40816 Findings G In oo fo d br Pr ief ac tic e Africa Region · Number 138 · July 2007 Findings Infobriefs reports on Good Practice in ongoing operational, economic and sector work carried out by the World Bank and its member governments in the Africa Region. It is published monthly by the Knowledge and Learning Center on behalf of the Region. The views expressed in Findings are those of the author/s and should not be attributed to the World Bank Group. Senegal: Nutrition Enhanhement Program (NEP), First Phase This project was the first nutrition project in Sub-Saharan Africa to use the Adaptable Program Lending (APL) instrument for the design of the program. The NEP was designed as a 10-year program ( 2002-2012), consisting of 3 phases : (i) developing strategies and demonstrating results; (ii) scaling up to national level and between sectors; and (iii) consolidation of the achievements. The development objectives of Phase I of the project, with a credit of US$ 14.7 million equivalent, were to (i) extend nutrition and growth promotion intervention into rural areas; (ii) consolidate and sustain the results gained from the earlier Community Nutrition Project (CNP ), whose experience and lessons learned were factored into the APL; and (iii) strengthen the institutional capacity of the National Commission for the Fight against Malnutrition (CLM; Cellule de Lutte contre la Malnutrition), the multi-sectoral coordination commission responsible for the implementation of the national nutritional policy, as well as its partners to develop, implement and monitor multi-sectoral nutrition activities. The 3 project components were (i) Community Nutrition and Growth Promotion; (ii) Capacity Building and Monitoring and Evaluation and (iii) Program Management. Project interventions were conducted in the 3 poorest rural regions of Senegal, and in 34 Health Districts selected on the basis of social indicators. Impact on the ground · Three major policy changes characterized the influence of the NEP. The first referred to a paradigm shift from mitigation by means of food supplementation to prevention and promotion through behavioral change communication. The second emphasized sustainability in a cost-effective manner – costs per targeted child were cut dramatically in order to improve the likelihood of sustaining the activities after project closure. The target annual costs per beneficiary were set at $8 in urban areas and $4 in rural areas. Third, the project outsourced nutrition interventions to multiple implementing agencies - 12 NGOs with strong community affiliations were transparently selected. This enhanced competition as well as greater flexibility with respect to local circumstances, innovation and development and the identification of best practices. · CLM established collaborative relationships with various public health programs in order to build synergy. As a result, the NEP became a major roll-out mechanism of existing programs for infant and young child feeding, Community-IMCI, and mass and routine distribution of Vitamin A supplements. · The integration of growth monitoring and promotion with Community-IMCI was innovative, and paved the way for enhanced collaboration with the Ministry of Health. The “Good Practice Infobrief” series is edited by P.C. Mohan, mail stop J-8-811, Knowledge and Learning Center, World Bank, 1818 H Street NW, Washington D.C., 20433. Tel. (202) 473-4114; e-mail: pmohan@worldbank.org · Data from the 2005 Demographic Health Survey ( DHS ) reveal a drop in malnutrition prevalence to 17.4% from 22.7% in 2000 following a decade of stagnation – 22.2% in 1992 and 22.3% in 1996. · Routine project monitoring of about 200,000 children showed a clear decline in malnutrition rates from 18% in December 2004 to 10% in December 2005 - equivalent to a 44%drop - as well as an increase in weight gain compared to the month before from 84% to 91% over the same 12-month period. · The prevalence of exclusive breastfeeding for the first 6 months rose from 30% to 58% between 2003 and 2005; the proportion of pregnant mothers seeking pre-natal care at least 3 times rose from 52% to 67% over the same period; the proportion of caregivers who recognize at least 2 danger signs in sick children grew from 55% in 2003 to 77%in 2005. · Additional indicators of progress over the 2003-2005 period included the following: the consumption of iodized salt increased from 46% to 59%; Vitamin A supplementation coverage of children aged 6-59 months in the last 6 months went up from 42% to 85%; the proportion of children sleeping under insecticide-treated bed nets rose from 28% to 59%; and the Vitamin A supplementation coverage of mothers within 8 weeks post-partum increased from 27% to 51%. · The capacity of selected NGOs was strengthened through extensive training programs - performance-based contracts contributed to the quality and results focus of the services provided. · The project has enhanced the organizational and institutional capacities of the participating communities, which has contributed in turn to collective decision-making. · The project has contributed to putting child survival, growth and development on the national agenda. This was facilitated by the active participation of the Senegal delegation, led by the Ministry of Planning and Sustainable Development, at the Countdown to 2015; Tracking Progress in Child Survival conference, London, December 2005; and the Prime Minister’s letter, together with that of his counterpart in Madagascar, in the medical journal, The Lancet, calling for all Prime Ministers in Sub-Saharan Africa to take on the fight for child survival. In March 2007, a new National Child Survival strategy was adopted with support from all development partners. · The central role played by the CLM in setting the policy agenda for nutrition in Senegal has made it possible for the institutionalization of direct nutrition action through sectoral reforms on the one hand and community- based development on the other to be addressed in the second phase of the APL. Lessons learned · The “learning by doing” approach, together with the consultative supervision approach, encourages stakeholders to learn skills, develop capacities and come up with innovative approaches. · Behavior change communication can bring about improvements in nutritional conditions, without a reliance on external food assistance. · Dynamic community mobilization processes can significantly enhance public service delivery systems. · Local government involvement increases a sense of ownership and accountability amongst stakeholders. · A strong orientation towards managing for results strengthens the sense of ownership and the performance of all stakeholders. A well-designed M&E system is critical to achieving this outcome. · Increasing awareness regarding malnutrition through strategic communication regarding the magnitude of the problem helps to build interest in and commitment to the fight. · The APL approach helps to move from a project to a program-based approach. Effective partnerships with all key players is critical to a sector-wide approach to nutrition. · The NEP has demonstrated that a combined top-down/bottom-up approach can generate awareness of critical problems, put them on the radar screen at both community and central levels and thereby expand the scope for development. This Infobrief was excerpted from Implementation Completion Report no. 0000107. For more information, e-mail Menno Mulder-Sibanda : mmuldersibanda@worldbank.org Persons accessing the Bank’s external and internal website can get more information on Health, Nutrition and Population by clicking on Topics.