PROJECT INFORMATION DOCUMENT (PID)

APPRAISAL STAGE
Report No.: AB3615
Project Name ET-Ethiopia Nutrition (FY08)
Region AFRICA
Sector Health (100%)
Project ID P106228
Borrower(s) FEDERAL DEMOCRATIC REP. OF ETHIOPIA
Ministry of Finance and Economic Development
Ethiopia

Implementing Agency
Environment Category
Date PID Prepared
Date of Appraisal
Authorization
Date of Board Approval
Ministry of Health
Ministry of Health
Addis Ababa
Ethiopia
Tel: 251-011-550 4365
[ ] A [ ] B [X] C [ ] FI [ ] TBD (to be determined)
January 29, 2008
February 25, 2008
April 29, 2008

1. Country and Sector Background

Ethiopia has become inexorably linked with images of severe drought and large-scale starvation
since the famine of the mid-1980s. As the result of national program efforts and a boost in GDP
growth averaging 6.4% annually in recent years, there have been some improvements in the
indicators of malnutrition among children under 5. While wasting remained unchanged at 11%,
stunting among children under 5 years of age declined from 52% in 2000 to about 47% in 2005.
Underweight prevalence in under-5 children reduced from an estimated 45% in 1995 to 38% in
2005, a change of 0.8 percentage point reduction per year.

High population growth rates have contributed to a decline in farm sizes, while environmental
degradation has deepened. Climatic variability is also high. Rainfall data for the period 1967 to
2000 indicates that annual variability in rainfall across different zones in Ethiopia ranged from a
low of 15% to a high of 81% among the highest in the world. The larger the coefficient of
variation in rainfall, the lower is household income and consumption (Poverty Assessment, World
Bank 2005). In addition to the failure of the rains, health risks including both malaria and
HIV/AIDS exacerbate the vulnerability of the poor, driving many thousands of people into
poverty traps. However, Ethiopia needs at least a 1.5 percentage points reduction in underweight
prevalence per year about double the present rate to reach the 2015 target for MDG 1. And,
despite the recent improvements, Ethiopia still has among the highest rates of malnutrition in
Sub-Saharan Africa. Protein-Energy Malnutrition (PEM) is responsible for 137,000 child deaths a
year. Stunting, one of the markers of PEM and largely irreversible after age 2, afflicts 47% of
children under 5. This is very high by developing country as well as regional standards.
Stagnation in wasting rates for urban children, in particular, is also of concern.
The prevalence of malnutrition imposes significant costs on the Ethiopian economy as well as
society. The high mortality due to malnutrition leads to the loss of the economic potential of the
child. Malnourished survivors require additional health care services, increasing the costs of
hospitalization and outpatient care in a country. In addition, there are productivity losses arising
from impaired cognitive development and stunted physical stature. Ethiopia loses hundreds of
millions dollars of productivity every year due to its comparatively high rates of malnutrition. It
is estimated that Ethiopia will lose approximately 144 Billion Birr ($15.8 million) between 2006-
2015 or about 10% of GDP, due to Iron Deficiency Anemia (IA), Iodine Deficiency Disorders
(IDD) and stunting alone.

Micronutrient deficiencies are some of the most prevalent disorders in Ethiopia. IDD, Vitamin A
Deficiency (VAD) and IA afflict a high proportion of the population and cause billions of birr in
lost earnings to the poorest households. VAD, which damages the immune system of a child and
lowers resistance to common infections, leading to about 80,000 deaths a year, affects 61% of
under 5 children. Iodine Deficiency Disorder robs 3.5 million Ethiopian children of as many as 15
IQ points, reduces their ability to learn and concentrate, causes high drop-out rates in primary
schools, and substantially reduces the benefits of Ethiopias large investments in schools and
education. IA has far-reaching effects on labor productivity among adults, and intellectual
development of children, in turn affecting learning ability and schooling success. Anemia affects
54% of children under 5, and 27% of women.

A very large proportion of women do not practice appropriate breastfeeding (BF) and
complementary feeding (CF) behavior. About a third of babies do not receive BF within one hour
of birth and only one in three children age 4-5 months is exclusively breastfed. There are also an
increased number of children, aged 6 to 9 months who are not breastfed at all. The result is that
about 50,000 infant deaths or 18% of all infant death a year are estimated to be caused by poor
BF habits. Much of the inappropriate BF behavior is due to lack of knowledge, rather than
practical or financial constraints in practicing such behaviors. This is supported by the fact that
there is no evidence of a positive relationship between wealth and optimal BF behavior.
Therefore, education and introduction of appropriate BF and CF practices are key to child
survival.

The last point illustrates the critical importance of factors other than economic growth for
reducing malnutrition. Malnutrition indicators in Ethiopia are generally high for higher-income as
well as lower-income households, and for some indicators there is little difference between the
two.

Another key fact to consider when formulating policy against malnutrition is that food insecurity
is only one of the reasons for malnutrition. As demonstrated in recent Economic and Sector Work
done by the World Bank1, food security is only one of the factors affecting nutritional status;
Ethiopias high malnutrition rates are also attributable to a range of other non-food factors,
including appropriate breastfeeding, other feeding and child care practices; hygiene; health status
and health interventions; immunizations; the perceived status of women in society; and adequate
water and sanitation. This points to the importance of addressing malnutrition using a multi-
sectoral approach.

Until recently, the broad inter-sectoral factors contributing to malnutrition had been insufficiently
emphasized, with the focus being on addressing food security as the primary means to address
nutritional insecurity. Traditionally, there has been a food-biased approach towards combating
1
See Malnutrition in Ethiopia: Current Interventions, Successes, Cost-Benefit Analysis, and the Way
Forward. Draft Report, World Bank. December 2007.
malnutrition in Ethiopia. But there has recently been a growing understanding of the
multidimensional and multi-sectoral characteristics of nutrition among policy makers in Ethiopia.

Based on a thorough assessment and analysis of the situation, the National Nutrition Strategy
(NNS) was formulated during 2005/2006. The NNS assessment showed the importance of a
multi-sectoral approach addressing food as well as non-food factors including in particular those
related to health.

In September 2006, the Government adopted its second five-year PASDEP (Plan for Accelerated
and Sustained Development to End Poverty) 2005-2010. The Ethiopia PASDEP explicitly called
for the implementation of the NNS and Action Plan to achieve the MDG for halving poverty and
hunger by 2015.

Although nutrition is recognized in the NNS as being multi-sectoral, overall responsibility for it
has been given to the Federal Ministry of Health. The National Nutrition Program (NNP) was
developed in order to implement the NNS. The Federal Ministry of Health (FMOH) is taking the
lead role in overseeing the NNP and implementing key aspects of it, but other ministries and
sectors are also involved in the process. And the importance and critical need for an inter-sectoral
approach, with committed involvement from all relevant sectors, is stressed in the NNS.

The NNS has been officially approved and launched on February 7, 2008 in a high-profile
ceremony presided over by the Deputy Prime Minister and Minister for Rural Development and
Agriculture H.E. Ato Adissu Legesse, as well as the Minister for Health H.E. Dr. Tedros
Adhanom. Both gave speeches stressing among other things the importance of a multi-sectoral
approach to combating malnutrition in the country. Speeches were also given by State Ministers
of Education and Water Resources, as well as by the head of the Disaster Prevention and
Preparedness Agency. Also present was the State Minister of Finance.

The NNP is a long-term program, with the first phase spanning the five years from July 2008 to
June 2013. The NNP is cross-sectoral; the NNP interventions that are relevant to the health sector
are incorporated in the Health Extension Program, a flagship government program that began in
2003. The program involves the training and placement of salaried Health Extension Workers
(HEWs) to basic curative and preventive health care services and education on various health
topics in every community. The aim is to place two HEWs in each kebele (community), and at the
same time to expand the physical health infrastructure by building one health post in each kebele.
To support the HEWs in their work, community volunteers will be trained and working in the
Kebeles. HEWs are given extensive training in 16 health focus areas as well as personal
development training. By December 2007, 24,600 HEWs had been trained and deployed. It is
planned that all 30,000 HEWs will be trained by 2009.

One key aspect that the NNS stresses on is the need for proper nutrition information/ surveillance
(NIS). In Ethiopia, it is not currently possible to obtain localized information on nutritional
indicators at the kebele or even the Woreda levels, except on a sporadic basis. Reviews of
Ethiopias nutrition situation and programs consistently end in recommendations to establish a
proper and comprehensive NIS. Such a system would be able to track localized nutritional
indicators at a large number of focal points, so that the nutritional status of households in different
localities could be tracked over time, at the woreda and even the kebele levels. A properly
functioning NIS can identify constraints in particular areas, help determine if project objectives
are being met, provide information to improve targeting, assess quantity, quality, and timeliness
of project inputs, and inform decision making at each level of government.
2. Objectives

The Project Development Objective (PDO) is to contribute to improved nutritional status of

under-5 children and pregnant women through: (i) improved child and maternal care behavior;
(ii) increased utilization of key micronutrients and (iii) strengthening institutional capacity.

Progress in terms of achieving the PDO will be measured by tracking: (i) the percentage of
infants aged 0-5 months exclusively breast fed; (ii) the percentage of households with adequately
iodized household salt; (iii) the percentage of pregnant women receiving iron and folate
supplementation; and (iv) establishment of an inter-sectoral National Nutrition Coordination
Body (NNC) with high-level membership from different nutrition-related sectors.

3. Rationale for Bank Involvement

The National Nutrition Program (NNP) represents a partnership between the government and
development partners, and is the main vehicle for implementing the NNS. The NNP harmonizes
various nutrition-focused programs and interventions into an integrated program. The
harmonization and coordination aspects are key, because there are already several programs in the
country some of them quite large affecting nutrition, but these operate largely independently
of each other. The present proposed IDA project would finance critical activities in support of the
NNP, as further described below.

The forthcoming Ethiopia CAS covering the period 2008-2010 will aim to support Ethiopia in
sustaining its emerging dual take-off in economic growth and basic services delivery. The
strategy includes nutrition as a key element of the Banks support on both growth and services,
due to its impact on productivity and health. As such, the proposed project is seen to be a critical
building block of the CAS lending program.

The Banks role in this proposed NNP is key, for a number of reasons:

The Bank can play a key role as a catalyst for the participation of other donors, for the
adherence to a harmonized and integrated approach with the aim of implementing the NNS,
and to ensure the implementation of key policies.

The Bank is best placed to take the lead role in the efforts to strengthen coordination and
linkages among different programs and sectors. This is because of the Banks involvement in
a range of different programs, sectors and multi-donor operations in Ethiopia (e.g. in
agriculture, water, infrastructure, and others; and involving the public as well as private
sector). The Bank currently plays the main leadership and coordination role in other multi-
donor operations like the Productive Safety Nets and Protecting Basic Services operations, as
well as the coming Education Quality Improvement Programme (FY09).

The proposed nutrition project in Ethiopia is consistent with the Africa Action Plan, which
calls for scaling up nutrition actions in at least 8 countries with the worst nutrition indicators.

The proposed nutrition project would be in support of implementation of the National

Nutrition Strategy which is a key action of PASDEP 2005-2010, the governments latest
Poverty Reduction Strategy Paper (PRSP).
 Nutrition interventions have extremely high benefit-cost ratios, as has been demonstrated by
the recently delivered Economic and Sector Work on Ethiopia Malnutrition. 2

The government of Ethiopia has asked the Bank for technical assistance and a contribution in
support of the NNP.

4. Description

The government of Ethiopia is embarking on a National Nutrition Program (NNP), with the
support of donor partners. The first phase of the NNP spans five years (2008-2013). The
proposed IDA Nutrition Project is a self-contained project that would finance critical activities in
support of the NNP. The success of these critical activities is expected to be the foundation for
the development of the rest of the NNP program. The proposed project will consist of two main
components: a Supporting Service Delivery component (Component 1) and an Institutional
Strengthening and Capacity Building component (Component 2) to support the service delivery.
The amounts to be provided to these two components will be $10 million and $20 million
respectively.

The description of activities below applies only to the proposed IDA project. Component
1 of Proposed IDA Project: Supporting Service Delivery ($10 million from IDA)

Component 1 will support two areas: preventative Community-Based Nutrition (CBN) and
Micronutrient Interventions. The focus of the supported preventative Community-Based
Nutrition (CBN) activities will be on Health Extension Workers (HEWs) and supervisors of
HEWs. The government is rolling out a program nationwide whereby there will be 30,000 HEWs
deployed two in every kebele (community) by the end of 2009. The government will soon
introduce a program where by supervisors of HEWs will be deployed at health centers, totaling
3,200 by year 2009.

Providing preventative CBN services is a part of the function of the HEWs, to be supported by
HEW supervisors. The project will strengthen and support this role, especially by supporting
relevant training activities and materials. The focus will be to provide preventative CBN services
through outreach to the community, and using model households identified in the community as
an integral part of the HEP. Preventative CBN will expand geographically in a manner consistent
with HEP expansion.

The preventative Community-Based Nutrition (CBN) activities will aim at: (1) building
community capacity for assessment, analysis, and action specific to preventing child malnutrition
(triple-A approachAssess, Analyze, and Actioninvolving serious sensitization effort at
woreda, kebele and gotte levels, followed by community mapping, community-based action and
participatory assessments of progress); (2) promoting improved caring practices for children and
women to prevent malnutrition; (3) improving referral linkages to relevant child health &
nutrition services and other linkages for addressing non-health causes of child malnutrition; (4)
developing and implementing strong advocacy & communication/mobilization strategy to support
all CBN activities; (5) enhancing capacity for CBN implementation at Regional and Woreda
levels.

2
See Malnutrition in Ethiopia: Current Interventions, Successes, Cost-Benefit Analysis, and the Way
Forward. Draft Report, World Bank. December 2007.
Component 1 will also support selected Micronutrient Interventions, focusing on critical
activities to enhance the appropriate utilization of iodine, iron and zinc. The project will support
the re-approval and enforcement of the law prohibiting sale and distribution of non-iodized salt
by the end of the second year of the project. It will also support the registration of zinc as a drug
by the end of the third year of the project, so that health workers and HEWs can administer it for
therapeutic purposes, especially in conjunction with the use of Oral Rehydration Salt (ORS)
therapy in cases of children having diarrhoea. The project will also support the purchase of key
micronutrients, including iron and folate tablets. The above inputs will be complemented by
appropriate technical assistance.

Component 2 of Proposed IDA Project: Institutional Strengthening ($20 million from IDA)

Component 2 will Strengthen Human Resources and Capacity Building, through various
means. First, it will support intersectoral coordination mechanisms, addressing both policy and
technical aspects, including the establishment of a National Nutrition Coordination Body with
high-level membership from different nutrition-related sectors. The nutrition unit at the Federal
Ministry of Health (FMoH) under the Family Health Department is new and will need capacity
building and expansion to support a multi-sectoral and multi-partner national nutrition program.
Other key agencies that will play a key role in implementing the NNP include the Health
Extension and Education Center (HEEC), the Ethiopian Health and Nutrition Research Institute
(EHNRI) and the Nutrition Units (or equivalents) of the regions to oversee key programmatic
areas. These agencies will also be strengthened, in line with their additional functions. The
strengthening will take the form of human resources strengthening as well as logistics support.
Component 2 also aims at strengthening (through training and capacity building) the capacity of
midlevel managers working on nutrition-related areas (those working at woreda health offices and
regional health bureaus); clinical nutritionists; and higher-level supernutritionists (e.g. those
working at higher level institutions). For strengthening the local research capacity, EHNRI has
been selected as it is the leading institution for undertaking health and nutrition research.

This component will also support Advocacy, Social Mobilization and Program
Communication (ASPC) activities, with the following overall aims: (1) generate ownership of
the countrys nutrition agenda by government and non-government decision makers, stakeholders
and the public at large; (2) identify the highest priority nutrition messages in need of
dissemination and the constraints and resistance points presently limiting changes in practices; (3)
incorporate these messages systematically into various communications channels including
mainstream media, community radio, community conversations 3 and materials of the health
sector and of other sectors; and (4) complement the efforts of HEWs and VCHWs to promote
appropriate caring practices among care providers, communities and service providers through
CBN with behavior change messages in various communications media. Community
conversations will be used to help disseminate appropriate messages.

Finally, this component will support Strengthening Nutrition Information/ Surveillance

(SNI/S), Monitoring and Evaluation (M & E), and Operations Research (OR). This set of
activities will, among other things, provide information for M & E activities regarding the various
NNP interventions, and will also strengthen nutritional surveillance. It will provide information
to support various other programs, and enhance understanding of their impacts on nutrition,
including the HEP, Enhanced Outreach Strategy and Productive Safety Net Programs, as well as
various food security programs and programs affecting disaster/epidemic prevention,
3
At community conversation sessions, community members analyze causes of nutrition problems in the
local context, using localized data (e.g. from child weighing sessions), and discuss how they can take action
at the family and community level by creating supportive environments for child caring.
preparedness and response. It will work by strengthening existing systems including the Health
Management Information System (HMIS), Integrated Disease Surveillance and Response system
(IDSR), Demographic Surveillance Sites (DSS) as well as the functions undertaken by the
Emergency Nutrition Coordination Units which are part of the Early Warning System (EWS).
The various sources of data collected, in particular surveys with national coverage, will be used
for the overall evaluation of the NNP. There will be overall consolidation and analysis of the
various diverse sources of available data, to produce outputs that will be useful for policymakers
and specifically for decisions about program design. In addition, relevant operational research for
the NNP will be supported.

5. Financing
Financing Plan (US$m)
Source Local Foreign Total
BORROWER/RECIPIENT 3.0 0 3.0
International Development Association 21.0 9.0 30.0
(IDA)
Total1: 24.0 9.0 33.0

6. Implementation

Partnership Arrangements

The proposed IDA project will fund cricital activities in support of the National Nutrition
Program (NNP). The NNP will be implemented by the Government of Ethiopia, with support
from various Development Partners (DPs).

Several DPs will use their own mechanisms (including financing and procurement) for
contributing to the NNP, but others may wish to contribute through a Multi-Donor Trust Fund
(MDTF) administered by the World Bank, in which case one or more such MDTFs will be set up.

Institutional and Implementation Arrangements

The National Nutrition Program (NNP) is the vehicle to implement the National Nutrition
Strategy (NNS), and the Federal Ministry of Health (FMOH) has been designated as the lead
implementation agency in this regard. Accordingly, the FMOH will be the lead agency overall in
charge of the NNP, but other agencies in other sectors will also play key implementing roles,
which is critical given the multi-sectoral nature of the problem.

The FMOH will also be the lead implementing agency for the proposed IDA project, which will
fund critical activities within the NNP program. Within FMOH, the main implementing units will
be the Nutrition Unit (under the Family Health Department or FHD), the Health Extension and
Education Center (HEEC), and the Health Management Information System (HMIS) unit, with
FHD (Nutrition Unit) being the main responsible agency with FMOH. Key activities will also be
implemented by the Ethiopian Health and Nutrition Research Institute (EHNRI). Although
EHNRI is nominally under FMOH, it is an autonomous agency that typically handles its own
procurement and financial management (financial reporting etc.), and is thus considered a
separate implementing agency for this project.
FMOH and EHNRI will be supported for purposes of implementation of this project by the
Regional Health Bureaus (RHBs) and the woreda Health Offices (WoHOs), as well as the Federal
ENCU (under the Federal DPPA) and the regional ENCUs (under the regional DPPBs).

The activities of the proposed project can be divided into five (mutually exclusive and
exhaustive) categories as described above, and the implementing agencies for each of these five
categories are listed in the table below:

Implementing Agencies for Proposed IDA Project

Component 1 of Project: Strengthening Serviced Delivery
Activity Category Implementing Agencies
Preventative Community-Based Nutrition (CBN) FMOH (mainly Nutrition Unit under FHD, and
HEEC); RHBs; WoHOs
Micronutrient Interventions FMOH (mainly Nutrition Unit under FHD, and
HEEC); RHBs; WoHOs
Component 2 of Project: Institutional Strengthening
Activity Category Implementing Agencies
Strengthen Human Resources and Capacity FMOH (mainly Nutrition Unit under FHD, and
Building HEEC); EHNRI; RHBs; WoHOs
Advocacy, Social Mobilization and Program FMOH (mainly Nutrition Unit under FHD, and
Communication HEEC); RHBs; WoHOs
Strengthening Nutrition Information/ Surveillance FMOH (mainly Nutrition Unit under FHD, and HMIS
(SNI/S), Monitoring and Evaluation (M & E), and unit); EHNRI; RHBs; WoHOs; Federal ENCU (under
Operations Research (OR) DPPA); Regional ENCUs (under DPPBs)

The proposed IDA project will support the establishment at the national level of (i) a National
Nutrition Coordinating Body (with high-level representation from different key ministries) that
deals with policy issues; and (ii) an intersectoral National Nutrition Technical Committee that
deals with technical issues. At the regional level, similar structures will be in place as for the
Federal level. The existing woreda development committee is proposed to oversee the
coordination and implementation of the NNP at the woreda level. All of these bodies should have
clear Terms of Reference with details including on frequency of meetings, key performance
indicators (outcome and process indicators) as well as progress on policy formulation that should
be monitored on a regular basis.

Monitoring and Evaluation of Outcomes/Results

Monitoring and Evaluation (M&E) activities for the proposed IDA project as well as for the NNP
as a whole are covered by Component 2 of the proposed project. Primary responsibility for M&E
will lie with the Ethiopian Health and Nutrition Research Institute (EHNRI), which is technically
under the FMOH but has an autonomous designation. Among other things, there will be a
baseline, midline and endline survey carried out under the supervision of EHNRI. EHNRI will
oversee the survey and evaluation activities, but will not implement them itself; the activities will
be implemented by an independent body/bodies contracted by EHNRI.

Information from the surveys mentioned above will be supplemented by other data sources
including: (i) Demographic and Health Surveys and Welfare Monitoring Surveys, as well as other
surveys including the micronutrient surveys with nationwide coverage conducted by EHNRI; (ii)
routine data collected as part of the Health Management Information System (HMIS); (iii) data
from demographic surveillance sites managed by universities; (iv) data collected through the
Emergency Nutrition Coordination Units (ENCUs) under the DPPA/DPPBs; and (iv) data
collected through EOS/TSF activities.
These various data sources will provide a rich base with which to conduct M&E activities for the
NNP, and also to provide overall monitoring of key indicators relevant to NNP as well as to other
related programs in different sectors (e.g. those that address mostly food security). The data
collected will enable rich analysis to be carried out, to enhance understanding of the various
factors affecting nutrition, and the impacts of various interventions in different sectors. EHNRI
will be overall in charge of these activities, but it will contract out some of the work to outside
bodies. The capacity of EHNRI to undertake these additional responsibilities will be strengthened
as an integral part of the proposed IDA project.

7. Sustainability

The risk of lack of sustainability is minimal due to the following factors:

A key focus of the project (and the NNP) is on appropriate policy legislation and
establishment of appropriate intersectoral coordination mechanisms. These institutional
changes are not dependent on the continued flow of funding, and yet the impact on outcomes
is expected to be very substantial.

Much of the focus of the project (and the NNP) is on behavior change. This is largely a
question of institutionalization of appropriate knowledge and attitudes (and also
institutionalization of the communication of appropriate knowledge and attitudes), which if
done properly should be self-sustaining,

The project mostly funds health aspects of the NNP, and these are designed as a part of the
flagship Health Extension Program (HEP) managed by FMOH. There is strong government
ownership of this program, and thus there is minimal risk of lack of sustainability due to lack
of funding from the government and/or its development partners. The Strengthening Service
Delivery Component (Component 1) is designed to be harmonized with the ongoing rollout
of the HEP.

Part of the burden of malnutrition in Ethiopia will be reduced through economic growth.
Ethiopia appears now to be on a sustainable growth path, registering real GDP growth rates of
11.6% in EFY98 (FY06) and 11.4% (projected) in EFY99 (FY07) according to IMF reviews,
with a high rate also expected in EFY00 (FY08). (It should be noted, however, that economic
growth alone would not suffice, since a substantial component of malnutrition is independent;
e.g. certain malnutrition indicators are high even among higher-income households in
Ethiopia.)

8. Lessons Learned from Past Operations in the Country/Sector

Good experience in previous projects with micronutrient and behavior change interventions; both
have very high-benefit cost ratios, but particularly the former. Previous nutrition projects have
generally had good experience in improving indicators of access to micronutrients and related
interventions. When well designed, they have also achieved significant success in improving
knowledge and practice of optimal nutrition behavior (e.g. regarding breastfeeding and
complimentary feeding), although there usually remains some gap between knowledge and
practice. Regarding the latter, recent experience in Ethiopia, with the Essential Health Services
project4, has been very good in terms of promoting optimal breastfeeding behavior and

4
This is an NGO project funded by USAID, focused on strengthening health workers skills, and improving
community and household practices.
handwashing (according to midline survey results), and these intervention were determined to
have benefit-cost ratios of 26 and 7 respectively (using project-specific figures) in the recent
Ethiopia malnutrition ESW (World Bank, 2007). This same ESW calculated the benefit-cost
ratios for micronutrient interventions in Ethiopia as even higher, exceeding 50.

Mixed experience with demonstrating change in Protein-Energy Malnutrition (PEM) Indicators.

The experience with improving PEM in nutrition projects, as measured by indicators such as
stunting, wasting and underweight measures, has been more mixed. This is because these
indicators are affected in part by a range of factors (e.g. droughts, health access, water and
sanitation access) outside the control of such projects. PEM indicators should thus be excluded
from the set of Project Outcome and Intermediate Indicators, which are typically used to
determine the success or failure of the project. The Project Outcome and Intermediate Outcome
Indicators should instead focus on measures that are more directly under the control of the
project, such as indicators of access, utilization and behavior change, or measurable indicators of
appropriate policy or process changes. However, it is appropriate and desirable to include PEM
Indicators among the Higher-Level Objective Indicators.

Other lessons learned from previous projects can be summarized as follows:

()i Community-based nutrition and ECD activities should, in particular, target

children below two years of age and pregnant mothers; this is critical since the major damage
caused by malnutrition takes place in the womb and during the first two years of life, and this
damage is mostly irreversible. Early childhood education and cognitive development have
also proved to be key, in enhancing educational outcomes; interventions should begin at the
under-2 stage.

()ii A strong orientation towards management for results strengthens the sense of
ownership and performance of all stakeholders involved in project implementation. A well-
designed nutritional surveillance and monitoring & evaluation framework is critical for
achieving outcomes.

()iii Continuous capacity building at all levels is crucial for the success of
malnutrition reduction efforts.

()iv Development of inter-sectoral coordination and collaboration is very

important for the establishment of a coherent national program.

()v Programmatically, activities need to be sufficiently broad, and to have

sufficient intensity, including adequate ratios of community volunteers to households in the
case of community-based nutrition, and sufficient length and intensity of initial and refresher
training which should be periodic.

9. Safeguard Policies (including public consultation)

Social

The project and the NNP recognize the considerable importance of social and cultural beliefs and
practices that influence maternal and child care, and eventually nutrition and health outcomes.
Particular attention is being and will be paid to these issues in the design and implementation of
the preventative Community-Based Nutrition activities (Component 1) as well as the Advocacy,
Social Mobilization and Program Communication activities (Component 2) of the project, which
deal with behavior change communication (BCC). Culture sensitive information and
communication strategies will be developed and used for these BCC activities. The culture
sensitive information will include beliefs surrounding breastfeeding behavior and its implications
for nutritional outcomes. The adoption of simple implementation strategies will encourage
participation and inclusiveness, and engender ownership and sustainability through behavioral
change. Another area where it will be essential to take into account cultural and social beliefs
will be in the promotion of improved diets, as part of the proposed project.

Environmental

There are no potential negative impacts from this project and therefore the environmental
category is C.

10. List of Factual Technical Documents

1. FMOH, Program Implementation Manual for NNP, Draft Report, January 3, 2008
2. UNICEF, Country Programme Action Plan, 2007-2011
3. World Bank, Economic and Sector Work, Malnutrition in Ethiopia: Current
Interventions, Successes, Cost-Benefit Analysis, and the Way Forward, Draft Report,
December 2007
4. World Bank, Aide-mmoire: Pre-Appraisal mission, October 8-31, 2007
5. World Bank, Project Concept Note September 27, 2007
6. World Bank, Aide-mmoire: Identification mission, May 1-30, 2007
7. FMOH, National Protocol for the Management of Severe Acute Malnutrition, March
2007
8. GOE, Plan for Accelerated and Sustained Development to End Poverty (PASDEP, 2005-
2010), 2006
9. Central Statistical Authority (Ethiopia) & ORC Macro, Ethiopia Demographic and
Health Survey 2005. Addis Ababa, Ethiopia and Calverton, Maryland, U.S.A. 2006
10. Ethiopian PROFILES Team & AED/Linkages, Why Nutrition Matters. PowerPoint
presentation on the Ethiopian PROFILES analysis. Addis Ababa: AED/Linkages 2005
11. World Bank, Well-Being and Poverty in Ethiopia: The Role of Agriculture and Agency,
July 2005
12. Ethiopia Welfare Monitoring System Report 2004
13. Central Statistical Authority. The 1994 Population and Housing Census of Ethiopia,
Addis Ababa, 1998
14. EOS/TSF Technical Working Group, Strategy Paper - Enhanced Outreach
Strategy/Targeted Supplementary Food Programme 2007-10 and Beyond, 2007
15. FMOH, Health Sector Development Plan (HSDP) III 2005/06-2009/10, Draft Report,
2005
16. FMOH, National Strategy for Child Survival in Ethiopia, 2005
17. World Bank, Guidelines: Procurement Under IBRD Loans and IDA Credits, May 2004
(Revised October 2006)
18. World Bank, Guidelines: Selection and Employment of Consultants by World Bank
Borrowers, May 2004 (Revised October 2006)
11. Contact point

Contact: Andrew Sunil Rajkumar

Title: Economist
Tel: (202) 458-1904
Fax:
Email: Arajkumar@worldbank.org

12. For more information contact:

The InfoShop
The World Bank
1818 H Street, NW
Washington, D.C. 20433
Telephone: (202) 458-4500
Fax: (202) 522-1500
Email: pic@worldbank.org
Web: http://www.worldbank.org/infoshop