Two Community Nutrition Projects in Africa. Interim Findings

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Julie Ford
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Findings reports on ongoing operational, economic and sector work carried out by the World Bank and its member governments in the Africa Region.

1 Findings reports on ongoing operational, economic and sector work carried out by the World Bank and its member governments in the Africa Region. It is published periodically by the Knowledge Networks, Information and Technology Center on behalf of the Region. Two Community Nutrition Projects in Africa Interim Findings The Madagascar Food Security and Nutrition Project (SECALINE) and the Senegal Community Nutrition Project (CNP) were designed to prevent malnutrition and to diminish existing malnutrition rates among children under 3 years old. The former has been in implementation since July1993 and the latter since mid-december Both projects have many similarities, due in part to strong political involvement, effective local commitment, very able and dedicated national staff, and in part to the fact that the same Bank staff helped to design them. Also, lessons learned from other nutrition projects have been fed into the dsin of these two projects. However, these two projects also differ in many respects. Analyzing these projects might therefore be useful for other countries which would like to diminish malnutrition rates through a completely preventive approach using non-governmental delivery mechanisms. The projects success The 1997 Africa nutrition portfolio review of World Bank-assisted projects titled Nutrition in Africa : The World Bank s Involvement, identified 4 projects out of the 57 documented that had recorded successes in addressing malnutrition. The projects mentioned here represent 2 of those 4 - the other 2 projects with successes refer to nutrition components of Bank-assisted health projects in Zimbabwe and Malawi. Success is defined here in terms of decreasing malnutrition rates among children who benefit from services provided by the project. While the impact on the whole community has been measured for SECALINE, this has not yet been done for the CNP. Using information from the Mid-Term Review of SECALINE and from the supervision reports for CNP, project results are shown below. the results are for 27 months for SECALINE, and for the first 6 months of 1996 for CN.

INDICATOR SECALINE (1994-95 and first 6 months of 1996) CNP (first 6 months in 1996) 1. Number of beneficiaries reached 54,227 women and children 4461 children 6223 women 2.

2 INDICATOR SECALINE ( and first 6 months of 1996) CNP (first 6 months in 1996) 1. Number of beneficiaries reached 54,227 women and children 4461 children 6223 women 2. Coverage of children in targeted communities for monthly weight monitoring 79% 40% 3. Number of children receiving food supplement Decrease in malnutrition rates among children enrolled in the program (a child is considered malnourished if weight for age is below 2 Standard Deviations) Antananarivo: from 51% to 37% Toliary: from 23% to 13% From 70% to 25% 5. Percent of mothers receiving weekly Information, Education and Communication (IEC) messages 75% 75% 6. Cost per beneficiary reached $7.31 per child Not available yet MADAGASCAR: SECALINE SENEGAL: CNP

The projects design Both projects offer a few standard nutrition services such as growth monitoring of children, nutrition education for their mothers, food preparation demonstrations, home visits,

3 The projects design Both projects offer a few standard nutrition services such as growth monitoring of children, nutrition education for their mothers, food preparation demonstrations, home visits, and reference to health facilities for severely malnourished or sick children. Both projects use an independent executing agency rather than a Ministry. In Senegal, an NGO called AGETIP manages the project; in Madagascar, the project is run by a unit reporting directly to the Prime Minister s office. These executing agencies then contract out to NGOs, local groups, or local institutions the services to be delivered, the supervision, training activities, and research initiatives. Senegal has gone further than Madagascar in this approach of delegated contract management and quite a lot of training is done by the project s unit itself in Madagascar. In Senegal, delegated contract management means the following : the National Commission against Hunger (a public entity) signs a convention delegating the work to AGETIP (an NGO). AGETIP then signs contracts with NGOs to supervise the local associations which run the Community Nutrition Centers. AGETIP also signs contracts with the local associations to deliver the core nutrition services. Similarities and differences in project design FEATURE SECALINE CNP 1. Targeting - poor rural population - children 6-36 months old (originally, now 6-59 months) - poor peri-urban population - children 6-36 months old

4 - pregnant & lactating women - pregnant & lactating women - self-targeting food (sweet and in powder, can only be made as porridge for children) 2. Services provided to beneficiaries: - monthly weight monitoring of child - weekly IEC to woman - food supplement to malnourished children - food supplement to pregnant and lactating women - drugs - income generation, local food is bought by World Food Program (WFP) and sent to target communities. An on-site supplementary meal of 500 calories/day is given daily for 5 days/week to the child. Women learn how to prepare enriched meals with local food - no (mebendazole, chloroquine, iron supplement) - through access to the Social Action Fund, local food is bought by WFP and a weaning food is made and distributed weekly to malnourishe children as take-home supplement providing 370 calories/day. Women learn how to prepare enriched meals with local food - no - for water supply workers through labor intensive works, for community nutrition workers (min salary), for landlords who rent their house to the CNP, & for workers who renovate the CNC - no (jobs were created) - water supply improvement in targeted communities 3. Length of time a child stays in program 4 months 6 months (being reviewed to shorten to 4 months)

5 4. Number of service delivery sites by mid Average nbr. of beneficiaries per community nutrition center 400 (half children and half mothers) Direct service provider - Community Nutrition Agent (CNC) from target community: a woman volunteer selected by community (based on objective criteria) who receives payment in rice and works 5 days a week for SECALINE - local group from target community selected based on objective criteria (4 people per group of which 58% are women). Each receives minimum salary and works 6 days a week for CNP 7. Community involvement/support 8. Financial participation of communities - village nutrition committee - selects and rents or builds a site for the community nutrition center for the rental of the center - neighborhood nutrition streering committee - participates in selection of a site for the community nutrition center (which is then rented by CNP) - $0.05/week/mother-child couple 9. NGO involvement/support - supervisors (31 NGOs selected based on objective criteria): each NGO selects a volunteer supervisor available for at least 1/2 day/week/site - the level of education for volunteer supervisor is at best high school level - an agreement is signed with NGO; - NGO is financially compensated for services, & its supervisor gets a motorcyle - supervisors (2 NGOs and 1 local association selected based on objective criteria) - the level of education for supervisors goes up to MD level - a contract is signed with NGO or local association; - NGO or local association is financially compensated for services

6 10. Executing agency a project unit (SECALINE office) reporting directly to the Prime Minister s office AGETIP, an NGO 11. Technical support for sick and severely malnourished kids - referred to MOH (7 nutrition rehabilitation centers - see comments in following text) - referred to MOH s closest infrastructure (see comments in following text) 12. Political support - Prime Minister s office - National Commission Against Malnutrition (under the Presidency) - Regional committees 13. Management information system - a census is undertaken by ANC and community leaders at the beginning of the project; - standardized data collection; - computerized quarterly assessment - a census is undertaken by CNC workers and consultants at the beginning of the project - standardized data collection tool are used at every level - monthly monitoring of the performance of each center using computerized system 14. Who provides training? - the regional project coordination unit - local consultants - supervision is selective based on results of monthly monitoring data The projects are different in three principal aspects: the Madagascar project is mainly rural, the Senegal project is largely peri-urban; the executing agency is the SECALINE office in Madagascar, while in Senegal it is an autonomous body, AGETIP. Both are, however, managed in an independent way. AGETIP uses delegated contract management as a way to execute the project; SECALINE uses more its own staff. Both projects are similar in the following four principal aspects: both are prevention projects;

7 the Ministry of Health serves only as a reference for sick and for severely malnourished children; both are highly targeted: by geographical area, by sex, by age, by self-targeting services (the supplementary food in Senegal for example, is sweetened so that it cannot be used for family meals); both involve the communities in some decision making, and both use the same approach : targeted communities are visited by project staff and are sensitized as to what the project could bring to the community ; the community is asked to think about the issues and, if interested to get organized ; people from the community are trained to deliver the nutrition services ; existing IEC material is used ; training modules are developed and updated often; the management information system is linked to supervision ; everybody is evaluated based on results. Main problems encountered Links with the health system Initially, there was first opposition from the MOH against a nutrition project being run outside the MOH in both countries. However, in Senegal, many District Health Officers now use the community nutrition centers mobilization capacity to hold vaccination sessions; some even provide lower cost care to children referred by the community nutrition centers. So, a certain collaboration has been established. There is still a problem with the inability of the health system to take care of severely malnourished children. In Senegal, while severe malnutrition in the cohort of children in the program decreased from 4.1% to 1.1% after 6 months in the CNP program, the children still need to be taken care of by the health system. In Senegal, operations research is under way to explore alternative ways to treat severely malnourished children, through home care and mother-doctor contracts. Both projects provide a unique opportunity for the MOH to redefine its role in terms of what services now provided by the MOH could be contracted out to the private sector. Unfortunately, this is not being focused on very much in either country. Food and cost In Senegal, only 41% of the food intended for distribution was actually given out to beneficiaries due to technological as well as food safety problems (aflatoxin). While cost effectiveness calculations are under way in both countries, it is well known that the food is a significant factor in the program cost. In Senegal, the food is the "carrot" that brings women to nutrition centers, and operations research is under way to find out if food could not be replaced by another service such as deworming, or in certain areas with good social cohesion, if improved social mobilization would not achieve the same results. Sustainability In Madagascar, there is a second community nutrition project in the making, extending from the original two regions to the whole country. In Senegal, the proven capacity of local groups to manage a contract could be used in other community activities such as literacy training, or family planning promotion. However, if the project is successful, financing from donors will probably continue and the Community Nutrition Centers could diversify their activities as malnutrition rates decrease.

8 Main reasons for success Design based on lessons learnt from other successful nutrition projects (mainly Tamil Nadu in India and Iringa in Tanzania); High level of political commitment Community involvement through social mobilization and involvement in monitoring progress ; Service delivery by non-governmental entities who are contracted and are accountable for results ; Linking the management information system to supervision and decision making; and Use of national expert capacity for training, operation research, and management, resulting in strong ownership. Conclusions Both projects are in the process of resolving their main problems and trying to improve efficiency and cost/effectiveness. Sustainability and replicability of both projects seems possible at this stage. Tonia Marek is the nutrition specialist who helped design both projects. She works with the World Bank s Resident Mission in Senegal and her internet address is tmarek@worldbank.org For information on SECALINE, contact Ms. Eileen Murray, Task Team Leader, at the World Bank. Internet address: emurray@worldbank.org

Successful contracting of prevention services: fighting malnutrition in Senegal and Madagascar

HEALTH POLICY AND PLANNING; 14(4): 382 389 Oxford University Press 1999 Successful contracting of prevention services: fighting malnutrition in Senegal and Madagascar TONIA MAREK, 1 ISSAKHA DIALLO, 2 BIRAM