Document of The World Bank Report No: 65924-ET RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF ET-ETHIOPIA NUTRITION (FY08) PROJECT GRANT: H376-ET 29-APRIL 2008 TO THE FEDERAL DEMOCRATIC REPUBLIC OF ETHIOPIA April 2, 2012 Africa Region Health, Nutrition and Population (AFTHE) ABBREVIATIONS AND ACRONYMS CBN Community-based Nutrition EHNRI Ethiopian Health and Nutrition Research Institute FMOH Federal Ministry of Health PDO Project Development Objective Regional Vice President: Obiageli Katryn Ezekwesili Country Director: Guang Zhe Chen Sector Manager: Jean Jacques De St Antoine Task Team Leader: Ziauddin Hyder 2 ETHIOPIA ET-ETHIOPIA NUTRITION (FY08) P106228 CONTENTS Page A. SUMMARY ......................................................................................................................................... 4 B. PROJECT STATUS ........................................................................................................................... 4 C. PROPOSED CHANGES .................................................................................................................... 4 ANNEX 1: SUMMARY OF CHANGES TO RESULTS FRAMEWORK .............................................. 6 ANNEX 2: PROPOSED RESULTS FRAMEWORK AND MONITORING ......................................... 8 3 ETHIOPIA NUTRITION PROJECT P106228 GRANT H0376-ET RESTRUCTURING PAPER A. SUMMARY 1. This restructuring paper seeks the approval of the Country Director to introduce changes to the Ethiopia Nutrition Project (H0376-ET). The current results framework of the Project is inadequate to monitor progress towards achievement of the Project Development Objective (PDO). The proposed changes are as follows: (a) changing one of the PDO indicators; (b) updating baseline and endline values of PDO indicators; and (c) revising intermediate results indicators to ensure they are technically sound, follow a logical sequence, and use available data sources to allow more frequent monitoring of progress. No changes are proposed to the PDO, project components, institutional arrangements, or project closing date. B. PROJECT STATUS 2. The PDO is to improve child and maternal care behavior and increase utilization of key micronutrients in order to contribute to nutritional status of vulnerable groups. The project, with an IDA allocation of US $30 million, was approved on 29 April 2008, became effective on 10 September 2008, and has a closing date of 7 January 2014. The project has been performing well. The MTR showed that the prevalence of malnutrition (underweight) in children under the age of two who participated in the project decreased from 31% to 14%. Over half of the funds (52%) have been disbursed, which is reasonable given that the project just crossed its mid-point. The project continues to be well managed by the Federal Ministry of Health. While progress toward achieving the PDO is satisfactory and disbursements are steadily increasing, there is a need to review the Results Framework. C. PROPOSED CHANGES 3. Changing one of the PDO indicators: Because there is a limited link between the project inputs and salt iodization, Universal Salt Iodization (USI) coverage is not a good PDO indicator. This indicator would be replaced by the percentage of children 0-23 months participating in monthly growth monitoring and promotion (GMP) sessions. This indictor reflects the importance of Community-based Nutrition (CBN) in changing maternal/child care behaviors, and is also useful because it can be monitored on a six-month basis through routine monitoring data. 4. Updating of baseline values: The baseline values of the PDO indicators will be updated using more recent nationally representative data, the National Nutrition 4 Survey (NNS), which was carried out in 2009 by the Ethiopia Health and Nutrition Research Institute (EHNRI). These values will replace the 2005 Demographic and Health Survey (DHS) data, and the endline target values will be updated accordingly. The EHNRI will repeat the NNS at the end of 2013. 5. Revising intermediate results indicators: The intermediate results indicators will be revised to ensure they are logically linked to the PDO and can be monitored more frequently. The revised intermediate indicators can be updated semiannually or annually either from routine monitoring data or the project reports prepared by the implementing agency. The proposed changes are detailed in Annex 1. The proposed results framework is provided in Annex 2 (Table 2), with details on data collection (Table 3). 5 ANNEX 1: Summary of Changes to Results Framework Table 1: Summary of Changes to Results Framework Project Development Objective (PDO) Current Proposed change Comments/ Rationale for Change To improve child and maternal care behavior, and No change increase utilization of key micronutrients in order to contribute to improving the nutritional status of vulnerable groups. PDO Indicators Current Proposed change Comments/ Rationale for Change Percentage of infants 0-5 Revised: Previous baseline data was from DHS 2005; months exclusively Baseline value updated with revised with 2009 data now available breastfed 2009 data and endline target (Data source: National Nutrition Survey, adjusted accordingly EHNRI) Percentage of households Dropped NP contributions to USI are modest. using adequately iodized However, as USI remains an important salt contributor to the PDO, an Intermediate Results Indicator was proposed to monitor progress (see below) Percentage of pregnant Revised: Previous baseline data was from DHS 2005; women receiving iron and Baseline value updated with revised with 2009 data now available folate supplementation 2009 data and endline target (Data source: National Nutrition Survey, adjusted accordingly EHNRI) People with access to a Revised: The indicator was revised to indicate that basic package of health, Number of people with the package of health services refers to CBN nutrition, or population access to a basic package of, (Data source: Routine CBN data, FMOH); services nutrition services (CBN), % The indicator will also report an estimate of female the percent of women covered. Children receiving a dose Revised: The indicator was revised to be more of Vitamin A Number and percentage of specific. (Data source: Routine Community children 6-59 months Health Day (CHD)/Enhanced Outreach receiving a dose of Vitamin Services (EOS) reports, FMOH) A every 6 months New: This additional indicator reflects the NP Percentage of children 0-23 focus on under-2 children and allows months participating in monitoring of progress in community-based monthly GMP sessions nutrition services, which is linked to the PDO (Data source: Routine CBN data, FMOH) 6 Intermediate Results Indicators Current Proposed Change Comments/Rationale for Change Health Extension Workers trained Revised: Revised to make the indicator more on revised curriculum: percentage Number and percentage of focused on NP: the existing indicator out of a target of 30,000 to be Heath Extension Workers refers to a curriculum that is not achieved by project completion (HEWs) trained on CBN nutrition-focused nor is it funded by curriculum the NP. (Data source: Routine NP reports, FMOH) Percentage of iodization machines Revised: Revised to allow better monitoring of functioning out of 60 planned Percentage of national salt progress in this area; most of the production iodized in iodized salt in the country is previous year produced and distributed from one region, which allows annual monitoring of iodized salt production. (Data source: Routine NP reports, FMOH) New: Cumulative core indicator, revised to Number and percentage of be more specific about the training health personnel (health content. Health personnel include center to federal level) targeted health workers from health receiving training on CBN centers to federal level (and exclude HEWs). (Data source: Routine NP reports, FMOH) Universal Salt Iodization policy (Data source: Routine NP reports, adopted and put in force, No change FMOH) supporting Proclamation 200/2000 Zinc registered as essential drug (Data source: Routine NP reports, and included in Health Post No change FMOH) package Percentage of nutritional Revised: Revised to make indicator more surveillance sites operating and Percentage of CBN woredas specific and to reflect NP focus on providing periodic data, out of a providing monthly nutrition building capacity to use routine data target of 20 to be achieved by data to federal level from woredas. (Data source: Routine project completion CBN data, FMOH) Percentage of operational research Revised: Revised indicator to make it more studies contracted out of a target of Percentage of NNP specific and results-oriented 10 to be achieved by project operational research studies (Data source: Routine NP reports, completion completed and disseminated EHNRI) (of a target of 10) New: Additional indicator to monitor the Percentage of persons in the institutional strengthening and health sector trained to capacity building component of the masters level in nutrition NP (Data source: Routine NP reports, (of a target of 30) FMOH) Establishment of inter-sectoral (Data source: Routine NP reports, National Nutrition Coordination No change FMOH) Body 7 ANNEX 2: Proposed Results Framework and Monitoring Table 2: Proposed Results Framework and Monitoring ETHIOPIA: ET-ETHIOPIA NUTRITION (FY08) Project Development Objective (PDO): To improve child and maternal care behaviors and increase utilization of key micronutrients to contribute to improving the nutritional status of vulnerable groups. PDO Level Results D=dropped Unit of Baseline Yr1 Yr 2 Yr 3 Yr 4 Frequency of Calculation of indicator Data source Core Indicators C=continue measure 2009 2010 2011 2012 2013 updating N= new indicator R= revised (geographic disaggregation) 1. Percentage of infants 0-5 N R % 51% 56% Baseline/ Not applicable (population- National months exclusively breastfed Endline1 based household surveys) Nutrition 2. Percentage of pregnant N R % 17% 25% (National level Surveys, women receiving iron-folate data) 20092/ 2013, supplementation EHNRI 3. Number of people with Y R Number 0 44 125 Semiannually Number of people in 353 Routine CBN access to a basic package of 0004 (CBN woredas) woredas with active CBN data, FMOH nutrition services (CBN) , % female3 4. Number and percentage of Y R % 90% 90%5 Annually Numerator: Children 6-59 Routine children 6-59 months receiving (10 200 (11 300 (National level months receiving a dose of CHD/EOS a dose of Vitamin A every 6 000) 000) data) Vitamin A in previous six reports7, months months6 FMOH Denominator: Number of total CSA projected children 6-59 months pop. estimates 5. Percentage of children 0-23 N N % 0 40% Semiannually Numerator: Number of Routine CBN months participating in (CBN woredas) children 0-23 months weighed data, FMOH monthly GMP sessions monthly8 Denominator: Number of children 0-23 months in 353 woredas planned to have CBN by project completion. 1 For population-based indicators, 2011 DHS and CBN Evaluation Surveys (2009, 2010, 2011, 2012) will be used for monitoring progress 2 For population-based indicators, 2009 National Nutrition Survey data replaced 2005 DHS data for 2009 baseline values. 3 % female will be based on Central Statistical Agency (CSA) estimates of population percentage that is female. 4 Based on estimate of population in 353 woredas 5 Endline target is to maintain existing high level of Vitamin A coverage 6 There are no baseline/endline population-based household survey data available for this indicator; the indicator will be monitored using routine program data 7 CHD/EOS: Community Health Day/Enhanced Outreach Service 8 There are no baseline/endline population-based household survey data available for this indicator; the indicator will be monitored using routine program data INTERMEDIATE RESULTS INDICATORS Intermediate Results (Component 1: Supporting Service Delivery) Core Intermediate Results D=dropped Unit of Baseline Yr1 Yr 2 Yr 3 Yr 4 Frequency of Calculation of indicator Data source Indicators C=continue measure 2009 2010 2011 2012 2013 updating N= new indicator R= revised (geographic disaggregation) 1. Number and percentage of N R % 0 85% Annually Numerator: Number of HEWs Routine NP HEWs trained on CBN (15 (CBN woredas) trained on CBN curriculum reports, curriculum 000) Denominator: 176509 (estimated FMOH HEWs in 353 woredas planned to have CBN by project completion) 2. Percentage of national salt N R % 0 50% Annually Numerator: Tons of salt iodized Routine NP production iodized in previous (National level in previous year reports, year data) Denominator: Annual national FMOH salt consumption goals 3. Number and percentage of Y N % 0 85% Annually Numerator: Number of health Routine NP health personnel (health center (1200) (CBN woredas) personnel receiving training on reports, to federal level) receiving CBN in 353 CBN woredas FMOH training on CBN Denominator: 141210 (NP target for personnel trained in 353 woredas planned to have CBN by project completion) 4. Universal Salt Iodization N C One time Not yet Achieved One time Not applicable Routine NP policy adapted and put in force, achieved reports, supporting Proclamation FMOH 200/2000 5. Zinc registered as essential N C One time Not yet Achieved One time Not applicable Routine NP drug and included in Health Post achieved reports, package FMOH Intermediate Results (Component 2: Institutional Strengthening and Capacity Building) 6. Percentage of CBN woredas N R % 0 50% Semiannually Numerator: Average number of Routine CBN providing monthly nutrition data (CBN woredas) CBN woredas reporting monthly data, FMOH to federal level nutrition data to federal level in previous six months Denominator:353 woredas planned to have CBN by project completion 9 The target of 17650 HEWs is based on estimated 50 HEW/woreda x 353 woredas planned to have CBN by project completion 10 Target is based on training 4 health personnel/woreda in 353 woredas planned to have CBN by project completion (excludes health extension workers) 9 Core Intermediate Results D=dropped Unit of Baseline Yr1 Yr 2 Yr 3 Yr 4 Frequency of Calculation of indicator Data source Indicators C=continue measure 2009 2010 2011 2012 2013 updating N= new indicator R= revised (geographic disaggregation) 7. Percentage of NNP N R % 0 80% Annually Numerator: Number of Routine NP operational research (OR) (National level completed and disseminated OR reports, studies completed and data) studies EHNRI disseminated (of a target of 10) Denominator: 10 (NP target for OR studies by project completion) 8. Percentage of health N N % 0 80% Annually Numerator: Number of health Routine NP personnel trained to masters (National level personnel trained to masters level reports, level in nutrition (of a target of data) in nutrition FMOH 30) Denominator: 30 (NP target for health personnel trained by project completion) 9. Establishment of inter- N C One time Achieved One time Not applicable Routine NP sectoral National Nutrition reports, Coordination Body (NNCB) FMOH with high-level membership from relevant sectors 10 Table 3: Details of data collection Means of Schedule Responsibility Implementation Geographic disaggregation Data Provided data Yr1 Yr2 Yr 3 Yr 4 Yr 5 Arrangements collection 2009 2010 2011 2012 2013 DHS/Mini X X CSA CSA & USAID National PDO indicators #1,2,4 DHS11 & prevalence of malnutrition National X X EHNRI EHNRI through WB National12 PDO indicators #1,2,4, Nutrition technical assistance & prevalence of Survey malnutrition CBN X X X X X EHNRI EHNRI through CBN woredas in 4 regions PDO indicators Evaluation UNICEF/WB technical (Amhara, Oromia, SNNPR, #1,2,4,5 & prevalence household assistance Tigray) of malnutrition Surveys Routine X X X X X FMOH FMOH through CBN woredas in 4 regions PDO indicators #3, 5 CBN data UNICEF/WB technical (Amhara, Oromia, SNNPR, IR indicator # 6, 13 assistance Tigray) Routine X X X X X FMOH FMOH through RHB and National PDO #4 CHD/EOS UNICEF assistance reports14 Routine X X X X X FMOH/EHNRI FMOH/EHNRI through National level and for CBN IR indicators #1, 2, 3, NP WB and UNICEF woredas in 4 regions 4, 5, 7, 8, 9 Reports15 technical assistance (Amhara, Oromia, SNNPR, Tigray) 11 Will only include subset of DHS modules 12 Efforts will be made to revise sampling framework to allow disaggregation by CBN and non-CBN Woredas 13 Monthly reports from woreda level, summarized quarterly at regional and national levels (Regional Health Bureau and FMOH) 14 Quarterly reports from woreda level, summarized at regional and national levels (Regional Health Bureau and FMOH) 15 Annual reports on NP disbursement and achievements from FMOH and EHNRI 11