Document of The World Bank FOR OFFICIAL USE ONLY
Public Disclosure Authorized Report No: ICR00005046
IMPLEMENTATION COMPLETION AND RESULTS REPORT Cr. 5337-BJ
ON A
CREDIT
Public Disclosure Authorized IN THE AMOUNT OF SDR 18.3 MILLION
(US$28 MILLION EQUIVALENT)
TO THE
Republic of Benin
FOR THE
Public Disclosure Authorized Benin Multisectoral Food Health Nutrition Project April 22, 2020
Health, Nutrition & Population Global Practice Africa Region
Public Disclosure Authorized
CURRENCY EQUIVALENTS
Exchange Rate Effective Oct 31, 2019
Currency Unit = Euro Euro 1 = US$1.11522 CFA Franc 1 = US$ 0.00170 US$1 = SDR 0.72549
FISCAL YEAR January 1 – December 31
Regional Vice President: Hafez M. H. Ghanem Country Director: Coralie Gevers Regional Director: Dena Ringold Practice Manager: Gaston Sorgho Task Team Leader(s): Menno Mulder-Sibanda ICR Main Contributor: Helle M. Alvesson
ABBREVIATIONS AND ACRONYMS
ANCB Association Nationale des Communes du Bénin (National Association of Benin Communes) C4D Communication for Development CAN Conseil de l’Alimentation et de la Nutrition (Food and Nutrition Council) CAS Country Assistance Strategy CCC Cadre Communal de Concertation (Municipal Coordination Committee) CDP Commune Development Plans CGN Core Group of Nutrition CMAM Community Management of Acute Malnutrition CNP Community Nutrition Project CPF Country Partnership Framework CPS Country Partnership Strategy EBF Exclusive Breastfeeding GAN Groupe d’Assistance pour la Nutrition (Nutrition Care Group) GPRS Growth and Poverty Reduction Strategy IDF Institutional Development Fund IEG International Evaluation Group LQAS Lot Quality Assurance Sampling MFHNP Multisectoral Food Health Nutrition Project MICS Multiple Indicator Cluster Survey NLTA Non-Lending Technical Assistance OPCS Operations Policy and Country Services ORT Oral Rehydration Therapy PDO Project Development Objectives PNAR Programme National de Nutrition Axé sur les Résultats (Results-Based National Food and Nutrition Program) PRS Poverty Reduction Strategy PSDAN Plan Stratégique de Développement de l’Alimentation et de la Nutrition (Food and Nutrition Strategic Plan) SBCC Social and Behavior Change Communication SOP Series of Projects SP-CAN The Permanent Secretariat of the Food and Nutrition Council SUN Scaling-Up Nutrition TOC Theory of Change VAS Vitamin A Supplement
TABLE OF CONTENTS
DATA SHEET ...... 1 I. PROJECT CONTEXT AND DEVELOPMENT OBJECTIVES ...... 5 A. CONTEXT AT APPRAISAL ...... 5 B. SIGNIFICANT CHANGES DURING IMPLEMENTATION (IF APPLICABLE) ...... 9 II. OUTCOME ...... 11 A. RELEVANCE OF PDOs ...... 11 B. ACHIEVEMENT OF PDOs (EFFICACY) ...... 12 C. EFFICIENCY ...... 24 D. JUSTIFICATION OF OVERALL OUTCOME RATING ...... 26 E. OTHER OUTCOMES AND IMPACTS (IF ANY) ...... 27 III. KEY FACTORS THAT AFFECTED IMPLEMENTATION AND OUTCOME ...... 30 A. KEY FACTORS DURING PREPARATION ...... 30 B. KEY FACTORS DURING IMPLEMENTATION ...... 31 IV. BANK PERFORMANCE, COMPLIANCE ISSUES, AND RISK TO DEVELOPMENT OUTCOME .. 34 A. QUALITY OF MONITORING AND EVALUATION (M&E) ...... 34 B. ENVIRONMENTAL, SOCIAL, AND FIDUCIARY COMPLIANCE ...... 35 C. BANK PERFORMANCE ...... 36 D. RISK TO DEVELOPMENT OUTCOME ...... 38 V. LESSONS AND RECOMMENDATIONS ...... 39 ANNEX 1. RESULTS FRAMEWORK AND KEY OUTPUTS ...... 42 ANNEX 2. BANK LENDING AND IMPLEMENTATION SUPPORT/SUPERVISION ...... 55 ANNEX 3. PROJECT COST BY COMPONENT ...... 57 ANNEX 4. EFFICIENCY ANALYSIS ...... 58 Economic and Human development 2010-2018 ...... 58 Estimating beneficiaries of the project ...... 59 Documented benefits on Stunting pre and ‘post’ Project period by the DHS ...... 61 Estimating benefits from increased lifetime earnings from reduced stunting ...... 62 ANNEX 5. BORROWER, CO-FINANCIER AND OTHER PARTNER/STAKEHOLDER COMMENTS ... 63 ANNEX 6. SUPPORTING DOCUMENTS ...... 65
The World Bank Benin Multisectoral Food Health Nutrition Project (P143652)
DATA SHEET
BASIC INFORMATION
Product Information Project ID Project Name
P143652 Benin Multisectoral Food Health Nutrition Project
Country Financing Instrument
Benin Investment Project Financing
Original EA Category Revised EA Category
Not Required (C) Not Required (C)
Organizations
Borrower Implementing Agency
Secretariat Permanent du Conseil de l'Alimentation et de Republic of Benin la Nutrition
Project Development Objective (PDO)
Original PDO The development objective of the new project is to increase the coverage and utilization of community-based child growth andnutrition interventions in selected areas in the Recipient’s territory.
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The World Bank Benin Multisectoral Food Health Nutrition Project (P143652)
FINANCING
Original Amount (US$) Revised Amount (US$) Actual Disbursed (US$) World Bank Financing
28,000,000 27,975,090 25,819,715 IDA-53370 Total 28,000,000 27,975,090 25,819,715
Non-World Bank Financing 0 0 0 Borrower/Recipient 0 0 0 Total 0 0 0 Total Project Cost 28,000,000 27,975,090 25,819,715
KEY DATES
Approval Effectiveness MTR Review Original Closing Actual Closing 19-Dec-2013 08-Apr-2014 16-Dec-2016 31-Jul-2019 31-Jul-2019
RESTRUCTURING AND/OR ADDITIONAL FINANCING
Date(s) Amount Disbursed (US$M) Key Revisions 29-Oct-2017 10.58 Change in Disbursements Arrangements 12-Jun-2018 24.06 Change in Results Framework 20-Feb-2019 24.06 Reallocation between Disbursement Categories
KEY RATINGS
Outcome Bank Performance M&E Quality Highly Satisfactory Highly Satisfactory Substantial
RATINGS OF PROJECT PERFORMANCE IN ISRs
Actual No. Date ISR Archived DO Rating IP Rating Disbursements (US$M) 01 29-May-2014 Satisfactory Satisfactory 0
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The World Bank Benin Multisectoral Food Health Nutrition Project (P143652)
02 25-Nov-2014 Satisfactory Moderately Satisfactory 2.07
03 18-May-2015 Satisfactory Moderately Satisfactory 2.16
04 30-Nov-2015 Moderately Satisfactory Moderately Unsatisfactory 2.66
05 19-May-2016 Moderately Satisfactory Moderately Satisfactory 3.06
06 11-Nov-2016 Satisfactory Moderately Satisfactory 4.44
07 12-May-2017 Satisfactory Satisfactory 7.40
08 02-Nov-2017 Satisfactory Satisfactory 10.58
09 04-May-2018 Satisfactory Satisfactory 15.62
10 19-Nov-2018 Satisfactory Satisfactory 24.06
SECTORS AND THEMES
Sectors Major Sector/Sector (%)
Public Administration 9 Other Public Administration 9
Health 46 Health 46
Social Protection 45 Social Protection 45
Themes Major Theme/ Theme (Level 2)/ Theme (Level 3) (%) Private Sector Development 100
Jobs 100
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The World Bank Benin Multisectoral Food Health Nutrition Project (P143652)
Human Development and Gender 100
Health Systems and Policies 50
Child Health 50
Nutrition and Food Security 50
Nutrition 25
Food Security 25
ADM STAFF
Role At Approval At ICR
Regional Vice President: Makhtar Diop Hafez M. H. Ghanem
Country Director: Madani M. Tall Coralie Gevers
Director: Ritva S. Reinikka Dena Ringold
Practice Manager: Trina S. Haque Gaston Sorgho
Task Team Leader(s): Menno Mulder-Sibanda Menno Mulder-Sibanda
ICR Contributing Author: Helle M. Alvesson
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The World Bank Benin Multisectoral Food Health Nutrition Project (P143652)
I. PROJECT CONTEXT AND DEVELOPMENT OBJECTIVES
A. CONTEXT AT APPRAISAL
Context The countdown of the Millennium Development Goals (MDG) was ongoing during appraisal. Maternal mortality was high at 350 per 100,000 live births in 2011, even though it had decreased from 397 per 100,000 in 2006 (Demographic Health Survey; DHS 2006). Under-five mortality rates were also dropping from 160 per 1000 live births in 2001 (DHS) to 115 in 2014 (Multiple Indicator Cluster Survey; MICS). Despite these gains the MDG goal 4 and 5 were not expected to be met.
With a population of 9.6 million in 2011, a low capita income of US$738 (2011) and ranking of 167th out of 187 countries in the Human Development Report (2011), the Republic of Benin faced multiple challenges. In particular, poverty reduction was limited with an incidence rate at 36 percent in 2006. Large regional, urban/rural and gender- based differences was also adding to the burden. The dependence on agricultural exports (i.e., cotton) and food imports, extensive cultivation practices, and reoccurrence of floods and occasional droughts made Benin's population particularly vulnerable to climatic shocks. The global economic and financial crisis contributed to an economic slowdown, even though economic growth was still averaging 4 percent annually (2000-2011).
No improvements were seen in the nutritional status of children. Malnutrition rates, including stunting and underweight, had stagnated at very high levels, 43 percent and 15 percent respectively, which were higher than neighboring West African countries and even above the Sub-Saharan African levels (39 percent and 13 percent). Food insecurity had worsened substantially during the 2-3 years prior to appraisal in 2013; around 50 percent or the country’s households were estimated to experience food insecurity. Regional differences existed, with Northern regions worst affected, where up to 2/3 of households were food insecure--of which the majority had young children and women of reproductive age.
The policy environment on nutrition had weakened by the late 1990s as institutional responsibility was instable. The challenges included: (i) leadership shifted from the Ministry of Agriculture, to Health, to Family Welfare; (ii) a shift in policy discourse at the global level; and (ii) all three ministries only initiated a few lower level forms of activities. At the time, these sectors tended to see each other more as competitors for (generally low) donor attention than collaborators. The competition undermined collective action and nutrition was trapped in a downward cycle. However, in 2007, the nutrition community itself concluded that they had to break the cycle, join forces and develop a multisectoral strategy. In 2007 a Core Group of Nutrition (CGN) was established with members from various ministries, the University of Abomey-Calavi, the Regional Public Health Institute, civil society and local government. The group was later that year approved by the Council of Ministers in Benin. The CGN produced several analytical studies on the political economy of nutrition policies, a Roadmap for Nutrition Reform that in 2009 fed directly into the Strategic Plan of Food and Nutrition Development (PSDAN), a four-year Results-Based National Food and Nutrition Program (PNAR) and drafting of the decree for the creation of the Council for Food and Nutrition (CAN). CAN was established directly under the President’s Office and a budget line was established in 2012. When the Scaling-Up Nutrition (SUN) movement was initiated during the General Assembly of the United Nations in New York
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The World Bank Benin Multisectoral Food Health Nutrition Project (P143652)
in 2011, the CGN was instrumental in securing Benin’s membership from the beginning. With the membership in SUN a donor coordination platform was created.
The health service integration of nutrition was weak and limited to curative services at the facility level and narrow preventive services through periodic outreach. Nutrition counseling or treatment of malnutrition was not consistently provided in facilities. Moreover, services did not reach the community level and had no means of following children through their early development. Social promotion services were similarly weak, and where functional, provided some nutrition education but mainly in facilities. Agriculture had some outreach to support food production, but the scale and the targeting was inadequate at the time. In general, the services at the community level, through extension agents and community health workers, were not adequate in numbers nor equipped to reach women and children with messages on nutrition. There was no community-based strategy in place. Overall, the package of services needed at the household level was not converging to benefit families in need of nutrition support, even if fragmented services were available in some areas.
The institution-building and reform agenda of the food and nutrition sector had, during the five years prior to appraisal, been growing much stronger. In the Country Assistance Strategy (CAS) (2009-2012) malnutrition of children under five was specifically mentioned as a priority and there was a call for increasing access to basic services and to improve health outcomes for children. The timing was ideal to start a large institutional capacity building process. The Poverty Reduction Strategy (PRS) had made nutrition a priority and as a result, progress in nutrition was recognized as a core dimension in the 2011-2015 Growth and Poverty Reduction Strategy (GPRS). The above mentioned PSDAN was incorporated into the GPRS in its entirety and more importantly informed the design of the Multisectoral Food Health Nutrition Project (MFHNP). The strategy included 10 priorities, including some of the global evidence-based approaches such as micronutrient deficiencies (Vitamin A, iron, iodine and zinc); strengthening the feeding of adolescent girls and pregnant and nursing women; encouraging community-based management of moderate acute malnutrition; and strengthening monitoring of nutritional status.
Collaboration between the World Bank and the Government of Benin had been explored through Non-Lending Technical Assistance (NLTA) since 2007. The assistance was built on a notion of emerging design in order to respond to the policy dialogues at national, as well as local government levels. As part of this process a pilot Community Nutrition Project (CNP) supported by the Bank was developed in 2011, in which multi-sectoral collaborations between local government structures, NGOs, and the Ministry of Health were tested. It was innovative at the time for a government to work systematically with NGOs to overcome the limitations of the public services. The project was implemented by Plan Benin on behalf of the Government. Experiences from the ten pilot municipalities were promising at appraisal. In particular, the benefits of targeting whole communities instead of specific households was important to transform social norms on nutrition and also gender. In addition, people from health, agriculture, local government, civil society and academia with an ambition to collaborate across sectors had come together; opportunities for making nutrition problems visible at the political scene were taken; the networking process was inclusive, with an emphasis on building a coalition for nutritional change; at the same time the suggested approaches were directly linked to the consolidated global evidence of nutrition interventions.
A number of developments came together: (i) the CNP indicated that community capacity existed; (ii) malnutrition was increasingly recognized as a problem for development of the country; (iii) key stakeholders were coming together, and a critical group of like-minded professionals was established. As a result, the appropriate climate for a larger scale implementation was created. The consensus that the maternal and child nutrition deficiencies could not
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The World Bank Benin Multisectoral Food Health Nutrition Project (P143652)
be solved satisfactorily through the existing programs, and that a more convergent and participatory approach to nutrition could bring more benefits, characterized the nutrition narrative at appraisal.
There were other ongoing Bank-supported projects and national programs that the project was related to: (i) the Bank-supported Decentralized Community Driven Services Project was an inspiration since it took the municipality as the entry point of the community-based activities; (ii) complemented the Bank-supported Health Systems Performance Project was complementing the project by strengthening the demand-side of service utilization; (iii) the Bank-supported Agricultural Productivity and Diversification Project provided opportunities for synergy on value chain improvement activities; and (iv) the National Food Security Program was supporting as part of the PSDAN.
Theory of Change (Results Chain) The results chain from expected input to impact is presented in Figure 1 below. The five critical assumptions are listed and marked in the processes in which they were considered most important.
Figure 1. Flow chart of the theory of change (results chain) as conceptualized during appraisal
The Theory of Change (TOC) for the project aimed at institutionalizing the planning of nutrition services and gradually increasing the scope and type of benefits for women and children under five. The TOC was built on; (i) comprehensive information about the social, cultural, and economical context, (ii) as well as the actors or stakeholders that influence the nutrition status; (iii) evidence-based practice of nutrition interventions and services that are documented to be effective globally or locally; and (iv) an understanding of the processes that are required to achieve change at
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The World Bank Benin Multisectoral Food Health Nutrition Project (P143652)
community, municipality, and national levels. These four dimensions are all represented at different stages of the project, indicating a strong conceptual starting point for the project.
Project Development Objectives (PDOs) The Development Objective of the project was to increase the coverage and utilization of community-based child growth and nutrition interventions in selected areas in the Recipient’s territory.
The PDO was initially assessed through four PDO indicators:
• Proportion of children 0-23 months benefitting from a minimum package of monthly growth promotion activities in the project’s targeted communities; • Number of women with children under five trained and engaged in the production or transformation of diversified and nutrient-rich foods; • Proportion of children 0-6 months who are exclusively breastfed; and • Number of municipalities with at least 25% execution rate of their joint annual work plan.
A fifth PDO-indicator was added later (see below).
Key Expected Outcomes and Intermediate Outcome Indicators Outcome indicators were developed for the two components that made up the project. Achievements in component 1 was measured through three indicators and component 2 through eight indicators according to the PAD:
Table 1. Project indicators per component
Component 1 Policy and program development, management and coordination: 1. Municipalities that disbursed funding for food and nutrition security development 2. Multisectoral strategy document for community-based health, food, and nutrition standardizing roles and responsibilities of stakeholders 3. Protocol for community management of moderately acute malnutrition finalized and validated. Component 2 Community mobilization and scale up of nutrition activities were assessed through eight outcome measures: 4. Direct beneficiaries of which female 5. Households in targeted Municipalities which established a designated hand washing station 6. Children under five with diarrhea who are treated with Oral Rehydration Therapy (ORT) in targeted Municipalities 7. Participants attending community nutrition education sessions in targeted Municipalities 8. Social and Health workers re-trained on Community Management of Acute Malnutrition (CMAM) 9. Health personnel receiving training 10. Children 6-59 months who received a Vitamin A supplement (VAS) in the past 6 months 11. Pregnant/lactating women, adolescent girls and/or children under age five reached by basic nutrition services
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The World Bank Benin Multisectoral Food Health Nutrition Project (P143652)
Components Component 1: Policy and program development, management and coordination (US$7.20)
Component 1 addressed the broader objectives of strengthening and supporting multisectoral action and collaboration at the national and decentralized policy levels. The component was designed to strengthen multisectoral coordination by the newly established CAN in order to support the nutrition agenda. More specifically, the activities were facilitating change through:
• Building local community accountability and nutrition integration in Municipality (Commune) Development Plans (CDP); • Integrating nutrition into sector plans and strategies; • Strengthening coordination mechanisms at all levels; and • Performing nutrition focused research.
Component 2: Community mobilization and services delivery strengthening (US$20.80)
This component focused on municipality-level coordinated action for the protection and promotion of food and nutrition security of mothers and young children by implementing and scaling up a package of community-based food and nutrition security actions. The project was implemented in 40 municipalities (communes) in six regions: Borgou/Alibori; Atacora/Donga; Zou/Collines; Mono/Couffo; Ouémé/Plateau and Atlantic/Littoral.1 In addition, this component included activities to strengthen the delivery and utilization of essential public food, health and nutrition services. The activities to be funded within this component included:
• Monthly growth monitoring of about 7,500 children from 0 to 59 months per municipality; • Community-based screening and management of moderate acute malnourished children and referral of severe acute malnourished children in specialized centers for appropriate management; • micronutrient supplementation; • Installing handwashing devices and other health-preserving personal hygiene measures in households; • Supporting households with children aged 0 to 59 months in order to produce and process food that allows them access to diversified food rations; and • Establishing a Municipality-level (Commune-level) Consultative Committee (CCC) for all municipal food and nutrition security services and other stakeholders in each of the participating Municipalities. The CCC is chaired by the municipality’s Mayor.
B. SIGNIFICANT CHANGES DURING IMPLEMENTATION (IF APPLICABLE)
Three minor restructurings were conducted during project implementation.
Revised PDOs and Outcome Targets The PDO and Outcome Targets remained unchanged during the project.
1 The targeted regions and municipalities were selected based on their high level of food insecurity as illustrated in their selection as target area for the National Food Security Program in Benin.
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The World Bank Benin Multisectoral Food Health Nutrition Project (P143652)
Revised PDO Indicators In 2018 one PDO indicator was added. In order to better assess the coverage of the expanded community-based services in component 2, one indicator was added: “Nutritional Care Group (GAN) members in place for delivering community-based services (number)”. The purpose of this indicator was to detail the mechanism through which coverage would be increased. The TOC was based on a critical assumption that households would in fact be reached by community-based interventions and the GANs were a critical link between households with young children and nutrition stakeholders at the municipality level. The TOC was not changed but the process of achieving an increased coverage was clarified through this additional indicator. At the intermediate level four indicators were also revised to more clearly specify project results. The revised targets were more ambitious in that they were targeted to the specific practices that had been observed in local communities and in the existing collaborations between NGOs, communities and nutrition stakeholders at municipality level:
• Indicator number 5 was revised to reduce the target for number of households having established a hand washing station, from 15,000 to 10,000, since handwashing stations were often established in shared areas in villages rather than at the level of each household; • Indicator number 7 was revised to specifically measure the participation of women with children under 5 and pregnant women in education sessions, given that these were the key beneficiary groups for the project, rather than the general population; • Indicator number 9 was revised to specifically track the training of GAN, given the project’s reinforcement of the GAN to deliver services; and • The outdated Core Sector Indicators (number 4,9 and 11) were replaced with the new Corporate Results Indicators.
Revised Components N/A
Other Changes The process of declaring the project effective was executed in a timely manner. The project was: (i) approved by the Bank on December 19, 2013; (ii) signed by the Ministry of Finance and Economy and the World Bank on February 11, 2014; (iii) ratified by Parliament on March 17, 2014 and signed into law by the President on March 18, 2014 and cleared by the Supreme Court on March 27, 2014; and (iv) declared effective on April 8, 2014.
In addition to the restructuring in the results framework mentioned above, two restructurings were implemented in 2017 and 2019.
The first restructuring (level II) involved changes in the disbursement letter. With the expansion of community-based interventions to 40 municipalities, the volume of expenditures could not be handled efficiently with the ceiling on the designated account of FCFA 1,000 million. Therefore, the Team processed a restructuring that allowed the use of unaudited Interim Financial Reports (rather than statement of expenditures) as the basis for withdrawal requests for the replenishment of the designated account. The new disbursement instructions of October 2017 states that the ceiling would be equivalent to the forecast of 2 quarters, thereby introducing more flexibility to project to process the large amount of payments at specific times.
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The World Bank Benin Multisectoral Food Health Nutrition Project (P143652)
The last restructuring was approved in 2019 and included a reallocation of the grant between the two components. Through reallocating funds from component 2 to component 1 the project was able to fully disburse by the end of the project. No other changes were part of this restructuring.
Rationale for Changes and Their Implication on the Original Theory of Change The changes in the results framework were well aligned with the critical assumption that many of the services to children and women needed to be developed. The added indicator clarified “how” the skills and capacity should be transferred through the GAN. This indicator thus visualized the mechanism - but did not imply a change in the original TOC.
The outcome variable of beneficiaries using hand washing facilities was contextualized to capture the community preference of placing hand washing facilities in clusters of households rather than within the individual household. The target was lowered in numbers to reflect this local practice even though the number of beneficiaries were not expected to change. This highlighted the importance of the critical assumption in the TOC that behavioral changes are integral to social and gender related preferences.
The restructuring related to disbursement method and reallocation of funds between the two components were based on the observations that the speed and scope of financial flow over the period of the project were changing. These efficiency enhancing modifications did not have any implications on the TOC, but rather confirmed that the multisectoral platforms in the municipalities were dynamic yet also sensitive to predefined time schedules.
II. OUTCOME
A. RELEVANCE OF PDOs
Assessment of Relevance of PDOs and Rating The Project Development Objective (PDO) to increase the coverage and utilization of community-based child growth and nutrition interventions in selected areas in the Recipient’s territory was fully aligned to the Country Partnership Strategy (CPS) that was developed during the appraisal period (CPS 2013-2017). In Pillar II “Improving access to basic social service delivery and social inclusion” it was clarified that the enhancement of household food security, maternal and child health and nutrition outcomes should be supported through community based multisectoral platforms.
The PDO is also directly relevant to the second development priority in the current Country Partnership Framework (CPF) that was developed during the implementation of the project: “Equitable access to opportunities and inclusion of the poor in the growth process” (CPF 2019-2023). In the third pillar, focusing on improving service delivery and social inclusion, improved access to the health and nutrition services are emphasized. It is clarified that tackling malnutrition is critical in breaking the intergenerational cycle of poverty. It is further emphasized that child nutrition is a particularly high priority for Benin for preventing nutritional and health problems, and also for modernizing the future economy. Child malnutrition affects educational and economic prospects later in life and thus imperils the development of Benin.
Since 2007 the Government of Benin has increasingly prioritized the fight against malnutrition in its development policy. The establishment of the CAN in the President’s Office is a testament to the prioritization of child nutrition as
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The World Bank Benin Multisectoral Food Health Nutrition Project (P143652)
a social and economic concern. The ambition of creating and maintaining a multisectoral platform to prevent and manage malnutrition also dovetails with the decentralization efforts of the Government, including closer collaborations with the civil society.
The relevance of the project has remained high throughout the project period.
B. ACHIEVEMENT OF PDOs (EFFICACY)
The achievement of the PDO will be reported in two parts in accordance with the double-pronged objective to increase:
i) the coverage of community-based child growth and nutrition interventions; and ii) the utilization of community-based child growth and nutrition interventions.
The coverage and the utilization of the interventions were built on different approaches to, and theoretical basis of, prevention and management of malnutrition. The TOC guides the reporting on the achievements of the project.
Overall, the project has achieved its objectives as formulated in the five PDO indicators and ten intermediate indicators (see Table 2). Most of the indicators have surpassed the target.
Table 2. Summary of indicator achievements
Result range PDO indicators Intermediate indicators Component 1 Component 2 Achieved to 75-90% Achieved 2 2 Achieved and surpassed 3 1 3 Achieved and surpassed by more than 100% 2 2 Total 5 3 7
The corporate indicator required for the project is “number of women and children who have received basic nutrition services”. Hence, only this corporate indicator is reported in the table above. Obsolete corporate reporting indicators are not included.
Assessment of Achievement of Each Objective/Outcome The TOC including activities, outputs and outcomes in terms of mobilizing nutrition stakeholders at local, municipality and national level has been achieved. The increased coverage and utilization of nutrition services have contributed to the longer-term targets of reducing stunting. More specifically, all five PDO indicators were achieved and surpassed; two by more than 100 percent. In table 3 below the PDO and the intermediate indicators have been listed according to their contribution to the PDO.
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The World Bank Benin Multisectoral Food Health Nutrition Project (P143652)
Table 3. Indicators and their contribution to the PDO Project Development PDO indicators (in bold) and intermediate Indicators Objective 1. Increasing coverage Indicators for coverage in the targeted municipalities: of community-based • Number of municipalities with at least 25 percent execution rate of their joint annual child growth and work plan nutrition • Number of municipalities that disbursed funding for food and nutrition security interventions development • Nutritional Care Group (GAN) members in place for delivering community-based services (number) • Multisectoral strategy document for community-based health, food and nutrition standardizing roles and responsibilities of stakeholders • Pregnant/lactating women, adolescent girls and/or children under age of five reached by basic nutrition services. • Households in targeted municipalities with established designated hand washing station • Children 6-59 months who received a VAS in the past 6 months. Other Indicators: • Protocol for community management of moderately acute malnutrition finalized and validated • Health personnel receiving training • Social and health workers re-trained on CMAM 2. Increasing utilization Indicators for utilization of services in the targeted municipalities: of community-based • Proportion of children 0-23 months benefitting from a minimum package of monthly child growth and growth promotion activities in the project’s targeted communities nutrition • Participants attending community nutrition education sessions in targeted municipalities interventions • Number of women with children under five trained and engaged in the production or transformation of diversified and nutrient-rich foods; • Proportion of children 0-6 months who are exclusively breastfed • Children under five with diarrhea who are treated with ORT in targeted municipalities. Other indicators: • -
Results in relation to coverage As illustrated in the TOC (Figure 1) the fundamental approach was to develop a multi-sectoral governance platform of integrated nutrition services. To achieve this new policies and strategies, in addition to coordination of services at local, municipality and national levels, were developed. Building an integrated platform at national, municipality and community levels during the project period was a premise for improving behavioral outcomes in the target group (utilization).
Building a multi-sectoral platform for nutrition: national level During the project period the Permanent Secretariat of the CAN (SP-CAN) established itself as the agency responsible for improving the nutrition standards through multi-sectoral collaboration. The process of normalizing the integration of nutrition into the national discourse on development has taken different forms:
While the CAN was already established at appraisal, the project served as a test of operationalizing the broad partnerships across sectors and levels of governance. The CAN was composed of 17 members including
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The World Bank Benin Multisectoral Food Health Nutrition Project (P143652)
representatives of the President’s Office, seven line ministries (Agriculture, Health, Social Protection, Development, Finance, Local Government, Trade), National Association of Municipalities (Communes) of Benin (ANCB), the food industry, research and teaching institutions, civil society, the Chamber of Agriculture, and farmers’ associations. The mixture of public, private and civil associations with political or economic interests have contributed to positioning nutrition as a core issue for development of Benin;
The approach to contract NGOs and make the municipalities the entry point for the implementation of nutrition activities was highly innovative. The fact that as many as 16 NGOs have been contracted during the project period is a big achievement;
To work with interest organizations that are politically driven can be a challenge. The CAN managed to build a coherent approach to nutrition in which all members have a role to play. This has been illustrated in high level meetings on gender and in the series of workshops in 2018/19 with all 77 municipalities. The collaboration with ANCB has directly influenced the entry points to all municipalities in Benin and emphasized the urgency to act on nutrition;
In addition, the SP-CAN has developed, finalized and validated during the project period the: “Multisectoral strategy document for community-based health, food and nutrition standardizing roles and responsibilities of stakeholders.” The strategy document sets out the reasons and the strategies for improving nutrition in Benin and operationalizes what multi-sectoral collaboration in nutrition means in Benin. The development of this strategic document was one of the intermediate indicators and has thus been achieved.
Globally, the project has contributed to the nutrition policy development and coordination at national level with emphasis on inclusive partnerships with other sectors, harmonization of approaches, active joint monitoring and reviews of the sector and resource mobilization from public resources and development partners.
The indicators that capture the ways in which the project has accomplished the increase in coverage of nutrition services will be presented below.
PDO indicator: Number of municipalities with at least 25 percent execution rate of their joint annual work plan This PDO indicator is achieved and surpassed. The target of 30 municipalities was surpassed when all 40 beneficiary municipalities reached this indicator. Establishing joint annual work plans on nutrition had been tested in the ten pilot municipalities under the previous project CNP. This indicator started therefore at 7 municipalities but exceed the expectations of the project by ten municipalities.
To increase coverage of community-based child growth and nutrition interventions it was assumed at appraisal that a multitude of interactions between beneficiaries, local leaders and stakeholders at the municipality, prefecture and national levels were required. Local government at the municipality level was considered to be best positioned to set- off the chain of events needed to facilitate and build nutrition capacity. Institutional capacity would have to be built during the full project period, and beyond, on several issues. With that in mind the 40 beneficiary municipalities were mobilized in two consecutive batches; 21 municipalities entered the project in the first quarter of 2016 and the next 19 municipalities joined in the second quarter of 2017. With this sequential process in mind, the achievement of supporting all municipalities to execute their work plans is impressive.
Initially, priority was given to capacity building on a range of issues, including technical knowledge on the prevention and management of nutritional deficiencies, mobilization strategies in local communities, monitoring and evaluation processes, and active collaboration with NGOs. During the first half of the project many municipal stakeholders did
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not yet understand the concept of nutrition and there was confusion about the differences between food, diet and nutrition. Nutrition was perceived as an issue of consumption, not a matter of investment. As noted in the TOC, improved nutrition outcomes require normative changes. Stakeholders at the municipality level were trained in the prevention and management of malnutrition provided by a pool of trainers from the SP-CAN, line ministries and NGOs which were in direct contact with stakeholders at the level of the municipality. The conceptual barriers were important to bridge at municipality level in order to formulate work plans that, in effect, would improve nutritional status of women and young children.
The implementation mechanism was designed to bring about collective action as close to the local communities as possible. After three years of project implementation, all 40 beneficiary municipalities had established a joint annual work plan by stakeholders in nutrition. Meanwhile, from the onset of the project, intensive and large-scale social mobilization, capacity building and skills transfer was ongoing in order to establish the municipality-level multi- sectoral platforms.
Mayors of the beneficiary municipalities are now leading the planning, monitoring and reporting of nutrition activities. The CCC meetings are held at the mayor’s office, thus making the institution building in nutrition visible for other sectors. Given the complex pathways to impact and the high number of collaborating partners that are needed in each municipality, the process of action on nutrition required sustained input during the full project period. Moreover, regular turnover of elected or appointed members make the collaboration fragile. Constant capacity building of all stakeholders was a way to mitigate against this and included training on nutrition and its causes and on setting up a results-based monitoring and evaluation system. Through the means of reflexive monitoring by the CCCs, the integration of the nutrition activities in the municipalities have been strengthened.
One NGO was contracted to support the community mobilization and capacity building efforts in each of the municipalities. The lead NGO in each municipality is a member in the CCC. Other CCC members are the sectors of health, agriculture, social welfare and education, in addition to other NGOs active in the municipality. Not all sectors are represented at the level of municipalities, water and sanitation being one example, but often had representatives at the regional level (Département). One of the first activities by the lead NGO was to facilitate the identification and selection of the beneficiary villages with the highest malnutrition burden by the CCC. This process was participatory to a very high extent and with a focus on capacity building so the municipalities could understand, support and execute the targeting. The selection was based on 11 indicators including food insecurity, poverty level, sanitation and availability of services among others.
The scope and intensity of the collaboration has varied among municipalities. Information sharing across sectors and actors have proven an effective first level of collaboration. The development of a common understanding of the causes of malnutrition, the evidence-based strategies to prevent and manage malnutrition, in addition to the roles and responsibilities of each CCC member, forms the backbone of the collaboration. In addition, chains of concrete action among multiple CCC members are continuously developing within each of the 40 beneficiary municipalities. One example is the collaboration between health centers, social services, village chiefs and individual households with acute malnourished children to transfer children to recuperation centers for treatment and follow up support for the family in their community when the child is stabilized. Other examples of executed activities are: support to households with malnourished children through setting up small vegetable gardens and provide support to raise chickens; educational talks on nutrition to all members in communities; promotion of women’s reproductive health in communities and at adolescent training centers; support in the organization of vaccination campaign to reach
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households that are difficult to reach; organization of world breastfeeding week; training of members of the municipal council, the heads of boroughs, members of civil society and staff of the Town Hall on nutrition issues and the roles and responsibilities of actors.
The ANCB has actively supported the project and has encouraged the 37 non-beneficiary municipalities in the country to actively engage in nutrition. Workshops have been held to increase the knowledge of non-beneficiary municipalities regarding the tools and protocols to be used when setting up a multi-sectoral platform. Recently, the ANCB produced a documentary on the collaboration between ANCB and the CAN in order to describe and promote multi-sectoral collaboration in the municipalities where nutrition is not yet addressed in a systematic manner.
The intermediate indicator “Municipalities that disbursed funding for food and nutrition security development” was also achieved and surpassed. At the end of project, 60 municipalities were disbursing funds compared to the target of 55 and a baseline of 10 municipalities. Budgeting and disbursing for nutrition in each of these municipalities is one of the transformative accomplishments. It has generated visibility to nutrition work and is one concrete achievement towards integrating nutrition costs into the municipal budget process. This achievement is noteworthy since it includes 20 non-beneficiary municipalities.
Table 4. Characteristics of a high performing municipality
Characteristics of a high performing municipality ✓ A well-organized municipality with a sufficient number of skilled staff ✓ A dynamic Focal Person with good understanding of nutrition and with high capacity ✓ Leadership and engagement of the Mayor (and the City Council) ✓ Information communicated directly to the Mayor on a routine basis from the SP-CAN ✓ Regular meetings in the CCC ✓ A functioning budget in the CCC ✓ Conviction of the elected officials of the benefits of nutrition and that they participate in activities and contribute with suggestions on solutions. ✓ Determination of outreach workers in all sectors to support the municipality on its nutrition targets ✓ Financing and implementation of nutrition activities from the municipality itself Source: The ex-ante study, SP-CAN 2019
The activities funded through the CCC may vary between villages according to the burden of nutritional deficiencies. The locally elected mayors are chairing the multi-sectoral nutrition coordination committees (CCC). Social accountability has been a guiding principle during the implementation of the project. Through situational nutrition analysis, municipal surveys, implementation and monitoring activities, the mayors and other CCC members have become more visible in local communities. Mayors have seized the opportunity to visit communities during events in the communities which in turn have given communities opportunities to express needs and suggested support from the mayors. Even though mayors also work under resource constraints, communities are experiencing more opportunities to raise nutrition related concerns. Table 4 highlights what factors make for a high performing municipality. It should be noted that some of the characteristics of performance are currently formulated in vague terms such as for example “dynamic Focal Person”. These factors are expected to be further clarified during the next assessments of the project.
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The project financed the:
• Development of the protocol for community management of moderately acute malnutrition (CMAM); • The training of health personnel on nutrition prevention and management; • Retraining of social and health workers on CMAM.
More than 1,000 social and health workers have been retrained on CMAM. This is more than double the end-of- project target and is an indication of SP-CAN’s support to the various sectors. Through these activities the SP-CAN has become known as the source of evidence-based nutrition knowledge and an agency able to deliver the input to other sectors in a format that is adjusted to their needs. According to data from UNICEF the needs are still comprehensive; only 10.9 percent of primary healthcare facilities offer infant and young child feeding counselling.
PDO indicator: Number of Nutritional Care Group (GAN) members in place for delivering community-based services The link between trusted persons in the communities and nutrition stakeholders at Municipality level (CCCs) was strengthened to achieve high coverage and to empower beneficiaries in local communities. This indicator is achieved and surpassed with more than 20,729 GAN members selected and trained in the 1,241 villages compared to the target of 17,000. In assessing the coverage of the project, it should be emphasized that four target groups were reached by the GANs: pregnant women; women with a child under the age of 5 years; children under the age of 5 years; and teenage girls.
One of the critical assumptions in the TOC was that local leaders and men are important in changing community norms on child nutrition. In facilitating the selection of GAN members, the NGOs reached out to the local village authorities for consultation on the selection process in reference to the social and technical skills requirements. The local recruitment of volunteer members was a part of the project design at appraisal but through adding a PDO indicator on the progress of setting up this group in each village, the operationalization of the promotion of behavior changes was clarified.
Box 1. GAN member tasks Delivery of monthly nutrition interventions by GAN members to women and children 0-59 months, and their families: • Home visits • Hygiene promotion • Education sessions • Growth and monitoring • Food production and transformation • Referral of women and children to sectoral services • Community mutual
The GAN members managed to mobilize the communities through a range of different strategies (see Box 1). The combination of home visits with group sessions including monthly growth monitoring and education sessions is contextualized in the different regions. The high intensity of community-based activities was made possible through the mobilization of local volunteers. The quality of their services needs continuous improvement and peer learning strategies have been emphasized as a means to transfer the skills from NGO staff to the GANs. GAN members’ ability
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to mobilize women is reflected in the high number of women and children reached by the nutrition services.
Households in targeted municipalities with established designated hand washing station Easy access to soap and water is a challenge for most households in the intervention municipalities. In some of the Northern villages the water insecurity is very high. According to the database from the “Joint Monitoring Programme for Water Supply, Sanitation and Hygiene” (2000-2017), 77 percent of the population in rural areas in Benin have no access to a facility for hygiene practices including handwashing with soap, as compared to 68 percent in urban areas. The beneficiary villages are expected to start with an even lower access to facilities. The indicator on 10,000 households who established a designated hand washing station was achieved and surpassed by the project. More than 20,000 households have access to a device put in place by the project or a device that villagers have made by themselves based on the project model, as shown below. Given the scope of the problem of lack of access to clean water and sanitation (according to the same report only 15 percent of people in rural areas have access to latrines), this is only a first step in alleviating households from known pathways of infections and other diseases.
Handwashing device in a beneficiary community in rural Benin
Source: SP-CAN
A range of factors continue to influence the relatively low access to hand washing stations. These include: lack of access to clean water, lack of interest and awareness of the importance of handwashing, lack of appreciation of the type of device made with local materials, inability or lack of skills to construct the device with local materials, the perception that the construction of the device is a man's business, passive attitude in the hope of additional handouts from the project, and the destruction of the device by bad weather.
The indicator “Children 6-59 months receiving Vitamin A supplement in the past 6 months” is a measure of an evidence- based intervention and also of the quality of the collaboration between parents, community and the healthcare facilities. The target of 80 percent of children reached has been achieved and surpassed with a reported coverage of 104 percent.
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At appraisal it was understood that the free supply of vitamin A supplements would stop, putting at risk the twice- yearly mass distribution campaign to all children under five years of age. As an indicator of multisectoral coordination, in this case with the Ministry of Health and with the support of UNICEF, the project’s aim was to maintain the past results of full coverage. It was known that countries who have discontinued mass campaigns and integrated the distribution into routine services have reported decreasing coverage. Through the continuation of the campaigns and the support from the project, the coverage has been maintained throughout the project period. The reported result of more than 100 percent should be interpreted in the way that non-eligible children occasionally were provided the Vitamin A capsule during the mass campaigns.
Results in relation to utilization of nutrition services
The PDO indicator: Proportion of children 0-23 months benefitting from a minimum package of monthly growth promotion activities in the project’s targeted communities Community promotion of child growth and nutrition is the core activity. Through the project monitoring system, the numbers and proportions of children 0-23 months is continuously documented. The monthly coverage reached 91.8 percent of targeted children and thus surpassed the goal of 70 percent. This corresponds to about 121,000 children. This is a major achievement, especially keeping in mind the continuous flow of new pregnancies and newborns into the target group. The coverage and intensity of service utilization was secured through the horizontal community- based structures and the collaboration between municipalities, NGOs, GANs and the healthcare providers and staff in municipal social services. The intensity of services in the first 1,000 days was an important learning from lessons and global evidence.
Figure 2: Nutritional status and morbidity of children
EDSB: Benin Demographic and Health Survey (2006 and 2018) MICS: Multiple Indicator Cluster Surveys; Investigation based on a Cluster of Multiple Indicators ESN: Nutrition Situational Survey (2018) Source: SP-CAN, 2018. Benin Nutrition Situational Surveys
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When children are reached by the GAN, we assume they are benefitting towards their nutritional status. Figure 2 shows the trend of key indicators on nutritional status of children, serving as an illustration of the improvements that the project has contributed to. The data compare the 40 beneficiary municipalities to the national representative samples as reported in the DHS 2011, MICS 2014 and DHS 2018. The trend is generally slightly downwards, meaning that the nutrition indicators are improving.
It should be noted that the ESN2018 is the project nutrition situational survey and covers 40 beneficiary municipalities out of a total of 77 municipalities. The other data sources include representative samples of all municipalities in Benin. The datasets are therefore not fully comparable because the project municipalities were the poorest municipalities at the time of selection. The data on stunting prevalence highlights the socio-economic gradient among households. While the average prevalence is 33.6 percent as shown in figure 2, it is 41 percent for the poorest households and 19 percent for the households that are best of according to the DHS 2018 (see figure 3 below).
Figure 3. Stunting by socio-economic group.
The results in the ESN 2018 are not consistent with the latest DHS 2018 when it comes to prevalence of diarrhea and underweight. This might be explained by seasonal variations during data collection, which play a particular role in diarrhea prevalence. Diarrhea incidence is often difficult to compare between surveys given the high fluctuation caused by factors outside a project’s control. Also, the selected villages in the ESN2018 are the poorest villages in the municipalities with regards to food insecurity and limited availability of services. This may mean that sanitation was significantly worse in the project villages represented in the ESN 2018 as compared to national level representation samples. With these methodological difficulties in mind regarding the prevalence of underweight at birth, it is suggested that the project contributed to narrowing the gap between poor and better off municipalities. This prevalence may narrow even more during the next years to eventually break the causal pathways of underweight children.
Women’s health and nutritional status before, during and after childbirth directly affects the survival rate of 0-23 months old. The trend in the nutritional status of women is therefore interesting on its own, and as an indication of the health of the child. A 2006-2018 comparison between national estimates and targeted municipalities indicate that the prevalence of anemia in women is decreasing.
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With a relatively short active and scaled-up implementation period, the project was able to demonstrate impressive outputs and outcomes. The project was implemented in about half of the Benin population, but the length of time of the scaled-up implementation was too short to achieve measurable impact using national level data. However, the initial ten PNC municipalities, that had received a less comprehensive set of interventions, had shown a reduction in malnutrition rates. For this ICR, we do not have evaluation data to be able to compare beneficiary/non-beneficiary municipalities.
Promotion of nutrition through education and informal interactions The indicator on number of women attending community nutrition education sessions is achieved. A National Strategy for Social and Behavioral Change Communication (SBCC) in Benin and its operational plan 2017-2021 were developed from a situational analysis on the SBCC for the promotion of nutrition in Benin. At the conceptual level, this strategy and operational plan were developed using the Communication for Development (C4D) model (http://www.unicef.org, UNICEF et al. 2012) and the “PRECEDE-PROCEED” model of health promotion planning, implementation and monitoring. The promotion of child growth, on the one hand, and the detection and management of acute malnutrition on the other hand formed the two strategic priorities in the education sessions.
Fourteen key behaviors were selected; namely early breastfeeding initiation, exclusive breastfeeding, the introduction of complementary foods from 6 months while continuing breastfeeding until 2 years or older, hand washing at critical times with clean water and soap, the correct and systematic elimination of feces, the use of nets to make children aged 0-5 years sleep every night to prevent malaria, management of diarrhea in children 0-59 months through the use of ORS/Zinc, recognition of signs of danger and early care, screening and management of acute malnutrition, feeding practices for teenage daughter, the pregnant woman, and lactating women.
Feeding practices, nutrition and health behaviors of mother and child depend in large part on knowledge, norms, values and beliefs that have their roots in ethnic and linguistic everyday practices. The main ethnic groups were included in the formative data collection processes for later use in the education materials (the Dendi, Betamaribé, Fon, Nago and Yorouba, Adja and N'Gnidé). To assure that normative issues would be captured, both fathers and mothers of children, adolescent girls, pregnant and lactating women were interviewed, as well as stakeholders at municipality level. The theoretical underpinnings were that malnutrition is a complex problem that has bearing on gender norms and requires behavioral, as well as environmental, changes.
The education sessions took place at least once per month by GANs with the support from NGOs. A series of communication tools were developed i.e. flip charts, image boxes, advice cards and posters. To intensify the process of change the education sessions were complemented with informal sessions. The communication strategy was based on a principle of making information sharing frequent, transparent and inclusive. Influential members of the community, including grandmothers, religious leaders, women and men with children were encouraged to talk about nutrition as often as possible to promote ownership and participation. An innovative approach of the project was to explicitly encourage community members to discuss nutrition related topics as a means of modifying norms around feeding practices.
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Box 2. Village Chief testimonial of change of engagement
Testimonial This is the story of a village chief who for several years was losing hope that anything would be gained from the community activities on nutrition. Then he heard about the case of the boy Bruno who was detected with acute malnutrition. All previous attempts to keep track of the child's health were unsuccessful by the parents even though his maternal grandmother had taken him to traditional care providers many times. When Bruno was screened by the GAN all attending women thought that there was no more life in him and that nothing could bring this child back to life. But thanks to the efforts of the project, the child recovered first at a recuperation center and then at home. Upon his return to the community the village chief made a commitment to personally follow this child and share with all his survival story as a testimonial to nutrition efforts made in the community.
Number of women with children under five trained and engaged in the production or transformation of diversified and nutrient-rich foods The community-based intervention addresses not only beneficiaries’ access to new services, but also transformative activities such as the production of local nutrient-rich foods. Due to the complexity of setting up a production system and preventing adverse effects in terms of work and time burden on women, this activity was initially delayed. Yet during the last year of the project this activity took off. The target of 9,000 women has been exceeded with a documented 16,435 women trained by the project on processing enriched flour to feed young children. In addition, the project has distributed 413,214 fruit trees (lemon trees and mango trees) to women in beneficiary communities. Women have received 2-3 trees each for long term contribution of making fruits more available to all children and contributing to a diversified and nutrient-rich diet.
Box 3. Production of fortified flour need engaged women who work together
Transformative change This municipality of Ouinhi is one of the first 21 municipalities benefiting from the project. A lot of training and behavior change communications have been carried out, but despite this the indicators of malnutrition are still high in all the villages of the municipality. In the implementation of the project training on the production of enriched flour was performed several times but the community has not really understood how to move this forward. Apart from family production for those who can and for culinary demonstrations, training on fortified flour has not been reaching the vulnerable families. Thus, in the last group of 25 women trained on the production of fortified flour they decided to unite and formed an association of women producing enriched flour, in order to help children with malnutrition in the municipality and elsewhere. This association is called CEBEDES-VITCHEGAN, which is also the name of their flour. The first flour production was released in November 2018.
The indicator “Exclusive breastfeeding (EBF) of children 0-6 months” is one of the most effective preventive measures of malnutrition. It is also one of the behaviors that globally is challenging to modify. The PDO indicator on “children 0- 6 months who are exclusively breastfed in targeted municipalities”, was measured through a Lot Quality Assurance Sampling (LQAS) survey at the end of the project to provide a more precise measurement of the intervention areas as compared to the previous DHS survey. According to the LQAS, the proportion of children exclusively breastfed has increased from a baseline of 33 percent to 75 percent at the end of the project. With a target of 45 percent, this
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indicator is well achieved.
All municipalities have exceeded the target of 45 percent but there are still many children who are not exclusively breastfed. In a couple of municipalities, it is only six of ten mothers who performed EBF until 6 months, which is still beyond the target but also reflects the long-term commitment that is required to achieve this behavior change. Beneficiaries are increasingly noting the benefits of EBF, such as good child growth, disease prevention, consolidation of the mother-child bond, and reducing expenses. However, mothers also experience constraints including delay in producing milk, concern that the child is not getting enough fluids and water is therefore given and demand from the older generation to give the child water or other foods. Continuous support to new parents is needed from mothers who exclusively breastfeed, GANs and healthcare providers.
The indicator on proportion of children being treated with ORT during episodes of diarrhea is another example of an indicator that captures behavioral changes towards individual children. In unpacking this indicator, it should be emphasized that the target is not dependent on diarrhea prevalence. The target set at 65 percent was achieved. The national estimate available at appraisal was lower than the results in the MICS a year later in 2014. This implied that the oral rehydration solution use had dropped significantly and thus posed a bigger challenge for the project than expected. This made it even more challenging for the project to achieve its target. Nevertheless, results from the LQAS in 2019 indicate that the target was met in all municipalities.
Beyond the achievements on the specific indicators, the project has contributed to the renewed focus on reducing stunting. In collaboration with other donors, UNICEF and the SUN movement, additional resources have been mobilized to intensify the development of human capital. Stunting being an important dimension in the Human Capital Index, reflects the timely investment in community nutrition.
The visibility of community nutrition in Benin has been strengthened through the project. The SUN movement has developed a global database with indicators related to decision-making towards transformative nutrition policy development. Benin has been rated with the highest score on several of the indicators, i.e. established multisectoral platform, undernutrition mentioned in development policies, funding of nutrition specific and sensitive interventions, Vitamin A supplements, prevalence of undernutrition and wasting. In addition, Benin is one of five countries with the highest availability of data. Benin reports on 95% of all the listed nutrition indicators. The system for collecting and reporting on nutrition data was not in place before the project started and the data availability can be attributed to the project. The improved results on the nutrition variables are also an achievement that the project has contributed directly to.
In conclusion, the project has achieved all expected results and surpassed many indicators including the PDO indicators. The TOC was well aligned to the evidence base of specific and sensitive nutrition interventions. In addition, at the more detailed level as to how to address the critical assumptions in the TOC, the interventions were well aligned to globally adopted theories on health promotion and prevention. One example is the effectiveness in linking health behavior messages to tacit understandings of gender and generational inequality. Finally, the implementation of participatory methods at community, municipality and national level is a major achievement towards building social accountability between beneficiaries, formal and informal community leaders, NGO and politically elected stakeholders.
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Justification of Overall Efficacy Rating The overall efficacy is rated substantial. The project has achieved all PDO and intermediate indicators and surpassed most of them. In addition, the project TOC is conceptually strong with high communicative validity towards all stakeholders interested in understanding the role of nutrition for development. The indicators capture different types of changes; some of the processes are about adjusting household behaviors while others include transformative changes in the institutional set-up as illustrated in the TOC. Many of the activities were not conducted before the project was effective and no other partner has intervened at the scale of the Bank in the selected beneficiary municipalities. It is therefore assessed that the main outcomes are ascribed to the contributions of the project.
C. EFFICIENCY The technical efficiency of the project was high. The interventions that were included were technically sound and evidence-based globally. The combination of developing the policy and institutional environment at national and municipality level (component 1) with creating demand of nutrition services at local communities (component 2) has been documented as being very cost effective in other countries with high stunting and wasting prevalence, e.g. Senegal, Malawi and the Gambia.
In 2006, 43 percent of children under age 5 were stunted, indicating that nearly half of Benin’s children were not able to earn as much as they would have if not affected by stunting. Thus, the benefits of reducing stunting in the project areas are measured by the increased income-earning capacity of the beneficiaries for whom stunting is prevented. Empirical estimates of the negative effects of stunting on worker productivity and adult earnings range from 10 percent to 20 percent (Granthan-McGregor et al., 2007; World Bank, 2006; Hoddinott 2003; Horton and Ross, 2003).
Intervening in the field of nutrition, specifically micronutrients and community nutrition in children under 5, is recognized as one of the world’s smartest investments globally and proven to generate returns among the highest of 30 potential development investments (World Bank 2006b) (see Table 5 below). The impact is so powerful that investments in micronutrients were rated above those in other areas, e.g. trade liberalization, malaria, and water and sanitation. Community-based programs are also cost-effective in preventing malnutrition, with benefit-cost ratios ranging from 5 to 200 (World Bank 2006). The Lancet series on maternal and child undernutrition (2018; 2016; 2013) recommended reinforcing healthy home care and nutritional support, with particular focus on the first 1,000 days of life in order to support children to have healthy and more prosperous futures. A World Bank study found returns on every dollar invested in nutrition are about US$4 for the wasting target, US$11 for the stunting target, US$12 for the anemia target and US$35 for the exclusive breastfeeding target (Kakietek et al. 2017).
An analysis of productivity losses over a period of ten years from anemia in women is estimated at US$670 million and US$636 million for anemia in children (PSDAN, 2009). Chronic malnutrition is estimated to reduce a person’s lifetime earnings by at least 10 percent. Similarly, a 1 percent loss in adult height results in a 2 to 2.4 percent loss in productivity. These economic costs and benefits are greatest for vulnerable populations. Benin’s per capita income is about 12 percent less that it would have been if none of its workforce had been stunted in childhood (Galasso and Wagstaff, 2017).
Implementation strategies were highly efficient in light of the steep scaling up of nutrition interventions from 10 to 40 municipalities. This is even more remarkable given the extended period when all procurement was blocked, delaying the signing of the NGO contracts. The failure of the Government to resolve this situation caused
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implementation progress to be downgraded to moderately unsatisfactory towards the end of 2015. Once the issue was resolved, the project was turned around thanks to strong local government involvement which had used the time to ready themselves and their communities to implement the program. All of the following factors contributed to a high intensity of project activities after the initial procurement delays: more than half of all municipalities were targeted; 16 NGOs were contracted; and stakeholders and staff in sector ministries received accelerated training.
Allocative efficiency of the project was substantial. After the team processed a restructuring in 2017 that allowed the use of unaudited IFR as the basis for withdrawal requests for the replenishment of the designated account, the scaling up of activities took off. A restructuring of the distribution between component 1 and 2, secured a complete allocation of the credit (99.9 percent) at the end of the project.
The sustainability of the decentralized multisectoral platform for the implementation of community-based food, health and nutrition interventions that were established with support of this project will depend on the continued level of ownership at the national, as well as the communal level, and the institutionalization and financial sustainability of the approach. The uptake of the activities in beneficiary municipalities and in non-beneficiary municipalities is very encouraging.
Table 5. Costs and benefits of project interventions on nutrition.
Intervention Cost Benefit Behavior change (through US$53 – 153 per disability- Reaching children in their communities secures higher community nutrition adjusted life-year saved (Ho, coverage than through facility-based interventions. behavior change 1985 in Tamil Nadu; Waters et communication programs) al., 2006 in Peru) Community-based US$41 per disability-adjusted Management in the communities strengthens the reach management of acute life-year saved (Bachmann, and compliance with feeding practices over the extended malnutrition 2009 in Zambia) time that treatment might be needed. Exclusive breastfeeding US$0.30 – 0.40 per birth to Infants who are breastfeed are six times more likely to support through six months promote breastfeeding survive, six times less likely to die from diarrhea and 2.4 (Horton, 2008) times less likely to die from acute respiratory infections in the first six months (Jones et al, 2003); breastfeeding is also associated with higher cognitive development (Horta and Victoria, 2013) Growth monitoring and No additional cost if included in May reduce child deaths before 36 months; and support a promotion community nutrition programs 15 percent reduction in prevalence of stunting at 36 months of age (Bhutta et al. 2008) Hygiene and hand washing No additional cost if included in May reduce diarrhea cases by as 30 percent (Horton, community nutrition programs Shekar, McDonald, 2010; Mason et al, 1999) Micronutrient US$0.20 per person/year for May reduce risk of low birthweight babies by 88 percent; supplementation flour fortification (Fiedler et al, Iodine for pregnant mothers can reduce risk of severe 2008); US$1.20 per child/year stunting by 27 percent; and increase child development for Vitamin A (Neidecker- scores by 10-20 percent (Bhutta et al. 2013); Vitamin A Gonzales et al. 2007); US$0.05 supplementation can reduce risk of child mortality (6-59 per person/year for salt months) by 24 percent (Horton, et al, 2008). iodization (Horton et al. 2008)
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The World Bank remained in a unique position to accompany multisectoral efforts to strengthen nutrition programming throughout the project period. The Bank continues a long-standing partnership with the Government, including the Core Group for Nutrition, the CAN and SP-CAN on the development of the national nutrition strategic plan, nutritional policies, the national SBCC strategy, and the M&E framework. Stakeholders within the Government see the World Bank as one of the key development partners supporting nutrition. Based on the assessment of project achievements, the technical efficiency rating is high.
The economic efficiency is substantial. The estimated benefits of the project exceed the costs, indicating that the project is a sound economic investment. Given the average 83 percent project coverage, 10 percent earnings premium from reduced stunting, no effect on stunting for better-off households, and 5 percent discount rate, the results of this economic analysis yields a net present value (NPV) of US$15,6 million and Benefit/Cost (B/C) ratio of 1.8 (See Annex 5, Table 4.5).
Assessment of Efficiency and Rating The technical efficiency was high, and allocative and economic efficiency is rated substantial.
D. JUSTIFICATION OF OVERALL OUTCOME RATING Applying the IEG ratings and the OPCS guidelines, the overall outcome rating is Satisfactory. The composition of the rating is shown in the table below:
Table 6. Overall rating of outcome Outcome Rating Relevance High Efficacy Substantial Efficiency Substantial Overall Satisfactory
The project has remained very relevant to the government of Benin throughout the project period. The project objective is integrated into several government policies and positioned as central to the development of Benin. The implementing agency has demonstrated commitment to advance nutrition in an integrated multisectoral manner.
Inclusiveness and participatory approaches have contributed to the outcomes achieved by all stakeholders. All indicators have been achieved and most of them exceeded. The indicators measure both coverage and utilization of nutrition services and cover fundamental and evidence-based outcomes for improved nutrition.
The technical efficiency of the project is rated high and the indicators to measure expected outcomes were very well chosen. They were built on theory and lessons learned in nutrition and captured implementation mechanisms that required multi-sectoral collaboration. The economic efficiency was rated substantial with a higher NPV than during appraisal.
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E. OTHER OUTCOMES AND IMPACTS (IF ANY)
Gender The project has been implemented through a gendered lens from appraisal to closure. One of the critical assumptions in the TOC was that the social and behavior change communication (SBCC) strategy should be tailored to social and gender norms. As a response, a comprehensive gender study was conducted that later informed the design of activities at the municipality level. In addition, a series of dissemination events took place at municipality level. A high-level meeting on the role of gender and nutrition was held at the national level.
In the communication strategy that was developed just before project start, one of the main guiding principles is gender equality. Gender-based differences in opportunities have been made visible through the project as a first step towards acknowledging and transforming them.
Institutional Strengthening During the last ten years the progress in positioning nutrition as a prerequisite of development in Benin has been significant. In terms of the number of policies that have been developed and validated by the government of Benin, the development curve is very steep as shown in the table below:
Table 7. Benin nutrition country profile in terms of institutional and legal frameworks
Policy Start Date End Date Directives nationales pour la surveillance de la croissance et du développement de 2016 --- l’enfant au Benin Plan de Renforcement de L’Allaitement Maternel au Benin 2016-2020 2016 2020 Plan d’actions de la Politique du Secteur Santé pour la Nutrition 2016-2020 2016 2020 Plan cadre des Nation Unies pour l’Assistance au Développement UNDAF 2014 2018 Plan Stratégique Intégré de Lutte contre les Maladies Non Transmissibles 2014-2018 2014 2015 Growth and Poverty Reduction Strategy 2011 Plan Cadre des Nations Unies pour l’Assistance au Développement du Benin (UNDAF 2009 2013 2009-2013) Plan Stratégique de Développement de l’Alimentation et de la Nutrition 2009 --- Act n° 98-019, Social Security Code 2003 --- Act n° 98-004, Labour Code 1998 --- Décret portant réglementation de la commercialisation des substituts de lait maternel 1998 --- et des aliments pour nourrissons (Décret n° 97-643) Plan D’Action National Pour L’Alimentation et La Nutrition 1993 --- Source: https://extranet.who.int/nutrition/gina/en/policies/summary
The project has directly contributed to the development of several of the polices through capacity building of the SP- CAN and all its collaborating partners (as part of component 1).
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The visibility of nutrition as a key issue in human and economic development is a major achievement within the project period. At appraisal, doubts about the gains of investing in nutrition were still expressed frequently at the national level. Uncertainty about the difference between food and nutrition was also prevalent. CAN took on this challenge even in the choice of its organization’s own name. Recognizing that labeling of new institutional structures matter, and with the ambition to create a strong multi-sectoral collaboration, the decision of having both the word “food” and “nutrition” in the name was a strategic choice to create broad ownership.
Building nutrition capacity in all existing institutional structures from the local villages to national level is a major achievement of the project. While building capacity and employing participatory methods, especially in the mobilization of the municipalities resulted in initial implementation delays, this investment has a good chance of sustainability.
According to the Global Nutrition Report (2018) Benin is one of only 35 countries on track to meet two of the nine global targets: child overweight, child wasting, child stunting, exclusive breastfeeding, diabetes among women, diabetes among men, anaemia in women of reproductive age, obesity among women and obesity among men. This is compared to only 15 countries being on track to reach three or four of the global targets.
Mobilizing Private Sector Financing -
Poverty Reduction and Shared Prosperity Children who are not stunted have a 33 percent higher chance of escaping poverty. Through the promotion of nutrition and the prevention of malnutrition, the project has contributed to reduce poverty for current and future beneficiaries.
The project has invested a lot of time and effort in coordination of projects and initiatives in order to use resources as efficiently as possible. The intervention municipalities were initially selected based on high malnutrition burden; see Map 1 below. In addition, maps have been generated to show the distribution of other projects per municipality as shown in Map 2 below.
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Map 1. Overview of intervention Municipalities Map 2. Overview of nutrition interventions
Source: SP-CAN 2018
Other Unintended Outcomes and Impacts The establishment of CCCs is not a new idea in Benin. They have been used in various areas of development in the municipalities. The issue of ownership and sustainability of these committees is essential, especially in nutrition as it is a multi-sector collaboration platform with many stakeholders for who priorities may change over time. The level of activity and ambition of CCCs are typically reinvigorated through inputs from projects; that is most likely also the case for the CCCs on nutrition. However, as municipality capacity matures, the CCCs for nutrition are meant to integrate into the broad consultative committees on municipality development that are being put in place under the decentralization policy.
The project has mitigated the risks of project dependency through several strategies: (i) mobilization of municipalities through participatory approaches that built on existing activities and structures in the municipalities, and the provision of capacity training that was adjusted to individual needs with a focus on M&E; (ii) development of partnerships through regular and systematic interaction with SP-CAN at regional and national level with the municipality council, the public service providers and the lead NGO; (iii) introduction of leadership coaching to
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strengthen and broaden the capacity of municipality leaders in nutrition; and (iv) development and/or strengthening of community-based structures to create demand for improved nutrition services in each beneficiary municipality.
The municipality presence of the lead NGO has contributed to the establishment of a strong and credible working relationship with the mayor, the municipality council, the nutrition focal points and the public sector service providers in each of the municipalities. This enhanced the effective skills transfer from the lead NGOs to municipalities. Other NGOs and community-based organizations (CBO) in the beneficiary municipality are also involved through the CCC, thereby contributing to the development goals of the municipalities.
Commitment by the municipalities is reflected in the integration of nutrition in the 3rd generation Municipality (Commune) Development Plans (CDPs) with budget lines in the 2018 Annual Investment Plans (AIPs). Budget allocations are at least 2 million CFA francs (up to 5 million CFA francs) per municipality per year. This allowed the municipalities to support functioning of the CCC and the monitoring of certain nutrition activities. These amounts are still well below the real needs of the resources needed to promote good nutrition, but they illustrate a progressive improvement in the beneficiary municipalities during the project period. The SP-CAN and the ANCB are also working with the: (i) Ministry in charge of decentralization and local governance to create a budget line for nutrition in the CDPs and AIPs; and (ii) National Commission for Local Financing (CONAFIL) to create a nutrition investment window in the Municipality (Commune) Development Fund (FADeC), which will further enhance the financial sustainability of nutrition programs at municipality level.
With the Bank’s commitment of the SOP on Early Years Nutrition and Child Development Project there are opportunities to advocate for, test and consolidate these changes.
III. KEY FACTORS THAT AFFECTED IMPLEMENTATION AND OUTCOME
A. KEY FACTORS DURING PREPARATION The readiness for a scaled-up investment in nutrition was confirmed by nutrition stakeholders. Several conditions were met: (i) the Government of Benin had nutrition policies and strategies in place (Programme National de Nutrition Axé sur les Resultats, PNAR and Plan Stratégique du Développement de l’Alimentation et de la Nutrition, PSDAN); (ii) these were aligned with global evidence on effective nutrition inventions; (iii) a multisectoral coordination structure, CAN, was set up with a budget line; (iv) an operational team in the SP-CAN was being set up. Technical staff were increasing in numbers and with relevant professional profiles, e.g. specialists in communication and monitoring and evaluation among others; (v) Benin had become a member in the newly established SUN- movement; (vi) the CGN had also managed to finalize an integrated Communication Plan for Food and Nutrition (PIC; “Plan Intégré de Communication”) in 2010; and finally, (vi) a Food Fortification Commission (CBFA; “Commission Béninoise de Fortification des Aliments”) had been established as part of an agenda for commercial food fortification in 2009. In 2012 as the project became effective the Commission issued a national inter-ministerial decree for the fortification of oil (with vitamin A) and wheat flour (with iron, Zinc and vitamin B).
The project was designed on the lessons learned from the pilot Community Nutrition Project (CNP). The implementation strategies of building municipality-level nutrition capacity through CCCs and the outsourcing of community mobilization to one lead NGO per municipality had been successful in the ten pilot municipalities. The CNP-contracted NGOs were expected to continue and thus safeguard the gained experiences. There was some
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uncertainty on the availability of high-quality NGOs in the new municipalities. A sequential scale-up plan was therefore developed to secure a high-quality mobilization process of all 40 municipalities.
Municipalities were inexperienced with contractual arrangements of NGOs and peer influence on municipality authorities was considered important in the scale-up municipalities. Collaboration with the ANCB was therefore prioritized in order to facilitate the strong inter-municipal leverage they had on municipality authorities.
An Institutional Development Fund (IDF) grant had been mobilized to support CAN in development and implementation of nutrition policies and programs, notably in the areas of coordination, learning, monitoring and evaluation, resource mobilization and fiduciary management in early 2013. The grant made preparatory activities possible for the newly established CAN including a South-South study visit to a community driven project, development of visual tools for the integrated communication plan that had been finalized, and training of fiduciary staff.
Outside the immediate nutrition community, there was limited knowledge and understanding of the causes of malnutrition and of the effectiveness of community-based nutrition interventions. There was a need to create more visibility of nutrition issues, even though nutrition already had been placed prominently in the GPRS; and the CAN was housed under the President’s Office. To increase awareness of the project, several high-quality studies were planned with the intention of creating comprehensive dissemination events at national and municipal levels early in the project period.
There was a clear preference within the nutrition community to use participatory implementation strategies. This required (i) regional SP-CAN coordinators in order to intensify interactions with municipality level nutrition stakeholders; (ii) early selection of nutrition focal points in each municipality to facilitate ownership and integration; (iii) a plan for reaching out to relevant informal and formal traditional leaders in the different ethnic communities in each municipality; and (iv) flexibility in developing different sub-projects and using diverse mobilization strategies in each municipality based on the nutritional and food security situation in each location.
B. KEY FACTORS DURING IMPLEMENTATION
Factors subject to World Bank control The WBG team worked closely with the Core Group for Nutrition, the CAN and the SP-CAN throughout the project period. The collaborations included targeted support for the development of the analytical studies, several policy documents including the national nutrition strategic plan, and the national SBCC strategy. These documents have been well tailored to the implementation mechanisms of the project and have improved the conceptual thinking as well as indicating the next steps.
The WBG team hired several consultants to assist the SP-CAN with various technical aspects of implementation, including gender, communication, organizational development, and M&E. The technical assistance combined with the frequent organization of implementation support missions helped contain the organizational delays from which the project suffered during the initial years of implementation.
The mid-term review focused on the institutional development and behaviors which included setting up collaborations with NGOs and CCCs. The review confirmed that the institutional developments were promising. This
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finding also confirmed that no major changes in the results framework were needed and paved the way for the team to carry through with minor adaptations of the indicators on implementation mechanisms in the communities.
The longer-term commitment of the Bank was confirmed when a series of projects (SOP) on early-years nutrition and child development project was approved by the Board in the spring of 2019. The SP-CAN was supported by the WBG team in the preparations of this project at the same time as the current project was scaled-up to all 40 beneficiary municipalities and the SBBC was intensifying in all regions.
Factors subject to the Government of Benin and/or implementing agency control After effectiveness, the project experienced a six-month delay in satisfying the dated covenants, notably: (i) the recruitment of a Technical Assistant on Financial Management; (ii) the recruitment of an internal and external auditor. A major constraint was the lack of office space for SP-CAN. For over a year, the SP-CAN staff worked from home, from the Bank office or a room they borrowed from another project, until in October 2014, the Government finally assigned office space to SP-CAN. The lack of office space was a major factor that slowed implementation down during the initial period. Another factor that slowed implementation down was when the Technical Advisor on Agriculture in the President’s Office was dismissed as part of institutional reforms. The Technical Advisor was the representative of the President’s Office in the CAN, as well as the approving authority for all project procurement. Without the approving authority for project procurement in place, all procurements were put on hold as the project with support from the Bank tried to find a solution. This issue caused a six-month delay for several major procurements including the baseline survey, and the contracting of NGOs for the first batch of 21 municipalities. This delay in the signing of the municipal sub-projects until 2016 affected the implementation progress of component 2. This also meant that the activities in the ten pilot CNP municipalities were paused during several months. The delay in hiring the firm responsible for the baseline survey meant that data collection started after implementation of community activities had already started. As a result, the survey which was completed in 2017 became a situational analysis rather than a baseline survey.
Following the arrival of a new President in 2016 there was some confusion on the project budget being under the President’s office rather than a ministry. Accordingly, there were initial instructions for the budget to be moved to the Ministry of Agriculture even though the budget was for the project implemented by the SP-CAN which was part of the President’s Office. The process was monitored closely until it was clarified that the budget belonged to the President’s Office for project implementation by SP-CAN.
The beneficiary villages were selected through a data driven process. A series of open-ended discussions were set up in each beneficiary municipality to ensure common understanding of the municipality’s nutrition development challenges. Beneficiary villages were identified based on their food and nutrition insecurity in addition to their poverty level. A total of eleven indicators were systematically analyzed and discussed in each municipality. This provided an opportunity for SP-CAN, the lead NGO in each municipality, and the mayor’s office to form a common understanding of the diversity and the challenges in each municipality. It thus served as a tool to select the relevant villages but also as a pedagogical strategy to demonstrate what kind of participation and process thinking that would be required from the beneficiary municipalities. This initial process has contributed to the ownership of the project at the municipal level.
Investing in nutrition is becoming normal at the municipal level. All 77 municipalities have now expressed commitment to nutrition in their new Municipal Development Plans and nutrition leadership training has been
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completed. The municipality of Cotonou has independently developed a Common Results Framework and has formalized its multisectoral coordination committee (CCC). This indicates the high relevance of the project and that it is well aligned to local contexts. The mayor’s offices have been instrumental in formally establishing CCCs on nutrition; developing and implementing work plans in beneficiary villages. ANCB has supported the municipalities with capacity building and also through incentivizing the best multisectoral practices through an annual competition. Active participation by public service providers from the three key sectors, health, social protection and agriculture, has not been developing in the speed that was expected. A more systematic and monitored process of the horizontal capacity building in the CCC of which the public service providers are part, as well as the vertical capacity building through the sectoral service delivery system could have been designed and implemented.
The PDO has been achieved as a result of the following key developments and decisions:
(i) Commitment of the CAN and the SP-CAN to advance nutrition through multisectoral coordination has contributed to the progress and increased visibility of nutrition. The collaboration with the Ministries responsible of Health, Social Protection and Agriculture, has strengthened the delivery of nutrition services. The complementarity in offering both facility-based and community-based growth monitoring activities is one example of the integrated approach that the project has achieved; (ii) Phased implementation process with initially 21 municipalities followed by 19 municipalities, was well designed and adjusted to the management capacity in the SP-CAN; (iii) Regional SP-CAN coordinators have facilitated the collaborations between regional stakeholders. They have been instrumental in mobilizing the Regional administration (Prefecture); (iv) Use of multiple mass communication channels has increased parents’ exposure to key nutrition messages. Community radio stations on local languages have been extensively used in some of the municipalities and formalized collaborations have been developed between the cultural division in the municipality, traditional leaders and the project.
The mechanisms of accountability of public services were very limited for individual households and GANs in the communities. The project has initiated processes where beneficiaries can express their level of satisfaction, for example in the interaction with NGOs, through local leaders who are member of the CCC, and regional SP-CAN coordinators. The Government developed a Community Score Card to assess feedback on the services in the Municipalities in the last year of the project which was the only formalized mechanism.
Social norm formation of nutrition-relevant behaviors and practices has been addressed in multiple ways throughout the project period. Changing gender norms at community, municipal and national levels is a complex and longer- term process. Women’s opportunities for decision making at household and community level were found to be limited in the gender study finalized by CAN in 2016. The project has called for women’s empowerment. One concrete example is in relation to the promotion and production of diversified foods. An initial constraint was that production decisions were considered a male task. Visual materials on the consequences of gender inequality are often used in the project, yet the gender inequalities are profound at all levels. Village chiefs in the more than 1,200 beneficiary villages are male; only two female mayors exist in the country and the same imbalance is noted at the national level in elective and professional positions. This also includes leaders in NGOs and associations.
Socio-economic inequality and ways to mobilize and support the most vulnerable households in each community remain a challenge for the longer-term goals of reducing stunting and child mortality. Testimonials from individual
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beneficiaries indicate that the social and financial support make a difference for the poorest households when a malnourished child needs treatment. NGOs report that the poorest households are difficult to support since they typically face multiple risks of income and asset loss that are constraints for keeping children well-nourished and healthy.
IV. BANK PERFORMANCE, COMPLIANCE ISSUES, AND RISK TO DEVELOPMENT OUTCOME
A. QUALITY OF MONITORING AND EVALUATION (M&E)
M&E Design The project developed and used a comprehensive national multisector nutrition routine monitoring and evaluation system that focused on: (i) monitoring the community and municipality-led activities; (ii) measuring the progress towards achieving the outcomes; and (iii) motivating stakeholders at all levels to analyze the progress of the project; and (iv) measuring the outcomes of the program on key health and nutrition outcomes.
The PDO was easy to communicate to stakeholders with its focus on coverage and utilization of nutrition services and the indicators therefore focused on practice and behavior. The indicators were selected to capture different types of outcomes along the pathway of change (see Figure 1 on the TOC). About half of the indicators had baseline values from the earlier nutrition project, CNP, or from the Ministry of Health. The remaining indicators were new and designed to monitor innovative aspects of the project and started therefore with baseline data equal to zero.
The M&E system was designed to engage as many stakeholders as possible. This reflected the objective of building a multisectoral nutrition platform and the indicators monitored results at all levels – from the community mobilization of women and children, GANs, Municipalities, and sector ministries to the President’s Office. It was a strategic choice to facilitate the visibility of nutrition and to demonstrate that nutrition indicators could be improved during a relatively short period of time. This focus on engaging stakeholders in the M&E was assessed as important to improve the understanding of a data-centered project implementation.
M&E Implementation Multiple sources of data, data collection methods and agreements on responsibility were developed, including a community registry, municipality and NGO reports, supervision reports and surveys. There was no rigorous base- and end-line survey with beneficiary and non-beneficiary groups conducted. A baseline was planned for the 40 beneficiary municipalities but faced multiple delays as a result of contracting problems with a private company that was to conduct the data collection and lack of detailed knowledge of the approval process in the government. Due to these delays, baseline data was not collected and the opportunity of comparing indicators at endline was lost. When the delays were overcome and data could be collected, the team opted for a survey that was renamed to a Situational Analysis. It served the purpose of developing nutritional profiles by municipality for the first time in Benin, and this experience became instrumental for the capacity building of data driven nutrition decisions in the CCCs.
During and at the end of project a Lot Quality Assurance Sampling (LQAS) survey was conducted in the 40 beneficiary municipalities. The LQAS was not originally planned for but was added to (i) secure a comparison with the data in the Situational Analysis; and (ii) to develop municipality level capacity to implement this type of methodology. The LQAS
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thus served the purpose of data collection but equally important as a test to verify if municipalities could implement systematic data collections.
A package of M&E tools had been developed, finalized and disseminated to the municipalities in line with the time plan. During the initial village selection in each municipality, the data driven approach was initiated through an inclusive and consultative process. The Mayor’s office worked in collaboration with the lead NGO in each municipality, municipality stakeholders and SP-CAN staff in synthesizing food insecurity and poverty data. Villages were ranked based on 11 indicators and provided the municipalities with a first overview of the nutritional vulnerability profile in their municipality. Only minor changes were made to the results framework. During the mid-time review the implementation of the framework was assessed, and smaller changes were made to clarify the mechanisms of the intended outcome; the added PDO-indicator on community volunteers (GAN) exemplifies this.
M&E Utilization SP-CAN has worked intensively with beneficiary municipalities to develop and use a system that collects routine data on key nutrition indicators. The CCC in each municipality is responsible for the results framework at municipality level and the NGOs have provided support to the systematic collection and analysis of the data. The case of Vitamin A supplementation serves as an example of the value of the community registry. During the project a start was made to change the vitamin A supplementation services to be provided on a routine basis and thus directly recorded in the community registry. Parallel to the routine basis the services were provided by the Ministry of Health on a campaign basis, which made monitoring of the indicator more challenging. GANs in the beneficiary communities are being trained to be responsible for collecting data on key indicators related to the community-based growth monitoring and nutrition education activities, but the need for capacity building in M&E in the communities remains substantial.
Justification of Overall Rating of Quality of M&E The design of the M&E was clear and coherent and aligned with the TOC. The system was designed to generate information on the main implementation mechanisms at community, municipal and national level. The implementation of the baseline survey was delayed for more than one year, which limited the monitoring of trends by municipality to the last two years of the project. For the end-line, the objective was shifted to capacity strengthening of the municipal stakeholders. The municipalities successfully implemented the LQAS and are able to conduct new surveys in the future. This is a major capacity strengthening achievement. A new Early Years project that builds on the MFHNP is already effective and as part of the new project, a household survey is being conducted in all beneficiary municipalities. The results are not ready for the assessment in the ICR but will be of great value for the beneficiary municipalities. Based on these processes, the overall rating of the M&E is substantial.
B. ENVIRONMENTAL, SOCIAL, AND FIDUCIARY COMPLIANCE
Environmental safeguards No environmental safeguards were triggered in the project that was labeled as a category C.
Social safeguards The main focus of the project is on social and behavior change of key household practices at the community level. Many social and cultural practices in relation to nutrition differ between local communities which pose a challenge to the intended changes of the project. To maintain respect of local practices yet advocate for gender equality and
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women’s empowerment, a comprehensive gender study was conducted in the beginning of the project. The study was instrumental in starting a dialogue on the high work burden of women and the absence of fathers in most activities related to the nutrition of children. Additional operational research and workshops with multiple stakeholders, have contributed to the understanding of barriers and facilitators of social change in relation to nutrition.
Fiduciary compliance The overall Financial Management (FM) risk at preparation of the project was rated substantial due to the limited experience of IDA-financed projects at the SP-CAN and the complexities in setting up disbursement mechanisms for the municipality-led subprojects for community-based activities. The rating of FM at end of project was rated Satisfactory after a period of being rated Moderately Satisfactory. Initially there was a delay in hiring an internal auditor. The FM capacity was strengthened during the project period through the recruitment of technical assistance that has trained a SP-CAN’s FM officer who served as the project FM specialist. At the end of project, the SP-CAN was staffed with: (i) one civil servant as FM Specialist in charge of the supervision of all FM activities of the project; (ii) one civil servant as Accountant; (iii) one civil servant as procurement specialist; and (iv) six regional accountants competitively recruited.
During the project period the project changed the disbursement application from a system based on statement of expenditures to a system based on unaudited interim financial reports, which required a higher FM capacity at the SP- CAN. SP-CAN has developed and used a procedures manual that includes detailed budgeting procedures and the preparation of annual work plans which has been implemented in accordance with the plans. The project has disbursed 99.90 percent of the funds at the end of project.2
Initial procurement delays of more than six months of major procurements, due to the absence of the approving procurement authority in the President's office, was solved through a clarification from the National Procurement Agency that the procurement responsibility rested with the SP-CAN. Internal audit arrangements were initially delayed but once they were established they have been implemented in accordance with Bank standards. The Interim un- audited Financial Reports (IFRs) have been satisfactory to the World Bank.
C. BANK PERFORMANCE
Quality at Entry The highest standards were applied to the identification of risks, the consultative preparation and final appraisal of the project. The WBG team was very experienced in designing community nutrition investments; had established strong collaboration with nutrition stakeholders within government, donor community and civil society during the CNP (P124191), the Technical Assistance (TA) project (P109724) and the institutional development project (P131975). The progression from a TA to an IDA credit indicate the high relevance and quality of the chosen project. The TTL of the technical assistance project stayed on board and has designed, facilitated and reported on the project during the whole period. This continuity has contributed to the success of the project which was innovative at the time and rather ambitious in trying to roll-out community-based activities and simultaneously engage in institution-building at
2 The difference with the figures in the data sheet are due to exchange rate differences between SDR and US$ at the start and end of the project
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the national and municipal level. When the implementation arrangements were decided and the Government placed the project in the relatively newly established CAN under the President’s Office, the team’s understanding of the history of nutrition and the institution building processes, directly contributed to the determination of reaching the development objectives. Communication strategies and M&E planning were two elements that were prioritized in order to generate results and support for nutrition work.
The WBG team’s understanding of the importance of addressing geographical targeting of poverty and food insecurity, women’s empowerment, and inter-generational power dynamics contributed to the emphasis on developing an inclusive and transparent mobilization process of municipalities. These processes are time consuming, but the team supported SP-CAN in this initial investment of time and resources to generate ownership of the project at the municipality level.
Quality of Supervision The project was effective within two months and well before the deadline set at four months following the signing of the agreement; the mid-term review and project closing were implemented according to plan and a follow-on investment project (the first of a SOP) has been developed and is already effective before the project closed. The team has provided regular and structured supervision-missions, and these have been documented in Aide-Memoires that have emphasized the positive achievements as well as results-based action points. The task team monitored the project performance closely, communicated timely through supervision and technical assistance missions as well as videoconferences, demonstrated candidness in up- or downgrading of implementation progress, and was proactive in conducting three minor restructurings to secure the development objective.
The factors that initially delayed project implementation were monitored closely. In addition, the WBG team provided support to SP-CAN in order to overcome obstacles regarding office space and procurement and delays in hiring of internal auditor and FM technical assistance. Also, the WBG team was proactive in their partnership with the SP-CAN by developing and/or revising plans to overcome obstacles, which has facilitated implementation delays to be kept to a minimum and push the project’s agenda forward.
A series of methods have been used to strengthen the capacity on how to progress at all levels: (i) the WBG team provided support from a core team of specialists in FM, procurement, M&E, communication, community-mobilization to SP-CAN throughout the project; (ii) the SP-CAN with support from the WBG team developed a results-based coaching strategy strengthen leadership for effective nutrition action at municipality level; (iii) SP-CAN developed reporting formats for NGOs and municipalities in order to strengthen the results-based strategies; and (iv) SP-CAN organized peer-learning opportunities for CCC and GAN. and (v) SP-CAN organized Encouragement at all levels to experience the realities in the field through joint supervision missions with different stakeholders with the various CAN members to encourage at all levels (municipality, prefecture, national) to experience the realities in the field. These field visits have often been followed up by adaptive management discussions in order to distill the challenges and most effective solutions.
The team has secured a longer-term commitment of the Bank to nutrition improvement in Benin. The first of three phases in the SOP was approved in February 2019. The new project expands on the community-based nutritional services and include parenting education, community spaces for child stimulation, protection and learning. Targeting of poor families, citizen monitoring of services, and operational learning on how to maximize the cost-benefit of interventions are also addressed in the project.
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Justification of Overall Rating of Bank Performance The overall rating of Bank performance is rated highly satisfactory. The results-driven approach of the core WBG team has engaged the SP-CAN and the municipalities to deliver beyond the PDO targets. During moments of uncertainty of selecting the best practice, the team has promoted an atmosphere of learning by doing. This pragmatic attitude has fostered self-regulation at the level of SP-CAN and an understanding of the strengths and limitations of their capacity. The diversity in the type and number of stakeholders currently engaged in nutrition is an indication of a conducive policy and inclusive practice environment.
D. RISK TO DEVELOPMENT OUTCOME
Technical: Transfer of skills in relation to the achieved outcomes in communities is continuously needed when new women become pregnant and new babies are born. The mobility of the population, particularly in the many municipalities along the border, with new women and children moving in and out of beneficiary municipalities is another challenge for the community-based intervention. SP-CAN has extensive experience with financial management, M&E and other aspects central to successful implementation.
Social: Trust in the project development objective has been built with beneficiaries at all levels. SP-CAN and other stakeholder in the project recognize that if trust is lost, it is very difficult to rebuild. The project has gained credibility in offering preventive services by providing at the same time support to children in need of treatment. These services are provided at community and health facility level and are the result of the strong collaboration with the Ministries responsible of Health and Social Protection in the CAN. The project outcomes can only be maintained through continued support from a variety of different sectors and a package of integrated services delivered by diverse stakeholders. Effective engagement of municipalities and communities is essential for coordination, implementation and monitoring.
Economic: Nutrition is an investment in the most vulnerable period of the life cycle. Some municipalities are contributing financial resources to the community-based work albeit at low levels. Additional public funding will be required to reduce stunting and mortality in the long term.
Political: The historical background of an institution matters for its resilience - this project has contributed to writing the history of CAN but the institutional roots are still young. Benin is known for its stable democratic system as compared to many other West African countries; nutrition is increasingly mentioned in development policy documents; the CAN has remained in the President’s office also after one election. Benin has remained a member of SUN since 2011 and strengthened its membership and participation in high level events during the course of the project period. The political commitment seems to be stable.
Environmental: The exposure to natural shocks in the form of drought, floods, pests are expected to rise as a result of climate change. Increased food insecurity, increased water shortage and challenging water and sanitation conditions for families are growing risks. The project has contributed to mitigate against these risks by supporting the planting of fruit trees and training on the production of nutritious foods which is one adaptive strategy towards climate change.
Ownership: Multisectoral collaboration can only be as strong as its weakest part, which makes this type of process exposed to multiple stakeholders’ own agendas. However, loss of ownership at community, municipality, or national
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level is unlikely given the commitment of the Government in partnership with the Bank to continue investing in nutrition. The main strategy is to strengthen the existing multisectoral coordination arrangements for nutrition, and CAN has proven to be able to coordinate complex strategies and policy reforms which involve many partners. The municipalities with the mayor’s in the lead has increasingly shown ownership of the objectives and the risks or reversing these achievements have reduced over the years of project implementation.
V. LESSONS AND RECOMMENDATIONS
Lessons Multisectoral coordination of nutrition policy require continuous visibility and participation in ongoing national level policy processes. When pushing for a paradigmatic shift in managing nutrition deficiencies in a context where the nutrition agency CAN is still relatively young, there is a need for high-level support, studies, and communications to prevent the issue from being sidetracked. SP-CAN has arranged high level meetings to create attention; CAN members can strengthen visibility of nutrition deficiencies and their impact on human development in the sectors and associations they represent. The documentary on nutrition engagement produced by the ANCB, and a recent SUN movement letter to the President of Benin are examples of activities that support the vision of CAN in ascribing weight to nutrition.
Capacity building for decentralized management of service delivery to communities through the consultative committees at municipality level imply in-depth knowledge and understanding of the general functioning of the municipality. The best performing CCCs were in municipalities that were well-organized, where stakeholders were many and engaged, where the Nutrition Focal Point was recognized as highly skilled and where the mayor was engaged.
The success of community-based nutrition programs to reduce stunting, depends on the institutional arrangements, from national to community levels. The understanding of multisectoral collaboration and the need of proximity of support to all implementing partners, notably communities, is essential. Encouraging an adaptive management approach through processes of “learning by doing” within the multisectoral collaborations, create trust in capacity building of nutrition. This approach has resulted in the development of multisectoral collaboration at the regional level (Département), which forms the basis for further upstream mobilization of nutrition investments.
A progressive development of M&E capacity of the municipalities and communities for routine data monitoring improved the motivation and skills of data driven decision making. Moreover, municipalities differed in capacity due to different prior experience with M&E, skills level within the Mayor’s office, and the Mayor’s ability to establish a working relationship with SP-CAN and the lead NGO. High implementation quality required navigation of simultaneous capacity strengthening of all stakeholders at all levels. Focal points, NGOs, GANs all needed close monitoring at the beginning of the project in order to be effective in their actions. A phased scaling-up process can facilitate high quality in all locations.
Local government ownership of the project is equally important as community mobilization. Fostering formal partnership within the CCCs is the backbone of the municipality level multisectoral platform. However, the CCCs are also useful for wide-ranging exchanges and sharing of information between the heads of decentralized services at the municipality level, who otherwise rarely meet. Mayoral commitment to continue supporting the CCCs is influenced by coaching support from SP-CAN and the ANCB, and by framing nutrition improvements as an integrated part of the
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development of the municipality.
NGOs contributed to the development of a nutrition narrative in the municipalities that collaboration across sectors and actors, based on nutrition data, strengthens the outreach to communities. Initially, the NGOs secured that the conversation on the severity of malnutrition was intensified, that risk and protective factors were made tangible and operational. The challenge is to assure that NGOs continuously transfer capacity through clear leadership by the SP- CAN.
Social mobilization of opinion leaders, media and other actors to promote nutritional change in households and communities, affect parents’ willingness to adopt improved practices on nutrition. The communication of key messages on early initiation of breastfeeding, length of breastfeeding, child spacing and distribution of work burden between men and women all have practical and normative implications for families. Social change can be promoted in a culturally and socially sensitive manner and still achieve the results intended. The use of NGOs with long-standing presence in the communities facilitates the translation of global evidence-based nutrition practices to locally accepted solutions. A pragmatic approach to the mobilization of traditional leaders to help with the transmission of key messages they believe in is a balancing act that requires trust in the project and profound understanding of their belief system and public discourse.
The community mobilization, organization and empowerment of community support groups builds on the trust and power in communities themselves. Effective communication for behavioral change requires the development of key messages on improved behaviors that are aligned with existing cultural models of malnutrition. Local testimonies of positive deviance of for example exclusive breastfeeding for 6 months or resilience under periods of food insecurity, are powerful in generating community narratives on responsibility of maternal and child health and nutrition. The social fabric of everyday decisions can be influenced through systematic, inclusive and participatory partnerships. The community support groups are voluntary and, for that reason alone, vulnerable over time, highlighting the need for continued support from village chiefs to be effective.
There is a window of opportunity of taking stock on the lessons learned of the Bank’s engagement with client countries on nutrition. This project has important dimensions such as: (i) multisectoral interventions; (ii) implementation autonomy at community level; (iii) strong institutional strengthening at all levels; and (iv) reliance on a Government structure directly attached to the Presidency (i.e., not directly reporting to a specific ministerial line). These approaches differ significantly from the standard mode of support for nutrition within the health system strengthening projects. With the increase in the number of projects designed and implemented around human capital, the lessons learned from this type of project could advance the agenda on community driven development. The Bank engagement from the initial NLTA to the longer-term SOP is in line with the recommendation on longer-term commitment between the Bank and clients.
Recommendations Communities must be seen as capable of social change, thus transfer of skills from nutrition stakeholders must be intensified. The borrower should monitor closely that progression of skills to communities are executed.
Formalizing partnerships with change agents such as opinion leaders and media can intensify nutrition and health promotion as well as prevention to all women and children and should be strengthened. Efforts should be made so
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that local journalists have access to the latest information from the CAN and beneficiary municipalities.
The continued visibility of nutrition at national level requires human resources at the SP-CAN and all other levels. When positive or negative developments occur on the nutrition indicators at community, municipality or national level, all stakeholders at the respective level should be informed and engaged to increase the communication on nutritional changes and challenges.
Malnutrition is still a recurring health problem that constitutes a significant threat to the wellbeing and development of children and women. The developed protocols for diagnosis and treatment must be used at health facilities to ensure the protection of women and children in the most vulnerable phases of their lives.
The borrower should facilitate interaction between the national and local government structures on nutrition and encourage sector ministries to create budgetary space to strengthen their contributions to local levels. The municipalities should ensure that the progressive financial contributions to the nutrition activities continue to increase. The Bank should support financial capacity building in the municipalities.
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ANNEX 1. RESULTS FRAMEWORK AND KEY OUTPUTS
A. RESULTS INDICATORS
A.1 PDO Indicators
Objective/Outcome: Increase the coverage and utilization of community-based growth and nutrition interventions Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Children 0-23 months who Percentage 0.00 25.00 91.80 benefit from a minimum package of monthly 14-Nov-2013 31-Jul-2019 31-Jul-2019 community-based growth promotion activities in targeted Communes
Comments (achievements against targets): The outcome has surpassed the target many times.
Source: Project Monitoring System
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Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Women with under-five Number 0.00 9000.00 16435.00 children trained and engaged in the production and 14-Nov-2013 31-Jul-2019 31-Jul-2019 transformation of diversified and nutrient-rich foods
Comments (achievements against targets): The actual outcome has surpassed the target by 83%.
Source: Project Monitoring System
Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Children 0-5 months who are Percentage 33.00 45.00 75.00 exclusively breastfed in targeted Communes 14-Nov-2013 31-Jul-2019 31-Jul-2019
Comments (achievements against targets):
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The actual outcome has surpassed the target and more than doubled from the baseline.
Source: Lot Quality Assurance Sampling (LQAS) Survey
Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Communes with at least 25% Number 7.00 30.00 40.00 execution rate of their joint annual work plan 14-Nov-2013 31-Jul-2019 31-Jul-2019
Comments (achievements against targets): The final outcome has surpassed the target.
Source: Project Monitoring System
Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion
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Nutritional Care Group Number 0.00 17000.00 20729.00 members in place for delivering community-based 14-Nov-2014 31-Jul-2019 31-Jul-2019 services
Comments (achievements against targets): The actual result has surpassed the target.
Source: Project Monitoring System
A.2 Intermediate Results Indicators
Component: Policy and program development, management and coordination
Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion
Communes that disbursed Number 10.00 55.00 60.00 funding for food and nutrition security 14-Nov-2013 31-Jul-2019 31-Jul-2019 development
Comments (achievements against targets):
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The actual result has surpassed the target.
Source: Project Monitoring System
Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Multisectoral strategy Yes/No N Y Y document for community- based health, food and 14-Nov-2013 31-Jul-2019 25-Jun-2019 nutrition standardizing roles and responsibilities of stakeholders
Comments (achievements against targets): The target has been achieved.
Source: SP-CAN
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Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Protocol for community Yes/No N Y Y management of moderate acute malnutrition finalized 14-Nov-2013 31-Jul-2019 30-Oct-2017 and validated
Comments (achievements against targets): The target has been achieved.
Source: SP-CAN
Component: Community mobilization and services delivery strengthening
Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Households in targeted Number 0.00 15000.00 10000.00 20977.00 Communes which established a designated 14-Nov-2013 31-Jul-2019 18-Jun-2018 31-Jul-2019 hand washing station
Comments (achievements against targets):
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The achieved result surpassed the revised target by more than double the number and even surpassed the original target.
Source: Project Monitoring System
Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Children under five with Percentage 54.00 65.00 65.00 diarrhea who are treated with ORT in targeted 14-Nov-2013 31-Jul-2019 31-Jul-2019 Communes
Comments (achievements against targets): The target has been achieved.
Source: Lot Quality Assurance Sampling (LQAS) Survey
Indicator Name Unit of Measure Baseline Original Target Formally Revised Actual Achieved at
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Target Completion Women with children under- Percentage 56.00 70.00 80.67 five and pregnant women attending community 14-Nov-2013 31-Jul-2019 31-Jul-2019 nutrition education sessions in targeted Communes
Comments (achievements against targets): The final result has surpassed the target.
Source: Project Monitoring System
Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Social and Health Workers Number 94.00 500.00 1038.00 (re-)trained on CMAM 14-Nov-2013 31-Jul-2019 31-Jul-2019
Comments (achievements against targets): The final outcome has surpassed the target by more than double.
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Source: Project Monitoring System
Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion GAN members trained in Percentage 0.00 80.00 91.00 community-based nutritional services 14-Nov-2014 31-Jul-2019 31-Jul-2019
Comments (achievements against targets): The outcome has surpassed the target.
Source: Project Monitoring System
Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion Children 6 -59 months who Percentage 104.00 104.00 104.00 received a vitamin A supplement in the past 6 14-Nov-2013 31-Jul-2019 25-Jun-2019
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months
Comments (achievements against targets): The target has been achieved.
Source: Ministry of Health
Formally Revised Actual Achieved at Indicator Name Unit of Measure Baseline Original Target Target Completion People who have received Number 0.00 8000000.00 13435873.00 essential health, nutrition, and population (HNP) 14-Nov-2013 31-Jul-2019 31-Jul-2019 services
Number of women and Number 0.00 8000000.00 13435873.00 children who have received basic nutrition services 14-Nov-2013 31-Jul-2019 31-Jul-2019
Comments (achievements against targets): The outcome has surpassed the target.
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Source: Project Monitoring System
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B. KEY OUTPUTS BY COMPONENT
Objective/Outcome 1 Increasing coverage of community-based child growth and nutrition interventions 1. Number of municipalities with at least 25 percent execution rate of their joint annual work plan Outcome Indicators 2. Nutritional Care Group (GAN) members in place for delivering community-based services (number) 1. Number of municipalities that disbursed funding for food and nutrition security development 2. Multisectoral strategy document for community-based health, food and nutrition standardizing roles and responsibilities of stakeholders 3. Protocol for community management of moderate acute malnutrition finalized and validated 4. Multisectoral strategy document for community-based health, food and nutrition standardizing roles and responsibilities of Intermediate Results Indicators stakeholders 5. Pregnant/lactating women, adolescent girls and/or children under the age of five reached by basic nutrition services. 6. Households in targeted municipalities with established designated hand washing station 7. Children 6-59 months who received a VAS in the past 6 months. 8. Protocol for community management of moderately acute malnutrition finalized and validated 9. Health personnel receiving training 10. Social and health workers re-trained on CMAM 1. Support to the development of policies, protocols, and tools Key Outputs by Component 2. Support to intersectoral collaboration at municipal level (planning, (linked to the achievement of the Objective/Outcome 1) supervision, monitoring)
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3. Capacity building of service providers through training and coaching 4. Capacity building of community structures to implement preventive and promotional interventions at community level
Objective/Outcome 2 Increasing utilization of community-based child growth and nutrition interventions
1. Proportion of children 0-23 months benefitting from a minimum package of monthly growth promotion activities in the project’s targeted communities Outcome Indicators 2. Number of women with children under five trained and engaged in the production or transformation of diversified and nutrient-rich foods 3. Proportion of children 0-6 months who are exclusively breastfed 1. Participants attending community nutrition education sessions in targeted municipalities Intermediate Results Indicators 2. Children under five with diarrhea who are treated with ORT in targeted municipalities 1. Support for community management of moderate acute malnutrition 2. Roll out of a community-based food health nutrition strategy Key Outputs by Component 3. Support to NGOs for community mobilization around growth (linked to the achievement of the Objective/Outcome 2) promotion and monitoring activities for children under 24 months in the communities, BCC activities; detection and community care of malnutrition cases
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ANNEX 2. BANK LENDING AND IMPLEMENTATION SUPPORT/SUPERVISION
A. TASK TEAM MEMBERS
Name Role Preparation Menno Mulder-Sibanda Task Team Leader(s)
Mathias Gogohounga Procurement Specialist(s)
Alain Hinkati Financial Management Specialist
Supervision/ICR Menno Mulder-Sibanda Task Team Leader(s) Mathias Gogohounga Procurement Specialist(s) Angelo Donou Financial Management Specialist Aissatou Chipkaou Team Member Abdoul Wahabi Seini Social Specialist Ibrahim Magazi Team Member Africa Eshogba Olojoba Environmental Specialist Valerie F. Trouillot-Ligonde Team Member Sylvie Charlotte Ida do Rego Procurement Team Jenny R. Gold Team Member Nikolai Alexei Sviedrys Wittich Procurement Team Codjo Ambroise Agbota Team Member Erick Herman Abiassi Team Member Safietou Toure Team Member
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B. STAFF TIME AND COST
Staff Time and Cost Stage of Project Cycle No. of staff weeks US$ (including travel and consultant costs) Preparation FY13 8.775 60,807.86 FY14 15.550 150,256.90 FY15 3.825 18,720.07
Total 28.15 229,784.83
Supervision/ICR FY14 .550 3,140.72 FY15 10.000 97,116.21 FY16 21.411 140,575.72 FY17 15.345 246,003.99 FY18 18.030 152,296.58 FY19 14.022 126,395.92 FY20 6.000 54,424.38 Total 85.36 819,953.52
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ANNEX 3. PROJECT COST BY COMPONENT
Amount at Approval Actual at Project Percentage of Approval Components (US$M) Closing (US$M) (US$M) Policy and program development, management 7.20 7.20 0 and coordination Community mobilization and services delivery 20.80 20.80 0 strengthening Total 0.00 28.00 0.00
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ANNEX 4. EFFICIENCY ANALYSIS
Economic and Human development 2010-2018 Despite the positive trends during the period of the project implementation, Benin remains a low-income country with a per capita income of US$829.80 (2017)3. Benin is ranked 167th out of 187 countries in the latest 2019 UNDP Human Development Report. If we focus on the relevant period for this evaluation (pre and near completion), we see that between 2010 and 2018 Benin has significantly improved its Human Development Index. It has increased from 0.473 in 2010 to 0.520 in 2018, an increase of 10 percent. Table 4.1, taken from the UNDP (2019) reviews Benin’s progress in each of the HDI indicators adjusted for changes in data collection and changes in goalposts. Education has experienced the steepest improvement in its trend, but the other indicators improved as well. Benin’s GNI per capita increased by about 16 percent between 2010 and 2018 and the life expectancy at birth increased by 2.2 years, the mean years of schooling of 1 year and the expected years of schooling of 1.6 years respectively.
Table 4.1: Benin’s HDI trends based on consistent time series data and new goalposts
Source: UNDP, Human Development Report 2019
Estimating the costs associated with malnutrition Malnutrition has substantial implications for economic growth and poverty alleviation. Malnutrition causes direct losses in productivity linked to poor physical status; and indirect losses due to poor cognitive function and learning deficits, as well as losses resulting from increased medical costs. The project investments were expected to bring both direct and indirect benefits for the population.
Evaluating the Impact of MFHNP The Project was designed to address some of the key challenges by increasing the coverage and utilization of community-based child growth and nutrition interventions in selected areas. In the analysis we use the data available of (a) the costs associated with the Project, (b) the development impact of the Project, and (c) the cost-benefit of the planned activities.
Project Costs The total budget for the Project US$28 million is fully depleted. From the start 26 percent of project costs were planned to be allocated for implementation of Component 1 (Policy and Program Development, management and
3 Real GDP growth was an estimated 6.0% in 2018, up from 5.4% in 2017, due to good performance in agriculture (ADB Economic Outlook, 2019
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coordination) and 76 percent for Component 2 (Community mobilization and service delivery strengthening).
Component 1 supported the strengthening of Commune-level coordination and monitoring capacity by establishing Communal Consultative Groups (CCGs); multisectoral policy development, coordination, and oversight; and strengthening of sectoral programs for improved nutrition. Specifically, this includes (i) long-term technical assistance for capacity building of the Permanent Secretariat of the CAN (SP CAN); (ii) joint planning with sectors and stakeholders to develop and support integrated nutrition-specific and nutrition-sensitive sector policies; (iii) orientation and in- service training workshops with stakeholders to improve coordination, implementation, and management of nutrition and food security at all levels; (Iv) monitoring, reporting, surveillance and operational research; and (v) advocacy and strategic communication to elevate the topic of food security, nutrition and health at all levels. In addition, this component financed materials, equipment, and operating costs.
Component 2 supported communal subprojects for social and behavior change communication; and public service delivery of food, health and nutrition. The community based interventions are: (i) growth monitoring and promotion, including individualized counseling on IYCF, IMCI, and adequate water, sanitation and hygiene practices; (ii) community management of acute malnutrition (CMAM); (iii) health and nutrition needs of pregnant women and adolescents; and (iv) food security through production, transformation, and diversification to improve availability, access and utilization of nutritious foods.
Cost-Benefit Analysis (CBA): Methodology and Assumptions Following the analysis done in the Project Appraisal Document (Report No: 81529-BJ) the standard World Bank methods for evaluating projects where investment costs of resources used are compared with the stream of economic benefits, are used. This is the standard cost benefit analysis, in which the stream of costs is discounted to present values using a discount rate to represent the opportunity cost of capital in the country. This analysis uses 5 percent discount rate, but a sensitivity analysis varies this rate between 5 percent and 10 percent to account for higher opportunity cost of capital.
Estimating beneficiaries of the project The direct beneficiaries of the project are children under the age of 5, adolescent girls, and pregnant women. To avoid double-counting benefits (e.g. those that accrue intergenerationally, adolescent girls who become pregnant during the course of the project), we restrict our CBA to benefits gained only by children under 5. This implies that the estimated benefits may be underestimated, but a more conservative estimate is preferred for the purposes of this analysis. Annual population growth rates (from WDI) are applied to census data from 2002 to estimate the number of children under 5 in each region of Benin in 2014.
To determine how many children under 5 were ‘treated’ in the project, the reported coverage level for the relevant PDO Result indicators, is assessed (see Table 4.2).
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Table 4.2: Coverage PDO Result Indicators.
Result Indicators Coverage Children 0-23 months who benefited form a minimum package of monthly 1 community based growth promotion activities in targeted communes 92 Women with under five children trained and engaged in the production and 2 transformation of diversified and nutrient rich food 83 3 Children 0-5 month who are exclusively breastfed in targeted communes 75 4 Communes with at least 25% execution rate of their joint annual work plan 5 Nutritional care group member in place for delivering community based service 6 Communes that disbursed funding for food and nutrition security development Multisectoral strategy document for community based health food and nutrition 7 standardizing roles and responsibilities of stakeholders Protocol for community management of moderate acute malnutrition finalized 8 and validated Households in targeted communies which established a designated hand 9 washing station Children under five with diarrhea who are treated with ORT in targeted 10 communes 65 Women with children under five and pregnant women attending community 11 nutrition education sessions in targeted communes 81 12 Social and health workers re trained on CMAM 13 GAN members trained in community based nutritional services 14 Children 6-59 months who received a vitamin A supplement in the past 6 months 100 15 People who have received essential health nutrition and population HNP services 16 Number of pf women and children who have received basic nutrition services Mean Coverage 82.66667
From the result indicators we can see that the national project surpassed its target and achieved an average coverage of 83 percent and min 65 percent and max 100 percent.
Estimating the no. of Beneficiaries under the age of 5 To calculate the total number of beneficiaries under age 5, the calculations done in the Project Appraisal Document (Report No: 81529-BJ) are followed. In this calculation we apply crude birth rates to the estimated population to calculate the number of new births and adjust for infant mortality rate.
Then implementing the reported coverage rate of 83 percent (min 65 percent- max 100 percent) we calculate the range of the number of additional new beneficiaries each year. In total, we estimate the total beneficiaries over the project period to be 1,637,669 (1,282,512 - 1,973,095) children under age 5. Table 4.3 displays the number of beneficiaries by region for the mean coverage rate.
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Table 4.3: Beneficiaries under age 5, based on the mean coverage rate of 83%
Unique 2014 2015 2016 2017 2018 2019 Beneficiaries Alibori 125668 4227 4291 4353 4411 4467 Atacora 125331 4216 4280 4341 4399 4455 Atlantique 162830 5477 5560 5640 5716 5788 Borgou 166625 5605 5690 5771 5849 5923 Collines 115927 3900 3959 4015 4069 4121 Couffo 117421 3950 4010 4067 4122 4174 Donga 73507 2473 2510 2546 2580 2613 Littoral 95973 3228 3277 3324 3369 3411 Mono 69763 2347 2382 2416 2449 2480 Oueme 134853 4536 4605 4671 4734 4793 Plateaux 84535 2844 2887 2928 2967 3005 Zou 123620 4158 4221 4282 4339 4394 BENIN 1396052 46962 47673 48354 49005 49623 TOTAL 1637669
Documented benefits on Stunting pre and ‘post’ Project period by the DHS Benin has seen little gains in nutrition in the 10 years prior to the start of the project. However, when we compare the nutritional status between 2005 and 2018 (see Table 4.4) documented by the Demographic Health Survey of 2006 and 2019 respectively we can see a significant improvement in Stunting heights (-10 percentage points) and Anemia (- 6.7 percentage points).
Table 4.4: Nutritional Status of Children in Benin
Stunting height for age Anemia Vitamin A Supplement Exclusive Breastfeeding % children < 5 below -2 SD % of children 6-59m % children 6-59m median duration of m 2006 2018 Diff 2006 2018 Diff 2006 2018 Diff 2006 2018 Diff Alibori 63.1 35.9 -27.2 89.7 75 -14.7 64.5 34.9 -29.6 3.30 2.8 -0.5 Atacora 39.1 36.4 -2.7 84.2 84.7 0.5 55.3 68.4 13.1 2.10 3 0.9 Atlantique 39.9 30.1 -9.8 75.2 67.5 -7.7 65.7 71.6 5.9 1.90 1.4 -0.5 Borgou 46.8 34.2 -12.6 69.6 74.4 4.8 45.5 44.1 -1.4 1.50 1.4 -0.1 Collines 42.6 23.7 -18.9 84.4 66.2 -18.2 84.8 59.9 -24.9 0.70 2.8 2.1 Couffo 37.8 38 0.2 83.1 76.8 -6.3 59.9 36.6 -23.3 3.10 2.1 -1 Donga 40.8 27.2 -13.6 88.1 75.8 -12.3 68.9 75.2 6.3 1.90 2.7 0.8 Littoral 26.2 19.1 -7.1 60.3 61.1 0.8 74.6 61.2 -13.4 1.50 a a Mono 44.7 28.5 -16.2 76.4 67.5 -8.9 70.3 44.9 -25.4 0.60 a a Oueme 37.0 29.7 -7.3 76.8 72.7 -4.1 53.4 39.7 -13.7 1.30 1.2 -0.1 Plateaux 45.1 36.2 -8.9 83.2 71.1 -12.1 41.8 49.1 7.3 1.00 a a Zou 52.5 35.4 -17.1 73.8 59.1 -14.7 56.7 52.9 -3.8 1.40 3.4 2 Benin 43.1 32.2 -10.9 78.1 71.4 -6.7 60.7 52.2 -8.5 1.69 2.1 0.41 Data source: DHS 2006 and 2019
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Estimating benefits from increased lifetime earnings from reduced stunting Following the assumptions set in the Project Appraisal Document (Report No: 81529-BJ) the benefits of reduced stunting as a result of the project are estimated in this analysis as the present value of the increase in future earnings/income flow of beneficiaries for ages 15-64. In order to be conservative about anticipated benefits, we use the estimated 10 percent earnings premium in our calculations. We assume that the project will be able to reduce stunting rates among the poorest quintiles down to the national average levels (43.1 percent). We also assume that the primary beneficiaries will be the poor and thus rates of stunting among the richer quintiles will not be affected by the project. Because this is likely not entirely accurate, the reduction in stunting is a conservative estimate. We account for annual adult mortality rates and discount future incomes at a rate of 5 percent per year. Therefore, the lifetime discounting factor is the sum of the adjusted annual discounted years from ages 15 through 64 years and interpreted as the number of years earning at the current wage that a child's future lifetime productivity is worth in the present after discounting and adjusting for expected mortality risk. Estimates of productivity premiums attached to stunting reduction vary from 10 percent to 20 percent. We vary this parameter accordingly but consider the lower bound (10 percent) in our base scenario.
Cost Benefit Estimations The estimated benefits of the project exceed the costs, indicating that the project is a sound economic investment. Given the average 83 percent project coverage, 10 percent earnings premium from reduced stunting, no effect on stunting for better-off households, and 5 percent discount rate, the results of this economic analysis yields a net present value (NPV) of US$8.7 million and Benefit/Cost (B/C) ratio of 1.3 (Table 4.5).
Table 4.5: Cost benefit Analysis of the Benin Multi Sectoral Food Health and Nutrition project
RGPH 2019 Estimation of Results # Beneficiaries over 2014-2019 (under 5) 1,637,669.2 Benefits -- Present value (in Million USD) -- 36.7 Costs -- Present value (in Million USD) -- 28.0 Benefits/Costs (%) 1.3 Benefits - Costs (in Million USD) 8.7
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ANNEX 5. BORROWER, CO-FINANCIER AND OTHER PARTNER/STAKEHOLDER COMMENTS
IMPORTANCE OF THE MULTISECTORAL FOOD, HEALTH AND NUTRITION PROJECT (PMASN) FOR BENIN
The PMASN followed on a series of policy and institutional reforms initiated since 2007 in the field of nutrition. It has enabled the Government to make significant progress in enhancing the governance of multisectoral nutrition, the capacity of stakeholders, partnerships, and the prevention and management of malnutrition.
Governance The PMASN allowed the institutional framework of the Food and Nutrition Council (CAN) to be rendered operational. The trust of the reforms which created the CAN is to ensure effective coordination of sectoral nutrition specific and sensitive interventions, so as to put nutrition at the heart of development, from the central level down to the community level, involving both the Region (Département) and the Municipality (Commune). Multi-stakeholder platforms for the coordination and monitoring of nutrition interventions have been set up at: (i) municipal level with more than 40 Communal Nutrition Consultative Committees (CCC); (ii) village level with 1,273 Food and Nutritional Surveillance Committees (CSAN); and (iii) community level with 6.338 Nutrition Care Groups (GAN). The same process was initiated at the regional level where three out of 12 Départements in Benin have set up a Regional Nutrition Consultative Committee (CDC).
These coordination platforms provide spaces for building awareness and empowering actors in their respective roles to create synergies of actions. The effective involvement of mayors, local elected officials and prefects in the implementation and supervision of PMASN activities in the field using their own resources, as well as their sensitivity to dealing with malnutrition problems, are reflective of the potential for effective and lasting ownership of nutrition public action by the political and administrative authorities.
In addition, coordination and accountability instruments in the nutrition sector have been developed by each of the 77 Communes in Benin. These include: (i) the integration of nutrition action in Municipal Development Plans (PDC); and (ii) Common Results Frameworks (CCR) for nutrition validated by the municipal council and linked to nutrition indicator dashboards based on sectoral assessments.
Other important achievements of the PMASN include the adoption of the National Nutrition Policy (PNN, 2019), the development of a national communication strategy for social and behavioral change for the promotion of nutrition (2018), and a comprehensive study on gender roles and norms in production, consumption and health (2016) which informs the integration of gender into policy documents and nutrition programs in Benin.
Prevention and management of malnutrition at community level GAN and CSAN members were trained by technical teams of partner NGOs and have taken an active part in interpersonal communication, community awareness-raising as well as the management of moderate acute malnutrition at the community level. Through child growth monitoring, home visits and nutrition education, these GAN members are gradually developing the skills necessary to promote good practices in food, health and nutrition within communities.
The establishment of more than 1,300 shared nutrition funds at village level provide local mechanisms for mobilizing resources for the treatment of malnutrition and a basis for nutrition actions in the villages.
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Stakeholder capacity building The PMASN contributed to building the capacity of SP-CAN staff and other nutrition stakeholders including the mayor’s office, the prefecture, the NGOs and public service providers. The implementing NGOs and nutrition focal points in mayors’ offices were comprehensively trained in food, health and nutrition issues based on the complete manual drawn up by the SP-CAN. Some health workers have benefited from training on the national protocol for the management of acute malnutrition with technical support from the Ministry of Health. CAN members, nutrition focal points and secretary generals in mayors’ offices and the prefectures have been trained in nutrition and efforts are being made to translate all the major concepts of nutrition into the main national languages of Benin.
Partnerships The implementation of the project used outsourcing through tripartite arrangements between the SP-CAN, the mayor’s office and the NGO with the contracting authority entrusted to local authorities. Also, a partnership agreement with the National Municipality Association of Benin (ANCB) enabled: (i) all municipalities of Benin to integrate nutrition in their development plans; and (ii) the advocacy for a nutrition window in the Municipal Development Assistance Fund (FADeC). Likewise, the partnership with 13 local radio stations facilitated the dissemination of key nutrition messages to beneficiary municipalities and beyond. Finally, the partnership with the Universities opens up the prospects for the integration of basic nutrition education in all academic training in Benin.
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ANNEX 6. SUPPORTING DOCUMENTS
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