Document of The World Bankdocuments.worldbank.org/curated/en/...children under 5 and 35% among women...

Document of

The World Bank FOR OFFICIAL USE ONLY

Report No: ICR00004261

IMPLEMENTATION COMPLETION AND RESULTS REPORT

ON A

CREDIT and GRANT

IN THE AMOUNT OF SDR 25.9 MILLION

(US$ 40 MILLION EQUIVALENT)

TO THE

Ministry of Finance

FOR THE

NEPAL: COMMUNITY ACTION FOR NUTRITION PROJECT (SUNAULA HAZAR DIN) ( P125359 )

March 28, 2018

Health, Nutrition & Population Global Practice

South Asia Region

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CURRENCY EQUIVALENTS

(Exchange Rate Effective {Oct31, 2017})

Currency Unit = NPR

NPR 103.63 = US$1

US$ 1.40 = SDR 1

FISCAL YEAR

July 1 ‐ June 30

Regional Vice President: Annette Dixon

Country Director: Qimiao Fan

Senior Global Practice Director: Timothy Grant Evans

Practice Manager: E. Gail Richardson

Task Team Leader(s): Manav Bhattarai

ICR Main Contributor: Abeyah A. Al‐Omair

ABBREVIATIONS AND ACRONYMS

AAMA Action Against Malnutrition through Agriculture

CDD Community Driven Development

CPS Country Partnership Strategy

DDC District Development Committee

DALY Disability Adjusted Life Year

DHS Demographic and Health Survey

FA Financing Agreement

FM Financial Management

GoN Government of Nepal

ICR Implementation Completion and Results

IDA International Development Association

IFA Iron and Folic Acid

ISN Interim Strategy Note

ISR Implementation Status Report

M&E Monitoring and Evaluation

MAM Moderately Acute Malnourished

MOFALD Ministry of Federal Affairs and Local Development

MSNP Multi Sector Nutrition Plan

MTR Mid‐Term Review

NAGA Nutrition Assessment and Gap Analysis

NFSSC Nutrition and Food Security Steering Committee

NHSP Nepal Health Sector Program

NLSS Nepal Living Standard Survey

PAD Project Appraisal Document

PDO Project Development Objective

PM Procurement Management

PMT Project Management Team

RRA Rapid Results Approach

RRI Rapid Result Initiative

RRNI Rapid Results for Nutrition Initiatives

SAM Severely Acute Malnourished

SHD Sunaula Hazar Din

SoE Statement of Expenditures

SWAp Sector Wide Approach

SUN Scaling Up Nutrition

UNICEF United Nations International Children's Emergency Fund

VDC Village Development Committee

WHO World Health Organization

TABLE OF CONTENTS

DATA SHEET ................................................................................................................................................................... 1

I. PROJECT CONTEXT AND DEVELOPMENT OBJECTIVES .......................................................................................... 6

A. CONTEXT AT APPRAISAL ................................................................................................................................... 6

B. SIGNIFICANT CHANGES DURING IMPLEMENTATION (IF APPLICABLE) ........................................................... 11

II. OUTCOME ........................................................................................................................................................... 13

A. RELEVANCE OF PDOs ...................................................................................................................................... 13

B. ACHIEVEMENT OF PDOs (EFFICACY) ............................................................................................................... 14

C. EFFICIENCY ...................................................................................................................................................... 19

D. JUSTIFICATION OF OVERALL OUTCOME RATING............................................................................................ 21

E. OTHER OUTCOMES AND IMPACTS (IF ANY) .................................................................................................... 21

III. KEY FACTORS THAT AFFECTED IMPLEMENTATION AND OUTCOME .................................................................. 22

A. KEY FACTORS DURING PREPARATION ............................................................................................................ 22

B. KEY FACTORS DURING IMPLEMENTATION ..................................................................................................... 24

IV. BANK PERFORMANCE, COMPLIANCE ISSUES, AND RISK TO DEVELOPMENT OUTCOME ................................... 25

A. QUALITY OF MONITORING AND EVALUATION (M&E) .................................................................................... 25

B. ENVIRONMENTAL, SOCIAL, AND FIDUCIARY COMPLIANCE ............................................................................ 27

C. BANK PERFORMANCE ..................................................................................................................................... 28

D. RISK TO DEVELOPMENT OUTCOME ............................................................................................................... 30

V. LESSONS AND RECOMMENDATIONS .................................................................................................................. 30

ANNEX 1. RESULTS FRAMEWORK AND KEY OUTPUTS ................................................................................................. 32

ANNEX 2. BANK LENDING AND IMPLEMENTATION SUPPORT/SUPERVISION ............................................................. 43

ANNEX 3. PROJECT COST BY CATEGORIES ................................................................................................................... 46

ANNEX 4. EFFICIENCY ANALYSIS .................................................................................................................................. 47

ANNEX 5. BORROWER, CO‐FINANCIER AND OTHER PARTNER/STAKEHOLDER COMMENTS ...................................... 49

ANNEX 6. SUPPORTING DOCUMENTS ......................................................................................................................... 51

The World Bank Nepal: Community Action for Nutrition Project (Sunaula Hazar Din) ( P125359 )

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DATA SHEET

BASIC INFORMATION Product Information

Project ID Project Name

P125359 Nepal: Community Action for Nutrition Project (Sunaula

Hazar Din)

Country Financing Instrument

Nepal Specific Investment Loan

Original EA Category Revised EA Category

Partial Assessment (B) Partial Assessment (B)

Organizations

Borrower Implementing Agency

Ministry of Finance Ministry of Federal Affairs and Local Development

Project Development Objective (PDO) Original PDO

The Development Objective for the Project is to improve attitudes and practices known to improve nutritional outcomes of women of reproductive age and children under the age of 2. Changes in attitudes and practices would address the key risk factors for child malnutrition and create demand for nutrition related services and products. The supply of these services and products will be provided through existing public sector and donor‐funded programs, the private sector and, to a limited extent, financed through the Project. Revised PDO

The proposed revised PDO is "to improve practices that contribute to reduced under‐nutrition of women of reproductive age andchildren under the age of two and to provide emergency nutrition and sanitation response to vulnerable populations in Earthquakeaffectedareas.”


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FINANCING

Original Amount (US$) Revised Amount (US$) Actual Disbursed (US$)

World Bank Financing IDA‐H7860

18,000,000 18,000,000 15,803,579

IDA‐51370

22,000,000 17,900,446 15,779,816

Total 40,000,000 35,900,446 31,583,395

Non‐World Bank Financing

Borrower 0 0 0

Total 0 0 0

Total Project Cost 40,000,000 35,900,446 31,583,394

KEY DATES

Approval Effectiveness MTR Review Original Closing Actual Closing

26‐Jun‐2012 24‐Aug‐2012 15‐Feb‐2015 30‐Jun‐2017 30‐Jun‐2017

RESTRUCTURING AND/OR ADDITIONAL FINANCING

Date(s) Amount Disbursed (US$M) Key Revisions

30‐Jun‐2015 4.86 Change in Project Development Objectives Change in Results Framework Change in Components and Cost Reallocation between Disbursement Categories Change in Disbursements Arrangements Change in Legal Covenants Change in Institutional Arrangements Change in Financial Management Change in Procurement

KEY RATINGS

Outcome Bank Performance M&E Quality

Satisfactory Satisfactory Substantial


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RATINGS OF PROJECT PERFORMANCE IN ISRs

No. Date ISR Archived DO Rating IP Rating Actual

Disbursements (US$M)

01 14‐Nov‐2012 Satisfactory Satisfactory 0

02 19‐Jun‐2013 Moderately Satisfactory Moderately Satisfactory 2.00

03 16‐Oct‐2013 Moderately Satisfactory Moderately Satisfactory 2.00

04 27‐Mar‐2014 Moderately

Unsatisfactory Moderately Unsatisfactory 2.04

05 06‐Aug‐2014 Moderately

Unsatisfactory Moderately Satisfactory 2.04

06 27‐Jan‐2015 Moderately


07 15‐Apr‐2015 Moderately


08 09‐Oct‐2015 Moderately


09 24‐Jan‐2016 Moderately

Unsatisfactory Moderately Satisfactory 12.06

10 30‐Mar‐2016 Moderately Satisfactory Moderately Satisfactory 16.65

11 25‐Sep‐2016 Moderately Satisfactory Moderately Satisfactory 16.65

12 23‐Mar‐2017 Moderately Satisfactory Moderately Satisfactory 27.65

13 23‐Jun‐2017 Moderately Satisfactory Moderately Satisfactory 27.65

SECTORS AND THEMES

Sectors

Major Sector/Sector (%)

Health 36

Public Administration ‐ Health 7

Health 29


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Social Protection 35

Social Protection 29

Public Administration ‐ Social Protection 6

Water, Sanitation and Waste Management 29

Sanitation 29

Themes

Major Theme/ Theme (Level 2)/ Theme (Level 3) (%) Human Development and Gender 76

Health Systems and Policies 50

Reproductive and Maternal Health 25

Child Health 25

Nutrition and Food Security 26

Nutrition 13

Food Security 13

Urban and Rural Development 25

Rural Development 25

Rural Infrastructure and service delivery 25

ADM STAFF

Role At Approval At ICR

Regional Vice President: Isabel M. Guerrero Annette Dixon

Country Director: Ellen A. Goldstein Qimiao Fan

Senior Global Practice Director: Amit Dar Timothy Grant Evans

Practice Manager: Julie McLaughlin E. Gail Richardson

Task Team Leader(s): Albertus Voetberg Manav Bhattarai

ICR Contributing Author: Abeyah A. Al‐Omair


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I. PROJECT CONTEXT AND DEVELOPMENT OBJECTIVES

A. CONTEXT AT APPRAISAL

Context 1. Despite the long period of political instability and transition towards peace, Nepal made significant progress

on reducing poverty and hunger. Nepal had gone through a long period of political unrest, insurgency, and violence which lasted more than a decade and resulted in a significant number of deaths and internally displaced persons. The country achieved remarkable progress by halving the percentage of people living on less than $1.25 a day in only seven years, from 53 percent in 2003/2004 to 25 percent in 2010/20111. Nepal Living Standards Surveys (NLSSs) II and III found the incidence of poverty to have declined by one percentage point per year between 2005 and 20102.

2. At the time of project appraisal in 2011, Nepal was achieving steady improvements in health outcomes. Between the period of 1990 and 2011, significant progress had been made to reduce under‐five mortality by 62%, from 142 per thousand live births in 1990 to 54 in 2011, and infant mortality by 54%, from 99 per thousand live births to 46. Similarly, the maternal mortality ratio had decreased by 76%, from 790 per 100,000 live births in 1996 to an estimated 190 in 2011. In 2009, Nepal received a “Child Survival Award” from GAVI Alliance (GAVI) for its outstanding performance in improving child health and immunization (progress in MDG43). Similarly, in 2010, Nepal received a UN MDG 5 award for its outstanding national leadership, commitment and progress toward achievement of improved maternity health goal under the MDG‐54,5.

3. Despite remarkable successes in achieving most of the MDGs targets, malnutrition had remained a serious problem for Nepal with deleterious consequences for the human development and overall economy. Nepal ranked in the top 10 countries with the highest prevalence of stunting and was one of the top 20 countries with the highest number of stunted children6. While the stunting rate of under‐five children had dropped from 57% in 2001 to 41% in 2011, Nepal needed to bring down the stunting rate to 30% to meet the MDG target on malnutrition by 20157. Similarly, over the same period, slow progress was made to reduce the ratio of underweight children under‐five (from 43% to 29%), and there was only a slow decline in reducing the proportion of wasted children (from 13% in 2006 to 11% in 2011)8. Nepal Demographic and Health Survey 2011 (DHS) showed that the key nutritional deficiency, anemia, continued to be high; it was recorded as 46% among children under 5 and 35% among women aged 15‐499 (DHS 2011) and half of pregnant women and children under five had micronutrient deficiencies.

1 Nepal Country Partnership Strategy FY2014‐2018, World Bank 2014 2 Nepal and the Millennium Development Goals ‐Status Report (2000‐2015). Accessed November 6,2017. 3 http://www.gavi.org/library/news/press‐releases/2009/gavi‐honours‐15‐countries‐for‐excelling‐in‐immunisation‐and‐child‐survival/. Accessed December 14,2017. 4 WHO Country Cooperation Strategy Nepal, 2013‐2017 5 MDG targets are to lower the prevalence of underweight children aged 6‐59 months to 29 and to reduce the proportion of stunted children aged 6‐59 months to 30 by 2015. 6 The State of the World’s Children Report. UNICEF 2009 7 Nepal and the Millennium Development Goals ‐Status Report (2000‐2015). Accessed November 6,2017. 8 Nepal and the Millennium Development Goals ‐Status Report (2000‐2015). Accessed November 6,2017. 9 Nepal Demographic and Health Survey 2011


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4. While the problem of malnutrition was pervasive across the country, there was a wide disparity of nutritional outcomes across economic and geographic strata. Glaring disparities existed between urban and rural dwellers, geographical regions and various social groups. In 2010/2011, the mountains and hills had a higher percentage of poor people than the Terai areas. Similarly, rural10 children were more likely to be underweight (30%) than urban children (17%). Children living in the mountain zone were also more likely to be underweight (36%) than those living in the Terai zone (30%) and the hilly zone (27%)11. Children in food‐secure households had the lowest rates of stunting (33%) while children in food‐insecure households had stunting rates up to 49%12.

5. The Government of Nepal (GON) had several successful engagements with the World Bank to support the health sector, which also included support for nutrition. The first Nepal Health Sector Program (NHSP I, 2004‐2010) was implemented using a Sector Wide Approach (SWAp) and involved donors across the health sector. The project focused on expanding access and increasing utilization of essential health care services. The project made significant improvements in key health indicators however, several challenges remained, especially for the underserved segments of the society. Therefore, the following engagement (NHSP II, 2010‐2015) was a continuation of IDA support and followed the same financing modality to enable the GON to increase access to essential health care services and their utilization by the underserved and the poor. While NHSP I and NHSP II focused on improving coverage and access, the current ongoing operation approved in 2016 (Nepal Health Sector Management Reform Program‐for‐Results) focuses on improving efficiency in public resource management of the health sector by financing against the achievement of a set of mutually agreed targets related to financial management, procurement management, use of information systems and citizen engagement13.

6. Improving nutritional status of children and women has been a top priority for the GoN. The GoN had been implementing a wide range of programs to improve the nutrition outcomes in the country. This included: (i) direct or nutrition ‘specific’ programs such as micronutrient supplements to children and women during pregnancy, salt iodization, and behavioral change communication on young children feeding; and (ii) indirect or nutrition ‘sensitive’ programs such as non‐conditional cash and in‐kind transfers, school feeding programs, etc. To step up the efforts to improve the nutrition profile for the Nepalese people, the GoN had undertaken a comprehensive Nutrition Assessment and Gap Analysis (NAGA) in 2010 to provide the synthesis of information necessary to accelerate the reduction of maternal and child malnutrition in the country. NAGA provided an impetus to the development of a multi‐sector nutrition plan (MNSP) for FY2013‐2017‐ which was being developed at the time of appraisal and provided a multi‐stakeholder, multi‐sectoral platform under the National Planning Commission, the highest planning level authority in the country.

7. Nepal launched the Sunaula Hazar Din (SHD) – Community Action for Nutrition Project, approved by the Bank in 2012. SHD was the first Bank‐supported standalone nutrition project in Nepal that focused on improving the nutritional status of women and young children. The project introduced an innovative community‐driven rapid results approach (RRA) in which communities would choose a focus area from a ‘menu’ of 15 different areas with 29 different goals relating to improved nutrition including, for instance, improved breastfeeding practices, improved hygiene practices, and continued schooling for girls (The complete list of focus areas and goals is in

10 Nepal is divided into 75 districts distributed across different ecological zones and development regions. The districts are divided into urban (municipalities) and rural (village development committees), VDCs are further divided into wards. 11WHO Country Cooperation Strategy Nepal, WHO 2012. 12 https://www.usaid.gov/what‐we‐do/global‐health/nutrition/countries/nepal‐nutrition‐profile Accessed December 13,2017 13 The Project Development Objective of the Program‐for‐Results is to improve efficiency in public resource management systems of the health sector in Nepal. Approved January 13,2017.


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Annex 6). The communities would then formulate a plan to achieve the self‐selected goal, and were to be provided with a grant to implement their plan in 100 days. The ultimate goal was to work at the community level to change practices known to lead to better nutritional outcomes in the long run.

8. Rapid Result Initiative (RRI): As discussed above, malnutrition in Nepal had been a persistent problem despite the local and international efforts to tackle it. Hence, the project adopted an innovative design using the RRI which is known to be a useful tool to solve complex problems14 under the pressure of short time frames and ambitious targets. The project design was unique because for the first time, the Rapid Results Approach was being used as the core method of design and delivery for a large scale five‐year project, rather than being brought in to ‘connect the last mile’ in projects that encountered implementation challenges.

9. The SHD project employed the community‐driven rapid results approach to help communities identify and change key nutrition‐related behaviors that have a detrimental effect on child growth and development within the nation’s poorest rural communities. Whilst this approach was new to Nepal, there was a strong track record in Nepal of community‐driven development (CDD).

Theory of Change (Results Chain) 10. The project’s theory of change is based on UNICEF’s conceptual framework of malnutrition which the nutrition

community has been using for programming since 1990 which emphasizes that causes of malnutrition are multisectoral.15 The framework classifies the causes of malnutrition as: (i) immediate (such as: inadequate food intake and diseases); (ii) underlying (such as household food security, adequate care and feeding practices, access to health services, and residing in a healthy environment, etc.); and (iii) basic (such as: social, economic, environmental, and political issues).

11. As illustrated in Table 1 below, the causal chain of the proposed activities is as follows:

Table 1. Causal Chain of the proposed activities

Activities Outputs Outcomes Long‐term Outcomes

Training of communities in selection of goals. Each community to implement a selected nutrition defined goal.

Rapid Results for Nutrition Initiatives (RRNIs) implemented by communities at ward level, with each RRNI dedicated to achieve one of pre‐defined nutrition related goals selected by targeted communities.

Improved attitudes and practices known to improve nutritional outcomes of women of reproductive age and children under the age of two.

Improved nutritional outcomes.

14 Obogn’o Sylvester (2012) “Rapid Results Approach/Initiative. Institutionalization of Results Based Management in Kenya Public Service” Mimeo. Commwealth Association for Public Administration and Management. 15 https://www.unicef.org/nutrition/training/2.5/4.html. Accessed December 5,2017.


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Project Development Objectives (PDOs) 12. The original PDO16 as stated in both the Project Appraisal Document (PAD) and the Financing Agreement was to

“improve attitudes and practices known to improve nutritional outcomes of women of reproductive age and children under the age of two”. The statements in the PAD (2014) and Financing Agreement (FA) are consistent.

Key Expected Outcomes and Outcome Indicators 13. The original PDO was measured through improvements in: (i) family planning practices of girls and young women

aged 15‐25 years; (ii) practices of pregnant women regarding iron and folic acid supplementation; (iii) breastfeeding practices of mothers with children 0‐6 months of age; (iv) child feeding practices of households with children 6 to 24 months of age; (v) attitude of community members towards the importance of keeping girls school until age 20; (vi) attitude of community members towards the importance of reducing indoor air pollution and (vii) attitudes of pregnant women towards their dietary needs. Annex 1 provides the complete Results Framework, including a description of intermediate indicators and how indicators were measured.

Components 14. The project originally had two main components with total cost of $40 million. A description of components is

as follows:

Component 1: Rapid Results for Nutrition Initiatives at the Ward Level (US$34.86 million) 15. This component supported the communities at the ward level to design and implement small projects (called

RRNIs) based on a predefined “menu” of interventions that address risk factors of malnutrition in Nepal. Each 100‐day “RRNI” cycle follows mainly six key steps as described below17 and as illustrated in Figure 1 below.

16. Selection of ‘focus area’ and RRNI team members: The first step involved a coach conducting a workshop with the Ward Citizen Forum (WCF). The WCF is a ward‐level body with 20‐25 members representing various socio‐economic, ethnic, religious and age groups of the ward. The WCF would identify needs of the ward in nutrition improvement and select an appropriate “Focus Area” to address that need. There were 15 Focus Areas pre‐identified by the SHD program, and the WCF members selected one focus area for that particular 100‐day cycle. The WCF, with guidance from the coach, also selected 9 people from the ward to form the “RRNI team”. Please refer to Annex 6 for the full list of focus areas.

17. Selection of RRNI team leader and 100‐day project goal: The second step was a meeting among these RRNI team members to develop a goal (i.e., activity) within the selected Focus Area, to be achieved through the 100‐day RRNI project cycle. For example, if the WCF had selected a focus area of “improved hand washing”, then the RRNI team would decide what kind of concrete activities were needed to work on in order to achieve better hand‐washing practice in 100 days. They would also select a RRNI team leader to coordinate team members and activities.

17 Qualitative Study of Community Action for Nutrition Project Nepal. March 2017


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18. Preparation and submission of proposal: Once a particular goal/activity was chosen, the RRNI team developed a detailed 100‐day work plan to help achieve that goal, as well as the budget required to execute the plan.

19. Review and approval of the proposal: The submitted work plan and budgets were reviewed and then approved by the local government (by the Village Development Committee (VDC) for projects less than $1,000; by the District Development Committee (DDC) for projects between $1000 and $3000), and the necessary funds were released to the communities.

20. 100‐day implementation: Communities started to execute their plan and achieve their goal within 100 days. Implementation was divided into first 50 days and second 50 days, separated by a mid‐term review to assess the progress, celebrate successes and make necessary course‐corrections.

21. Review of results and sustainability: Finally, after this 100‐day cycle, the community organized a ‘sustainability review’ to assess the achievements, celebrate success and plan for sustainability of the practices. The coach (and sometimes an outside monitor) also assessed whether or not the goal had been achieved. If the community had been unsuccessful, it could apply for another cycle to try to achieve the same goal or another one. If the community had been successful, it could then apply for two goals at once.

Component 2: Project Management, Capacity Building, Monitoring and Evaluation (US$5.14 million)

22. This component comprised three subcomponents: (i)capacity enhancement of the Project Management Team, including Cluster Units, and Food Security and Nutrition Steering Committees (NFSSCs), as well as of coaches and social mobilizers; (ii) providing necessary inputs (consultants, goods and operating costs) for effective project management at national, DDC and VDC levels; and (iii) ensuring monitoring and evaluation of the Project, including the evaluation of the RRNI process through routine and third‐party monitoring. Please refer to Annex 3 for project cost by categories.

1) Selection of Focus Area & RRNI team members at

Ward Citizen Forum

2) Selection of RRNI team leader & 100‐day subproject goal

3) Preparation and submission of

Proposal

4) Review and approval of proposal

5) 100‐day Implementation

6) Review of results and sustainability RRNI

Project

Cycle

Figure 1: Key Steps in the 100‐day Rapid Results Nutrition


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B. SIGNIFICANT CHANGES DURING IMPLEMENTATION (IF APPLICABLE)

Revised PDOs and Outcome Targets

23. Following the project’s mid‐term review (MTR), the project underwent a Level 1 restructuring which was approved on June 17, 2015. The key changes are summarized as follow:

(i) Revision of the PDO. The modified PDO was "to improve practices that contribute to reduced under‐nutrition

of women of reproductive age and children under the age of two and to provide emergency nutrition and

sanitation response to vulnerable populations in earthquake affected areas”. The rationale for revising the PDO

was to sharpen the focus of the project on improved practices as well as the emerging nutrition and sanitation

needs. The focus on attitudes was dropped because it was realized that such changes were likely to take longer

than the project period thus making this part of the PDO not fully measurable.

(ii) Addition of an Earthquake Relief Component. The rationale for adding an earthquake component (US$12

million) was to address the emergency nutrition issues which had arisen from the devastating effect of the April

25, 2015 earthquake and its aftershocks in critically affected districts18. It was decided that the implementing

agency (MoFALD) would be supported by UNICEF Nepal in providing emergency response in areas of nutrition

protection and water, sanitation and hygiene as UNICEF had the required technical capacity and standard

protocols to support the delivery of this component.

(iii) Revision of the Results Framework to reflect the changes to the PDO and ensure better alignment with the

intended project outcomes. The list of dropped, modified, added indicators is in Table 2 as follows:

Table 2. Changes to Project Indicators

Dropped PDO level indicators

Modified PDO level indicators Added PDO level indicators

Percentage of unmet family planning needs among women 15‐25 years of age

Attitude of community members towards the importance of reducing indoor air pollution. Changed to: percentage of households reporting no smoke in the room while cooking.

Percent of households reporting using improved toilet facilities (flush toilet, covered pit within household, community latrine).

Attitude of community members towards the importance of keeping girls in school until at least 20 years of age

Attitude of pregnant women towards the importance of eating three time a day including at least one animal‐sourced food per day. Changed to: percent of pregnant women reporting consuming animal‐sourced protein in the previous day.

Percent of mothers (of children aged 0‐2) reporting always washing hands at critical times (composite of 4 indicators: washing hands after defecation, washing hands after cleaning child’s bottom, washing hands before eating, washing hands before feeding the children).

Number of children 6‐59 months old in the earthquake affected districts with Severe Acute Malnutrition receiving therapeutic care.

Number of households in the earthquake affected districts provided with hygiene and sanitation kits (water treatment products and soap.)

18 The critically affected 12 districts were: Dhading, Gorkha, Rasuwa, Sindhupalchowk, Kavre, Nuwakot, Dolakha, Sindhuli, Makwanpur, Okhaldhunga, Ramechhap and Lalitpur.


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Other changes included:

(iv) Revision of fiduciary and implementation arrangements. Several corrective steps were introduced to increase

the overall effectiveness of project management, improve the quality of the sub‐project proposals and enhance

efficiency of proposal processing as follows: (i) strengthening the project management team (PMT) by hiring of

additional staff namely three M&E officers, an administrative officer and finance staff; (ii) adding two staff in

each of the 15 districts to expedite proposal processing; (iii) allowing each ward to submit two proposals at the

same time to reduce processing time; (iv) conducting intensive training for FM staff, coaches and supervisors;

and (v) carrying out re‐orientation sessions on project approach, targets and implementation modalities for DDC

level staff.

(v) Revision of the disbursement estimates. A total of US$12 million had been moved from component 1 to the

added third component “Earthquake Relief Component”. As discussed below, given that the project adopted a

demand‐driven approach and relied on mobilizing communities to collectively commit to address the risk factors

of malnutrition, the initially estimated budget for the RRNIs could not be precise but sufficient funds were

allocated to allow communities to implement sub‐projects in all selected districts if all such communities would

apply. At the MTR, it became clear that not all funds would likely be absorbed and hence when the earthquake

took place immediately following the MTR, US$12 million was reallocated to that component as part of the

Bank’s earthquake response relief plan.

Implications on the original theory of change

As per the revised PDO, the theory of change is as follows:

Activities Outputs Outcomes Long Term Outcomes

1) Training of communities in selection of goals. Each community to implement a selected nutrition defined goal.

2) Provide emergency nutrition and sanitation response to vulnerable populations in earthquake affected areas (namely: (i) provision of therapeutic care and supplementary food supplies and protection of breast feeding, (ii) provision of safe water and of appropriate sanitation and hygiene kits, and (iii) provision of latrines).

1) RRNIs implemented by communities at ward level, with each RRNI dedicated to achieve one of pre‐defined nutrition related goals selected by targeted communities.

2) Provide nutrition care and treatment to severely acute malnourished (SAM) and moderately acute malnourished (MAM) children, and malnourished mothers.

1) Improve attitudes and practices known to improve nutritional outcomes of women of reproductive age and children under the age of two

2) SAM and MAM children and malnourished mothers are treated and prevented from deterioration of their nutritional status.

Improved nutritional outcomes of children and mothers.


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II. OUTCOME

24. The outcome rating for this project is assessed against the original and revised objectives. Given that the original scope of the project was not narrowed as a result of restructuring but actually expanded with the Earthquake Component, the assessment of outcomes does not apply a split rating even though the PDO was slightly revised. However, this ICR assesses all parts of the PDO, including the original and revised.

A. RELEVANCE OF PDOs

Rating: High

Assessment of Relevance of PDOs and Rating

25. The project was highly relevant to and consistent with the priorities laid out in the Bank’s Nepal Interim Strategy Note (ISN 2010‐2011). At the time of project preparation, Nepal was going through a transitional period of its history, with a new government to be formed and a new constitution to be drafted. The country’s overarching goal – as stated in ISN FY2010‐2011‐ was to build peace and focus on development19. The ISN indicated that the high burden of malnutrition in Nepal was a major persisting shortcoming and undermined the human potential needed to achieve sustained and resilient growth. Similarly, the following ISN (FY2012‐2013) also emphasized food and nutrition security as a main area of intervention. The focus on nutrition was highly relevant to the third pillar, namely, promoting access to better quality services20.

26. The PDOs and project activities remained well‐aligned with government priorities. The GoN development strategy outlined in the Three Year Plan Approach Paper for FY2010‐2013 included nutrition as a separate chapter. Nutrition and nutrition related indicators were explicitly included in the Three‐year Interim Plan (2007‐10). The following Three‐Year Plan (2010‐13) included nutrition as a separate chapter under Health and Nutrition for the first time with an emphasis on nutrition under the agriculture, labor, water and sanitation, education, forest, and women and social welfare sectors21.

27. Globally, Nepal joined the Scaling Up Nutrition (SUN) movement in 2011. At the same time, the government launched a multi sectoral nutrition plan (2013‐2017) under the leadership of the Prime Minister. The plan aimed to address both the immediate underlying causes of undernutrition with a package of nutrition specific and nutrition sensitive interventions focusing on the critical 1000‐day window including the mother’s pregnancy and the child’s first two years. The plan engaged the National Planning Commission and with participation of five‐line ministries covering health, education, water and sanitation, agriculture, and local development and social protection.

28. The project remained highly relevant. On April 25, 2015, a catastrophic magnitude 7.8 earthquake struck the south‐central Asian country of Nepal, killing more than 8,600, making this the nation’s deadliest disaster on record. After weeks of aftershocks, another powerful magnitude 7.3 earthquake struck the same region on May 12. Some 8 million people were affected by the quakes. According to UNICEF, 1.7 million children urgently needed

19 The project is particularly relevant to the third pillar of “Enhancing equitable access to services and social inclusion”. 20 The Country Partnership Strategy FY2014‐2018 focused on Improved health and nutrition services, particularly for the poor and disadvantaged under pillar two (Pillar 2: Increasing inclusive growth and opportunities for shared prosperity). 21 https://scalingupnutrition.org/wpcontent/uploads/2013/03/Nepal_MSNP_2013‐2017.pdf


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aid and more than 750,000 homes were destroyed. The project was restructured to respond to the emergency nutrition needs in critically affected areas. This included adding a new component for earthquake relief and adding more districts to target beneficiaries in the earthquake critically affected areas. The project restructure was aligned to the Bank’s Nepal Country Partnership Strategy22 (CPS FY14‐18) to enhance disaster risk management systems. The restructure was solidly anchored within the “Foundations and Cross‐Cutting Dimensions” of the Nepal CPS, which states that the “risks from natural disaster will also continue to be addressed in a cross‐cutting manner by the World Bank”.

B. ACHIEVEMENT OF PDOs (EFFICACY)

Rating: Substantial

Assessment of Achievement of Each Objective/Outcome

29. Given the novelty of the design of this project which offered the communities the option to choose from 15 different focus areas based on their needs and aspirations, the assessment of PDO 1 and 2 uses the correlation between the focus areas selected and the achievement of the goal/objective linked to them. The assessment of achievement of project objectives in this ICR reflects the data from the end‐line survey which was completed after project closing in June 30, 2017. Based on the end‐line survey data, it appears that the project met most of its objectives.

Assessment of achievement of PDO1: Improvement in attitudes of women of reproductive age and children under the age of two. Rating: Modest

30. The original PDO encompassed expected improvements in attitudes and it was realized at the time of restructuring that such changes were actually part of a long‐term process and that it was likely not the appropriate PDO for this project with a four‐year time frame. It was also felt that measuring improvements in practices was sufficient to understand the impact of RRNIs on nutrition outcomes. Hence, the PDO was revised and the attitude indicators were dropped. However, it is still possible to assess improvements in attitudes using data from the midline impact evaluation survey.

31. The project managed to make some modest positive changes in attitudes during the first two years of its implementation. The project had four attitude indicators which are discussed below:

i. Attitude of community members towards the importance of keeping girls in school until at least 20 years of age. Education of girls in Nepal has improved tremendously in the last decade. 8% of wards selected young girls’ education as a focus area. However, the midline data showed a decline on the percentage of households believing girls should be sent to school until at the least 20 years old, compared to the baseline. This is not surprising as the global evidence shows23 that young girls marriage and drop out school rates increased during the time of emergencies. Globally, adolescent girls from displaced populations are five times more likely to drop out of school. Given that the midline data was collected after the earthquake, the attitude towards girls education was likely impacted.

ii. Attitude of community members towards the importance of reducing indoor air pollution: Due to women’s

22 Nepal Country Partnership Strategy (CPS FY14‐18, Report No. 83148‐NP) 23 http://unesdoc.unesco.org/images/0024/002448/244847E.pdf . Accessed January 18,2018.


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customary involvement with cooking in Nepal, their exposure to harmful smoke inside the house is much higher than that of men. 16% of wards selected this focus area at the time of midline. A higher percentage of households (43%) reported a positive attitude towards reducing exposure to indoor smoke for pregnant women and young children compared to the baseline (32%). So, this was a particularly important finding and achievement.

iii. Attitude of community towards dietary needs for pregnant women. 16% of wards selected a focus area to maintain adequate weight and regular eating among pregnant women and young children. There was a statistically significant increase of positive attitudes of household heads in the treatment group towards importance of adequate diet of pregnant women compared to those in the control group. This was also an important achievement.

iv. The fourth PDO indicator was to assess the unmet family planning needs among women 15‐25 years of age. This was one of the least popular focus areas (i.e. at the time of midline only 1% of wards selected this focus area) and there was no data on any improvements in this area.

Assessment of achievement of PDO 2: Improvement of practices known to improve nutritional outcomes of women of reproductive age and children under the age of two. Rating: Substantial

32. The risk factors that the project was addressing arose from a combination of individual and community level knowledge and practices. They included practices such as exclusive breast feeding, taking iron and folic acid (IFA) supplements, consuming animal‐sourced protein and using improved toilet facilities. The project achieved its targets on focus areas which provided the communities with tangible and universal (community‐wide supply) outputs such as using improved toilet facilities and consuming animal sourced protein.

33. Before restructuring, the project assessed improvements on practices through the following three areas: pregnant women taking an IFA supplement, breastfeeding practices, and complementary feeding practices. As mentioned above, the revised PDO re‐emphasized the project’s focus on improving practices. Thus, in addition to the three practice PDOs mentioned above, seven indicators to assess improvement on practice were added (namely: households reporting no smoke in the room while cooking, women consuming animal‐sourced protein, using improved toilet facilities, and washing hands at critical times‐which is a composite of 4 indicators: washing hands after defecation, washing hands after cleaning child’s bottom, washing hands before eating, washing hands before feeding the children). Please refer to Annex 1 for the results framework and key outputs.

34. Overall, the project showed good improvement in 9 out of the 10 PDO indicators. Figure 2 below presents the project achievement by comparing the baseline and endline values for each of the PDO 2 indicators.


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Figure 2: Results of PDO2 Indicators

35. Given that SHD is a unique type of a CDD project in which focus area selection was demand‐driven (i.e. communities choose from a ‘menu’ of 15 different focus areas relating to improved nutrition), the frequency of selection of a focus area varies based on the communities’ selections of what they were interested in implementing. As illustrated in Table 4 below, some focus areas (such as consuming animal sourced food and using improved toilet facilities) were more popular than other focus areas (such as taking IFA supplementation, and breastfeeding).

Table 4: Percentage of Wards Selecting Each Focus Area

Indicators (PDO 2)

% of Wards selecting each Focus Area

Indicator level of achievement

Percentage of pregnant women reporting consuming animal‐sourced protein in the previous day

43% Surpassed

Percentage of households reporting using improved toilet facilities (flush toilet, covered pit within household, community latrine)

38% Surpassed

Percentage of mothers (of children aged 0‐2) reporting always washing hands at critical times

37% Surpassed

Percentage of pregnant women taking IFA supplements for 180 days 4 % Partially achieved

Percentage of children 0‐6 months age who are exclusively breastfed 6 % Not achieved

Percentage of children 6‐24 months age who consume a minimum acceptable diet

*(data is not available)

Not achieved

Percentage of households reporting no smoke in the room while cooking

28% Not achieved

36. It was noted that there is a significant correlation between the level of exposure to a particular focus area and achieving the desired outcome related to it. The areas selected also happened to be some of the most critical in impacting overall nutritional outcomes. As presented in Table 4, the four most popular focus areas selected by the


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beneficiary communities and measured were:(i) increase consumption of animal protein among pregnant women and young children, (ii) practice proper and consistent handwashing, (iii) end open defecation, and (iv) reduce exposure to indoor smoke for pregnant and young children. As Table 4 shows, the project surpassed its targets for all of these 4 measures except for exposure to indoor smoke. The project was close to achieving the target (45%) of reducing exposure to indoor smoke by midline (43%), however it dropped to (39%) by endline. It is expected that this was due to lack of access to fuel and other amenities required to build improved cooking stoves which was likely a result from the trade blockade in the Indian border that followed the earthquake.

37. Simultaneously, the two least selected focus areas: breastfeeding (selected by only 6% of wards) and IFA supplementation (selected by 4% of wards), did not achieve their PDO targets. Contrary to WHO recommendation that children under 6 months should be exclusively breastfed, Nepal’s 2016 DHS shows a country‐wide drop on rates of breastfeeding compared to 2011 (66% and 70% respectively). There is not yet a clear explanation for this trend. It is possible that the massive earthquake experienced by the Nepalese population placed greater pressure on women to work more to repair the damages and this limited their time and commitment to breastfeeding.

38. The end‐line survey shows that the project achieved remarkable success in improving sanitation practices. The five PDO indicators that assessed sanitation practices have all surpassed their targets (see Figure 3) and showed a steady improvement over time. The impact evaluation study (IE) revealed that the overall hygiene and cleanliness practices have improved. Even though it is not a PDO indicator it is noteworthy that fewer households reported observing human feces around the house as well (from 30% at baseline to 10% at endline).

Figure 3: Sanitation PDO Indicators

39. Sanitation and hygiene practices are directly linked to children’s health, and inadequate access to water or sanitation facilities can cause illnesses such as diarrhea, which increases risk of malnutrition. The IE asked the households if the child had an illness in the past 15 days prior to the interview. Households reported fewer children suffered from illnesses like coughing, diarrhea and vomiting compared to baseline (see Figure 4).


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Figure 4. Child Illness in the Past 15 Days

40. While the PAD clearly stated that the targeted changes in practices would not necessarily result in improved nutritional outcomes during the project period since improvement on nutritional outcomes takes longer period of time, in reality, the achievements did show direct impacts on outcomes. The IE included anthropometric measurements for children under two to assess changes in stunting24, wasting25 and underweight26. The assessment of anthropometric indicators showed a significant improvement over the course of the project. The rate of stunting dropped from 38% at baseline to 33% at endline, wasting dropped from 21% at baseline to 16% at endline, and underweight dropped from 32% at baseline to 15% at endline (see Figure 5). These improvements are a remarkable testament to the project’s success. It is also critical to point out that because the project was implemented in areas where no other donor was providing support (as this was an intentional split of responsibilities among the donor community), these remarkable achievements can only be attributed to this project.

Figure 5. Anthropometric Measurement of Children Under Two in Project Areas

24 Stunting: low height for age, is caused by long‐term insufficient nutrient intake and frequent infections. UNICEF 2010. 25 Wasting: low weight for height, is a strong predictor of mortality among children under five. UNICEF 2010. 26 Underweight: low weight for height, is a physical growth delay and used as a proxy for the deleterious effects undernutrition. UNICEF 2010.


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Assessment of achievement of PDO3: Emergency nutrition and sanitation relief. Rating: High

41. The project had two PDO indicators for nutrition and sanitation response to vulnerable populations in earthquake affected areas and both had surpassed their targets. The two PDO 3 indicators were: (i) number of children 6‐59 months in the earthquake affected districts with Sever Acute Malnutrition (SAM); and (ii) number of households in the earthquake affected districts provided with hygiene and sanitation kits. The project sub‐contracted UNICEF to prevent the deterioration of malnutrition in children under five and pregnant and lactating mothers in the 14 districts most critically affected by the 2015 earthquake. Active case finding of the moderately acute malnourished (MAM) children 6‐59 months led to management of about 36,100 cases out of estimated 23,250 cases. Successful management of MAM children naturally led to decrease in the number of SAM children 6‐59 months. Thus, there were only about 4,300 SAM children out of estimated 4,850 children who required attention and were managed effectively in the 14 critically affected districts.

42. Despite all the serious external challenges faced by the project, including the huge disruption which resulted from the earthquake, the project continued to be implemented in every ward mapped to it. At project closing, 9096 RRNIs had been implemented. More than 85% were publicly audited. The number of RRNIs per ward per year varied from one district to the other (average was .98/ward/year). Overall, the percentage of RRNIs which achieved 80% of their targets was 92%. Again, it is hard to overstate what an achievement this was in the context of Nepal over this particular period. Another achievement of the project was ensuring inclusivity of the RRNI team. The percentage of females participating in all RRNIs was 68%, exceeding the target of 40%. Similarly, the percentage of minority participation in all RRNIs was 63%, exceeding the target of 40%. This had a positive impact on improving community cohesion and integration. The emergency nutrition and sanitation relief activities reached out to a total of 169,700 mothers of children 6‐24 months who received information counselling on complementary feeding practices and hygiene behaviors, exceeding the target of 86,500. Breastfeeding support for children 0‐24 months was provided to 169,700 mothers, surpassing the target of 115,000. About 80,015 households received hygiene kits and counselling on hygiene and sanitation, exceeding the target of 77,280.

Justification of Overall Efficacy Rating

43. The overall Efficacy rating is Substantial because the project achieved the majority of its original and revised PDOs and recorded a remarkable success in the area of sanitation in particular as well as demonstrated significant achievements in the reduction of stunting, wasting and underweight which were beyond what was expected. Please refer to Annex 7 for weighted average of success per each of the PDO indicators.

C. EFFICIENCY

Rating: Substantial

Assessment of Efficiency and Rating

44. It is evident that the returns on investing in nutrition are very high. According to the World Bank report27, malnutrition slows economic growth and increases poverty through direct costs from increased burden on the health care system, and indirect costs from lost productivity. An analysis of several countries indicates that the overall economic costs of malnutrition run to as high as 2‐ 3% of the growth of GDP of developing countries 27https://siteresources.worldbank.org/NUTRITION/Resources/2818461131636806329/NutritionStrategyOverview.pdf accessed December 12, 2017


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(please refer to Annex 4 for more details). It is estimated that Nepal loses nearly $190 million annually in GDP to vitamin and mineral deficiencies. Childhood anemia alone is associated with a 2.5% drop in adult wages28. (Harton S. and Ross the Economics of Iron deficiencies). A costing exercise conducted by the World Bank to determine the annual cost of scaling‐up well proven nutrition interventions in high burden countries shows that such investments give very high economic returns. Table 7 below illustrates the cost‐benefit ratio of a number of focus areas of the RRNI. Similarly, the Lancet series29 estimated the cost of handwashing counselling that can lead to 30% reduction in the risk of diarrhea, a direct cause of malnutrition (see Table 7).

Table 7. Estimated Benefits from Scaling‐up Nutrition Interventions

Intervention Estimated benefit: cost ratios or cost‐effectiveness

Behavior change through community nutrition programs

US$ 53‐153 per DALY

Hygiene promotion US$ 3.35 per DALY

Iron‐folic acid supplements US$ 66‐115 per DALY (iron)

Complementary foods US$ 500‐1000 per DALY

Latrine construction US$ 270 per DALY30 Source: Horton,S., et al. Scaling‐Up nutrition; What Will it Cost?, World Bank,2010

45. The project was characterized by strong technical efficiency and targeting resources to the neediest populations. The global evidence shows that behavioral change and community based interventions are among the most cost‐effective interventions to improve nutrition outcomes, with some of the highest cost‐benefit ratios in terms of poverty reduction and economic development. The project made substantial contributions to improving equity and targeting resources to the neediest populations. The selection of districts (15 out of 75 districts) under the project was based on population density, stunting levels, poverty levels and absence of overlapping interventions by other partners. Within the selected districts, SHD targeted 25% of the most disadvantaged VDCs. Similarly, the emergency relief component activities targeted the most critically affected districts.

46. Implementation efficiency: The efficiency of project execution improved with time, after initial delays in starting project activities which was expected given the novelty of the approach. However, implementation efficiency improved in the second year as there was a better understanding of the projection implementation modality among stakeholders as well as community members. The implementation efficiency further improved after project restructuring as the project modified its fiduciary and implementation arrangements to improve quality and efficiency (see para 16 for more details) and added a third component (emergency relief component).

Notably, despite the earthquake, the project closed within the originally stipulated time frame and completed most of its envisioned activities. The project disbursed 88% (22.8M out of 25.9M SDR) of its commitment by the closing.

47. Considering the very high cost‐effectiveness of the interventions, coupled with the successful implementation of a novel approach to improve nutritional outcomes at the community level, and the completion of the project by its original closing date, the overall efficiency is considered as Substantial.

28 http://siteresources.worldbank.org/NUTRITION/Resources/281846‐1271963823772/Nepal.pdf accessed Dec 5,2017 29 http://www.thelancet.com/article/S0140‐6736(07)61693‐6. Accessed March 5, 2018 30 https://globalhandwashing.org/about‐handwashing/why‐handwashing/economic‐impact/ Accessed March 5,2018


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D. JUSTIFICATION OF OVERALL OUTCOME RATING

48. The overall rating for Outcome is Satisfactory given that the PDOs of the project remained highly relevant throughout the years of implementation and before and after restructuring. Most of the outcomes’ targets were achieved, and in some cases surpassed its targets, and the project funded highly cost‐effective interventions and was completed on time.

Table 8. Overall Outcome Ratings

Rating

Relevance High

Efficacy: Substantial

(1) PDO 1‐attitudes (2) PDO 2‐practices (3) PDO 3‐nutritional and

sanitation emergency relief

Modest Substantial High

Efficiency Substantial

Outcome Rating H/S/S = Satisfactory

E. OTHER OUTCOMES AND IMPACTS (IF ANY)

Gender

49. The project made a positive impact on gender in many ways. The outcomes of many sub‐projects implemented by communities contributed to better health conditions for women beneficiaries through better indoor air quality, less workload by supplying potable water, and improved sanitation.

50. The qualitative study associated with the project indicated that although it was difficult to include women in RRNI teams due to social norms in addition to women’s full engagement with household work, women’s participation in RRNI teams was significant. All 18 wards included in the sample of the study had women in their RRNI teams and 12 out of 18 RRNI teams had women as RRNI team leader.

51. Moreover, 64% of the hired coaches were women belonging to the local residence and they were empowered to voice issues related to malnutrition of children and women.

Institutional Strengthening

52. The project contributed to improving the capacity of the implementing agency. At the central level, project management team received training to strengthen project management skills. Training to Nutrition and Food Security Steering Committee (NFSSC) at district and VDC level had been carried out in 15 districts and 146 VDCs to enhance participants’ skills in steering the multi‐sectoral nutrition programs in the country. In addition to capacity building activities of coaches and supervisors, more than 350 personnel were hired and their capacity enhanced in the field of nutrition.


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Social Capital

53. Since the project adopted the CDD approach, several social cohesion elements (such as trust and collective action) were measured through the impact evaluation study. Overall, the trust level31 was statistically higher for members of communities of the treatment wards compared to the control wards. Higher percentage of treatment households reported to have worked with others in the village for benefits of the community compared to the control wards. In addition, members of the treatment communities/wards were more likely to attend village council meetings, public hearings, or public discussion groups and were more likely to vote in the last election compared to those in the control communities32.

III. KEY FACTORS THAT AFFECTED IMPLEMENTATION AND OUTCOME

A. KEY FACTORS DURING PREPARATION

54. The project was well aligned with the GoNs Multi‐Sectoral Nutrition Plan (NMNP). At the time of project’s preparation33, Nepal had just joined the SUN movement, and the government launched a multi‐sectoral nutrition plan under the Prime Minister’s leadership. The plan aimed to address the underlying and basic causes of undernutrition with a package of nutrition‐specific and nutrition‐sensitive interventions, both based on evidence, focusing on the critical 1,000‐day window including the mother’s pregnancy and the child’s first two years.

55. Technical design. The focus of the project on stunting on the first 1,000 days (from conception up to the age of 24 months) was technically sound (adopting a life‐cycle approach). Good nutrition during pregnancy and in the first years of a child’s life has a profound impact on a child’s ability to grow, learn and thrive—and a lasting effect on a country’s health and prosperity. The damage done by malnutrition early in life has lasting effects that can surpass through generations. This is seen throughout the world as malnourished and anemic women giving birth to malnourished daughters who grow up to become malnourished mothers themselves, thereby perpetuating the cycle.

56. Robust targeting mechanism. The project was implemented in 15 districts out of a total of 75 districts in Nepal. The 15 districts were selected based on (i) stunting levels of children; (ii) population size; (iii) poverty levels; and (iv) the absence of interventions by other partners. There are approximately 1,100 VDCs in these 15 districts. The program targeted 25% of the most disadvantaged VDCs ‐in total approximately 280 VDCs and operated in all wards of the selected VDCs. The baseline data confirmed that the VDCs selected under the project were the most disadvantaged VDCs as most of the baseline indicators of those VDCs were far below the national average of the country.

57. Implementation modality. The implementation arrangement of this adopted a number of “innovative” approaches as described below:

31 Measured via household survey question (most people can be trusted in general). 32 Nepal Sunaula Hazar Din Community Action for Nutrition Project. Impact Evaluation Midline Report, April 2017. 33 The project was prepared in 18 months (from January 2011 to June 2012).


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i. Community based approach in the implementation of nutrition interventions has been proven to be effective and efficient globally and locally, particularly when the focus is to change attitude and behavior. The community approach taken in Action Against Malnutrition through Agriculture (AAMA)34 has shown positive results in terms of knowledge of health and nutrition among mothers and young children. Most of these interventions benefited from community involvement.

ii. Selection of the RRNI approach to improve practices known to improve nutritional outcomes was a particularly ambitious undertaking. As the PAD notes, the project design built upon lessons learned from projects which used RRI in both health and non‐health related programs in other countries. However, in most of these cases, the RRI was implemented at much smaller scale and the targeted changes were much more attainable (mostly in systems and policies). This is clearly different than the case of the SHD project as changes in attitudes and behaviors are much more complex and require longer time35. Nonetheless, the approach was selected because of the strong presence of community based interventions in Nepal, which made the RRNI a potentially successful choice.

iii. The flexibility built into the design of the project (communities select from a menu of focus areas and decide how they will achieve their goals) was the right approach but it was also risky because it relied on communities to select all 15 interventions whereas there were clear preferences for some specific intervention which was an important lesson in this project.

58. Risk assessment. The overall risk rating was judged to be substantial at appraisal. The project rightly identified several substantial risks that could affect project implementation. Weak capacity was considered as one of the main substantial risks, which included: (i) capacity of the implementing agency to effectively manage the project given the project’s innovative nature; (ii) capacity of financing management including flow of funds; and (iii) capacity of coaches to guide the RRNI teams and wards in goals selection. Each were planned to be addressed through capacity building and hiring of consultants. In addition, the project planned for capacity enhancement of the project management team including cluster units and NFSSCs at DDC and VDC levels to ensure they were able to review and process work plans and secure necessary supplies at the village level. Another substantial risk was governance and lack of clarity of roles and responsibilities between DDCs and VDCs. To mitigate this risk, detailed description of roles and responsibilities of all project actors was provided in the Operations Manual which helped to lessen the level of confusion.

59. Early introduction of the RRNI approach. Prior to the start of the project, the plan was to introduce the RRNI approach in two VDCs36 based on a preliminary operations manual to test the approach and incorporate lessons learned into the final operations manual‐ which was one of the legal covenants. Despite the delays in piloting RRNIs, the feedback from communities was very encouraging and the pilot provided the foundation to articulate all dominions of project implementation in the operational manual.

34 http://pdf.usaid.gov/pdf_docs/PA00KMDV.pdf. Accessed December 14,2017. 36 Bhimeshwor and Ratamata JhangJholi VDCs of Sindhuli disctrict.


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B. KEY FACTORS DURING IMPLEMENTATION

Factors outside the control of government/implementing entity:

60. Project implementation was adversely impacted by the 2015 earthquake followed by six months of trade blockade at the Indian border. The project faced many challenges following the 2015 earthquake: communities and beneficiaries were displaced, some of the tangible and intangible outputs of the project were damaged (such as latrines), and priority was shifted to construction activities particularly in the districts critically affected by the earthquake (4 out of the 15 project districts). The protracted political unrest in the Terai districts (9 out of 15 project districts) and the trade blockade at the Indian border resulted in a fuel crisis which made travel difficult and increased the cost of goods such as food or construction materials needed for communities’ subprojects, which made it difficult for communities to undertake planned work for their subprojects within the approved budget.

Factors within the control of the government/implementing entity:

61. Project implementation initially suffered from some setbacks that resulted in implementation delays and low disbursement. After project effectiveness, the project could not secure funds for almost a year due to a country wide delay in approval of a full budget for FY13. This resulted in delays in initiating project activities including the identification of the most disadvantaged VDCs and the poorest wards in the selected VDCs which in turn delayed the baseline study. Similarly, the finalization of the project's Operations Manual took longer than expected.

62. Human resources and implementation capacity. The SHD Project was the first standalone nutrition project implemented by MOFALD and as a result there was a steep learning curve for MOFALD and was supported by frequent trainings given to the stakeholders by the project. Several challenges were faced by the project due to weak capacity and lack of competent human resources, for example (i) the SHD project was implemented by staff from the MOFALD who were involved in other projects and other ministerial jobs and were not fully dedicated to implementing the SHD project. In addition, there was frequent turnover of key project officials (i.e. Project Coordinator and Monitoring and Evaluation Officer) and vacant or part‐time posts (i.e. Accounts Officer, Accountant); (ii) MOFALD staff at VDCs who carried out project management activities at the local level did not have the adequate technical knowledge and experience to manage the project in addition to that they were already swamped by other ministerial work; (iii) NFSSCs which constitute members of different line agencies did not have sufficient capacity to review and process work plans/proposals particularly at the village level. Approval of proposals typically took longer than planned due to lack of timely meetings. In some cases, proposals were pending approval for more than 6 weeks; (iv) coaches needed more technical support to help communities complete the forms, in many cases proposals were returned to communities for re‐writing and re‐submission due to poor quality (missing information and not completed sections); and (v) low capacity of the FM personnel at the DDCs and VDCs levels resulted in a slow pace of flow of fund to communities. As mentioned in para 16, the MTR introduced several corrective steps to increase the overall effectiveness of project management, improve the quality of the sub‐project proposals and enhance efficiency of proposal processing.

Factors subject to World Bank control:


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63. The Bank worked closely with MOFALD to monitor project progress and jointly took several corrective actions during implementation to improve project effectiveness (prior to restructuring). For instance, in order to make up for implementation delays of one year, the project agreed to allow communities which completed their sub‐projects successfully to submit more than one proposal in the following cycle. However, despite MOFALD's agreement to allow multiple initiatives, the approval of these second proposals submitted by communities became a lengthy process due to difficulty in convening the approval committees (NFSSC). Furthermore, fund release was slow to communities whose proposals were approved.

64. The project had a very successful MTR (February 15‐20,2015) which took place 2 months prior to the earthquake. During the MTR, a decision was made to restructure the project to introduce several changes in institutional arrangement and increase project effectiveness. Directly after the MTR, was as a result of the earthquake, the restructuring was used to make several other changes (along with an added component on provision of nutrition supplements in earthquake affected districts). Some of the key changes that were introduced to improve project efficiency and quality were as follows:

- Strengthening the PMT capacity by hiring additional staff ‐ three monitoring and evaluation officers, an

administrative officer and a finance officer.

- Adding 2 staff in each of the 15 districts to expedite proposals processing

- Enhancing capacity of FM staff

- Modifying the approval threshold such that all RRNI proposals for up to US$3,000 could be approved at the

VDC level (previously the VDC could approve proposals only up to US$ 1,000 and DDC had to approve those

between US$ 1,000 and 3,000). The VDC was also responsible for ensuring a 60‐day turn‐around between

proposal submission and disbursement of funds, whereas DDC’s role focused on supervision and monitoring

of all RRNI projects.

- Add 2 coaches per VDC and 2 supervisors per district.

- Enhance training of coaches and supervisors and carry out re‐orientations sessions for DDC level staff on the

project approach, targets and implementation modalities.

IV. BANK PERFORMANCE, COMPLIANCE ISSUES, AND RISK TO DEVELOPMENT OUTCOME

A. QUALITY OF MONITORING AND EVALUATION (M&E)

M&E Design

65. The project had a rigorous M&E design. The PAD defined a clear set of monitoring indicators. The PDO level indicators were monitored through the impact evaluation surveys. Given the novelty of the project, adequate resources were dedicated under component 2 to support regular monitoring and evaluation activities. This included: (i) regular collection of data on the implementation of the RRNIs; (ii) independent third‐party monitoring to verify the results of the RRNI; and (iii) an impact evaluation study (baseline, mid‐term and end‐line surveys were supported by a trust fund37) employing randomized control trials.

37 Conducted by the Development Impact Evaluation (DIME) team of the World Bank, and financed by SUNITA TF (Scaling Up Nutrition Initiative Technical Assistance)‐ window of the South Asia Food and Nutrition Security Initiative (SAFANSI).


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66. To complement the quantitative evaluation, an in‐depth qualitative study was planned to promote a better understanding of implementation and outcomes of the community‐driven rapid results approach under the SHD project38. Furthermore, the project planned semi‐annual learning events for coaches as well as an annual Nutrition Learning Forum where successful RRNI were recognized and lessons learned were shared.

M&E Implementation

67. Overall, the monitoring requirements of the project were significant due to the large number of sub‐projects that were carried out simultaneously in 15 districts. The PMT with the Bank team regularly conducted supervision visits to districts to monitor the implementation of sub‐projects and provide support to districts stakeholders.

68. As cited above, due to the delayed start of implementation, the baseline study could not be initiated in a timely manner39. The project ran in two phases and VDCs were randomized into two groups ‐early starter for VDCs started in FY14 and late starter for VDCs started in FY16.

69. Despite the fact that the project planned and supported the installment of digital reporting (via MIS software), it was not utilized and data from the field were collected manually throughout the project life. The hiring of the MIS firm was delayed for more than two years due to administrative reasons, but even after the firm had been hired and the software installed, it was recognized that additional personnel recruitment would be needed for staff with skills in using MIS.

70. During the MTR, the Bank team noted that the PMT was over‐stretched with other responsibilities and there was a need to increase human resources for effective monitoring both at the PMT level as well as the DDCs level. Three monitoring and evaluation officers were hired in the first quarter of 2016 to strengthen project monitoring. This enhanced the implementation of RRNIs as M&E officers helped in providing technical support to the coaches, facilitated submission of RRNIs proposals and expedited approval of sub‐projects and fund flow.

71. As planned, the project hired an independent third‐party monitoring during the period of March to August 2014. 529 ‐out of the 843 RRNI projects under implementation at that time‐ were visited. The monitoring visits revealed that although sub‐projects generally followed the guidelines in the Operational Manual, there were some areas where the project needed to strictly comply with monitoring visits by DDC/VDC and public audits (as they were conducted for only 44% and 46% of the projects visited respectively).

M&E Utilization

72. The PMT used regular M&E data to keep track of RRNI proposals, status of implementation, focus group selection and budget which was useful on the overall monitoring of implementation and reporting. The impact evaluation surveys provided comprehensive input to track project PDO level indicators.

38 By examining the implementation steps and social and political dynamics at the community level in detail, it seeks to provide design and implementation lessons and evidence to practitioners and policy makers of the SHD and similar development programs 39 Although the baseline is financed by a trust fund yet it required identification of the disadvantaged Village Development Committees (VDCs) and few poorest wards in the selected VDCs to come up with the sample of treatment and control groups for the study.


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Justification of Overall Rating of Quality of M&E Overall rating: Substantial

73. Justification Despite the shortage of human resources to carry out monitoring activities, the project managed to put in place innovative mechanisms to capture progress and fully capture the impact of the project.

B. ENVIRONMENTAL, SOCIAL, AND FIDUCIARY COMPLIANCE Environmental Compliance

74. As per the Bank’s standards, the Environmental and Safeguards Management Framework (ESMF) was prepared during project preparation to address possible environmental and social issues. The ESMF was included in the operation manual of the project. Key environmental and social management guidelines were prepared for various interventions and included in the coaches’ training manuals and during the trainings for DDC/VDC level stakeholders. This enhanced their ability to address safeguard issues on the ground and help communities to implement the activities with full compliance to the environmental and social safeguard guidelines.

75. Several environmental issues regarding contamination of water sources and water quality were raised by communities following the earthquake. The Bank worked with the DDCs and UNICEF to support protection of water sources and rehabilitation of water supply.

76. The Bank team conducted several visits to different project sites to observe sub‐project implementation. In most cases, environmental safety standards were followed. For example, a visit was conducted to the Okhaldhunga district on February 24, 2017 and the team noted that the toilet constructed for open defecation free conformed to the environmental standards. Likewise, communities who selected the focus area of increasing intake of animal source protein had constructed chicken coops, and it was observed that improved cooking stoves have been constructed for reducing indoor air pollution. These initiatives have improved the health of women through better indoor air quality, significantly reduced the drudgery of local women by supplying potable water and improved the overall sanitation. However, visit to Sindhuli and Ramechhap districts on May 30, 2017, revealed that few sub‐projects were not fully compliant with the environmental safety standards and have been encouraged to stick to safeguard compliance when designing the work plan for the sub‐projects.

Social Compliance

77. The project triggered the Bank’s Safeguard policy for ‘Indigenous People’ (OP4.10) to ensure that any adverse effects of the activities on indigenous people are minimized or avoided. During implementation, several measures were followed to ensure minorities inclusion in all project activities including their active participation in the RRNI teams. Both of the project’s intermediate results indicators on minority and women participation on RRNI teams have been met.

78. To ensure incorporation of the citizens’ voice, the training package for DDC/VDC included a grievance handling mechanisms, coaches and social mobilizers were oriented to handle grievance as the first point of contact for the complainants, and complaints referred to the VDC secretary for decision. However, if the grievance needed to be escalated higher, then the final decision rested with the Local Development Officer of the respective district.


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Financial Management Compliance

79. Despite considerable efforts made by MOFALD in building its financial management capacity, a number of challenges were persistent throughout the course of the project. For the first year of project implementation, there was no dedicated full‐time accountant (although this was one of the agreed actions during negotiations). The assessment of the financial management capacity of the DDCs was only done after the second year of implementation and it highlighted the significant lack of FM capacity at the DDCs level.

80. The project had a slow pace of flow of funds due to the delays in establishing institutional arrangements for rolling‐out the sub‐projects. The FM performance (including flow of fund) improved after restructuring, but slowed down again in the last year of implementation due to pending settlements of sub‐projects that had not provided Statement of Expenditures (SoE). The rating of FM performance was thus rated moderately unsatisfactory in the last two Implementation Status and Result Reports (ISRs). The disbursement from the Bank was thus affected as it was agreed to not claim reimbursement without confirmation of advanced settlement.

Procurement Compliance

81. The Project suffered delays in the implementation of procurement activities agreed in the procurement plan at the initial stage of the project, which however, quickly picked up, and by the time of project closing all planned procurement was completed. The initial delays were due to inadequate budget and delays in hiring a dedicated procurement staff throughout the first year of implementation.

82. In addition to hiring consulting firms for BBC, digital MIS and other goods and services, the project had two high value procurement activities: (i) to hire National Service Providers (NSP) for all the three clusters who were responsible for hiring the coaches, and (ii) to engage UNICEF for the earthquake relief component. As coaches facilitated the implementation of the community driven nutrition initiatives, the delays of hiring the NSPs resulted in delays in rolling out the project activities. The PMT proactively terminated the contracts of NSP in clusters 1 and clusters 2 eight months prior to closing due to their default in fulfilling contractual obligations. UNICEF was financed through a Technical Assistance and Related Supplies contract with MOFALD and was responsible for supplying all required inputs for the delivery of the targeted outputs agreed with MOFALD and the Bank.

C. BANK PERFORMANCE

Quality at Entry

83. The project was well aligned with the GoN’s response to the persistent problem of malnutrition. As mentioned above, while the team ensured adequate consultations and detailed preparation for the startup period ‐with a planned pilot at smaller scale before rolling out, the implementation modality that was chosen was highly innovative and may have been overly ambitious for Nepal’s context. However, it was well acknowledged that the informal NGO sector and community outreach was well developed and therefore this approach was selected.

84. The Bank team recognized the weak capacity of the main counterpart but did not anticipate the delay in the hiring of the coaches and that it would take that much longer to get the process started. Also, the team could have likely done better to anticipate the lengthy approval process and the associated funds flow mechanism.


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More analysis should have been done to address potential bottlenecks.

85. Project preparation benefited from a Quality Enhancement Review on March 27, 2012. Reviewers helped the project team to sharpen the focus of the PDO and enhance the M&E design. While the project took a very specific focus on addressing the root causes of malnutrition at the individual and community level, it was wise that the project set realistic expectations that actual improvement in nutrition outcomes would not necessarily be captured during the project period.

86. The Bank team was likely overly ambitious in expecting that communities would select all 15 types of interventions; however, it did not mandate any ceilings or limitations on selection. In this way, the Bank team allowed for a flexible approach to implementation. As a result, it was also difficult to predict the exact costs of the project and the team decided to allow for more funds to ensure there was no financing gap. In a sense, this was a pilot project which was to yield lessons for ways to address the malnutrition problem in Nepal. What was certainly not anticipated was the Nepal earthquake and ironically the project funds were able to be used support the aftermath of the crisis.

87. The overall quality at entry therefore is considered as Moderately Satisfactory.

Quality of Supervision

88. Regular and sustained engagement with the Project Management Team. The project benefited from a steady and committed Bank team. The project had two task team leaders, the first TTL was in charge of the design and the first two years of implementation. Both initial and subsequent TTLs were based in Nepal and were able to work closely with project counterparts and provide adequate supervision support with at least two supervision missions per year and regular field visits. Please refer to Annex 2 for list of task team members.

89. The project benefited from a successful MTR (February 2015). As mentioned above, the MTR identified implementation obstacles and decided on restructuring the project to enhance project performance. This led to efficiency gains and smoother implementation.

90. The Bank team was responsive to the emergency nutrition issues which arose from the devastating effects of the April 25, 2015 earthquake and its aftershocks in critically affected districts. The team proactively worked with MOFALD to contract UNICEF to take the technical lead to support the delivery of essential nutrition interventions to women and children in the affected areas.

91. Monitoring and reporting. ISRs documented regularly (biannually) and included candid and detailed assessment of project progress and implementation challenges.

92. M&E, safeguards and fiduciary compliance. The Bank team made a significant effort to ensure close M&E supervision which included qualitative and quantitative data in addition to third party monitoring. The Bank team supervised the environmental and social safeguards of the sub‐projects and conducted field visits to ensure compliance. Despite the fact that the Bank provided extra support to address the weaknesses in project FM, the delays in reporting SoE and reimbursement could not be entirely resolved.

93. The quality of supervision is considered Satisfactory.


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Justification of Overall Rating of Bank Performance

94. The ICR rates overall Bank performance as Satisfactory in view of the overall outcome rating of Satisfactory.

D. RISK TO DEVELOPMENT OUTCOME

95. The main risks to sustain project outcomes are as follow:

‐The project helped in raising awareness and improved understating of nutrition at different levels including communities and stakeholders. However, sustainable changes in ‘some’ practices might require longer implementation period (more than 100 days) and continuous support. In the focus group discussion conducted by the qualitive study, participants were confident that some of the changes are sustainable such as the construction of toilets which has been accompanied by tailored behavior change messages.

‐Overall, the project helped in strengthening organizational capacity. Extensive training programs have taken place under the project and several rounds of boosters have been provided to PMT staff at MOFALD, NFSSCs at DDC and VDC levels, coaches, social mobilizers and FM officers. Under federal restructuring, there will be movement of officials across sectors and different levels of government. However, these officials whose capacity was enhanced through the project are likely to contribute to nutritional outcomes even if they are placed in other sectors as nutrition interventions require a multi sector effort (please refer to Annex 5).

V. LESSONS AND RECOMMENDATIONS

96. Rapid Result Approach (RRA) which uses a series of mini projects, implemented typically in 100 days, demonstrated good results in creating a momentum and inspiring communities to adapt behavioral changes related to nutrition.

97. While giving the communities the freedom to choose builds ownership, the ability to choose without enough education and advocacy is a risky approach which requires more capacity building at the outset. The project design followed a demand based approach, and implemented a number of activities to generate demand for good nutrition outcomes. However, communities tend to ask for tangible outputs like building toilets, piped water supply for safe water, and improved cooking stoves while they focus less on the importance of softer outputs such as awareness and support on exclusive breastfeeding or sexual reproductive health.

98. Implementing an innovative project in a country with limited human resources has been a steep learning curve. The project had initial delays due to lack of support at district levels. However, the timely restructuring of the project in June 2015 brought greater implementation efficiency and better quality when additional capacity building activities and institutional strengthening measures have been added. The results of the restructuring could be seen during the last year of project implementation when a greater number of sub‐projects kicked off and disbursement increased tremendously.

99. Inclusion of women in the RRNI process was fundamental in addressing women and children nutrition needs. The project made a conscious effort to integrate women and ensure their active participation in the whole RRNI process. This has helped in empowering women and provided them with an opportunity to voice their health and


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nutrition needs.

100. Addressing malnutrition in a sustainable manner needs the entire community – men, women, minority groups, and local leaders and authorities – to raise awareness on the importance and concrete ways of improving knowledge and behavior.

101. It seems that the project had been named with an appropriate and catchy title in Nepali. “Sunaula Hazar Din” or “Golden 1000 days”, which was coined at the project formulation, has become a “brand name” now in Nepal. This phrase is now synonymous to the first 1000 days of early childhood nutrition and health and is understood by all people.

102. Given that the SHD is one of the first initiatives in Nepal and in the world to implement the RRA on the large scale, i.e., across 15 districts of the country, from the onset, the project team have recognized the importance of conducting a rigorous evaluation and relevant studies of SHD’s experiences and achievements which helped in assessing different elements of the project and capture the lessons learned.

103. The emergency relief component provided a great learning experience in collaborating with development partners. In response to the urgent humanitarian crisis that happened in Nepal after the 2015 earthquake, the project team worked side by side with UNICEF and the ministry team to provide a comprehensive response.

.


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ANNEX 1. RESULTS FRAMEWORK AND KEY OUTPUTS

A. RESULTS INDICATORS A.1 PDO Indicators

Objective/Outcome: Improve practices that contribute to reduced under‐nutrition of women of reproductive age and children under the age of two.

Indicator Name Unit of Measure Baseline Original Target Formally Revised

Target

Actual Achieved at Completion

Percentage of pregnant women taking iron and folic acid (IFA) supplements for 180 days

Percentage 21.00 30.00 30.00 27.00

03‐Feb‐2014 03‐Feb‐2014 30‐Jun‐2017 30‐Jun‐2017

Comments (achievements against targets): Target is partially achieved.


Target


Percentage of children 0‐6 months age who are exclusively breastfed

Percentage 69.00 80.00 80.00 58.00

03‐Feb‐2014 03‐Feb‐2014 30‐Jun‐2017 30‐Jun‐2017

Comments (achievements against targets): Target has not been achieved.


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Target



Percentage 9.00 25.00 25.00 15.00

03‐Feb‐2014 03‐Feb‐2014 30‐Jun‐2017 30‐Jun‐2017



Target



Percentage 35.00 0.00 45.00 39.00

03‐Feb‐2014 03‐Feb‐2014 30‐Jun‐2017 30‐Jun‐2017



Target



Percentage 60.00 0.00 75.00 76.00

03‐Feb‐2014 03‐Feb‐2014 30‐Jun‐2017 30‐Jun‐2017

Comments (achievements against targets): Target has been surpassed.

Indicator Name Unit of Measure Baseline Original Target Formally Revised Actual Achieved at


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Target Completion


Percentage 25.00 0.00 35.00 80.00

03‐Feb‐2014 03‐Feb‐2014 30‐Jun‐2017 30‐Jun‐2017



Target


Percentage of mothers (of children aged 0‐2) reporting always washing hands at critical times (after defecation)

Percentage 71.00 0.00 80.00 98.00

03‐Feb‐2014 03‐Feb‐2014 30‐Jun‐2017 30‐Jun‐2017

Comments (achievements against targets): This PDO indicator is composite of 4 indicators: washing hands before defecation (baseline:71%, target 80%, achieved: 98%) , washing hands after cleaning child’s bottom (baseline:53%, target 70%, achieved: 76%), washing hands before eating (baseline:17%, target: 25%, achieved:57%), washing hands before feeding the children (baseline: 10%, target:20%, achieved: 39%). All targets have been surpassed.

Objective/Outcome: Provide emergency nutrition and sanitation response to vulnerable populations in Earthquake affected areas.


Target


Number of children 6‐59 months in the earthquake affected districts with Severe

Number 0.00 0.00 4000.00 4299.00

21‐May‐2015 21‐May‐2015 30‐Jun‐2017 30‐Jun‐2017


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Acute Malnutrition receiving therapeutic care



Target


Number of households in the earthquake affected districts provided with hygiene and sanitation kits (water treatment products and so ap)

Number 0.00 0.00 45000.00 80013.00

21‐May‐2015 21‐May‐2015 30‐Jun‐2017 30‐Jun‐2017


A.2 Intermediate Results Indicators

Component: Rapid Results for Nutrition Initiatives at the ward level


Target


Number of RRNIs completed (disaggregated by 15 focus areas)

Number 0.00 0.00 10000.00 8950.00

16‐Jul‐2012 16‐Jul‐2013 30‐Jun‐2017 30‐Jun‐2017

Comments (achievements against targets): Disaggregated by focus areas during the project period: Adequate weight and regular eating‐ 12%


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Consumption of animal Sourced food‐ 13% Clean water‐ 22% Open Defecation Free‐ 13%


Target


Number of RRNIs per ward per year

Number 0.00 0.00 2.00 1.40

16‐Jul‐2012 16‐Jul‐2012 30‐Jun‐2017 30‐Jun‐2017

Comments (achievements against targets):


Target


Characteristics of RRNI teams: % females participating in all RRNIs

Percentage 0.00 0.00 40.00 68.50

16‐Jul‐2012 16‐Jul‐2012 30‐Jun‐2017 09‐Mar‐2017



Target


Characteristics of RRI teams: % minority participation in all RRNIs

Percentage 0.00 0.00 40.00 63.30

16‐Jul‐2012 16‐Jul‐2012 30‐Jun‐2017 09‐Mar‐2017


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Target


Percentage of RRNIs achieving 80% of their targets

Percentage 0.00 0.00 75.00 92.00

16‐Jul‐2012 16‐Jul‐2012 30‐Jun‐2017 09‐Mar‐2017


Component: Project management, capacity building, monitoring and evaluation


Target


Average time between RRNI proposal submission and fund release to communities (days)

Days 0.00 0.00 60.00 73.00

16‐Jul‐2012 16‐Jul‐2012 30‐Jun‐2017 09‐Mar‐2017



Target


Number of coaches trained Text 0 200 300 311

16‐Jul‐2012 16‐Jul‐2012 30‐Jun‐2017 09‐Jun‐2017


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Comments (achievements against targets): Male 113 and female 198


Target


Percentage of RRNIs publicly audited as part of citizen engagement

Percentage 0.00 90.00 100.00 85.10

16‐Jul‐2012 16‐Jul‐2012 30‐Jun‐2017 09‐Mar‐2017


Component: Earthquake relief component.


Target


No. of mothers & caregivers of 6‐23 mo. counseled for appropriate complementary feeding, frequency & diversity of foods, and continued breastfeeding for up to 24 mo. in earthquake affected districts

Number 0.00 50000.00 50000.00 169701.00

15‐May‐2015 15‐May‐2015 30‐Jun‐2017 30‐Nov‐2016



Target



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Number of children 6‐59 months old in the earthquake affected districts with moderate acute malnutrition (MAM) receiving supplementary food

Number 0.00 18000.00 18000.00 36101.00

15‐May‐2015 15‐May‐2015 30‐Jun‐2017 30‐Nov‐2016



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B. KEY OUTPUTS BY COMPONENT

Objective/Outcome 1

Outcome Indicators

1. Attitude of community members towards the importance of keeping girls in school until at least 20 years of age

2. Attitude of community members towards the importance of reducing indoor air pollution

3. Attitude of pregnant women towards the importance of eating three time a day including at least one animal‐sourced food per day

Intermediate Results Indicators

1. Number of RRNIs completed (disaggregated by 15 focus areas).

2. Number of RRNIs per ward per year.

3. Percentage of RRNIs achieving 80% of their targets.

Key Outputs by Component (linked to the achievement of the Objective/Outcome 1)

1.Rapid Results for Nutrition Initiatives (RRNIs) implemented by communities at ward level, with each RRNI dedicated to achieve one of pre‐defined nutrition related goals selected by targeted communities.

Objective/Outcome 2

Outcome Indicators

1. Percentage of pregnant women taking iron and folic acid (IFA) supplements for 180 days

2. Percentage of children 0‐6 months age who are exclusively breastfed 3. Percentage of children 6‐24 months age who consume a minimum

acceptable diet 4. Percentage of households reporting no smoke in the room while

cooking


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5. Percentage of pregnant women reporting consuming animal‐sourced protein in the previous day

6. Percentage of households reporting using improved toilet facilities (flush toilet, covered pit within household, community latrine)

7. Percentage of mothers (of children aged 0‐2) reporting always washing hands at critical times (after defecation)


1. Number of RRNIs completed (disaggregated by 15 focus areas).

2. Number of RRNIs per ward per year.

3. Percentage of RRNIs achieving 80% of their targets.


1. Rapid Results for Nutrition Initiatives (RRNIs) implemented by communities at ward level, with each RRNI dedicated to achieve one of pre‐defined nutrition related goals selected by targeted communities.

Objective/Outcome 3

Outcome Indicators

1. Number of children 6‐59 months in the earthquake affected districts with Severe Acute Malnutrition receiving therapeutic care

2. Number of households in the earthquake affected districts provided with hygiene and sanitation kits (water treatment products and

soap)


1. No. of mothers & caregivers of 6‐23 mo. counseled for appropriate complementary feeding, frequency & diversity of foods, and continued breastfeeding for up to 24 mo. in earthquake affected districts


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2. Number of children 6‐59 months old in the earthquake affected districts with moderate acute malnutrition (MAM) receiving supplementary food


1. Provide nutrition care and treatment to severely acute malnourished (SAM) and moderately acute malnourished (MAM) children, and malnourished mothers.


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ANNEX 2. BANK LENDING AND IMPLEMENTATION SUPPORT/SUPERVISION

A. TASK TEAM MEMBERS

Preparation

Name Role

Albertus Voetberg Lead Health Specialist/Task team Leader

Maria E. Gracheva Senior Operations Officer

Mohammad Khalid Khan Program Assistant

Bigyan B. Pradhan Sr Financial Management Specialist

Roshan Darshan Bajracharya Senior Economist

Kiran R. Baral Senior Procurement Officer

Gayatri Acharya Senior Economist

Venkatesh Sundararaman Senior Economist

Afrah Alawi Al‐Ahmadi Senior Human Development Specialist

Phoebe M. Folger Operations Officer

Tekabe Ayalew Belay Sr Economist (Health)

Drona Raj Ghimire Environmental Specialist

Hiramani Ghimire Senior Governance Specialist

Mohan Prasad Aryal Operations Officer

Silva Shrestha Research Analyst

Luc Laviolette Sr Nutrition Spec.

Jasmine Rajbhandary Social Protection Specialist

Jaya Karki Team Assistant

Shambhu Prasad Uprety Procurement Specialist

Saurav Dev Bhatta Senior Education Specialist

Bandita Sijapati Consultant

Manav Bhattarai E T Consultant


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Name Role

Supervision/ICR

Manav Bhattarai Task Team Leader(s)

Shambhu Prasad Uprety Procurement Specialist(s)

Timila Shrestha Financial Management Specialist

Kari L. Hurt Team Member

Jaya Sharma Social Safeguards Specialist

Phoebe M. Folger Team Member

Abeyah A. Al‐Omair Team Member

Jaya Karki Team Member

Ramesh Raj Bista Team Member

Annu Rajbhandari Environmental Safeguards Specialist

B. STAFF TIME AND COST

Stage of Project Cycle Staff Time and Cost

No. of staff weeks US$ (including travel and consultant costs)

Preparation

FY11 0 6,096.45

FY12 44.964 206,974.98

FY13 8.312 18,265.73

FY16 0 3,135.60

FY17 0 91,445.05

FY18 0 1,035.60

Total 53.28 326,953.41 Supervision/ICR

FY12 1.726 7,495.35

FY13 44.524 178,696.69

FY14 61.946 251,523.91


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FY15 48.815 147,161.79

FY16 49.059 123,159.12

FY17 57.195 137,527.93

FY18 15.675 56,186.85

Total 278.94 901,751.64


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ANNEX 3. PROJECT COST BY CATEGORIES

Components Amount at Approval

(SDR‐M)

Amount at Project

Restructuring (SDR‐M)

Actual amount at project closing

(SDR‐M)

Percentage of Approval (based on

the amount at restructuring)

Sub‐grants for ‐Rapid Results for Nutrition Initiatives at the ward level.

19.6 12.2

12.4 102%

Consulting Services and training

2.1 2.1

1.2

57%

Goods, non‐consulting services and incremental operating costs

4.2 3.0

0.7

20%

Eligible expenditures under component 3‐Earthquake Relief Component

0.00 8.6

8.5

98%

Total 25.9 25.9 22.8 88%


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ANNEX 4. EFFICIENCY ANALYSIS

Assessment of Efficiency and Rating

1. It is evident that the returns on investing in nutrition are very high. According to the World Bank report40, malnutrition slows economic growth and increases poverty through direct costs from increased burden on the health care system, and indirect costs from lost productivity. Not addressing malnutrition has high costs in terms of higher budget outlays as well as lost GDP.

2. An analysis of several countries indicates that the returns from programs for improving nutrition far outweigh their costs. Overall economic costs of malnutrition run to as high as 2 to 3% of the growth of GDP of developing countries. According to the World Health Organization (WHO), underweight is the single largest risk factor contributing to the global burden of disease in the developing world. It leads to around 15% of the total DALY (disability‐adjusted life years) losses in countries with high child mortality.

3. It is estimated that Nepal loses nearly $190 million annually in GDP to vitamin and mineral deficiencies. Childhood anemia alone is associated with a 2.5% drop in adult wages41 (Harton S. and Ross the Economics of Iron deficiencies). Similarly, a 1% loss in adult height as a result of childhood stunting is associated with 1.4% loss in productivity. In addition to its effect on immune function, poor nutrition also increases susceptibility to chronic diseases in adulthood. Low birthweight may reduce a person’s IQ by 5%, stunting ,ay reduce it by 5‐11%, and iodine deficiency by nearly 10‐15%41.

4. A costing exercise conducted by the World Bank to determine the annual cost of scaling‐up well proven nutrition interventions in high burden countries shows that such investments give very high economic returns. Table 7 below illustrates the cost‐benefit ratio of a number of focus areas of the RRNI. Similarly, the Lancet series42 estimated the cost of handwashing counselling that can lead to 30% reduction in the risk of diarrhea, a direct cause of malnutrition (see table 7).

Table 7. Estimated Benefits from Scaling‐up Nutrition Interventions

Intervention Estimated benefit: cost rations or cost‐effectiveness

Behavior change through community nutrition programs

US$ 53‐153 per DALY

Hygiene promotion US$ 3.35 per DALY

Iron‐folic acid supplements US$ 66‐115 per DALY (iron)

Complementary foods US$ 500‐1000 per DALY

Latrine construction US$ 270 per DALY43 Source: Horton,S., et al. Scaling‐Up nutrition; What Will it Cost?, World Bank,2010

5. Based on nutrition data from the Institute for Health Metrics and Evaluation (IHME), during the project life (2011‐2016) the number of estimated direct deaths associated with nutritional deficiencies in all ages, was

40https://siteresources.worldbank.org/NUTRITION/Resources/2818461131636806329/NutritionStrategyOverview.pdf accessed December 12, 2017 41 http://siteresources.worldbank.org/NUTRITION/Resources/281846‐1271963823772/Nepal.pdf accessed Dec 5,2017 42 http://www.thelancet.com/article/S0140‐6736(07)61693‐6. Accessed March 5, 2018 43 https://globalhandwashing.org/about‐handwashing/why‐handwashing/economic‐impact/ Accessed March 5,2018


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reduced from 0.59% to 0,49%. The estimations of the number of deaths at age 0‐12 months by nutrition deficiencies reduced from 348 to 225, between 2011 to 2016.

6. The project was characterized by strong technical efficiency and targeting resources to the neediest populations. The global evidence shows that behavioral change and community based interventions are among the most cost‐effective interventions to improve nutrition outcomes, with some of the highest cost‐benefit ratios in terms of poverty reduction and economic development. The project made substantial contributions to improving equity and targeting resources to the neediest populations. The selection of districts (15 out of 75 districts) under the project was based on population density, stunting levels, poverty levels and absence of overlapping interventions by other partners. Within the selected districts, SHD targeted 25% of the most disadvantaged VDCs. Similarly, the emergency relief component activities targeted the most critically affected districts.

7. Implementation efficiency: The efficiency of project execution, as measured by the speed of disbursement, was not strong in the first year of implementation. There were initial delays in starting project activities which was expected given the novelty of the approach. However, implementation efficiency improved on the second year of implementation as there was a better understating of the projection implementation modality among stakeholders as well as community members. The implementation efficiency has further improved after project restructuring as the project modified its fiduciary and implementation arrangements to improve quality and efficiency (see para 16 for more details) and added a third component (emergency relief component).

8. Since the project adopted a demand‐driven approach and relied on mobilizing communities to collectively commit to address one of the risk factors of malnutrition, the initially estimated budget for the RRNIs could not be precise but sufficient funds were allocated to allow communities to implement sub‐projects in all selected districts. At the MTR, it became clear that not all funds would likely be absorbed and hence when the earthquake took place, US$12 million could be reallocated. Notably, despite the earthquake, the project closed within the stipulated time frame and completed most of its envisioned activities. The project disbursed 87% (31.58M out of 35.9MSDR) of its commitment by closing.

9. Considering the very high cost‐effectiveness of the interventions, coupled with the novel approach to improve nutritional outcomes at the community level, the completion of the project by its original closing date, the overall efficiency is considered to be Substantial.


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ANNEX 5. BORROWER, CO‐FINANCIER AND OTHER PARTNER/STAKEHOLDER COMMENTS

1. Community Actions for Nutrition Project: Sunaula Hazar Din was successfully implemented to reduce malnutrition mainly focusing to the central terai and mid hill of the country. The primary focus of the project was to reduce malnutrition implementing through local governance structure namely then the VDCs and DDCs. At the time of implementing the project, the NDHS 2011 report came out with the finding of 41% children under 5 years of age were stunting, 11% wasting and 29 underweight. The concentration of malnutrition was obvious in the area of high densely populated, weighted poverty and dalit as well as backward community. Considering the fact and figures, the project was implemented in 15 districts namely Khotang, Okhaldhunga, Udayapur, Sunsari, and Saptari in Cluster I, Ramechap, Sindhuli, Siraha, Mahottari and Sarlahi in Cluster II and Makawanpur, Bara, Parsa, Rautahat, and Sarlahi in Cluster III. In total 25% VDCs (approximately 292 VDCs) of the 15 districts were selected based on Disadvantaged Group (DAG) mapping. The project was supposed to start implementation from FY 2012/13 but couldn't come to effect till March 2014 because of procurement delayed in placing National Service Providers (NSPs) in each cluster. Though, the piloting of the project was carried out in Sindhuli district in FY 2031/14 but real field work got started in the last trimester of FY 2013/14. The project got implemented in phase in strategy as early starter and later starter for the sake of impact evaluation.

2. The project adopted a unique approach of community demand driven known as Rapid Results Approach in which the targeted community frames their need and aspiration outlining as Rapid Results Nutrition Initiatives (RRNI). The RRNI thrives to achieving nutritional outcomes within 100 days selecting from the given focus area and implemented at particular settlement by the community people themselves officially known as RRNI Team. The process of the approach was pre‐launch meeting, launch meeting /workshop, mid‐point review and sustainability review with in a 100 day. The entry point of the each RRNI begins from the lower level of local governance unit known as Ward Citizen Forum (WCF).

3. As to smooth implementation of the project different implementation arrangement were set up from central level to grass root level. A Project Coordination Committee (PCC) was formed headed by the head of division of self‐governance division of the Ministry and members representatives from the sectoral Ministries including National Planning Commission. The role of the committee was to coordinate at central level. In addition, Project Management Team (PMT) was also formed to functionalize day to day project works in leadership of Joint Secretary comprising the officials of the ministry and technical expert team for the project. Likewise, a district Nutrition and Food Security Steering Committee headed by Local Development Officer (LDO) comprised of the members from different sectors at all 15 districts including NGO federation and private sectors. Similarly, same nature of steering committee was formed 292 the VDCs.

4. As Rapid Results Approach was new for the Ministry, a pilot test was done before the project implementation took off. It was done in 2 VDCs of Sindhuli district namely; Bhimeshwor, Ratamata JhangaJholi. Based on the learnings of the pilot project, considering the financial agreement of Government of Nepal and the World Bank and referencing other related legal documents; a separate operational manual was developed as one of the milestones which paved the way of RRNI selection/development, implementation modality, fund flow mechanism and financial arrangement/settlement. As to introduce the operational manual separate cluster level orientation was carried out in Biratnagar, Janankpur and Hetauda on 20 January 2014, 22 January 2014 and on 24 January


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2014 respectively inviting all sectors (local governance, agriculture, livestock, education, water & sanitation and women & children) representatives at each districts. Ministry also awarded to 3 NGOs in all the 3 clusters to hire a coach in each VDCs. The coaches and concerned staffs were also oriented as basic RRNI implementation training followed by different capacity building interventions known as booster training and review meetings.

5. The project has defined 15 focus area of interventions. Based on facilitation of coaches, the picked‐up focus area to be implemented in respect to the needs and aspiration of the community. Selection of focus area was in increasing trend for the last 4 years (070/71 to 73/74). It was counted as 832 in the base year FY 070/71 increasing to 1991 to 3427 in 71/72 and 72/73 respectively. But it was reduced to 2646 in 73/74. Total was 9096 combining all the 15 focus areas. Out of 15 focus areas ODF was highest demanded followed by clean water. Similarly, immunization was in lowest position followed by family planning. In addition, amidst the project implementation, the country felt some devastated effects of the earthquake of 7.9 magnitudes on April 25, 2015 followed by strong aftershocks which affected some 39 districts of the country where some 14 districts were highly affected by the earthquake. Realizing this alarming situation of the country MoFALD contracted to UNICEF to address the severe condition of malnutrition in emergency and to support and contribute to the government’s early relief and recovery efforts.

6. As to vibrate and functionalize all actors involved in the project; national, sub‐national, district and village level orientation and review workshops were carried out aiming to inform / sharing status of project to stakeholders. The event addressed by the Honorable Minister and Secretary reflected the national priority in investing children and women. As to transfer knowledge, a training package was developed and delivered to Nutrition and Food Security Steering Committee at district and VDC level. The main objective of the assignment was to strengthen capacity of the central project management team, district and village level stakeholders including the line ministries/agencies and social mobilizers/coaches. The project organized booster training/s primarily focusing on strengthening skills and knowledge on proposal preparation and other areas as well.

7. Having enormous efforts of the Ministry, the numbers of layers from district to VDC to RRNIs, the delivery of the project couldn't be as expected. Functional role of the sectoral agencies like health, agriculture, education, women were relevant at local level but couldn't be respected properly. MoFALD has realized that the project was one which solely respects the demand of the community and brings the community to implement themselves. The number of best practices and positive behavior at the community need to be sustained. For the same the newly formed federal government has transferred Sunaula Hazar Din Program to local government; rural municipality and municipality. Hence, the spirit of project will definitely expand widely at local level. However, the sequel of the project is highly demanded and required since there pessimistic progress of reducing stunting, wasting and underweight.


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ANNEX 6. SUPPORTING DOCUMENTS

Focus areas and examples of Goal Templates

Focus Areas 1 Adequate Weight and Regular Eating 2 Animal Source Food for pregnant mothers and children 3 Breastfeeding 4 Clean Water 5 Delayed Marriage 6 De‐worming and Iron Supplementation 7 Extending Education 8 Hand Washing 8 Family Planning 10 Immunization of children 11 Open defecation Free 12 Prompt Medical Treatment 13 Reduce Workload 14 School Sanitation 15 Smoke Reduction

NEPAL: Sunaula Hazar Din – Community Action for Nutrition Project

Girls and young women aged 15 to 25 (Priorities: Anemia, Delayed Pregnancy, School Attendance) These RRNIs would be implemented primarily by youth aged 15 to 25. Senior leaders would mostly likely be members of an SMC, Citizen Ward Forum, FSNC. Alternatively the team could be formed from an existing youth‐focused group. The primary focus of these RRIs would be youths. However, at the group’s discretion, for some goals there could be overlap into other sub‐populations (e.g. the goal focused on FP could focus on all women who want to delay a first or next pregnancy and not just youths).

Goal Template Illustrative Sub‐projects

At least ___ families with adolescent girls make a public pledge to delay marriage and first pregnancy of daughter(s) until at least 20 years of age, in the next ___ days

Training for health facilities to provide youth‐friendly services, peer program, positive deviance analysis, establishment of youth center, community based services for the youth

At least ___ girls of school‐going age who do not want to become pregnant are regularly attending school , in the next ___days

Provision of school supplies, mid‐day meals, take‐home rations, performance based grants

At least ___ girls receive de‐worming and weekly iron‐folic acid

supplementation, for the next ____ weeks.

Peer programs, health worker visits to schools

At least ___ girls/women who do not want to become pregnant are using a family planning method, in the next ___ days

Training for health facilities to provide youth‐friendly services, establishment of youth center and community based services for the youth


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Pregnant women or women who want to become pregnant in the next 6 months. (Priorities: Protein, Iron, Smoking, Breastfeeding) These RRNIs would mostly like be implemented by mother’s/women’s groups, or an existing health‐focused group. Senior leaders would be from Ward Citizen Forum or NFSSC


At least ____ women who may want to become pregnant/are pregnant take the appropriate amount of supplements of iron and folic acid in the next ___ days.

Peer programs with mother groups, group‐wise monitoring of IFA intake

At least ____ women who may want to become pregnant/are pregnant complete a treatment of de‐worming in the next ___days

Peer programs, FCHV and mother‐group advocacy

At least ___ (families with) women who may want to become pregnant/are pregnant make a public declaration not to smoke inside the house, in the next ___ days

Peer programs, advocacy programs

At least ___ women who may want to become pregnant make a public declaration to stop smoking before pregnancy, in the next ____ days

Peer programs

At least ___families with women who are pregnant make a public pledge to lessen their workload.

Peer and advocacy programs, positive deviance analysis

At least ____ families with underweight girls or women who are pregnant or may want to become pregnant gain the appropriate amount of weight, in the next ___ days

Peer programs , goat/chicken rearing, fisheries project

At least ____ women who are pregnant eat three times a day, including, at least one animal‐sourced food per day for the next ___ days.

Children 0‐6 months and breast feeding mothers (Priorities: Breastfeeding, Hygiene, Immunization, BMI) These RRNIs would mostly like be implemented by mother’s/women’s groups, or an existing health‐focused group. Senior Leadership could come from Ward Citizen Forum or NFSSC.


At least ____ children under the age of 1 year receive immunizations to be in compliance with the recommended schedule, in the next ___ days

Outreach vaccination program for the VDC, “Fully Immunized VDC” campaign

At least _____families with make public pledge for exclusive breast feeding of children until the age of 6 months, in the next ___days

Mother group peer programs with FCHVs

At least _____HH with children 0‐24 mo pass hand washing checklist, in the next ___ days

Advocacy and peer programs, soap distribution, “Community Led Total Behavior Change in Hygiene and Sanitation” campaign

At least ____ lactating women eat three times a day, including, at least one animal‐sourced food per day for the next ___days.

Advocacy, peer programs with mother groups, animal husbandry projects

At least ____ HH with children 0‐24 that have an improved cooking stove, in the next ___days

Improved stove construction, advocacy.

At least ____ women with children 0‐24 months make a public pledge to keep the inside of their house smoke‐free , in the next ___days

At least ___children with signs of chest infection, diarrhea and/or a fever receive proper treatment within 1 day of on‐set of symptoms, in the next ___days

Mother group/FCHV meetings and education on early signs and symptoms and the benefits of early treatment


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Children 6‐24 Months (Priorities: Comp feeding. Iron/MNPs, Protein, Diarrhea/ORS) These RRNIs would mostly like be implemented by Mother’s/Women’s groups, or an existing health‐focused group. Senior Leadership could come from Ward Citizen Forum.


At least ___ underweight children gain an appropriate amount of weight, in the next ___days

CMAM, goat/chicken rearing, fisheries project, growth monitoring

At least ____ children age 6‐24 months eat at least one egg/piece of meat/fish or a glass of dairy each day for the next ___days

Community advocacy, goat/chicken rearing, fisheries projects

At least ___HH with children 6‐24 months pass a IYCF checklist, in the next ___days

Mother group peer programs, community advocacy.

At least ___ HHs with children 6‐24 months eat a meal with MNPs once a day, each day for the next ____ days.

Community branding of MNPs, peer programs among mother groups

At least ___children with diarrhea immediately receive proper treatment (ORS, Zinc and increased feeding), in the next ___days

Mother group peer programs, branding and marketing of Zinc

At least ___ HH with children 0‐24 mo pass hand washing check‐list, in the next ___days

“Community Led Total Behavior Change in Hygiene and Sanitation” campaign

Community wide (Priorities: Protein, safe water, Hygiene) Teams could come from a variety of different community‐based groups, selected at large by the Ward committee. Senior Leaders could come from Ward Citizen Forum or NFSSC.


___% of HH make public commitment against open defecation, in the next ___days

Latrine construction, Community Led Total Behavior Change in Hygiene and Sanitation” campaign

Community declared ODF within ____ days

Ensure ____ sources of water in the community pass “clean water check list” at the point of consumption, in the next ___days

Small construction (spring boxes, pumps, etc), Community Led Total Behavior Change in Hygiene and Sanitation” campaign

At least ____ HHs with children or women of child baring age have access to a source of eggs, meat/fish or dairy , in the next ___days

Funds for goat/chicken rearing, fisheries

School has appropriate number of latrines in ____days. Advocacy, latrine construction


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Annex 7‐ Results Achieved under PDO 2 and PDO 3

Surpassed‐ > 100%, Achieved‐ 85‐100%, Partially achieved‐ 65‐84%, and Not achieved‐ < 65%

A= (Ia‐Ib)/(It‐Ib), where A is achievement, Ia is indicator’s actual; Ib is indicator’s baseline, and It is

indicator’s target.

PDO 2 indicators

Indicators (PDO 2) KPI#

Value and date of the indicator at baseline

Value of the indicator target

Actual values of the indicator endline

Ratio of achievement


Percentage of pregnant women taking IFA supplements for 180 days

21 30 27 67% Partially achieved

Percentage of children 0‐6 months age who are exclusively breastfed

69 80 58 ‐100% Not achieved


9 25 15 38% Not achieved


35 45 39 40% Not achieved


60 75 76 107% Surpassed


25 35 80 550% Surpassed

Percentage of mothers (of children aged 0‐2) reporting always washing hands at critical times

after defecation

71 80 98 300% Surpassed

After cleaning child’s bottom

53 70 76 135% Surpassed

Before eating 17 25 57 250% Surpassed

Before feeding the children

10 20 39 290% Surpassed


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Indicators (PDO 2)

IO#

Value and

date of the

indicator at

baseline

Value of

the

indicator

target

Actual

values of the

indicator

endline

Ratio of

achievement

Indicator

level of

achievement

Number of RRNIs completed

(disaggregated by 15 focus

areas)

0 10000 8950 89.5% Achieved

Number of RRNIs per ward

per year

o 2 1.4 70% Partially

achieved

Characteristics of RRNI teams:

% females participating in all

RRNIs

0 40 68.5 171% Surpassed

Characteristics of RRI teams:

% minority participation in all

RRNIs

0 40 63.3 158% Surpassed

Percentage of RRNIs achieving 80% of their targets

0 75 92 123% Surpassed

Average time between RRNI

proposal submission and fund

release to communities (days)

0 60 73 82% Partially

achieved

Number of coaches trained 0 300 311 104% Surpassed

Percentage of RRNIs publicly audited as part of citizen engagement

0 100 85.1 85% Achieved


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PDO 3 indicators

Two KPIs and two IOs

Indicators (PDO 3) KPI #






Number of children 6‐59 months in the earthquake affected districts with Severe Acute Malnutrition receiving therapeutic care

0 4000 4299 107% Surpassed

Number of households in the earthquake affected districts provided with hygiene and sanitation kits (water treatment products and soap)

0 45000 80013 178% Surpassed

Indicators (PDO 3) IO#






Number of mothers and

caregivers of 6‐23 months

children who are counseled

for appropriate

complementary feeding,

frequency and diversity of

foods, and continued

0 50000 169701 339% Surpassed

Number of children 6‐59

months old in the earthquake

affected districts with

moderate acute malnutrition

(MAM) receiving

supplementary food

0 18000 36101 201% Surpassed


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PDO 2 Indicators

Rating categories and corresponding point of intervals

KPI# IOI#

Surpassed (>100%) 6 4

Achieved (85%‐100%) 2

Partially achieved (65%‐84%) 1 2

Not achieved (<65%) 3

Total PDO 2 Indicators 10 8

% Achieved, surpassed and partially achieved 83% 106%

Success rate is the percentage of indicators surpassed, achieved or partially achieved as a

share of the total project indicators. A weighted average was calculated using the following

scale: Surpassed=1.25 times; Achieved=1.0 times and Partially achieved=0.75 times.

PDO 3 Indicators

Rating categories and corresponding point of intervals

KPI# IOI#

Surpassed (>100%) 2 2

Achieved (85%‐100%)

Partially achieved (65%‐84%)

Not achieved (<65%)

Total PDO 3 Indicators 2 2

% Achieved, surpassed and partially achieved 125% 125%

Success rate is the percentage of indicators surpassed, achieved or partially achieved as

a share of the total project indicators. A weighted average was calculated using the

following scale: Surpassed=1.25 times; Achieved=1.0 times and Partially achieved=0.75

times.

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