected readiness for implementation. This is demonstrated by the fact that it took three years to build any significant capacity for implementation. The underlying rationale for fast-tracking will be discussed in section 5.1 on Bank performance. Quality at Entry was not assessed by QAG either during preparation or after effectiveness. Based on project preparation and design, Quality at Entry is rated Moderately Satisfactory.

2.2 Implementation (Including any project changes/restructuring, mid-term review, Project at Risk status, and actions taken, as applicable) The first two years of the Project were very challenging as neither the Bank nor the Borrower had any previous experience of implementing a complex operation in a “no war no peace” environment. The following two years saw the PMT gain considerable traction in harmonizing the activities of the different line ministries towards achieving the PDO. However, in the last two years concerted efforts were made towards implementing an integrated package of ECD services at the community level as was originally planned. The most important positive factor during implementation was the GoE’s and the Bank’s commitment to make the Project work. On the negative side, the main factors affecting

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implementation were: (i) the “no war no peace situation” that prevailed since the Peace Accord was signed in December 2000ii; (ii) the GoE’s lack of capacity for structured, long term project planning; (iii) the prolonged drought; and (iv) the difficulty involved in ensuring the integrated ECD package reached the village level with the limited resources available.

Factors (ii) and (iv) were overcome with consistent engagement by the partners throughout implementation, whereas the other two issues caused the Project irreversible damage. While the Project was conceived and prepared during the war, the Cessation of Hostilities signed in June of 2000 led to the belief that Eritrea had entered the post conflict phase and was on a steady path to recovery. Instead, a “no war no peace situation” ensued which had an adverse impact on the country’s reconstruction, economic recovery, and overall development process by absorbing a substantial amount of financial and human resources in an already challenging environment.

During the first three years of the Project, inflation substantially affected implementation. As a consequence of soaring building costs, the GoE changed the design of KG’s at an advanced stage of planning, causing a delay of more than two years in the roll out and construction of the KGs. Also the income generating grants to the households reunified with one or more orphans had to increase from Nf 6,000 per family at appraisal to Nf 10,000. Rising prices, combined with nominally fixed travel allowances, the severe shortage of fuel and many other supplies, and relative unavailability of vehicles negatively affected local supervision and implementation support particularly during the last two years of the Project, when the activities on the ground intensified.

The factors discussed above, coupled with the need to change the Project Manager and the TORs for the TSC during the early stage of implementation significantly delayed progress, especially in the nutrition component. As a consequence, after the mid-term review, the Project went into “at risk” status. The discussions during the CPPR that took place shortly thereafter were instrumental in turning around the Project, in the sense that the Borrower was finally persuaded that integration at the village level was the key to the Project’s success and therefore had to be given priority over any other consideration. The mid-term review had also been useful, pointing out among other things that CCGs seemed to be more cost effective than KGs, and that the Project was now ready to bring the integrated ECD package to the villages. While the GoE was receptive to the first message, integration of the services at the community level proved more challenging.

The Project came out of “at risk” status about one year later, upon fulfillment of the Action Plan the GoE had committed to during the CPPR. At that point it was too late to try and realize integration in all the Project villages, so a subset of communities was selected, on the basis of objective criteria, to carry out a pilot within the Project. In that context a decision was taken to extend the operation by one year to give the pilot a minimal amount of time for impact – if any – to show. A procurement delay during the latter stages of the Project necessitated a second extension of three months.

ii The agreement called for the withdrawal of the Ethiopian army from Eritrean territory and the deployment of a UN peacekeeping force along a 25-kilometer Temporary Security Zone between the two countries to remain until a neutral Boundary Commission demarcated the border. Progress towards the border demarcation process has since been stalled for seven years.

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The drought affected the outcomes of Project substantially. It started while the Project was being prepared and did not end until 2006. Its effects were likely compounded by the GoE’s decision to convert the free food distribution into a food-for-work program in 2005. Finally, in the same year, USAID left the country; the agency was very active in capacity building for C-IMCI at all administrative levels.

2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization

The M&E component was intended to incorporate activities from all participant line ministries to form an integrated M&E framework towards evaluating Project progress and outcomes. Both intermediary and outcome indicators chosen were adequate. However, the availability of data from the different ministries was uneven at different phases of the Project as some project components were more advanced than others. Most interventions in ECE, CNSP and MCH were already active at the time of commencement and the line ministries involved had experience in collecting and interpreting data for those respective components. However, the GMP, C-IMCI and rural KG programs were new and capacity and experience for theses activities was low.

As a consequence, while baseline data collection and regular progress were adequately addressed for the established components, the new components lagged behind for significant portions of the project life. GMP baseline data were not collected until 2003/2004 and became available in 2005 with the result that the final impact evaluation was also the first. The ICR team could not access data on the duration of the GMP sites to verify the hypothesis that "older" sites had more impact than "younger" ones. This is discussed further in section 3.2. Other impediments to timely data collection and analysis included the lack of transport and adequate manpower as well as of a good M&E officer in the unit for approximately one third of the Project’s life. However, over the last two years of the Project, the M&E component greatly improved, as did general Project implementation. The PMT was able to secure a full time M&E officer, the collection of information and its flow from the village to the national level improved, timely quarterly reports were produced and, to a greater but still inadequate extent, decision making was based on M&E reports.

2.4 Safeguard and Fiduciary Compliance (Focusing on issues and their resolution, as applicable) The Project was given a C rating for environmental safeguard purposes. From the fiduciary point of view, there were no reported issues of significance; the only exception being that the plan to switch to FMR based disbursement was not realized due to lack of capacity.

2.5 Post-completion Operation/Next Phase During the last year of the Project, the GoE approved the national IECD Policy for Eritrea outlining the responsibility of each Ministry towards young children which incorporated much of the Project components (adopting the implementation of the Project). In spite of this, as at the time of the last supervision/ICR mission, no substantive transitional arrangements had been made and no decision had been taken on any follow up project. While the GoE indicated its willingness to finance the core incremental costs of the Project, funding for these has seemed to cease after December 2006. Coupled with Eritrea’s current poor economic state, this raises some significant concerns about the preservation of the gains made through the Project. This is discussed further in section 4.

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3. Assessment of Outcomes

3.1 Relevance of Objectives, Design and Implementation (to current country and global priorities, and Bank assistance strategy)

The PDO remains relevant given the GoE’s priority to provide its youth with all amenities necessary for healthy growth and development, and the EFA (Education for All) initiative.

Were a similar operation to be designed with the same objectives today, two aspects would probably change significantly:

• The underlying rationale for the structure of the project components. The complexities associated with the implementation of a multi-sectoral, decentralized project could be minimized by designing the components based on the level at which they need to be implemented (household, community, region, centre) rather than on the type of intervention they offer. In fact, this approach makes the planning phase easier as well, and it was recently applied to the costing of the national IECD Policy; and

• The relative emphasis placed on food security and GMP. While it has long been

recognized that malnutrition in developing countries can only be effectively addressed by a combination of GMP and food security interventions, this Project showed that the balance between the two elements depends largely on the country specific circumstances. In a country at high risk of severe food insecurity, for instance, the food security portion of a nutrition component should get the lion’s share vis a` vis GMP, especially if GMP is being introduced for the first time. In the case of Eritrea, an effective solution would have been combining sensitization and awareness creation at the community and household levels about the importance of GMP with a range of short-, medium- and long-term food security interventions. This is discussed further in section 3.2

As to project implementation, the financial and human resources available at the time were inadequate to offer an integrated package of ECD services to every village in the country. It is important to note that, as the Project took off just after a sustained war, equity issues were predominant and hence the decision to “spread” the Project inputs widely. However, as implementation progressed, it was found that both equity and development impact could be attained by expanding the integrated package gradually, zoba by zoba. As shown in Table 11 in Annex 2, zoba Debub, where C-IMCI and c-GMP interventions were integrated, saw a marked decrease in malnutrition with respect to the national average. Those zobas that had less integration e.g. the Northern Red Sea and Southern Red Sea zobas experienced an increase in malnutrition rates. A strategy of rolling out a full complement of interventions, when funds become available, would seem the most effective approach. As the village is the center around which all the activities revolve, the implementation arrangements, designed on the strengths of the decentralization structure, remain relevant.

3.2 Achievement of Project Development Objectives (including brief discussion of causal linkages between outputs and outcomes, with details on outputs in Annex 2) The Project Development Objectives and indicators are detailed in Section 1.2. With technical assistance from the Bank, the Borrower designed and conducted the Project final impact evaluation from which the results presented in the ICR are drawn.

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The final evaluation report comprised both quantitative and qualitative assessments, based on two main sources:

• special studies drawing on primary data (the impact of integration on the orphans’ psychosocial status, a tracer study for the ECE component, and a GMP impact evaluation); and

• line ministries’ information systems The qualitative assessment was participatory, based on the step-wise methodological approach recommended for participatory evaluations: (i) review of documents; (ii) field survey; (iii) structured interviews and focus group discussions; and (iv) direct observation. The field work took place in October 2006 and the results were shared with the Bank during the last supervision/ICR mission. The main results are presented in Table 2. Table 2: PDO achievement Component Indicator Target Results Child Health Combined Case

Fatality Rates (CFR) 20% reduction 53.4% reduction

Child and maternal nutrition.

Prevalence of underweight children less than 3 years of age.

20% reduction 6.4%iii increase

Early Childhood care and education.

Repetition and Dropout rates between grades 1 and 2.

20% reduction 36% reduction in dropout rates and 30% reduction in repetition rates.

Support for Children in need of special protection measures.

Reunification of orphans with close relatives.

32,000 orphans 31,556 orphans reunified

The intermediate outcome indicators to monitor progress towards the PDO achievement are detailed in Annex 2, Table 1. The results obtained in all components were a product of collaborative efforts between the Project and its development partners (WHO, UNICEF, USAID) and local civil society organizations. Considering the fact that these achievements occurred in an ongoing conflict environment without any previous multi-sectoral experience, the Project provided a platform through which the various institutional strengths- both the GoE’s and development partners’- could be leveraged into producing the results attained. The multi-sectoral nature of the Project, as well as the strong presence of other development partners, makes attribution of outcomes difficult. Throughout the following discussion, the figures in parentheses represent the Project’s targets (see Annex 2, Table 1).

iii This figure represents the percentage change in the un-weighted averages of the malnutrition rates from baseline collection to final evaluation. As baseline averages per zoba were not weighted, the ICR team decided to utilize simple averages to maintain consistency.

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Component 1 Improving Child Health The achievements under this component are summarized in Annex 2, Tables 1-4 and Figure 1. The achievements in this component were made possible by the improvement in the quality of care due to continued IMCI training, as well as the synergetic effect of the Project with a number of maternal and child health programs within the MoH supported by many development partners. The core contributions of this component to the overall achievement of the PDO are: (i) training of 1096 health workers (150); and (ii) the procurement and distribution of US$10 Million worth of drugs and equipment Additional interventions included;

(i) C-IMCI: training of 39 Community Health Workers (CHWs) and 41 Volunteer Health Counselors (VHCs) in 17 pilot villages to implement IMCI at the community level with a focus on provision of primary health care in households for children aged 2 months to 5 years;

(ii) Environmental Health: construction of 85 school latrines (125), 39 health facility latrines as well as 2366 latrine slabs and training of teachers in all zobas in Participatory Hygiene and Sanitation Transformation (PHAST).;

(iii) School Health: in partnership with the MoH and the MoE, developed national strategic guidelines for school based delivery of health and nutrition services, training and equipping of 30 school health teams as well as KG and Elementary teachers for ophthalmic, dental and Ear Nose and Throat (ENT) diagnosis and treatment.

The interventions had a significant impact:

• The Health Facility Assessment (HFA) done in 2003 showed that the percentage of children inappropriately treated with antibiotics reduced from 46.8% to 31.8% and that for children whose weight was checked against a growth chart increased from 2.1% to 53.3%.

• The HFA also showed that stock outs of essential drugs reduced significantly between 2000 and 2003 as is shown in Annex 2, Figure 1; as a result of the C-IMCI intervention, in the intervention areas, 40% of the interviewed sought treatment and care within 48 hours of noticing a child’s sickness, compared to less than 20% in the control villages. In addition, ORS use during diarrhea episodes was higher in intervention villages than in control villages - 78% vs. 47%.

• With regard to environmental health and hygiene, 28 of the 30 schools evaluated (93.33%) were found to have access to water and sanitation facilities funded by the Project.

• Iron supplementation had remarkable impact on anemia in Northern Red Sea where the prevalence of anemia fell from 12% to 3% between 2001 and 2006.

• A life skills curriculum was introduced into junior and secondary schools. Between 2001 and 2006, knowledge of malaria, TB, as well as general health and hygiene increased in primary school children; and

• As a result of improved communication, by-laws were initiated by communities that e.g. oppose and prevent female circumcision (genital mutilation) and promote changes in

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sanitation habits (see Table 15 in Annex 2). The aforementioned clearly establishes a strong link between the achievements of this component and the PDO’s for the following reasons: (i) the major childhood illnesses were effectively addressed by improvements in the quality and access of health workers as a result of the training given; and the (ii) the positive impact on educational development through the activities of the school and environmental health sub-components. The impact could have been much more significant had the C-IMCI been operational earlier in the Project. As was shown later on, C-IMCI effectively complements interventions at the health facility and school levels. Moreover, C-IMCI has the potential to provide a more sustainable entry point to influence broader issues that affect the development of healthy behavior in children i.e. social, economic, and environmental factors. The human resources developed in the MoH and the MoE, coupled with the strengthening of the health system will ensure some measure of sustainability past the Project’s life. Based on the previous discussion, this component performance was satisfactory. Component 2 Improving Child and Maternal Nutrition The achievements under this component are summarized in Tables 5-13 in Annex 2. The results as measured by the indicator for malnutrition are relative to the GMP baseline data collected in 2003/04 which were not significantly different from the figures in the EDHS 2002. Malnutrition increased by 6.4% instead of decreasing by 20% as was the Project’s target, primarily owing to a severe, protracted drought combined with the stoppage of the World Food Program (WFP) feeding program (see section 2.2) which were beyond the control of the Project. Also, as the GMP program was a new and complex intervention, it needed a substantial amount of training and supervision which resulted in a short duration of the intervention. Finally, the prevailing harsh macro-economic environment negatively affected this as the costs of supervision and training continued to rise (e.g. fuel costs). This component’s major contributions to the overall achievement of the PDO were the training of(i) 8,667 mothers in food security and nutrition; and (ii) 2544 GMP promoters in 659 GMP sites. Additional Interventions included:

• 130 water pumps for irrigation were provided to groups of ten women in select villages. • 82,668 chicks were distributed to 3,307 households. • 15,962 smokeless stoves were distributed.

The superficially poor result at the national level conceals considerable variations across zobas as well as between integrated vs. non- integrated villages (see section 2.2).

• In zoba Debub, where GMP started early and was then complemented by the C-IMCIpilot in 2005, the malnutrition rate declined by 27.3%, clearly showing the benefits of integrating health and nutrition interventions at community level. In zobas Northern Red Sea (NRS) and Southern Red Sea (SRS), the malnutrition rate increased substantially -27% and 19% respectively. Considering that these latter are the most food insecure zobas in the country, it is likely that the final outcome of the Project was heavily

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influenced by the interruption of the free food distribution program in mid 2005. • The malnutrition rate in non-integrated sites remained virtually unchanged at 39.1%,

while integrated sites had an average malnutrition rate of 43.8%. This could be explained by the fact that the average GMP site in the pilot integrated villages had been functional for a shorter period of time compared to its analogue in the non integrated villages.Indeed, the proportion of mothers attending regular weighing sessions - a decisive intermediate indicator - was very similar in the two kinds of sites (70.6% vs. 71.4%).However, this hypothesis could not be verified as the ICR team was unable to obtain the necessary data.

• Behaviorally, about 85% of mothers exclusively breastfed for the first six months in 2006, a major achievement with respect to the 52% reported in the EDHS 2002.

• The smokeless stoves were extremely popular, and the qualitative evaluation found that more than 90% of the respondents were satisfied with this innovation, including reduced smoke as well as less wood and time consumption.

• Capacity was built within the MOH in nutrition as evidenced by the establishment of the Nutrition Surveillance System (NSS) whose reports are published bi-annually.

• 75% of recipients in the integrated villages and 70% in non-integrated villages reported that the grants given were used for interventions that were still productive.

• The emergency food distribution intervention is discussed in detail in section 1.7 above. The impact of the poultry (chicks) and water pump distribution depends on the productivity and survival of the chickens and the presence of rains respectively. In light of the degree of malnutrition nationwide and the lack of explicit feeding programs for the poorest, these interventions are not deemed sustainable towards realizing its intent. The intent of this component with regard to promoting holistic healthy childhood development was compromised by the insufficient emphasis put on food security in the design. While relatively substantial capacity was built, both in the number of GMP promoters and mothers trained, the late start and prolonged drought jeopardized the achievements that could have been realized. The stoppage of the food-aid, which was in effect at the Project’s commencement, also negatively affected the nutritional status of the most vulnerable, hence limiting the positive effects other project interventions might have made. In conclusion, this component is rated unsatisfactory as its implementation did not yield the intended results. Component 3 Improving Early Childhood Education and Care. The achievement under this component surpassed its targets. This component contributed to the overall achievement of the PDO’s by: (i) constructing 105 (105) KG’s and 286 (250) CCG’s; and (ii) training 230 (315) KG teachers and 304(250) CCG teachers (see Annex 2, Table 14). Additionally:

• 97% of these preschools were established in the rural areas and equipped with trained teachers/caregivers.

• An ECE Resource Center was built in each zoba (6), for training purposes. Impact was positive:

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• Enrollment of children in preschools increased by about 6 times over the level in the 1999/2000 academic year, and the net enrolment rate went from about 2% to over 10% - still below the developing countries average, but approximately double the average for sub-Saharan Africa. (See Annex 2, Table 1).

• In addition to the substantial decrease in repetition and dropout rates in Grade 1, teachers interviewed during the qualitative assessment reported that the academic achievement of children in the experimental group in grade one was rated between “very good’ and good” in 75% of the cases, compared to 36% in the control group (children who did not have pre-primary education).

In spite of the implementation delays experienced due to inflationary pressures (see section 2.2), this component significantly increased access to education for Eritrea’s children, mostly through the CCG intervention in rural areas. The training of teachers, sanitation interventions as well as the introduction of life skills and the updating of the school curriculum will provide the children access to positive health, and behavioral and educational benefits, all of which contribute positively to early childhood development. The GoE’s decision as advised at the MTR to increase the investment in the more cost-effective CCGs as well as the availability of 6 resource centers for training suggests a high likelihood of continuity beyond the Project’s life. Based on these considerations, this component is rated as satisfactory. Component 4: Support for Children in Need of Special Protection Measures. Under the MOLHW’s leadership, 14,000 orphans had already been reunified with their relatives prior to the Project’s start. The Project provided an opportunity to expand coverage. This component contributed to the overall achievement of the PDO by: (i) integrating 31,556 (32,000) additional orphans with 11,820 Host Families (close relatives of orphan children); (ii) training 36 (90) social workers; and (iii) constructing 10 group homes with 95 children enrolled (see Annex 2, Table 15). Additionally:

• Host families were given grants for income generating activities, from poultry to petty trading enterprises, and training on how to manage them.

• 1000 street children were enrolled in regular schools in five zobas and provided with learning materials and uniforms, while 494 older children received vocational training.

• 567 families of street children received income generating assistance. Achievements were positive:

• 93% of the school age orphans attended school regularly and reported having sufficient liberty to socialize, both within and outside the group homes, as well as interacting pleasantly with the group home mothers.

• 65% of the GH children were reportedly performing above average in school. Challenges included fuel scarcity and lack of transportation to find relatives as well as an insufficient pool of social workers. These jointly hampered the psychosocial follow up of the children and resulted in weak support for commercial/entrepreneurial skills of the beneficiary

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families. Children reached under this component were given access to shelter, food, education and care- benefits that would have eluded most of them had the Project not been in place. The GHs provided a normalized environment for these children to grow and interact thus increasing their chances of growing up in a healthy environment and becoming productive members of society. This component was heavily dependent on the monthly stipend given to the GH mothers which stopped in December 2006, the continuity of this, at least at the standards attained during the Project’s life, is in doubt. This component is rated as satisfactory. Component 5: Project Management, Evaluation and Strategic Communications. Project Management: The organizational structure described in section 1.5 was effective. The initial difficulties in project management mainly impacted progress in the nutrition component – the most challenging in the Project for a variety of reasons. A new PMT leadership and increasing clarity of responsibilities across the stakeholders markedly improved cohesion and determination during the last two years of the Project. This enabled the Project to reach 588 villages and contributed to marked improvements during the last two years of the Project and increased the likelihood of achieving the PDO (see Annex 2, Table 16). M&E is discussed in section 2.3. Advocacy and strategic communication activities were intended to mobilize support and raise awareness of parents and caregivers towards early childhood development issues. This started late since an integrated communications strategy was not developed until early 2004. Communications:

• The PMT was staffed with a full time communication officer. • A resource manual with 33 integrated project messages was developed with the input of

stakeholders and was translated from English to Arabic, Tigrigna, Tigre and Kunama. 6000 posters, 23,000 calendars, 25,000 brochures and 20,000 T-shirts were produced and distributed to ECD service providers for distribution to the communities.

• Billboards were made and placed in 116 selected integrated villages and translated into the 6 local languages.

• 50 radio programs, 54 live children’s programs and 43 print messages in the local languages were disseminated and the national cultural troupe staged drama and music shows in 35 selected sites throughout the country.

Behavioral changes resulting from these inputs are discussed throughout section 3.2. An Innovation Fund was instituted and 20 proposals were submitted from ministries, zobas, sub-zobas, individuals and groups, of which 4 were selected: (i) strengthening the Asmara toy and play materials workshop; (ii) strengthening the Sheka-Fertit recreation center for children; (iii) rehabilitation of street children; and (iv) the Indigenous Knowledge (IK) study. All have been fully implemented. As mentioned earlier, the disparity in preparedness of the different components affected the

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homogeneity of the M&E system. However, these evened out within the last two years of the project and sufficient capacity has been developed to monitor the activities of all components. The development of an integrated communications strategy in 2004, which was adopted by the participating line ministries, preserves the “all-inclusive” nature of the integrated message in future communication activities. Project management does raise some concerns. While significant efforts were made to develop very substantive capacity at the PMT, its future is uncertain. Whether these skills will be retained in the PMT, absorbed into the various line ministries or lost to emigration, raises some concerns about the sustainability of the Project inputs. In view of the achievements attained, this component is rated as satisfactory. On the basis of the information presented in this section, the PDO achievement is rated Satisfactory.

3.3 Efficiency (Net Present Value/Economic Rate of Return, cost effectiveness, e.g., unit rate norms, least cost, and comparisons; and Financial Rate of Return) The Project was a long-term investment in Eritrea’s work force. Significant investments were made towards providing an enabling environment through which Eritrean children could develop into healthy wage-earners. Hence, benefits were designed to materialize far into the future. Considering the lack of an appropriate overall baseline, and the duration of the Project, particularly the short-lived availability of the integrated package at the community level, an analysis towards determining the economic benefits of the Project would be neither robust nor reliable. Over the last ten years a large body of international evidence based on longitudinal studies has accumulated that unequivocally points to high economic returns from investing in ECDiv. It is estimated that over 200 million children under 5 years – mostly in South Asia and sub-Saharan Africa – do not reach their potential in cognitive development because of poverty, poor health and nutrition, and deficient care. Recent estimates indicate that investing in these children yields benefit-to-cost ratios substantially above 1. Seven characteristics common to the most successful interventions were also identified. In the ICR team’s assessment, currently the Project scores high on five of the seven attributesv - the weakest being “Sufficient intensity and duration, including direct contact with children beginning early in life”. A fair evaluation of the integrated or life-cycle approach to ECD means that the experimental cohort must benefit from the services uninterruptedly from the prenatal stage to five years of age, and then be followed up at least up to completion of the lower primary cycle – a total of seven to eight years. This is confirmed by the average life of the evaluated programs worldwide, which is about ten years. The ICR team noted that a Bank-Netherlands Partnership Program (BNPP) approved a trust fund allocation for a rigorous, forward looking impact evaluation conditional on

iv See The Lancet, Vol. 369 January six, 2007 for the most recent comprehensive review and analysis of the research on the subject.

v See The Lancet, Vol. 369, January six, 2007, Page 234.

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the Project interventions being sustained. This provides an incentive for the GoE to continue the activities initiated by the Project, as well as an entry point for an adequate economic analysis. In terms of cost-effectiveness of the education component, the ICR team’s assessmentvi indicates that: (i) with everything else being equal, the investment will start paying off financially once a further combined reduction of 32% of the repetition and dropout rates is attained; and (ii) investing in CCGs would be much more cost-effective relative to the KGs. The details are in Annex 3. The smokeless stoves were probably the most cost effective of the food security interventions as they require a minimum investment (approximately US$30), bring significant health and environmental benefits, and are much less time-consuming than the regular stoves. The environmental impact is particularly impressive as the smokeless stoves reportedly need about 25% less firewood. The investment in water pumps was seemingly not very efficient in the lowlands as the latter’s lifestyle and sparse distribution of inhabitants do not match the communal use intended for the water pumps. Finally, considering that eggs are an expensive commodity in Eritrea, the benefits from the chicks are likely to affect the beneficiaries’ income significantly as well as their food security status. Regarding the grants, the majority of the families benefited from and were able to sustain their income generating schemes as well as to improve their daily food intake. Of those who preferred small-scale business, 70.4% had increased their capital value and generated sustainable income to support their families. Based on the considerations above and the discussion in section 2.1, this aspect of the Project is considered satisfactory.

3.4 Justification of Overall Outcome Rating (Combining relevance, achievement of PDOs, and efficiency)

As the discussion above highlighted, this was a complex project to design, plan and implement. The results achieved are substantial taking into consideration: (i) the “no war no peace” situation; (ii) the prevailing poor macroeconomic conditions during implementation; (iii) the incipient difficulties in executing the integrated package at the community level without any significant experience, especially at this scale; (iv) the drought; (v) stoppage of food aid; and (vi) the ambitious targets.

Based on the relevance (see section 3.1), PDO achievement (see section 3.2) and efficiency (see section 3.3) of the Project, the overall outcome is rated as Satisfactory.

3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development:

vi The data are from a draft Eritrea Education Public Expenditure Review, and the costing of the Eritrea Integrated ECD policy.

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Poverty: Grants: Besides being a source for food, the products of the grants and assistance given to host families of orphans provided a sustainable source of income if supervised and managed well. Group Homes: Orphans placed in group homes go to school and have an opportunity to grow up in a more normal environment thus increasing their prospects of meaningful employment in the future. Food Security: Improved macro- and micro-nutrition as well as IMCI interventions, gave the children a better chance of living a healthy childhood. This reduced the associated costs of managing morbidity that would be borne by the parents. Food security interventions like water pumps and poultry distribution provided the women and their families in the village food to eat in the short term and farming income in the longer term. ECE: Long term benefits will accrue from a more productive population through sustained education interventions.

Gender: A majority of the interventions had women as the secondary beneficiaries, since all childhood interventions except the CNSP, were carried out with mothers as co-participants. The NUEW played a major role in the implementation of this project as they were represented at every administrative level. They were extremely influential in selecting women as CCG’s, for agricultural interventions and for GMP promoters. Also, a majority of the group homes and host families were headed by women.

Over the period 1999-2002, the dropout rate for girls in the first grade was higher than for males. In 2005/06, however, the dropout rate for girls drastically fell to 1.6% as compared to 5.15% for boys. In general, the findings indicate that females repeat grades less. Social Development: The strong community involvement required by the Project and the substantial investment made to build capacity at the community level suggest that significant social capital development is likely to have taken place. (b) Institutional Change/Strengthening Institutional strengthening has been significant. As a result of the numerous training and implementation activities, capacity within the line ministries has significantly improved at the national, zoba, sub-zoba and village levels. Most significantly, the different line managers and technical experts have learnt how to work across ministries to achieve common outputs. These synergistic effects have come at an opportune time as Eritrea strives to rebuild its economy. The country has a severe shortage of trained personnel but staff usually accept postings irrespective of the location. The ECE Resource Centers are available to produce more teachers and trained volunteers e.g. GMP agents and these are not capital intensive. (c) Other Unintended Outcomes and Impacts (positive or negative) An unintended but positive outcome of the Project was the development of an integrated ECD policy. Leadership for this effort was provided by the MoE which drew on experience from the Project in all the line ministries. The policy provides a framework for Government, communities, families, and international & national Development Partners for investing in and implementing integrated ECD programs. Seven policy objectives were outlined and include: (i) the establishment of a national framework of institutional capacities; (ii) advocacy and awareness creation; (iii)capacity building for stakeholders and service providers; (iv) strengthening of the health system to promote child and maternal health including VCT for HIV/AIDS; (v) developing and implementing quality formal

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and non-formal preschool curricula; (vi) improving household and community level food security; and (vii) promoting environmental hygiene, sanitation and access to safe water. Of note is that the fact that the institutional arrangements more or less follow what was tried and worked well in the Project. The policy document clearly defines the roles and responsibilities of all the stakeholders in ECD.

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

Not applicable. 4. Assessment of Risk to Development Outcome In the Letter of Sector Policy signed at appraisal the Borrower committed to covering the program recurrent costs once the Credit was exhausted, until the communities had become self-reliant. However, as at the time of project closure in March 2007, no arrangement was in place for the GoE to be able to meet even the core incremental costs (salaries and allowances) except for the KG/CCG teachers whose salaries it was agreed would be covered by the Education Sector Investment Project. It was also unclear which ministry/agency would take responsibility for coordinating the interventions both at national and zoba levels. The coordinating activities of the PMT can arguably be described as the glue that held the different pieces of the Project together. Capacity developed in project management and M&E has been very significant as the Project progressed. Coordination between line ministries is commonly a difficult task, one which the current PMT has been able to manage. At the time of Project closure, concrete transitional and reassignment arrangements had yet to be made by the GoE, casting doubts on the incorporation of these skills within the administration. The GoE is in the process of deciding what project activities will be absorbed by individual ministries and whether a full follow up project will be requested. Political commitment remains high as demonstrated by the participation of four implementing Ministers in the last wrap-up meeting of the Project. While there have been substantial gains in setting up the policy framework and in building institutional capacity (through training etc.), a great deal may be lost because of lack of funds to (i) train more teachers, health and social workers; (ii) build more KGs; and (iii) pay group home mothers may. Ultimately, the financial sustainability of the Project development outcomes rests with the GoE’s own ability to: (i) increase domestic resource allocations for project interventions; and (ii) further expand ECD activities. However, in light of the exceptional level of commitment that the GoE has consistently shown, there is reason to be somewhat optimistic. In light of the aforementioned, as well as the poor state of the economy, the very limited public resources available for childhood development interventions and the prevalent poverty levels, the risk to development outcomes is Significant.

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5. Assessment of Bank and Borrower Performance (Relating to design, implementation and outcome issues) 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry (i.e., performance through lending phase)

The Project was designed on a tight schedule, especially considering that there was no precedent. The financial, technical and institutional considerations were appropriate as was the amount of resources made available for Project preparation, and the lending instrument. As discussed in section 2.1, the Bank underestimated the risks associated with implementing a complex project in a conflict environment. After the approval of the ISN which emphasized the need for emergency interventions on basic social services, it would have been advisable to simplify the design of the Project and to put more emphasis on food security.

The Bank performance in ensuring quality at entry is considered to be moderately satisfactory. (b) Quality of Supervision The Bank demonstrated substantial engagement in supporting effective implementation consistently throughout the Project. Supervision missions were regular and the expertise of team members was of high quality throughout. Though leadership of the task-teams was changed thrice during the Project life, disruptions were minimal. Supervision reports focused on achievement of objectives, were informative and identified key issues that needed to be addressed by the Bank and the Borrower. The ratings were realistic and reflective of project progress. In spite of the increasingly limited financial resources available for supervision, its quality never suffered, with technical inputs being provided steadily in-between missions. Furthermore, the Bank was instrumental in bringing about the decision to implement integration at the village level. The Bank also exercised good judgment in reversing its decision to switch to FMR based disbursement, thus avoiding implementation delays that would have likely been fatal to the Project outcome. The Bank also provided support in hosting an International ECD conference in Eritrea. Procurement processes were smooth; however there were some delays during the latter stages of the Project, resulting in the second extension of the closing date by three months. In anticipation of the Project’s completion, the Bank team initiated discussions a year in advance with the GoE regarding possible follow-up alternatives ranging from a follow up project to a ministry absorption strategy of the different project components. The multi-sectoral coordination required was difficult particularly as there were no precedents of projects of this type. However, considering the results of similarly designed programs within the continent and other social programs within Eritrea, the challenges have been well handled as observed by the remarkable progress made since the MTR. The Bank could have mitigated the high risk for the nutrition outcome of the drought and the stoppage of WFP’s food distribution program WFP by putting more emphasis on food security, especially in the lowlands. The Bank performance in supervision is rated satisfactory. (c) Justification of Rating for Overall Bank Performance Based on the discussion in (a) and (b) above, the overall Bank performance is rated Satisfactory.

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5.2 Borrower Performance (a) Government Performance The Government of Eritrea prepared well for this project. The preparation process was swift and focused as the planned interventions were mostly predicated on on-going activities in health, social protection and education. PSC meetings were regular and were committed to project success and to improved project implementation. Initially, the TOR’s for the TSC did not require a hands-on approach to implementation support. However, appropriate changes were made early enough for the TSC to be able to supervise Project implementation more effectively. Reflective of this was the change in leadership of the PMT, largely as a result of poor performance by both the PSC and TSC. However, the decision to stop WFP’s food distribution program raised significant concerns regarding the undesired consequences on the achievement of the nutrition outcome, particularly in light of the macro-economic decline and the drought. Also of concern is the inability of the GoE to articulate a transition plan and its possible consequences on sustainability of the Project outcomes. The Borrower deserves special recognition for its unwavering commitment to the Project in spite of the extraordinarily difficult circumstances. Based on the preceding discussion, the Borrower’s performance is rated moderately satisfactory. (b) Implementing Agency or Agencies Performance The Implementing Agency was the MoE and implementation activities were coordinated through the PMT. The lack of capacity was recognized at the outset and efforts to address this at the PMT level became paramount. Significant capacity building was carried out in financial management, procurement, communication and leadership amongst others. Leadership of the PMT was initially problematic and was significantly implicated in the shortcomings of the nutrition component. Change in the PMT’s leadership caused considerable delays in planning and implementation hence stunting the Project’s progress. With the new (and current) leadership consultation and coordination steadily improved between the PMT and the ministries. The TSC and PMT developed an effective synergy in following up project activities. As discussed previously, positive behavioral change achievements were made in every component. Concerted activities aimed at promoting an integrated package of delivery, such as the preparation of an integrated communication strategy and training manuals and multiple joint training activities were carried out. These activities all had a focal point of strengthening relationships among project partners. The major shortcoming of the PMT stems from the inadequate attention given to M&E. These are detailed above. Implementation might have been more effective if weaknesses in M&E activities had been promptly addressed, e.g. delayed and improperly completed Output Monitoring Reports, a prolonged period to recruit an M&E expert, delayed baseline data collection as well as inconsistent reporting. Based on the above discussion, Implementing Agency performance is rated as satisfactory. (c) Justification of Rating for Overall Borrower Performance

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Considering: (i) the outstanding implementation ability the Borrower showed; and (ii) the constraining environment in which the Borrower had to operate, the overall Borrower performance is rated Satisfactory. 6. Lessons Learned National ownership and buy-in is important in achieving development outcomes. Clearly, the achievements realized in this project result from the GoE not viewing its role as purely that of a beneficiary or facilitator. The commitment and responsiveness shown by the GoE was that of a majority shareholder whose development interests were the paramount considerations in all deliberations made and decisions taken. PMTs can be functional if focused and adequately supported. The Project proved that PMTs are not necessarily an outdated concept of implementation. The ongoing conflict coupled with the complexity of the integrated, multi-sectoral approach justified the PMT in this project. Although the implementing agency was the MoE, day to day project coordination was carried out by the PMT. Performance was shaky at the beginning, but as management changed and the link between the TSC and PMT grew stronger, the Project performed better. Coordination was also strongly supported by the high level of access the PMT had upstream, i.e. with the TSC and PSC, as well as downstream with the line ministries and zoba coordinators. Monitoring and Evaluation. It is very common to underestimate the risk of insufficient M&E capacity, especially in multi-sectoral, decentralized operations as these require both horizontal and vertical links, in turn calling for a complex/integrated M&E framework. A thorough, systematic needs assessment of the capacity to operationalize such a framework, including the relative readiness of the participating line ministries, and a corresponding risk mitigation strategy should be mandatory in projects of this type. This is particularly relevant for Eritrea because it was their first multi-sectoral experience. Finally, impact evaluation should be planned as part of Project design. Component Design. Considering the intent of delivering an integrated package of services, it would be advisable to design project components around the level of implementation (e.g. community, regional, national) as opposed to the lines of the interventions, as was the case here. This was particularly relevant for the Project in light of the amount of time and resources spent in getting a project to provide integrated services at the community level. While the present design might have been relevant initially, considering the capacity level on the ground and the new interventions being implemented e.g. GMP, future engagements would benefit more from a more integrated approach. Finally, in a country at high risk of severe food insecurity, a component aimed at reducing the prevalence of malnutrition should put more emphasis on food security relative to GMP interventions. Development Partners Engagement and Coordination. Last but not least, of the three self-standing ECD projects in Sub-Saharan Africa (Kenya, Uganda and Eritrea) this is the only successful one. A major lesson to be learnt from the evaluation of the three operations is that a formal, well coordinated partnership among all the involved development partners, local and international, is necessary for a successful outcome. This was not the case in any of these projects. However, in Eritrea an informal partnership worked because of: (i) the Project almost exclusively built on existing interventions supported by the GoE and other development agencies; (ii) the small number of development partners; and (iii) the GoE’s unwavering commitment and consistent guidance. Considering the richness of the experience and knowledge gained from

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these projects, the ICR team recommends that a special, comparative study be conducted to capture all the valuable lessons.

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)

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Annex 1. Project Costs and Financing

(a) Project Cost by Component (in USD Million equivalent)

Component Appraisal Estimate

US$ Million Actual/Latest Estimate US$ Million

Percentage of Appraisal

IMPROVING CHILD HEALTH 10.5 14.3 136%

IMPROVING CHILD AND MATERNAL NUTRITION

4.6 3.8 83%

IMPROVING EARLY CHILDHOOD CARE AND EDUCATION

11.8 15.2 129%

SUPPORT FOR CHILDREN IN NEED OF SPECIAL MEASURES

11.7 12.4 106%

Total Baseline Cost 44.05 51.7 117% Physical Contingencies 2.00

Price Contingencies 2.95 Total Project Costs 49.0 51.7 106% Front-end fee PPF 0.00 0.00 Front-end fee IBRD 0.00 0.00 Total Financing Required 49.0 51.7 106%

(b) Financing Source of Funds Type of Co-financing Appraisal Estimate

US$ Million Actual/Latest Estimate US$ Million

BORROWER Counterpart Funding 4.0 5.1 ITALY, GOV. OF (EXCEPT FOR DEV. COOP. DEPT. - MOFA)

Bank Executed Trust Fund 5.0 5.0

INTERNATIONAL DEVELOPMENT ASSOCIATION

Credit 40.0 41.6

FOREIGN SOURCES (UNIDENTIFIED)

TOTAL 49.00 51.70

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(c) Project Financing by Category (in US$ million equivalent) Appraisal Estimate Actual/Latest

Estimate Percentage of

Appraisal Category

IDA ITALY GOE IDA ITALY GOE IDA ITALY GOE

Civil Work 7.6 1.0 0.6 10.7 1.0 2.2 141% 100% 367%Goods 12.0 1.1 1.8 16.6 1.1 1.4 138% 100% 78%Services Consultant, studies, Training & innovation Activities

8.6 0.8 0.0 4.3 0.5 0.0 50% 63% 0.0

Grant 8.1 1.9 0.0 8 2.2 0.0 99% 116% 0.0 Operating cost 3.7 0.2 1.6 2 0.2 1.5 54% 100% 94%Total Baseline Cost 40 5.0 4.0 41.6 5.0 5.1 104% 100% 128% (d) Project Cost by Procurement Arrangement (Actual/Latest Estimate) (in US$ million equivalent)

Procurement Methodvii Category ICB NCB Othersviii

N.B.F Total Cost

0.00 13.9 0.00 0.00 13.90 Civil Work (0.00) (10.70) (0.00) (0.00) (10.70) 11.4 7.7 0.00 0.00 19.2 Goods

(10.90) (5.70) (0.00) (0.00) (16.60) 0.00 0.00 4.80 0.00 4.80 Services Consultant, studies,

Training & innovation Activities (0.00) (0.00) (4.30) (0.00) (4.30) 0.00 0.00 10.20 0.00 10.20 Grant

(0.00) (0.00) (8.00) (0.00) (8.00) 0.00 0.00 3.70 0.00 3.70 Operating cost

(0.00) (0.00) (2.00) 0.00 (2.00) 11.40 21.60 18.70 0.00 51.70 Total

(10.90) (16.40) (14.30) 0.00 (41.60)

vii Figures in parenthesis are the amounts to be financed by the IDA Credit. All other costs are inclusive of contributions by the GoE and the Italian Cooperation. All costs include contingencies. viii Includes civil works and goods to be procured through national shopping, consulting services, services of contracted staff of the project management office, training, technical assistance services, and incremental operating costs related to (i) managing the project, and (ii) re-lending project funds to local government units.

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Annex 2. Outputs by Component Table 1

Measurement Baseline Value Progress To Date End-of-Project Target

Value

Indicators

Number or text

Date Number or text

Date Number or text

Date

Intermediate outcome indicator(s)

1. # of health workers trained in IMCI case management by ECD project

None 04/20/2000 1096 Health workers

10/31/2006 150 12/31/2006

2. Number of mothers training in food security and nutrition through the Ministry of Agriculture training program, with support from the Ministry of Health through the ECD project.

13,374 trained mothers

03/31/2000 8,667 mothers trained through project

10/31/2006 12/31/2006

3. Cumulative enrolment in Kindergartens and Child Care Givers

12,436 04/29/2000 31,653 and 50,425 respectively

10/31/2006 31,000 and 50,000 respectively

12/31/2006

4. Number of social workers trained

zero through the Project

04/29/2000 36 10/31/2006 90 12/31/2006

Source: Implementation Support Report of February 2007

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Additional tables referenced in text: Child and Maternal Health: Table 2: Assessment and treatment performance indicators Indicator Percentage Index 2000 Percentage Index 2003 Children checked for three danger signs 0.0 36.9 Underweight children who are assessed for feeding problems

0.0 21.1

Children whose weight is checked against a growth chart

2.1 53.3

Children whose vaccination is checked 18.5 58.0

Percent of children who are inappropriately treated with an antibiotic

46.8 31.8

Children who did not get needed vaccinations 15.8 7.0 Source: MOH, HFA, 2003 Report

Table 3: Distribution of equipment Equipment Zoba Laundry Generator Health

Facility stoves

Anseba 7 2 7 Debub 8 2 8 Gashbarka 5 5 Maakel 8 2 4 NRS 7 2 6 SRS 1 Total 36 8 30 Source: ECD Final Evaluation Report, 2007 Figure 1: Stock out level of essential drugs

0 20 40 60 80 100

O R S

F a n s i d a r

V i t . A

P a r a c e t a mo l

G e n t a my c i n

B e n z y l p e n i c i l l i n

% o f facilit ies

20032000

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Source: MOH, HFA, 2003 Report Table 4 Distribution of Constructed Water points and Latrines in Health Facilities (HF) by Zoba

Rain Water Reservoirs in Health Facilities

Zoba

Pipeline Connection

Rain Water Reservoirs

Total

Protected Water Wells

HF Latrines Slabs

HF (Qty) HF (Qty) HF (Qty) (Qty) Villages Quantity Quantity Anseba - 3 3 2 6 600 Debub 5 3 8 4 350 G/Barka 1 - 1 2 10 600 Maekel 18 - 18 10 700 NRS 3 - 3 9 - SRS 1 6 7 - 116 Total 28 12 40 4 39 2366 Source: ECD Output Monitoring Table Dec.2006 Child and Maternal Nutrition: Table 5: Prevalence of Children Underweight in all the Sampled Villages CHARACTERISTICS SEVERE

UNDER WEIGHTED

MODERATELY UNDER WEIGHTED

NORMAL TOTAL UNDER WEIGHT

TOTAL

SEX # % # % # % # % # MALES 77 16.6 130 28.0 257 55.4 207 44.6 464 FEMALES 55 11.8 126 27.0 286 61.2 181 38.8 467 ZOBA ANSEBA 30 15.2 61 30.8 107 54.0 91 46 198 DEBUB 19 8.8 50 23.3 146 67.9 69 32.1 215 GASH BARKA 42 14.6 90 31.3 156 54.2 132 45.9 288 MAEKEL 16 13.8 22 19.0 78 67.2 38 32.8 116 N/R/SEA 20 22.7 20 22.7 48 54.5 40 45.4 88 S/R/SEA 5 19.2 13 50.0 8 30.8 18 69.2 26 TOTAL 132 14.2 256 27.5 543 58.3 388 41.7 931

Source: (c-GMP Impact Evaluation, 2007) Table 6: Selected Food Security and Nutrition Inputs Zoba

High Energy Biscuits Pkts

Water pumps

Chicks Fish Nets

Anseba 167.03 7 12,500 Debub 195.58 46 25,000

Gash Barka 186.74 12 12,500 Maekel 204.60 30 10,667 NRS 132.43 11 18,167 SRS 43.62 24 3,834 19 Total 930.00 130 82,668 19 Source: ECD Final Evaluation Report, 2007

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Table 7: Mass Vitamin A supplementation Zoba Number of children

supplemented Total children (2003-04)

Est. percent children

Anseba 48267 75244 64%Debub 0 191924 0%Gash Barka 65028 99705 65%Maekel 336 144385 0%Northern Red Sea 37660 40580 93%Southern Red Sea 6458 7255 89%Total 157749 559093 28%

Source: Eritrean School Health and Nutrition Program Evaluation Report, 2007

Table 8: Mass iron supplementation Zoba Number of children

supplemented Total children (2003-04)

Est. percent children

Gash Barka 36561 99705 37%Northern Red Sea 40055 40580 99%Southern Red Sea 6261 7255 86%Source: Eritrean School Health and Nutrition Program Evaluation Report, 2007

Table 9: Percent of children who reported malaria in the last two weeks in each zoba Zoba Number PercentageDebub 0 0Gash Barka 57 17.43Maekel 0 0Northern Red Sea 2 0.5

Source: Eritrean School Health and Nutrition Program Evaluation Report, 2007 Table 10: Anemia prevalence in those who did and did not report malaria illness Anemia prevalence Did not report malaria

6.91%

Reported malaria

20.75%

Source: Eritrean School Health and Nutrition Program Evaluation Report, 2007

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Table 11: Prevalence of malnourished children in the Total sampled villages by Zoba. Zoba Project Baseline (%) Final (%) Change (%) Anseba 53.8 46.0 14.5 Debub 38.1 32.1 15.7 Debubix (IMCI+GMP Pilot)

38.1 27.7 27.3

Gash Barka 45.3 45.9 1.3 Maekel 30.7 32.8 6.8 N/Red Sea 35.7 45.4 27.2 S/Red Sea 58.3 69.2 18.7 National Average 39.2 41.7 6.4 Source: c-GMP Impact Evaluation, 2007 Table 12: Prevalence of malnourished children in the Total sampled villages by Integration status. Village Type Project Baseline (%) Final (%) Change (%) Integrated 39.2 43.8 11.7 Non-Integrated 39.2 39.1 0.3 National Average 39.2 41.7 6.4 Source: c-GMP Impact Evaluation, 2007 Education: Table 13: ECCE Project Output 2001-2006 Early Childhood Care and Education

Planned Actual Percent Remarks

KG Constructed 105 105 100.0 Communities with functioning CCG

250 286 114

KG Directors Trained in basic management and pedagogy

105 150 143

KG Teachers Trained 315 230 73.0 CCG Teachers Trained 250 304 121.6 Resource Centers Established 6 6 100.0 School Latrines Constructed 125 85 68.0 Protected water points Constructed 76 No planned target available in

PIM School garbage disposal Units 147 19 12.9

ix Represents a separate pilot with joint c-GMP and C-IMCI interventions only for 17 villages in Zoba Debub.

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Children Enrolled in KGs 31.000 31,653 102.1 Children Enrolled in CCGs 50,000 50,425 100.1 Source: Tracer Study; ECD Final Evaluation Report, 2007 Table 14: Children in Need of Special Protection Zoba Reintegrated

Host families Orphan Unified

GroupHomes

Children placed in Group Homes

Anseba 2582 7182 2 12 Debub 3200 8752 4 48 Gash Barka 950 2216 1 11 Maekel 1970 4627 2 12 NRS 2048 6277 1 12 SRS 1070 2502 0 0 Total 11820 31,556 10 95 Source: ECD Final Evaluation Report, 2007 Communication Strategy: Table 15: Behavioral changes achieved by the sanitation project

Integrated Villages

Non-Integrated

Villages

Behavioral changes

(N=23) % (N=8) % Open defecation is avoided 91.3 87.5Proper hand washing is practiced 47.8 100Use of Clean water storing containers

0 50

Proper Use Of latrines 56.5 50No change 4.3 100Source: ECD Final Evaluation Report, 2007

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Annex 3. Economic and Financial Analysis (Including assumptions in the analysis) As mentioned in section 3.3, a meaningful economic assessment of the Project’s benefits is not feasible at this time due to its short lived presence on the ground. In the future such analysis will be possible if (i) a baseline is collected in the integrated villages, with a control group to match; and (ii) the GoE sustains the integrated package for at least another five years. A BNPP trust fund allocation is available to fund the baseline data collection if the GoE commits to sustaining the Project activities in the integrated villages. However, it is possible to estimate the cost effectiveness of the education component by comparing savings derived from the intervention with its annual recurrent costs. The amount saved by the GoE from a reduction in dropout rates i.e. a reduction in the “sunk cost” spent for a child who eventually drops out of grade 1 as well as the amount saved by reducing the number of years a pupil remains in school due to the lower repetition rate is computed as follows: The estimated annual unit cost at the elementary level is 300 Nakfa. In the baseline year, 2000, the parameters were: Repetition rate in 2000 = 25.97% Dropout rate = 13.7% In 2006 there were 73,222 children in grade 1: Total cost to GoE was 73,222*300 Nakfa = 21,966,600 Nakfa. Repetition rate in 2006=18.24% Dropout rate = 8.79% Savings from the lower repetition rate = (0.2597-0.1824)*21,966,600 =1,698,018.2 Nakfa or US$113,201.21 Savings from the lower dropout rate= (0.137-0.879)*21,966,600) =1,078,560.1 Nakfa or US$71,904.00 Assuming that the repetition and dropout rates remain stationary, every year the total savings amount to US$185,105. Subtracting the annual recurrent costs for the KGs and CCGs, estimated at US$396,642, yields an annual loss of US$211,537. It was calculated that in order for this investment to break even, the repetition and dropout rates would have to continue decreasing until they reach a combined 12.67%. This would entail replicating the Project’s achievement, or accumulating a 68% combined reduction vis a` vis the baseline in 2000. Considering that most of the KGs and CCGs had been functional for a maximum of three years at the time of the final project evaluation, the benefits are likely to continue accruing at a fast rate even without an expansion of the program. This means that, everything else being equal, the further decline of the

35

repetition and dropout rates could occur in a short period of time. Moreover, the high annual costs are largely driven by the KGs whose unit recurrent cost is almost six times its analogue for CCGs. If the GoE starts expanding the program giving priority to the provision of CCGs, the recurrent cost would go down gradually but substantially over time. Since the tracer study showed that CCGs seem to prepare the children as well as the KGs, the shift towards more CCGs would greatly increase the profitability of the investment. Finally, this kind of analysis is extremely “myopic” as it does not take into account the effects of improved cognitive development.

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Annex 4. Bank Lending and Implementation Support/Supervision Processes

(a) Task Team members

Names Title Unit Responsibility/ Specialty

Lending Marito Garcia Economist AFTH-1 Christine Pena Health Specialist AFTH-1 Lesley Drake Consultant Marylou Bradley Operations Adviser AFTH-1 Caroline Pond Consultant

Paola Viero Child and Youth Coordinator Italian

Cooperation

Sam Muziki Medical Officer WHO Ghirmai Andemichael Family Health Program Adviser WHO John Ogallo Financial Management Specialist AFTQK Francis Onyango Public Health Specialist WHO Simon Kerpal ECD Specialist HDNED

Erasmo Macera Public Health Specialist Italian

Cooperation

Alan Pence Consultant Yordanos Seium Operation’s Analyst HDNVP Krishna Pidatala Information Specialist AFTQK

Supervision/ICR Christopher D. Walker Carla Bertoncino Economist AFTH1 Donald A. P. Bundy Lead Specialist HDNED Christine Lao Pena Senior Human Development Econo LCSHH E. V. Shantha Consultant AFTH1 Saba Solomon Tekle Executive Assistant AFMER Sofia Woldu Team Assistant AFMER

Peter Wolff HRSSD-HIS

Peter Gaius-Obaseki Research Analyst AFTH1 Efrem Fitwi Procurement Analyst AFTPC Francesco Sarno Procurement Specialist AFTPC Rogati Kayani Procurement Specialist AFTPC Janne Lexow Consultant AFTH1 Moses Wasike AFTFM Brighton Musungwa Sr Financial Management Specialist AFTFM Rajat Narula Senior Finance Officer LOAG2 Rajat Narula

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(b) Staff Time and Cost Staff Time and Cost (Bank Budget Only)

Stage of Project Cycle No. of staff weeks USD Thousands (including

travel and consultant costs)Lending

FY00 42 140.90 FY01 3 7.13 FY02 0.00 FY03 0.00 FY04 0.00 FY05 0.00 FY06 0.00 FY07 0.00

Total: 45 148.03 Supervision/ICR

FY00 9 22.22 FY01 16 74.97 FY02 20 130.63 FY03 23 112.81 FY04 21 103.11 FY05 20 107.76 FY06 22 101.47 FY07 15 57.39

Total: 146 710.36

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Annex 5. Beneficiary Survey Results (if any)

39

Annex 6. Stakeholder Workshop Report and Results (if any)

40

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

41

Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders

42

Annex 9. List of Supporting Documents

1. World Bank. Project Appraisal Document on a Proposed Credit in the amount of SDR 29 Million (US$ 40 Million Equivalent) to the Government of Eritrea for the Integrated Early Childhood Development Project. Report No. 20373-ER. Washington, D.C. 2000.

2. World Bank. Aide-Memoirs’ from the Project Identification Mission in 1999 to the last Supervision Mission in February, 2007. Washington, D.C.

3. World Bank. Implementation Status and Results for Investment Projects. Eritrea IECDP (Sequence 1-18). Washington, D.C.

4. World Bank. Back To Office Reports for ER-IECDP. Project ID: P068463. Washington, D.C.

5. Final Project Evaluation Report. “Reaching the Chilled Through an Integrated Approach”. SDCS Consultants, Asmara Eritrea.

6. Eritrea School Health and Nutrition Evaluation Report. Ministries of Education and Health of Eritrea and the Partnership for Child Development, Imperial College, London. January, 2007.

7. Five year Report, 2000-2005, ECD, 2006. 8. Final year Report, 2005-2006, ECD, 2007. 9. “Early childhood development: the global challenge” Richard Jolly, Lancet

2007; 369:8-9. 10. Health Facility Assessment, Ministry of Health, 2003. 11. Implementation Completion Report (IDA-3440 PPFI-Q2210) on a Credit in the

amount of US$40 Million to the State of Eritrea for a HIV/AIDS, Malaria, STD and Tuberculosis (HAMSET) Control Project. Report No. 37558. June, 2006.