Evaluation of the Bringing Nutrition to Scale Project in , and

Regions (2013–2017)

Evaluation Report

23 April 2018

Prepared by

Stephen Turner (Team Leader) Bjorn Ljungqvist Joyce Kinabo Jim Grabham

Proposal contacts: Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe

ACKNOWLEDGEMENTS AND DISCLAIMER

The evaluation team are grateful to the nutrition colleagues at the UNICEF Country Office in and the Sub-office in Mbeya for all their support in providing information and facilitating meetings throughout this assignment. Quality support for the evaluation has been provided by the QS team assigned to the evaluation: Stephen Anderson (Food Economy Group) and Stephen Lister (Mokoro Ltd). The authors take full responsibility for the contents of this report. The designations employed, maps and the presentation of the material in this document do not imply the expression of any opinion whatsoever on the part of UNICEF concerning the legal status of any country, territory, city or area, or of its authorities, or concerning the delineation of its frontiers or boundaries.

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe

Contents Summary v 1. Introduction ______1 1.1. Evaluation purpose and scope ______1 1.2. Country context ______1 1.3. Nutrition in and the project area ______2 2. The BNTS and ASRP projects ______5 2.1. Project description ______5 2.2. Key stakeholders and linkages ______8 2.3. Summary of reported performance ______10 3. Approach and methods ______11 3.1. Evaluation approach ______11 3.2. Evaluation methods ______11 3.3. Evaluation activities ______12 4. Findings ______12 4.1. Relevance ______12 4.2. Effectiveness ______16 4.3. Efficiency ______30 4.4. Sustainability ______33 4.5. Equity ______41 4.6. Gender ______41 5. Conclusions ______43 5.1. Relevance ______43 5.2. Effectiveness ______43 5.3. Efficiency ______47 5.4. Sustainability ______48 5.5. Equity ______48 5.6. Gender ______49 6. Recommendations ______50 Annex A. Terms of Reference ______54 Annex B. BNTS and ASRP design diagrams ______62 Annex C. Evaluation matrix ______64 Annex D. Research instruments ______79 Annex E. Stakeholder analysis ______86 Annex F. Nutrition sector data ______89 Annex G. Project performance data ______102 Annex H. Maps______116 Annex I. Evaluation mission schedule______121 Annex J. Persons and ‘counselling groups’ met ______123 Annex K. Bibliography ______127 Abbreviations ______134

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Tables Table 1 BNTS and ASRP key results, outcomes and outputs...... 6 Table 2 Project Regions and their districts...... 9 Table 3 Other nutrition stakeholders in MINS ...... 34 Table 4 Recommendations ...... 50 Table 5 Stakeholder analysis ...... 86 Table 6 Nutrition scorecard: : Q3, 2017 ...... 89 Table 7 Nutrition scorecard: : Q2, 2017...... 90 Table 8 BNA IYCF determinants, indicators and calculation methods ...... 92 Table 9 BNA: IYCF: data by Region...... 93 Table 10 BNA: SAM treatment determinants, indicators and calculation methods ...... 94 Table 11 BNA: SAM treatment of children: data by Region ...... 95 Table 12 BNA: VAS determinants, indicators and calculation methods ...... 96 Table 13 BNA: VAS: data by Region...... 97 Table 14 BNA: IFAS determinants, indicators and calculation methods ...... 98 Table 15 BNA: IFAS: data by Region ...... 99 Table 16 BNTS results matrix, fourth annual report: May 2017 ...... 102 Table 17 BNTS results matrix, quarterly update 6: November 2017 ...... 110 Table 18 Evaluation mission schedule ...... 121 Table 19 List of officials met for interviews or group meetings ...... 123 Table 20 Meetings with ‘counselling groups’ ...... 126

Figures Figure 1. Tanzania scorecard: SUN MEAL assessment ...... 3 Figure 2. BNTS impact pathways ...... 62 Figure 3. ASRP logic model ...... 63 Figure 4. Example of stunting data recorded at a Village Health Day ...... 100 Figure 5. Example of stunting data recorded at a Village Health Day ...... 101

Maps

Map 1. Regional Map of Tanzania 116 Map 2. 117 Map 3. Mbeya Region 118 Map 4. 119 Map 5. Songwe Region 120

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe

Summary

Introduction

1. UNICEF has commissioned an evaluation of the Bringing Nutrition to Scale in Iringa, Mbeya and Njombe Regions (BNTS) project, covering the period from its launch in 2013 to the time of the evaluation mission in November 2017. The project is funded by Irish Aid (IA). The BNTS project has, for operational purposes, been merged with the Accelerated Stunting Reduction Project (ASRP), funded by the United Kingdom Department for International Development (DFID) through the Addressing Stunting in Tanzania Early (ASTUTE) project.

2. This exercise has served as a mid-term evaluation of the ASRP, which recently completed its second year of operations. Following approval of a matrix of 16 evaluation questions submitted in an inception report, it has reviewed progress across all four Regions in which ASRP is being implemented: Mbeya, Iringa, Njombe and Songwe (MINS). In answering the 16 questions, the evaluation is intended to be formative, with a view to generating evidence and lessons to strengthen programme design and accelerate the achievement of results. It reports on the ASRP as a whole, with specific reference to the BNTS where appropriate. It is based on detailed assessment of available documentation and a two-week evaluation mission in November 2017, which included visits to communities and Local Government Authorities (LGAs).

3. The ASRP has a broad scope of ambition ranging from national policy and systems to support at household level. It has made equally broad contributions, which are mainstreamed in overall national efforts to combat stunting – and has the potential, subject to available resources, for further creative support across the spectrum of those national efforts. The evaluation therefore offers equally broad observations on the progress that those national efforts are making, although its focus is on the performance of the ASRP, and its recommendations specifically concern the project itself.

4. Levels of malnutrition have declined significantly in Tanzania since the 1960s, but not far enough. In MINS, some child nutrition indicators remain poor, despite the progress in commercial agriculture that is being achieved in some areas. Stunting is a particular concern, with MINS among the Regions that are furthest above the national average. Tanzania’s National Multisectoral Nutrition Action Plan (NMNAP) has continued the emphasis of the Government of Tanzania (GOT) on enhancing the nutrition of young children and their mothers, aiming at rapid scaling up and a strong impact on reducing the high burden of stunting and acute malnutrition in children under five and the high levels of anaemia in women of reproductive age. The BNTS, and the ASRP, were intended to contribute to this accelerated effort to enhance nutrition in MINS.

The project 5. The BNTS had a difficult start. It was launched in 2013, but the selected implementing partner (IP) withdrew from Tanzania in 2015. By then, UNICEF had negotiated funding for

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe the ASRP with DFID. A new start was made in late 2015, with three international IPs, each working with a national partner organisation. The BNTS planned four key results (KRs); the ASRP has two. Both projects focus on social and behaviour change communication (SBCC), in order to achieve better practice of key nutrition-relevant behaviours. Both also support a range of policy, planning and capacity development efforts at national, Regional and LGA levels. A small agriculture component that was included in the BNTS continues in the six districts on which that project originally focused ‘intensive’ support, aiming to promote availability of and access to diverse, micronutrient-rich foods at household level. DFID did not fund this through the ASRP, being concerned that it could increase women’s already heavy work load. The BNTS also has an evidence and learning component, which funded five baseline studies in 2014.

6. The project’s target beneficiaries are children aged under five; their mothers and caregivers; and pregnant women. Its nutrition strategy is focused on the first 1,000 days of life from conception, in line with Tanzania’s commitments as a member of the Scaling Up Nutrition (SUN) movement. Target coverage in MINS is 75% of communities.

7. The project benefits from having three local IPs in partnership with the three international ones. UNICEF works with and through the GOT on all components of the project, emphasising that all activities are either the direct responsibility of the relevant authorities or are performed under the co-ordinating authority of government officers and structures, such as District Executive Directors (DEDs) and Council Multisectoral Steering Committees on Nutrition (CMSCNs).

Findings and conclusions Relevance 8. The ASRP’s alignment with international thinking on nutrition priorities is strong. Originally well aligned with the National Nutrition Strategy (2011 – 2016), the project has been directly contributing to, and engaged with, the development of national nutrition policy, institutions, systems, procedures and plans, especially the NMNAP 2016-21, which replaced the National Nutrition Strategy. Its relevance has thus been high. The ASRP is well aligned with, and has made a major contribution to, national policies and priorities on nutrition. But this is still work in progress.

9. The project responds to the needs of end beneficiaries and local communities in having identified target areas in Tanzania where stunting is generally worse than the national average, and in having focused on SBCC approaches. Its agriculture component is relevant in principle, although currently only reaching very small numbers of beneficiaries.

Effectiveness 10. Planning, budgeting, co-ordination and monitoring by Regional and local government authorities. The policy and institutional environment is currently favourable for combating stunting in Tanzania. The ASRP has helped to achieve this. With its assistance, the NMNAP was developed and launched, and Regional and Council Multisectoral Steering Committees on Nutrition were established. These have now been meeting regularly

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe for some time. Awareness, debate, capacity and commitment have been developed with strong support from this project.

11. These are important achievements, and it was appropriate to begin by helping to build policy and institutional frameworks at national level. More remains to be done to give these achievements full substance and effect. The preparation of multisectoral plans for nutrition at LGA level required policy and programming guidance, and planning and budgeting tools. These are now in place, making it possible to plan and budget on the basis of factual evidence about performance and bottlenecks, and to capitalise on the stronger government commitment to fund nutrition – which the project helped to stimulate. Intensified project support will be required over the remaining project period to optimise LGA planning, budgeting and management of nutrition services and nutrition-specific interventions on this basis. Council Multisectoral Nutrition Steering Committees (CMSCNs) need further support in building strong leadership, participation, decision-making and co-ordination so that they can drive effective multisectoral efforts to combat stunting and address other nutrition issues.

12. Effective nutrition action means a genuinely multisectoral combination of nutrition- specific and nutrition-sensitive actions. Despite the progress made with ASRP support, this combination is not yet strong enough in practice. The dominant perspective is still of nutrition as primarily a health concern.

13. The project has made significant progress in helping to build strong foundations for enhanced monitoring of nutrition. Now that the systems and procedures are ready, continuing to support LGAs in effectively adopting and using them to achieve well-designed plans and effective implementation mechanisms will be a major and central task for the remainder of the ASRP.

14. ASRP SBCC, as developed so far, is a significant achievement. The SBCC strategy focuses on changing individual behaviours and social norms, addressing a large number of practices with a proven impact on stunting reduction (nutrition, health, water, sanitation and hygiene (WASH) and early childhood development (ECD) practices). With the competence and confidence that the IPs and their LGA partners have now built, there is a growing consensus that the project should, if possible, extend its coverage from 75% to 100% of communities in the four Regions – although this would certainly require more resourcing.

15. Not surprisingly, implementation of the project in the field reflects the usual interim stage of focus on outputs – numbers of groups formed, individuals trained, participants enrolled in ‘counselling groups’ (CGs) etc. There have been substantial achievements in this regard, at scale, in difficult operating conditions. Groups that the evaluation team met in the field showed impressive levels of knowledge, understanding and commitment about the SBCC messages that have been conveyed to them. Now is the time to check whether the outputs will in fact lead to the planned outcomes. A combination of SBCC approaches is used, including CGs and social mobilisation. However, it was observed that the CGs are more about training caregivers than dialogue among peers and facilitators. The continuity of the process will depend on whether current mothers will undergo the same CG experience during and after further pregnancies, and whether future mothers, now in school, will

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe receive similar support. Other questions about continuity concern the ongoing availability, commitment and competence of the vitally important cadre of Community Health Workers (CHWs), who may be partly or wholly replaced by the new cadre of salaried CHWs that the GOT is currently training but has not yet resourced. Despite the project’s awareness of the importance of engaging men in SBCC, and efforts to promote male involvement, their participation so far is low.

16. Nutrition services provided through the health sector. The ASRP has worked to increase the proportion of health facilities implementing integrated management of acute malnutrition (IMAM). The MINS Regions are performing relatively well on a variety of indicators regarding the treatment of children with severe acute malnutrition. Despite this progress and its achievements in SBCC training for health facility staff, the ASRP’s efforts to combat stunting are inevitably constrained by the limits on nutrition services at these facilities. Lack of staff and budget mean that the package of nutrition support to Tanzanian children and their parents is still incomplete. At the same time, although the project’s IPs do work in close consultation with LGAs and maintain liaison with ward and village government structures, some officials at the community level are insufficiently engaged in this all- important effort to bring nutrition to scale.

17. Agriculture. This component has made modest progress, and achieved useful benefits, on a very small scale. In this component, SBCC on consumption of nutritious food is not adequately articulated in the implementation of the activities. Messages in the project’s main SBCC component about consumption of appropriate foods are not sufficiently delivered to participants in the agriculture component. The project is focusing on increasing production and availability rather than on increasing appropriate consumption. The importance of consuming vegetables or diversifying the diet is not emphasised in agriculture component extension messages.

18. In the context of the ASRP, an intervention this small (its scale was agreed with the donor) has to be justified on the basis of consensus about the need for such interventions, and greater clarity about how what might be called pilot work will be scaled up. Discussions with beneficiaries and with IPs show that home gardening can be developed in ways that women find acceptable within their daily work schedules. Water is sometimes scarce, but grey water use and other techniques can overcome that obstacle. Homestead garden production and dietary behaviour change are necessary and feasible as part of efforts to combat stunting. Something like the current agriculture component is needed, and it is needed on a larger scale.

19. However, the best way to scale up these efforts to enhance the availability and consumption of appropriate food is not to make the current agriculture component bigger. The best way to do it is to confront the broader challenge facing this project: existing capacity in the GOT at ward and village levels is not being fully used. The next challenge for policy- and decision-makers is to build the programmatic and budgetary arrangements (through CMSCNs) for LGA agriculture staff to start taking over nutrition-sensitive food production and availability interventions as piloted by the BNTS, without further donor funding. This will need to be integrated with arrangements to continue SBCC and nutrition-

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe specific activities with domestic resources. Expanding Tanzania Social Action Fund (TASAF) systems and programmes can help deliver support to registered beneficiaries of such nutrition interventions.

20. Evidence and learning. Among the most significant results of the first two years of BNTS were the five baseline studies, which were valuable. BNTS also contributed to the important National Nutrition Survey, carried out for the first time in 2014, which generated evidence that was helped to identify priority Regions for nutrition interventions such as ASTUTE. While some of the original emphasis on further research studies faded during the period under review, the project made important contributions to the GOT’s development of new systems for management information, evidence generation and learning, which are now coming on stream. The bottleneck analysis and scorecard processes promise to give performance and trends in the nutrition sector a higher profile and a much better empirical basis in government decision-making. Additional research into the changing patterns and causes of malnutrition in MINS remains necessary. But initial results from bottleneck analysis and the scorecard system show that the MINS Regions are performing better on various nutrition indicators.

21. To succeed, the new nutrition management information system (NMIS) must be competently operated by LGAs – building on the ASRP’s important contributions in introducing a nationwide bottleneck analysis system, as well as the multisectoral nutrition ‘scorecard’ system. This will require considerable, sustained technical support. The current presence of the ASRP and its IPs offers an opportunity to develop the required capacity, systems and procedures in the President’s Office – Regional Administration and Local Government (PO-RALG) and among CHWs, health facilities and LGAs in MINS – a substantial task that will need more funds than the ASRP and ASTUTE are likely to have available. This is a challenge for all Tanzania’s partners in the nutrition sector.

22. It is important for a project dedicated to combating stunting to promote the collection of data about young children’s length and height. UNICEF has supported adoption of the World Health Organisation growth standard in Tanzania. The ‘Village Health Days’ undertaken in some parts of the project area have included a welcome introduction of length and height measurement at community level. Length boards and related training are gradually being spread across MINS health facilities. Early and consistent implementation of these measurements, fed into the NMIS, would be an important step forward.

Efficiency 23. Due to the withdrawal of the first IP and the need for design changes, the BNTS had an inefficient start, with relatively little accomplished in the first two years. While the result of its reconfiguration was a more relevant project with more sharply focused strategies, it should have been possible to design it that way from the outset.

24. The evaluation has been unable to undertake detailed analysis of the efficiency of project operations. The organisational complexity of the project, across multiple levels of government through three sets of IPs, might be thought to reduce its cost efficiency. But it is more accurate to see these arrangements as an investment in designing appropriate

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe strategies that can be implemented more widely in future, and building the local capacity to do this. Furthermore, administrative arrangements with the IPs limit the project’s total overhead costs.

25. The ASRP constitutes one component of a broader GOT initiative, in which the development partners and other stakeholders made a committed effort to respond to the call for support to rapidly scale up stunting prevention measures. With the establishment of a High-Level Steering Committee on Nutrition (HLSCN), (chaired by the Prime Minister’s Office), and gradually increasing national capacity to assess and evaluate the effectiveness of the different stunting reduction initiatives, there are good expectations that the different initiatives will all contribute to finding optimal solutions to the factors causing stunting.

Sustainability 26. The project has helped to put the required nutrition governance structures in place (notably Regional and Council Multisectoral Steering Committees on Nutrition). But these bodies do not yet function in the way they will need to if intensive action against stunting is to continue beyond the project period. Supporting the necessary development of understanding, attitudes, leadership and procedures in these bodies will be one of the most critical tasks for the project during its remaining life.

27. Many questions remain to be answered about the continuation of health-based nutrition-specific interventions. Some are simple issues of management and resourcing: ensuring that GOT health facilities have the capacity and the supplies to carry out the required support, monitoring and therapeutic functions. Others are still issues of institutional strategy: the future funding and management of the CHW cadre, for example, and what institutional restructuring will be done to recognise that nutrition is a national, multisectoral priority rather than a subordinate function of the health services. It will be essential for the project to maintain intensive, proactive consultation with the GOT on these questions.

28. Maintenance of the required multisectoral, nutrition-sensitive actions will depend in part on the institutional restructuring just mentioned. For a strong and long-term contribution to these actions in the agriculture sector, it is vital for agricultural and other field staff to be more thoroughly engaged in promoting the production and consumption of nutritious foodstuffs at community and household levels. Stronger efforts are needed to link water and sanitation efforts into nutrition-sensitive programming.

29. Overall, the sustainability of the project’s likely achievements is not yet assured. That is natural, at this interim stage. But it is vital now for all concerned to lift their attention from the detailed work of achieving outputs to consider also the mid- and longer-term challenges of achieving and sustaining the intended outcomes. The scale of the institutional and resourcing challenges is such that attaining sustainability by the end of the currently funded project period is unlikely. A longer period of funding is appropriate.

Equity 30. Given that the poorest and most marginalised households are likely to be the worst nourished, and that these households’ children are the most vulnerable to stunting, the

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe

ASRP has taken useful steps towards better targeting, by building operational links with the Tanzania Social Action Fund (TASAF) and its growing (but still incomplete) social safety net register and systems. But better-off households in MINS – both rural and urban – are not necessarily better nourished or less vulnerable to stunting. The ASRP, particularly as it contributes to the sustainability of appropriate nutrition services for the whole Tanzanian population, advocates appropriate dietary standards for all families who have, or will have, children in the target age range. Gender 31. Stunting and other nutritional challenges will not be sustainably overcome until men have an adequate understanding and strong commitment to play their necessary roles in ensuring proper nutrition for pregnant women and young children. The ASRP is increasing its efforts to promote this understanding and commitment among current and future fathers. SBCC approaches and school curricula need to be reinforced accordingly. Just as the challenge of stunting cannot be overcome if the response is limited to nutrition-specific responses by health agencies, it cannot be overcome if nutrition interventions give insufficient attention to men.

32. It is possible to address the well-meant misgivings in some quarters about the potential increase in women’s workloads that the promotion of increased vegetable production might cause. Such increases can be achieved by appropriate siting, scale and water supply arrangements for homestead gardens. More significantly, the project’s current SBCC approaches are not doing enough for the social empowerment of women. For this purpose, more could be done to use the ‘influencers’ with whom the project works in each community. The ‘counselling group’ concept also has important potential in this regard, but so far that potential has not been exploited enough. Women’s empowerment also depends on changes in men’s attitudes and behaviour.

Recommendations 33. These recommendations focus on what it should be possible for UNICEF and the IPs to achieve through the ASRP’s support to national policy processes and its direct implementation in MINS, rather than on potentially broader efforts by the GOT or the nutrition sector as a whole.

No. Recommendation Responsibility Time frame Project structure and budget 1 UNICEF should seek funding to extend the UNICEF, funding 2018 coverage of the ASRP’s SBCC and evidence agencies, IPs and learning components to 100% of villages in MINS and 75% of the target group within them, strengthening the working links with TASAF for the identification and monitoring of beneficiaries. At the same time, the project should clarify how long it sustains the current mode of operations, through the IPs, in any community. Now is the time to start planning withdrawal from communities where the

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe

No. Recommendation Responsibility Time frame project has worked the longest, on the basis that the enhanced nutrition advocacy and services that the ASRP has introduced will be continued by established structures and services (recommendation 4 below). 2 For all the purposes outlined by the UNICEF, funding 2018 recommendations of this evaluation, UNICEF agencies, GOT and the GOT should negotiate with funding partners to ensure a further five-year funding schedule for the ASRP in MINS, with commitment to, and a strategy for, full handover to ongoing GOT implementation in these Regions from 2022. Increasingly, the ASRP’s emphasis, at all levels and within all key result areas, should be on continuity in nutrition services to ensure that stunting is permanently overcome. SBCC component 3 The ASRP should strengthen the character UNICEF, IPs, GOT 2018-2019 and content of its ‘counselling groups’ so that they fully perform the intended longer-term roles within the community of counselling and peer support, in addition to simple training, and that – under the auspices of village governments – they become permanent local institutions through which successive cohorts of parents pass, facilitated by a permanent CHW cadre. 4 The ASRP should adjust its SBCC approach to UNICEF, IPs, GOT 2018-2019 stimulate the participation of men and to promote men’s engagement in appropriate nutritional practices within their households. The innovative approach with selected ‘influencers’ could be more effectively used for this purpose. It will also involve the adoption of additional outreach and publicity strategies, for example through sports that attract men and boys. 5 As part of its SBCC strategy, the ASRP should UNICEF, IPs, GOT 2018 strengthen its support for child care and development through the period from birth, through entry into primary school, to the age of eight years. It should promote and support training for CHWs and health facility staff on ECD. Agriculture component 6 The BNTS agriculture component should be UNICEF, funding 2018 reformulated, and its budget revised, so that agencies, IPs while its current level of pilot field activities is continued and refined (on a more participatory basis that encourages beneficiaries to engage in identifying

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No. Recommendation Responsibility Time frame appropriate crops, livestock and production methods), its emphasis is on identifying lessons from these pilots (linked to KR 4) and on developing a package of nutrition- sensitive support activities that can be carried out by LGA agricultural staff at scale in MINS from 2022, in association with TASAF and broader livelihood development initiatives.

7 Adjustments to the agriculture component UNICEF, IPs 2018 should include the use of more locally-specific seed/crop selections, increased emphasis on the use of grey water in homestead gardens, and exploration of additional water capture techniques that can be used in residential areas. Effectiveness, sustainability 8 While maintaining their efforts to achieve UNICEF, IPs 2018-2022 planned project outputs, UNICEF and the IPs should strengthen their focus on achievement of the planned outcomes and on the sustained operation of the required multisectoral programme of nutrition-specific and nutrition-sensitive actions by the GOT, its social partners and parents after project termination, so that nutrition indicators continue to improve in MINS. Multisectoral nutrition governance 9 The project and its IPs should intensify their GOT, stimulated 2018-2022 emphasis, at all levels, on the multisectoral by UNICEF character of the effort to combat stunting – which means combating the perception that nutrition is only a health issue and only a responsibility for the health services. This also means combating the perception that the ASRP is only a nutrition-specific project. 10 UNICEF and the ASRP should advocate GOT, stimulated 2018-2022 changes to supervision and reporting by UNICEF arrangements so that District and Regional Nutrition Officers report directly to the DED and the RAS respectively. This is a challenging proposition, given that these staff currently fall under the MOHCDGEC. But they would be more effective in a direct reporting line to the RAS or DED within the team responsible for co-ordination of plans and budgets across sectors – ultimately serving in a position like ‘Nutrition Planning Officer’. 11 The recommended multisectoral emphasis GOT, stimulated 2018-2022 means that the ASRP should intensify efforts by UNICEF to strengthen leadership, participation and action in Council Multisectoral Steering

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe

No. Recommendation Responsibility Time frame Committees on Nutrition, so that these bodies have the capacity and commitment to combat stunting and other nutrition problems across all relevant sectors, with functional linkages to the overall development planning and management process. It should also strengthen operational linkages with TASAF registration, targeting and monitoring systems so that multisectoral support for appropriate nutrition becomes an integral part of Tanzania’s social protection framework. Multisectoral nutrition programmes and budgets 12 Through its links with PO-RALG, the ASRP GOT, stimulated 2018-2022 should negotiate increased GOT recurrent by UNICEF funding for nutrition-sensitive support activities in the agriculture sector. 13 In addition to this greater use of LGA GOT, stimulated 2018-2022 agriculture personnel, the ASRP should by UNICEF maximise its consultation, engagement and joint action with other development- orientated staff in ward and village governments – again working at all levels to promote multisectoral combinations of nutrition-specific and nutrition-sensitive interventions, including stronger engagement with the WASH sector and with TASAF. 14 The ASRP should work proactively to support GOT, stimulated 2018-2022 the absorption of the new, formally trained by UNICEF cadre of CHWs into field service in support of ASRP and longer-term efforts to combat stunting. As part of this effort, the project should work with the MOHCDGEC to confirm the proportion of the CHW cadre’s time that will be devoted to nutrition; how CHWs will be supervised for this purpose after project termination; and how current and future CHWs will be provided with refresher training on nutrition. 15 The ASRP should work with the MOHCDGEC GOT, stimulated 2018-2019 to expedite the rapid roll out of routine by UNICEF length/height measurement and reporting at and by all health facilities. 16 The ASRP should expand the Village Health UNICEF, IPs, GOT 2018-2019 and Nutrition Day concept throughout MINS, and link it to enhanced technology for data capture and reporting. 17 The ASRP should advocate the adequate and GOT, stimulated 2018-2019 consistent MOHCDGEC funding and supply of by UNICEF nutrition supplements and materials at health facilities.

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No. Recommendation Responsibility Time frame 18 The ASRP should work with selected schools UNICEF, IPs, GOT 2018-2019 to pilot education modules on the importance of the first 1,000 days in human development.

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1. Introduction

1.1. Evaluation purpose and scope 1. The Tanzania Country Office (CO) of UNICEF has commissioned an evaluation of the Bringing Nutrition to Scale in Iringa, Mbeya and Njombe Regions (BNTS) project, covering the period from its launch in 2013 to the time of the evaluation mission in November 2017. The project is funded by Irish Aid (IA). 2. The terms of reference (TOR) for the evaluation are shown at Annex A. They state that the evaluation is intended to be formative, with a view to generating evidence and lessons to strengthen programme design and accelerate the achievement of results. Its three main objectives are: • to assess the progress of the first phase of the BNTS project; • to assess the project design with a view to identifying ways of strengthening design for acceleration of results; • to identify lessons learned and formulate recommendations for improvement during the second phase of the project1. 3. As explained further in section 2.1 below, the BNTS project has, for operational purposes, been merged with the Accelerated Stunting Reduction Project (ASRP), funded by the United Kingdom Department for International Development (DFID) as part of its Addressing Stunting in Tanzania Early (ASTUTE) project. This exercise has effectively served as a mid-term evaluation of the ASRP, which recently completed its second year of operations. It has reviewed progress across all four Regions in which ASRP is being implemented, including Songwe, where there are no IA-funded activities2. Except where the context requires otherwise, this report refers to the ASRP, and not to the BNTS as originally conceived. As it is technically an evaluation of the BNTS, however, its references to project Key Results (KRs – see section 2.1) concern the four KRs originally defined for the BNTS.

1.2. Country context 4. The inception report submitted earlier in the evaluation process (Mokoro, 2017) included an outline of key aspects of the Tanzanian national context that are pertinent to the implementation of nutrition programmes. It is not necessary to repeat that well-known context here, beyond highlighting some significant points. 5. The national economy has been growing fast. There has been a slight decline in poverty levels, aided by social safety net measures delivered by the Tanzania Social Action Fund. There are significant opportunities in some parts of the country, including the south west where the ASRP is implemented, for people to move beyond subsistence into higher levels of income generation. But the increasing monetisation and commercialisation of livelihoods are not necessarily accompanied by a comprehensive reduction of poverty. Time poverty may become a significant constraint, especially for women, as adults spend more of each day on income generation and less on other livelihood activities, potentially including the provision of adequate nutrition and other care for their children. This is arguably one explanation why, in comparatively prosperous areas of commercial agriculture like those of south-west Tanzania, some nutritional indicators – including stunting – remain poor.

1 The TOR refer to a first phase of three years’ funding from IA. 2 Songwe was created in 2016 from what was formerly the western part of Mbeya Region.

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe

6. Tanzania continues to benefit from a solid and well-understood architecture of government institutions, from the Offices of the President and the Prime Minister through the line ministries to the local government authorities (LGAs) at Regional, district, ward, village and hamlet levels. These institutions are capable of effecting change at many levels: through directives from the centre, and also through local bylaws. However, despite recent efforts to galvanise government services and make them more responsive to the needs of the people, their potential contribution is not yet fully realised. At the local levels where a nutrition programme must be implemented, there is more that LGA personnel could do, particularly in nutrition-sensitive work. Their currently limited work in these fields may be linked to the lack of recurrent resources, notably for transport and salaries. Major questions about sustainable operations therefore arise whenever an externally funded field project plans to exit, particularly in light of the current commitment of the Government of Tanzania (GOT) to reduce dependence on donor funding.

1.3. Nutrition in Tanzania and the project area 7. Tanzania’s National Multisectoral Nutrition Action Plan (NMNAP) for 2016-2021 describes the levels of malnutrition in the country as “unacceptably high” (GOT, 2016b: ii). Although Tanzania has made some good progress in addressing the problem of undernutrition in children, the pace of improvement, especially for the alleviation of stunting, has been slow, with data showing that the prevalence of stunting reduced from about 50 percent in 1992 to about 34 percent in 2015/16. This current level of stunting is categorized as “high” in terms of its public health significance and is higher than the 30 percent average observed for Africa. Moreover, a double burden of malnutrition has emerged where undernutrition exists together with a rapidly increasing problem of diet-related non- communicable diseases, especially overweight, obesity, hypertension and type-2 diabetes that have doubled in adults over the last decade. (GOT, 2016b: iii). 8. The NMNAP thus argues that levels of malnutrition have declined significantly in Tanzania since the 1960s, but not far enough. Furthermore, due to national population growth, the absolute numbers of children in various categories of malnutrition have either risen or declined only slightly. Some 600,000 children aged under five were estimated to be acutely malnourished in 2015, with 100,000 of those categorised as severely malnourished. The number of stunted children rose from below 2m in 2000 to about 3m in 2010, before decreasing to 2.7m in 2015 (GOT, 2016b: 19). 9. At the international level, it is useful to review Tanzania’s ‘scorecard’ as recently assessed by the SUN working group on Monitoring, Evaluation, Accountability and Learning (MEAL: SUN, 2017b). The MEAL framework is derived from recent international agreement on key progress indicators for ‘successful’ SUN progress. The first global report on individual country performances on these key indicators has just been completed and published. 10. According to the SUN MEAL analysis, the Tanzania scaling-up nutrition process is evidently doing comparatively well, with progress in all key areas being ahead of the global median for SUN countries. The only two areas where progress lags behind the median concern finance and ‘SDG3 nutrition drivers’. Budget allocations at LGA level in Mbeya, Iringa, Njombe and Songwe are currently still preliminary and not always fulfilled. But substantial efforts have been initiated to establish proper action-plan based budgets in all key sectors and to ensure minimum budget allocations, starting with health-based interventions in the coming financial year. The ‘SDG nutrition drivers’ relate to underlying

3 Sustainable Development Goal.

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe and structural factors that negatively affect the levels of malnutrition. For Tanzania, these include access to safe water and rates of new HIV infection.

Figure 1. Tanzania scorecard: SUN MEAL assessment

Source: SUN, 2017b. 11. In the south-western Regions of Mbeya, Iringa, Njombe and Songwe (MINS) on which this evaluation focuses (see maps at Annex H), some child nutrition indicators remain poor, despite the progress in commercial agriculture that is being achieved in some areas. The BNTS project proposal, quoting the Tanzania Demographic and Health Survey of 2010, quoted stunting in children aged under five as 51.9% in Iringa4 Region and 49.8% in Mbeya, compared with 42.0% nationally. Wasting in the under-fives, at 3.5% and 1.2% respectively in those Regions, was below the national average of 4.8%, while underweight was above the national average of 15.8% in Iringa (18.2%) but below in Mbeya (9.7%). Anaemia, iron deficiency and vitamin A deficiency in this age group were all below the national averages (UNICEF Tanzania, 2012: 16). 12. A comprehensive baseline study was conducted in the then three Regions in order to assess trends in the practice of optimal infant and young child feeding (IYCF), water, sanitation and hygiene (WASH), early childhood development (ECD) and health behaviours, and to identify the main barriers to the adoption of such behaviours by pregnant women and mothers and caregivers of children under two years old. Health and IYCF behaviours were suboptimal. In addition, assessment of nutrition status of children was done to determine prevalence of stunting, underweight and wasting. Stunting rates of children aged 24 to 47 months were high in all regions; 50% in Iringa, 46% in Mbeya and 61% in Njombe; prevalence of underweight was 15%, 11% and 13% for Iringa, Mbeya and Njombe, respectively, and that of wasting was low, 2% for Iringa and Mbeya and 0.2% for Njombe (Concern Worldwide, 2014e: 2.) 13. More recent data for the MINS Regions are given in the annual Multisectoral Nutrition Scorecards now being produced by the Tanzania Food and Nutrition Centre (TFNC; ¶127 below). Recent scorecard data for two of the MINS Regions are reproduced at Annex F5. As discussed in section 4.2 below, the ASRP has not yet achieved comprehensive collection and compilation of stunting data. In some areas, these data are beginning to be collected at health facilities and at community level during Village Health Days. The data are plotted on

4 Iringa Region had not yet been split into Iringa and Njombe Regions. 5 It has not yet been possible to obtain scorecard data for Iringa and Njombe Regions.

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe length/height for age charts that are often posted on the walls of village government offices. Two examples, photographed during the evaluation mission, are also shown at Annex F, Figure 4 and Figure 5. Plotting data collected in 2017, they indicate that, while the length of children aged under two has been generally satisfactory, stunting is apparent during the following three years of children’s lives. 14. Earlier nutrition programmes in Tanzania, including the Iringa Nutrition Project of 1983 – 1988, focused on aspects of child malnutrition like wasting and underweight, along with improved maternal nutrition. Stunting was not a prominent concern. That issue gained prominence in international nutrition circles following the stimulation in The Lancet in 20086 of awareness and concern about nutrition during the first 1,000 days of life – from conception to the second birthday – and the irreversible harm that stunting caused by poor nutrition of child and mother during that period can cause for health and cognitive development (The Lancet, 2008). These conceptual developments, linked with dissatisfaction about the international architecture for addressing nutrition that was also expressed in The Lancet’s 2008 publication, led to the establishment of the Scaling Up Nutrition (SUN) movement in 2010. 15. In 2010, the National Strategy for Growth and Reduction of Poverty (NSGRP, MKUKUTA II) set six operational targets for addressing infant and child health and nutrition, including a reduction in stunting from 35% of children under five to 22% by 2015 (GOT, 2010: 73). Tanzania joined SUN in 2011. The then President Kikwete became a member of the movement’s Lead Group in 2012, and issued a Presidential Call for Action on Nutrition, which emphasised both nutrition-specific and nutrition-sensitive actions, in May 2013 (WHO, n.d.7). This followed the launch of a National Nutrition Strategy (NNS), 2011 – 2016, in September 2011 and the establishment of a High-Level Steering Committee on Nutrition under the Prime Minister’s Office (PMO). The National Nutrition Strategy acknowledged the national decline in stunting but called for a further reduction, aiming to bring it down from 42% of under-fives in 2010 to 27% in 2015 (GOT, n.d. a: 16). Also in 2011, Tanzania joined the United Nations Renewed Effort Against Child Hunger and Undernutrition (REACH) Initiative and prepared a Country Implementation Plan. 16. The NMNAP has continued the GOT’s emphasis on enhancing the nutrition of young children and their mothers “to assure quality human capital formation”, noting that the actions it prioritises are amenable to rapid scaling up and a strong impact “on reducing the high burden of stunting and acute malnutrition in children under five and the high levels of anaemia in women of reproductive age”. It notes that Iringa and Njombe are among the five Regions with a very high prevalence of stunting, along with Rukwa, and Geita. “Ironically, Rukwa, Njombe and Iringa are known to be the food basket regions in Tanzania.” It set an “impact result” of reducing the prevalence of stunting in children under five from 34% in 2015 to 28% in 2021, linking this to the World Health Assembly global Nutrition Target 1 (GOT, 2016b: 6, 24, 41; WHO, 2014: 1). 17. It was the high stunting rates in MINS that led to selection of these areas for the BNTS project, subsequently reinforced by DFID funding for the ASRP. UNICEF’s BNTS proposal noted that the Regions of Iringa (then including the future Njombe Region) and Mbeya ranked third and fourth in the country in terms of child stunting according to the 2010 Tanzania Demographic and Health Survey (DHS): “these regions represent some of the most food secure areas of the country, indicating that food production does not automatically translate into better nutritional outcomes” (UNICEF Tanzania, 2012: 15). Noting that “support for scaling up nutrition in Tanzania is off to a good start”, UNICEF’s ASRP proposal two years later referred to the same data for these three Regions (Njombe having been created in the interim), and added information from the BNTS baseline nutrition

6 With a further publication in 2013 (The Lancet, 2013). 7 n.d.: not dated

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe survey undertaken in 2013, showing an average stunting prevalence of 44% across the MINS Regions, with Njombe the worst at 51% (Concern Worldwide, 2014e: 42-43).

2. The BNTS and ASRP projects

2.1. Project description Overview 18. UNICEF submitted its BNTS project proposal to IA in October 2012. IA approved an initial three years of funding, since when it has been making additional grants. A project agreement was signed in April 2013: the Irish non-governmental organisation (NGO) Concern Worldwide, long active in Tanzania, was contracted to implement the project. Concern undertook five baseline studies in 2013-2014 (Concern Worldwide, 2014a – Concern Worldwide, 2014e) and began field implementation on a small scale, mainly in Iringa Region. In June 2014, Concern informed UNICEF of its decision to withdraw from all operations in Tanzania. A one-year period of exit and handover then began, with UNICEF submitting its ASRP proposal to DFID and IA in November 2014. Following approval of the ASRP proposal, UNICEF then undertook recruitment of a new set of implementing partners (IPs), pairing international NGOs with Tanzanian ones, as shown in ¶25 below. Practical implementation of the ASRP, incorporating the BNTS and with funding from IA and DFID, began in December 2015. Project year (PY) 2 was thus ending at the time of the evaluation mission, in November 2017, although UNICEF has submitted four annual reports on the BNTS to IA (for the most recent, see UNICEF Tanzania, 2017a).

Planned results 19. In its BNTS proposal, UNICEF identified four KRs, or outcomes, that it would pursue to realise the intended impact of reducing the prevalence of stunting among young children in six districts by ten percentage points (UNICEF Tanzania, 2012: 5). As explained above, it included three KRs in its subsequent ASRP proposal but later excluded the agriculture component, so that it now reports to DFID on two outcomes. Table 1 shows the four BNTS KRs and the eventual two ASRP outcomes, as well as the outputs shown in the two design documents. For ease of comparison, ASRP outcome 2 has been placed alongside BNTS KR 1, and ASRP outcome 1 alongside BNTS KR 2. It can be seen that ASRP outcome 2 partly reflects the intention of BNTS KR 4, as well as KR 1. 20. UNICEF’s ASRP proposal said that the aim was to reduce stunting among children aged under five in Mbeya, Njombe and Iringa from 44% in 2013 to 35% in 2019 – representing “a 20% relative reduction of stunting prevalence” (UNICEF Tanzania, 2014b: 22). 21. Each proposal included a schematic presentation of the ways in which project activities were intended to lead to the planned results. These are shown at Annex B. The BNTS proposal presented a more comprehensive diagram of the pathways through which the project was intended to affect stunting. This included identification of the barriers that would have to be overcome if the problem were to be addressed successfully. The ASRP proposal offered a conventional logic model linking outputs through outcomes to impact. The diagram showed the agriculture component that was subsequently excluded.

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe

Table 1 BNTS and ASRP key results, outcomes and outputs

BNTS8 ASRP9 KR 1: Regional and local government Outcome 2: Strengthened evidence based authorities effectively plan, budget, multisectoral response to undernutrition coordinate and monitor the delivery of in Tanzania. nutrition services and nutrition sensitive interventions: Output 2.1: Enhanced planning, coordination and monitoring systems across multiple sectors 1.1 Council Steering Committees on Nutrition at the national and subnational level. coordinate and monitor actions across multiple sectors and with multiple stakeholders Output 2.2: Increased resources for nutrition at national and district level to operationalize the 1.2 Government Nutrition Officer posts at National Nutrition Strategy. Regional and district level are filled, maintained and supported Output 2.3: Strengthened national nutrition information system for timely and evidence- 1.3 District plans and budgets include nutrition based decision-making. specific and sensitive interventions in line with the National Nutrition Strategy KR 2: Pregnant women and caregivers of Outcome 1: Increased proportion of children aged less than two years enabled pregnant women and caregivers of to practise nutrition-relevant behaviours children under two years old who practice and take up nutrition services: key nutrition-relevant behaviours (IYCF, WASH, ECD and health) in Mbeya, Iringa 2.1 Context-specific communication channels and Njombe Regions. identified and materials developed and rolled out to enhance knowledge and practices Output 1.1: Increased participation of pregnant women and caregivers of children under two 2.2 Coverage and quality of nutrition services years old in counselling on IYCF, WASH, ECD provided through the health sector for pregnant and health practices. and breastfeeding women and children aged less than two years is enhanced Output 1.2: Increased participation of key community members and local leaders in supporting pregnant women and caregivers of children under two years old to practicing nutrition-relevant behaviours.

Output 1.3: Increased proportion of health service providers who provide appropriate and timely counselling and support for nutrition- relevant behaviours in health facilities. KR 3: Availability and access to diverse and micronutrient-rich foods at household level enhanced:

3.1 Production of appropriate nutrient rich foods is promoted at household level

3.2 Improved access to nutritious foods through market stimulation

8 UNICEF Tanzania, 2012: 18-22. 9 UNICEF Tanzania, 2017k: 4; UNICEF Tanzania, 2014b: 22.

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe

BNTS8 ASRP9 KR 4: Evidence and learning from district and community programming on nutrition documented and used to inform the scale- up of nutrition actions to reduce stunting:

4.1 Underlying determinants of stunting in the three Regions identified

4.2 Evidence of best practices generated and shared with stakeholders

Planned beneficiaries 22. The BNTS proposal identified direct and indirect beneficiaries. The former were defined as children aged 0-23 months and pregnant and breastfeeding women. The intention was to reach 74,000 children in this age group, along with their caregivers, as well as 25,000 pregnant women – “reflecting about 60% of the target group population. Through interventions at the district level in both high and low intensity districts, the project aims to indirectly reach a further 255,000 children aged 0-23 months and 74,000 pregnant women” (UNICEF Tanzania, 2012: 17). 23. The ASRP proposal, incorporating the ongoing IA funding, said that “overall, the project aims to reach up to 1.47 million children under five years, of which 585,000 children aged 0-23 months, their mothers/caregivers, and 315,000 pregnant women. In 2019, the project is expected to achieve its target coverage of 75% of beneficiaries in Mbeya, Iringa and Njombe regions” (UNICEF Tanzania, 2014b: 27; Songwe Region had not yet been established). It can be seen that the target coverage was raised from 60% to 75%. This is variously interpreted as meaning 75% of villages in the four Regions, or 75% of the target group, with the former approach more common. Within each village covered, the project strives to give priority to the poorest and most vulnerable households. Since 2016, it has been able to share Tanzania Social Action Fund (TASAF) data that identify such households. It can be seen that the shifting definitions and interpretations of target coverage leave scope for greater clarity – an issue addressed in ¶176 and ¶196 below. Implementation arrangements 24. The original plan for the BNTS was to implement the project in six ‘high intensity’ districts, with only selected project activities relating to Key Result 1 (see below) undertaken in the remaining, ‘low intensity’ districts of the target Regions. Two ‘high intensity’ districts were selected in each of the (then) three Regions: Iringa Rural and Mufindi in Iringa Region; Makete and Njombe in Njombe Region; and Mbeya Rural and Mbarali in Mbeya Region. 25. In the expanded ASRP, the full suite of project interventions is carried out in all districts of the (now) four MINS Regions. CUAMM (the Italian NGO Doctors with Africa) and the Tanzania Home Economics Association (TAHEA) are the IPs for Iringa and Njombe Regions. Catholic Relief Services (CRS) and the Centre for Counselling, Nutrition and Health Care (COUNSENUTH) implement the project in Mbeya Region. The United States-based NGO Pact works with the Integrated Rural Development Organisation (IRDO) to implement the ASRP in Songwe Region. 26. The ‘full suite’ of ASRP interventions excludes the agriculture component that was included in BNTS design and continues to be implemented in the original six ‘intensive’ BNTS districts in Mbeya, Iringa and Njombe Regions. One of the ‘barriers’ identified in the BNTS proposal was that “households [are] unable to grow or purchase sufficient nutritious foods for mothers and children under two years” (UNICEF Tanzania, 2012: 14). The project’s

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe agriculture component, aimed at KR 3 (see below), thus aimed to diversify home production of nutritious food for consumption by this target group. In consultation with DFID (which reportedly felt that such an activity would increase the already heavy work load of women), UNICEF did not include an agriculture component in the ASRP (although it was included in the 2014 project proposal). 27. UNICEF transfers funds to these IPs for activities in support of KRs 2 and 3 (see below). It funds some activities under KRs 1 and 4 directly, and transfers money to LGAs and the TFNC for others. The former IP Concern Worldwide received funding under KR 4 for carrying out the five baseline studies. 28. Table 2 below shows which categories of work (at community level (KR 2 and KR 3) and at Regional Administration and LGA levels (KR 1)) are carried out by which IPs in the various districts and Regions. It also shows USAID-funded activities, which are explained below. 29. With multiple IPs, the arrangements described above impose additional administrative complexities on UNICEF. On the other hand, working with three different, widely experienced international NGOs gives the project access to a deeper, broader range of insights and skills; while UNICEF’s insistence that each international IP partner with a Tanzanian one may strengthen the potential for sustainability while adding local expertise and understanding. 30. Development projects in many countries have been criticised for relying on external implementation capacity and bypassing government systems and staff – with negative effects on sustainability. UNICEF’s approach has been to work with and through the GOT on all components of the project, emphasising that all activities are either the direct responsibility of the relevant authorities (as under KR1) or are performed under the co- ordinating authority of government officers and structures, such as District Executive Directors (DEDs) and Council Multisectoral Steering Committees on Nutrition (CMSCNs), involving LGA field personnel as much as possible.

2.2. Key stakeholders and linkages 31. The inception report for this evaluation included a stakeholder analysis that is reproduced at Annex E. For analytical purposes, some of the stakeholders identified there are particularly significant. 32. As pointed out above, the roles, perspectives and performance of government authorities are centrally important. At national government level, the PMO continues to play its established role of co-ordinating technical aspects of nutrition policy and strategy. The President’s Office – Regional Administration and Local Government (PO-RALG) took over the roles of co-ordinating and capacitating local government services from the PMO in 2016, and thus has an important role in steering the achievement of the BNTS KR 1. That role is shared with the LGAs (City, Municipal, Town and District Councils), which are the fulcrum of co-ordination, administration and implementation at local level, linking in one direction to the Regional Secretariats and in the other to the structures of ward, village and hamlet governments. In the ASRP, they and their CMSCNs have central roles in the co-ordination of BNTS KRs 2 and 3.

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe

Table 2 Project Regions and their districts

Implementing partner USAID funding (Irish Aid and DFID (Mwanzo Bora: other Region District funding) Irish Aid funding DFID funding implementing partners) Comm. LGA RA Comm. LGA RA Comm. LGA RA Mbeya Mbeya Regional Administration CRS and COUNSENUTH X Council X X Mbeya City Council X X X Council X X Council X X X District Council X X Council X X X Council X X X Songwe Songwe Regional Administration PACT and IRDO No Irish Aid funding in Songwe X Council X X X Council X X X Tunduma Town Council X X Council X X X Council X X X Iringa Iringa Regional Administration CUAMM and TAHEA X No DFID funding in Iringa Iringa District Council X X Iringa Municipal Council X X Council X X Council X X Mafinga Municipal Council X X Njombe Njombe Regional Administration CUAMM and TAHEA X No USAID funding in Njombe Council X X Njombe Town Council X X Council X X District Council X X Wanging'ombe District Council X X Town Council X X

Comm.: community. LGA: local government authority. RA: Regional administration.

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe

33. The ASRP responds to the GOT’s continuing commitment to scale up nutrition action and, in particular, to tackle stunting. This is the project’s most significant linkage, particularly through BNTS KR 1 and ASRP Outcome 2 (Table 1 above). UNICEF has worked in close collaboration with the Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC), PO-RALG, the PMO and TFNC, and has used project funds to support policy and capacity development at central and LGA levels – for example, the formulation of the NMNAP and of nutrition monitoring and information systems, and the systematic operation of nutrition management and monitoring structures such as CMSCNs. The project is meant to be an integral part of this national effort, with field implementation in MINS spearheading direct action in priority areas of the country. 34. The responsibilities of the MOHCDGEC range from community to national government levels. The long-established cadre of volunteer Community Health Workers (CHWs), who play a central role in the project’s social and behaviour change communication (SBCC) strategy, are co-ordinated by the Ministry’s local health facilities. The recently established cadre of District Nutrition Officers report through this ministry’s District Medical Officers to their DEDs. The TFNC, which has significant roles in support of project KRs 1 and 4, is a parastatal under the MOHCDGEC. All these arrangements are relevant to ongoing debate in Tanzania (and elsewhere) about whether nutrition should be treated as a health challenge or a more multisectoral one, emphasising nutrition-sensitive as well as nutrition-specific interventions. 35. While IA and DFID are clearly significant as donors to BNTS and the ASRP, USAID is also shown in Table 2 above because the Mwanzo Bora Nutrition Programme (MBNP), which it funded from 2011 to 2017 through its Feed the Future Initiative, has been active in three of the four MINS Regions. Like the BNTS project, the MBNP has promoted SBCC and included an agriculture component. Significantly, the MBNP’s SBCC approach differs from that of BNTS and the ASRP. Efforts were made to ensure that the two projects did not overlap in the field, but these were not fully successful. There is some overlap in Mbeya, for example, and some CHWs reportedly work with both projects – as do some of the Tanzanian NGOs that serve as IPs in the ASRP. 36. DFID’s ASTUTE programme is also significant in funding two nutrition initiatives in Tanzania. In addition to the ASRP, it funds IMA World Health to implement the programme in all districts of five Regions in the Lake Zone of north west Tanzania. The IMA project started field implementation in mid-2016, with an SBCC approach that gives great importance to home visits and puts a stronger emphasis on the use of (radio) media than the ASRP, whose central SBCC instrument is ‘counselling groups’ (CGs) set up by the project, complemented by individual messaging to parents and caregivers during their visits to health facilities.

2.3. Summary of reported performance 37. The project had a preliminary period of operations, as the BNTS with Concern Worldwide as the IP, and a substantive period of operations over the last two years, as the ASRP, partly funded by IA. During the preliminary period, the main area of performance concerned BNTS KR 4, with the production of the five baseline studies referred to above (Concern Worldwide, 2014a – Concern Worldwide, 2014e). 38. The level and quality of performance are discussed and explained in chapter 4 below. A summary of performance is provided in results matrices that UNICEF includes in each of its annual and quarterly progress reports to IA. The most recent results matrices are shown at Annex G. Understandably, these matrices focus at this stage in project implementation on the achievement of outputs. While taking account of output-level performance, this evaluation is primarily concerned with progress towards the intended outcomes, and the

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe likely sustainability of project results. This is the principal focus of the findings presented in chapter 4 and of the conclusions drawn in chapter 5.

3. Approach and methods

3.1. Evaluation approach 39. As explained in the inception report and in section 1.1 above, this is a formative evaluation at the mid-term of the currently planned and funded ASRP, focusing on but not restricted to the BNTS that is funded, as part of the ASRP, by IA. It does not attempt to assess results in terms of reducing stunting, but it does aim to assess the ways in which the project has operated to date, the likelihood of achieving the intended outcomes and impact, and the possible ways in which its design, implementation and performance could be enhanced – within the framework of the GOT’s overall NMNAP and related structures and system. 40. The inception report also committed the evaluation team to high standards and principles of confidentiality and ethics in its work with informants, in accordance with the requirements of the United Nations Evaluation Group10. The evaluation team has striven to comply with those requirements, and to conform to its own standards of collegial, constructive engagement with UNICEF and its partners in learning together about the project’s experience to date and identifying the best ways forward.

3.2. Evaluation methods 41. The evaluation team has applied the methods set out in its inception report. Central to these was the development of the evaluation matrix included in that report (and reproduced at Annex C). The findings and conclusions presented in chapters 4 and 5 below answer the 16 key evaluation questions (EQs) posed in the matrix, which elaborate the questions asked in the TOR (Annex A). The relevant EQs are shown in a box at the start of each section in chapter 4. 42. As anticipated, the methods used to answer the EQs were based on the assessment by the evaluation team of findings obtained from a combination of document review, interviews and focus group discussions (FGDs). The research instruments developed during the inception phase were used to guide some of the interviews and FGDs. These are reproduced at Annex E. Annex J presents a list of persons met and of FGDs held. 43. The evaluation team did not elaborate a full theory of change (TOC) for the project. Instead, as explained in the inception report, it carefully analysed the diagram of causal pathways that was included in the BNTS proposal (UNICEF Tanzania, 2012: 14). The conclusions in chapter 5 include discussion of the veracity, or otherwise, of the assumptions implicit in that causal logic. 44. Four debriefing discussions towards the end of the evaluation mission were an important part of the overall approach, allowing the team to test and triangulate their emerging findings and conclusions. Two team members held a debriefing with CUAMM and TAHEA before leaving Iringa. The full team held a meeting at the UNICEF office in Mbeya with local staff of UNICEF and the ASRP IPs. A third meeting comprised internal discussion

10 UNEG Norms for Evaluation in the UN System, April 2005; UNEG Code of Conduct for Evaluation in the UN system, July 2007; UNICEF-Adapted UNEG Evaluation Reports Standards, July 2010; UNICEF Procedure for Ethical Standards in research, Evaluation, Data Collection and Analysis, April 2015.

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe with UNICEF in Dar es Salaam. The fourth debriefing was a presentation to, and discussion with, a broader set of stakeholders, including IPs and IA, at the same venue.

3.3. Evaluation activities 45. Following initial review of documentation, the evaluation team undertook a brief evaluability mission (by one member) to Mbeya on 16-17 October. An inception mission (by three members) then took place from 18 to 20 October in Dar es Salaam. The team submitted its inception report to UNICEF on 31 October. Following comments and revisions, it was finalised on 8 November and approved by UNICEF on 9 November. It thus became the team’s principal guide to the task, complementing the TOR. 46. Team members Theresia Jumbe (research assistant), Joyce Kinabo, Bjorn Ljungqvist and Stephen Turner then undertook the evaluation mission from 13 to 24 November11. The focus of activities during the mission was on meeting stakeholders (Annex J) and observing project activities in the MINS Regions themselves. The team split into two pairs in order to be able to cover more LGAs and field sites. Only a short series of key meetings were held in Dar es Salaam before and after the field work period, which lasted from 14 to 22 November12. 47. Following final meetings in Dar es Salaam (¶44 above), the team has analysed the documentation, information and insights assembled to prepare this report. The planned date for submission of a first draft of the report was 15 December 2017. Because of other commitments at that time, and the holiday season, UNICEF said that submission of the first draft could be deferred to mid-January 2018. This report takes into account comments received on that draft and on a revised draft. 48. Annex I shows the full schedule of the evaluation mission. As noted, Annex J presents a list of persons met and of FGDs held.

4. Findings

4.1. Relevance

Alignment with national and EQ 1. To what extent does the intervention align international policies and with and contribute to national and international priorities policies and priorities on nutrition? 49. As noted in section 2.1, the design and implementation modalities EQ 2. To what extent does the intervention respond of the BNTS/ASRP have evolved during to the needs of end-beneficiaries and local programme implementation, starting communities? from the original BNTS proposal in 2012. Some of the adjustments are based on various studies and early operational experiences, while others appear to be related to ongoing discussions with the government, donors and other partners in an effort to align the programme design and operational approach to existing and emerging national policy and programme guidelines and standards as well as to emerging global evidence and good practices. This reflects good programming practice. The way the programme was conceived, planned, initiated and is presently being

11 Dr Jumbe worked with the team until 22 November, having been recruited to assist with the field activities only. 12 An unannounced flight rescheduling caused Kinabo and Turner to lose one day in the field.

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe regularly monitored and reviewed represents a good example of an adaptive programming process (Pelletier et al., 2017). This is particularly appropriate given that many aspects of stunting prevention strategies are still insufficiently defined and proven – especially those actions that are labelled ‘nutrition-sensitive’ (UNICEF, n.d. h). 50. The current Tanzania Food and Nutrition Policy (TFNP) dates back to 1992 (GOT, 1992). It was then one of the most ‘advanced’ policies in the world, as it was the first to adopt the principles of the conceptual causality framework and Triple-A approach. These two important principles actually originated in Tanzania but later became known and universally adopted as the ‘UNICEF conceptual framework’ (UNICEF, 1990). However, the 1992 TFNP is considered by many to be somewhat outdated, as it was formulated before many recent advances in human nutrition science and applied nutrition programming (including the recent understanding of the problem and implications of childhood stunting (The Lancet, 2008; The Lancet, 2013)). The 1992 TFNP also placed the leadership for nutrition policy and programming squarely under the Ministry of Health, which has some implications for multisectoral co-ordination at national and sub-national levels (¶33, ¶77). Those implications are presently addressed by using the convening and co-ordinating mandates of other government bodies (PMO, PO-RALG and LGAs); but an update of the 1992 TFNP is currently under preparation and review and may lead to more effective arrangements. 51. There has been a series of updates of national nutrition strategies and action plans during recent decades. This process has at times been rather ad hoc and scattered, often prioritising ‘vertical’ approaches and specific interventions. Tanzania’s decision to join the SUN movement in 2011 helped to accelerate finalisation and adoption of the updated and comprehensive 2011/12-2015/16 (NNS; ¶15 above), which subsequently provided the formal programming guidance to both the BNTS (2012) and the ASRP (2014) proposals. The NNS included eight ‘strategies and strategic objectives’ that recognised the need for a multisectoral and multi-stakeholder approach, but which clearly prioritised health-based nutrition services (i.e. essentially nutrition-specific interventions) and control of micronutrient deficiencies (through health-based services and food fortification). The need for strong ‘behavioural change communication’ (BCC) was also recognised, but household food security was mentioned only as an important precondition for nutrition adequacy and not elaborated into a coherent strategic approach (GOT, n.d. a: 25). Hence, it is understandable that the BNTS proposal is rather tentative regarding actions to address household food security and that it does not really advance any clear proposals for other nutrition-sensitive activities. 52. Parallel to these nutrition strategy and action planning developments in Tanzania, quite extensive and comprehensive developments took place at global level and in selected countries to better articulate a series of nutrition-sensitive actions in key sectors. This notion was largely based on the postulate in one of the 2013 Lancet papers that nutrition- specific interventions would only be able to reduce stunting by 20-25% and that a multisectoral approach with carefully designed nutrition-sensitive actions would therefore be required to achieve sustainable reductions in stunting as well as most other forms of malnutrition (Bhutta et al., 2013). Although the 20-25% impact limit of nutrition-specific interventions has subsequently been disputed (it depends on circumstances), the imperative of a multisectoral approach to stunting prevention is presently generally agreed and is, indeed, one of the ‘hallmarks’ of the global SUN movement. 53. In response to the calls for a stronger multisectoral and multi-stakeholder approach to stunting reduction, a process to update the 2011/12-2015/16 NNS was initiated quite early. It resulted in the drafting and official government approval of the NMNAP 2016 - 2021. Strongly supported by UNICEF with ASRP funds, the preparation of the NMNAP was characterised by strong government leadership, qualified technical support as well as commendable stakeholder participation, and the final document thus has broad support and

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe buy-in by all key actors – beyond the health and nutrition-specific sectors. Therefore, as recommended by the SUN movement, it is likely to serve the purpose of a ‘Common Results Framework’ for all the actors engaged in the Tanzania SUN movement, defining roles, responsibilities and accountabilities at critical administrative levels. 54. In addition to the more general provisions of the NMNAP, a series of follow-up actions have been initiated by GOT bodies – especially the PO-RALG – to clearly define, for example, the roles of nutrition steering committees at Regional, district, ward and village levels; design the tools needed for district planning, budgeting, expenditure tracking and review of nutrition actions; and prepare guidelines for short- and long-term budget allocations. 55. Some of this work has been supported by the ASRP. Despite the limited and somewhat outdated guidance provided in existing government policy and programme documents at the start of the BNTS and ASRP, UNICEF, in collaboration with the donors as well as other partners, intensified support to government to update and improve these policy provisions and programming guidelines, partly using project funds for the purpose. At the same time, project implementing agencies started implementation of a series of activities that were already well endorsed by existing government policies and programming guidelines, i.e. primarily health-based nutrition-specific interventions and SBCC. 56. This parallel move to accelerate agreed priority action while tackling the gaps in national policy and strategy was supported by the GOT and transparently discussed and agreed in the national High-Level Steering Committee on Nutrition (HLSCN, a body set up in 2012 under the PMO). Hopefully, this has already saved many Tanzanian children from stunting. But the negative implications of mobilising community actions before local development structures were fully informed and enabled will need to be addressed in order to achieve full effectiveness and sustainability. The fact that various project IPs developed and applied different tools and implementing strategies is also emerging as an issue that needs to be addressed as soon as possible. 57. The project’s alignment with national policies and priorities has thus been evolving, as the necessary national formulation – supported by the project – was ongoing. The ASRP’s alignment with international thinking on nutrition priorities is strong. The project has been directly contributing to, and engaged with, the development of national nutrition policy, institutions, systems and procedures. Its relevance has thus been high. 58. Following adoption by the HLSCN in October 2016, the NMNAP began to be applied in national planning and budgeting processes. It was officially launched in September 2017. It would be premature to judge whether the NMNAP and the nutrition governance provisions and technical working group structures it has initiated will provide the technical and operational guidance needed to address the current institutional and operational shortcomings observed at LGA and community levels during the evaluation – and this is not an evaluation of the NMNAP. But the following NMNAP-related issues are critical for the ultimate and sustained success of the ASRP. • The NMNAP adopts a multisectoral approach. But so far the policy underpinning of this approach is not in place; human nutrition is largely still considered a health sector responsibility. This issue is presently resolved through PMO and PO-RALG co- ordination at national and regional levels. But it becomes increasingly challenging at LGA, ward and village levels. • The NMNAP is vastly improved compared to the 2011-2016 NNS. It presents a list of nutrition-sensitive interventions to be scaled up, and reflects the government- approved budgets in each of the relevant sectors. But it is still not very clear or explicit in terms of these non-health nutrition-sensitive actions, and does not provide sufficient guidance to operational level (LGA) nutrition planners in that respect. Specification of the required activities needs to be accompanied by operational guidance on how they are to be accomplished. In particular, nutrition-sensitive plans

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe

and activities need to be developed, operationalised, implemented and regularly reviewed in the areas of agriculture and rural development, gender and community development, WASH, education and ECD, and social protection. • The gender aspects of the NMNAP may be most critical to review and further articulate, in order to achieve meaningful change at scale. A special gender assessment of the NMNAP has been conducted recently and is discussed in more detail in section 4.6. • SBCC is a very high priority for effective and sustained prevention of stunting and other forms of malnutrition, but the strategic and operational approach to it is not well defined in the NMNAP. As a result, a number of different models are implemented within the different ‘scaling-up nutrition’ programmes (including ASRP) being implemented by different partners in different parts of the country. • Governance structures and mechanisms at sub-national levels are not fully articulated in the NMNAP. But, as noted above (¶54), these are presently subject to clarification and detailed specification by PO-RALG. 59. Again, therefore, as analysis of effectiveness and sustainability will show in sections 4.2 and 4.4 below, the ASRP is well aligned with, and has made a major contribution to, national policies and priorities on nutrition. But this is still work in progress. Response to the needs of beneficiaries and communities 60. The first 1,000 days are considered key in terms of improving nutritional status and preventing stunting in children. During this period, a woman needs to consume adequate amounts of all nutrients in order ensure her own nutrition and be well prepared for pregnancy and, later on, lactation. However, for many women in Tanzania this usually does not happen. This is partly due to limited understanding about nutrition in general and nutrition during pregnancy in particular, and poor quality of care by people around her (spouses, health providers, extended family members). This is because pregnancy is considered a normal situation; therefore it is not accorded the attention it deserves. The project has selected pregnant women and care givers of children below two years as a target population for its interventions. This is highly relevant, since it is through this group that the project can have significant impact in reducing stunting in children. It should be noted, however, that the incidence of teenage pregnancies and low birth weights has decreased in MINS. One step towards reducing stunting has been at least partially taken. 61. The selection of the original three Regions for the BNTS was appropriate because of the high levels of stunting and underweight (section 1.3 above). All the prevalence levels are above the national average. To address this problem the project is implementing interventions to change the behaviour of mothers and caregivers towards child feeding and provision of care in general. 62. As explained in section 4.2, identified behaviours that impede adequate maternal nutrition and child care have been compiled as SBCC messages to help mothers change behaviour. In order to reach the target population and be able to influence behaviour, the project has designed activities to strengthen the capacities of key local actors (especially CHWs and health agents) to deliver adequate nutrition services to women in this critical period, at both the health system and the community levels. In the health system, health workers have been empowered with information about pregnancy management and other materials such as supplements to support pregnant mothers (assessment of foetal development, weight measurements of the pregnant mothers, determination of haemoglobin to assess anaemia, and distribution of iron and folate tablets (IFA)). At community level, ‘counselling groups’ (CGs) have been established to provide information on adequate IYCF, as well as WASH, maternal health and ECD.

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe

63. The project is relevant in having identified target areas in Tanzania where stunting is generally worse than the national average, and in having focused on SBCC approaches (assessed in more detail below) to address the critical issue of adequate nutrition during the first 1,000 days of life. The fundamental question, however, is whether the intervention, through its chosen strategies, is responding to the needs of end beneficiaries and local communities – given that those needs, as they affect stunting, may have gender and livelihood dimensions as well those of nutritional behaviour. As the BNTS proposal put it, “stunting coexists with relatively good food security”. To be fully relevant, the project must address what the proposal called “the social, cultural and gender issues influencing nutritional status” (UNICEF Tanzania, 2012: 21). 64. The original BNTS therefore included an agriculture component, which is continued in IA-funded ASRP districts, but not in those funded by DFID (¶26 above). To the extent that promotion of nutritious vegetable and fruit production is considered a necessary part of strategy to combat stunting in MINS – an issue assessed further below – project relevance might therefore not be considered optimal. 65. Livelihood and gender factors are interrelated in their likely influence on women’s nutrition and on women’s nutritional care of young children. Many informants refer to the time poverty suffered by women in MINS as they focus on income generating agriculture and other activities, arguably to the detriment of their children’s care and nutrition. Informants also point to the lack of male understanding, commitment and involvement in those tasks. The project is seeking to address the gender imbalance in support for young children’s nutrition and in understanding and commitment on these issues by men and by women respectively. Whether it is doing so adequately, thus enhancing the relevance of its response to beneficiaries’ and communities’ needs, is discussed further below.

4.2. Effectiveness 66. This section deals in turn with the project’s effectiveness to date in working towards each of the four BNTS key results (Table 1 above). Planning, budgeting, co-ordination and monitoring by Regional and local government authorities

67. According to UNICEF’s BNTS EQ 3. What progress has been made towards Key proposal to IA, Output 1.1 in support Result/Outcome 1? [Regional and local government of KR 1 would be that “Council Steering authorities effectively plan, budget, co-ordinate and Committees on Nutrition co-ordinate monitor the delivery of nutrition services and and monitor actions across multiple nutrition-sensitive outcomes.] sectors and with multiple stake- holders”. To this end, the project would EQ 4. What factors have stimulated or impeded “assist councils in establishing and progress towards KR 1? convening the multi-sector and multi- stakeholder Council Steering Committees on Nutrition, and ensure appropriate representation and active participation of women” (UNICEF Tanzania, 2012: 18-19). A CMSCN was in place and meeting regularly (every quarter) in each of the LGAs visited during the evaluation mission. Regional Nutrition Officers confirmed to the mission that, indeed, these committees were in place in each of the LGAs in all MINS Regions. The composition of these CMSCNs roughly corresponded to the key sectors stipulated by the NMNAP. However, in most cases those attending CMSCN meetings were not the substantive office holders (District Medical Officer, District Agriculture Officer, etc.), but subordinates delegated by them. Possibly because of this – since the district sector heads in Tanzania are still predominantly male, but would tend to delegate nutrition work to a female colleague – the gender balance was fairly even in the CMSCNs met during the mission.

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe

68. However, apart from the ASRP IPs, there seemed to be no other representation of NGOs, civil society organisations (CSOs), faith-based organisations (FBOs) or the private sector in CMSCNs, and there was no evidence that the LGA had made an effort to ‘map’ an update of nutrition actions and corresponding stakeholders in the district. The TOR issued by PO-RALG for CMSCNs provide for two members representing FBOs, two from nutrition-based CSOs and two from NGOs (GOT, 2017g: 27-28). 69. The CMSCNs are established as ‘advisory committees’ to the DED, to provide technical advice and support on nutrition matters to her/him in her/his work in the District Council and the District Executive Committee13. As such, the DED is expected to chair the CMSCN. But this was rarely the case in the LGAs visited during the evaluation mission. 70. The CMSCNs met during the mission could offer few concrete examples of important decisions or actions taken so far. In fact, most of the CMSCNs met seemed to have rather limited understanding of their role both as a multi-sectoral committee and as sector representatives for key nutrition-related sectors. Primarily, they complained of lack of resources (especially transport) to undertake any nutrition work – not realising that they themselves represent critical resources in the efforts to prevent malnutrition and that this, indeed, is the whole purpose of a multi-sectoral approach to nutrition. 71. Much of the confusion and inactivity encountered in CMSCNs can be attributed to the lack, until recently, of clear TOR and guidelines for their work. However, the mission encountered one CMSCN that had used its position and mandate to co-ordinate several nutrition-related initiatives in its district successfully. This success was largely due to close collaboration between the DED and the CMSCN. 72. To help achieve Output 1.1, the BNTS proposal also made a commitment to “strengthen district systems for compiling, analysing and using nutrition data and information to track progress and inform nutrition programming, with a focus on identifying and tracking equity bottlenecks in the delivery and scale-up of services. Approaches such as the ‘Reach every child’ (REC) approach14 for immunisation services will be explored to determine whether they can be adapted for nutrition services” (UNICEF Tanzania, 2012: 19). REC approaches have not been adapted for this purpose. More broadly, it is logical to assess performance with regard to district systems for monitoring and analysis in the framework of KR 4 on evidence and learning (page 27 below), where nutrition management information systems are discussed. This is also in line with the Global SUN movement’s MEAL working group approach (SUN, 2017a). 73. A further activity planned towards Output 1.1 was to “conduct a mapping of CSO and private sector organisations active in the districts, and facilitate discussions with LGAs leading to Memorandums of Understanding or equivalent declarations of intent to sign up to the district plans on reducing stunting” (UNICEF Tanzania, 2012: 19). As already noted in ¶68 above, there were no CSOs apart from the ASRP IPs participating in CMSCNs, and no effort had been made to conduct a district-based nutrition activity and stakeholder mapping to identify existing and potential CSOs that should be invited to join these committees. The Partnership for Nutrition in Tanzania (PANITA15) is very keen to facilitate, and ready to support the engagement of local NGOs and CBOs, both in the Tanzania SUN in general and also in local multi-stakeholder co-ordinating mechanisms like CMSCNs. 74. BNTS Output 1.2 in support of KR 1 was that “Government nutrition officer posts at regional and district level are filled, maintained and supported”. The first of the planned

13 Or the corresponding City or Municipal bodies in the case of urban LGAs. 14 The REC approach uses strategies aimed at improving immunisation systems in areas with low coverage. The approach involves the development of district micro-plans to identify local problems and adopt corrective solutions to improve the coverage of services, particularly in hard-to-reach and underserved areas. The approach allows for making practical links with nutrition services provided through the health sector. 15 PANITA is the recognized SUN CSO network in Tanzania.

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe activities in this regard was to “advocate with regional and district authorities to ensure Regional and District Nutrition Officer positions are filled and maintained” (UNICEF Tanzania, 2012: 19). It is clear, as evidenced by reference to the project baseline study on LGA capacity (Concern Worldwide, 2014c), that recruitment to the new Nutrition Officer posts at Regional and district levels in MINS was carried out promptly. The evaluation mission still identified a few vacancies, but these were caused by the fact that the originally recruited District Nutrition Officers (DNOs) had left for training or promotion and had been temporarily replaced by Acting DNOs. 75. A further planned activity was to “introduce and foster a government-led supervisory system for Regional and District Nutrition Officers”. Many activities relating to capacity building for the newly established posts of Regional and District Nutrition Officers, as well as to the Regional and Council Multisectoral Steering Committees for Nutrition, had to wait for clarifications from the policy level (especially PMO and PO-RALG) and from the national technical co-ordination level (TFNC). Hence, while UNICEF and other partners were, indeed, engaging and supporting such policy and technical guidance from the national level authorities, the direct project support to Nutrition Officers and CMSCNs was provided on a more ad hoc basis, delivered as specific technical trainings (e.g. on bottleneck analysis (BNA), review of annual nutrition work plans, and Scorecard analysis and reporting systems) and as ongoing technical backstopping by the local experts of the IPs. 76. The basic competencies and capacity development of the Regional and District Nutrition Officers have been the focus of a nationwide, extensive on-the-job training effort involving a number of national institutions and supported by a range of nutrition partners in Tanzania. Sokoine University of Agriculture developed the modules; the training was co- ordinated by TFNC using national facilitators. However, when the training was being conducted, not many of the current RNOs and DNOs had been recruited. There is therefore a gap in capacity at present. There were no arrangements to make this training sustainable in the sense of running it periodically. It was a one-time event. The training effort is subject to a parallel evaluation, the results of which are not yet available. 77. A basic concern about the Nutrition Officer posts as currently established is that they fall under the MOHCDGEC and continue to be perceived in some quarters as being primarily concerned with nutrition as a health issue. There are also Agriculture and Community Development staff at Regional and district levels who have nutrition training; but their capacity is not adequately deployed to address the multisectoral challenges that poor nutrition poses. 78. The aim of BNTS Output 1.3 in support of KR 1 was that “district plans and budgets include nutrition specific and sensitive interventions in line with the National Nutrition Strategy”. To help achieve this, it was intended that the project would “assist… LGAs in conducting a gender sensitive rapid situation analysis on nutrition and… use this information to develop district scale-up plans to guide the operationalisation of the … NMNAP”. The project felt that it was necessary to first help update and improve the national, NMNAP plan to establish a ‘common results framework’ for all Tanzanian districts and has, consequently, not yet supported LGAs in the systematic performance of such situation analyses. This now appears to become a very helpful next step in order to enhance the understanding of the nutrition programmes implementers in the MINS regions about the trends and causes of the stunting and other nutrition problems in their own areas. Such analysis could become an effective way of stimulating multisectoral action by the CMSCNs, helping each of the local government sectors more clearly to identify their respective role in preventing stunting. It is timely and appropriate now to launch such efforts and to combine this with an update and clear definition of important sources of nutrition information at district and sub-district level, along with the design and establishment of appropriate nutrition management information systems (NMISs) for Regional, district, ward and village management of (multisectoral) nutrition actions (see discussion of BNTS KR 4 below). This would imply a major investment

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe and effort as the next phase of programme implementation is initiated. However, with substantial experience gained and support from local leaders and communities clearly demonstrated, plus the temporary availability of IPs’ technical expertise at district level, such an ambitious effort may just become the much-needed catalyst for the wide-ranging action that is needed for the stunting prevention effort to take root and become sustainable at the local level. 79. Another activity to help achieve Output 1.3 was to “support annual Regional level meetings with District Planning Officers, District and Regional Officers and sector managers in all key sectors on planning and budgeting for nutrition. Support the District Nutrition Officers to take an active role in advising key sectors (including health, agriculture, WASH and community development) to focus their budgets on nutrition-specific and nutrition- sensitive interventions in the most deprived areas, and to ensure women gain equal access to services.” These meetings have been held, although adequate distinction of nutrition- specific and nutrition-sensitive activities in the resultant plans has taken time to achieve. In future, they will benefit from the NMISs that are now in place and can provide annual updates on the nutrition situation in the Region. 80. Formulation of explicit district nutrition plans with clearly defined activities and budgets in all the key nutrition-related sectors is clearly a prerequisite for meaningful and effective work by CMSCNs. Progress in formulating such plans has been dependent on the necessary first steps at national level: formulating the overall updated NMNAP and the appropriate LGA planning and budgeting tools. The ASRP also supported necessary preparations by PO-RALG: the definition of minimum budget allocations for nutrition, which were communicated officially to all LGAs and Regions. Now, the NMNAP and the tools are in place, and the relevant district staff from the concerned sectors have recently been given training on them. The formulation of stronger multisectoral plans is now in progress. It is expected to result in the first ‘generation’ of district nutrition-specific and nutrition-sensitive plans taking effect at the start of the 2018-2019 financial year, as part of their respective Comprehensive Council Development Plans (CCDPs). The new TOR for CMSCNs expect these “council [nutrition] strategic action plans [to] be used to develop a nutrition compact with the Regional Commissioner”, linked to the nutrition compacts already in place between the Vice-President and Regional Commissioners (GOT, 2017g: 5, 24; see GOT, n.d. b for the format of the new compact). Performance under these compacts can be tracked through the enhanced nutrition information systems that the project has helped to introduce. 81. It is further expected that LGA nutrition planning will be stimulated by the recent government instruction that a minimum of TZS 1,000 per child must be allocated towards improving nutrition-specific interventions at local level. Such budget planning levels for nutrition actions will be increased during forthcoming years. 82. It was inevitable that work towards BNTS Output 1.3 in terms of comprehensive multi- sectoral nutrition planning (guidelines for nutrition specific interventions have been in place and used since 2008) had to be delayed until appropriate government guidelines and tools were in place. Now that the NMNAP systems and procedures are in place, accelerated efforts can be made to support LGAs in effectively adopting and using them to achieve well- designed plans and effective implementation mechanisms. This will be a major and central challenge for the remainder of the ASRP.

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe

SBCC

83. The project’s SBCC strategy, as EQ 5. What progress has been made towards Key described in UNICEF’s ASRP proposal, Result/Outcome 2? [Pregnant women and is articulated around five pillars: caregivers of children aged less than two years context-specific research and analysis enabled to practise nutrition-relevant behaviours of barriers to behaviour change; development of messages and and take up nutrition services.] communication material; focus on EQ 6. What factors have stimulated or impeded individual and social change; use of a progress towards KR 2? combination of communication approaches; and regular monitoring and evidence-based one-to-one counselling (UNICEF Tanzania, 2014b: 36-39). 84. The core of the strategy, as observed by the evaluation mission at community level, is the formation of ‘counselling groups’ (CGs) and delivery of messages to them. Each participating village has at least one CG. The messages are targeted to a particular group of women depending on the life stage: whether foetal, infant (baby) or older (6-24 months). The criteria for participating in the groups are that members should be pregnant or lactating women or other care givers of children under two years. Other members of the community are not considered eligible unless they have children below two years. The behaviour messages focus on three stages of development of a child, i.e. foetal, 0-6 months (the period of exclusive breastfeeding) and 6-24 months (the period of complementation or complementary feeding). Formation of CGs in some villages is based on these three phases. As a result there are three different groups: one for pregnant women, one for women with children aged 0-6 months and one for women with children aged 6-24 months. Each group is provided with the relevant messages based on the stage of growth and development of the baby, which is good for immediate application of the information. It was observed in one of the FGDs in Mbeya that when the different groups were put together in one session, some members did not know the messages that were intended for children age 0-6 months if they themselves were still pregnant. In addition, women are no longer considered eligible after their children ‘graduate’ at the age of two; but there are no messages for them on how to continue with practices to ensure adequate growth beyond that age. (As mentioned in ¶15 above, the concern is with stunting among children aged under five.) This may be based on the assumption that the woman has already been empowered and would be able to continue on her own. However, it was observed during discussions with women that they needed further knowledge and information on child feeding and care after the age of two, which is the focus period for the project. 85. Although there is thus room for improvement in the ‘counselling group’ approach, the groups that the evaluation team met in the field showed impressive levels of awareness and understanding of the SBCC messages that had been conveyed to them. Some participants did express concerns about the feasibility of some of the proposed behaviour changes, on the grounds of existing work load or problems of access and cost. Many said that men were insufficiently engaged. But there is no doubt that those who have experienced ASRP SBCC have a deeper understanding of how to combat stunting and are committed to try. 86. Two challenges are only partially addressed by the project’s SBCC approach so far. The first is the heavy workloads, and consequent time poverty, of most women, limiting their availability for CG sessions. Many of the CGs participating in evaluation mission FGDs said that they held two sessions per month. Field observation and participant consultations indicate that this is insufficient contact time to achieve the intended results. The second challenge is that of continuity, during and after project implementation: whether ongoing cycles of CG training (and counselling?) will be maintained for new cohorts of pregnant and lactating women and caregivers of children in the target age range; whether women (and

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe men?) who have had some or all of the advice during previous parenting cycles will re- engage in refresher activities; and who will continue to deliver and direct SBCC activities. 87. The ‘counselling groups’ were expected to work as support groups. This was not observed during the evaluation mission. CGs appear to be functioning more as training groups than as forums for counselling and mutual support – which is why they have been labelled with inverted commas above. Traditionally, there were support groups in the communities that were responsible for helping each other, especially after delivery, when other women in the group would take over all the activities at the household of the woman who had delivered, to ensure that she got enough rest after the challenges of pregnancy and labour and was able to breastfeed successfully for a period of three months. While simply reverting to traditional structures would be inappropriate, it is important to retain and build on the established principle of peer support. 88. It was observed that the majority of members in the CGs are women in the active reproductive stage. However, women live with other people such as their husbands, in-laws or their own parents. Some of the behaviours that they learn during CG sessions cannot be implemented if other members of the household are not aware of them or do not understand the implications of not practising them. For example, consumption of a balanced diet, diversified foods, adequate rest during pregnancy, sufficient time to breastfeed, and support and care during pregnancy and lactation, should be understood by all household members and the community in general. These are behaviours that need support from other members of the household and community to ensure that women practise them and adhere to the practice. Most of the behaviours that women told the evaluation mission are difficult to practise are related to lack of understanding by other members of the family and community on the key aspects related to pregnancy and infant feeding. This limits their capacity to support pregnant women and children: e.g. poor water supply in the community, making it hard for women to adhere to the appropriate WASH practices that the project advocates. 89. Ensuring that the SBCC approach is adequately gender sensitive is a significant challenge for the longer-term effectiveness and sustainability of the ASRP (¶185 below). The project’s SBCC approach involves the identification of ten ‘influencers’ per village: respected leaders such as pastors and school principals who are given some orientation on stunting and its causes and are then expected to provide long-term guidance and advocacy, urging and stimulating community members to take the issue seriously and adopt the necessary measures to combat it – with a particular emphasis on mobilising men. There is little hard evidence on the effectiveness of the ‘influencers’ strategy, although some of them have certainly taken the role seriously. Their role was more one of community mobilisation (for which they lacked training, although their local leadership position and skills may have been useful); they were not expected to provide support on the technical aspects of nutrition. IPs reportedly hold quarterly community mobilisation meetings and public advocacy sessions, involving the ‘influencers’ and other local leaders, to broaden nutrition understanding and commitment beyond the mostly female participants in CGs. But, as noted, evidence from the field suggests that further work is needed to make this strategy fully effective. 90. SBCC content is rich in advice for pregnant women, but less so for lactating women, who need to be given adequate guidance on healthy eating to ensure successful breastfeeding. Some women told the evaluation mission that they terminate breastfeeding too soon, because their own food intake is insufficient. 91. The information and communication materials leave room for improvement. Although enlarged from A4 to A3 in 2017, the size of the ‘bango kitita’ set of visual aids still makes presentation during the sessions challenging. In CGs visited by the mission, despite the large numbers of leaflets and flyers distributed by the project, women stated that there were no such supplementary materials for them to take home to refresh learning and for sharing with other household members to ensure high knowledge retention at household level.

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe

These should include recipes that women can take home and use as they apply what they have learned about good nutrition for their children. UNICEF reports that these materials are produced and disseminated, but this evidently needs to be done on an even larger scale. 92. Although the ASRP reportedly provides refresher training for CHWs – an important part of an effective SBCC strategy – this was not evident from the discussions that the evaluation team held with some of them. CHWs told the evaluation team that they need more training. The team also observed that there are limited information, education and communication (IEC) materials to support CHWs’ own learning, keep them up to date in terms of information and make them confident to face the challenges that may arise in the course of implementation of the activities. 93. Delivery of materials has a micro-level emphasis on teaching, based on simple dissemination of knowledge in classroom, clinic or other village settings, complemented by the quarterly public sessions mentioned in ¶89 above. In some villages, this approach has contributed to limited participation by men and other members of the household or community. In this regard the approach used does not meet the needs of the beneficiaries especially on the issue of gender. Unless this is addressed, beneficiaries and communities will not be able to benefit fully from project activities. However, in some areas participants commended the ASRP approach of combining theory and practice (such as cooking demonstrations), arguing that it is better than the approach used at health facilities, where women are given instructions on what to do without being shown how to do it. The ASRP approach reinforces the messages obtained during theory sessions and is seen as enhancing the consistency and effectiveness of the learning process. 94. The appropriate aim of ASRP SBCC is to enhance the nutrition of children in the first 1,000 days of life. The baseline survey results and the current growth monitoring in some of the implementing villages have shown that faltering of growth, in terms of length and height, indeed occurs before the age of two years. What is concerning from the limited data available, is that the magnitude of longitudinal growth restrictions seems to accelerate between the age of one and two years (maybe starting as early as 9 months of age), with culmination of stunting prevalence at age two to three (as is clear also from the national DHS data). Hence, problems that may not yet have been fully comprehended could be aggravating around the child’s first birthday, with deterioration in the second year of life. For example, at age one, children finish their vaccination schedule at health facilities, cease their regular attendance at these facilities and drop out of regular growth monitoring and promotion services. The children are also more likely to be left behind at home when the mother goes for work or other chores. An unpublished study carried out in the same Regions16 showed a similar pattern of faltering growth, but with slight improvement at age four to five years; but then the damage to mental functions may already be irreversible. It might be beneficial to carry out further investigations of the effectiveness of the SBCC approach during the second year of life. 95. Another question is, what happens to children after attaining the age of two? What follow up mechanisms are in place to see how these children progress up to school age and school performance? This would be necessary for generating evidence on the relationship between stunting and school progress, which is used in some areas as a motivation for women’s participation and sensitisation or mobilisation of communities. 96. Awareness and general knowledge about stunting and its impact on the overall wellbeing (physical, social and economic) of an individual and a household have been a motivation for women to participate in CGs. In addition, implementation of Village Health Day (VHD) activities in some LGAs has helped to generate interest and stimulated

16 Unpublished study on Tanzania by the Agriculture to Nutrition (ATONU) initiative of the Food, Agriculture and Natural Resources Policy Analysis Network (FANRPAN). ATONU currently focuses on Ethiopia, Nigeria and Tanzania (FANRPAN, 2017).

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe community members to participate. This is because, during VHDs, participants get information about the nutrition situation of their children as well as that of adults. There is also dialogue or discussion about the results, which may lead to negotiations as to what course of action to take to improve the situation. Nutrition services provided through the health sector 97. The ASRP has worked to increase the proportion of health facilities implementing integrated management of acute malnutrition (IMAM). The original BNTS target (not directly replicated in the ASRP proposal) was that by 2016/17, 35% of health facilities in the six ‘intensive’ districts would be implementing IMAM. UNICEF’s November 2017 BNTS progress report says that “the proportion of health facilities providing SAM [severe acute malnutrition] management has increased to 26% in 2016/17, resulting in an increase in the coverage of SAM treatment to 72%” Table 17, Annex G: on page 112). As can be seen in Table 11 (Annex F, page 95), national bottleneck analysis data show the MINS Regions to be performing relatively well on a variety of indicators regarding the treatment of children with SAM. 98. Despite this progress and its achievements in SBCC training for health facility staff, the ASRP’s efforts to combat stunting are inevitably constrained by the limits on nutrition services at these facilities (although coverage of Vitamin A supplementation is good (¶158 below)). Growth monitoring is still mainly based on routine weight measurement (¶161). There are few data so far on length and height of children. In addition, the supply of supplements is inadequate, as observed in all health facilities visited by the evaluation mission. In some areas it was reported that lack of IFA at the health facilities has discouraged women from continuing in the CGs or visiting the health facilities for check-up (¶159). There are no dedicated staff at the health facility or in communities to provide counselling on nutrition; the staff in post have heavy workloads across the primary health care spectrum. The equipment for growth monitoring has been supplied and distributed to the health facilities but in some areas staff have not yet been trained on how to do the measurements. Therefore there is a lag in terms of data on stunting. Measurement of haemoglobin concentration is not done in many of the facilities due to lack of cuvettes, so data on anaemia is scanty. In Regions like Njombe and Iringa, where VHDs are not done, no data on length and height are being collected yet, and therefore stunting cannot be monitored. However, efforts are now being made to revive and intensify the growth monitoring programme (¶161 below). 99. As noted in ¶23, section 2.1 above, the project does not fully cover the target Regions, with IPs generally aiming to deliver the full SBCC package in 75% of villages. This means that 25% of the target beneficiaries are left out. The consensus among informants is that, with the project systems and infrastructure now in place and functioning, it would be appropriate to try to expand SBCC to all communities in MINS. 100. Although local government structures at ward and village level are consulted and informed about project activities, the project and, more importantly, the commitment to reduce stunting are not adequately integrated at these local levels. They remain partially external, in two senses. First, the project approach, despite its multisectoral messages on topics like WASH, is still seen as largely a health concern, driven by CHWs who are supervised by health facilities. Secondly, communication, ownership and understanding with and in ward and village governments remain incomplete, with some staff and office holders at these levels telling the evaluation mission that the project does not engage and inform them enough. Although their recurrent budgets are very limited, government staff in wards and villages are a significant human resource that could make a stronger contribution to combating stunting – and who will still be there after the project ends.

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe

Agriculture

101. Agricultural and livestock EQ 7. What progress has been made towards Key production are two of the main ways Result/Outcome 3? [Availability and access to to produce the nutrients needed for diverse and micronutrient-rich foods at household sustaining life and improving level enhanced.] nutritional status. However, increasing production alone has EQ 8. What factors have stimulated or impeded limited impact on improving nutrition, progress towards KR 3? especially if the agricultural production is focused on high production of staples (maize), with less attention to other crops such as legumes, fruits, vegetables and animal source foods. The MINS Regions produce sufficient amounts of maize, bananas and potatoes but not enough of many other crops such as pulses, vegetables and fruits. Cereals and starch-based crops provide the bulk of the energy in the diet but are very limited in essential vitamins, minerals and protein. Food security in Tanzania is often equated to maize availability (ugali), but crops that provide other nutrients, such as animal sources of foods (meat, eggs, dairy), pulses, vegetables and fruits are not considered, and sometimes their production statistics are not captured. These food crops provide essential nutrients which are needed for physical growth, brain development and health of the child. Although these Regions are known to produce diverse foods, diversity in production or on the market is not reflected in the diversity of diets, suggesting – as the project proposal recognises (¶63 above) – that there is something amiss. 102. The paradox arises because the largest share of the area under production is occupied by staple crops. This is reflected in the household diet, where 75% or more of the meal is staple and for children below two years of age it is often 100%. Basically there is overfeeding of starch-based foods and underfeeding of micronutrient-rich foods. This suggests that food availability by itself does not necessarily lead to adequate nutrition. Other factors such as poor levels of care and support for children, heavy workload of women, seasonal variations in food and income availability, the prevalence of poverty in rural areas and production dynamics may contribute to poor nutrition. In this regard, the contribution of agriculture to nutrition depends on both adequate production and consumption of diverse foodstuffs. 103. The BNTS baseline survey showed that people do not eat sufficient vegetables and fruits when in season, and that some vegetables and fruits are not available throughout the year (Concern Worldwide, 2014b). The BNTS design therefore included an agricultural component aimed at increasing the availability and accessibility of vegetables, fruits and animal source foods in the participating households and at creating awareness about the importance of agriculture in nutrition. It was also intended to demonstrate the necessity of consuming nutritious food, especially for pregnant and lactating women and young children. Activities were designed to help the poorest farmers to increase production of selected nutrient-rich crops and increase awareness about dietary diversity – on the assumption that they have the land, labour and access to inputs that such production would require. 104. The results of the baseline survey also showed that the crops produced and available in MINS were maize, which was produced on average by about 91% of the households, followed by paddy (17%) and wheat (11%). Other crops included Irish potatoes (37%), pumpkins (67%), beans (74%) and vegetables such as bean leaves (29%). The aggregate data at Regional or even zonal levels suggest that there is a wide diversity of crops in the project area. This was confirmed through interviews and market survey. However, this masks what is happening at household level. Dietary diversity data did not match the data on availability of diverse crops in the market. The information from the baseline survey is limited because it presents one-time point data based on a single survey, done in March 2014 when crops were still in the field. In addition, assessment of crop diversity was based

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe on the preceding crop season and not on crops standing in the field, rendering the findings vulnerable to respondent memory lapse. In many of these areas, production is seasonal and the availability of foods varies with season. The availability of foods like vegetables and fruits is critical during the dry season. This is when many of the rural households face significant shortages. Availability through their own production is low, or zero, and they have limited capacity to access these foods through the market because of high prices and low incomes. 105. The project uses ‘progressive farmers’ (PFs) in implementation of the project activities. PFs are volunteers from the community. They have been trained in vegetable production and are expected to train and provide support to other farmers to implement the agricultural component of the project, which is being implemented in a few of the villages in IA-funded ASRP districts. They were drawn from among farmers who showed interest and capacities in diversifying agricultural production and willingness to increase nutrient-rich food production to improve household food diversity. PFs have been trained in vegetable production and processing so that they can act as change agents for other farmers in the community through farmer field schools (FFSs), to promote the cultivation of household (kitchen) gardens among women and vulnerable households, giving them a greater control over household nutrition. Production uses open pollinated varieties of fruits and vegetables rather than hybrids, to ensure sustainable availability of seeds. Start-up seeds were procured from the Asian Vegetable Research and Development Centre – World Vegetable Centre (AVRDC- WVC) in . Farmers have been taught how to multiply them and later distribute them to other farmers who were not initially targeted. The project has also trained PFs on vegetable and fruit preservation using solar dryers to reduce post-harvest losses and ensure a sustained dietary diversity throughout the year. Other activities include training on livestock rearing practices and culinary demonstrations on proper cereal and vegetable preparation for maximum nutrient retention. Other messages on optimal IYCF, WASH, ECD and health practices are also delivered during FFS meetings. 106. Each PF is responsible for providing weekly training to a group of 30 farmers, meant to comprise 50% women and 50% men and to include the most vulnerable people in the community (widows, poor farmers etc.). Each member of the group is responsible for training at least four or five more people among her/his friends and neighbours, and encouraging them to start kitchen gardens for growing micronutrient-rich food crops. The project has supplied inputs such as seeds, fertiliser, herbicides, pesticides, farming tools, hand sprayers, hand hoes, bags, boots and watering cans. 107. As noted in ¶26, section 2.1 above, the agriculture component is implemented in six of the 23 LGAs in MINS, with no activities in Songwe Region. According to the project’s latest progress report (Table 16, Annex G), 200 PFs had been trained and 200 FFS established by May 2017, with a total 15,677 farmers receiving training and inputs and a total 13,779 households (5% of all households in the project area) starting kitchen gardens and/or small animal keeping. Within the target districts, some wards are selected for this component: eight of the 28 wards in Mbeya District Council (DC), for example, and eight of the 20 in Mbarali DC. So far, 28 of the target 40 villages in Mbeya Region have been reached. In Njombe DC, 16 of the total 37 villages are covered; in Makete DC, 19 out of 65. Project progress reports refer to a target of PFs being trained and in turn providing nutrition extension services in 60% of wards (UNICEF Tanzania, 2017a :35). This does not seem realistic. 108. Participation in the agricultural activities is a challenge. There are variations in the proportion of people who participate. It is not the same each time the groups meet. In addition, male participation in vegetable gardening activities is very low compared to that of women; men are mostly interested in the small animal component of the project. When small animals were introduced the number of people joining the groups increased, especially of men. However, the involvement of youth (boys and girls or schools) is poor.

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe

109. PFs manage demonstration plots and have been given all the necessary tools for gardening and training. They are supposed to teach other farmers about vegetable gardening. However, the diffusion process has been slow due to the limited capacity of PFs to supply seeds and tools to other farmers who want to join. In addition, it has been hampered by the geography of the villages and the reluctance of some farmers to participate. However, people in some areas in Mbeya and Njombe DCs feel that this knowledge is important for many households and should therefore be expanded, especially the sack garden, which many people are interested in and adopt very easily. For example, farmers from Wanging’ombe, Ludewa and Makete districts have requested it. 110. Water is scarce during the dry season and the programmes and agencies responsible for provision of water in the rural areas cannot meet the demand. There are projects that are dealing with provision of water in these areas but during the dry season this water is also scarce and cannot be used for irrigation. People in some communities must therefore continue to cultivate vegetables in the valleys, far from their homes. It is envisaged that with the adoption of kitchen gardens, households would be able to use their waste water to water their vegetables. At present, the distance to vegetable gardens can be a challenge for women in some areas, e.g. the lowland areas in village. This increases the work load of women, who are involved in crop production throughout the year. However, the credible consensus is that vegetable gardens at the homestead, irrigated with grey water from the house if no other water is available, are both feasible and beneficial without imposing a significant extra burden on women – some of whom told the evaluation mission that, if the garden is very close to the house, they can look after it at the same time as performing some other household tasks. 111. Food processing and preparation are other issues that cause nutrient losses in the food consumed. For example, the maize meal that is used for making stiff porridge is highly polished; many of the nutrients are lost in the bran or water that is used for soaking before milling. Vegetables are cooked for a long time, leading to significant nutrient loss. The project has not addressed this issue adequately. 112. It was noted that the types of seed distributed are chosen by the project rather than by farmers. The seeds that are distributed are the same in all areas. There was no effort to customise and contextualise the type of seeds to be distributed. Farmers have observed that some seeds being distributed are not suitable for the area. Therefore some farmers have asked for soil analysis to be done to establish the properties of the soils so that the seeds being distributed can correspond to the type of soil that can support the crop. Similarly, some crops being introduced are not what farmers prefer. Consequently, farmers who have adopted the crops are producing them for sale rather than for their own consumption. A further concern is the limited number of seeds distributed (linked to the limited budget for this component). Seeds are distributed only once; farmers are expected to save seed for further plantings, or procure it themselves elsewhere. Those who do not join the activity at the start may find there are no seeds left to give to them, which obviously reduces the incentive to adopt the recommended practice. 113. In addition to vegetable and fruit production, the agriculture component promotes small animal production, distributing rabbits and guinea pigs to selected participants. This activity has just started and very few farmers have received the animals so far. Distribution of rabbits and guinea pigs needs to be expanded. However, it is unclear whether households would be able to consume the animals. They are not part of the traditional diet in the project area. Some community informants said that some households that keep small animals such as guinea pigs do so mainly for production of manure rather than for consumption. 114. Agricultural Extension Officers (AEOs) and other personnel at ward and village levels are not actively involved in providing extension services to project participants. Generally, AEOs do not provide advice to farmers on what foods should be grown to meet their

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe families’ nutritional needs. The capacity to provide such information is limited, partly due to the training they go through, which does not provide knowledge on linking agriculture to nutrition. Inadequate utilisation of human resources at these levels is one of the limitations of the project’s approach. If community development and livestock personnel in the project areas were trained on nutrition, the involvement of this cadre in the project could help to build capacity on the linkage between their areas of specialisation and nutrition. This would help ensure sustainable implementation of the activities after the project is completed, and slowly strengthen the integration of nutrition in other sectors for multi-stakeholder collaboration in enhancing the nutrition of children and the population as a whole. 115. In the agriculture component, SBCC on the consumption of nutritious food is either lacking or not adequately articulated in the implementation of the activities. Messages in the project’s main SBCC component about consumption of appropriate foods are not sufficiently delivered to participants in the agriculture component. The project is using the traditional approach, which focuses on increasing production and availability rather than on increasing consumption. The importance of consuming vegetables or diversifying the diet is not emphasised. In addition, knowledge about the importance of these foods/crops in the body is not being shared. People are just advised to produce without being told enough about why they should produce and how best to consume the crop. The approach of the agriculture component is thus not holistic. AEOs should also provide advice on diversification of field crops to ensure supply of an appropriate range of foods for household consumption. At present, the project is implementing a narrow range of activities promoting production of vegetables, fruit and small animals. 116. The focus of the agriculture component on poor women farmers is understandable (UNICEF Tanzania, 2012: 21), but may diminish the overall effectiveness of the intervention from a nutrition perspective. The common perception is that poor people cannot afford to eat meat and must restrict themselves to carbohydrates and vegetables. This element of stigma may be associated with the idea of growing and eating more vegetables as the project promotes these practices among the poor. In fact, higher-income families should be producing and consuming just as much of these nutritious foods, and from this perspective it would be more appropriate for the ASRP to target all members of the community. 117. The agriculture component as implemented by the project can help to alleviate the problem of accessing animal source foods and vegetables. However, coverage of the agriculture component is very limited compared to the size of the problem. It is not certain whether this component of the project will manage to achieve a significant impact in MINS.

Evidence and learning

118. The issue of generating evidence EQ 9. What progress has been made towards Key and learning was explicitly emphasised Result/Outcome 4? [Evidence and learning from in the original programme proposal, district and community programming on nutrition which said that “a detailed context documented and used to inform the scale-up of analysis of undernutrition will be nutrition actions to reduce stunting.] carried out at the start of the project to better understand the factors EQ 10. What factors have stimulated or impeded responsible for high stunting in the progress towards KR 4? three regions, in particular why stunting coexists with relatively good food security, and the social, cultural and gender issues influencing nutritional status” (UNICEF Tanzania, 2012: 21). In view of the socio- economic context (section 1.2) and the findings presented in this chapter on SBCC (page 20), and gender (section 4.6) these broader issues should have been given stronger attention through studies early in the project period, which might have led to better focused actions. Instead, three rather specific studies related to micronutrient deficiency control were initially proposed (but not conducted). Eventually, five priority areas were selected for

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe initial baseline studies and exploratory research, carried out by the initial BNTS IP, Concern Worldwide. 119. The nutrition baseline survey report (Concern Worldwide, 2014e) presented data collected in November 2013. The survey was professionally planned and conducted and will provide useful baseline data for evaluation of the overall impact and outcome of the project if a comparable endline survey can be conducted at the appropriate time. Given the delays and staggered implementation of the project, it would be prudent to start planning now for the endline survey data collection to take place in November 2020. It should be noted, however, that the baseline survey used the three original Regions of Iringa, Njombe and Mbeya as the sampling frame, so no district level comparisons will be possible and it will be difficult to get separate valid estimates for the two parts of the original Mbeya Region, which is now divided into Mbeya and Songwe Regions. 120. The baseline nutrition capacity assessment of LGAs at the district level in Mbeya, Iringa and Njombe (Concern Worldwide, 2014c) provides simple and useful documentation of the situation at the level of the district authorities at the start of the project. However, the assessment is confined to the presence of District Nutrition Officers (DNOs) and Nutrition Steering Committees, and does not attempt any in-depth assessment of capacity or performance. Most of the ‘physical’ capacity gaps, i.e. vacant posts, now appear to have been filled. 121. The baseline barrier analysis (Concern Worldwide, 2014a) is quite a comprehensive assessment and analysis of apparent barriers to adopting four selected key behaviours deemed to be closely related to stunting prevention: exclusive breastfeeding (EBF), adequate diet during pregnancy, meal frequency, and diet diversity in complementary feeding. It is not clear, however, whether and how the results of the study were used in the implementation of the SBCC component of the programme, except that the need to address and involve ‘influencers’ was generally adopted in project strategy (¶83 above). The last two of the selected behavioural change areas (meal frequency and diet diversity in complementary feeding) were still identified as the most difficult to adopt during the counselling group discussions carried out during the evaluation. The specific results of the study thus seem not to have been very useful or easy to act upon. With hindsight, it would have been more useful for the study to look more closely at the ‘deeper’ gender and social norms issues, which should have been more directly addressed – instead of just instructing women on how to behave without challenging the social and economic constraints that they face as a result of the continuing male control of household resources and decision-making (section 4.6 below). The potentially positive or negative advisory influence of older women received little mention. 122. The baseline crop and livestock survey (Concern Worldwide, 2014b) was conducted to assess production and availability of crops and livestock in the then Iringa, Njombe and Mbeya Regions. Basically, the results showed that crops that were produced and available in the three regions were maize, which was produced on average by about 91% of the households, followed by paddy (17%) and wheat (11%). Other crops included Irish potatoes (37%), pumpkins (67%), beans (74%) and vegetables such as bean leaves (29%). The results are presented by Region, which masks what is happening at household level. Aggregate data at Regional or even zonal levels suggest that there is wide crop diversity in the Regions; this was confirmed through interviews and market survey. However, dietary diversity does not match the diversity in production and market availability. This could be related to limited knowledge on consumption, since much emphasis and effort in terms of technological and information support has been directed to production and marketing, and less on consumption. Consequently, farmers produce certain types of food purely for the market and not for their own consumption – and appear not to use enough of the resulting income to procure an appropriately diverse diet for their families. However, the information from the baseline survey is limited because it presents one time point data.

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe

What is clear in many of these areas is that production is seasonal, and therefore the availability of foods tends to vary with season. Across the Regions, the survey found that less than 20% of households owned any kind of livestock (except poultry, which were owned by 67%). Of all surveyed households, 27% had a kitchen garden. Overall, it concluded that “most farmers grow their crops mainly for home consumption, however at least 88% of them end up selling some” (Concern Worldwide, 2014b: 32). Although the survey did not directly address the apparent paradox of an agriculturally productive part of Tanzania suffering above average levels of stunting (¶128 below), it did recommend more work to promote the production of nutritious crops, particularly vegetables, and nutrition education for farmers and households. 123. A baseline market survey assessment of private and commercial traders in village and ward level markets was the fifth of the original studies (Concern Worldwide, 2014d). This exercise was overtaken by events, as it was decided not to proceed with the ‘market stimulation’ activities set out in the BNTS proposal (output 3.2: UNICEF Tanzania, 2012: 21). Like the baseline crop and livestock survey, this assessment was based on one round of data collection, in the harvest season; the report recommended that “a follow-up survey should be done during off peak season to understand seasonal market dynamics” (Concern Worldwide, 2014d: 14). The survey identified the strong role of middlemen: hardly any of the retailers interviewed were buying directly from farmers. It also found that “75% felt there are no difficulties in selling a range of diverse foods” (Concern Worldwide, 2014d: 3). 124. Apart from these five baseline studies, project resources were used to develop and roll out two important assessment methodologies: the ‘bottleneck analysis’ (BNA) and ‘scorecard’ systems. Both systems were developed as tools and management information systems to support the TFNC, to enhance their capacity to monitor and identify gaps in the implementation of the NMNAP (section 1.3 above). 125. Based on the original Tanahashi/WHO model (Tanahashi, 1978) and as further developed by UNICEF globally, the ASRP supported development of a bottleneck analysis methodology to identify overall barriers to implementation and effectiveness at district level for a set of critical nutrition-specific interventions: vitamin A supplementation (VAS); iron- folic acid supplementation in pregnancies (IFAS); treatment of severe acute malnutrition (SAM); and infant and young child feeding (IYCF) counselling. The methodology was then rolled out to all LGAs in 2015 and annual updates were submitted to TFNC from most LGAs in Tanzania. The results were presented and discussed at the annual national Joint Multisectoral Nutrition Review (JMNR) meetings (see also ¶157 below and Table 8 – Table 15 at Annex F). The 2017 JMNR stated that most LGAs were facing problems with IYCF, IFAS and SAM implementation, but that there were significant improvements compared with 2016. 126. An example of use of BNA was observed in Iringa District Council (DC), where the CMSCN applied the method to analyse weaknesses in their implementation of nutrition- specific interventions and subsequently to help them to direct new budgetary resources to address these bottlenecks. The methodology has important potential for enhanced understanding and management of nutrition issues in Tanzania. 127. Also with ASRP support, a scorecard analysis methodology for assessing progress at the LGA level was developed using the African Leaders Malaria Alliance (ALMA) model (ALMA, 2017). The indicators to be used in the assessment were developed and agreed at a national workshop organized by TFNC with support from UNICEF. The national JMNR meeting in , in September 2017 was the first occasion where TFNC could present an almost complete set of reports from the districts. These scorecard data are useful in assessing the performance of the BNTS/ASRP LGAs compared with the rest of the country (¶13 above and Annex F). This was the first time the LGAS, their CMSCNs and their Nutrition Officers had used this methodology, and there is still considerable uncertainty

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe about how to find and enter the required information and how to use this information at LGA level. However, the methodology will undoubtedly become a very useful tool in the future management and co-ordination of the implementation of the NMNAP, both at national and subnational levels. 128. The fundamental question of why stunting coexists with relatively good overall food availability (¶118 above) was not directly addressed by the five baseline studies, nor by the BNA. Concern Worldwide and the UK-based Centre for Research on the Epidemiology of Disasters (CRED) did produce a further report that analysed data from the baseline studies to produce an “in-depth analysis of the factors associated with stunting” (Concern Worldwide, 2015b). While offering useful insights into these factors, it did not offer a clear answer to the question – although it did point to the problems of “maternal time allocation” and to measures that might reduce women’s workload, including the adoption of conservation agriculture and reduction in the time needed to collect water (Concern Worldwide, 2015b: 20-21). 129. Stunting data. It is important for a project dedicated to combating stunting to promote the collection of data about young children’s length and height. So far, relatively little actual updated, detailed information on stunting has been generated and is available in MINS, although in 2014 BNTS did support the Tanzania National Nutrition Survey, which generated useful evidence that was used, inter alia, for identifying the Regions on which efforts to tackle stunting should focus. The only information to which project participants could refer to was the 2015 Tanzania Demographic and Health Survey (TDHS) data, which do not even separate Mbeya and Songwe Regions but offer one common estimate (34.4%). Even the baseline survey was not widely circulated; but it does, of course, have the same limitation of using the original three Regions as its sampling frame. 130. Under such circumstances it is very difficult for project participants – especially at sub- national levels – to assess and analyse trends and differentials in stunting which could help them to understand major differences and causal factors and, indeed, to measure any success or failure in their efforts to improve the situation. The recent decision by the project to reintroduce and strengthen growth monitoring of children under five (¶161 below) should radically change this situation – provided these efforts are properly organised, supervised and combined with good, real time reporting and compilation mechanisms. This is a reintroduction since a series of earlier nutrition programmes in the MINS Regions – starting with the globally well-known Iringa Nutrition Project of 1983 – 1988 (¶14 above) – actually used community-based growth monitoring not only for detecting and addressing undernutrition (weight for age) in individual children, but also for participatory learning and nutrition programme management at community, district and Regional levels. These were based on ongoing Assessment-Analysis-Action (Triple A) cycles where the community measurements of children’s nutritional status provided the (quarterly updated) inputs to drive the cycles forward. New information technology for data transmission and analysis can now make these older systems much more effective, provided the basic measurements can be carried out with sufficient quality and coverage.

4.3. Efficiency 131. Available data are not structured or detailed in a way that permits a EQ 11. To what extent were results achieved with complete empirical answer to EQ 11 the most economic use of resources? (see box); and the project is, in any case, only part way towards achieving EQ 12. To what extent does the intervention the results to which the question refers. complement other nutrition activities? 132. One clear weakness, from the perspective of economic use of resources, was summarised in section 2.1. The originally selected implementing agency gave notice of its

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe intention to withdraw 14 months after the BNTS project agreement was signed, and it was not until late 2015, some two and a half years after that original agreement was designed, that a substantially revised project began with a different set of IPs. While the initial work through Concern Worldwide did achieve a limited amount of field implementation and five valuable baseline studies, it is plain that time and money were wasted by the events of 2013 – 2014. 133. A key aspect of organisational efficiency concerns the use of six IPs rather than the original one. The original arrangement, with Concern Worldwide as the sole IP, was arguably simpler from an administrative perspective than the subsequent contracting of three international and three national IPs. However, the engagement of national IPs has potentially enhanced efficiency and effectiveness by bringing much greater local knowledge to bear on project implementation (under administrative arrangements that have not unduly increased total overheads). It also, arguably, strengthens the sustainability of project interventions by increasing the national knowledge base on which subsequent implementation of nutrition programmes can draw. Furthermore, some of the international IPs also draw on many years of experience in the Tanzania nutrition sector, which reduced potentially inefficient learning time when they took over project implementation. It is important that the three IP consortia be able to learn enough, often enough, from each other’s ideas and operational experience. There are opportunities for bilateral learning with UNICEF at the annual joint partnership review meetings (held separately with each IP), and for the IPs to meet together at the quarterly consortia co-ordination meetings. 134. UNICEF’s implementation arrangements for the BNTS and the ASRP combine donor funding from IA (and DFID) with contributions from the international IPs and from UNICEF’s own resources. IPs, for example, contribute some of their own staff time, office space and transport to project activities and/or support. From the donor perspective, this increases project efficiency. 135. UNICEF’s most recent annual report to IA presents cumulative expenditure data to 31 May 2017 (‘Year 4’: UNICEF Tanzania, 2017a: 38-41). Across the four BNTS Key Results it shows total expenditure to that date of USD 9.85m, of which USD 4.21m (43%) was provided by IA and USD 5.64m by ‘other sources’ – mainly DFID through the ASTUTE programme’s funding for the ASRP. The total IA contribution towards the four KRs excludes other amounts reported for ‘supplies’, ‘technical assistance’ and UNICEF’s 8% overhead (‘HQ support costs’). Taken together, those three categories totalled 27% of all IA funding used. Without detailed analysis of those categories, it is not possible to comment further on the efficiency of the operation. 136. What can be noted, however, are the proportions of the USD 4.21m of IA funding to date that were used directly in activities towards each of the four KRs. KR 1 (planning, budgeting, co-ordination and monitoring by Regional and local government authorities) received 8%; KR 2 (SBCC), 63%; KR3 (agriculture), 7%; KR4 (evidence and learning), 22%. While IA funding for KR 1 activities was matched by twice as much money from ‘other sources’, there was no other funding for the agriculture component (KR 3), which received 3% of the total disbursements from IA and ‘other’ sources. It is debatable whether it is efficient to implement a project component on such a small scale. While useful lessons are being learned, it is unlikely that the intended outcomes of KR 3 can be achieved or that enough is being done to lay the foundations for effective implementation across the whole MINS population after project termination. This is an inefficient way to aim for sustainable results. 137. EQ 12 in the box above (and set out in full in the matrix in Annex C) refers to another aspect of efficiency: whether the project complements, duplicates or contradicts other activities in the nutrition sector. The latter two possibilities are likely not only to waste resources, but also to slow the overall achievement of Tanzania’s nutrition objectives.

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe

138. As shown in sections 4.1 and 4.2 above, there is a good basis for the ASRP to be complementary to other nutrition initiatives in MINS and Tanzania because it has not been developed in isolation. Instead, it was prepared and has been developed and implemented in close consultation with the GOT, and has itself made important contributions (under KR 1) to the development of national policy, plans, systems and procedures. All this took place in the context of Tanzania’s membership of the SUN movement. The governments of Ireland, UK and USA as well as UNICEF and other UN agencies (WHO, FAO and WFP) were all among the original founders of SUN and – at that time – had ongoing support to nutrition and nutrition-related developments in Tanzania. Hence, they all made an effort to quickly mobilise support or re-focus other development support activities in order to respond to the call to scale up nutrition in Tanzania. 139. USAID responded quickly with the launch of the Mwanzo Bora project (¶35 above). DFID then started its ASTUTE programme in 2014 (¶36). Additional support was later forthcoming from other sources, e.g. the Children’s Investment Fund Foundation (CIFF), to cover additional parts of Tanzania in the common effort to rapidly scale up the ‘new’ nutrition approach, with the main objective of accelerating stunting reduction. Other partners – primarily NGO and private sector – provided additional support to address other related aspects of stunting reduction (food fortification, advocacy/communication, etc.) within the context of the Tanzania SUN initiative. All these efforts were coordinated by the newly established High-Level Steering Committee on Nutrition, chaired by the Prime Minister’s Office, with TFNC as the secretariat. UNICEF and the ASRP were in the mainstream of this new national approach, and the way the ASRP began to work it out in practice probably helped to attract additional funding to the sector. 140. The ASRP thus constitutes one component of a broader GOT initiative, where the development partners and other stakeholders made a committed effort to respond to the call for support to rapidly scale up stunting prevention measures. In this rapidly accelerating process, for which the GOT had limited financial and technical resources at the early stages, development partners were given considerable discretion in designing the different (and parallel) programmes; it was assumed that there was a common understanding of the causes of stunting and of pathways to stunting reduction. In practice, approaches have not been exactly the same, causing occasional problems at implementation level. But with the HLSCN and gradually increasing national capacity to assess and evaluate the effectiveness of the different stunting reduction initiatives, there are good expectations that the different initiatives will all contribute to finding the best possible solutions to the complex and changing patterns of factors causing stunting. 141. The ASRP can again be confirmed, therefore, as complementary to these other nutrition interventions. At operational level, however, the interface with Mwanzo Bora is not optimally efficient (¶35 above). Nor is co-ordination with other nutrition initiatives in MINS as close as it could be (¶143 - ¶145 below). The variable involvement and inadequate co- ordination of the CHW cadre is another example, with CHWs trained by one project (including ASRP) sometimes leaving to work for another project if it offers better opportunities. 142. Among the multiple stunting reduction initiatives in Tanzania, the ASRP has managed to play a central role, because the funding partners and UNICEF have balanced direct implementation with careful attention to and support for the development and formulation of updated national strategies and guidance notes on nutrition, as well as support to national capacity development of technical capacity for nutrition policy and programming (¶138). Consequently, as presently planned and implemented, the project reflects existing strengths, as well as weaknesses and ambiguities, in the national nutrition strategy and implementing guidelines rather than presenting significant contradictions to or deviations from these. For the remaining implementation period, the project needs to be open to

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe discuss and try out constructive ideas and initiatives from other sources, and to create a model for learning and synthesis through its KR 4.

4.4. Sustainability Alignment with other initiatives EQ 13. Does the design of the intervention make 143. Interventions being implemented appropriate provision for sustained good nutrition or by the ASRP include nutrition-specific align with initiatives that seek to do this? interventions, which are delivered through health facilities. These are iron, EQ 14. What are the prospects of sustaining the folic acid and vitamin A supplements, enhanced nutrition system introduced by the deworming, management of childhood intervention? diseases and growth monitoring (see also ¶158 – 162 below). Nutrition-sensitive interventions delivered through community interventions include WASH, ECD, agriculture/livestock and food processing and preservation. However, in the same Regions other projects have been supporting related interventions. These include: • vitamin A supplementation and deworming for children under five years old during child health days; • food fortification with micronutrients (oil and flour); • promotion of optimal infant and young child feeding; • counselling and nutritional care for pregnant and lactating women with HIV; • delivery of an integrated package for anaemia control for pregnant women including: iron and folic acid supplementation, deworming, intermittent presumptive treatment of malaria, promotion of insecticide-treated bed nets, nutrition education on adequate diet, screening for anaemia and referral for treatment, hygiene and environmental sanitation; • nutrition-sensitive programmes under the: • National Package on Essential Health Interventions; • Agriculture Sector Development Programme; • Water Sector Development Programme; • Education Programme. 144. In MINS there are a number of other stakeholders implementing nutrition activities, as shown in Table 3 below. 145. Together with the ASRP itself, these numerous organisations and initiatives should serve as an ample foundation for sustained good nutrition. The question is whether they are adequately aligned with each other and with the structures, capacity and programmes of the GOT and LGAs. There is some collaboration, notably between the ASRP and the Baylor programme. But there is insufficient evidence that these activities are adequately co- ordinated (by the GOT and LGAs) to prevent duplication, or all sufficiently focused on building sustainable operations that can function without external support.

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe

Table 3 Other nutrition stakeholders in MINS

Stakeholder Activity Target group Funding agency

Baylor College of Management of severe Children with severe and UK based, depends on Medicine Children’s acute malnutrition acute malnutrition Charitable Trusts and Foundation Foundations

Kilio cha Waathirika wa Nutrition education Households living with USAID through Pact, Ukimwi Tanzania HIV/AIDS 2013-2015 (KIWAUTA)

Shirika la Kuhudumia Nutrition education Households living with Not known Watu Wanaoishi na Virusi HIV/AIDS vya Ukimwi Majumbani (SKAMAVMM)

Service, Health and Supports implementation Households living with Not known Development for People of HIV prevention, home- HIV/AIDS Living Positively with HIV based care services, and AIDS (SHDEPHA) voluntary counselling and testing; gender-based violence and violence against children, in Mbarali District. It also provides nutrition education to PLWHA

Shirika la Kuhudumia Defending women's Abandoned children living Not known Wanawake na Watoto rights and children's in difficult situations Mbuyuni Mbarali rights as well as (SAMAWAMBU) providing support Combating AIDS and its effects Usangu NGO Network Co-ordination and Umbrella organisation of Not known (USANGONET) integration of CSOs to NGOs in Usangu area of build up capabilities, south west Tanzania exert influence and stimulate advocacy Communication centre/hub for all organizations and government and other stakeholders Deals with multiple issues including food security Policy analysis Promotion of good governance

146. In response to EQ 14 about the prospects of sustaining the enhanced nutrition system introduced by the intervention (see box), the following three sub-sections address the three specific questions that the evaluation matrix poses on the issue (Annex C, page 76).

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe

Nutrition governance 147. One of the conclusions of the original 1983-1988 Iringa Nutrition Project (¶14 above) was that it had adopted very appropriate and effective priority interventions and implementation modalities but that the nutrition governance system, upon which the whole programmatic approach depended, became dysfunctional once the (then) Tanzanian one- party system was abandoned in 1994 to give way to multi-party democratic governance structures and mechanisms (GOT, WHO & UNICEF, 1988; Ljungqvist & Jonsson, 2015). In the 1983-1988 project, the party secretaries at village, ward and divisional levels were the true ‘drivers’ of the programme and ensured effective implementation of agreed activities as well as regular reporting of nutrition developments. When these functionaries were changed they were not replaced by other mechanisms that could ascertain effective implementation of nutrition actions in a similar way. The importance of nutrition governance for the effective and sustained success of nutrition programmes has been further studied and confirmed in recent years (Haddad & Mejía Acosta, 2012). 148. In the ASRP, the nutrition governance structures during the initial stages of the project have essentially been the local representatives of UNICEF and the contracted IPs, linking up with executive heads and other selected representatives of the LGAS (typically the newly appointed Nutrition Officers) and maintaining an open and multisectoral communication with other key nutrition actors within the CMSCNs at Regional and LGA levels. At first, these committees, especially at the critical LGA level, instead of being the true nutrition governance structure in charge of nutrition management and co-ordination, tended to act as a ‘reference group’ for information sharing. 149. These committees, discussed in more detail in section 4.2 (¶67 – 71 above), were formally established by a government decree in 2011, but with limited clarity on their TOR, reporting accountabilities and working modalities. Consequently, it may not be surprising that the CMSCNs visited during the evaluation mission – with few exceptions – seemed not to be functioning effectively in their nutrition governance role, although they were apparently meeting regularly. 150. The observed inadequate multisectoral management strength in the CMSCNs is understandable, given the fact that their TOR, mode of operation and reporting responsibilities were poorly defined until very recently when the updated NMNAP and PO- RALG guidance documents were completed (GOT, 2017g). But the basic fact is that the ASRP currently lacks sustainable nutrition governance structures and mechanisms. Unless urgent and systematic efforts are put in place, that will probably result in effective programme leadership and management fading away once the present co-ordination and support from UNICEF and the IPs are discontinued. 151. Given the strongly decentralised LGA mechanisms in place in Tanzania, it is clear that district level nutrition governance is key to effective implementation and – as it now stands – an effective, multisectoral CMSCN constitutes the core building block of that nutrition governance system. However, the effectiveness of the CMSCN will then depend on well- organised and technically adequate capacities of its component parts. As discussed below, these are the leadership; the secretariat; the CMSCN NMIS; the various nutrition-relevant sectors represented on it; and all other nutrition sector stakeholders represented in the district or town. 152. Formally, the chair of the CMSCN is the DED, whom the CMSCN is supposed to provide with the necessary technical and operational support to enable him/her to exercise effective leadership on nutrition development issues. However, in most cases DEDs do not participate in CMSCN meetings. They rarely (with a few good exceptions) actively use the CMSCN to provide advice on critical nutrition matters. In general, most of the district leaders interviewed expressed very strong support for ASRP objectives, individual activities and implementation modalities but very few of them had a clear understanding of the basic

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe process, the ‘1,000 days’ concept behind stunting in children and why stunting has such serious and irreversible impact on children and on society at large. This obviously limits their ability to assume full leadership of the stunting prevention process. 153. In most cases the secretary to the CMSCN is the District Nutrition Officer – often supported by the local implementing Agency. Since the DNO is a functionary under the District Medical Department, however, s/he does not have a multisectoral convening mandate and cannot effectively follow up what is happening in other sector departments (sometimes even within the health sector). A more appropriate secretariat to the CMSCN would be the District Planning Office: this is the proper way to mainstream nutrition as a core developmental issue for presentation, deliberations and decisions in the District Council and the District Executive Committee. 154. It cannot be emphasised enough that without a nutrition management information system operating at LGA level, it will be very difficult for the CMSCN to function effectively. The NMIS needs to provide regular updates of nutrition status in the district, town or city, as well as updates on the implementation of all important nutrition activities included in the LGA nutrition development plan. 155. Most of the nutrition-related sectors and departments at LGA level are, indeed, participating in the CMSCN meetings. But they are normally represented not by the head of the department but by some more junior member with limited authority to speak on behalf of the sector. Furthermore, this delegation is not consistent. Different officers may be chosen from one meeting to the next to represent the head of department, destroying the continuity of engagement on which effective CMSCN performance depends. 156. Effective, sustained action to combat nutrition in Tanzania requires not only that CMSCNs are competent and active, but also that corresponding capacity is strengthened, co- ordinated and committed through the relevant development management mechanisms at sub-district levels – ward, village and hamlet (kitongoji/mtaa). These must be appropriately orientated and organised towards effective nutrition actions at community level. As indicated above, this is not currently the case. The structures and potential capacity available at these local levels are underused, and some of their staff told the evaluation mission that they felt the project was bypassing them. Health-based, nutrition-specific interventions 157. There has been significant progress in improving health-based, nutrition-specific interventions in the project areas. The nationwide bottleneck analysis system shows the ASRP districts as among the best performers in this respect (Table 8 – Table 15 at Annex F present some recent BNA analysis, although not all of it is based on recent data). There is a distinct prioritisation of these nutrition-specific interventions in both the 2011-2016 National Nutrition Strategy and the 2017-2021 NMNAP as far as both planning guidelines and budgetary allocations are concerned (section 4.1 above). Hence, the prospects for sustaining these actions are comparatively good – even after phasing out the temporarily increased financial and technical support presently provided by the project in MINS. Each of the interventions, however, is struggling with implementation issues like those found in other parts of Tanzania and in other African countries with similar conditions. 158. Vitamin A supplementation (combined with deworming) is implemented twice annually with UNICEF support as a national campaign programme with outreach to organised community recipients. Coverage was consistently over 80% for many years. But according to the 2015-16 TDHS, it then declined to 41% (GOT, 2016a: 233). BNA data for 2017, however, show improved coverage in MINS (TFNC, 2017). The major sustainability concern is related to the dependency of this intervention on external financing and the fact that effective VAS has probably delayed the urgency of introducing alternative, long-term solutions like fortification and diet improvements. An updated survey of actual Vitamin A deficiency is also a priority to provide evidence for continued blanket (outreach)

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe supplementation, or a shift to other implementation modalities or targeting of ‘at risk’ groups (WHO, 2017). 159. Despite considerable discussions and efforts, there is still poor compliance with iron/folic acid supplementation in pregnancy. Attendance at ante-natal clinics is good and most women are reported to be given and to be starting IFAS, but few (21% according to the 2015-16 TDHS) seem to be continuing their supplementation for the stipulated minimum 90 days (Fiedler et al., 2014; GOT, 2016a: 258). According to field informants, this is because of a lack of supply at health facilities. The situation is similar in many African countries but there are many initiatives17 being tried out. There should be ways for the ASRP to do more to use its intensive intervention approach to help explore viable options to better address maternal and childhood anaemia in Tanzania. 160. More broadly, a stronger dietary component to nutrition interventions can reduce reliance on externally sourced and/or industrially produced inputs that must be procured and supplied by health facilities, posing obvious challenges of sustainability. In this regard, the ASRP’s agriculture component has made an insufficient contribution. 161. After being the mainstay of nutrition actions (both facility-based and community- based) since the 1970s in Tanzania and many other countries, growth monitoring and promotion (GMP) fell into disrepute as it was found in several reports to be ineffective for the prevention of undernutrition if not done properly and – especially – if the promotion (i.e. counselling) part was not carried out in a way that could truly help poor and overworked mothers. Identification of early longitudinal growth restriction (i.e. emerging stunting) also has some challenges as there is a need to correctly measure small length differences in an unsettled child lying down on a length board. However, with no alternative ways of detecting early growth restrictions and thereby triggering actions to help the child to regain healthy growth, new efforts are under way to revive GMP while making sure that the potential challenges and deficits are properly addressed. The ASRP is making strong efforts in this regard, following UNICEF support for Tanzania’s adoption and roll out of the World Health Organisation 2006 growth standard. This will help to follow up and support individual ‘at risk’ children, and give the communities, wards and districts the opportunity to better detect important nutrition trends and differentials. These efforts have, however, only recently been initiated through training of health staff and distribution of measuring equipment. There is much to be done before a sustained and well-functioning GMP system is in place, where GMP staff meticulously ensure proper measurements and follow-up in individual children and correctly calculate and report their findings for district and sub- district nutrition surveillance. Such a system is an obvious and basic element of a sustainable nutrition programme. To date, although it aims to combat stunting, the ASRP has not been able to achieve routine measurement of young children’s length or height, due to the need first to adopt and adapt the new WHO growth standards and adjust the corresponding health system charts and records. Length measurement has been introduced in a limited number of villages through Village Health Days, an approach that is now being scaled up. (¶13 above). 162. The fatality rate for children with severe acute malnutrition used to be very high at 25-50%, especially in emergency situations such as famine. Progress in the SAM treatment schedule over the last 10-15 years has dramatically improved this situation. The ASRP has contributed to this with its work to increase the integrated management of acute malnutrition in MINS. Repeated or extended SAM will also lead to chronic undernutrition and stunting, so there is presently a strong move to adapt and adopt the new SAM treatment schedules into national nutrition programmes and make them part of the health-based nutrition specific interventions. In the ASRP efforts are taking place along these lines, although there are complaints that the essential supplies of therapeutic foods are still not

17 Including, in Tanzania, by Mwanzo Bora (still to be evaluated).

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe made universally available in the project area (¶98 above). Some emerging issues of effectiveness and sustainability need to be noted and addressed. • Access: the overall plan is to make SAM treatment available at each district hospital, at all health centres and at most dispensaries. • Cost: although treatment with therapeutic foods is free for the family of a SAM child, the related costs of travel and of staying at or near the hospital for a full course of treatment (normally three weeks) is prohibitive. In most cases, the parents also need to pay for additional drugs required for treatment of various infections that usually occur in SAM children. • Supplies of therapeutic foods and preparations: these supplies are rather expensive. ASRP and other UNICEF funding are presently providing these inputs. But a long- term solution through the MOHCDGEC Medical Supplies Department needs to be found and initiated as soon as possible. • The screening/detection of SAM children is not systematic enough. For now, SAM cases are primarily identified by individual health workers (including CHWs) as they see suspected SAM cases and confirm their status using their newly provided mid- upper arm circumference measuring tapes. 163. As explained in ¶83 – 100 above, the progress of the ASRP SBCC component in establishing strong awareness and understanding of critical stunting prevention behaviours and practices is encouraging. However, behavioural change achievements of this nature have a tendency to reverse if the SBCC efforts are discontinued or not followed up by complementary and/or more in-depth ‘social norms’ approaches. The extensive use of IPs and associated arrangements, however, raises concerns about the sustainability of this approach. Of particular concern are the introduction of CHW supervisors, who are appointed and paid by the programme, and the payments made to individual CHWs for performing and reporting project work. These arrangements are reportedly very important for the success of the project so far and for the SBCC component in particular. But there is unlikely to be any way to continue these arrangements after the completion of the project. A potential good solution may lie within current government efforts to revamp and reorganise the CHW system in Tanzania (see below); but the issue needs continued attention and follow up during the remaining years of the project. 164. Three cross-cutting issues are important for the sustainability of the health-based, nutrition-specific interventions. They are outlined in the paragraphs below. 165. Community–health services linkages, including CHWs: the CHW cadre has long played very important roles as an extension of the government health services to community and household levels. As the original government CHW programme was initiated and piloted (by the then Ministry of Health) in the Iringa Nutrition Programme (1983-88), the role of CHWs in community-based nutrition actions has always been well recognised in MINS. As the need for CHW involvement dramatically increased in a wide range of primary health-related initiatives during the 1990s and onwards, the original organisational principles were loosened up and the concept of a less strictly organized but more flexible cadre of Community Owned Resource Persons evolved, through whom specific initiatives were allowed to introduce their separate implementation modalities in order to gain optimal effectiveness for their own purposes. As a result, many of the roles and responsibilities originally assigned to the CHWs – including many nutrition-related activities – were given lower priority, depending on competing activities at different locations and times. 166. The Ministry of Health, Community Development, Gender, Elderly and Children has recognised the need to establish updated and clear principles, guidelines and terms of service for the CHW programme. A special Task Force has been established and several consultative meetings conducted with government bodies and other stakeholders. It is

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe expected that firm proposals will be presented shortly. There are good prospects that the new system will be able to benefit from some positive ASRP experiences and to put these experiences and approaches on a more sustainable foundation, where – for example – the important organising, co-ordination and reporting role of the current CHW supervisors might be fulfilled by (some of) the new cadre of formally employed CHWs. However, these developments are still ‘work in progress’. It will require continued engagement of UNICEF and the other ASRP partners to promote an effective and sustainable conclusion by the GOT. 167. Moving away from ‘vertical’ programmes: considering the range of nutrition- specific nutrition interventions presently promoted in the NMNAP and implemented in MINS, it appears that each of these interventions is still treated as a separate, ‘vertical’ programme approach, often having separate sources of (typically external) funding, targeting and implementation modalities. For sustainability and for effectiveness purposes, it is timely to mainstream these critical, health-based nutrition services as key components of a revised national maternal and child health standardized protocol for health/nutrition services – part, as emphasised below, of a multisectoral approach to nutrition-specific and nutrition-sensitive interventions. Given the fact that stunting prevention does require systematic monitoring and support over an extended period of 1,000 days, a standardised protocol would be an important avenue to ensure that each of these critical interventions is put in place and provided at the right time and across the whole country. Emphasising the principle of a standardised protocol would also help to avoid having parallel and contradictory operational approaches for these services (e.g. for SBCC). This will take some time to plan and organise, but the ASRP would present a very appropriate opportunity for the GOT and partners to try out such an approach before it is formally adopted and scaled up to the whole country. This approach has already been initiated with UNICEF support in several nearby countries, like DRC (RDC, 2015), Ethiopia and Egypt; so there is a good opportunity to benefit from some cross-country sharing of experience. 168. Paying stronger attention to nutrition-related childhood illnesses: one area related to health-based nutrition interventions that has received insufficient attention is the linkages between nutrition developments and common childhood illnesses. It is well known, and was further evidenced in the BNTS baseline survey (Concern Worldwide, 2014e), that some childhood illnesses are significantly more prevalent in MINS than elsewhere in Tanzania. These include acute respiratory infections (ARI) in particular, but also diarrhoeal diseases and fevers. Most of the health facilities visited during the evaluation mission confirmed that ARI, including pneumonia, were very common in young children. More in- depth studies on this are needed, and opportunities to improve ARI prevention and immediate treatment should be explored. Likewise, the linkages to WASH and prevention of diarrhoeal diseases and related problems should be more systematically explored (¶88, 100 above and ¶172 below). Multisectoral, nutrition-sensitive actions 169. As noted in ¶117 (section 4.2), the prospects of a significant impact from the current agriculture component of the project are poor. After the five baseline studies, the project has undertaken less research under its KR 4 than originally envisaged. It is important to recognize that there are already many agriculture and rural development programmes being implemented in MINS. One contribution the project could make would be to help to carefully assess the nutritional impacts of these programmes and try to influence their design and implementation towards stronger emphasis on critical aspects of household food security (diversity rather than quantity, and access to an appropriate diet), ensuring real impact on consumption and child feeding. Project resources could be used for formative and operations research in close collaboration with other partners engaged in the design and implementation of agriculture and rural development programmes. This could easily be linked to the much-needed improvements of the (local) nutrition management information system that are needed in the next phase of project implementation. More could also be

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe done to enhance the sustainability of some of the practices of the ASRP’s own agriculture component: for example, by promoting solar drier technologies that use low-cost, locally available materials, and by increasing households’ knowledge about the loss of nutrition caused by some food processing methods, such as maize polishing, soaking and milling. 170. The sustainability of multisectoral, nutrition-sensitive actions in the agriculture sector is also linked to the stronger involvement of AEOs in reaching nutrition outcomes (¶114 above). This should be easier to achieve once the ward level administrative and technical capacities are better involved in ASRP implementation. But some refresher training of AEOs in applied nutrition would greatly enhance their capacity to engage proactively in making their work more nutrition-sensitive. This would also enhance their capacity to participate in the critical SBCC activities where their voices and views are already highly respected by the large farmer populations of MINS. 171. Some of the current IPs – like TAHEA and IRDO – already have extensive agriculture and rural development experience and capacities that could be tapped. In addition, some of the premier agriculture research institutions in Tanzania, like Sokoine University of Agriculture and Uyole Agriculture Research Institute (in Mbeya) already have a strong presence and research history in MINS. Hence, there is adequate capacity readily available to support an orientation of the agriculture component towards stronger focus on formative and operations research that would better define the critical conditions and approaches needed to achieve stronger nutrition sensitivity of agricultural activities in the prime food producing areas of Tanzania. 172. Globally, UNICEF is in the forefront of establishing strong links between WASH developments and nutrition programming for stunting reduction. In the ASRP, the hygiene messages are effectively integrated in the SBCC approach. Programmatic linkages to water and sanitation developments are more limited. Developing them more strongly, for example through stronger co-ordination by CMSCNs, would enhance the effectiveness and sustainability of nutrition-sensitive action to improve nutrition. The ASRP WASH component focuses on activities to protect children from diarrhoeal diseases that interfere with nutrient utilisation and lead to undernutrition. The design of this intervention is not linked to the supply of water, which is key for ensuring adequate hygiene and sanitation practices, especially during the dry season. This was mentioned during FGDs as a key challenge to implementing best practices related to WASH. Because of limited water supply in many communities, the approach used – of providing education and not the needed facilities and water – is inadequate. In addition, the ASRP’s approach to this activity is through the media, social events and counselling sessions. But it is not clear from the field visits how often these methods are used to share information on WASH and how sustainable these activities will be after the project ends. The WASH component should also be implemented in schools to increase the coverage and promote sustainability. 173. According to field informants, very little has been done to explore and develop nutrition-sensitive education approaches. Primary and secondary schools and staff represent by far the largest resource for change in rural Tanzania and provide a major avenue for equity- and gender-related actions, which are also of prime importance for nutrition improvements (sections 4.5 and 4.6 respectively). 174. There are clear efforts to establish linkages between the project’s approach and TASAF, the key instrument for improving and scaling up government social protection systems. Although clearly articulated at the national level, these links are incomplete at operational, community level. This may be because TASAF is still struggling to establish viable and reliable implementation mechanisms in its accelerated scaling up process, which has so far constrained other initiatives’ access to its beneficiary registration and identification system. But the agreement and commitment on both sides to use TASAF data for nutrition beneficiary identification are laudable. They lay valuable foundations for further work to strengthen the social protection dimension of multisectoral, nutrition-sensitive programming.

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe

175. Child care and development is a new emphasis spurred by UNICEF’s global and national commitment to promote stronger, scaled-up ECD systems to ensure that all children reach school readiness and will be able to achieve their full potential as they grow up. ECD and nutrition are closely related. It makes good sense to explore opportunities to strengthen ECD within a nutrition programming approach. Early childhood stimulation, protection and socio-emotional support have been shown to have positive, direct impact on nutrition developments, from the foetal stage through immediate ‘skin-to-skin’ contact after birth, to responsive feeding during both breast-feeding and complementary feeding, and systematic stimulation and support for cognitive developments as the child grows older (UNICEF, n.d. i). The ASRP has initiated some activities to explore such ECD approaches, including promoting the making of toys and preparing playgrounds. But these activities are still at a very early stage and are on a small scale: most of the CGs visited during the evaluation were not practising them. They will require further work before their effectiveness can be established and their sustainability seriously assessed.

4.5. Equity 176. Evidence on the project’s EQ 15. To what extent is the intervention reaching performance in reaching the most marginalised children and communities the most marginalised children and communities? is incomplete. It is likely that some of the most marginalised communities have been left out so far, because they are the remotest and the most difficult for the IPs to reach. If it becomes possible to raise the geographical coverage target to 100%, this challenge will be overcome. 177. Within communities, the poorest and most marginalised households and their children have a fair opportunity to benefit from the ASRP – mainly by joining ‘counselling groups’, since the agriculture component is on such a small scale. Caution is needed with respect to the possible stigma associated with being identified as poor and encouraged to participate in activities targeting the poor (¶116 above), although this issue was not directly mentioned to the evaluation mission in the field. 178. Some use has been made of local leaders to identify these families and encourage their participation, but this has not been a systematic effort. More recently, with the support of the Prime Minister’s Office, agreement has been reached with TASAF for the use of its Productive Social Safety Net (PSSN) database, which is being developed for nationwide social protection purposes (¶23 and ¶174 above). Once liaison and data management issues have been successfully dealt with (¶174), ASRP effectiveness should improve from the equity perspective. 179. Overall, some caution is advisable in planning, implementing and assessing the ASRP from the equity perspective. Higher food production, higher incomes and less ‘poverty’ do not necessarily mean better nutrition or less stunting. There is no guarantee that families with more money will use it to improve their diets (although, for some, money is essential if they are to have the access they need to appropriately diversify nutrition). As observed above (¶116), it is essential to advocate proper nutrition to the less poor and marginalised, while also ensuring that those who are worst off have the ability and the knowledge to ensure good nutrition during the first 1,000 days and beyond.

4.6. Gender

180. In attempting an answer to this EQ 16. To what extent is the intervention benefiting evaluation question (see box), it is both girls and boys, men and women equally? important to consider engagement, as well as direct benefit. For direct benefit, the concern is primarily with the children whose diet

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe

(and whose mothers’ diet) may be improved in such a way that they do not grow up stunted. But, to achieve this nutrition objective, men (and boys) must also be engaged in the issue and accept and perform revised roles in their families’ nutrition. 181. The evaluation matrix (Annex C) recognises this by posing three sub questions under EQ 16. The first of these is whether the intervention is benefiting girls and boys equally. This turns out to be an unhelpful question. Concerned as it is with the first 1,000 days of life, the ASRP targets parents (mainly mothers) rather than girls and boys. To the extent that it is achieving genuine benefits by reducing stunting – which cannot yet be ascertained – those benefits are bound to be distributed in the same sex ratio as the population, which is 100.1 for the 0-4 age group across Tanzania (marginally more boys than girls: GOT, 2015d: 8). 182. The second sub question under EQ 16 is whether the intervention is contributing to the social and economic empowerment of women. The evaluation has assessed the argument that the (very small-scale) agriculture component could do the opposite, by increasing women’s work load as they try to add vegetable production to their many other duties (notably field crop production for the market: ¶26 above). It finds that this is potentially, but not necessarily, the case. Some women told the evaluation mission that they could multitask further, without significant extra work load, if vegetable gardens were placed close to their homesteads (implying at least partial irrigation with household grey water). For those women who must currently cultivate distant vegetable gardens in field areas where some dry season water is available, on the other hand, the work load is increased. In no case is participation in the project likely to empower women economically, except in the long-term, indirect sense that better-nourished children should grow up to earn higher incomes and contribute more to their natal households’ revenue. 183. More positively, the consensus is that participation in ‘counselling groups’ can be a socially empowering experience for participants, who are almost all young women. Learning new things in a supportive social setting is normally an empowering experience. But the empowerment could be significantly stronger if CGs provided more than the rather conventional training that they mostly offer at present. Groups of women who can recite slogans and sing songs about stunting may be cheerful and more knowledgeable, but are not necessarily empowered. 184. The project is more likely to achieve social empowerment for women if the answer to the third sub question is positive: whether the intervention is increasing the understanding of men on the nutritional needs of children and women, and enhancing their support in ensuring that these needs are met. So far, overall, the answer is negative. The SBCC component is enhancing the knowledge and attitudes of some men, but this is not necessarily leading to substantive changes in their attitudes, behaviour and practical roles within the household. 185. Poor involvement of men in CGs was mentioned in all villages and districts visited and was considered as one of the major barriers to adequate practice of nutrition-relevant behaviours by women, and one of the causes of stunting in children. The current approach adopted by the project, of targeting mainly women and children, is seen as inadequately gender-sensitive. It has paid insufficient attention to the contribution of men in the entire spectrum of reproductive health and maternal as well as child nutrition. The phrasing of the behaviour statements as well as the content of the training or counselling materials in the ‘bango kitita’ flipchart used by the ASRP are either too gender-specific or too general, and therefore limit participation of men and other household members. In addition, the information does not spell out clearly what the roles of various members of the household and community are in ensuring that nutrition-relevant behaviours are practised by all, and specifically by women. 186. The evaluation mission did meet a few men at CG meetings (Table 20, Annex J), and there are ways in which men’s understanding and engagement could be strengthened, for

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe example through linking nutrition advocacy to sporting events, as is often done to raise awareness about HIV and AIDS (Kick4Life, 2018; Tackle Africa, 2018). Men’s attitudes to masculinity and family responsibilities are not unchangeable (African Arguments, 2018), and it is important for the ASRP to revise its SBCC approaches accordingly. It is also important to engage the next generation of men (and of mothers) by building gender-sensitive nutrition education into school curricula: both to strengthen future mothers’ and fathers’ understanding of appropriate nutrition in the first 1,000 days of life, and to promote more supportive engagement by future men and fathers in their households’ nutritional responsibilities.

5. Conclusions

5.1. Relevance 187. Through the BNTS and ASRP, UNICEF and its funding and implementing partners are making a highly relevant contribution to improved nutrition in Tanzania, and specifically to alleviating the continuing burden that stunting places on the nation’s development. This report refers back to earlier decades of nutrition work in the country, and particularly the Iringa Nutrition Project of the 1980s. Those, too, were strongly relevant efforts. But relevance is redefined as some challenges are overcome, understanding of issues grows and priorities are reassessed. Through those processes, linked to emerging global priorities and Tanzania’s engagement in the SUN movement, stunting has been identified as the key target for nutrition programming in this country. In combating stunting, this project has been optimally relevant. 188. A project can be relevant in policy terms and in operational terms. This project has been relevant at both levels. UNICEF has used some of its funds to support national government processes of decision-making, policy, guideline and TOR formulation and capacity development, while also building practical ways to tackle stunting at operational level through LGA systems and community level structures. 189. For policy relevance to convert to optimal operational performance takes time, however. The highly relevant new NMNAP was only officially launched two months before this mid-term evaluation. In the meantime, the project has been going ahead to accelerate implementation of a set of agreed priority actions – primarily in the areas of health-based nutrition interventions and SBCC. This was fully supported by the GOT and probably has saved many Tanzanian children from stunting impairments. But it has also created some confusion as effective organization of government management and co-ordinating bodies at district and sub-district levels has been lagging behind. This is presently being actively addressed by PO-RALG – partly with technical support funding from the project. 190. Questions can be asked about the detailed strategic relevance of the project’s chosen operational approaches – in terms, for example, of feasibility at scale, technical appropriateness and likely sustainability. These questions have been raised in particular, but not only, about the agriculture component. They are assessed further in the remainder of this chapter.

5.2. Effectiveness 191. In assessing effectiveness, evaluators are primarily concerned with the achievement of planned outcomes – in this case, the four key results specified in BNTS design. For KRs 2 and 3 – arguably the core purpose of the project – it is premature and impractical to

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe measure the extent to which the outcomes have been achieved so far. A replica of the 2013 baseline survey will be necessary for that purpose, at the end of the project. Nevertheless, interim conclusions can be drawn about the project’s progress towards effectiveness. Planning, budgeting, co-ordination and monitoring by Regional and local government authorities 192. The policy and institutional environment is currently favourable for combating stunting in Tanzania. The project has helped to achieve this. The NMNAP has been launched; Regional and Council Multisectoral Steering Committees on Nutrition are in place. These have now been meeting regularly for some time. Awareness, debate, capacity and commitment have been developed within the framework of Tanzania’s participation in the SUN movement and with strong support from this project. 193. These are important achievements, and it was appropriate to begin by helping to build policy and institutional frameworks at national level. More remains to be done to give them substance and effect. The preparation of multisectoral plans for nutrition at LGA level required policy and programming guidance, and planning and budgeting tools. These are now in place, making it possible to plan and budget on the basis of factual evidence about performance and bottlenecks, and to capitalise on the stronger government commitment to fund nutrition – which the project helped to stimulate. Intensified project support will be required over the remaining project period to optimise LGA planning, budgeting and management of nutrition services and nutrition-specific interventions on this basis. Council Multisectoral Nutrition Steering Committees (CMSCNs) need further support in building strong leadership, participation, decision-making and co-ordination so that they can drive effective multisectoral efforts to combat stunting and address other nutrition issues. 194. Similarly, the formation of committees and the approval of guidelines do not necessarily mean effective action. CMSCNs may be meeting, but the quality of leadership, participation, decision-making and co-ordination is not yet adequate for them to drive effective multisectoral efforts to combat stunting or address other nutrition issues. A related concern is the current lack of authority and influence that DNOs can wield, given their continuing comparatively junior position within the MOHCDGEC hierarchy. More broadly, effective nutrition action means a genuinely multisectoral combination of nutrition-specific and nutrition-sensitive actions. Despite the progress made with ASRP support, this combination is not yet strong enough in practice. The dominant perspective is still of nutrition as primarily a health concern. 195. The situation is similar with regard to monitoring. The project has made significant progress in helping to build strong foundations for enhanced monitoring of nutrition. The project should continue to support this monitoring system, to ensure full ownership and institutionalisation. But overall, although the progress at which the project aims is still incomplete, it is important to recognise how significant that progress has been. The new commitment of TZS 1,000 per child is an important stimulus to additional domestic resourcing for nutrition action, and some LGAs are now earmarking funds within their budgets for this purpose – although they are careful to emphasise that expenditures will depend on local revenue collection. SBCC 196. The project, through UNICEF’s IPs, has made important progress over the last two years in developing and implementing an SBCC programme across MINS. The complexity and operational difficulties of this should not be underestimated. ASRP SBCC, as developed so far, is a substantial achievement. The SBCC strategy focuses on changing individual behaviours and social norms, addressing a large number of practices with a proven impact on stunting reduction (nutrition, health, water, sanitation and hygiene (WASH) and early childhood development (ECD) practices). With the competence and confidence that the IPs and their LGA partners have now built, there is a growing consensus that the project should,

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe if possible, extend its coverage from 75% to 100% of communities in the four Regions – although this would certainly require more resourcing. 197. At the same time, however, field observations show a project at the usual interim stage of focus on outputs – numbers of groups formed, training events held, participants attending etc. Impact of the project on behaviour change will be measured during the 2018 Tanzania Food and Nutrition Survey, which will also be supported by the ASRP. Meanwhile, a mid-term evaluation is an important opportunity to consider progress towards outcomes. Here, a number of questions arise. 198. Some questions concern the nature and continuity of the SBCC process so far developed by the project. It is more focused on training than on counselling; the vital support function is not yet strong enough. Fragmentation of the process into separate sessions for women at different stages of the 1,000 day period (i.e. pregnancy, lactation and complementary feeding) is unhelpful and is one of the threats to the overall continuity of the SBCC process through the years as women who have participated move through subsequent pregnancies, stop having children and may (should) be replaced by younger mothers who are currently under reproductive age. Other questions about continuity, linking to those raised in section 5.4 below, concern the ongoing availability, commitment and competence of CHWs, who may be partly or wholly replaced by the new cadre of salaried CHWs that the GOT is currently training but has not yet resourced. A further issue is the inadequate nutritional and related support available to children aged between two and five, for whom Care for Child Development (CCD) and dietary interventions remain vitally important. Men’s engagement in SBCC remains limited. 199. A final conclusion on SBCC must be that it is insufficiently supported, so far, by the progress made at policy and institutional levels. The implicit BNTS theory of change assumption (Figure 2, Annex B) is that enhanced planning, budgeting, co-ordination and monitoring can have a direct effect on the prevalence of chronic undernutrition among young children. This is incorrect. Such enhancements are vital; but they help achieve the overall objective through the support they give to effective SBCC and related socio-economic support to the target group. This means the genuine, multisectoral, functional combination of nutrition-specific and nutrition-sensitive interventions advocated above – which is not yet in place. Nutrition services provided through the health sector 200. The ASRP has worked to increase the proportion of health facilities implementing integrated management of acute malnutrition (IMAM). The MINS Regions are among the best performing in Tanzania on a variety of indicators regarding the treatment of children with severe acute malnutrition. 201. Despite this progress and its achievements in SBCC training for health facility staff, the ASRP’s efforts to combat stunting are inevitably constrained by the limits on nutrition services at these facilities. Additional nutrition messaging during women’s visits to the facilities, and the provision of supplements (complemented when necessary by therapeutic feeding for malnourished children), are examples of these constraints. Lack of staff and budget mean that the package of nutrition support to Tanzanian children and their parents is still incomplete. At the same time, although the project’s IPs do work in close consultation with LGAs and maintain liaison with ward and village government structures, officials at the community level are not yet sufficiently engaged in this all-important effort to bring nutrition to scale. A broader problem, which this project cannot solve on its own, is that the wealth of capacity that Tanzania has built at ward and village levels cannot be fully exploited for nutrition or other purposes, partly because recurrent budgets (and consequently staff motivation and supervision) are so inadequate.

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Agriculture 202. A key part of this combination of interventions in support of the required behaviour change is ensuring appropriate food consumption. How to do this has been the most contentious issue in BNTS and, subsequently, ASRP design. The original theory of change – advanced in ASRP design as well as the BNTS, as Annex B shows – was that the availability of and access to diverse and micronutrient-rich foods at household level would have to be enhanced if women’s and children’s nutrition during the first 1,000 days is to be adequately improved. But, after DFID objections to the inclusion of activities that it feared would increase the already heavy work burden on women, only a very small agriculture component remains in the current project. This component has made modest progress, and achieved useful benefits, on a very small scale. The potential for SBCC messaging on the production and consumption of a more diverse diet has not been fully exploited within the agriculture component. 203. In the context of the ASRP, an intervention this small has to be justified on the basis of consensus about the need for such interventions, and greater clarity about how what might be called pilot work will be scaled up. 204. Complex factors affect the need to address the production and consumption of appropriate food as part of an effort to bring nutrition to scale. MINS are Regions of comparatively abundant food production and availability, as well as above average stunting. Much of the needed change concerns behaviour and livelihood strategies: ensuring enough production goes to household consumption by the nutritionally vulnerable, rather than to the market (or that households have the cash to buy an appropriate diet); that enough of the required nutritious foodstuffs are produced; and that parents give their children an appropriate diet, instead of the current excessive focus on staples (carbohydrates). Women have heavy workloads, often diverting them from adequate child feeding and care and from production for the family to production for the market. But home gardening can be developed in ways that women find acceptable within their daily work schedules. Water is sometimes scarce, but grey water use and other techniques can overcome that obstacle. In other words: production and dietary behaviour change are necessary and feasible as part of efforts to combat stunting. Something like the current agriculture component is needed, and it is needed on a larger scale. 205. The best way to scale up these efforts to enhance the availability and consumption of appropriate food is not to make the current agriculture component bigger. That would be unattractive (or unacceptable) to the current funding agencies; and UNICEF is not an agricultural agency. The best way to do it is to confront the broader challenge facing this project, already mentioned above: existing capacity in the GOT at ward and village levels is not being fully used. There are agriculture staff at these levels who, with some orientation, would be well capable of performing the required tasks at scale; and expanding TASAF systems and programmes can help deliver support to registered beneficiaries of nutrition interventions. The required changes are not easy: recurrent budgets cannot be transformed overnight. But, as discussed below, similar challenges will face the SBCC activities that this project has scaled up, after the project has ended. 206. The policy trajectory and momentum are favourable. Tanzania is committed to a multisectoral attack on stunting and related nutrition problems, combining nutrition-sensitive interventions in sectors like agriculture, social protection and education with nutrition- specific ones. The next challenge for policy- and decision-makers is to build the programmatic and budgetary arrangements for LGA agriculture staff to start taking over nutrition-sensitive food production and availability interventions as piloted by the BNTS, without further donor funding. This will need to be integrated with arrangements to continue SBCC and nutrition-specific activities with domestic resources.

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Evidence and learning 207. Both the BNTS and the ASRP designs (Annex B) stressed the importance of basing strategies to tackle stunting on solid evidence, and specified separate outcomes around evidence and learning. This was laudable. One of the most significant results of the first two years of BNTS was the five baseline studies, which were valuable (although not uniformly so). While some of the original emphasis on further research studies faded during the period under review, the project made important contributions to the GOT’s development of new systems for management information, evidence generation and learning, which are now coming on stream. The National Nutrition Survey will be repeated in 2018. The bottleneck analysis and scorecard processes promise to give performance and trends in the nutrition sector a higher profile and a much better empirical basis in government decision-making. Developments to date lead to the following conclusions. 208. Additional research into the changing patterns and causes of malnutrition in MINS remains necessary. This includes the need for a deeper understanding of the relationship between apparently abundant agricultural production and stunting, as discussed above. 209. To succeed, the new nutrition management information system (NMIS) must be competently operated by LGAs – building on the ASRP’s important contributions. This will require considerable, sustained technical support. The current presence of the ASRP and its IPs offers an opportunity to develop the required capacity, systems and procedures in PO- RALG and among CHWs, health facilities and LGAs in MINS – a substantial task that will need more funds than the ASRP and ASTUTE are likely to have available, but which might be facilitated by linking the NMIS to the TASAF database and monitoring system. This is a challenge for all Tanzania’s partners in the nutrition sector. At present, as some field informants pointed out, the targeting, efficiency and effectiveness of nutrition interventions are weakened by the lack of accurate (or any) data. 210. It is important for a project dedicated to combating stunting to promote the collection of data about young children’s length and height. While it will take some years to be able to demonstrate the desired impact of project interventions (largely on the basis of an endline survey), the ‘Village Health Days’ undertaken in some parts of the project area have included a welcome introduction of length and height measurement at community level, with presentation of the data on charts in public places a helpful way to stimulate people’s awareness of the issue. Length boards and related training are gradually being spread across MINS health facilities. Early and consistent implementation of these measurements, fed into the NMIS, would be an important step forward.

5.3. Efficiency 211. The BNTS had an inefficient start, with relatively little accomplished in the first two years – a period that saw the departure of the originally contracted IP and the restructuring and reassignment of the project to three pairs of IPs. While the result was a more relevant project with more sharply focused strategies, it should have been possible to design it that way from the outset. 212. The evaluation has been unable to undertake detailed analysis of the efficiency of project operations. The organisational complexity of the project, across multiple levels of government through three sets of IPs, might be thought to reduce its cost efficiency. But it is more accurate to see these arrangements as an investment in designing appropriate strategies that can be implemented more widely in future. Furthermore, administrative arrangements with the IPs limit the project’s total overhead costs. As emphasised below, the ultimate value of the project will be measured in terms of the continuation of work to combat stunting using domestic capacity and funding.

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5.4. Sustainability 213. As argued in section 4.4 above, the sustainability of the project should be assessed at three levels: the prospects of ongoing effective nutrition governance; the continuation of appropriate health-based nutrition-specific interventions; and the maintenance of the required multisectoral nutrition-sensitive actions. 214. The project has helped to put the required nutrition governance structures – notably the Regional and Council Multisectoral Steering Committees on Nutrition – in place. But these bodies do not yet function in the way they will need to if intensive action against stunting is to continue beyond the project period. Supporting the necessary development of understanding, attitudes, leadership and procedures in these bodies will be one of the most critical tasks for the project during its remaining life. 215. Many questions remain to be answered about continuation of health-based nutrition- specific interventions. Some are simple issues of management and resourcing: ensuring that GOT health facilities have the capacity and the supplies to carry out the required support, monitoring and therapeutic functions. Others are still issues of institutional strategy: how the momentum developed by CHWs will be continued once the project ceases to fund the important supervisor positions currently in operation; how and when the new, formally employed cadre of CHWs will be phased in, relative to those already in post, and how much nutrition work the new cadre will do; and what institutional restructuring will be done to recognise that nutrition is a national, multisectoral priority rather than a subordinate function of the health services. It will be essential for the project to maintain intensive, proactive consultation with the GOT on these questions. 216. Maintenance of the required multisectoral, nutrition-sensitive actions will depend in part on the institutional restructuring just mentioned. For a strong and long-term contribution to these actions in the agriculture sector, it is vital for AEOs and other field staff to be more thoroughly engaged in promoting the production and consumption of nutritious foodstuffs at community and household levels. So far, the project’s small agriculture component has not made a strong contribution in this regard, and opportunities to address the paradox of poor nutrition in agriculturally productive areas through ASRP-funded research have not been addressed. Stronger efforts are needed to link water and sanitation efforts into nutrition-sensitive programming. Stronger links with TASAF should strengthen the prospects of sustainable targeting and monitoring systems for multisectoral nutrition programmes. A promising start has been made in the vital CCD dimension of nutrition- sensitive action, but it is too soon to judge the sustainability of the work done in this area. 217. Overall, the sustainability of the project’s likely achievements is not yet assured. That is natural, at this interim stage. But it is vital now for all concerned to lift their attention from the detailed work of achieving outputs to consider also the mid- and longer-term challenges of achieving and sustaining the intended outcomes. The scale of the institutional and resourcing challenges is such that attaining sustainability by the end of the currently funded project period is unlikely. A longer period of funding is appropriate. But that is not a reason to defer detailed and urgent attention to the question of how combating stunting can be continued within an integrated, multisectoral programme of nutrition action that is funded and implemented entirely by the GOT – potentially in association with NGOs and the private sector.

5.5. Equity 218. Given that the poorest and most marginalised households are likely to be the worst nourished, and that these households’ children are the most vulnerable to stunting, the ASRP has taken useful steps towards better targeting, by building operational links with TASAF and its growing (but still incomplete) social safety net register and systems. At this

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Evaluation of Bringing Nutrition to Scale in Iringa, Mbeya and Njombe point, the efficiency and effectiveness of the project would be regarded as lacking in these equity terms – due also to its failure to reach some of the most geographically marginal communities. 219. But better-off households in MINS – both rural and urban – are not necessarily better nourished or less vulnerable to stunting. The ASRP, particularly as it looks towards the sustainability of appropriate nutrition services for the whole Tanzanian population, advocates appropriate dietary standards for all families who have, or will have, children in the target age range. Beyond the ASRP, such efforts need to be integrated with broader advocacy against the different dietary challenges that increase the burden of non-communicable disease as society grows richer.

5.6. Gender 220. Stunting and other nutritional challenges will not be sustainably overcome until men have an adequate understanding and strong commitment to play their necessary roles in ensuring proper nutrition for pregnant women and young children. The ASRP is increasing its efforts to promote this understanding and commitment among current and future fathers. SBCC approaches and school curricula need to be adjusted accordingly. Just as the challenge of stunting cannot be overcome if the response is limited to nutrition-specific responses by health agencies, it cannot be overcome if nutrition interventions give insufficient attention to men. 221. Some well-meant misgivings about the potential increase in women’s workloads that the promotion of increased vegetable production might cause can be addressed – although, as argued above, this is not a reason to expand the current very small agriculture component of the ASRP (restricted to some of the original BNTS districts). More significantly, the project’s current SBCC approaches are not doing enough for the social and economic empowerment of women. The ‘counselling group’ concept has important potential for this purpose, but so far that potential has not been exploited enough.

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6. Recommendations

222. The following recommendations arise from the findings and conclusions presented in chapters 4 and 5 above. They focus on what it should be possible for UNICEF and the IPs to achieve through the ASRP’s support to national policy processes and its direct implementation in MINS, rather than on potentially broader efforts by the GOT or the nutrition sector as a whole.

Table 4 Recommendations No. Recommendation Responsibility Time frame Project structure and budget 1 UNICEF should seek funding to extend the UNICEF, funding 2018 coverage of the ASRP’s SBCC and evidence agencies, IPs and learning components to 100% of villages in MINS and 75% of the target group within them, strengthening the working links with TASAF for the identification and monitoring of beneficiaries. At the same time, the project should clarify how long it sustains the current mode of operations, through the IPs, in any community. Now is the time to start planning withdrawal from communities where the project has worked the longest, on the basis that the enhanced nutrition advocacy and services that the ASRP has introduced will be continued by established structures and services (recommendation 4 below). 2 For all the purposes outlined by the UNICEF, funding 2018 recommendations of this evaluation, UNICEF agencies, GOT and the GOT should negotiate with funding partners to ensure a further five-year funding schedule for the ASRP in MINS, with commitment to, and a strategy for, full handover to ongoing GOT implementation in these Regions from 2022. Increasingly, the ASRP’s emphasis, at all levels and within all key result areas, should be on continuity in nutrition services to ensure that stunting is permanently overcome. SBCC component 3 The ASRP should strengthen the character UNICEF, IPs, GOT 2018-2019 and content of its ‘counselling groups’ so that they fully perform the intended longer-term roles within the community of counselling and peer support, in addition to simple training, and that – under the auspices of village governments – they become permanent local institutions through which successive cohorts of parents pass, facilitated by a permanent CHW cadre. 4 The ASRP should adjust its SBCC approach to UNICEF, IPs, GOT 2018-2019 stimulate the participation of men and to

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No. Recommendation Responsibility Time frame promote men’s engagement in appropriate nutritional practices within their households. The innovative approach with selected ‘influencers’ could be more effectively used for this purpose. It will also involve the adoption of additional outreach and publicity strategies, for example through sports that attract men and boys. 5 As part of its SBCC strategy, the ASRP should UNICEF, IPs, GOT 2018 strengthen its support for child care and development through the period from birth, through entry into primary school, to the age of eight years. It should promote and support training for CHWs and health facility staff on ECD. Agriculture component 6 The BNTS agriculture component should be UNICEF, funding 2018 reformulated, and its budget revised, so that agencies, IPs while its current level of pilot field activities is continued and refined (on a more participatory basis that encourages beneficiaries to engage in identifying appropriate crops, livestock and production methods), its emphasis is on identifying lessons from these pilots (linked to KR 4) and on developing a package of nutrition- sensitive support activities that can be carried out by LGA agricultural staff at scale in MINS from 2022, in association with TASAF and broader livelihood development initiatives. 7 Adjustments to the agriculture component UNICEF, IPs 2018 should include the use of more locally-specific seed/crop selections, increased emphasis on the use of grey water in homestead gardens, and exploration of additional water capture techniques that can be used in residential areas. Effectiveness, sustainability 8 While maintaining their efforts to achieve UNICEF, IPs 2018-2022 planned project outputs, UNICEF and the IPs should strengthen their focus on achievement of the planned outcomes and on the sustained operation of the required multisectoral programme of nutrition-specific and nutrition-sensitive actions by the GOT, its social partners and parents after project termination, so that nutrition indicators continue to improve in MINS. Multisectoral nutrition governance 9 The project and its IPs should intensify their GOT, stimulated 2018-2022 emphasis, at all levels, on the multisectoral by UNICEF character of the effort to combat stunting –

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No. Recommendation Responsibility Time frame which means combating the perception that nutrition is only a health issue and only a responsibility for the health services. This also means combating the perception that the ASRP is only a nutrition-specific project. 10 UNICEF and the ASRP should advocate GOT, stimulated 2018-2022 changes to supervision and reporting by UNICEF arrangements so that District and Regional Nutrition Officers report directly to the DED and the RAS respectively. This is a challenging proposition, given that these staff currently fall under the MOHCDGEC. But they would be more effective in a direct reporting line to the RAS or DED within the team responsible for co-ordination of plans and budgets across sectors – ultimately serving in a position like ‘Nutrition Planning Officer’. 11 The recommended multisectoral emphasis GOT, stimulated 2018-2022 means that the ASRP should intensify efforts by UNICEF to strengthen leadership, participation and action in Council Multisectoral Steering Committees on Nutrition, so that these bodies have the capacity and commitment to combat stunting and other nutrition problems across all relevant sectors, with functional linkages to the overall development planning and management process. It should also strengthen operational linkages with TASAF registration, targeting and monitoring systems so that multisectoral support for appropriate nutrition becomes an integral part of Tanzania’s social protection framework. Multisectoral nutrition programmes and budgets 12 Through its links with PO-RALG, the ASRP GOT, stimulated 2018-2022 should negotiate increased GOT recurrent by UNICEF funding for nutrition-sensitive support activities in the agriculture sector. 13 In addition to this greater use of LGA GOT, stimulated 2018-2022 agriculture personnel, the ASRP should by UNICEF maximise its consultation, engagement and joint action with other development- orientated staff in ward and village governments – again working at all levels to promote multisectoral combinations of nutrition-specific and nutrition-sensitive interventions, including stronger engagement with the WASH sector and with TASAF. 14 The ASRP should work proactively to support GOT, stimulated 2018-2022 the absorption of the new, formally trained by UNICEF cadre of CHWs into field service in support of ASRP and longer-term efforts to combat

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No. Recommendation Responsibility Time frame stunting. As part of this effort, the project should work with the MOHCDGEC to confirm the proportion of the CHW cadre’s time that will be devoted to nutrition; how CHWs will be supervised for this purpose after project termination; and how current and future CHWs will be provided with refresher training on nutrition. 15 The ASRP should work with the MOHCDGEC GOT, stimulated 2018-2019 to expedite the rapid roll out of routine by UNICEF length/height measurement and reporting at and by all health facilities. 16 The ASRP should expand the Village Health UNICEF, IPs, GOT 2018-2019 and Nutrition Day concept throughout MINS, and link it to enhanced technology for data capture and reporting. 17 The ASRP should advocate the adequate and GOT, stimulated 2018-2019 consistent MOHCDGEC funding and supply of by UNICEF nutrition supplements and materials at health facilities. 18 The ASRP should work with selected schools UNICEF, IPs, GOT 2018-2019 to pilot education modules on the importance of the first 1,000 days in human development.

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Annex A. Terms of Reference UNICEF TANZANIA COUNTRY OFFICE Evaluation Terms of Reference Institutional Contract

1. Summary

Title Evaluation of the project Bringing Nutrition to Scale in Iringa, Mbeya and Njombe regions (2013-2016)

Location: Dar es Salaam, Mbeya, Iringa and Njombe

Total budget: $100,000

Budget Code: SC140536 (Irish Aid Grant: Tanzania Bringing nutrition actions to scale in Iringa, Njombe and Mbeya Regions) valid until October, 2017

Start Date: 01 February 2017

Duration: Approximately 6 months

Supervisor: Nutrition Specialist

2. Background information

Nutrition situation

Tanzania has made significant progress in improving the situation of nutrition in the last 25 years, with notable reduction in the prevalence of stunting, wasting and underweight among children under 5. Evidence shows that the prevalence of chronic malnutrition (stunting) among children under 5 decreased from 50% in 1992 to 34% in 2015. The prevalence of global acute malnutrition (wasting) decreased from 8% in 1992 to 4.5% in 2015, whereas the prevalence of underweight among children under 5 decreased from 25% in 1992 to 13.7% in 2015.

Despite this remarkable progress, it is estimated that more than 2,700,000 children under five years of age are stunted and that more than 600,000 children under five years will suffer from acute malnutrition in 2016 including more than 100,000 severe cases. Moreover, significant disparities persist between the poorest and richest households, between boys and girls and between and within regions of the country.

With regards to micronutrient deficiencies, between 2005 and 2010 prevalence of anaemia has decreased from 72% to 59% among children and from 49% to 43% among adolescent girls aged 15-19 years. One third of children are affected by vitamin deficiency (33%).

Children become malnourished if they suffer diseases that cause undernutrition or if they are unable to eat sufficient nutritious food. These two causes often occur together and are caused by multiple underlying factors including inadequate physical or economic access to food, poor health services, an unhealthy environment and inadequate caring practices for children and women. More basic causes include poverty, illiteracy, and low status of women, social norms and behaviours.

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Project overview

There are three focus regions for UNICEF Tanzania Office’s subnational support: Mbeya, Iringa and Njombe. The regions were selected on the basis of three critical indicators from the Tanzania Demographic and Health Survey (TDHS 2010) and Tanzania HIV and Malaria Indicator survey (THMIS 2011): (1) childhood stunting, (2) sanitation situation and (3) HIV prevalence.

The project “Bringing nutrition actions to scale in Iringa, Njombe and Mbeya Regions” was initiated by UNICEF Tanzania Country Office in 2012 with the expected impact of reducing the prevalence of stunting among children under five years old in the three regions from 44% in 2013 to 35% in 2019 (i.e. 20% relative reduction or 3.4% Average Annual Reduction Rate). To reach this impact, the project is expected to achieve the following outcome: • Regional and local government authorities effectively plan, budget, coordinate and monitor the delivery of nutrition services and nutrition sensitive interventions; • Pregnant women and caregivers of children aged less than two years enabled to practice nutrition-relevant behaviours and take up nutrition services; • Availability and access to diverse and micronutrient-rich foods at household level enhanced; • Evidence and learning from district and community programming on nutrition documented and used to inform the scale-up of nutrition actions to reduce stunting.

In the initial project proposal, the overall objective (expected impact) was to reduce the prevalence of chronic undernutrition among young children in six districts by 10 percentage points. The prevalence of stunting among children under two years old was proposed as the indicator to measure impact. Funding from Irish Aid covered only a first phase of three years which is deemed not enough time to detect a measurable and meaningful change in stunting. It was expected that based on the results of this first phase, a decision would be taken after Year 3 of whether to continue the project for a second phase of four years.

During the first phase, the project was also planned to roll out in two levels of intensity.

a) “High intensity” districts: Six districts have been selected for high intensity interventions. Two districts have been selected from each of the three regions: Iringa District Council (DC) and Mufindi DC in Iringa Region; Makete DC and Njombe DC in Njombe Region; and Mbeya DC and Mbarali DC in Mbeya Region. b) “Low intensity” districts: it was planned that selected activities will be implemented in the remaining districts in the regions starting from year 2 of the project. Here, the focus was expected to be on support at the district level only, and main activities expected were on strengthening the capacity of the district teams to plan, budget and coordinate nutrition-specific and nutrition-sensitive interventions. LGAs, CSOs and other partners were expected to utilise their own resources to scale-up access to nutrition-specific and nutrition-sensitive interventions.

In December 2012, a funding grant was approved by Irish Aid to support the first phase of the project with the agreement that a detailed monitoring and evaluation plan will be developed during the first year of the project. This plan was expected to include a baseline and an endline survey, designed to measure change in key project impact indicators related to behaviours, practices and child nutrition, as well as defined mechanisms for process monitoring over the project period.

The first year of the Project was mainly used for recruitment of implementing NGO (i.e., Concern Worldwide) and the baseline studies in Mbeya, Iringa and Njombe regions, covering five main areas: 1. Anthropometry and Infant and Young Child Feeding (IYCF) survey for children under the age of five and their primary care givers.

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2. Nutrition Capacity assessment of Local Government Authorities (LGAs) at the district level in Mbeya, Iringa and Njombe. 3. A Barrier Analysis to identify barriers to key behaviours that affect infant and young child feeding. 4. A Crop and Livestock survey to understand available nutritious crops and livestock and identify bottlenecks in production. 5. A Market survey, to identify nutritious crops bought and sold in rural areas, and bottlenecks in trading nutritious crops and fortified foods.

In December 2014, DFID through its “ASTUTE” project agreed to support UNICEF to expand the LGA’s Support and SBCC components in 12 districts of Mbeya and Njombe regions.

3. Purpose of the evaluation

After three years of implementing the Project, a formative evaluation of the first phase will be carried out with a view to generating evidence and lessons learnt to strengthen the programme design and accelerate the achievement of results. The timing of the evaluation was agreed with Irish Aid and the findings will contribute to the preparation of a country assistance strategy by the Embassy of Ireland in Tanzania for the period 2017-2021. UNICEF and government counterparts will use the evaluation results and findings to assess how best to revise and modify project implementation for improvement. The primary audience of this evaluation is thus the Government of Tanzania, UNICEF Tanzania Country Office and the Embassy of Ireland in Tanzania.

The main objectives of this formative evaluation are: 1. To assess the progress of the first phase of the project “Bringing nutrition actions to scale in Iringa, Njombe and Mbeya Regions”. 2. To assess the project design with a view to identifying ways of strengthening design for acceleration of results. 3. To identify lessons learned and formulate recommendations for improvement during the second phase of the project.

4. Scope of the Evaluation

This evaluation will be more formative than summative. The purpose of the evaluation will be to assess program design and progress on achievement of outputs (Key Results), likelihood of achieving expected outcomes, and factors that may facilitate or prevent the achievement of results – with a view to accelerating the achievement of results. The evaluation will cover all districts in Mbeya, Iringa and Njombe regions, with a focus on six “high intensity” districts and the period from January 2013 to June 2016.

Key informants that should be interviewed include regional and district nutrition officers, members of the multisectoral nutrition steering committee, health staff, community health workers and Care Groups members, progressive farmers, mothers/caregivers and village executive officers.

In line with UNICEF Evaluation Policy and UNEG Norms and Standards for Evaluation, the evaluation will apply the internationally agreed OECD-DAC evaluation criteria18. As such, the evaluation will assess the project against the following criteria:

18 Impact of the project in terms of stunting and behavioral change is not assessed due to the short implementation period of this first project phase.

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1. Relevance. To what extent does the intervention align with and contribute to national and international policies and priorities on nutrition? To what extent does the intervention respond to the needs of end-beneficiaries and local communities? 2. Effectiveness. How effective are implementation arrangements in reaching target beneficiaries and in ensuring progress towards stated outcomes? What is the quality and utility of the different project activities? 3. Efficiency. To what extent were results achieved with the most economic use of resources? To what extent does the intervention complement other nutrition initiatives? 4. Sustainability. Sustainability assessments should look at all aspects, including financials, local government ownership, capacity, and acceptability. 5. Equity. To what extent did the intervention reach the most marginalized children and communities? 6. Gender. To what extent did the intervention benefit both girls and boys, men and women equally?

Impact will not be assessed because the period of implementation has not been of sufficient duration, and also because this is a formative evaluation.

More specific evaluation questions are expected to be defined during the inception phase, along with a detailed evaluation matrix outlining how each criterion will be assessed.

UNICEF being a rights-based organization, the evaluation will mainstream gender, equity and human rights considerations throughout.

As this is a formative evaluation, it will seek to generate lessons learnt which will guide implementation of the next phase of the intervention.

5. Methodology

The Evaluation is expected to adopt a mix of methods to ensure triangulation. The contracted institution is not expected to collect additional quantitative data, but he is expected to: • Review key documents (proposal, logframe, baseline studies, progress reports, expenditure reports, and relevant national policy and strategy documents) • Prepare an inception report including the protocol for the formative evaluation, evaluation questions, interview guides for key stakeholders and checklist for field visits • Collect qualitative data using interview with key informants, focus group discussions and observations.

Interested candidates should suggest a more detailed methodology as part of their technical proposal.

6. Activities, deliverables and schedule The evaluation will go through the following interrelated processes: inception phase, data collection phase, data analysis and report writing phase, validation, dissemination and follow-up.

Inception Phase The main part of the inception work will be to conduct a desk review and an evaluability assessment as the basis for selecting an appropriate evaluation design. The brief and succinct evaluability assessment will be based on the logical framework of the project, outlining any challenges anticipated.

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On the basis of this ToR, additional information collected and discussions with UNICEF, the contracted institution will propose its evaluation design plan including the following:

a) The evaluation questions, clarifying at the outset any limitations that can be foreseen in adequately responding to the questions. b) An evaluation matrix that details sub-questions against the questions, indicators, and data collection methods that will be used. The matrix will detail to the extent feasible, the analytical frameworks that will be used to respond to the evaluation questions. c) A detailed work plan for the duration of the evaluation. This detailed timeline will establish more precise deadlines for consultations and submission of outputs.

The inception report should specify the evaluation design, evaluation framework for analysis to answer the evaluation questions, data collection tools, data management methods including how the quality of data will be assured and outline of the report.

The inception report should include a brief discussion on any ethical consideration arising in this specific evaluation and how the contracted institution will address these. See also section below on Evaluation Standards and Ethical Considerations.

Data Collection Phase Following the acceptance and signing off of the evaluation design plan and evaluation tools, the contracted institution will undertake the necessary data collection activities as per the agreed schedule. If during the course of the fieldwork any deviations from the agreed methodology and/or schedule are perceived necessary, the consultant must receive approval of UNICEF Tanzania before they can be applied.

Data Analysis and Report Writing Phase The contracted institution will submit the draft evaluation report in conformity with UNICEF standards and guidelines and present preliminary findings to the technical reference group. When evaluation supervisors consider the report of sufficient quality, it will be circulated for comments to the reference group comprised of representatives from UNICEF Tanzania Country Office (Nutrition and Social Policy sections) and selected stakeholders. On the basis of comments expressed by the reference group, the contracted institution will make appropriate amendments. The draft report will undergo internal quality review within UNICEF Tanzania and externally. On the basis of the comments received, the contracted institution will prepare the final report. Recommendations will be discussed and validated with Irish Aid and Representatives of the Government of Tanzania prior to finalization.

Dissemination and follow-up After approval of the final report, the Nutrition section in consultation with other UNICEF Tanzania sections will proceed with the dissemination of the results of the evaluation to partners and stakeholders.

UNICEF Tanzania’s Monitoring and Evaluation Specialist will assist the Nutrition section to prepare a management response to the evaluation recommendations.

7. Evaluation Standards and Ethical Considerations The evaluation will be conducted in accordance with the UN Evaluation Group (UNEG) Norms and Standards and UNICEF Procedure on Ethics in Evidence Generation. The contracted institution is required to act with independent judgment, give a comprehensive and balanced presentation of strengths and weaknesses of the programme being evaluated, and demonstrate consistent and dependable findings and recommendations.

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The contracted institution will need to demonstrate awareness of the ethical considerations arising from the data collection, as well as appropriate procedures and planning for ethical evidence generation with children, including informed consent and confidentiality.

Once the evaluation methodology is agreed, it will have to be forwarded to an institutional ethical review board for approval. The contracted institution will be responsible for obtaining the ethical approval and will submit the report from the review to UNICEF prior to data collection.

8. Stakeholder participation:

A number of stakeholders will be closely involved in the evaluation. In gathering data and views from stakeholders, the contracted institution will ensure that it considers a cross-section of stakeholders with potentially diverse views to ensure the evaluation findings are as impartial and representative as possible. The Technical Reference Group will consist of representatives from UNICEF Tanzania, relevant development partners and government officials, as appropriate. The group’s principal functions will be: • To validate the evaluation design • To provide the contracted institution with all available information and documentation about the objectives of the evaluation • To review the draft evaluation report • To assess and evaluate the quality of work of the contracted institution

9. Deliverables and Schedule

• Inception report describing the methodology for the formative evaluation including evaluation tools by 28st February2017 • Draft report of the formative evaluation by 30th April 2017 • Final report of the formative evaluation by 30th June 2017 • A 2 page summary of the main findings by 30th June 2017 • A powerpoint presentation detailing main findings by 30th June 2017

Reporting Framework The final report should include the following elements: an executive summary, background to the intervention, a profile of the evaluated activities, description of the evaluation methods employed, the main findings, conclusions, recommendations and lessons learned.

Conclusions, recommendations and lessons learned should be firmly based on evidence and analysis, be relevant and realistic, with priorities for action made clear. The contracted institution should avoid making recommendations that are too general or impossible to implement.

The report must state any potential conflict of interest arising.

The evaluation report will be reviewed and rated by the UNICEF Global Evaluation Report Oversight System (GEROS) Quality Assurance System based on UNEG standards for evaluation reports.

10. Evaluation team composition

The contracted institution will be fully responsible for the deliverables under the contract and must field an appropriate team comprised of technical contracted institution, data analysis specialists and field staff.

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Institutional profile:

• A well-equipped research department with an at least eight year old evaluation/research portfolio with extensive experience in evaluation and data analysis. • At least three good quality evaluation reports involving field level data collection. • Established experience in the area of evaluation of health and nutrition projects / services.

The evaluation team leader will be responsible for managing and providing overall leadership and direction in the proposed evaluation. The team leader is expected to have specific competencies in planning, designing and carrying out evaluations and performance measurement, including use of both qualitative and quantitative methods.

Team Leader experience: • At least eight years of experience in research, data collection, monitoring and evaluation, including specific experience evaluating nutrition, health or similar programme / services management, and in conducting participatory evaluations. • Demonstrated strong familiarity with nutrition and programme management areas. • Strong analytical and project management skills. • Good communication skills and report writing abilities. • Excellent knowledge of English; Kiswahili will be an asset.

In addition to the team leader, the evaluation team should consist of two-three additional members. The composition of the team is required to be gender-balanced.

Team Member experience: • At least five years of experience in research, data collection, monitoring and evaluation, including specific experience evaluating nutrition, health or similar programme / services management, and in conducting participatory evaluations. • Thorough knowledge and demonstrated experience with evaluation methods and principles. • Demonstrated strong familiarity with nutrition and programme management areas. • Strong analytical skills. • Good communication skills and report writing abilities. • Excellent knowledge of English. • Team members with spoken and written fluency in Kiswahili will be an asset.

Every effort has to be made to ensure evaluation team leader and members are not in a position of conflict of interest. Consequently, individuals who have been directly involved in implementation of the programme cannot serve as members of the evaluation team. Any other potential conflicts of interest will need to be declared by members of evaluation team at the point of application.

11. Accountabilities

Institution: Overall management, leadership and technical oversight. Design, review of data collection tools. Data collection and compilation. Liaison with the district offices, logistical arrangements and team supervision. Analysis and report writing. Communication of evaluation findings.

Stakeholders’ role and responsibilities are reflected through the process/ methodology and stakeholder participation. UNICEF Tanzania Nutrition Specialist will be responsible for supervision of the consultancy including approval of intermediary and final products, in consultation with the Chief Nutrition, and Chief Social Policy, Research Monitoring and

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Evaluation and senior management as outlined in the process and methodology part of the ToR.

12. Procedures and Logistics

UNICEF Tanzania is planning to sign an institutional contract based on the following conditions: • No work may commence unless the contract is signed by both UNICEF Tanzania and the institution. • The institution is responsible for making arrangements for office premises, transport and equipment (laptop and other ICT equipment). • Should the institution require specific assistance/materials from the UNICEF Tanzania office and/or national partners, he/she should make the request at least 10 days prior to the start of the mission. • Where necessary UNICEF Tanzania and government counterparts will direct and or facilitate necessary access to specific data/institution/personnel/location for the purpose of this exercise. • The institution will be in regular communication with UNICEF Tanzania designated focal person for the assignment, the Nutrition Specialist.

UNICEF Tanzania will provide venue and facilities for meetings with the Technical Reference Group comprised of representatives from UNICEF Tanzania Country Office, TFNC, PO-RALG and selected nutrition officers and focal persons.

13. Selection Process

UNICEF Tanzania Country Office will identify at least 5 institutions from ESARO rolodex. The shortlisted institutions will be invited to submit a technical proposal and budget to carry out the evaluation. The contracted institution is also required to provide relevant samples of previous work.

The institution will be selected based on the quality of the technical proposal and budget. The weight allocated between the two will be 60/40 – 60 points for technical quality and 40 points for budget.

14. Budget and Payment

The budget of the consultation including Fees, flight tickets, in country travels, DSA should not exceed USD 100,000.

The payment schedule will be as follows: • 20% of fees and 100% Flight tickets and DSA after o Approval of the inception report describing the protocol for the formative evaluation including interview guides for key stakeholders and checklist for field visits. o Approval travel plan for field visit • 30% of fees after submission of draft report of the formative evaluation by end of April 2017 • 50% of fees after submission and approval of final report of the formative evaluation by end of June 2017.

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Annex B. BNTS and ASRP design diagrams

Figure 2. BNTS impact pathways Source: UNICEF Tanzania, 2012: 14.

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Outputs Outcomes Impact

1. Increased participation of pregnant women and 1. Increased proportion of caregivers of children under two years old in counselling on IYCF, WASH, ECD and health practices pregnant women and Reduced caregivers of children 2. Increased participation of key community members and prevalence of local leaders in supporting pregnant women and under two years old who practice key nutrition- stunting caregivers of children under two years old to practicing among nutrition -relevant behaviours relevant behaviours (IYCF, WASH, ECD and health) in children 3. Increased proportion of health service providers who Reduced provide appropriate and timely counselling and support Mbeya, Iringa and Njombe under five for nutrition-relevant behaviours in health facilities Regions years old in prevalence three regions of stunting 2. Increased availability of among 4. Increased capacities of households to produce diverse of Tanzania diverse nutrient-rich foods (Mbeya, children nutrient-rich foods at household level in under-five 5. Increased capacities of households to preserve Iringa and Mbeya, Iringa and Njombe years in nutrient-rich foods Regions Njombe) from 44% in Tanzania

6. Enhanced planning, coordination and monitoring 2013 to 35% systems across multiple sectors at the national and 3. Strengthened evidence in 2019. (i.e. subnational level based multisectoral 20% relative 7. Increased resources for nutrition at national and district level to operationalize the National Nutrition Strategy response to undernutrition reduction or 8. Strengthened national nutrition information system for in Tanzania AARR: 3.4%) timely and evidence-based decision-making

Figure 3. ASRP logic model OR finding and nutrition data disseminated. Source: UNICEF Tanzania, 2016b: 21.

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Annex C. Evaluation matrix

Area of enquiry Specific questions Analysis/indicators Main sources of information Triangulation approach

Relevance Key question 1: To what extent does the intervention align with and contribute to national and international policies and priorities on nutrition?

To what extent does the • Compare stated project design • Documentation • Compare documentary intervention align with and with documentation, notably • Interviews evidence with KI perceptions contribute to national National Nutrition Policy and • Compare KI perceptions on nutrition policies and plans? National Multisectoral Nutrition project alignment Action Plan (NMNAP)19 • Compare stated project design with perceptions of key informants (KIs) in Tanzania nutrition sector To what extent does the • Compare stated project design • Documentation • Compare documentary intervention align with with documentation on • Interviews evidence with KI perceptions international policies and international nutrition policies • Compare KI perceptions on strategies on nutrition? and strategies, notably Scaling up project alignment Nutrition (SUN) • Compare stated project design with perceptions of key informants (KIs) in global nutrition sector

Key question 2: To what extent does the intervention respond to the needs of end-beneficiaries and local communities?

19 The project was designed before the NMNAP was approved. But it is still important to check for alignment of BNTS and ASRP to the NMNAP, as any divergence would probably imply that BNTS and ASRP should be adjusted.

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Area of enquiry Specific questions Analysis/indicators Main sources of information Triangulation approach

To what extent does the • Assess activities as implemented • Project design and • Compare documentary intervention respond to the and planned for relevance to implementation evidence with KI perceptions needs of children during the dietary requirements of children documentation • Cross-check KI views first 1,000 days from during first 1,000 days, and likely • Documentation on infant and • Compare documentary conception? enhancement of dietary provision young child feeding (IYCF) evidence and KI perceptions • Assess activities as implemented requirements and challenges with beneficiary perceptions and planned for relevance to in project areas, including requirements of children under Tanzania National Strategy two years old for appropriate and Guidelines20 on Infant WASH, CCD/ECD and health and Young Child Nutrition behaviours and UNICEF guidelines on community-based IYCF21 • Documentation on WASH, CCD/ECD and health behaviour standards for Tanzania and globally • Interviews • Focus group discussions (FGDs) To what extent does the • Assess activities as implemented • Project design and • Compare documentary intervention respond to the and planned for relevance to implementation evidence with KI perceptions needs of mothers and carers dietary and livelihood documentation • Cross-check KI views during the first 1,000 days requirements of mothers during • Documentation on IYCF and • Compare documentary from conception, taking into the first 1,000 days from livelihood requirements and evidence and KI perceptions account their livelihood conception challenges in project areas with beneficiary perceptions context? • Assess activities as implemented • Documentation on WASH, and planned for relevance to CCD/ECD and health WASH, CCD/ECD and health behaviour standards for behaviours of mothers and carers Tanzania and globally • Interviews

20 GOT, 2013. 21 UNICEF, 2013.

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Area of enquiry Specific questions Analysis/indicators Main sources of information Triangulation approach

• Focus group discussions (FGDs) How well does the • Assess activities as implemented • Project design and • Compare documentary intervention respond to the and planned for relevance to implementation evidence with KI perceptions overall nutrition challenges nutritional and livelihood documentation • Cross-check KI views of local communities? challenges of local communities, • Documentation on nutritional • Compare documentary and their feasibility in the context and livelihood challenges in evidence and KI perceptions of these challenges project areas with beneficiary perceptions • Interviews • Focus group discussions (FGDs) Effectiveness Key question 3: What progress has been made towards Key Result/Outcome 1? [Regional and local government authorities effectively plan, budget, co-ordinate and monitor the delivery of nutrition services and nutrition-sensitive interventions.]

Have activities intended to • Compare activities reported as • Project proposal • Check for consistency between achieve KR 1 been implemented with project • Project work plans proposal, work plans and implemented as planned so proposal and work plans • Project implementation implementation reports far? reports Have outputs intended to • Compare project implementation • Project proposal and results • Check for consistency between achieve KR 1 been achieved reports with indicators of output framework proposal, work plans and as planned so far? achievement specified in results • Project implementation implementation reports framework reports Has work towards KR 1 • Compare project proposal, more • Project proposal • Cross-check documentary deviated from what was detailed project work plans and • Project work plans information with that provided originally planned? project implementation reports • Project implementation by KIs reports • Interviews

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Area of enquiry Specific questions Analysis/indicators Main sources of information Triangulation approach

Have activities intended to • Assess technical quality of • Project proposal • Cross-check KI opinions achieve KR 1 been of activities in terms of international • Project implementation • Compare KI views with those sufficient quality and utility standards22 and project design reports of LGAs so far? • Identify any gaps in • Interviews implementation that might weaken utility of design • Determine views of Local Government Authorities (LGAs) about quality and utility Key question 4: What factors have stimulated or impeded progress towards KR 1?

What factors have had a • Identify design factors that • Project implementation • Compare analysis drawn from significantly positive or significantly stimulated or reports documentation with views negative effect on impeded progress • Recent analytical expressed by KIs achievement of KR 1 so far? • Check on validity of implicit TOC documentation on nutrition • Cross-check KI opinions assumptions, including: and related sectors in understanding and acceptance of Tanzania advocacy by the responsible • Interviews authorities; co-ordination achieved through enhanced structures; development and delivery of effective capacity building strategies; stakeholder willingness; causal relationship between KR 1 and overall objective • Identify funding and budget factors that significantly stimulated or impeded progress

22 Referring, for example, to The Lancet, 2008 and The Lancet, 2013.

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Area of enquiry Specific questions Analysis/indicators Main sources of information Triangulation approach

• Identify operational factors that significantly stimulated or impeded progress • Identify institutional factors that significantly stimulated or impeded progress • Identify extraneous factors that significantly stimulated or impeded progress Key question 5: What progress has been made towards Key Result/Outcome 2? [Pregnant women and caregivers of children aged less than two years enabled to practise nutrition-relevant behaviours and take up nutrition services.]

Have activities intended to • Compare activities reported as • Project proposal • Check for consistency between achieve KR 2 been implemented with project • Project work plans proposal, work plans and implemented as planned so proposal and work plans • Project implementation implementation reports far? reports Have outputs intended to • Compare project implementation • Project proposal and results • Check for consistency between achieve KR 2 been achieved reports and local health and framework proposal, work plans, as planned so far? nutrition data with indicators of • Project implementation implementation reports and output achievement specified in reports local health and nutrition data results framework • Local health and nutrition data Has work towards KR 2 • Compare project proposal, more • Project proposal • Cross-check documentary deviated from what was detailed project work plans and • Project work plans information with that provided originally planned? project implementation reports • Project implementation by KIs. reports • Interviews Have activities intended to • Assess technical quality of • Project proposal • Cross-check KI opinions achieve KR 2 been of activities in terms of international • Project implementation • Compare KI views with those sufficient quality and utility standards and project design reports of beneficiaries so far? • Interviews • FGDs

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Area of enquiry Specific questions Analysis/indicators Main sources of information Triangulation approach

• Identify any gaps in implementation that might weaken utility of design • Determine beneficiary views of quality and utility Key question 6: What factors have stimulated or impeded progress towards KR 2?

What factors have had a • Identify design factors that • Project implementation • Compare analysis drawn from significantly positive or significantly stimulated or reports documentation with views negative effect on impeded progress • Recent analytical expressed by KIs and achievement of KR 2 so far? • Check on validity of implicit TOC documentation on nutrition beneficiaries assumptions, including: linkage and related sectors in • Cross-check KI opinions between KR 1 and KR 2; Tanzania • Cross-check beneficiary effectiveness of KR 3 in • Interviews opinions enhancing availability of and • FGDs access to diverse and micronutrient-rich foods at household level; effectiveness of planned causal linkages between training and communication outputs and coverage and quality of nutrition services and SBCC • Identify funding and budget factors that significantly stimulated or impeded progress • Identify operational factors that significantly stimulated or impeded progress • Identify social factors that significantly stimulated or impeded progress

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Area of enquiry Specific questions Analysis/indicators Main sources of information Triangulation approach

• Identify institutional factors that significantly stimulated or impeded progress • Identify extraneous factors that significantly stimulated or impeded progress Key question 7: What progress has been made towards Key Result/Outcome 3? [Availability and access to diverse and micronutrient-rich foods at household level enhanced.]

Have activities intended to • Compare activities reported as • Project proposal • Check for consistency between achieve KR 3 been implemented with project • Project work plans proposal, work plans and implemented as planned so proposal and work plans • Project implementation implementation reports far? reports Have outputs intended to • Compare project implementation • Project proposal and results • Check for consistency between achieve KR 3 been achieved reports and local agricultural data framework proposal, work plans, as planned so far? with indicators of output • Project implementation implementation reports and achievement specified in results reports local agricultural data framework • Local health and nutrition data Has work towards KR 3 • Compare project proposal, more • Project proposal • Cross-check documentary deviated from what was detailed project work plans and • Project work plans information with that provided originally planned? project implementation reports • Project implementation by KIs reports • Interviews Have activities intended to • Assess technical quality of • Project proposal • Cross-check KI opinions achieve KR 3 been of activities in terms of international • Project implementation • Compare KI views with those sufficient quality and utility standards and project design reports of beneficiaries so far? • Identify any gaps in • Local health and nutrition implementation that might data weaken utility of design • Interviews • Determine beneficiary views of • FGDs quality and utility

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Area of enquiry Specific questions Analysis/indicators Main sources of information Triangulation approach

Key question 8: What factors have stimulated or impeded progress towards KR 3?

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Area of enquiry Specific questions Analysis/indicators Main sources of information Triangulation approach

What factors have had a • Identify design factors that • Project implementation • Compare analysis drawn from significantly positive or significantly stimulated or reports documentation with views negative effect on impeded progress • Recent analytical expressed by KIs and achievement of KR 3 so far? • Check on validity of implicit TOC documentation on nutrition beneficiaries assumptions, including: and related sectors in • Cross-check KI opinions effectiveness of extension Tanzania • Cross-check beneficiary through ‘progressive farmers’ and • Interviews opinions of LGA efforts to address • FGDs bottlenecks in increasing production of relevant foods and enhancing market efficiency; livelihood circumstances of target group enable them to respond to project stimuli; realism of project design given existing work load of women • Identify funding and budget factors that significantly stimulated or impeded progress • Identify operational factors that significantly stimulated or impeded progress • Identify social factors that significantly stimulated or impeded progress • Identify institutional factors that significantly stimulated or impeded progress • Identify extraneous factors that significantly stimulated or impeded progress

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Area of enquiry Specific questions Analysis/indicators Main sources of information Triangulation approach

Key question 9: What progress has been made towards Key Result/Outcome 4? [Evidence and learning from district and community programming on nutrition documented and used to inform the scale-up of nutrition actions to reduce stunting.]

Have activities intended to • Compare activities reported as • Project proposal • Check for consistency between achieve KR 4 been implemented with project • Project work plans proposal, work plans and implemented as planned so proposal and work plans • Project implementation implementation reports far? reports Have outputs intended to • Compare project implementation • Project proposal and results • Check for consistency between achieve KR 4 been achieved reports with indicators of output framework proposal, work plans and as planned so far? achievement specified in results • Project implementation implementation reports framework reports Has work towards KR 4 • Compare project proposal, more • Project proposal • Cross-check documentary deviated from what was detailed project work plans and • Project work plans information with that provided originally planned? project implementation reports • Project implementation by KIs reports • Interviews Have activities intended to • Assess technical quality of • Project proposal • Cross-check KI opinions achieve KR 4 been of activities in terms of international • Project implementation sufficient quality and utility standards and project design reports so far? • Identify any gaps in • Interviews implementation that might • FGDs weaken utility of design Key question 10: What factors have stimulated or impeded progress towards KR 4?

What factors have had a • Identify design factors that • Project implementation • Compare analysis drawn from significantly positive or significantly stimulated or reports documentation with views negative effect on impeded progress • Recent analytical expressed by KIs achievement of KR 3 so far? • Check on validity of implicit TOC documentation on nutrition • Cross-check KI opinions assumptions, including: evidence and related sectors in and learning generated lead to Tanzania more effective planning, • Interviews

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Area of enquiry Specific questions Analysis/indicators Main sources of information Triangulation approach

budgeting, co-ordination and monitoring • Identify funding and budget factors that significantly stimulated or impeded progress • Identify operational factors that significantly stimulated or impeded progress • Identify institutional factors that significantly stimulated or impeded progress • Identify extraneous factors that significantly stimulated or impeded progress Efficiency Key question 11: To what extent were results achieved with the most economic use of resources?

What do available data show • If data permit, calculate costs per • Project implementation and • Check any available data on about the cost per unit of activity type and per unit of financial reports cost efficiency against KI views delivery? delivery • Interviews • Obtain and apply professional judgement on cost efficiency of project implementation Are there lower-cost ways of • Assess project design in the light • Project proposal • Cross-check KI views achieving the planned of implementation experience to • Project implementation and • Compare KI views on cost outputs? date, and in comparison to financial reports efficiency with other relevant similar interventions in • Documentation on similar experience as reported in comparable settings interventions in comparable documentation on comparable settings interventions • Interviews

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Area of enquiry Specific questions Analysis/indicators Main sources of information Triangulation approach

Key question 12: To what extent does the intervention complement other nutrition initiatives?

What other relevant nutrition • Present summary data on other • Project reporting • Compare KI views and initiatives are being relevant nutrition initiatives • Interviews information obtained from undertaken in the project project documentation area and in Tanzania? Does the project • Cross-check this project’s • Project plans • Compare KI views and complement, duplicate or activities, objectives, target • Project reporting information obtained from contradict what other group, working area with those • Interviews project documentation nutrition initiatives are of other initiatives doing? Is there synergy between • Determine whether this project • Project plans • Compare KI views and the project and other and other relevant initiatives add • Project reporting information obtained from nutrition initiatives? up to more than the sum of the • Interviews project documentation parts Sustainability Key question 13: Does the design of the intervention make appropriate provision for sustained good nutrition or align with initiatives that seek to do this?

Does the design of the • Check project design against • Project document • Cross-check project design intervention make internationally recognised • Literature on internationally against more than one appropriate provision for the definitions of food security recognised standards for internationally recognised food security and livelihood elements of sustained good sustained good nutrition23 definition elements of sustained good nutrition nutrition? Does the design of the • Check project design against • Project document • Cross-check project design intervention make internationally recognised • Literature on internationally against more than one appropriate provision for the definitions of health elements of recognised standards for internationally recognised health elements of sustained sustained good nutrition sustained good nutrition10 definition

23 Including GOT, 2013 and UNICEF, 2013

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Area of enquiry Specific questions Analysis/indicators Main sources of information Triangulation approach

good nutrition, including WASH? Does the design of the • Check project design against • Project document • Cross-check project design intervention make internationally recognised • Literature on internationally against more than one appropriate provision for the definitions of care elements of recognised standards for internationally recognised care elements of sustained sustained good nutrition sustained good nutrition10 definition good nutrition?

Key question 14: What are the prospects of sustaining the enhanced nutrition system introduced by the intervention?

Do LGAs display adequate • Assess LGA awareness and • Interviews with LGA KIs • Cross-check KI views ownership of, and understanding of the enhanced commitment to, the nutrition system enhanced nutrition system? • Assess LGA ownership of and commitment to the enhanced nutrition system What are the prospects of • Assess prospects of staff capacity • Review of LGA plans and • Cross-check KI views sustaining the added to sustain the added community budgets community health resources health resources • Interviews with LGDA KIs introduced for • Assess prospects of budgetary implementation of the capacity to sustain the added programme? community health resources What are the prospects of • Assess prospects of staff capacity • Review of LGA plans and • Cross-check KI views sustaining the resources to sustain the enhanced budgets introduced for scaling up the ‘nutrition-sensitive’ interventions • Interviews with LGDA KIs ‘nutrition sensitive’ • Assess prospects of budgetary interventions in agriculture, capacity to sustain the enhanced social protection, water, ‘nutrition-sensitive’ interventions sanitation and hygiene (WASH) and control of communicable diseases (CCD)?

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Area of enquiry Specific questions Analysis/indicators Main sources of information Triangulation approach

Equity Key question 15: To what extent is the intervention reaching the most marginalised children and communities?

Within the communities • Check data, if any, on socio- • Project implementation data • Compare information, if any, served by the project, is the economic status of children • Health facility data available from data with views project reaching the most served by project • Interviews of KIs and beneficiaries marginalised children? • Determine community views on • FGDs • Compare KI views with those correlation, if any, between of beneficiaries children’s and mothers’ access to project services and their socio- economic status Within the Regions served • Check project implementation • Map(s) of project area and • Compare findings from by the project, is the project data for potential geographic bias intervention sites mapping and data with views reaching the most • Check data, if any, on socio- • Interviews of KIs and beneficiaries marginalised communities? economic status of communities • FGDs • Compare KI views with those served by project of beneficiaries • Determine community views on correlation, if any, between communities’ access to project services and socio-economic status Gender Key question 16: To what extent is the intervention benefiting both girls and boys, men and women equally?

Is the intervention benefiting • Compare data on gender of child • Project implementation data • Compare implementation data girls and boys equally? beneficiaries • Interviews with views of analysts and • Determine analysts’ and • FGDs communities communities’ views on any • Cross-check analysts’ and differentials in how girls and boys communities’ views benefit from project interventions

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Area of enquiry Specific questions Analysis/indicators Main sources of information Triangulation approach

Is the intervention • Assemble information on • Documentation on women’s • Compare analysis in contributing to the social and women’s livelihoods in project livelihoods documentation with economic empowerment of areas, with particular reference • Interviews interpretation of analysts and women? to social, economic and • FGDs women beneficiaries institutional status • Determine analysts’ and women beneficiaries’ views on whether project has contributed to social and economic empowerment of women Is the intervention increasing • Views of project implementation • Interviews • Compare official views and the understanding of men on staff and local officials on any • FGDs community views the nutritional needs of changes in men’s understanding • Compare men’s views and children and women, and and/or in their level of support women’s views enhancing their support in • Views of men in communities • Cross-check opinions expressed ensuring that these needs served by project on any changes by each category of informant are met? in their understanding and/or in their level of support • Views of women in communities served by project on any changes in men’s understanding and/or in their level of support

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Annex D. Research instruments Introduction

This annex presents the outline research instruments that were developed during the inception phase for use by the evaluation team during visits to the project area. They were intended as guidelines only, and were used flexibly according to the team’s judgment in the flow of each meeting or discussion.

D1. District Nutrition Officer and/or UNICEF representative and/or NGO implementing agency

1. Timelines for the implementation of the project in this particular district (important for interpretation of data). 2. Complete list of activities and actors/partners. This could be filled out on a preliminary basis before district visit based on background info and then validated with these officials. Try to get time to get specific information on constraints and progress on each of the ongoing nutrition specific and nutrition sensitive activities. 3. Ask them specifically to describe how the villages/communities have been selected in order to achieve a 75% coverage; which areas are left out? Equity concerns? 4. Exactly how were the ‘supervisors’ selected, by whom? Are these functionaries now considered as part of the ‘external’ Implementation Agency or still being a ‘community owned resource person’ (which we assume they were before being selected as supervisor)? 5. Exactly how were the (approximately) ten ‘influencers’ selected and how is the active participation of this group ascertained and sustained? Why wasn’t the relevant village committee used and trained since you could argue that this is, indeed, their role? 6. The BNTS represents a rather ‘massive’ boost of temporary technical and financial assistance to the district. What measures have been put in place to facilitate the final phasing out of the programme in the district? 7. Exactly how – if at all – are UNICEF and implementing agency staff mentoring or coaching the district nutrition officer and other nutrition staff in the district? Any organised ‘on the job’ training planned?

D2. District Executive Director

• Introductions (including DED’s length of service in this office, acquaintance with project); purpose of evaluation. • SWOT structured interview:

Tell us some of your impressions of the ASRP: a) What are the greatest strengths? b) What are the most concerning weaknesses of the project? c) What would be some opportunities to further strengthen project effectiveness and impact? Additional things you would like to see (if possible). d) What do you see as the greatest threats or risks of the project as presently implemented?

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• Follow up questions: a) make reference to Scorecard results and ask the DED to give his/her ideas why the district may be performing better or worse than other districts b) the same as a) using the bottleneck analysis conducted in the district c) ask for actual evidence on how the project or the Tanzania ‘scaling up nutrition’ movement in general (PORALG budgeting directives, etc.) has influenced this LGA’s planning and budgeting priorities. Ask if we can share any concrete evidence.

• Documentation: evidence of District Council initiatives to accelerate stunting reduction - District Plans - District Budgets - Other evidence, e.g. communication initiatives and events

D3. District Nutrition/NMNAP Co-ordinating Committee

• Introductions, purpose and expectations - It will be very important to emphasise the nature of the evaluation as a ‘formative exercise’, i.e. not judging or blaming anybody but trying to make an early assessment of ‘what works’ and ‘what does not work’ in order to further refine and ‘sharpen’ the ASRP approach. “This is your chance to change what needs to be changed and added…” • Perception of the situation and trends - How do you see the nutrition situation in the district? Better or worse than neighbouring districts? The average for Tanzania? - Is the situation getting better or worse? What evidence do you have? What do you think are the main reasons for improvements and deteriorations? • SBCC - Stunting (udumavu) is sometimes difficult to see but still having very serious negative impact on the child’s development. It develops slowly during 1,000 days rather than being a result of short-term food shortages or loss of appetite due to infection. In order to address this problem we all need to understand this better in order to do the right things. How do you think the ASRP is managing to achieve this: a) With the mothers and caretakers…. b) With the community and – especially important ‘influencers’ such as mothers-in-law, women leaders, etc. c) What about government and political leaders themselves (like you)…

- Is the programme using the best and most appropriate approach? - Can ‘supervisors’ and paid CHWs be sustained? Do they need to or do you think once the problems are understood then the communities will be able to maintain healthy and nutritious behaviours? • Support to nutrition services in the health sector - What works well? Less well? Missing?

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• Support to nutrition-sensitive actions in other sectors - What works well? Less well? Missing? • Multisectoral co-ordination and management - Do you feel you have enough capacity (mandate, resources, skills) to manage the district multi-sectoral nutrition activities effectively? - Resources/budget? Skills/training? Management information systems?

D4. District Medical Officer

• BNTS/ARSP support to district nutrition services in the health sector - Do you think it is sufficiently clear what nutrition-related services you are expected to provide through the health sector in your district? What are the question-marks? - Do you have the technical capacity and the supplies and equipment to provide these services in all parts of your district? What are the most critical gaps in that respect? - Does the BNTS/ARSP programme provide you sufficient support to enable you to provide the expected and necessary nutrition-related services? What more would you wish could be added? • Collaboration with the Implementing Agencies - Do you feel your collaboration with the IAs is working well at both (district) coordination level as well as at (ward/village) service delivery level? - Do you think there is anything the IAs should do differently to become more effective in supporting you to provide essential nutrition services? - How does the IA appointment of “supervisors” and paying of selected CHWs affect the work of the PHC/CHW activities in your district? Positive and negative effects? - Do you think these supervisors and specially trained and CHWs need to be maintained in their positions in order to ensure that good nutrition practices are sustained in the communities? • Anaemia and Severe Acute Malnutrition - These are two nutrition conditions that require special resources for prevention and treatment. How well do you manage in your district? What are specific problems that need further support? • Nutrition-related childhood illnesses - Compared to other districts in Tanzania, your district has very high prevalence of some childhood illnesses, especially Acute Respiratory Infections (ARI) and this is likely to contribute to high levels of malnutrition. Do you agree that this is a problem and is there anything that can be done to better prevent and control these illnesses? • Early signs of success? - Are there any signs in your reporting system reflecting improvements in the nutrition situation in your district after the start of the BNTS/ARSP? Reduction of low birth weight (LBW)? Reduction of teenage pregnancies? Increased initiation of breast-feeding within one hour of birth? Growth monitoring data?

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- Do you think your health information system is well designed to help identify such signs of success AND/OR lack of improvements? • Final thoughts on ideas that could improve the programme during the next phase of implementation?

D5. District Agricultural/Livestock Officer(s)

One of the key results in this project is to enhance availability and access to a diverse and micronutrient-rich food at household level. This means ensuring adequate production and supply in the market so that households can have access to micronutrient-rich foods. • In your area what micronutrient-rich foods were identified and promoted for production and marketing? • How were these produced and marketed, including prices of these foods at the market? • In addition, progressive farmers were trained to produce diversified crops. How were you able to assess crop diversity? Is there any index that was used? If not what method did you use to assess crop diversity? • In your area, how many farmers were reached? • What has been the response of farmers to this project? • What is the link between extension officers and farmers/livestock keepers? • Any challenges that influenced the implementation of this project? • An additional way of accessing foods that are rich in micronutrients is through the market; how many households rely on the market for foods? What foods are purchased from the market? Are they micronutrient-rich? • How are prices monitored or controlled? These include prices for crops to be sold and purchased by farmers/households • If we were to implement this project again what would be your views as to how this project could be done differently?

D6. Health Centre

• Observe/ check: - Organisation/ provision of nutrition services: - Antenatal care health/nutrition assessment of pregnant mothers, (age, height, weights, BMI?, MUAC?, anaemia - Special attention to risk indicators - …. - Birth…. - Breast-feeding (immediate initiation, exclusive, continued) - IYCF - GMP - IMAM? - IMCI (those related to malnutrition in particular) - EPI - Participation in Child Health Days

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- Records: Collection, compilation and reporting of nutrition data AND use of data at HC itself! - Specifically: check and note: a) Records from 2017 on: Low Birth Weight, age, gestational age, and weight/ height of mothers at first ANC visit b) GMP

• Discussion with HC staff: - Experiences from ASRP support, positive/negative - Links to ASRP ‘supervisors’ and designated CHWs - Follow up/referral of children showing faltering growth - Ideas for improvements in ASRP support

D7. Community Counselling Group: focus group discussion

• The focus group discussion will aim to assess how the counselling group has been informed, and how they understand, accept and adopt some of the key behaviours that the programme has set out as priorities in order to prevent stunting (i.e. as reflected in the nutrition education tools, like the ‘Bango Kitita’). Four key areas, each with three key behaviours are selected as follows: • Thematic area 1: Pregnancies - No teenage pregnancies before the girls reach at least 18 years of age - Pregnant mothers start attending ante-natal clinics early (2-3 month of pregnancy) and attend the clinic a minimum of 3-4 times - Pregnant mothers eat enough of well mixed foods and avoid heavy labour and are given time to rest • Thematic area 2: Breast feeding - Mothers start breastfeeding immediately after birth (within one hour) - The child is fed only breastmilk until they reach 6 months of age - The mother continues to breastfeed her child until they reach 2 years or beyond • Thematic area 3: Complementary feeding - After reaching 6 months of age, the child is given complementary feeding at least 4 times per day - The complementary feeding should include foods from each of the 5 food groups (staple foods, protein-rich foods, vegetables, fruits, fat/oil and sugar) - The child should receive a food from animal source at least once per day Ask them to consider each of the key behavioural change areas they have been taught; what makes sense, what is difficult to follow/why. (A simple flip-chart in Swahili can be used to facilitate the discussion below.)

- Pregnancies (teenage pregnancy, early reporting of pregnancy, minimum ANC, avoiding heavy work, ensure good food, support from household members, delivery at safe place) - Appropriate breast feeding (3 aspects: early initiation, exclusive breast feeding and continued breast feeding)

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- Complementary feeding 3 aspects (frequency, animal source, food diversity, responsive feeding) - Hygiene: 3 aspects (handwashing, faecal disposal, food/utensil safety in child feeding) • Thematic area 4: Water, Sanitation and Hygiene, WASH - Washing hands with soap before feeding the child - Ensure that the utensils and containers used for feeding the child are clean - Ensure that all faeces are disposed of safely

The Swahili translations of these points are included below.

During the focus group discussion, each of the thematic groups and its related behaviours are read out one at a time from a pre-prepared Swahili flip-chart (one for each thematic group). Then the facilitator will ask:

1. Have the group heard about all the three behaviours on this chart and had a chance to discuss them? Is there any of these behaviours that does not make sense? Which one? 2. Is there any of these behaviours that the people in your village find difficult to follow? Which one(s)? 3. What is the most important thing to do to ensure that all people in your community will adopt these behaviours (and reduce stunting) and then continue even after the programme is finished?

Swahili translation of the key nutrition-related behaviours to be discussed in the Focus Group Discussions with the village nutrition counselling groups.

Mwongozo wa majadiliano kwa vikundi shirikishi

1. Tabia zinazochangia kupunguza matatizo ya udumavu zinazohusiana na wajawazito: • Wasichana wasipate mimba kabla ya kutimiza umri wa mwaka 18 • Wajawazito waanze kuhudhuria kliniki mapema sana (mara baada ya kujihisi ni mjamzito- ndani ya miezi 2-3 ya mimba) na wahudhurie kliniki hizi angalau mara 3-4 kipindi chote cha ujauzito. • Wajawazito wale chakula mchanganyiko and chakula cha kutosha na wasifanye kazi ngumu na wapate mda wa kutosha kupumzika

2. Tabia zinazochangia kupunguza matatizo ya udumavu zinazohusiana na unyonyeshaji bora: • Mama aanze kunyonyesha mtoto mara tu baada ya kujifungua (ndani ya saa moja) • Mtoto anyonye maziwa ya mama pekee mpaka anatakapo fikisha umri wa miezi sita (bila kupewa maji au chakula kingine) • Mama anaendelea kumnyonyesha mtoto wake hadi mtoto atakapofika umri wa miaka miwili au zaidi

3. Tabia zinazochangia kupunguza matatizo ya udumavu ambazo zinahusiana na Ulishaji wa chakula cha nyongeza

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• Baada ya kufika umri wa miezi 6 watoto wapewe chakula cha nyongeza angalau mara nne kila siku • Wakati huu wapewe chakula angalau cha aina 4 kila siku kutoka kwenye makundi ya chakula; Nafaka mizizi na ndizi, Vyakula vya jamii ya mikunde na asili ya wanyama, Mboga mboga, Matunda, Sukari na mafuta. • Vilevile, ni umuhimu watoto wapewe chakula chenye asili ya wanyama angalau mara moja kwa siku, kwa mfano nyama aina yo yote, samaki, mayai, maziwa n.k

4. Tabia zinazochangia kupunguza matatizo ya udumavu ambazo zinahusiana na maji na usafi • Lazima kunawa mikono na sabuni kabla ya kulisha mtoto • Lazima vyombo vinavyotumika kulishia mtoto viwe safi na salama • Lazima kuhakikisha utupaji sahihi wa kinyesi pamoja na kuwa na choo bora

D8. Progressive farmers (selected sites only)

A few farmers will be selected for face-to-face interviews. The aim of this interview is to capture information about their participation in the project; their experience and/or challenges; and what needs to be done to scale up what has already been achieved. • What is the size of your agricultural land? • What is the status of ownership? • What have you been producing on the land for the past five years? • Has there been any change in the pattern of production over this period? • What has influenced these changes? • How did you happen to be in this project? Did you volunteer or you were recruited to participate? • For how long have you been participating in this project? • What kind of support have you received from this project? • From whom? Agriculture extension officer, project officer or fellow farmers? • How effective/efficient has the support been? • What is your opinion about diversified production? Is it a new concept or is it something that has been in practice for many years? • What considerations are taken into account when planning for production (price, markets, gender…)?

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Annex E. Stakeholder analysis

The stakeholder analysis shown in Table 5 below was included in the evaluation inception report (Mokoro, 2017: 9-11).

Table 5 Stakeholder analysis

Stake- Role in the programme and Participation in the Who will holder interest in the evaluation evaluation participate A. Internal (UNICEF) stakeholders Country Responsible for country-level planning Primary stakeholder, CO and SO staff Office and operations implementation. informants and source of responsible for (CO) Accountable to beneficiaries and information. Also primary nutrition. Tanzania partners for performance and results. user of (as well as being (and affected by) evaluation Mbeya Direct stake in the evaluation, an findings / recommendations sub office interest in learning from experience to to inform programming. (SO)) inform decision-making, notably related to programme implementation Facilitate logistical and/or design, country strategy and arrangements for in- partnerships, also related to country mission; participate approaches to monitoring. in briefing and de-briefing meetings. Sub office responsible for local planning and implementation of Participated in and nutrition programmes. facilitated inception mission. UNICEF Interest in lessons that emerge from Source of information on No direct Regional evaluations, particularly as they relate UNICEF approaches, participation Office and to UNICEF strategies, policies, standards and success envisaged. HQ thematic areas or implementation criteria, as well as modality with wider relevance to corporate strategic UNICEF programming. directions where these may influence programming/ operations. B. External stakeholders B1. Government of Tanzania (national and LGAs) The Government of Tanzania (GOT) falls into various stakeholder categories (see below). Overall, both LGAs and national government have a direct interest in knowing whether UNICEF activities in the country are aligned with their priorities, harmonised with the action of other partners, and meet the expected results. They also have an interest in whether the capacity of stakeholders in government ministries and LGA structures has been built and what further inputs might be needed in future. This is especially true for the relevant sector ministries at national and district levels. B2. Ultimate beneficiaries Benefi- The project’s intention to reduce Informants for the Direct participants ciary stunting is directed at children during evaluation, who will be in/ beneficiaries of house- their first 1,000 days of life (from consulted during site visits, project activities. holds, in conception). Improved nutrition of to determine the type of Respondents to particular pregnant women is vital for this support received, whether include women, mothers, purpose. The project also seeks to it has been effective, etc. men, counselling carers enhance the nutritional knowledge of group members/ and parents (and carers) and nutritional Likely to be affected by representatives and children practices for children under 24 evaluation participants. months. recommendations, but unlikely to engage directly in report findings.

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Stake- Role in the programme and Participation in the Who will holder interest in the evaluation evaluation participate B3. Operational beneficiaries Commun- The direct interface between the Informants for the CHWs in ity Health project and the target group, evaluation, both as communities Workers responsible for daily communication promoters of enhanced selected for site (CHWs) and advocacy of nutrition messages. nutrition practice and as visits. recipients of training and stipends from the project. LGAs Project implemented in consultation Informants for the District Executive with LGAs, which should ultimately evaluation, particularly for Director (DED); take responsibility for nutrition KR 1. District Nutrition programmes in association with Officer; District national government. LGAs also benefit Will facilitate evaluation Nutrition Co- from project activities under Key field mission in association ordinating Result (KR) 1: institutional with UNICEF and Committee (DNCC); development, enhanced planning, implementing partners District Medical information systems and consultations. (IPs). Officer; District Agricultural/ Livestock Officer. B4. Strategic partners Develop- Other UN agencies with responsibilities Informants for the Senior officers of the ment for nutrition and primary health care, evaluation, providing data relevant agencies. partners notably the World Food Programme and views on the (WFP) and the World Health performance and direction Organisation (WHO). of the project.

Members of the Development Partner Likely to take the Group Nutrition, notably Irish Aid, the evaluation’s findings and United Kingdom Department for recommendations into International Development (DFID) and account in further the United States Agency for development of nutrition International Development (USAID). programming in Tanzania. DFID funds ASRP interventions alongside those funded by Irish Aid (IA) in Mbeya, Iringa, Njombe and Songwe (MINS) (and elsewhere in Tanzania) through the Addressing Stunting in Tanzania Early (ASTUTE) programme. USAID funds the Mwanzo Bora (‘Good Start’) Nutrition Programme in MINS (and elsewhere). Irish Aid funds the project, along with UNICEF.

DFID funding for the ASRP is complementary to that from Irish Aid and UNICEF, and in practice funding from the three sources is integrated across the ASRP in MINS (although financial reporting distinguishes between funding sources). B5. Direct partners LGAs LGAs in Mbeya, Iringa, Njombe and Informants for the District Executive Songwe have direct roles in project evaluation, providing data Director (DED); interventions under KRs 1, 2 and 3. and views on the District Nutrition They receive funding from UNICEF to performance and direction Officer; District implement activities such as training of the project. Nutrition Co- health workers on social and ordinating

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Stake- Role in the programme and Participation in the Who will holder interest in the evaluation evaluation participate behavioural change communication Directly interested in Committee (DNCC); (SBCC) for pro-nutrition behaviours, as findings and District Medical well as local governance and recommendations of Officer and local information system activities (nutrition evaluation, may adjust Health Centre staff; steering committees, supportive implementation as a result. District Agricultural/ supervision, etc.). Livestock Officer. NGOs Three international NGOs and three Informants for the Representatives at national NGOs took over evaluation, providing data national and district implementation of the project from and views on the levels. Concern Worldwide in 2015. CUAMM performance and direction (Doctors with Africa) and the Tanzania of the project. Home Economics Association (TAHEA) implement the ASRP in Iringa and Will facilitate field Njombe; Catholic Relief Services (CRS) evaluation mission in and the Centre for Counselling, consultation with UNICEF Nutrition and Health Care and LGAs. (COUNSENUTH) are in Mbeya; US NGO Pact and the Integrated Rural Directly interested in Development Organisation (IRDO) are findings and in Songwe and Mbeya. recommendations of evaluation, may adjust implementation as a result.

Also interested in the evaluation for broader policy and programming purposes. Central TFNC and PO-RALG receive funding Informants for the Senior officers Govern- from UNICEF to implement national evaluation, providing data responsible for ment level activities to improve governance and views on the nutrition. and information systems, such as the performance and direction Planning and budgeting for Nutrition, of the project. the BNA, etc. B6. Policy makers Govern- GOT ministries and agencies Informants at both policy Senior officers ment of responsible for nutrition, notably the and technical levels. Likely responsible for Tanzania MOHCDGEC, PMO, PO-RALG and the to be interested in findings nutrition. Tanzania Food and Nutrition Centre and recommendations with (TFNC). (TFNC, PO-RALG and LGAs are reference to policy also direct implementing partners.) development and sustainability of nutrition Interest in issues around capacity interventions. development, handover and sustainability.

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Annex F. Nutrition sector data Table 6 and Table 7 below reproduce nutrition ‘scorecards’ that are now produced by TFNC for each Region. For this report, it was only possible to obtain those for Mbeya and Songwe Regions.

Table 6 Nutrition scorecard: Mbeya Region: Q3, 2017

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Table 7 Nutrition scorecard: Songwe Region: Q2, 2017

Source: TNFC data.

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Table 8 – Table 15 below show bottleneck analysis data recently presented by TFNC (with UNICEF technical support: see GOT, 2017h). For each of four areas of nutrition performance, a table shows how the indicators for the various BNA determinants are calculated. It is followed by a table presenting the data themselves, with the four MINS Regions and the national average highlighted.

The ‘quality’ indicator is not yet useful as a reflection of ASRP performance, as it is drawn from surveys carried out before project activities began. The ‘utilisation’ indicator, on the other hand, is based on the most recent attendance data, and should therefore be starting to reflect the results of the project.

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Table 8 BNA IYCF determinants, indicators and calculation methods

Source: GOT, 2017h.

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Table 9 BNA: IYCF: data by Region

Regions Commodities Human Resources GA Utilization Quality Arusha 6% 3% 1% 0% 43% Dar es Salaam 4% 3% 41% 2% 45% Dodoma 2% 55% 93% 47% 9% Geita 45% 54% 62% 3% 7% Iringa 75% 78% 83% 60% 7% Kagera 29% 31% 41% 14% 11% Katavi 14% 12% 1% 0% 1% Kigoma 81% 49% 41% 11% 16% Kilimanjaro 0% 0% 12% 6% 64% Lindi 100% 83% 14% 9% 12% Manyara 6% 62% 97% 45% 5% Mara 23% 1% 12% 6% 12% Mbeya 89% 64% 66% 48% 5% 22% 64% 98% 45% 12% 0% 10% 0% 5% 18% Mwanza 59% 44% 31% 13% 11% Njombe 90% 57% 67% 80% 24% Pwani 6% 1% 6% 18% 41% Rukwa 1% 7% 1% 1% 10% Ruvuma 14% 14% 16% 6% 28% Shinyanga 96% 100% 24% 3% 11% Simiyu 14% 22% 46% 17% 7% Singida 31% 18% 12% 4% 4% Songwe 88% 65% 48% 35% 5% <25% Tabora 56% 37% 42% 16% 4% 25-50% Tanga 15% 0% 7% 0% 71% 50-75% National average 36% 34% 42% 18% 20% >75%

Source: GOT, 2017h.

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Table 10 BNA: SAM treatment determinants, indicators and calculation methods

Source: GOT, 2017h.

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Table 11 BNA: SAM treatment of children: data by Region

Regions Commodities Human Resources Geographic Access Utilization Continuity Quality Arusha 38% 11% 45% 13% 11% 12% Dar es Salaam 25% 10% 13% 9% 5% 5% Dodoma 49% 6% 7% 2% 4% 4% Geita 1% 2% 20% 7% 10% 26% Iringa 77% 12% 61% 367% 100% 90% Kagera 4% 0% 14% 64% 22% 31% Katavi 23% 1% 12% 0% 0% 0% Kigoma 13% 23% 78% 14% 7% 6% Kilimanjaro 0% 5% 6% 0% 1% 7% Lindi 61% 33% 76% 3% 6% 8% Manyara 24% 2% 3% 1% 2% 3% Mara 45% 0% 10% 2% Mbeya 91% 26% 26% 100% 37% 38% Morogoro 40% 3% 13% 18% 16% 16% Mtwara 28% 39% 51% 29% 15% 27% Mwanza 24% 13% 1% 5% 4% 3% Njombe 81% 13% 17% 100% 43% 42% Pwani 34% 3% 8% 5% 7% 12% Rukwa 35% 6% 1% 2% 2% 2% Ruvuma 56% 7% 32% 100% 47% 35% Shinyanga 33% 54% 95% 12% 4% 29% Simiyu 55% 10% 15% 92% 14% 14% Singida 90% 3% 10% 9% 7% 6% Songwe 99% 18% 23% 85% 100% 34% <25% Tabora 7% 30% 46% 79% 22% 23% 25-50% Tanga 50% 1% 44% 38% 22% 23% 50-75% National average 40% 13% 21% 14% 10% 10% >75%

Source: GOT, 2017h.

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Table 12 BNA: VAS determinants, indicators and calculation methods

Source: GOT, 2017h.

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Table 13 BNA: VAS: data by Region

Regions Commodities Human Resources Geographic Access Utilization Continuity Quality Arusha 72% 30% 51% 98% 90% 90% Dar es Salaam 100% 17% 42% 76% 67% 67% Dodoma 95% 4% 32% 100% 92% 92% Geita 90% 4% 22% 100% 91% 91% Iringa 100% 45% 37% 100% 98% 98% Kagera 100% 1% 46% 100% 100% 100% Katavi 97% 26% 20% 100% 86% 86% Kigoma 92% 46% 41% 100% 85% 85% Kilimanjaro 100% 23% 71% 83% 82% 82% Lindi 100% 43% 55% 100% 92% 92% Manyara 100% 51% 36% 100% 94% 94% Mara 82% 40% 55% 100% 82% 82% Mbeya 84% 8% 48% 87% 84% 84% Morogoro 99% 46% 32% 98% 87% 87% Mtwara 96% 61% 28% 100% 98% 98% Mwanza 93% 9% 28% 98% 81% 81% Njombe 100% 21% 53% 100% 100% 100% Pwani 100% 9% 42% 99% 94% 94% Rukwa 100% 10% 45% 100% 98% 98% Ruvuma 68% 3% 28% 100% 100% 100% Shinyanga 74% 25% 29% 95% 73% 73% Simiyu 100% 52% 34% 100% 98% 98% Singida 100% 35% 73% 100% 94% 94% Songwe 65% 18% 46% 100% 100% 100% <25% Tabora 100% 46% 43% 92% 86% 86% 25-50% Tanga 91% 1% 51% 89% 75% 75% 50-75% National average 93% 23% 42% 97% 88% 88% >75%

Source: GOT, 2017h.

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Table 14 BNA: IFAS determinants, indicators and calculation methods

Source: GOT, 2017h

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Table 15 BNA: IFAS: data by Region

Regions Commodities Human Resources Geographic Access Utilization Quality Arusha 74% 12% 49% 15% 18% Dar es Salaam 90% 0% 44% 30% 29% Dodoma 65% 5% 33% 27% 27% Geita 75% 16% 25% 36% 17% Iringa 81% 100% 10% 88% 30% Kagera 68% 4% 43% 33% 12% Katavi 57% 6% 34% 25% 12% Kigoma 30% 22% 52% 15% 7% Kilimanjaro 75% 4% 53% 18% 28% Lindi 38% 39% 41% 28% 33% Manyara 46% 53% 34% 29% 11% Mara 91% 7% 52% 28% 9% Mbeya 53% 0% 58% 35% 32% Morogoro 53% 46% 29% 36% 28% Mtwara 55% 11% 17% 27% 27% Mwanza 92% 24% 28% 26% 19% Njombe 53% 12% 48% 15% 26% Pwani 59% 6% 39% 34% 25% Rukwa 94% 2% 45% 25% 20% Ruvuma 21% 3% 43% 13% 21% Shinyanga 56% 0% 29% 49% 26% Simiyu 69% 37% 34% 25% 9% Singida 52% 0% 57% 19% 22% Songwe 69% 9% 31% 39% 32% <25% Tabora 83% 44% 43% 23% 22% 25-50% Tanga 59% 0% 52% 19% 28% 50-75% National average 65% 14% 40% 27% 21% >75% Source: GOT, 2017h.

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Figure 4. Example of stunting data recorded at a Village Health Day

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Figure 5. Example of stunting data recorded at a Village Health Day

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Annex G. Project performance data

Table 16 BNTS results matrix, fourth annual report: May 2017

Expected achievement by Programme key results/outputs Indicator the end of year 3 Progress to date Key Regional and local % of districts that integrate District plans for 4 sectors − The number of Districts having integrated Result government authorities nutrition with medium term (health, agriculture, WASH and nutrition in MTEF increased from 16 of 21 1 effectively plan, budget, expenditure framework (MTEF) community development) include (76%) in FY 2013/14 to 23 of 2324 coordinate and monitor the a set of nutrition- (100%) for FY 2017/18, delivery of nutrition services specific/sensitive interventions − All of 23 districts included in their 2017/18 and nutrition sensitive plans a set of nutrition specific, nutrition interventions sensitive and enabling environment interventions. Budget breakdown will be available by July, 2017.

% of districts with nutrition Increased % of districts with − Annual Bottleneck analysis has been monitoring system in place that nutrition monitoring system in institutionalized in all generates annual up-dates on place that generates annual up- and provides annual updates on the available nutrition services and dates on available nutrition performance of nutrition services. monthly number of patients services and monthly number of − Multisectoral Nutrition Scorecard reached patients reached consolidating information from all regions and districts of Tanzania will be available by September 2017. − A national action plan to strengthen nutrition information system was developed as part of the NMNAP.

24 Two additional District Councils, Busokelo DC and Songwe DC, were created in Mbeya and Songwe regions, bringing the total number of Councils in the four regions to 23.

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Expected achievement by Programme key results/outputs Indicator the end of year 3 Progress to date Regions/ districts where Regional All Regions/Districts recruit − As of June, 2017, 23 out of 23 (100%) and District Nutrition Officer salary Nutrition Officers. district / municipal councils and 4 out of 4 is included in government budget regions (100%) have appointed Nutrition Officers or Focal Points with salaries included in government budget. Output Council Steering Committees Number of District Councils Council Steering Committees are − In FY 2016/17: 22 out of 23 (96%) 1.1 on Nutrition coordinate and conducting at least 75% of operational in all districts in the districts have conducted at least 1 monitor actions across scheduled Nutrition Steering three regions. meeting of District Steering Nutrition multiple sectors and with Committee meetings Committee. multiple stake-holders Output Government nutrition officer Number of District Councils with Nutrition Officers in at least 10 As of June, 2017: 1.2 posts at regional and district nutrition officers districts. − 23 out of 23 districts in Mbeya, Iringa and level are filled, maintained Njombe regions have nutrition officers / and supported focal persons within Health department. Proportion of District Nutrition Supervisory system in place in all − In FY 2016/17: 22 out of 23 (96%) Officers receiving supervisory districts with nutrition officers. districts had a supervisory system in support within the previous three place. months Output District plans and budgets Number of districts that have Districts include nutrition − The number of districts which included 1.3 include nutrition specific and integrated nutrition into Medium activities into MTEF. nutrition activities in MTEF has increased sensitive interventions in line term expenditure framework from 16 in FY 2013/14 to 23 (100%) for with the National Nutrition (MTEF) FY 2016/17. Strategy Annual regional level meeting with Annual regional meeting on − Planning and budgeting workshops on District Planning Officers, Regional nutrition. nutrition for FY 20167/18 were organized and District Nutrition Officers and in November 2016 and all districts in MINS sector managers on planning and regions participated (this activity was also budgeting for nutrition carried out in all the districts and regions in Tanzania mainland).

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Expected achievement by Programme key results/outputs Indicator the end of year 3 Progress to date Key Pregnant women and Percentage of children 6-23 10 percentage point increase − Barrier analysis carried out indicated result caregivers of children aged months who receive a minimum from baseline in six districts. caregivers’ lack of information on the key 2 less than two years enabled to acceptable diet (MAD) according to IYCF practices, lack of time and support practice nutrition-relevant IYCF standards (from 3+/4+ food from close relatives as the main reasons behaviours and take up groups, breast milk / milk product, for failure to carry out appropriate infant nutrition services minimum meal frequency and young child feeding practices. according to age) − Percentage of children 6-23months that receive a minimum acceptable diet in 2013: 9.4% in Iringa, 8.6% in Mbeya and 9.7% in Njombe (Concern, 2013) − Percentage of children 6-23 months who receive a minimum acceptable diet in 2014: 7.3% in Iringa, 5.3% in Mbeya and 23.9% in Njombe (NNS-SMART, 2014) − The sample size for TDHS 2015 disaggregated data on MAD at the regional level is insufficient.

Percentage of children aged 0 to 5 10 percentage point increase − Percentage of children 0-5 months months exclusively breastfed from baseline in six districts. exclusively breastfed in MIN regions: in 2013: 39% (Concern, 2013) − Percentage of children 0-5 months exclusively breastfed in 2014: 62.7% in Iringa, 27.3% in Mbeya and 44.4% in Njombe (NNS-SMART, 2014) − Disaggregate data on EBF at the regional level not available in TDHS 2015

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Expected achievement by Programme key results/outputs Indicator the end of year 3 Progress to date Percentage of children aged 12 to 10 percentage point increase − Percentage of children 12-15 months on 15 months on continued breast from baseline in six districts. continued breastfeeding in MIN regions in feeding 2013: 91% (Concern, 2013) − Percentage of children 12-15 months on continued breastfeeding in 2014: 96.6% in Iringa, 100% in Mbeya and 89.3% in Njombe (NNS-SMART) − TDHS 2015 sample size for data disaggregated by regions on continued breast feeding is insufficient Percentage of mothers of children 10 percentage point increase − Percentage of mothers of children 0-23 0-23 months who report that they from baseline in six districts. months who report that they are the main are the main decision-makers decision-makers regarding feeding regarding feeding their children. children in 2013: 74% in Iringa, 67% in Mbeya, 82% Njombe (Concern, 2013) − This indicator is not available in NNS- SMART, 2014 and TDHS 2015 Percentage of women who took 10 percentage point increase − Percentage of women taking Iron-folate iron-folate supplements for at least from baseline in six districts. supplements for at least 90 days during 90 days during their most recent pregnancy in 2013: 28.3% in Iringa, pregnancy 42.6% in Mbeya, 39.8% in Njombe (Concern, 2013) − Percentage of women taking iron-folate supplements for at least 90 days during pregnancy: 21% in Iringa, 12% in Mbeya, 33% in Njombe (NNS-SMART, 2014) − Percentage of women taking iron-folate supplements for at least 90 days during pregnancy: 30% in Iringa, 31% in Mbeya, 27% in Njombe (TDHS, 2015)

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Expected achievement by Programme key results/outputs Indicator the end of year 3 Progress to date Output Context-specific Proportion of mothers of children 60% of children aged less than 2 − Major communication channels were 2.1 communication channels 0-23 months who have received years whose caregivers receive identified: 1. Group counselling using identified and materials counselling, support or messages information and counselling on CHWs. 2. Health staff during ANC visits developed and rolled out to on optimal breastfeeding and infant and young child feeding. and MCH clinics. 3. Local radios. enhance knowledge and complementary feeding from CHWs − SBCC material adapted from existing practices or facility based HWs during the national IYCF and RMNCH. past 3 months − 75 LGAs and HWs were trained as trainers for IYCF, WASH, CCD, health − 499 HWs were trained on counselling on IYCF, including in the context of HIV, WASH, CCD and health. − 35 NGOs supervisors and 977 CHWs were trained on counselling on IYCF, including in the context of HIV, WASH, CCD and health. − 97,131 pregnant women and mothers / caregivers of children under two years (64%) participated in counselling sessions on IYCF, including in the context of HIV, WASH, CCD, health.

Output Coverage and quality of Proportion of health facilities in the 50% of health facilities in the six − Regional resource team (60 people) for 2.2 nutrition services provided six districts implementing districts implementing integrated IMAM was trained for Mbeya, Iringa, through the health sector for integrated management of severe management of severe acute Njombe and Songwe regions. pregnant and breastfeeding acute malnutrition malnutrition. − 1,545 CHWs (40%) trained on screening women and children aged less and referral of SAM than two years is enhanced − 551 HWs (32%) trained on SAM treatment − 269 (31%) health facilities providing service (26 (68%) hospitals, 75 (83%) health centres, 168 (22%) dispensaries) − 3,464 (52% of caseload) children under five years with SAM treated

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Expected achievement by Programme key results/outputs Indicator the end of year 3 Progress to date Number of districts delivering an 6 districts deliver an expanded − 22 out of 22 districts have been trained on expanded package of interventions package on CHDs. the integrated Child Health and Nutrition through Child Health Days Months (CHNMs) approach, which includes Vitamin A supplementation and deworming, screening for malnutrition and nutrition education − CHNMs is currently being implemented (in June 2017) in all 22 districts in Mbeya, Iringa and Njombe regions. − In December 2016, in Tanzania Mainland coverage for Vitamin A supplementation for children 6-59 months was 93.5% and for de-worming for children 12-59 months was 93%.

Key Availability and access to % of households in the focus 20% increase from baseline − Mean household dietary diversity in 2013 result diverse and micronutrient-rich wards who reach a household is: 5.76 in Iringa, 6.03 in Mbeya, 5.35 in 3 foods at household level dietary diversity score of at least 4 Njombe (Concern, 2013) enhanced. (20% age point increase by Year 1. 3)

Individual dietary diversity score 20% increase from baseline − Mean IDDS in 2013 is: 2.27 in Iringa, 2.36 (IDDS for <2 children) in 3 regions Mbeya, 2.34 in Njombe (Concern 2013) − Percent of children 6-23 months with a minimum dietary diversity is: 9% Iringa, 6% Mbeya, 27% Njombe (NNS-SMART, 2014) − The sample size for TDHS 2015 disaggregated data on minimum acceptable diet at the regional level is insufficient.

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Expected achievement by Programme key results/outputs Indicator the end of year 3 Progress to date Output Production of appropriate Proportion of villages in the focus Progressive farmers trained and − Crop and livestock survey carried out. 3.1 micronutrient rich plants and wards with Progressive Farmers providing extension services in − Appropriate crops to promote identified: animal source foods is trained to promote the production nutrition in 60% of Wards. e.g. squash and pumpkins promoted at household level of nutritious plants and animal − Bottlenecks for production identified source foods − 200 progressive farmers trained and 200 farmer field school established − 15,677 farmers received training and inputs to increase the production of nutritious plants and animal source foods − 13,779 households (5% of the total number of households in the project area) started kitchen gardens and / or small animals keeping − 23,341 farmers attended counselling sessions on relevant IYCF, including in the context of HIV, WASH, CCD and health practices − Progressive farmers trained and providing extension services in nutrition in 80 out of 158 (50%) of Wards Output Improved access to nutritious Food diversity score for rural Barriers to a more diverse supply − Market assessment finalized 3.2 foods through market markets of foods are identified. − After discussion with Concern and Irish intervention Aid, it was agreed that having an impact on food diversity score for rural markets was beyond the scope of this project

Number of different fortified foods Barriers to a more diverse supply − Market assessment finalized available in the markets (foods not of foods are identified. − After discussion with Concern and Irish brands) Aid, it was agreed that having an impact on the availability of different fortified foods in the market was beyond the scope of this project.

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Expected achievement by Programme key results/outputs Indicator the end of year 3 Progress to date Key Evidence and learning from Evidence on best practices Continuous participation in Final reports on nutrition survey, barrier result district and community disseminated relevant fora to disseminate analysis, LGAs capacity assessment, crop 4 programming on nutrition experience and influence survey and market survey have been shared documented and used to practitioners and policy level with the government at the local and national inform the scale-up of discussions. level, and with partners in nutrition. This nutrition actions to reduce evidence was instrumental to obtain additional stunting funding from UNICEF and DFDI to scale-up this accelerating stunting reduction programme to all districts in Mbeya, Iringa and Njombe regions. Output Underlying determinants of Report on baseline assessment Baseline survey conducted and − Baseline survey conducted. 4.1 stunting in the three regions key issues identified. − Barrier analysis carried out – it showed identified that caregivers’ lack of information on key Barrier analysis on IYCF IYCF practices, lack of time and support completed. from close relatives were the main reasons for failure to carry out appropriate IYCF practices. Output Evidence of best practices Report on operational research By Year 3: Results of operational − Concern with the Centre for Research on 4.2 generated and shared with research available the Epidemiology of Disasters (CRED) stakeholders published an article on the determinants of stunting in Mbeya, Iringa and Njombe regions based on the project’s baseline study.

Source: UNICEF Tanzania, 2017a: 29-36.

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Table 17 BNTS results matrix, quarterly update 6: November 2017

Key results Planned activities Progress Remarks Key Result 1: Support to LGAs in - UNICEF supported TFNC and PORALG to conduct evidence based planning and budgeting Regional and local planning, workshops for FY 2018/19. Participants reviewed findings of the annual review of 2016/17 government implementation, work plans to identify the main funding gaps, and findings of the bottleneck analysis of specific nutrition interventions for the year 2016/17 to identify main barriers to be addressed authorities coordination and in 20918/19 nutrition annual work plans. Participants were also oriented on the re-designed effectively plan, monitoring the delivery web-based Plan Rep. All regional secretariats and councils managed to develop quality annual budget, coordinate of nutrition services and multisectoral nutrition plans and budgets for 2018/19. and monitor the nutrition sensitive delivery of nutrition interventions services and - The 3 regional secretariats directly supported by this project conducted supportive nutrition sensitive supervision to the respective councils within the region while all the supported councils conducted supportive supervision to monitor nutrition activities implemented at health facility interventions and community level while.

- UNICEF also continued to support LGAs delivery of nutrition interventions. In order to increase coverage and quality of nutrition services provided at health facilities, 30 additional health care workers were trained on counselling on optimal MIYCN, WASH, Health and CCD practices. This makes a cumulative total of 730 (90%) health care workers were trained since the project started (out of 820 to be reached by 2017). Trained health care workers are key in promoting maternal and child nutrition behaviours during pre-natal, post-natal and child growth monitoring visits.

- UNICEF supported LGAs to conduct cascade trainings to health facilities targeting two health workers per facility are ongoing in the councils. Currently more than 150 health care workers have been capacitated to support child growth monitoring and promotion using the New WHO Child Growth standards. The plan is to support all the health facilities in 3 regions to have adequate anthropometric equipment and child health booklets to facilitate routine growth monitoring and promotion using New WHO Child Growth Standards.

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Key results Planned activities Progress Remarks

- UNICEF continue to support the LGAs and regional secretariats to conduct quarterly district multi-sectoral nutrition steering committee (DMNSC) meeting. All the 3 RSs and 9 LGAs directly supported by the project managed to organize at least one multi-sectoral nutrition steering committee (MNSC) meeting. These meetings are used as a platform to strengthen multi-sectoral nutrition coordination and track progress of specific and sensitive nutrition interventions as guided by the National Multisectoral Nutrition Action Plan (NMNAP).

- All 9 councils supported by the project conducted bi-annual data validation workshops and reported to PORALG to contribute to the national Bottleneck Analysis (BNA) of selected nutrition interventions which aims at tracking barriers to effective coverage of nutrition services.

- UNICEF also supported TFNC and PORALG to review and update the terms of reference (ToR) of the key coordination structures operating at the national and sub-national level i.e. National Multisectoral Nutrition Technical Working Group (NMNTWG), Thematic Working Groups which were recently established to support the 7 NMNAP Outcomes, and Region and District Nutrition Steering Committees (R/CMSCN);

Key Result 2: Support to stunting - NGOs Partners have continued to progressively increase the coverage and quality of nutrition Pregnant women prevention through services at community level. Villages covered by TASAF were included by NGOs to foster the and caregivers of promotion of infant and synergy among the two programmes and ensure equity by reaching the most vulnerable TASAF beneficiaries with group counselling to improve child and maternal nutrition. children aged less young child feeding than two years enabled to practice - Currently implementation of the community based interventions covers 65% of villages in the nutrition-relevant 6 selected districts. A total of 995 CHWs have been trained on key MIYCN, WASH, health and behaviours and take CCD behaviours band equipped with communication materials to facilitate promotion of up nutrition services positive key behaviours. These CHWs with the support from community supervisors, Government officers and NGOs staff in every target village have continued to organize and facilitate group counselling sessions (at least once a month) targeting pregnant women, mothers and care-givers of children under 2 years. 19,000 additional pregnant women and

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Key results Planned activities Progress Remarks caregivers were enrolled into the counselling groups this quarter, making a cumulative total of over 115,000 (77%) pregnant women, mothers and caregivers of children under two years enrolled into the counselling groups since the project started.

- Supportive supervision visits conducted by NGO partner project staff, LGAs and supervisors continued in the project area. Supervisors have a role of mentoring/coaching an average of 20 – 30 CHWs in 15 villages every month and ensuring that the CHWs are continuing to enrol beneficiaries into counselling groups and provide quality nutrition services. Through quarterly meetings between CHWs, supervisors and health care workers happening in the villages, CHWs have been able to share achievements, challenges encountered and discuss on ways to mitigate them. These meetings have been useful in also strengthening synergies between communities and health facility services.

- Quarterly social mobilization events have been conducted in the communities in order to reinforce the adoption of promoted behaviours and change of social norms. Local community leaders and key influential family members (i.e. fathers, grandparents) have been reached out so that they can influence beneficiaries to adopt the positive behaviours. A total of 7,043 (120%) influential people and community leaders participated in the quarterly counselling groups aiming at promoting optimal MIYCN, WASH, health and CCD practices among the influencers, for them to support and influence adoption of the key behaviours

Support to scaling up - LGAs and NGOs supported to continue implementing the integrated management of acute treatment of severe malnutrition (IMAM) component of the programme in Mbeya, Iringa and Njombe regions. The acute malnutrition proportion of health facilities providing SAM management has increased to 26% in 2016/17, resulting in an increase in the coverage of SAM treatment to 72%, which contributed to increase national level coverage to 14%. NGOs and LGAs continued to conduct on-job

mentoring and joint supportive supervision in order to improve quality of services and reporting of nutrition data in health facilities. UNICEF also supported the Government of Tanzania to review and update the national guidelines and training materials on IMAM in line with the 2013 global updates of the World Health Organization. The updated national guidelines are a key step towards improving the management of SAM for children under five years of age.

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Key results Planned activities Progress Remarks

Key Result 3: Support to stunting - NGO partners in close collaboration with LGAs continued to promote production and Availability and prevention through consumption of nutrient rich foods in order to improve diet diversity among pregnant women, access to diverse promotion of production mothers and children under 2 years. 48 new Progressive Farmers in the target village were and micronutrient- and access to nutritious identified and trained on establishment of different types of kitchen gardens, food rich foods at foods preservation using solar driers and small animal keeping especially rabbits, guinea pigs and household level chickens. Trained Progressive Farmers were provided with agriculture inputs to enable them establish farmers’ Field Schools and support beneficiaries to start home gardens. This makes enhanced a cumulative total of 174 of Progressive Farmers identified and trained since the beginning of the project.

- The Progressive Farmers conducted training to farmers and beneficiaries. A total of 4,995 new farmers received training and inputs to increase the production, and consumption of nutrient-rich foods, of whom 4,740 have managed to establish home gardens. Cumulatively, more than 29,495 farmers have received training and inputs while more than 27,740 have established home gardens

- 9,272 new farmers participated in counselling sessions on conducted by Progressive Farmers with the support from trained CHWs and Supervisors to promote optimal MIYCN, WASH, Health and CCD practices, making a cumulative total of 47,786 farmers. Key Result 4: 4. Conduct the evaluation of - UNICEF contracted JIMAT to support assessment of contribution of the in-service training Evidence and the in-service national (IST) to enhancing the capacity of nutrition officers to coordinate, manage, plan and budget learning from training programme for for the delivery of nutrition services; and document lessons learned in terms of the cost- effectiveness of delivering such training. The evidence that will be generated will be used to district and nutrition officers support advocacy for not only the need for further IST, but also for the best cost-effective community and cost-efficiency approaches. The JIMAT team has finished the inception phase and they programming on have submitted the inception report. Data collection and interviews will be conducted early nutrition next year. documented and Prepare the National - UNICEF continued to support the Government to operationalize the National Multisectoral used to inform the Multisectoral Nutrition Nutrition Action Plan (NMNAP) 2016 – 2021 (which was prepared with UNICEF support), both scale-up of nutrition Action Plan (NMNAP) at the central and decentralized level. The NMNAP was officially launched by the Prime Minister of Tanzania together with the Minister of Finance, Minister of Health, and 2016/17 - 2020/21 representative of all “nutrition-sensitive ministries” involved in operationalizing the NMNAP, during the Joint Multisectoral Nutrition Review (JMNR) in September 2017.

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Key results Planned activities Progress Remarks actions to reduce Conduct zonal planning - UNICEF supported TFNC and PORALG to organize and facilitate nutrition planning and stunting and budgeting budgeting workshop for the FY 2018/19. Planning and budgeting workshops included workshops orientation of key officers (i.e. nutrition officers, health secretaries and planning officers) on re-designed Plan Rep (web-based). Planning and Budgeting workshop also included a review

of existing evidence, including: findings of the annual review of 2016/17 work plans to identify the main funding gaps and findings of the bottleneck analysis of specific nutrition interventions for the year 2016/17 in order to inform new plans and budgets.

Conduct Public - UNICEF selected Oxford Policy Management Ltd (OPM) to carry out the second Public Expenditure Review Expenditure Review (PER) of Nutrition. The PER led by the PMO and implemented through every three years the Ministry of Finance and Planning aim to assess public spending in achieving targets set forth in the recently completed National Nutrition Strategy (2011-16). The data collection phase was slightly delated due to sensitivity of financial information, and OPM is still collecting some missing information among key government stakeholders and development partners. Recommendations that will be derived from the PER are expected to support decisions about future spending for the successful implementation of the NMNAP (2016-21). UNICEF will continue to support the government to complete the PER by the second quarter of 2018.

Conduct annual joint - UNICEF supported TFNC to prepare the JMNR 2017, which was successfully held in multisectoral nutrition September 2017. UNICEF also supported TFNCF and PORALG to conduct the Bottleneck review (JMNR) Analysis of specific nutrition interventions for FY 2016/17 and the Review of LGAs and MDAs annual work plans for FY 2016/17. This information was used to track progress against the first year of implementation of the NMNAP through its Common Results, resources and Accountability Framework (CRRAF) during the JMNR 2017.

Carry out the National - It has been agreed with the Government that the Tanzania National Nutrition Survey (TNNS) Nutrition Survey every N/A should be carried out in 2018 instead of 2016 as it was initially planned. In fact, the TDHS two years report was finally published in 16, and the TNNS will be used to evaluate the progress of the NMNAP 2016-2021 at mid-term.

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Key results Planned activities Progress Remarks Conduct an assessment - An assessment on the causes of reduction in stunting prevalence between 2010 and 2015: on the causes of UNICEF contracted IFPRI for this assessment. IFPRI has already started the assignment. The reduction in stunting preliminary results will be presented during a workshop on Analysis of the drivers of change in nutrition status of children and women in Tanzania which is planned for February, 2018 in prevalence between 2010 Dar es Salaam. and 2015

Conduct an evaluation of - UNICEF contracted Mokoro Ltd. to carry out the evaluation of the Bringing Nutrition to Scale the Bringing nutrition in Mbeya, Iringa and Njombe. The Mokoro Ltd. team has finalized the evaluability mission, actions to scale in Iringa, inception mission, data collection and interviews with key stakeholders. The team has already presented the preliminary findings, and is now in the process of drafting the report before Njombe and Mbeya sharing for comments and feedback. Regions program

Support to PMO for the - UNICEF continued to support PMO and PORALG to coordinate the implementation of the leadership and NMNAP, resource mobilization and fostering synergies between various programs including large scale nutrition programmes and the Tanzania Social Action Fund (TASAF). coordination of Implementing partner NGOs started to track the proportion of TASAF beneficiaries who are Tanzania’s SUN activities currently enrolled in the group counselling on pro-nutrition practices. Currently, over 40% TASAF beneficiaries have been enrolled and regularly participate to monthly group counselling on optimal caregiving practices to improve maternal and child nutrition.

Source: UNICEF Tanzania, 2017l: 13-18.

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Annex H. Maps

Map 1. Regional Map of Tanzania

Source: Wikimedia Commons

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Map 2. Njombe Region

Source: Wikimedia Commons

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Map 3. Mbeya Region

Source: Wikimedia Commons

No district map of the adjusted Mbeya Region is available yet.

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Map 4. Iringa Region

Source: Wikimedia Commons

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Map 5. Songwe Region

Source: Wikimedia Commons

No district map of the new Songwe Region is available yet.

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Annex I. Evaluation mission schedule

Table 18 below outlines the team’s schedule during the evaluation mission. Annex J gives details of the persons met at the various meetings shown here.

Table 18 Evaluation mission schedule

Team Date Activity Location members25 12 November 2017 Arrival Dar es Salaam TJ, JK, BL, ST 13 November Briefing, UNICEF Dar es Salaam TJ, JK, BL, ST Meeting, DFID Skype call with PO-RALG (Dodoma) 14 November Meeting, TFNC Dar es Salaam TJ, BL Meeting, PO-RALG JK, ST Dar es Salaam - Iringa TJ, BL Meeting, CUAMM Iringa 15 November Dar es Salaam - Njombe26 JK, ST Meeting, CUAMM Njombe Courtesy call to RAS27 Iringa TJ, BL Meetings with LGA personnel Iringa MC28 Meeting with LGA personnel Iringa DC29 Meetings and FGD Mkungugu 16 November Courtesy call to Acting RAS Njombe JK, ST Meetings with LGA personnel Njombe DC Meetings and FGD Lupembe Njombe - Makambako Meetings with LGA personnel Mafinga MC TJ, BL Meetings with LGA personnel Iringa DC 17 November Meetings with CRS and LGA personnel Mbarali DC JK, ST Meeting with Ward personnel Chimala FGD Lyambugo Lyambugo - Rujewa Meeting with Ward and Village personnel Ihalimba/Chogo TJ, BL Meeting at dispensary Mapanda FGD Ihalimba/Chogo 18 November Meeting with Ward personnel Igurusi JK, ST FGD Lunwa Visit to Health Centre Igurusi Igurusi - Mbeya Debriefing, CUAMM, TAHEA Iringa TJ, BL Iringa - Mbeya 19 November Team meeting Mbeya TJ, JK, BL, ST 20 November Courtesy call to Acting RAS Mbeya JK, ST Meetings with LGA personnel Mbeya DC Meeting with RNO30 Mbeya

25 TJ: Theresia Jumbe. JK: Joyce Kinabo. BL: Bjorn Ljungqvist. ST: Stephen Turner. 26 Airline rescheduled flight Dar es Salaam – Mbeya on 14 November without informing JK and ST, who then had to wait to travel on 15 November instead. 27 Regional Administrative Secretary. 28 Municipal Council. 29 District Council. 30 Regional Nutrition Officer.

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Team Date Activity Location members25 Meeting with CRS Mbeya Courtesy call to Acting RAS Mbozi TJ, BL Mbozi – Ileje Meetings with LGA personnel Ileje 21 November Meetings with LGA personnel Mbeya CC31 JK, ST Meetings with Ward and Mtaa personnel Soko Street, Ruanda Ward, Mbeya FGD Soko Street Meetings with Ward and Village Mshewe personnel FGD Muvwa Meetings with Ward and Village Ibaba TJ, BL personnel FGD Ibaba Meetings with Ward and Village Kasanga personnel FGD Kasanga Ileje - Mbeya 22 November Debriefing with UNICEF and IPs Mbeya TJ, JK, BL, ST Mbeya – Dar es Salaam Departure TJ 23 November Meeting, IMA World Health Dar es Salaam JK, BL, ST Internal debriefing, UNICEF 24 November External debriefing, UNICEF Dar es Salaam JK, BL, ST Departure JK 25 November Departure ST

31 City Council.

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Annex J. Persons and ‘counselling groups’ met

Table 19 below lists officials met for interviews or in group meetings. One meeting with a PO-RALG official was held by Skype.

Table 20 shows the meetings held with ‘counselling groups’ during the evaluation mission.

The evaluation mission schedule is shown at Annex I above.

Table 19 List of officials met for interviews or group meetings

Name Position J. Alex m Kikundi cha Huduma Majumbani Mbeya M. Aloyce f Principal Agriculture Field Officer, Iringa DC M. Andrew m VEO, Igurusi, Mbarali DC M. Anonyisye m Religious leader, Mbeya O. Baharia m Supervisor, Chimala, Mbarali DC J.P. Basibasi f Agriculture Officer, Igurusi, Mbarali DC J. Bifile m PF, Lupembe, Njombe DC M. Brero m Nutrition Specialist, UNICEF, Dar es Salaam H. Bwashehe m Acting DED, Mufindi DC M. Capuzzo m Country Manager, CUAMM T. Chanelo m Village Agricultural Extension Officer, Muvwa, Mshewe, Mbeya DC Z.I. Chekachene f Medical Officer In Charge, Lupembe, Njombe DC P.S. Chengula m VEO, Lupembe, Njombe DC G.E.S. Chiduo m Research Officer – Economics - TFNC N. Chonya m DNO, Mufindi DC G.S. Cosmas m Acting DHEO, Mbarali DC S.E. Daimon m Nutritionist, IRDO, Songwe H. Daudi m Assistant Nurse Officer, Lupembe, Njombe DC T. Edwin f Nutrition Officer, UNICEF, Dar es Salaam G. Farasi m CDO, CUAMM, Njombe A. Fitzgerald m Deputy Head of Development Co-operation, Embassy of Ireland B. Gabriel m Chair, Muvwa, Mshewe, Mbeya DC A. Godfrey f CRS, Mbeya J. Jivike f CHW, Mkungugu Village, Iringa DC S. John m CHW, Muvwa, Mshewe, Mbeya DC Z. Juma f Water Officer, Mbarali DC G. Kacheche m District Education Officer (Primary), Ileje DC J. Kafwinga m Planning Officer, Mbarali DC L. Kajela m Isangati Agricultural Development Organisation, Mbeya I. Kamamule m Village Chair, Lunwa, Igurusi, Mbarali DC Z.I. Kapama f District CDO, Mbeya DC K. Kapungu m WEO, Lupembe, Njombe DC M. Kaundama m Hamlet Chair, Lunwa, Igurusi, Mbarali DC R.P. Kessy m CDO, Mbarali DC D.S. Kidai f CHW, Lupembe, Njombe DC M. Kigahe f Progressive Farmer, Ihalimba Village, Mufindi DC H. Kihwele f Councillor, Igurusi, Mbarali DC A. Kilagwa f Agriculture Officer, CRS, Mbeya Y. Kiliwasha m Statistician, Iringa DC H. Kilungu m Health Officer, Chimala, Mbarali DC M. Kimario f Senior Livestock Officer, Iringa DC J. Kimboka m Livestock Officer, Mufindi DC D. Kimunda m Economist, Mbarali DC I. Kipaule m Supervisor, Ihalimba Village, Mufindi DC

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Name Position S. Kipeta f WEO, Mshewe, Mbeya DC Y. Kisapi f CHW, Ihalimba Village, Mufindi DC V. Kishen m Agriculture Officer, TAHEA, Njombe A. Kitime f CHA, Mlimbila Village, Iringa DC F. Kitule m Progressive Farmer, Mlimbila Village, Iringa DC P. Kitwange m CHW, Mkungugu Village, Iringa DC I. Komba m Health Officer, Mufindi DC A. Kubetia m M&E Officer, IRDO, Songwe A. Kuluzilwa m DED, Mbeya DC M.P. Kwiluhya f DED, Njombe DC S. Lalji m M&E Officer, IMA World Health R.B. Lekule m Acting DNO, Ileje DC S.P. Lemile m WEO, Igurusi, Mbarali DC Limandola m Education Officer, Mbarali DC R. Lokule m Acting DNO, Ileje DC E. Macha f Nutrition and ECD Specialist, UNICEF, Dar es Salaam M. Macha f District Reproductive Health Co-ordinator, Mbeya DC R. Mafuru f Director, TAHEA, Iringa J.Y. Maguya m VEO, Igurusi, Mbarali DC L. Mahembe m RNO, Mbeya Z. Mahenge f DNO, Mbarali DC Manase m Acting City Director, City Economist, Mbeya CC E. Mang’onda f Livestock Officer, Mbeya DC P. Mapunda m Project Manager, TAHEA, Iringa D. Massawe m Agriculture Officer, Mbeya DC N. Massay m Project Manager, Pact, Songwe E. Mbele m CDO, Muvwa, Mshewe, Mbeya DC Y. Mbughi m Acting DAICO, Ileje DC M. Mbugulu m Supervisor, Muvwa, Mshewe, Mbeya DC T. Mbula f DNO, Iringa DC S.J. Mgawe m CHW Supervisor, Ruanda, Mbeya CC S. Mgelingoha m CHW, Mlimbila Village, Iringa DC S. Mgina f Progressive Farmer, Ihalimba Village, Mufindi DC H. Mhagama f Enrolled Nurse, Mshewe Dispensary, Mbeya DC P.E. Mhavile m WEO, Chimala, Mbarali DC T.S. Mihele m Nutrition Officer, CUAMM, Njombe J. Miller f Deputy Head, DFID, Dar es Salaam M. Mkwaya m District Planning Office, Mbeya DC B. Mlimbila f Progressive Farmer, Mkungugu Village, Iringa DC Y. Mlomo m Acting DAICO, Mbarali DC S.E. Msamba f CDO, Chimala, Mbarali DC K.H. Msangi m DED, Mbarali DC J. Msebeni f Health Secretary, Mbeya DC W. Msokwa m Nutrition Officer, TAHEA, Njombe Y.L. Msyani m Health Officer – Preventive, Mbarali DC F.L. Mtega m Councillor and Council Chair, Chimala, Mbarali DC G. Mtega m Supervisor, Mlimbila Village, Iringa DC S. Mtega f Assistant to RNO, Mbeya P. Mtelele f VEO, Muvwa, Mshewe, Mbeya DC M. Mtoni f Nutritionist, Pact, Songwe J. Mugyabuso m Nutrition Adviser, IMA World Health G.I. Mulokozi f Team Leader, ASTUTE, IMA World Health A. Mumba m Supervisor, Mkungugu Village, Iringa DC C. Mushi m Acting RAS, Mbeya G. Musi f CHW, Ihalimba Village, Mufindi DC S. Mutambi m Assistant Director for Nutrition Services, PO-RALG, Dodoma J. Mwafute m Field Officer, CUAMM, Njombe G. Mwakalila m DMO, Mbarali DC J.N. Mwakibinga m Clinical Officer, Mshewe Dispensary, Mbeya DC

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Name Position S. Mwakipokile f Agriculture Officer, Mbeya DC B. Mwakyabula m Chair, Soko Mtaa, Ruanda, Mbeya CC M. Mwakyaka m Livestock Officer, Mufindi DC M. Mwalemwile m RNO, Songwe P. Mwalukasa m IRDO, Songwe D. Mwalusamba m Livestock Field Officer, Mbeya DC E. Mwambalaswa m Acting DMO, Ileje DC J. Mwandenga m WEO, Ruanda, Mbeya CC S.H. Mwangonda m Executive Director, IRDO, Songwe Y. Mwasaka m Agriculture Officer, Mbarali DC A. Mwasanguti f Agriculture Officer, Mufindi DC A. Mwashambwa f CHW, Muvwa, Mshewe, Mbeya DC O. Mwashubila m Mtaa Executive Officer, Soko Mtaa, Ruanda, Mbeya CC I. Mwasibanda m Village Chair, Lyambogo, Chimala, Mbarali DC G. Mwinami m Acting RAS, Njombe C. Mwita m Co-operative Officer, Igurusi, Mbarali DC J. Ndaro m Acting Medical Health Officer, Mbeya CC B. Ndiaye m Head of Nutrition, UNICEF, Dar es Salaam G. Ngaiza f Health Adviser, DFID, Dar es Salaam C. Ngogo m Hamlet Chair, Lunwa, Igurusi, Mbarali DC E. Nkinda m Hamlet Chair, Lunwa, Igurusi, Mbarali DC R. Nkurlu f Nutrition Officer, UNICEF, Mbeya T.A. Nswila m Livestock Officer, Mbarali DC A. Nyamwele m Co-operative Officer, Igurusi, Mbarali DC B. Nyigu f RNO, Njombe E.L. Nzogela f Water Officer, Mbeya DC S. Oberlin m Health Officer, Iringa DC E. Occa m Project Manager, CUAMM, Iringa E. Panday m Fisheries Officer, Ileje DC E. Paul f COUNSENUTH, Mbeya C. Pius m Health Officer, Igurusi, Mbarali DC K. Samlelwa f School Health Coordinator, Iringa DC E. Sanga m M&E Officer, CUAMM, Iringa F. Sanga f Community Development Officer, IRDO, Songwe K. Sanga m CHW, Lunwa, Igurusi, Mbarali DC C. Sembo f Fisheries Officer, Mbeya DC S. Sepilla f Progressive farmer, Mlimbila Village, Iringa DC J. Shirima f Acting DNO, Mbeya DC F. Shitengo m Hamlet Chair, Lunwa, Igurusi, Mbarali DC C.J. Tandika m VEO, Chimala, Mbarali DC H.P. Tesha m Acting RAS, Songwe M. Twete m Acting DMO, Mufindi DC E. Tweve m Hamlet Chair, Lunwa, Igurusi, Mbarali DC P. Umberto m Agriculture Officer, Mufindi DC M. Waibe m Nutrition Officer, PO-RALG, Dodoma W. Wikedzi m Agriculture Officer – Horticulture, Njombe DC E. Wingisihoja f CHW, Lunwa, Igurusi, Mbarali DC M.R. Yamulinga f CDO, Ruanda, Mbeya CC P. Yaredi f Regional Nutrition Officer, Iringa T. Yilongo m Nutrition Co-ordinator, Njombe DC

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Table 20 Meetings with ‘counselling groups’

Date LGA Place 15 November Iringa DC Mkungugu 16 November Njombe DC Lupembe 17 November Iringa DC Ihalimba/Chogo 17 November Iringa DC Mgama 17 November Mbarali DC Lyambogo 18 November Mbarali DC Lunwa 21 November Mbeya CC Soko Street 21 November Mbeya DC Mbingu 21 November Ileje DC Ibaba 21 November Ileje DC Kasanga

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Annex K. Bibliography The ‘location’ column in the list below refers to the item’s location in the electronic library developed for this evaluation and retained by UNICEF.

Reference Title Location # 1. African Arguments, 2018 African Arguments, 2018. Meet some of the men redefining masculinity in Kenya. http://africanarguments.org/2018/01/04/meet-some-of- the-men-redefining-masculinity-in-kenya/ [accessed 4 January 2018] # 2. African Economic African Economic Outlook, 2017. Tanzania. [online] Outlook, 2017 Available at: africaneconomicoutlook.org/en/country- notes/Tanzania [Accessed 26 Oct. 2017]. # 3. ALMA, 2017 ALMA, 2017. ALMA scorecard for accountability and action. http://alma2030.org/scorecards-and-reports/map [accessed 13 December 2017] # 4. Bhutta et al., 2013 Bhutta, Z.A., Das, J.K., Rizvi, A., Gaffey, M.F., Walker, N., Horton, S., Webb, P., Lartey, A., Black and R., 2013. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? The Lancet 382: 452-477. # 5. Concern Worldwide, Concern Worldwide, 2014. BNTS, Barrier Analysis, 1.6.1-1 2014a Baseline Report # 6. Concern Worldwide, Concern Worldwide, 2014. BNTS, Crop and Livestock 1.6.1-2 2014b Survey, Baseline Report # 7. Concern Worldwide, Concern Worldwide, 2014. BNTS, LGA Nutrition Capacity 1.6.1-3 2014c assessment of Local Government Authorities at the district level in MIN - Baseline Report # 8. Concern Worldwide, Concern Worldwide, 2014. BNTS, Market Survey 1.6.1-4 2014d Assessment of private and commercial traders in village and ward level Markets in MIN - Baseline Report # 9. Concern Worldwide, Concern Worldwide, 2014. BNTS, Nutrition Survey MIN 1.6.1-5 2014e Baseline Report # 10. Concern Worldwide, Concern Worldwide, 2015. Tanzania Annual Programme 1.5.4-1 2015a Plan 2015 # 11. Concern Worldwide, Concern Worldwide, 2015. BNTS In-depth analysis of the 1.8-1 2015b factors associated with stunting # 12. CUAMM, 2017a CUAMM, 2017. ASRP Narrative Report 1.7.3-1 # 13. CUAMM, 2017b CUAMM, 2017. ASRP Reporting for 2 1.7.3-2 # 14. FANRPAN, 2017 FANRPAN, 2017. ATONU – agriculture to nutrition. https://www.fanrpan.org/projects/ATONU/about [accessed 20 December 2017] # 15. FAO, 2013 FAO, 2013. Monitoring African food and agricultural policies (MAFAP). Review of food and agricultural policies in the United Republic of Tanzania 2005 – 2011. Country report. Rome: FAO.

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Reference Title Location # 16. Fiedler et al., 2014 Fiedler, J., D’Agostino, A. and Sununtnasuk, C., 2014. 1.8-6 Nutrition technical brief: a rapid initial assessment of the distribution and consumption of iron-folic acid tablets through antenatal care in Tanzania. Arlington: USAID/ Strengthening Partnerships, Results and Innovations in Nutrition Globally (SPRING) project. # 17. GOT, 1992 GOT, 1992. The food and nutrition policy for Tanzania. 1.4.1.8-1 Dar es Salaam: Ministry of Health. # 18. GOT, 2010 GOT, 2010. National strategy for growth and reduction of poverty II. Dar es Salaam: Ministry of Finance and Economic Affairs. # 19. GOT, 2013 GOT, 2013. Infant and young child feeding: national guidelines. Dar es Salaam: Ministry of Health and Social Welfare # 20. GOT, 2014a GOT, 2014. Improving Public Financing for Nutrition 1.4.1.1-1 Sector in Tanzania: Ministry of Finance # 21. GOT, 2014b GOT, 2014. Public Expenditure Review of the Nutrition 1.4.1.1-2 Sector, Ministry of Finance # 22. GOT, 2014c GOT, 2014. Public Expenditure Review of the Nutrition 1.4.1.1-3 Sector, Ministry of Finance – Plan of Action # 23. GOT, 2015a GOT, 2015. Curriculum for Basic Technician Certificate in 1.4.2-3 Community Health, Ministry of Health # 24. GOT, 2015b GOT, 2015. National Costed Community Based Health 1.4.2-4 Program Strategic Plan 2015 – 2020 # 25. GOT, 2015c GOT, 2015. National Policy Guidelines for Health 1.4.3-1 Promotion, Ministry of Health and Social Welfare # 26. GOT, 2015d GOT, 2015. Gender dimension monograph. The 2012 1.4.7-1 population and housing census Volume IV. Dar es Salaam: National Bureau of Statistics. # 27. GOT, 2016a GOT, 2016. Tanzania Demographic and Health Survey 1.10.5-1 and Malaria Indicator Survey 2015 -2016. Ministry of Health # 28. GOT, 2016b GOT, 2016. National Multisectoral Nutrition Action Plan 1.4.1.2-2 (NMNAP) – From Evidence to Policy to Action – July 2016 – June 2021. Dodoma: Prime Minister’s Office # 29. GOT, 2017a GOT, 2017. Annual Review of NMNAP 1.4.1.2-1 # 30. GOT, 2017b GOT, 2017. Tanzania National Nutrition Survey 2014 – 1.4.1.2-3 Final Report # 31. GOT, 2017c GOT, 2017. Review of Nutrition Activities implemented 1.4.1.2-4 by LGAs and RS during FY 2016/17 # 32. GOT, 2017d GOT, 2017. Tanzania Stakeholder and Nutrition Action 1.4.1.3-1 Mapping # 33. GOT, 2017e GOT, 2017. National Community Based Health 1.4.2-1 Programme – Implementation Design, Ministry of Health # 34. GOT, 2017f GOT, 2017. National Community Based Health Program 1.4.2-2 Policy Guidelines, Ministry of Health

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Reference Title Location # 35. GOT, 2017g GOT, 2017. Terms of reference for Multisectoral Steering 1.4.4-2 Committees on Nutrition for Regions and Local Governments. Dodoma: PO-RALG. # 36. GOT, 2017h GOT, 2017. Results of the bottleneck analysis of selected 1.10.1-6 nutrition specific interventions at LGA level in Mainland Tanzania. FY 2016/17. PowerPoint presentation. # 37. GOT, n.d. a GOT, n.d. National nutrition strategy July 2011/12 – 1.4.1.7-1 June 2015/16. Dar es Salaam: Ministry of Health and Social Welfare. # 38. GOT, n.d. b GOT, n.d. Mkataba Wa Utendaji Kazi Na Usimamizi Wa 1.4.1.2-3 Shughuli Za Lishe Kati Ya Ofisi Ya Rais Tawala Za Mikoa Na Serikali Za Mitaa (Or - Tamisemi) Na Mkuu Wa Mkoa Wa ……………………………… Dodoma: PO-RALG. # 39. GOT, WHO & UNICEF, GOT, WHO and UNICEF, 1988. The Joint WHO/UNCEF 1988 Nutrition Support Programme in Iringa, Tanzania, 1983- 88. Evaluation report. Dar es Salaam: GOT, WHO and UNICEF. # 40. GSDRC, 2016 GSDRC, 2016. Methods and approaches to 1.8-2 understanding behaviour change. GSDRC Research Helpdesk # 41. Haddad & Mejía Acosta, Haddad, L. and Mejía Acosta, A., 2012. Accelerating 1.8-5 2012 reductions in undernutrition. What can nutrition governance tell us? Brighton: Institute of Development Studies IDS in Focus Policy Briefing 22. # 42. IFPRI, 2015 IFPRI, 2015. Global Nutrition Report – Actions and 1.2.2-2 Accountability To Advance Nutrition & Sustainable Development. International Food Policy Research Institute # 43. Kick4Life, 2018 Kick4Life, 2018. Kick4Life Football Club. http://www.kick4life.org/ [accessed 4 January 2018] # 44. Ljungqvist & Jonsson, Ljungqvist, B. and Jonsson, U., 2015. Nutrition 1.8-4 2015 governance: Iringa Nutrition Program revisited. Statement to the Panel on Nutrition Governance, FANUS 3rd African Nutrition Conference, Arusha, 24-29 May. # 45. Mokoro, 2017 Mokoro, 2017. Evaluation of the project Bringing Nutrition to Scale in Iringa, Mbeya and Njombe Regions (2013-2017): inception report. Oxford. # 46. Nutrition International, Nutrition International, n,d. Tanzania MEAL Country 1.10-2 n.d. Profile # 47. OECD, 2014 OECD, 2014. OECD-DAC: http://www.oecd.org/dac/stats/aid-at-a-glance.htm # 48. Pelletier et al., 2017 Pelletier, D., Gervais, S., Hafeex-Ur-Rehman, H., Sanou, D. and Tumwine, J., 2017. Boundary-spanning actors in complex adaptive governance systems: the case of multisectoral nutrition. International Journal of Health Planning and Management 10. http://onlinelibrary.wiley.com/doi/10.1002/hpm.2468/full [accessed 19 December 2017]

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Reference Title Location # 49. Prime Minister’s Office, Prime Minister’s Office, 2016. Word Food Program (WFP) 2016 Strategic Review 2016: Framework for Food and Nutrition Security in Tanzania # 50. RDC, 2015 République Démocratique du Congo, 2015. Nutrition à 1.13-1 assise communautaire. Manuel d’orientation. Kinshasa: Ministère de la Santé Publique. # 51. SUN, 2017a SUN, 2017. Monitoring, Evaluation, Accountability and Learning (MEAL). http://scalingupnutrition.org/progress- impact/monitoring-evaluation-accountability-learning- meal/ [accessed 13 December 2017] # 52. SUN, 2017b SUN, 2017. Monitoring, Evaluation, Accountability and 1.10.4-1 Learning (MEAL) 2016-2020. Country profile: Tanzania. # 53. Tackle Africa, 2018 Tackle Africa, 2018. Sexual health through football coaching. https://tackleafrica.org/ [accessed 4 January 2018] # 54. Tanahashi, 1978 Tanahashi, T. (1978). Health service coverage and its evaluation. Bull World Health Organ, 56(2), pp.295-303. # 55. TFNC, 2017 TFNC, 2017. BNA results by Region 28 Sept. 2017. Excel 1.10.1-3 spreadsheet. Dar es Salaam: TFNC. # 56. The Lancet, 2008 The Lancet, 2008. The Lancet’s series on Maternal and Child Undernutrition: Executive Summary # 57. The Lancet, 2013 The Lancet, 2013. Maternal and Child Nutrition. Executive Summary of The Lancet Maternal and Child Nutrition Series # 58. UN, 2013 UN, 2013. Revised Evaluation Policy of UNICEF. 1.2.1-5 Economic and Social Council # 59. UN, 2017a UN, 2017. UNICEF Gender Action Plan, 2018-2021. 1.2.4-1 Economic and Social Council. # 60. UN, 2017b UN, 2017. UNICEF Gender Action Plan, 2018-2021, 1.2.4-2 Indicator Matrix. Economic and Social Council. # 61. UN, n.d. UN, n.d. SUN in MIN Programme Beneficiaries 1.7.1-1 # 62. UNDAP, 2011 UNDAP, 2011. United Nation Development Assistance 1.5.3-1 Plan 2011-2015 # 63. UNDAP, 2016 UNDAP, 2016. United Nations Development Assistance 1.5.3-2 Plan to Tanzania 2016-2021 # 64. UNEG, 2005 UNEG, 2005. Norms for Evaluation in the UN System 1.2.1-7 # 65. UNEG, 2007 UNEG, 2007. Code of Conduct for Evaluation in the UN 1.2.1-3 System # 66. UNEG, 2009 UNEG, 2009. UNEG Principles of Working Together. 1.2.1-8 Evaluation Office. Geneva. # 67. UNEG, 2010a UNEG, 2010. UNICEF-Adapted UNEG Quality Checklist 1.2.1-4 for Evaluation Terms of Reference. Evaluation Office. # 68. UNEG, 2010b UNEG, 2010. UNICEF-Adapted UNEG Evaluation Reports 1.2.1-9 Standards. Evaluation Office.

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Abbreviations

AARR average annual rate of reduction AEO Agricultural Extension Officer AfDB African Development Bank ALMA African Leaders Malaria Alliance ARI acute respiratory infections ASRP Accelerating Stunting Reduction Project ASTUTE Addressing Stunting in Tanzania Early ATONU Agriculture to Nutrition AVRDC Asian Vegetable Research and Development Centre BCC behavioural change communication BMI Body Mass Index BNA bottleneck analysis BNTS Bringing Nutrition To Scale C4D communications for development CBO community-based organisation CC City Council CCD Care for Child Development CCDP Comprehensive Council Development Plan CDO Community Development Officer CFSVA Comprehensive Food Security and Vulnerability Analysis CG counselling group CHD child health drugs CHNM Child Health and Nutrition Model CHW Community Health Worker CIFF Children’s Investment Fund Foundation CMSCN Council Multisectoral Steering Committee on Nutrition CNuO City Nutrition Officer CO Country Office COUNSENUTH Centre for Counselling, Nutrition and Health Care CP co-operating partner CRED Centre for Research on the Epidemiology of Disasters CRS Catholic Relief Services CSO civil society organisation CUAMM Doctors with Africa DAC Development Assistance Committee DAICO District Agriculture, Irrigation and Co-operatives Officer

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DC District Council DED District Executive Director DFID Department for International Development DHEO District Home Economics Officer DHS Demographic and Health Survey DMO District Medical Officer DNO District Nutrition Officer DPG Development Partner Group EBF exclusive breastfeeding ECD early childhood development EQ evaluation question ER evaluation report ET evaluation team FANRPAN Food, Agriculture and Natural Resources Policy Analysis Network FANUS Federation of African Nutrition Societies FBO faith-based organisation FeFA iron+folic acid FEG Food Economy Group FFS farmer field school FGD focus group discussion FHHH female-headed household GMP growth monitoring and promotion GOT Government of Tanzania HIV human immunodeficiency virus HLSCN High Level Steering Committee on Nutrition IA Irish Aid IDDS Individual Dietary Diversity Score IEC information, education and communication IFA iron and folic acid IFAS iron-folic acid supplementation IMA Interchurch Medical Assistance IMAM integrated management of acute malnutrition IP implementing partner IR inception report IRDO Integrated Rural Development Organisation IYCF infant and young child feeding JMNR Joint Multisectoral Nutrition Review KI key informant KIWAUTA Kilio cha Waathirika wa Ukimwi Tanzania

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KR Key Result LGA Local Government Authority M&E monitoring and evaluation MBNP Mwanzo Bora Nutrition Programme MEAL monitoring, evaluation, accountability and learning MINS Mbeya, Iringa, Njombe and Songwe MOA Ministry of Agriculture MOHCDGEC Ministry of Health, Community Development, Gender, Elderly and Children MTEF Medium Term Expenditure Framework NACS nutrition assessment, counselling and support NGO non-governmental organisation NMIS nutrition management information system NMNAP National Multisectoral Nutrition Action Plan NNS National Nutrition Strategy NSGRP National Strategy for Growth and the Reduction of Poverty ODA official development assistance OECD Organisation for Economic Co-operation and Development OPV open pollinated varieties PANITA Partnership for Nutrition in Tanzania PER public expenditure review PF progressive farmer PLWHA people living with HIV and AIDS PMO Prime Minister’s Office PO-RALG President’s Office – Regional Administration and Local Government PSSN Productive Social Safety Net PY project year QS quality support RAS Regional Administrative Secretary RDC République Démocratique du Congo (Democratic Republic of Congo) REACH Renewed Efforts Against Child Hunger and under-nutrition REC Reach Every Child RNO Regional Nutrition Officer SACCOS Savings and Credit Co-operative Societies SAGCOT Southern Agricultural Growth Corridor of Tanzania SAM severe acute malnutrition SAMAWAMBU Shirika la Kuhudumia Wanawake na Watoto Mbuyuni Mbarali SBCC social and behaviour change communication SDG Sustainable Development Goal

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SHDEPHA Service, Health and Development for People Living Positively with HIV and AIDS SKAMAVMM Shirika la Kuhudumia Watu Wanaoishi na Virusi vya Ukimwi Majumbani SMART specific, measurable, attainable, relevant and timely SO sub office SUN Scaling Up Nutrition TAHEA Tanzania Home Economics Association TASAF Tanzania Social Action Fund tbc to be confirmed TDHS Tanzania Demographic and Health Survey TFNC Tanzania Food and Nutrition Centre TFNP Tanzania Food and Nutrition Policy TOC theory of change TOR terms of reference TZS Tanzania Shilling UN United Nations UNEG United Nations Evaluation Group UNICEF United Nations Children’s Fund USAID United States Agency for International Development USANGONET Usangu NGO Network USD United States dollars VAS vitamin A supplementation VEO Village Executive Officer VHD Village Health Day WASH water, sanitation and hygiene WEO Ward Executive Officer WFP World Food Programme WHO World Health Organisation WVC World Vegetable Centre

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