Document of The World Bank FOR OFFICIAL USE ONLY
Public Disclosure Authorized Report No: ICR00004611
IMPLEMENTATION COMPLETION AND RESULTS REPORT
ON A SMALL GRANT (TF015755)
IN THE AMOUNT OF US$ 2.8 MILLION Public Disclosure Authorized TO THE
REPUBLIC OF TAJIKISTAN
FOR TAJIKISTAN JSDF NUTRITION GRANT SCALE UP (P146109)
Health, Nutrition & Population Global Practice Public Disclosure Authorized Europe And Central Asia Region
Regional Vice President: Cyril E Muller Country Director: Lilia Burunciuc Senior Global Practice Director: Timothy Grant Evans Practice Manager: Tania Dmytraczenko
Public Disclosure Authorized Task Team Leader(s): Huihui Wang ICR Main Contributor: Mutriba Latypova
ABBREVIATIONS AND ACRONYMS
CPF Country Partnership Framework CRF Common Results Framework DHA District Health Administration DHC District Health Center DHS Demographic and Health Survey DP Development partners EA Environmental Assessment ECD Early Childhood Development ERR Economic Rate of Return FM Family Medicine FY Fiscal Year GDP Gross Domestic Product GIZ German Corporation for International Cooperation GmbH GoT Government of Tajikistan ha Hectare HSIP Health Services Improvement Project HNP Health Nutrition and Population IMCI Integrated Management of Childhood Illnesses ISR Implementation Status and Results Report JSDF Japan Social Development Fund M&E Monitoring and Evaluation MHSPP Ministry of Health and Social Protection of Population MSNP Multi-Sectoral Nutrition Plan NDS National Development Strategy NGO Non-government organization NMSS National Micronutrient Status Survey NPV Net Present Value ORS Oral rehydration salt PAD Project Appraisal Document PCG Project Coordination Group PDO Project Development Objectives PHC Primary Health Care SDG Sustainable Development Goals SUN Scaling Up Nutrition ToT Training of trainers UNICEF United Nations Children`s Fund US United States USAID United States Agency for International Development WB World Bank WFP World Food Programme WHA World Health Assembly WHO World Health Organization
TABLE OF CONTENTS
DATA SHEET ...... ERROR! BOOKMARK NOT DEFINED. I. PROJECT CONTEXT AND DEVELOPMENT OBJECTIVES ...... 4 II. OUTCOME ...... 6 III. KEY FACTORS THAT AFFECTED IMPLEMENTATION AND OUTCOME ...... 13 IV. BANK PERFORMANCE, COMPLIANCE ISSUES, AND RISK TO DEVELOPMENT OUTCOME .. 14 V. LESSONS LEARNED AND RECOMMENDATIONS ...... 16 ANNEX 1. RESULTS FRAMEWORK AND KEY OUTPUTS ...... 18 ANNEX 2. PROJECT COST BY COMPONENTS ...... 25 A. Statement of Project Expenditures ...... 25 B. Disbursements, by Years ...... 28 ANNEX 3. SUPPORTING DOCUMENTS ...... 29 A. Project Achievements by Sub-Objectives...... 29 B. Additional Indicators Monitored by the JSDF-supported Project ...... 34 C. Output Indicators Included in the Approved Tajikistan JSDF Nutrition Grant Scale Up Proposal ...... 35 D. Distribution of Seeds in Pilot Districts...... 37 E. Distribution of Mineral Fertilizers in Pilot Districts ...... 38 F. Distribution of Micronutrients ...... 39
The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
DATA SHEET
BASIC INFORMATION
Product Information Project ID Project Name
P146109 Tajikistan JSDF Nutrition Grant Scale Up
Country Financing Instrument
Tajikistan Investment Project Financing
Original EA Category Revised EA Category
Not Required (C)
Organizations
Borrower Implementing Agency
Ministry of Finance Ministry of Health & Social Protection
Project Development Objective (PDO)
Original PDO The Grant Development Objective is to improve health and nutrition status among children less than five (5) years of age and pregnant and lactating mothers in the 14 districts affected by the food price shocks in Khatlon Province.
FINANCING
FINANCE_T BL Original Amount (US$) Revised Amount (US$) Actual Disbursed (US$) Donor Financing TF-15755 2,800,000 2,800,000 2,800,000 Total 2,800,000 2,800,000 2,800,000
Total Project Cost 2,800,000 2,800,000 2,800,000
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
KEY DATES
Approval Effectiveness Original Closing Actual Closing 15-May-2013 07-May-2014 07-May-2018 07-May-2018
RESTRUCTURING AND/OR ADDITIONAL FINANCING
Date(s) Amount Disbursed (US$M) Key Revisions
KEY RATINGS
Outcome Bank Performance M&E Quality Satisfactory Satisfactory Substantial
RATINGS OF PROJECT PERFORMANCE IN ISRs
Actual No. Date ISR Archived DO Rating IP Rating Disbursements (US$M) 01 15-Nov-2014 Satisfactory Satisfactory 0.00
02 05-Nov-2015 Satisfactory Satisfactory 1.07
03 16-Nov-2016 Satisfactory Satisfactory 2.14
04 16-Nov-2017 Satisfactory Satisfactory 2.65
05 10-May-2018 Satisfactory Satisfactory 2.80
ADM STAFF
Role At Approval At ICR
Regional Vice President: Laura Tuck Cyril E Muller
Country Director: Saroj Kumar Jha Lilia Burunciuc
Senior Global Practice Director: Timothy Grant Evans Timothy Grant Evans
Practice Manager: Daniel Dulitzky Tania Dmytraczenko Task Team Leader(s): Wezi Marianne Msisha Huihui Wang
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
ICR Contributing Author: Mutriba Latypova
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
I. PROJECT CONTEXT AND DEVELOPMENT OBJECTIVES
Context
1. Country and Sector Background. Tajikistan is a small landlocked country, with mountains covering more than 90% of the territory. The country is largely dependent on food imports and remittances from its citizens working abroad, mainly in Russia. The financial crisis of 2008, which resulted in dramatic decline of remittances and food price shocks, severely affected household income and food security in Tajikistan. Constant food price increases negatively affected the food diversity of the households as well as eating frequency, with an impact on the population’s nutritional status, especially that of children. According to the World Food Programme (WFP) Food Security Monitoring System, by 2009, about 22%1 of population in Tajikistan were food insecure, with this figure further increasing to 24% by 20112. A persistent trend of food insecurity contributed to shockingly high malnutrition rates among infants and young children. The 2012 Demographic and Health Survey (DHS) reported that the number of stunted children was 29% in 2009 and 26% in 2012, respectively3. Besides, the DHS revealed that a large proportion of children less than five years old and women of reproductive age were suffering from micronutrient deficiencies, such as anemia, iodine deficiency, etc. Stunting is associated with an underdeveloped brain, with long- lasting harmful consequences, including diminished mental ability and learning capacity, poor school performance in childhood, reduced earnings and increased risks of nutrition-related chronic diseases, such as diabetes, hypertension, and obesity in future.
2. Khatlon province, in the south of Tajikistan, has persistently experienced high malnutrition rates among women of childbearing age and children under five years of age. The highest level of child mortality and the lowest percentage of women receiving antenatal care from a skilled health service provider were also reported in this province. Moreover, Khatlon province was particularly affected by the price shocks of 2008-2011, which contributed to the high malnutrition rates in the province.
3. A preceding Grant for a Pilot of Nutrition Investments in Severely Food Insecure Districts of Khatlon Province (TF097132) from the Japan Social Development Fund (JSDF) in the amount of US$ 2.8 million covering 10 districts was implemented between December 2010-2013. It comprised of the following activities: strengthening the capacity of primary health care workers to manage childhood nutrition problems and common illnesses, education of mothers on child nutrition, breastfeeding promotion, and provision of micronutrient supplements to pregnant and, breastfeeding women and children under age five. Given the continued problems with household food security and childhood nutrition outcomes in Tajikistan and Khatlon Province in particular, high demand for nutrition-related interventions, and satisfactory implementation of this grant, a new grant was requested from JSDF to deepen the investments and expand the ongoing activities to cover the remaining 14 districts of Khatlon Province.
4. Rationale for Bank Assistance and Country Assistance Strategy. Good nutrition is vital to achieving the World Health Assembly’s (WHA) Global Targets on Maternal and Child Health and Nutrition by 2025 and the Sustainable Development Goals (SDGs) by 2030. The Government of Tajikistan (GoT) has identified improved nutrition as one of the country’s key goals in the current National Development Strategy (NDS) 2016-2030, which is
1 Tajikistan Food Security Monitoring System, WFP, 2009.https://documents.wfp.org/stellent/groups/public/documents/ena/wfp213517.pdf 2 Tajikistan Food Security Monitoring System, WFP, 2011.https://www.wfp.org/content/tajikistan-food-security-monitoring-system-2011 3 Tajikistan Health and Demographic Survey, 2012. https://dhsprogram.com/pubs/pdf/FR279/FR279.pdf
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
supported by a national movement for its implementation. The objective of addressing nutrition related issues has been included in the National Health Strategy 2010-2020; the National Nutrition and Physical Activity Strategy 2015- 2020; Concept for Social Protection and Concept for the School Feeding to 2027, the National Food Security Program to 2020 and Strategy for the sustainable development of School Feeding to 2027. Tajikistan has also been a member of the global Scaling Up Nutrition (SUN) movement since 2013, further demonstrating government leadership and engagement in the nutrition agenda. Under the SUN platform in Tajikistan, the Ministry of Health and Social Protection of Population (MHSPP) with the technical support of international consultants have developed a Common Results Framework (CRF) to improve nutrition. The CRF is a single and agreed set of expected results generated through the effective engagement of different sectors of government and the multiple non-government actors who have the capacity to influence people’s nutrition. The CRF forms a basis for the Multi-Sectoral Nutrition Plan (MSNP) for Tajikistan, which is being developed under the leadership of the MHSPP with the participation of numerous government ministries and departments. The overall goal of this Plan is to improve maternal and child nutrition status in the Republic of Tajikistan.
5. Recognizing the social and economic importance of adequate nutrition, the country’s leadership and development partners (DPs) have joined forces to address the issue, with priority given to ensuring food security and people’s access to good quality nutrition. The objective of the JSDF Nutrition Grant Scale Up Project fully reflects the country’s current development priorities. It is also consistent with the Bank’s Country Partnership Strategy (CPF) for FY2013-2018 aiming to maintain access to critical public services and to strengthen the quality of public services provided to enhance the human capital potential. Furthermore, the issue of stunting among children has been included in the Bank’s new CPF for FY2019-2023 to be addressed through the proposed Early Childhood Development (ECD) Project.
Project Development Objectives (PDOs)
6. The Project Development Objective was to improve health and nutrition status among children less than five (5) years of age and pregnant and lactating mothers in the 14 districts affected by the food price shocks in Khatlon Province.
7. The Grant in the amount of US$ 2.8 million4 was provided by the Japanese Government through the JSDF for the Nutrition Grant Scale Up Project, as a follow-on to the preceding JSDF-funded operation, to address the persistent and very high malnutrition rates among infants and young children in Khatlon Province.
Key Expected Outcomes and Outcome Indicators
8. To achieve its PDO, the Grant was expected to scale up Pilot Nutrition Investments in Severely Food- insecure Districts of Khatlon Province, supported by the preceding JSDF Grant (TF097132), by covering the remaining 14 districts of Khatlon Province with similar activities. To increase impact and sustainability of interventions, the new grant included additional activities to: (i) enhance the capacity of district health administrators for nutrition monitoring; and (ii) improve household consumption of nutritious foods through household gardening, with the combined use of locally available gardening approaches, the delivery of high quality seeds and fertilizers, and by training households to cultivate, preserve, and store food safely.
4 In addition to this Recipient-executed grant amount, the total grant amount also included US$ 180,000 in Bank incremental costs.
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
9. The achievement of PDO was to be measured by the following outcome indicators as identified in the approved Grant Proposal:
(a) Proportion of children under the age of 5 years within the 15th and 85th quintiles of growth in pilot districts (i.e., weight to age correlation); (b) Proportion of children under the age of 5 years consuming nutritious food; (c) Proportion of households growing more nutritious food; (d) Proportion of mothers able to correctly mention at least 3 key actions for managing children’s illness at home; (e) Proportion of mothers/caregivers able to name at least 3 key actions to improve their children’s nutrition.
Components
10. To achieve its PDO, the Project included the following 7 key components:
i. Household Gardening to build capacity of household members and improve their skills on growing nutritious food and preparing animal fodder, preservation and storage of food for consumption during the lean months. ii. Community-Based Nutrition Improvement Interventions intended to increase family and volunteer participation in improving child health, strengthen the effectiveness of the community health workers, and reinforce the relationship between communities and primary health care providers. iii. Community Training on Management of Childhood Illnesses aimed to create better conditions for a child survival by improving the management of childhood illnesses at home, the primary care level, and the community. iv. Educational Campaign to Promote Healthy Behavior Change such as exclusive breastfeeding for infants under 6 months and appropriate complementary feeding for infants 6-24 months of age. v. Provision of Micro-Nutrient Supplements to supplement the diet of the targeted groups of population— such as children between 6 months to 2 years of age, pregnant and lactating women—with essential micronutrients. vi. Strengthening Local Capacity in Maternal & Childhood Illnesses (MCI) and Nutrition Surveillance to build capacity of district-level PHC facilities on carrying out continuous surveillance of nutrition-related indicators of the targeted groups and reporting on them. vii. Project Management, Monitoring and Evaluation and Knowledge Dissemination to support the costs of managing the Project, including procurement, financial management and audits.
II. OUTCOME
A. Relevance of Objectives, Design and Implementation Rating: High
11. The objective of this Project was, and remains, highly relevant to the country’s current development priorities, with the malnutrition and stunting issue being one of the national strategic goals under the NDS 2016- 2030. Stunting is also included as a development challenge in the Bank’s new CPF for FY2019-2023 and would be addressed through the forthcoming ECD Project and other interventions. Results and evidence-based data gathered during the Project have proved that the problem of stunting is critical in Tajikistan, therefore this Project
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
received a great deal of attention from the Bank management, policy-makers, donor agencies and other nutrition stakeholders. An innovative, integrated, multi-sectoral and multi-facetted Project design combining activities in health, nutrition and agriculture was also highly relevant as it allowed the MHSPP to comprehensively address health and nutrition issues of the targeted beneficiaries. Relevance of implementation arrangements is also assessed as high since the existing and well-performing mechanisms, tools, capacity and partnerships were effectively used to successfully implement the Project.
B. Assessment of Achievement of Project Development Objectives Rating: Substantial
12. Health and nutrition status are closely inter-linked so that good health is an outcome of good nutrition. Improved nutrition contributes to better health by reducing morbidity and mortality caused by malnutrition and micronutrient deficiencies, such as, for example, anemia in women and children. Retarded growth in the first two years of life is especially damaging as it increases children’s exposure to illnesses and mortality in early childhood. If they survive, such children suffer from poor physical health and constrained opportunities for learning and earning income throughout their lives. Therefore, adequate nutrition, being an integral part of good health, is crucial for growth and health of young children, as surely as for good health of pregnant and lactating women. Given these inter-linkages, “improved nutrition status” was considered an integral part of “improved health status” and both were assessed as one outcome.
13. Overall, the Project made an important contribution to the overall objective of improving the health and nutrition status of children under 5 years of age and pregnant and lactating mothers in the 14 districts affected by the food price shocks in Khatlon Province. This contribution was mainly measured by the degree of achievement of all five PDO indicators as well as additional indicators monitored by the Project. As illustrated in Table 1 below, targets for all five PDO-level indicators were exceeded, achieved, or substantially achieved, as were most of the Intermediate Results indicators (refer to Annex 1.A, 3.B, and 3.C for details). In addition, feedback received from the Project beneficiaries and various stakeholders, both during Project implementation and after its closure, has testified favorably about the Project’s positive impact on changing behaviors and practices and on improving health and nutrition status of the targeted population groups in the Khatlon Province. The complementary interventions under each Project component and their output-level results, which collectively led to these accomplishments, are described in Annex 3.A.
Table 1. Consolidated End-of-Project Status of Project Indicators
Status 5 PDO Indicators 8 Intermediate Outcome % of Total Indicators (IO) Exceeded/Achieved 3 6 69.20% Substantially Achieved 2 2 30.80% Not Achieved n/a n/a Impossible to measure n/a n/a n/a: not applicable
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PDO-level indicators from the approved Grant proposal
14. Between 2015 and 2018, the proportion of children under age 5 years within the 15th and 85th quintile of growth (i.e. weight for age) in the new project districts (PDO indicator No.1) increased from 59.4% to 63.4% against the target of 65.00%. Although the target value of 65.0% for this PDO-level indicator was not fully achieved, this PDO-level indicator is considered as substantially achieved.
15. Since Project inception, there have also been increases in the proportions of children under the age of five years consuming nutritious food in the Project districts (PDO indicator No.2) from 42.6% to 49.8% (against the target of 52.6%). Although the target value of 52.6% for this PDO-level indicator was not fully achieved, the positive dynamic on this indicator has been observed from the Project beginning. As the final survey shows, 92% of households in the Project pilot areas knew the types of nutritious foods such as meat products, dairy and legumes; however, it was noted by respondents that their dietary diversity is restricted by their purchasing power.
16. The proportion of households growing more nutritious food products (PDO indicator No.3) has increased from 12.8% to 30.3% (against the target of 30.0%). This is likely to have contributed to improving the nutrition status of children under the age of 5 by increasing the proportion of children consuming nutritious food products.
17. During Project implementation period, the proportion of mothers who improved their knowledge on management of child illnesses at home (PDO indicator No.4) has increased from 42.5% to 88.5%, significantly exceeding the target of 52.5%. Although the following outcome is not directly attributable only to the JSDF Project, the DHS conducted in 2017 showed a decrease of mortality of children under the age 5 years from 43% in 2012 to 33% in 2017 at the national level.5
18. Finally, the proportion of mothers/caregivers who were able to name at least 3 key actions to improve their child’s nutrition (PDO indicator No.5) increased from 38.2% to 54.6%, which also exceeded the target of 48.2%).
Additional indicators monitored by the Project
19. In addition, notable progress has also been evident based on several additional indicators monitored by the Project using the Project surveys and / or supplementary sources of data (e.g. Demographic and Health Survey). These indicators provide further evidence for the contribution of the Project as follows.
20. According to the project baseline and final surveys, the average indicators of various malnutrition forms among children under 5 years of age have improved as follows: stunting rate dropped from 27.5% to 21.9%, wasting rate decreased from 7.3% to 6.5%, and the proportion of underweight children decreased from 13.6% to 6.3%. These improvements in indicators of nutritional disorder were facilitated, among other things, by increase in knowledge and ensuing positive changes in practices and behaviors at the family level regarding nutritional matters, such as diversity of consumed food, healthy cooking practices, choice of healthy, nutritious products, etc.
5 Demographic and Health Survey. Key Indicators. 2017, https://www.dhsprogram.com/pubs/pdf/PR93/PR93.pdf
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
21. According to the studies carried out under the Project (baseline survey, interim and final surveys), the share of children with low birth weight under 5 years of age (Z score below -2 standard deviations) fell from 8.5% in 2015 to 6.5 % in 2018 while the target value was a decrease to 7.4%.
22. The above-mentioned data are consistent with findings from the National Micronutrient Status Survey (NMSS) and DHS, which are not specific to Project districts but can be considered as a reliable independent source of data. The NMSS conducted in Tajikistan by the MHSPP in 2016 showed that the rate of underweight children under the age of 5 years in Khatlon decreased from 13.5% in 2009 to 4.7% in 2016. A significant decrease in the rates of wasting among children under the age of 5 years from 11.1% in 2009 to 2.4% in 2016 has also been achieved in Khatlon while the rate of underweight women of reproductive age has decreased from 11.6% to 7.5% in the same period. These complementary data sources also corroborate an apparent decrease in the rates of underweight and stunting among children under the age of 5 years in Khatlon province. Thus, the rate of stunted children has decreased from 26.9% in 2009 to 22.6% in 2016 while the rate of underweight children decreased from 13.5% in 2009 to 4.7% in 2015. Even though the Project was implemented only in 14 districts of Khatlon province, the Project has likely contributed partially to these aggregate improvements.
23. To determine the impact of the Project on nutritional status of children and women, additional estimates were performed at the level of Project districts using the DHS data for 2012 and 2017. The height-for- age index measures linear growth. A child who is below -2 standard deviations from the reference median for growth by age is considered short for his/her age, which is a condition reflecting the cumulative effect of chronic malnutrition. The data show that, compared with the 2012 DHS data (28.2%), only 19.7% of children under the age of 5 years were considered short for their age (below -2 standard deviations) in 2017, which indicates a decrease of 8.5 percentage points. The severe stunting rate (below -3 standard deviations) was 4.4% in 2017 representing a decrease by 6 percentage points compared to 2012.
24. Children whose body weight-for-height is below minus 2 standard deviations from the median of the reference population are considered depleted (or thin). Data from 2017 show that 5.2% of children in Project districts suffered from exhaustion, and 0.6% from severe forms of exhaustion. In comparison with the 2012 DHS data, the values displayed decreases by 5.8 and 2.6 percentage points, respectively.
25. Children whose weight-for-age is below minus two standard deviations from the reference median are considered underweight. This measure reflects the effects of both acute and chronic malnutrition. The analysis showed that 9.8% of children in the Project districts had insufficient body weight in 2017, and 2.2% were classified as children with severe body mass insufficiency. Based on a comparison of 2012 DHS data, there has been a decrease in the indicator values by 3.9 and 1.3 percentage points, respectively.
26. In addition, the Project measured additional nutrition-specific indicators, such as prevalence of anemia among women and children in the Project districts. The baseline survey showed that the prevalence of anemia among pregnant women was 64.3% in 2015, and 50.5% among children under the age of 5 years. The end-line survey showed that prevalence of anemia among pregnant women dropped to 45.2% in 2018, and to 45.6% among children under the age of 5 years. The end-line survey also showed a decrease in all forms of anemia among children towards the end of Project. More specifically, lower prevalence of mild forms of anemia was found in 44.1% of children, compared to 48.7% in 2015, and severe degree of anemia was recorded in only 1.5% of children in 2018, compared to 1.8% in 2015. The 2017 DHS data provide a similar picture on prevalence of anemia among
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
children under the age of 5 years in Khatlon province (46.4%)6. This picture can be attributed to the high percentage of children who received micronutrient Sprinkles during the last 3 years, provision of PHC facilities with iron and folic acid supplements, awareness-raising and training activities aimed at improving nutrition practices, and household gardening activities carried out under the Component 1.
C. Efficiency Rating: Substantial
27. Given that Net Present Value (NPV) or Economic Rate of Return (ERR) was not calculated at Project preparation stage, the outcome efficiency was assessed and rated based on the global evidence for investments in nutrition, including existing cost-benefit analyses.
28. Poor nutrition generates economic costs through three main routes: direct losses in productivity from poor physical status and losses caused by diseases linked with malnutrition; indirect losses from poor cognitive development and school performance; and increased health care costs both from acute illnesses such as diarrhea and a higher risk of chronic diseases in adulthood. These healthcare costs are borne both by individuals and by governments. The global economic costs of malnutrition are very high—several billion dollars a year in terms of lost gross domestic product (GDP)7. Undernutrition is estimated to cost Tajikistan US$ 41 million annually8.
29. The global evidence base has identified nutrition-specific interventions that are highly effective and should be scaled up in countries with a high burden of stunting. These include promotion of exclusive breastfeeding and use of high quality complementary foods, peri-conceptional and maternal micronutrient supplementation, and micronutrient supplementation in children, which were all included in Project activities9. It is estimated that implementation of these nutrition-specific interventions to achieve 90% coverage in countries with the highest global burden of undernutrition would reduce stunting by 20%. To further reduce stunting, complementary nutrition-sensitive actions in other areas and sectors are required, such as investment in household gardening that were made under this Project, which provided a source of diverse and nutritious food to families10. There have been numerous cost-benefit analyses estimating the return on investment from a package of nutrition-specific interventions in countries with a similarly high burden of stunting as Tajikistan11. The cost-benefit ratio of scaling up these interventions ranges from 1:3.8 to 1:47.9 depending on the country. While the specific package of interventions included in this Project has not been the focus of a cost-benefit analysis to date, it is reasonable to apply the same cost-benefit ratios given that the Project included some of the same nutrition-specific interventions as well as complementary nutrition-sensitive activities. Therefore, given the cost of the Project at US$ 2.8 million, the benefits to Tajikistan may range from US$ 10.6 million to US$ 134.1 million (excluding discounting).
6 Prevalence of anemia was not measured in DHS-2012. 7 Why Invest in Nutrition. World Bank. 2013. http://siteresources.worldbank.org/NUTRITION/Resources/281846- 1131636806329/NutritionStrategyCh1.pdf 8 Situational Analysis. Improving economic outcomes by expanding nutrition programming in Tajikistan. World Bank/ UNICEF. 2012. https://www.unicef.org/tajikistan/Tajikistan_Nutrition_Report_Eng.pdf 9 Bhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker N, Horton S, et al. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet. 2013;382(9890):452-77. 10 Global Panel. 2016. The cost of malnutrition. Why policy action is urgent. London, UK: Global Panel on Agriculture and Food Systems for Nutrition. 11 Hoddinott, J., Alderman, H., Behrman, J. R., Haddad, L. and Horton, S. (2013), Economic rationale for stunting reduction. Matern Child Nutr, 9: 69-82. doi:10.1111/mcn.12080.
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30. As for the project design, it can also be considered highly efficient as it included nutrition-specific and nutrition-sensitive interventions as well as capacity building efforts in nutrition such as trainings on nutrition and IMCI. The implementation progress has also been highly satisfactory throughout the implementation period, with all project management requirements fulfilled and 100% of funds disbursed from the Grant account by the closing date. Moreover, this Project was implemented on the premises of the existing WB-funded project, therefore, most of the funding was spent directly on project activities with minimal administrative costs.
Overall Outcome Rating
31. The overall outcome rating is Satisfactory based on the High rating for relevance and Substantial ratings for both efficacy and efficiency.
Other Outcomes and Impacts
32. Capacity development / strengthening: by their design, all project components and activities contributed to the development and strengthening of communities, beneficiaries, PHC workers, and relevant institutions involved in the Project. Within the household gardening component, the Project strengthened skills and knowledge of 3,000 households to grow nutritious food, and families now have the motivation to continue this activity, which has demonstrated its potential to improve their food security and dietary diversity. Additionally, pregnant and lactating women learnt about the healthy nutrition practices, cooking nutritious food at home, managing children’s common illnesses at home, and the importance of micronutrients for supporting their own health and healthy development of their children.
33. The 1,000 PHC workers, including 300 doctors and 700 nurses, trained by the Project have gained knowledge on newborn and child nutrition, child physical development, prevention of micronutrient deficiencies among children aged 6-24 months, IMCI, computer literacy for nutrition monitoring, and malnutrition treatment. Thanks to these newly-acquired comprehensive knowledge and skills, they have enhanced their own recognition within their communities and, with the inherent self-motivation that such recognition provides, have improved the scope and quality of services they provide to their communities. An unintended result of the Project has been the larger than planned number of nurses trained in family medicine, which was due to a high demand and preference for trained nurses rather than doctors in geographically isolated project districts. This was, in part, due to the ease that home visits by a larger number of nurses have provided to the communities, but, to some extent, also the socio- cultural patterns whereby (predominantly female) nurses are more likely to be comfortably approached by women and mothers with children regarding even seemingly non-threatening symptoms. Anecdotal evidence suggests that this has helped, at times, to identify and prevent more serious health implications on a timely basis.
34. Furthermore, PHC institutions from 14 project districts of Khatlon Province were provided with computers and Internet access as well as medical equipment such as stethoscopes, blood pressure monitors, fetoscopes, clinical thermometers, measuring tapes, gloves, consumable supplies, scales, and height meters, which has enhanced their ability to timely monitor and report the health and nutrition status of children and pregnant and lactating women.
35. Equipped with enhanced knowledge on diverse issues related to health and nutrition and with special bags containing hygiene kits and thermometers to use during home visits, the 300 trained community volunteers
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have become an essential link between their communities and the PHC facilities by conducting educational and informational activities and performing health status monitoring, basic consultative and preventive health services.
36. Mobilization of Resources: Close alignment and coordination of nutrition interventions with other DPs, such as Food and Agriculture Organization of the United Nations (FAO), WFP, German Corporation for International Cooperation (GIZ), United States Agency for International Development (USAID) and United Nations Children`s Fund (UNICEF), and the Grassroots Projects of the Japanese Embassy in Tajikistan helped avoid duplication of efforts and mobilize their expertise and resources. This contributed, to a certain degree, to the achievement of the PDO by improving the targeting and efficiency of JSDF-supported interventions. For example, while the USAID-supported “Feed the Future” Program covered 12 districts in the Khatlon Province, the JSDF-supported Project extended its coverage to the remaining 14 districts of the Province. Likewise, the JSDF Project used the training modules and information materials on nutrition and IMCI, disease management toolkits, etc. already developed by other DPs, such as WHO and UNICEF.
37. Knowledge exchange: Knowledge exchange process commenced right from the Project design stage through close collaboration between the MHSPP MCH Division and nutrition programs supported by FAO, WFP, USAID, UNICEF and GIZ to avoid duplication and inform the Project activities. During implementation, information about Project implementation was shared in a number of nutrition-related events such as Nutrition Forums in 2016 and 2017 and the SUN multi-stakeholder workshop in 2017. The results achieved under the Project and the impact of the JSDF program on the beneficiaries, community groups and other stakeholders were also showcased at the 10th JSDF dialogue seminar “Japan Social Development Fund: Investment in Human Capital in Tajikistan and Mozambique.”12 The event provided an important opportunity to bring together key stakeholders involved in the Project to disseminate knowledge and share lessons, hear stories of beneficiaries about a transformative impact the Project made on their livelihoods, and discuss sustainability of the achievements. According to feedback received after the event, the Project accomplishments and impact were appreciated by the Government of Japan and stakeholders.
38. At the end of the Project, a final report was produced, and a stakeholder roundtable was organized in Dushanbe with key governmental agencies and DPs to disseminate the results of the Project, knowledge generated, and lessons learned. Roundtable participants agreed that the Project was highly successful, with its multi-sectoral approaches—supplementing interventions in health and nutrition areas with household gardening activities— recommended for use by other DPs in their nutrition programming. Nomination of this Project for inclusion in the results stories chapter of the Fiscal Year 2018 Trust Fund Annual Report issued by the World Bank Development Finance Vice Presidency also testified to Project’s notable accomplishments. In addition, the reduction of stunting was included in the Country Partnership Framework for 2019-2023 between the World Bank and Tajikistan, and a strong foundation and political capital has been built for follow-up work on a proposed ECD Project.
39. Recipient policy / program implementation: This Project provided an opportunity and direct experience for the MHSPP Project Coordination Group (PCG) to use multi-sectoral approaches to nutrition, such as various training themes and modalities, use of community health volunteers, household gardening interventions. Despite fiscal constraints making the MHSPP’s continuation of funding or scaling up the Project activities questionable, PHC facilities in the Project districts report continued engagement of the trained community health volunteers in efforts to address health and nutrition issues in their communities. Post-project interviews with Project beneficiaries also
12 The event took place on November 15, 2017 and was organized by the World Bank Group’s Trust Funds and Partner Relations in cooperation with the Tokyo Development Learning Center and World Bank Tokyo Office.
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
indicate that households have continued the acquired household gardening practices by storing seeds from year to year, which points to their understanding of the importance of dietary diversity and the benefit of household gardening as a means of income generation.
40. Replicable best practices: The Project’s nutrition-specific, nutrition-sensitive and nutrition capacity building interventions followed the globally-recommended approach to nutrition. The Project’s undeniable achievements in improving health and nutrition status of the targeted population have a great potential to be replicated to other parts of the country provided funding is available. However, the country may not able to accommodate various competing needs and demands on its own due to the limited fiscal envelope, with infrastructure spending and salaries taking the lion’s share of the state budget. On the other hand, food security and nutrition remain the country’s strategic goals for the next 10 years. To achieve them, the country is moving towards developing its Multi-Sectoral Nutrition Plan under the auspices of the national multi-sectoral SUN platform hosted by the MHSPP.
III. KEY FACTORS THAT AFFECTED IMPLEMENTATION AND OUTCOME
41. Key positive project-specific factors that affected implementation and outcomes of the Project include the following:
i. Strong coordination and ownership of the Project by the MHSPP, which started with the careful selection of Project districts, and continued with strong support throughout the Project period. ii. Extensive experience of the MHSPP in implementing World Bank-funded projects. MHSPP’s PCG has had long-standing experience in implementing projects funded by the World Bank and experience working at the primary health care level in Khatlon province. This contributed to timely completion of and skillful navigation through administrative, logistical and other issues. iii. Establishment of a robust M&E system not only helped formulate realistic and measurable targets and timely monitor progress but also led to a more streamlined operation. Continuous monitoring of reporting on selected indicators helped provide regular feedback to the Project team and district PHC facilities, based on which training programs were adopted and adjusted as needed. iv. Deployment of cascade trainings on nutrition and IMCI helped improve the knowledge of beneficiaries significantly, and to cover larger number of beneficiaries. For example, the assessment conducted in 2018 on the level of knowledge and awareness of mothers/caregivers on main actions to be taken to improve nutrition of a child showed an increase from 38.2% in 2015 to 54.6% in 2018. The same assessment showed that the levels of knowledge of mothers/caregivers about 3 main actions to manage child illnesses at home increased from 42.5% in 2015 to 88.7% in 2018. v. Inclusion of an agriculture component that combined the use of locally available gardening approaches, delivery of high-quality seeds and fertilizers, and training of households to cultivate, preserve, and store food safely added substantial value to Project outcomes. Household gardening has contributed to improving household nutrition and alleviating micronutrient deficiencies. It supported the selected households in several ways, most importantly through: (i) direct access to a diverse set of nutritionally- rich foods; (ii) training of households in preserving and storing food products for consumption during seasonal lean periods; and (iii) increased purchasing power of the households by creating savings on food bills and income from sales of garden products.
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
42. Less effective factors that affected implementation and outcomes include the following:
vi. Lack of inclusion of a water and sanitation component. It is globally recognized that there is a strong correlation between access to improved water and sanitation and lower risks of diarrhea, child mortality, and stunting. Although the Project did not conduct such an analysis, observations showed that the intended outcomes were reasonably lower in the households with no proper portable water and sanitation. vii. PDO 2 indicator on ‘proportion of children under the age of 5 years consuming nutritious food” was substantially achieved; however, the low purchasing power of some households limited their ability to provide nutritious food to their households, despite the fact that members of those households knew about the importance of nutritious food.
IV. BANK PERFORMANCE, COMPLIANCE ISSUES, AND RISK TO DEVELOPMENT OUTCOME
43. Bank performance at both preparation and implementation stages is rated satisfactory. Although there was no formal review meeting at preparation, the quality at entry was ensured through the Bank team’s effort to closely match the design to the country development challenges, preparation of the Project in an expedited manner building on the design of and lessons learned from the preceding JSDF-supported operation, and engagement in extensive consultations with all relevant DPs to ensure synergies and avoid duplication. The Bank team also employed an innovative, multi-sectoral approach by including an agricultural component in the Project to enhance its impact and ensure sustainability.
44. The quality of Bank supervision was reflected in effective and proactive implementation support, which, along with intensive PCG efforts, compensated for the initial delays in commencing the implementation. Aide- memoires provided detailed reviews of the implementation progress and recommendations for specific, time- bound actions. Likewise, the prepared Implementation Status and Results reports provided the Bank management with a candid overview and assessment of project performance and policy issues. The task team’s effort to ensure fiduciary compliance and progress in meeting intermediate results was instrumental in facilitating timely and successful implementation.
45. Mid-term review (MTR) of the Project held in early 2017 did not identify a need for any critical changes to the Project given its timely and satisfactory implementation. At the same time, agreements were reached between the Bank and the MHSPP to further strengthen Project implementation and reporting by: (i) ensuring sustainability of the household gardening component through continuous promotion of preservation and storage of seeds among the beneficiary households; (ii) monitoring proper use of growth charts to increase accuracy of detection of malnourished children; (iii) exploring the possibility of enhancing the role of communities in promoting early childhood development and nutrition; and (iv) strengthening Project monitoring by supplementing existing data collection arrangements using the software developed under the previous JSDF operation with a mini-survey tool to collect additional data on growth monitoring; testing knowledge of health workers, volunteers, and beneficiaries; and household gardening. During the MTR, the Japanese Ambassador to Tajikistan also joined a visit to one of the Project-supported districts and expressed his satisfaction with the achieved results and ongoing Project activities, particularly the roll out of the MCH manual, which originated in the 1950s in Japan.
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
46. Recipient performance is rated satisfactory throughout the preparation and implementation stages. Specifically, this Project was requested by the MHSPP as a much needed follow up to the previous JSDF-supported operation and was designed simultaneously with the other two nutrition-focused projects supported by UNICEF and USAID. This way, interventions of the three DPs were aligned in terms of coordinated selection of project districts and the use of unified approaches to M&E aspects, procurement of micronutrients, and use of MHSPP- approved standardized information and education materials. All Project activities were also part of and supported the MHSPP nutrition action plan, including household gardening, involvement of community volunteers, and community-based IMCI interventions.
47. Similar to Project design, its implementation has also been strongly owned by the MHSPP thanks to the appointment of a highly competent and dedicated professional, the head of the MHSPP MCH Division, as the Coordinator of the JSDF Project. Close involvement of the MCH Division, reflected below as one of the lessons learned, again, ensured coordinated and timely implementation of all the three nutrition projects, with ensuing timely resolution of emerging issues, knowledge exchange, unified monitoring, and necessary adjustments in interventions. For example, the initially envisaged provision of folic acid and iron supplements to pregnant women under the JSDF-supported Project was scaled down given their sufficient supply under the other DPs’ projects. Likewise, given the apparent preference and high demand for nurses in geographically isolated districts, necessary adjustments were made in the numbers of doctors and nurses remaining to be trained in family medicine.
48. Compliance Issues: The Project was successfully completed, with funds disbursed in their entirety. This Project was rated as a “category C” project in terms of environmental and social aspects; therefore, no safeguard policies were triggered at design stage and no environmental or social issues were encountered during implementation. Financial management performance of the MHSPP was satisfactory throughout. Procurement was conducted according to the approved plan, with procurement and contract administration processes as well as performance of procurement staff generally maintained at a satisfactory level. It should also be noted that the unified procurement arrangement for micronutrients, whereby UNICEF procured micronutrients for both JSDF- and UNICEF-supported projects, helped save time and achieve efficiencies of scale. Delivery and distribution of micronutrients was also very timely and well organized as it was done and coordinated through the MHSPP. Compliance with M&E requirements of the Project was also satisfactory, with a detailed assessment of the overall quality of M&E design, implementation, and utilization presented in Annex 3.A.
49. Risks to Development Outcome: When the effect of awareness/knowledge generated and capacity built under the Project is concerned, the risk to the achieved development outcome is considered modest to substantial, because the project-supported households, community health volunteers, PHC workers, and DHA officials have been fully equipped to continue exercising the acquired knowledge and practices and maintain or improve the attained results. That said, high turnover of PHC staff and potential shifts in the importance of nutrition on the development agenda may both have erosive effects on sustainability of project investments. At the same time, risks are considered substantial to high regarding interventions where tangible inputs—such as seeds, fertilizers, micronutrient supplements, and equipment—were supplied by the Project. In such instances, the risks, to a large extent, relate to the likelihood of further investments by DPs and the government in sustaining and further improving the development outcomes achieved by the Project. Although the government’s financial capability to sustain Project achievements remains questionable to a large extent, the progressing policy initiatives related to food fortification and the MSNP developed as part of the SUN movement provide a
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
promising platform for continued joint efforts to improve maternal and child health and nutrition status in Tajikistan.
V. LESSONS LEARNED AND RECOMMENDATIONS
The learning gained from the process of performing the Project can be summarized as follows:
i. Active coordination of DPs’ activities by the government’s lead agency made the nutrition projects, including the JSDF Project, truly effective and enhanced their sustainability prospects by using an integrated approach and creating synergies, efficiencies, and continuity. A multi-sectoral approach led by the MHSPP and actively supported by the GoT also helped having a stronger policy dialogue and attracted stakeholders’ attention to the nutrition issues. ii. Deep knowledge of the country’s most acute development challenges and opportunities, coupled with genuine efforts to address them in a comprehensive and coordinated manner, led to successful health and nutrition outcomes. iii. High level of MHSPP PCG’s capacity in coordinating and implementing health projects at the PHC system and community levels in various districts across Khatlon as well as the capacity of its technical, fiduciary and administrative staff led to smooth and timely implementation of the Project. iv. Having the Head of MHSPP MCH Division, who also served as the MHSPP Lead Specialist on Nutrition and Tajikistan’s Technical Focal Point for the SUN initiative, as the Project Coordinator added significant value to the MHSPP work on nutrition and ensured a broader perspective of the specific project interventions in the context of interventions needed to improve the nutrition status of children under the age of five, lactating and pregnant women in Khatlon Province. v. Combination of micronutrients distribution, trainings on the community-based IMCI and behavior change communication activities has the potential to reduce severe stunting rates among children in the short-run. In the long-run, childhood stunting can be prevented only if a multi-sectoral approach is adopted whereby, for example, households learn appropriate gardening practices and, at the same time, acquire good knowledge about ECD concepts. vi. Coordination and joint actions with other nutrition-focused agencies have helped avoid duplication of efforts and ensured substantial efficacy and efficiency. For example, UNICEF procured and distributed micronutrients for both the WB-funded project beneficiaries as well as beneficiaries of its own project. The Project also effectively used education and awareness-raising materials produced by UNICEF and WHO, which saved significant amounts of time and resources for the Project. vii. Use of appropriate interventions and establishment of monitoring mechanisms have helped achieve the PDOs effectively, which led to high level of satisfaction of Project stakeholders with the Project accomplishments.
Recommendations
50. Responsibility for instituting health and nutrition policies and programs to prevent mortality and morbidity and to improve the health and nutrition status of the population in Tajikistan falls within the MHSPP mandate. Based on this Project’s experience, the following are key recommendations for future nutrition and ECD programming:
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
i. Despite the results achieved, the overall stunting rate in Tajikistan is still very high at over 20%. Given that the determinants of chronic malnutrition, including stunting, are multi-faceted, continued collaborative efforts are required to scale up programs that span multiple sectors, especially health, agriculture, education, water, sanitation and hygiene, environment, social protection, and economic planning. Such multi-sectoral approaches at multiple levels should consider the double-burden of malnutrition across the life cycle. Therefore, in Tajikistan’s context, the MHSPP, Ministry of Agriculture, Ministry of Economic Development and Trade, Ministry of Education and Science, Ministry of Industry and New Technologies, State Committee on Local Development, government regulatory agencies, private and civil society sectors should all be engaged to comprehensively address the issues of stunting and malnutrition. ii. Develop an effective mechanism to follow up on practical implementation of regular child growth and development monitoring with clear records in the child development cards, and improve the quality of such monitoring, including the training of health workers on proper measurement of child growth. iii. Provide all health workers with registry and reporting forms required for proper monitoring of children’s development. Provision of health services on hypotrophy, breastfeeding and introduction of supplementary feeding by PHC workers should be improved. iv. Refresh training materials on healthy nutrition based on results of the final survey on the level of knowledge of population about nutrition practices. v. Strengthen interventions aimed at improving the knowledge of mothers on childhood illnesses management, strengthen parents’ skills to recognize dangerous symptoms in children aged under 5 as well as develop an understanding on the need to timely seek health care for the child. vi. Considering a high turnover of health specialists who are migrating to the Russian Federation or elsewhere, there is an urgent need to develop and implement strategies for provision of regular short-term workshops on nutrition of pregnant and lactating women as well children aged under 5 for PHC workers. Workshops on childhood illnesses management are, also, in high demand. For this work, PHC, IMCI and healthy style promotion centers should be engaged.
51. Proposed follow-up and/or next steps. Malnutrition and stunting remains a critical issue in Tajikistan. Therefore, MHSPP is committed to maintaining nutrition and food security issues high on the development agenda given strong economic arguments for investing in nutrition. However, fiscal constraints the GoT is facing are likely to hinder its ability to finance nutrition programs on its own in the coming years. At the same time, it is envisaged that the GoT, represented by the MHSPP, would be able to attract the right kind of technical assistance and off-budget funding for nutrition; coordinate the investments in nutrition; and implement the needed interventions through the MSNP platform.
52. The ECD project proposed for FY21 under the CPF for FY2019-2023 would target children (from conception to the age of seven) and key ECD players to improve access to quality ECD services. In doing so, it would build on the knowledge, results, and lessons learned on nutrition interventions under the JSDF Project, and aim to contribute towards the GoT goals of increasing pre-school enrollment and decreasing stunting among . children under age of five.
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
ANNEX 1. RESULTS FRAMEWORK AND KEY OUTPUTS
A. RESULTS INDICATORS
A.1 PDO Indicators
Objective/Outcome: To improve health and nutrition status among children less than five (5) years of age in the 14 districts affected by the food price shocks in Khatlon province. Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Proportion of children in Percentage 59.40 65.00 63.40 project areas under age 5 within 15th and 85th quintile of 11-Nov-2015 07-May-2018 07-May-2018 growth (i.e. weight for age) in the project districts
Comments (achievements against targets): Substantially achieved. Source: Project End-line Survey, May 2018; PIU/MOH Final Completion Report.
Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Proportion of children under Percentage 42.60 52.60 49.80 the age of 5 years consuming nutritious food 11-Nov-2015 07-May-2018 07-May-2018
Comments (achievements against targets): Substantially achieved.Source: Project End-line Survey, May 2018; PIU/MOH Final Completion
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
Report.
Objective/Outcome: To improve health and nutrition status among pregnant and lactating mothers in the 14 districts affected by the food price shocks in Khatlon Province.
Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Proportion of mothers able to Percentage 42.50 52.50 88.50 correctly mention at least 3 key actions for managing children’s 11-Nov-2015 07-May-2018 07-May-2018 illness at home
Comments (achievements against targets): Exceeded. Source: Project End-line Survey, May 2018; PIU/MOH Final Completion Report.
Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Proportion of Percentage 38.20 48.20 54.60 mothers/caregivers able to name at least three key actions 11-Nov-2015 07-May-2018 07-May-2018 to improve their children’s nutrition
Comments (achievements against targets): Exceeded. Source: Project End-line Survey, May 2018; PIU/MOH Final Completion Report.
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
Unlinked Indicators Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Proportion of households Amount(USD) 12.80 30.00 30.30 growing more nutritious food 11-Nov-2015 07-May-2018 07-May-2018
Comments (achievements against targets): Achieved. Source: Project End-line Survey, May 2018; PIU/MOH Final Completion Report.
A.2 Intermediate Results Indicators
Component: Community Training on Management of Childhood Illnesses
Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Number of Primary Health Care Amount(USD) 0.00 1000.00 1000.00 workers trained on nutrition and management of common 31-Dec-2013 07-May-2018 07-May-2018 childhood illnesses
Number of Female Primary Amount(USD) 0.00 500.00 700.00 Health Care workers trained on nutrition and management 31-Dec-2013 07-May-2018 07-May-2018 of common childhood illnesses
Comments (achievements against targets): Achieved. From the outset of project implementation, 1,000 health workers (and 300 volunteers) were trained annually in various subject areas related to nutrition and common childhood illnesses, resulting in a total of 3,047 training
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
person-sessions. Source: Project End-line Survey, May 2018; PIU/MOH Final Completion Report
Component: Provision of Micronutrient Supplements
Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Number of children under the Amount(USD) 0.00 50000.00 140000.00 age of two who received micronutrient sprinkles 31-Dec-2013 07-May-2018 07-May-2018
Comments (achievements against targets): Exceeded. Source: Project End-line Survey, May 2018; PIU/MOH Final Completion Report
Component: Community-Based Interventions
Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion People who have received Number 0.00 125000.00 535437.00 essential health, nutrition, and population (HNP) services 31-Dec-2013 07-May-2018 07-May-2018
People who have received Number 0.00 100000.00 465437.00 essential health, nutrition, and population (HNP) services 31-Dec-2013 07-May-2018 07-May-2018 - Female (RMS requirement)
Number of women and Number 0.00 125000.00 535437.00 children who have received basic nutrition services 31-Dec-2013 07-May-2018 07-May-2018
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
Comments (achievements against targets): Substantially exceeded. Source: Project End-line Survey, May 2018; PIU/MOH Final Completion Report
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
B. ORGANIZATION OF THE ASSESSMENT OF THE PDO
Objective/Outcome 1 1. Proportion of children under age of 5 within 15th and 85th quantile of growth in pilot districts (i.e., weight to age correlation) 2. Proportion of children under the age of 5 consuming nutritious food 3. Proportion of households growing more nutritious food. 4. Proportion of mothers able to correctly mention at least 3 key actions for managing children’s Outcome Indicators illness at home. 5. Proportion of mothers/caregivers able to name at least 3 key actions to improve their children’s nutrition. 6. Number of children under the age of 2 who received micronutrient sprinkles. 7. People who have received essential HNP services. 8. Females who have received essential HNP services. 1. Number of PHC workers trained on nutrition and management of common childhood illnesses. 2. Number of female PHC workers trained on nutrition and management of common childhood Intermediate Results Indicators illnesses. 3.Number of women and children who have received basic nutrition services. Key Outputs by Component Component 1. Household gardening. - Approximately 3,000 households with children and with pregnant mothers (about 30,000 people) garden and consume nutritious food. Component 2. Community-based nutrition improvement interventions. - Approximately 1,000 PHC workers, 300 community volunteers, and 75,000 pregnant and breastfeeding women are trained. Component 3. Community training on management of childhood illnesses. - Approximately 1,000 public health workers, 300 community volunteers, and 75,000 mothers and pregnant women are trained on management of childhood illnesses. - Approximately 80 doctors and 160 nurses are trained in family medicine. Component 4. Educational campaign to promote healthy behavior change. - Approximately 75,000 mothers and pregnant women are trained. - Approximately 1,000 health workers and 300 volunteers are trained on nutrition including micronutrient supplementation. Component 5. Provision of micronutrient supplementation.
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
Objective/Outcome 1 - Provision of Micronutrient Sprinkles to approximately 50,000 children under the age of 2 years. - Provision of Micronutrient supplements to approximately 70,000 pregnant women. Component 6. Strengthening local capacity in Maternal and Childhood Illnesses and Nutrition Surveillance. - Coordination of roundtables for PHC workers, volunteers and DHA officials. - Monitoring reports on quality of nutrition services, activities undertaken, and results achieved. Component 7. Project management, M&E and knowledge dissemination. - Quarterly progress and final evaluation study. - Completion report. - Communication strategy on project objectives and results, including disclosure of M&E indicators. - One baseline and one final surveys and reports of a random sample of households. - Annual audit reports.
- Proportion of pregnant women with anemia. - Proportion of children under the age of 5 years with anemia. - Proportion of children from 0 to 6 months under exclusive breastfeeding. Additional Indicators - Proportion of children under 5 with low weight (whose scores on Z are below 2-х SD against age). - Proportion of households in pilot districts consuming iodized salt pursuant to the norm. - Crop yield percentage on cultivating agricultural crops in home gardens. .
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
ANNEX 2. PROJECT COST BY COMPONENTS
Amount at Approval Actual at Project Percentage of Approval Components (US$M) Closing (US$M) (US$M) Household Gardening 344,750 468,260 12 Community-Based Nutrition 192,660 321,877 7 Improvement Interventions Community training on management of childhood 669,328 635,317 24 illnesses Educational campaign to promote healthy behavior 415,875 246,622 15 change Provision of micronutrient 309,950 301,267 11 supplements Strengthening local capacity in Integarted Maternal & 317,500 185,262 11 Childhood Illnesses (IMCI) and Nutrition Surveillance Project Management, Monitoring and Evaluation and 549,937 637,691 20 Knowledge Dissemination Total 2,800,000 2,800,000 100
A. Statement of Project Expenditures COMPONENT/SUB-COMPONENT/ACTIVITY Amount, US$ COMPONENT 1. Household gardening 468,260 Fertilizer supply and delivery (1st distribution) 43,731 Fertilizer supply and delivery (2nd distribution) 20,540 Seeds supply and delivery (1st distribution) 48,419 Fertilizer supply and delivery (3d distribution) 37,897 Fertilizer supply and delivery (4th distribution) 42,369 Seeds supply and delivery (3d distribution) 53,542 Seeds supply and delivery (2nd distribution) 48,995 Fertilizer supply and delivery (5th distribution) 43,812 Fertilizer supply and delivery (6th distribution) 43,215 Consultation on farming, information campaign on growing nutritious food and fodder, storage of food for 39,028 consumption and diversification of products
National Expert/ Agriculture 46,712 COMPONENT 2. Community-based nutrition improvement interventions 321,877 Training of Trainers (ТоТ) for conducting training on infant and children nutrition for health staff and 6,860 volunteers Training on rational nutrition for infants and children up to 5 years for the health staff and volunteers 44,614 Training on early development of young children 70,557
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
COMPONENT/SUB-COMPONENT/ACTIVITY Amount, US$ Purchase of office supplies (pencils, markers, paper, flip charts) for the health staff for conducting training 9,979 for mothers on child nutrition and its improvement - 1st stage Purchase of office supplies (pencils, markers, paper, flip charts) for the health staff for conducting training 23,423 for mothers on child nutrition and its improvement – 2nd stage Purchase of office supplies (pencils, markers, paper, flip charts) for the health staff for conducting training 28,069 for mothers on child nutrition and its improvement – 3rd stage Procurement of office supplies and bags for volunteers trained 5,939 Purchase of hygiene kits and thermometers for volunteers 9,343 Replication of registers, questionnaires, brochures and booklets for the health staff (5 types) aimed at improving their understanding of IMCI management and nutrition. Replication of Guidelines on proper micronutrients use, their composition, ingredients for distribution among beneficiaries/ Replication of 84,505 brochures and informational materials on nutrition for the population (1st group – 35 000 women, 2 types booklets) Nutrition Consultant 38,588 COMPONENT 3. Community training on management of childhood illnesses 635,317 Training of Trainers (ТоТ) for conducting training on IMCI management for health staff and volunteers 6,519 Training on IMCI management for health staff 1st stage 195,501 Strengthening the capacity of PHC staff based on the FM centers - training (6 stages) 264,079
Provision of medical wallets (stethoscope, blood pressure monitor, clinical thermometer, measuring tape) 69,560 Provision of medical wallets (stethoscope, blood pressure monitor, fetoscope, clinical thermometer, 99,658 measuring tape, gloves, consumable supplies) to the trained FM doctors and nurses COMPONENT 4. Educational campaign to promote healthy behavior change 246,622 Replication of brochures and information materials on nutrition for the population (group 2 - 35 000 women 13,210 2 types of booklets) Replication of brochures and information materials on nutrition for the population (group 2 - 35 000 women 59,201 2 types of booklets) Replication of brochures and information materials on IMCI management for the population (group 1 - 35 40,532 000 women 2 types of booklets) Replication of brochures and information materials on IMCI management for the population (group 2 - 35 22,799 000 women 2 types of booklets) Replication of brochures and information materials on IMCI management for the population (group 3 - 35 18,371 000 women 2 types of booklets) Replication of brochures and information materials on IMCI management for the population (group 4 - 35 18,346 000 women 2 types of booklets) Replication of the physical development form (chart) on child weight and height basis 1,386 Replication of the Manual on early childhood and development 28,628 Conduct of training sessions to demonstrate how to cook and feed nutritious food to children in households 14,302 (1st year) Conduct of training sessions to demonstrate how to cook and feed nutritious food to children in households 13,082 (2nd year) Conduct of training sessions to demonstrate how to cook and feed nutritious food to children in households 13,181 (3rd year) Public awareness through multimedia training materials 3,584 COMPONENT 5. Provision of micro-nutrient supplements 301,267
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
COMPONENT/SUB-COMPONENT/ACTIVITY Amount, US$ Provision of sprinkles to 50000 children from 6 months to 2 years of age (1 pack consists of 30 sachets) and Provision of micronutrients to 35000 pregnant women. (90 tablets per woman during 3 months. 1 pack 245,906 consist of 1000 granules.) Micronutrients packing and delivery to final destination 29,961 Consultant/Support to the Project implementation 25,399 COMPONENT 6: Strengthening local capacity in IMCI (Integrated Maternal and Childhood Illnesses) and 185,261 nutrition surveillance Provision of premises and presentation equipment to IMCI Surveillance units in the MOHSP, regions and 89,133 districts, PHC Centers for maintenance of the regular data flow and activity monitoring Replication of reporting forms for data collection (logs, registration forms) for IMCI Surveillance Units in 6,781 district PHC centers Provision with office supplies for IMCI Surveillance 11,691 Procurement of scales and height meter 71,832 TOT for health staff on malnutrition and IMCI surveillance 2,875 Provision of Internet access via GPRS and USB 3G modems to PHC centers for data exchange 2,949
COMPONENT 7: Project management, monitoring and evaluation, and knowledge dissemination 637,691 A. Project management 346,042 Consultant/Support to the Project implementation in Khatlon Region 34,121 Disbursement Consultant 40,234 Translator (Russian/English/Russian) 35,334 Annual audit 34,464 Office supplies for CG 18,773 Access to Internet 38,314 Driver 16,582 Guard 11,904 Tax duties/taxes 300 DHL; announcements; phone; Internet; advertisement 18,300 Fuel and lubricants 16,860 Vehicle repair/lease 31,686 Banking services 5,077 Travel expenses 26,373 Knowledge distribution 17,736 Final Round table presenting project progress 17,736 B. Monitoring and evaluation of the Grant implementation 291,649 Procurement of the blood test kits (for the Baseline survey) 9,929 Procurement of the blood test kits (for the Final Survey) 4,978 Baseline Survey 92,656 Mid-Term Survey 29,873 Final Impact Evaluation Survey 93,807 M&E Consultant 39,407 Assistant to Office Manager 20,997 Total for all Components 2,800,000
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B. Disbursements, by Years
Disbursement period Allocated Components Total % 2015 2016 2017 2018 funds
Component 1. Household gardening 84,738 132,020 149,037 102,464 468,260 470,468 99
Component 2. Community-based 165,397 110,875 40,601 5,004 321,877 333,732 96 nutrition improvement interventions
Component 3. Community Training on 274,704 58,670 263,137 38,806 635,317 636,849 100 Management of Childhood Illnesses
Component 4. Educational Campaign to 76,541 73,640 71,298 25,156 246,622 244,368 101 Promote Healthy Behavior Change
Component 5. Provision of Micronutrient 159,930 144,740 -3,403 0 301,267 301,267 100 Supplements Component 6. Strengthening Local Capacity in IMCI (Integrated Maternal and 107,606 2,547 2,549 72,559 185,262 185,277 100 Childhood Illnesses) and Nutrition Surveillance
Component 7. Project Management, Monitoring and Evaluation and 171,828 104,911 168,690 195,955 641,395 628,039 102 Knowledge Dissemination Total 1,040,744 627,404 691,909 439,944 2,800,000 2,800,000 100
ANNEX 3. SUPPORTING DOCUMENTS
A. Project Achievements by Sub-Objectives.
Sub-objective 1: Building capacity of the households and improve their skills on growing nutritious food and animal fodder, preservation and storage of food for consumption during the lean months.
This activity was implemented in collaboration with local authorities in 1013 out of 14 project districts to avoid duplication of similar activities already being implemented under the USAID-funded Family Farming Program in Shartuz, Qabodiyon, Kulob and Vose. A total of 3,000 households from 29 jamoats (communities) benefited from trainings aimed at increasing knowledge and skills of those households on household gardening, food preservation and storage as well as raising their awareness on consumption of nutritious food. The Project has also developed a manual on growing crops, the useful properties, storage and consumption of the agricultural products for the households’ use. In addition, high-quality seeds (potato, carrot, peas, beetroot, and beans) and fertilizers were distributed to the households in several rounds from November 2015 to April 2018.
The distribution of seeds and mineral fertilizers led to an increase in the percentage of households using household plots by 28 percentage points, from 70% in 2015 to 98% in 2018, substantially exceeding the target of 10 percentage points over the baseline value. Also, the provision of the households with seeds and fertilizers, coupled with training in proper gardening practices has improved the productivity of cultivated agricultural products. Specifically, during the interval between the baseline and final surveys, the growth by 65% was registered in the yield of potato, from 0.38 to 0.63 centers per 0.01 hectare of land, significantly exceeding the target of 10 percentage points over the baseline value.
Sub-objective 2: To increase participation and level of responsibility of families and community volunteers in improving children’s health, strengthen the effectiveness of community health nurses, and reinforce the relationship between communities and primary health care providers.
The intended outcomes under Component 2 were achieved through: (i) training of PHC nurses and community volunteers from among active local women, religious authorities, teachers and other specialists in monitoring the nutrition status of vulnerable infants and children under 5 years of age and filling out child development forms; (ii) strengthening of PHC workers in monitoring child growth and development, malnutrition prevention and management; (iii) providing practical trainings to communities, especially pregnant and lactating women, in preparing healthy food, recognizing signs of malnutrition / childhood illnesses and taking appropriate preventive measures at home; and (iv) distributing educational materials on the covered topics to the communities and volunteers, including bags, hygiene kits and thermometers to volunteers, as well as technical guidelines, manuals, child development monitoring forms, and necessary supplies to PHC workers. Pre- and post-training knowledge measurement tests consistently showed substantial increases in the level of training participants’ knowledge after the trainings received.
As a result, 1,039 health workers (339 doctors and 844 nurses) and 300 community volunteers received training on various aspects of preventing / treating malnutrition and managing childhood illnesses, and 182,979 pregnant and lactating women were trained on healthy nutrition, prevention of childhood illnesses and caring for a sick child.
Thanks to the acquired knowledge and skills, health staff and community volunteers have learned how to detect children with malnutrition and developmental delays in a timely manner. The children with detected physical developmental delays and disorder were consulted in a timely manner, and their parents were given appropriate advice. Compared with the baseline survey, the regularity of
13 Danghara, Baljuvan, Temurmalik, Khovaling, Muminobod, Shurobod, Hamadoni, Farkhor, Norak, Panj.
The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
anthropometric studies of children increased by almost two times, and the child height and weight rates were recorded in accordance with the specially designed Mother and Child Health (MCH) Guidelines.
The results of the activities carried out by Project staff also clearly demonstrated positive dynamics in improving mothers’ nutrition knowledge and practices in the Project areas. The share of breastfeeding women being aware of a minimum of three main actions to improve the children nutrition increased from 38.2% in 2015 to 54.6% in 2018, which exceeded the target of 10% over the baseline value.
Sub-objective 3: To promote child survival by improving the management of childhood illnesses at home, community and primary health care level.
To ensure child survival, prevention of child mortality and deterioration of a child’s condition during his/her illnesses, it is important for the PHC nurses, doctors, community volunteers, mothers to be able to detect the symptoms of common childhood diseases at an early stage. Under this component, the intended outcomes were to train 1,039 public health workers, 300 community volunteers, and 182,979 lactating and pregnant women on management of childhood illnesses.
All activities under this component were successfully completed. The Project initially trained 26 qualified doctors as local trainers by organizing a 7-day Training of Trainers (ToT) workshop on Integrated Management of Child Illnesses (IMCI) based on World Health Organization (WHO) programs and standards. These lead trainers, in their turn, conducted workshops on IMCI with attendance of 3,047 doctors and nurses and 726 community volunteers in the Project districts. To improve IMCI at the PHC level, medical bags—which included a stethoscope, clinical thermometer, measuring tape, gloves, handouts—were procured for health workers. The community volunteers were also trained to encourage communication between families and health care providers to ensure timely intervention by parents and health workers.
Pregnant and lactating mothers were trained in identifying and managing more common child illnesses at home and recognizing when it is important to take the child to a health facility to decrease the deterioration of health condition and mortality among children. Training curriculum included such topics as how to manage the condition of pregnant women with dangerous symptoms; children up to 2 years of age with dangerous symptoms; oral respiratory infections, fever and diarrhea; first aid; use of oral rehydration solutions and micronutrient powders, with the participants also trained to use the maternal and child health handbook. During the workshops, lactating and pregnant women were provided with brochures on prevention and symptoms of child illnesses, child and pregnant women nutrition, diarrhea, prevention of pregnant and breastfeeding women illnesses, family planning and other informational materials to keep handy and use when needed.
Overall, during the Project period, 1,039 health workers, 300 community volunteers and 182,979 pregnant and lactating women developed knowledge and skills to help a child during illnesses and prevent more serious illnesses and mortality.
Sub-objective 4: Strengthen capacity of doctors and nurses on family medicine (FM).
To strengthen capacity of doctors and nurses on family medicine, the Project supported training of family medicine specialists at the PHC level. According to the Project training plan, 6 cycles of a 6-month training for 80 doctors and 160 medical nurses were supposed to be conducted. However, because of the high need for nurses in the pilot districts, the Project trained an additional group of nurses instead of doctors, resulting in a total of 79 doctors and 285 nurses trained in family medicine. Trainings in family medicine provided by the Project have resulted in doctors and nurses acquiring the necessary capacity 30
The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
for them to provide comprehensive and continued family-based, community-supported care and guidance for health and nutrition related matters to their catchment area populations. The newly acquired, broader knowledge and skills have also enhanced the reputation of these health workers within their communities, which, in turn, has provided inherent motivation for them to serve their communities better. Thus, the higher than planned numbers of motivated health workers with upgraded skills have made their fair contribution to improved health and nutrition outcomes in the Project- supported districts.
Sub-objective 5: To promote behavior change of mothers and pregnant women on exclusive breastfeeding for infants’ under-6 months of age and appropriate complementary feeding for infants’ ages 6 to 24 months through education campaigns.
This sub-objective aimed to promote exclusive breastfeeding for infants’ under-6 months of age and appropriate complementary feeding for infants’ ages 6-24 months, to promote consumption of balanced, nutritious, and affordable food by families with young children and by pregnant and breastfeeding mothers through education campaigns. To achieve this, in close coordination with the household gardening activities, community health volunteers visited households in the Project districts to promote consumption of balanced, nutritious, and affordable food by families with young children and by pregnant and breastfeeding mothers. More specifically, they organized practical group trainings on how to cook and feed nutritious food to children, distributed simple and culturally appropriate education materials and brochures. Finally, the Project supported creation of TV and radio broadcasts, which delivered consistent messages to encourage the population towards good dietary practices, household hygiene and sanitation.
Short video clips on “Exclusive breastfeeding”, “Cooking of supplementary foods for children under the age of 23 months”, “Basic knowledge on physical development of children”, “Nutrition of pregnant women”, “Proper food storage and preservation” have been developed and displayed to educate lactating mothers and pregnant women and promote healthy and diverse nutrition. These short videos were replicated and disseminated in all pilot districts. Besides, the following booklets and brochures have been printed and disseminated in the pilot districts: How to feed a child (100,000 copies), Nutrition of women during pregnancy and breastfeeding (10,000 copies), Manual on supplementary food for children (10,000 copies), Manual on prevention of acute malnutrition among children aged 6-24 months (2,000 copies), Manual on prevention and identification of moderate malnutrition (2,000 copies), Guide on using of micronutrients “Sprinkles” (100,000 copies). In addition, 39 TV programs totaling 253 minutes of air time on the national and regional TV channels, 18 broadcasts in radio totaling 100 minutes of air time, 6 newspaper articles, 6 publications on various websites, 5 films and video-clips were developed and broadcasted.
The Project activities clearly influenced the behavior of mothers and pregnant women substantially increasing exclusive breastfeeding. Results of the final survey showed that proportion of children under the age of 6 months that are exclusively breastfed increased from the baseline of 11.3% in 2015 (baseline survey data) to 31.1% in 2018 (end-line survey data).
Sub-objective 6: To provide critical micronutrients to supplement the diet of the target groups of children aged from 6 months to 2 years, pregnant women, and lactating mothers.
The Project initially planned to distribute micronutrient supplements to 50,000 children and 70,000 pregnant women. However, when the Project started, coverage figures for pregnant women was re- considered and reduced because monitoring data showed that the real need for the micronutrients for pregnant women was much less given similar activities supported by other DPs. In total, 140,000 31
The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
children received Micronutrient Sprinkles and 17,501 pregnant women received iron and folic acid supplements over the Project period. Thus, the Project was able to strengthen the health of 140,000 children and 17,501 pregnant women with critical micronutrients.
Sub-objective 7: Strengthening local capacity of PHC workers, volunteers and district health administrators (DHA) in Maternal and Childhood Illnesses and continuous nutrition surveillance and their reporting to improve the health and nutrition status of children, pregnant and lactating women.
To strengthen the capacity of PHC workers, volunteers and District Health Authorities’ officials in maternal and childhood illnesses and continuous nutrition surveillance and reporting to improve the health and nutrition status of children, pregnant and lactating women, the Project supported PHC facilities in pilot districts with organization of nutrition monitoring and surveillance rooms. After conducting situational analysis, the Project equipped these rooms with height meters, medical scales to properly measure the weight, office furniture and computer equipment. A database was installed in all nutrition monitoring rooms to allow for continuous monitoring of data coming from pilot districts. The database aimed to monitor child’s growth and development as well as was linked with collection of information on distribution of micronutrients. All computers of the monitoring rooms were provided with internet modems and were connected to Internet. Furthermore, the Project has organized various types of trainings such as: 1) a 2-week training on computer literacy in Khatlon province for 28 nutrition monitoring specialists, 2 per each of the pilot districts; and 2) a cycle of trainings on objectives for control of children’s malnutrition and its reporting at PHC level for 30 local trainers from PHC facilities as well as national-level trainers.
Establishment of monitoring rooms, trainings for the nutrition specialists, and the development of database and forms on nutrition surveillance improved regularity and accuracy of reporting on nutrition indicators. It has been reported that these rooms have continued to function after the Project completion.
Sub-objective 8: Ensure effective project management, monitoring and evaluation, and dissemination of knowledge
Project management: Activities under this component have facilitated the achievement of the PDO by following diligent and efficient processes in procurement, financial management and project auditing, technical and administrative support, public communications, logistics, and other related aspects to ensure smooth and timely project implementation and compliance with the World Bank and JSDF requirements. Efficiencies and synergy in project management, including monitoring and evaluation, were achieved by using the same project management team, the MHSPP’s Project Coordination Group (PCG), to implement, in a coordinated way, three inter-related health sector interventions, including the World Bank-supported PHC-focused Health Services Improvement Project (HSIP), the JSDF-supported project, and the Institutional Development Fund grant. Timely submission of implementation progress, monitoring and evaluation (M&E), and financial monitoring reports to all concerned stakeholders, including the World Bank, MHSPP, and State Committee on Investments and State Property Management of the Republic of Tajikistan, has contributed to efficient project management as well as transparency and accountability in the use of grant proceeds.
M&E system: The overall quality of M&E design, implementation, and utilization is considered Substantial. The Project Results Framework and detailed M&E implementation plan were developed by the PCG and approved by MHSPP to monitor the implementation progress and measure the extent of achievement of the project results. Per project design, a private survey firm was contracted to conduct the baseline, interim, and final surveys for monitoring project results in a systematic way. In addition, to 32
The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
create synergies, the Project utilized, to some extent, the M&E system developed under the HSIP, with monitoring and reporting for both projects carried out by the same M&E consultant of the PCG. More specifically, a total of 9 additional indicators at the PDO and intermediate results levels were also monitored for the JSDF Project thanks to data available from the HSIP M&E system (see Annex 3.B). The only design-related shortcoming was the failure to define realistic yet motivating end-targets for those additional indicators, which is considered moderate given the additionality of those indicators to the ones already defined in the original grant proposal.
All components of the JSDF Project included output-level indicators, including ones related to monitoring and evaluation and dissemination of knowledge, such as: (i) coordination of roundtables for PHC workers, volunteers and DHA officials; (ii) submission of quarterly progress and final evaluation study and completion report, (iii) communication strategy on project objectives and results, including disclosure of M&E indicators; (iv) one baseline and one final surveys, and (v) annual audit reports. All these activities were successfully completed, with targets of all indicators achieved, which contributed to the achievement of the PDO indicators and, ultimately, to improved health and nutrition status of the key targeted beneficiaries.
Dissemination of knowledge: As described under the Sub-objective 5, the Project also systematically disseminated knowledge related to all its activities and results by distributing various educational manuals, awareness-raising and results-reporting materials among the targeted population groups as well as more widely among the general population. The Project conducted 154 coordination meetings, discussions with PHC workers, community volunteers and community leaders (heads of jamoats) on nutrition and IMCI issues. Multiple communication channels, such as printed and electronic materials, trainer-delivered theoretical and practical training sessions, TV and radio broadcasts, website publications were actively and effectively used for behavior-change communication to achieve its intended results. Increase in the number of mothers able to correctly mention at least 3 key actions for managing children’s illness at home and mothers/caregivers able to name at least three key actions to improve their children’s nutrition shows the effectiveness of these interventions.
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B. Additional Indicators Monitored by the JSDF-supported Project
№ Name of indicator 2015 baseline survey 2017 interim survey 2018 final survey End Target Remarks
47% Decrease by 19 1. Proportion of pregnant women with anemia 64% 45% N/A DHS-2017 percentage points 46% Decrease by 5 percentage 2. Proportion of children under 5 with anemia 50% 46% N/A DHS-2017 points
Proportion of children from 0 to 6 months under exclusive Increase by 19.8 3. 11% 30% 31% N/A breastfeeding percentage points
Proportion of children under 5 with low weight (Z scores Decrease by 20% 4. below minus two standard deviations from median weight 7% 6% 6% Overachieved Underweight 7.4% for age)
Proportion of households in pilot districts consuming iodized Increase by 3 percentage 5. 90% 91% 94% N/A salt pursuant to the norm points 10% increase over 6. Proportion of households using small household gardens 70% 96% 98% Overachieved baseline
Crop yield percentage on cultivating agricultural crops in 10% increase over 7. 38 kg per 1 acre of land 150 kg per acre of land 63 kg per acre of land Overachieved household gardens baseline
Proportion of health workers able to correctly answer 10% increase over 8. 53% 82% 92% Overachieved questions on managing more common children’s illnesses baseline
Proportion of volunteers able to correctly answer questions 10% increase over 9. 25% 78% 84% Overachieved on managing more common children’s illnesses baseline
The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
C. Output Indicators Included in the Approved Tajikistan JSDF Nutrition Grant Scale Up Proposal
Indicator 2015 2016 2017 End Target
Number of doctors and nurses re-trained 9 doctors 15 doctors 55 doctors 80 doctors on Family Medicine. 29 nurses 72 nurses 184 nurses 160 nurses
1,039 health workers 1,031 health workers 977 health workers 1,000
Number of trained health workers on healthy nutrition and IMCI 301 doctors and 730 133 doctors and 844 339 doctors and 700 1,000 health nurses (including 1,097 nurses (including 653 nurses workers female health workers) female health workers)
Number of community volunteers 300 300 126 300 trained on healthy nutrition and IMCI Number of pregnant and lactating women trained on healthy nutrition, 56,249 182,979 154,364 75,000 child care, care for a sick child, prevention of childhood illnesses 3,000 households provided in 4th and 5th Number of households provided with 3,000 households once 3,000 households twice rounds with fertilizers 12,000 seeds and fertilizers and in 2nd and 3rd rounds with seeds Number of households trained on cultivation of agricultural crops in small 2,100 900 - 3,000 household gardens
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
Indicator 2015 2016 2017 End Target
Number of children under two years of age who received Micronutrient Sprinkles*(each child received 2 sachets 0 70,000 70,000 50,000 of Micronutrient Sprinkles per distribution) Number of pregnant and lactating women who received iron supplements 0 15,277 2,223 70,000 and folic acid Number of coordination roundtables /discussions of the representatives of the PHC facilities, volunteers and chiefs of 0 42 56 56 the jamoats regarding nutrition and IMCI issues
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
D. Distribution of Seeds in Pilot Districts
1st Round, Seeds, kg 2nd Round, Seeds, kg 3rd Round, Seeds, kg
No. District
Peas Peas Peas
Bean Bean
Lentil
Carrot Carrot Carrot
Potato Potato Potato
Beetroot Beetroot Beetroot
1 Norak 7,500 300 90 7,500 300 90 7,500 300 300 2 Danghara 7,500 5 200 15 60 7,500 8 200 20 60 7,500 8 200 20 200 3 Temurmalik 7,500 4 225 11 67 7,500 6 225 15 67 7,500 6 225 15 225
4 Baljuvon 7,500 300 90 7,500 300 90 7,500 300 300 5 Khovaling 7,500 7,5 150 22,5 45 7,500 12 150 30 45 7,500 12 150 30 150 6 Muminobod 7,500 5 200 15 60 7,500 8 200 20 60 7,500 8 200 20 200 7 Sh. Shohin 7,500 7,5 150 22,5 45 7,500 12 150 30 45 7,500 12 150 30 150
8 Panj 7,500 15 45 7,500 24 60 7,500 24 60
9 Farkhor 7,500 15 45 7,500 24 60 7,500 24 60
10 Hamadoni 7,500 15 45 7,500 24 60 7,500 24 60 Total 75,000 74 1,525 221 457 75,000 118 1,525 295 457 75,000 118 1,525 295 1,525
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
E. Distribution of Mineral Fertilizers in Pilot Districts
Round 4, mineral Round 6, mineral Round 1, mineral Round 2, mineral Round 3, mineral Round 5, mineral fertilizers fertilizers Number of fertilizers fertilizers fertilizers fertilizers No. Districts (Nitroammophoska (Nitroammophoska households (Nitroammophoska) (Carbamide) (Nitroammophoska) (Nitroammophoska) and Carbamide) and Carbamide) distribution distribution distribution, kg distribution, kg distribution, kg distribution, kg 1 Norak 300 3,600 1,800 3,600 3,000 3,600 3,000 2 Danghara 300 3,600 1,800 3,600 3,000 3,600 3,000 3 Temurmalik 300 3,600 1,800 3,600 3,000 3,600 3,000 4 Baljuvon 300 3,600 1,800 3,600 3,000 3,600 3,000 5 Khovaling 300 3,600 1,800 3,600 3,000 3,600 3,000 6 Muminobod 300 3,600 1,800 3,600 3,000 3,600 3,000 7 Sh. Shohin 300 3,600 1,800 3,600 3,000 3,600 3,000 8 Panj 300 3,600 1,800 3,600 3,000 3,600 3,000 9 Farkhor 300 3,600 1,800 3,600 3,000 3,600 3,000 10 Hamadoni 300 3,600 1,800 3,600 3,000 3,600 3,000 Total 3,000 36,000 18,000 36,000 30,000 36,000 30,000
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The World Bank Tajikistan JSDF Nutrition Grant Scale Up (P146109)
F. Distribution of Micronutrients
Number of Iron and Folic acid № Name of district Sprinkles supplements
1 Vose 2,340 40,000 2 Kulob city 2,892 18,000 3 Kulob district 20,000 918 4 Danghara 32,000 1,620 5 Sh. Shohin 8,000 1,350 6 Muminobod 16,000 522 7 Khovaling 11,000 234 8 Hamadoni 28,000 531 9 Temurmalik 12,000 1,350 10 Farkhor 36,000 613 11 Baljuvon 7,000 603 12 Norak 12,000 477 13 Kurgan-Tube 18,000 900 14 Panj 1,400 22,000 Total: 280,000 15,750
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