Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Project Name PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: AB2377 SN-Nutrition Enhance Phase 2 APL (FY07) Region AFRICA Sector Other social services (80%); Health (20%) Project ID P097181 Borrower(s) CELLULE DE LUTTE CONTRE LA MALNUTRITION Implementing Agency National Nutrition Council (CLM) Senegal Environment Category [ ] A [ ] B [X] C [ ] FI [ ] TBD (to be determined) Date PID Prepared May 11, 2006 Date of Appraisal June 06, 2006 Authorization Date of Board Approval September 28, 2006 1. Country and Sector Background Senegal s economy has been growing at a steady rate since the devaluation in 1994, averaging five percent of the past decade, in spite of severe exogenous shocks such as droughts and locust invasion. The latest household survey indicates that the share of the population living in poverty decreased from 67.9 percent in 1994 (61.4 percent of households) to 57.1 percent in 2001 (48.5 percent of households). 1 Yet, in spite of recent progress, Senegal remains a poor country, with a GNI per capita of US$640 in 2004, and social indicators continue to be a cause of concern. Senegal is currently (2003) ranked 157 out of 177 on the Human Development Index, barely up from where it was in 1992 when it occupied the rank of 152 out of 174. In this context, malnutrition in under-five year old children remained stagnant at around 22-23 percent between the early 90s and 2000. Economic growth alone did not lead to significant reductions in malnutrition, a conclusion that was to be drawn by various other countries in the region and often runs counter to a widely held perception of how nutrition improves. 2 Conversely, malnutrition is known to have long-term cognitive and productivity effects on the children involved and may generate cumulative economic costs, up to three percent of GDP annually, which outweigh the short-term fiscal savings from direct nutrition action to prevent malnutrition and promote adequate growth in young children. Over the past five years, the Government of Senegal has been showing increased interest in engaging in the fight against malnutrition as integral part of poverty reduction as evidenced in 1 La Pauvreté au Sénégal: de la dévaluation de 1994 à 2001-2002, Ministry of Economy and Finance and World Bank, January 2004; or PRSP Progress Report, Report N. 28813-SEN, April 28, 2004. 2 See How Nutrition Improves by Stuart Gillespie, John Mason and Reynaldo Martorell, Nutrition Policy Discussion Paper No.15, UN ACC/SCN, Geneva, 1996; or Repositioning Nutrition as Central to Development; A Strategy to Large-Scale Action Directions in Development, World Bank, Washington, 2006. 1
the Poverty Reduction Strategy Paper (2002) and the 2005 Progress Report by the Ministry of Economy and Finance (MEF). A National Policy on Nutrition and Development (NPND) was issued in 2001 and formed the basis for the design of the Senegal Nutrition Enhancement Program (SNEP) by building on past community-based nutrition experiences and enhancing synergy between various direct nutrition interventions, notably those through the health system. The SNEP became effective in 2002 and direct interventions at community level were launched in early 2004. By December 2004, the program reached more than 200,000 children under the age of three and their mothers, representing approximately 18% of the total number of underthree year old children in Senegal. This result was obtained by enhancing capacity of implementing agencies (NGOs) which set up a total of 924 community sites in 34 Districts and trained almost 2,500 community agents. Monitoring data have shown that initial malnutrition rates were 27% in June 2004 and progressively came down to 18% in December 2004 to 13% in June 2005 to just 10% in December 2005. Preliminary data from the 2005 national Demographic and Health Survey (DHS) suggest a drop in malnutrition from 23 percent (2000) to around 17 percent (Figure 1). It is tempting to attribute part of this drop to the SNEP, although the current data do not yet allow this type of conclusion. However, since 2004, an independent impact study is being carried out to demonstrate the change in malnutrition in the intervention areas attributable to the program activities, which then helps to predict the contribution of the project to the national trend. Notwithstanding, the turn around in malnutrition prevalence since 2000, which if continued puts Senegal on track of reaching the Millennium Development Goals (MDG) of halving malnutrition rates of 1990 by 2015, suggests the relevance of continuing and accelerating what has been started since 2000 in terms of direct nutrition action. Figure 1 Trend in underweight malnutrition in children < 5 years 30 20 10 0 Percentage S urvey es timates MDG target T rend 2000-2005 projected to 2015 T rend 1992-2000 projected to 2015 1992/93 1996 2000 2005 2010 2015 The SNEP has established synergic links with various public health programs, including the promotion of infant and young child feeding, the Integrated Management of Childhood Illnesses at community level (c-imci), mass and routine distribution of vitamin A supplements, implementation of an integrated anemia policy including the promotion of iron supplementation, deworming, and malaria prevention, and the promotion of iodized salt consumption. 2. Objectives Source: WHO global database on child growth and malnutrition The second phase objective is (i) to improve the nutritional status of the population, in particular the growth of children under the age of two residing in poor urban and rural areas, and (ii) to strengthen the institutional and organizational capacity in-country to implement, monitor and 2
evaluate the NPND. The extent to which these objectives have been attained by 2011 will be measured by (i) a reduction of 25% in the prevalence of underweight malnutrition in under five year old children in the intervention areas, and (ii) an increase of 25% in the prevalence of exclusive breastfeeding among 0-6 months old children in the intervention areas. Progress of the SNEP implementation will be monitored by (i) the percentage of children showing adequate weight gain from one month to another, (ii) the percentage of under-five year old children sleeping under impregnated bed nets, (iii) the percentage of pregnant women making at least four prenatal care visits, (iv) the percentage of under-five year old children receiving two doses of vitamin A supplements, (v) the percentage of schoolchildren adequately receiving iron supplements and deworming medication, (vi) the percentage of LGs which are engaged in a formal relationship with public and/or private sector actors implementing direct nutrition actions, and (vii) the amount of government budget allocated to nutrition. The NPND (2001) being an integral part of the Poverty Reduction Strategy aims at improving the living conditions of the poor, and has as overall objective to contribute to the improvement of the nutritional status of vulnerable groups, notably children and women of reproductive age, and the elderly. With specific reference to the fate of children, the policy envisages a reduction in the prevalence of underweight children of 30-60% depending on residence environment being rural and urban through an acceleration of multisectoral programs and interventions. The SNEP would assist Senegal with reaching the hunger target of the MDGs, i.e., reducing malnutrition by half, by supporting the implementation of the NPND, with particular reference to the improvement of nutritional status of children, pregnant and lactating women. 3. Rationale for Bank Involvement The MDGs represent a key frame of reference for the World Bank Group s strategy. Nutrition status is an essential component for the goals on primary education, gender equity, child mortality, maternal health, combating disease, poverty and hunger. It is difficult to see how it would be possible to meet the MDGs without proactively dealing with malnutrition; it is, essentially, a foundation for their attainment. Senegal has taken on the fight against malnutrition as part of its poverty reduction strategy and adopted the target to reduce malnutrition rates in children under-five to 10% by 2015. The Country Assistance Strategy (CAS; 2003), which supports the country s poverty reduction strategy, recognizes that Senegal has made considerable progress in the economic domain, but that human development indicators have been lagging behind, particularly in rural areas. The CAS sees the SNEP as an investment in human capital with a particular focus on improving the living conditions of the poor as well as those of women. The SNEP has shown to be an effective strategy in reducing malnutrition. Provided that the program will be scaled up to the national level, the SNEP could bring the attainment of the MDG on malnutrition within reach. This would place Senegal in the small league of sub-saharan African countries on track of achieving the non-income target of the first MDG on eliminating poverty and hunger. 3
The World Bank is in a unique position to (i) strengthen high level leadership attention to a cross-sectoral issue that often falls between the cracks of development assistance; (ii) assist the country in effectively achieving the non-income target of the first MDG by supporting the program s scaling up to national level, and (iii) continue its involvement in one of the best managed operations in the Senegal portfolio and in the Health, Nutrition and Population sector. 4. Description This component corresponds to a package of community services and activities and consists of three subcomponents; 1) Community-based growth monitoring and promotion/c-imci; This subcomponent represents the core of the program and refers directly to the first development objective. It builds on the successful experience from the first phase by integrating the activities of communitybased growth monitoring and promotion with c-imci. Activities include monthly evaluation of growth of children under two with counseling feedback to mothers, home visits to children requiring special attention, and cooking demonstrations. The behavior change communication strategy will particularly focus on infant and young feeding practices as recommended by WHO and UNICEF 3, disease preventive measures, home-based care, recognition of danger signs, and care seeking for sick children. A particular emphasis will be put on the prevention of malaria as a major cause of child morbidity and mortality through the distribution of impregnated bed nets and the promotion of its use by children and pregnant women. 2) Micronutrients: The thee main strategies for reducing micronutrient malnutrition are dietary diversification, supplementation, and food fortification. The community level communication activities will disseminate messages on dietary diversification and create demand for vitamin A and iron supplements and fortified foods, notably iodized salt. The community workers will take part in national distribution days for vitamin A supplements and deworming medication, and refer children at risk for vitamin A deficiency to health centers to receive a curative dose under the supervision of health workers. The program will support the national health policy that women take iron supplements during the nine months of pregnancy and the two months post-partum, impregnated bed nets are distributed and its appropriate use by children and pregnant women is promoted. 3) Community initiatives: The program will continue the small grant facility to communities to finance micro projects that address specific problems affecting child growth. Problems will be identified through a participatory community analysis with particular attention to women s needs. These micro projects will be developed in synergy with other community development programs such as the Local Development Program and the Agricultural Services and Producers Organizations Program and used for activities that will receive no other financing. II. Sectoral Support for Nutrition: This component continues the work started during the first phase by involving line ministries in a more formal and systematic manner. On the basis of their strategic work plans, areas of 3 Global Strategy for Infant and Young Child Feeding Promotion, UNICEF & WHO, 2003. 4
collaboration will be identified, with a particular emphasis on strengthening their planning capacity. Activities considered for financing will mainly be in the health and education sectors as the two with most immediate implementation responsibilities, and for priority activities that for the time being cannot be assured by the respective two sectors. Collaboration with other line ministries, such as agriculture, with important roles in creating the right conditions for child growth and development, would aim at identifying and elaborating micro projects under community initiatives. These micro projects are often specific to one ministerial sector. III. Support to Implementation, Monitoring and Evaluation of the National Policy The CLM s main function is to ensure that nutrition remains high on the national development agenda and to keep oversight of the implementation of the NPND. The program would continue to strengthen the performance of the CLM and its decentralized representations at regional level by enhancing the discussions on nutrition-relevant issues as well as promoting the participation of stake holders, including LG representatives who will play a more important role in the second phase of the program. During the first phase, the program developed a simple and effective monitoring system for community nutrition activities. This system and its tools will be updated in the light of the new orientations of the second phase, notably the formal implication of LG, and the enhanced and formalized role of line ministries. The decision-making process will be strengthened by enhancing the analytical capacity and accountability at local, district and central levels. This entails efficient communication of results and actions to all directions. 5. Financing Source: ($m.) BORROWER/RECIPIENT 5.0 INTERNATIONAL DEVELOPMENT ASSOCIATION 15.0 UNICEF 1.4 WORLD FOOD PROGRAMME 2.7 MICRONUTRIENT INITIATIVE 0.8 Total 24.9 6. Implementation During the first phase of the APL, the CLM/BEN has gone to great length to improve relations with other sectors and organizations, including ministries, donors and NGOs, which have all become active partners in the design, implementation and monitoring of the program. Most national partners are members of the CLM and include among others representatives of the MOHP, the MEF, the Ministry of Education, the Ministry of Agriculture, the Ministry of Local Development and Decentralization, and LG. LG, public (health) service delivery system, and CIOs are the implementing partners of the community-based nutrition component. Line ministries and national organizations such as the ITA and the Cheikh Anta Diop University collaborate with the program on specific sector-related responsibilities for nutrition, e.g., the SNEP has become MOHP s principal roll-out mechanism of c-imci and an important partner in 5
the effective delivery of priority health services. International agencies (e.g., UNICEF, WHO, WFP, the Micronutrient Initiative, USAID and the USAID-supported project BASICS) provide technical, operational and financial support to the implementation. The CLM has developed a financing strategy based on contributions from international partners, the national budget, and the local level. The latter is expected to remain small and will be used for specific direct actions to support the program, e.g., building or renovating community sites, remuneration and/or motivation of community workers, or organizing transport for supervision. Financing partnerships are gradually being strengthened with parallel financing to the IDA credit coming from the Japanese Counterpart Funding (for micronutrients and scales) and the Micronutrient Initiative (for salt iodisation). In kind contributions are also foreseen, e.g., drugs, micronutrients and scales from UNICEF, and food for cooking demonstrations during the hungry season by WFP. In search of additional financial resources and partners, the CLM, through the MEF, is approaching other financial institutions in an effort to close the budget gap. The following structures make up the principal actors of the SNEP; the community, the CLM, line ministries, LG, CIOs, public services and the private sector (Figure 2). The CLM was created in 2001 to assist the Prime Minister with the elaboration of a policy and strategies for nutrition, and monitor and coordinate the implementation. It consists of representatives of the Prime Minister s Office, line ministries with responsibilities in nutrition, LG and civil society. The secretariat is assured by the BEN. The CLM can set up consultative technical committees to address or advice on specific nutrition-relevant issues. Most recently, the CLM created a National Committee for Food Fortification (COSFAM) to see into the technical and operational aspects of food fortification with essential micronutrients. Line Ministries, notably the MOHP, assist the CLM with the elaboration of policies, norms and protocols, contribute to the implementation of the program, and ensure quality of interventions. The MOHP and the Ministry of Education can apply for financial support for the implementation of interventions on the basis of strategic work plans. Annex 7 provides a schematic presentation of the proposed flow of funds in the second phase of the program. Figure 2 Institutional Framework of the SNEP 6
Prime Minister s Office Cellule de Lutte contre la Malnutrition Line ministries, National organizations Local Government Private sector Public services Community Implementing Organizations Community Nutrition, health and education are among the responsibilities that in the decentralization process have been transferred to LGs, although few include nutrition as a priority in their LDP. Yet, improving nutritional conditions have a better chance of success if local authorities are actively engaged. During the first phase, the program created awareness among more than 100 rural and urban municipalities. This forms the basis for enhancing LG responsibility in managing nutrition interventions along the lines of the decentralization policy. Accordingly, it is expected that LG will (i) include nutrition and nutrition indicators in the LDP, (ii) select one CIO to which it will contract out the community-based nutrition interventions, and (iii) monitor activities. The CLM/BEN will accompany LG authorities in the process of increased responsibility of the community-based nutrition component through formative workshops, frequent monitoring and supervision visits, and regional meetings. The CIOs will be expected to have juridical status and capacity to implement community-based nutrition interventions in an entire health district. On behalf of the LG, the CIO will be in charge of implementing the activities which are financed by the CLM. Therefore, the selected CIOs will assist LGs with preparing proposals to be submitted to the CLM for approval. CIOs will then sign a contract with their respective LGs and the CLM to implement the activities while reporting to the local authorities and the health district. The role of communities is to (i) identify and mobilize members of the community to operate as community agents (ARC), (ii) allocate appropriate sites for ARCs to conduct monthly growth promotion activities, and (iii) set up management committees to oversee the activities and the community nutrition sites. The ARCs belong to (and will be supported by) the community. Technical support in the form of training, formative supervision and learning exchanges will be provided by the CIO in collaboration with public health service providers and local authorities. Table 2 shows in summary the distribution of roles and responsibilities comparing the situation of the first phase with that of the second phase. In the second phase, LG will have a formal role in all the listed activities except for quality control, and in many, it will have a leading role as indicated in the table. 7
Table 2 Roles and responsibilities under the community-based nutrition component Awareness creation on SNEP Selection of implementing partners (NGO) Selection of intervention villages Preparation of project proposals Proposal submission to CLM Financing agreement Implementation agreement Quality control agreement Monitoring Reporting Leading role/responsibility Phase I Phase II CLM LG Health CIO CLM LG Health CIO Equal or minor responsibility The second phase implementation calendar for community based nutrition will roughly follow three progressive stages of extension and consolidation. In 2007-2008, the program will increase the coverage within the 34 districts that were part of phase I. The program will go nationwide in 2008-2009, while the last stage (2009-2010) will focus on consolidating the achievements by improving the quality of services. Private sector is increasingly engaged in social development. In the area of nutrition, private sector plays an important role in the fortification of food with essential vitamins and minerals. Food industries for oil and cereals are members of the newly created COSFAM under the CLM. Whilst fortification of oil with vitamin A and cereals with iron is under preparation, the enrichment of salt with iodine that started more than a decade ago will be further enhanced. 7. Sustainability Relying heavily on behavior change outcomes, sustainability depends on the program s ability to influence the adoption of positive behaviors and attitudes by parents, grandparents and community members. This in turn depends on support from community workers, community leaders, LG, CIOs, public service providers, regional authorities, central government and development partners. Borrowing from the approach of building capacity through results, the program will continue to improve its performance and communicate its results to all levels of authority and leadership to generate broad ownership of the program. The first phase has been successful in placing nutrition on the development agenda and creating demand for direct nutrition-relevant action at all levels. The second phase will build on these results by steering discussions for the long-term institutionalization of the national nutrition program. Financial sustainability, inherent to the long-term institutionalization, will be ensured by a multipronged financing strategy which broadly distinguishes (i) local financing by community and LG contributions, (ii) national financing through an allocation from Government s own resources, and (iii) external support from donors, development banks and international organizations. Depending on the decentralization process, local financing may or may not increase significantly. Compared to the first phase, national financing will increase from 7.5% in Phase I to at least 15% of the total budget for Phase II, or a 4.5-fold increase in absolute terms. Mobilizing other donors and development banks has potential; the challenge being 8
harmonization of procedures when the number of financial contributors increases. The longterm aim is to have nutrition financed as part of an enduring government program rather than a time-bound project. 8. Lessons Learned from Past Operations in the Country/Sector Window of opportunity: There is consensus that under nutrition has damaging impact on health, brain development, intelligence, educability and productivity which are largely irreversible. The most damaging effect occurs during the months of rapid growth and development, i.e., during pregnancy and in the first two years of life. This period between conception and 24 months is also referred to as the window of opportunity for effective intervention. Actions targeted to older children have little, if any, effect. Hence, the focus of the community-based communication and counseling efforts are targeted to this age range of minus nine and plus 24 months. Community mobilization: To improve nutrition is to change behaviors and this requires access to parents, households and communities. The first phase has shown the strategy of communitybased communication and services to be very effective in reducing malnutrition by changing behaviors. If brought to scale, the program would provide an important contribution to Senegal achieving the MDG target of reducing malnutrition to 10% by 2015. Moreover, dynamic community mobilization processes can significantly enhance public service delivery systems if effective links are established. Results from the first phase have shown that health service delivery is greatly enhanced in the intervention areas. The second phase intends to further strengthen the links between health services and communities. Local government involvement: In the past, many community-based development efforts have discontinued because they were not embedded in a sustainable institutional set up that could provide continued support and guidance to the community and their development efforts. The decentralization policy provides an opportunity to place community-based development programs under the responsibilities of LG. The first phase has provided experience in collaborating with local authorities, and these experiences will now be used to invoke a formal and systematic approach to include LG in the management of the community-nutrition program. Role of women: In Senegal, women are key to improving the well-being of household members. By taking stock of issues affecting children s growth on a monthly basis, and bringing systematic problems to the attention of community leaders, the community-based nutrition program is in a unique position to make women s voice heard in community development activities and ultimately in Local Development Plans (LDP). Learning by doing and subsidiarity: Community development does not follow a straight jacket approach. The program therefore, adopted from the start a hands-off approach leaving as much room to the various stakeholders and partners to learn as they go. The lending instrument suited this approach in which the first phase led to the identification of best practices which are incorporated into the second phase design. Despite temptations to control, the hands-off approach has worked well and allowed a better understanding of the subsidiarity of organizations and institutions, notably LG, public services, and NGOs, in the fight against malnutrition. 9
Strategic communication: Malnutrition is not typically on the development agenda, be it at household, community, district, or national level. Reasons are plentiful and include the fact that many forms of malnutrition are invisible, the magnitude of the destructive impact of malnutrition has only recently come to light, and those who suffer most have the least voice. An early task is thus to create interest in the fight against malnutrition by increasing awareness of the magnitude of the problem as well as the scope for direct intervention. Nothing sells better than success and the second phase will continue the successful communication strategy adopted in the first phase based on evidence of the program s ability to reduce malnutrition rates. This kind of strategic communication is conducted at community, regional and national level. Quite recently, the program has expanded its communication to the international level as Senegal is proudly becoming a source of inspiration for other countries. Institutional development for nutrition: Much has been written about the institutional home for nutrition. The bottom line is that in Senegal there was none. While there were units and focal points in various line ministries, there was no authority capable of bringing the multisectoral dimensions and responsibilities of nutrition into a consolidated policy and program. This is not limited to community-based nutrition which has an institutional challenge in itself (described above), but to a wide spectrum of nutritional responsibilities hidden away in various public service sectors such as health, education, agriculture, trade, industry and others. In Senegal, the institutional capacity was extremely weak when the project started in 2002. The first phase has built capacity, as measured by the reduction in malnutrition rates in the intervention areas, and the government has taken note of these results and started to engage in discussions on a permanent structure that will continue to oversee nutrition over and beyond the length of IDA support. Therefore, the second phase will further this process of strengthening the institutional capacity in Senegal to continue the fight against malnutrition. Sector wide approach: It is not common to refer to nutrition as a sector, yet the advantages of a Sector Wide Approach are very relevant. In many countries, nutrition tends to be fragmented along the lines of sectors and donors producing a series of incoherent, small scale, time-bound interventions. Senegal has made considerable strides in consolidating actions for tackling malnutrition. The SNEP was urged from the beginning to establish effective partnerships with all key players, the most prominent partner being the Ministry of Heath and Prevention (MOHP). As a result, partners have come to see the SNEP as the national program and the CLM as the national focal point for advancing nutrition policies. As the program grows in scope, there will be a need for additional financial resources and with it the harmonization of financing and reporting procedures. 9. Safeguard Policies (including public consultation) This operation falls under environment category C. Safeguard Policies Triggered by the Project Yes No Environmental Assessment (OP/BP 4.01) [ ] [x] Natural Habitats (OP/BP 4.04) [ ] [x] Pest Management (OP 4.09) [ ] [x] Cultural Property (OPN 11.03, being revised as OP 4.11) [ ] [x] 10
Involuntary Resettlement (OP/BP 4.12) [ ] [x] Indigenous Peoples (OP/BP 4.10) [ ] [x] Forests (OP/BP 4.36) [ ] [x] Safety of Dams (OP/BP 4.37) [ ] [x] Projects in Disputed Areas (OP/BP 7.60) 4 [ ] [x] Projects on International Waterways (OP/BP 7.50) [ ] [x] 10. List of Factual Technical Documents 11. Contact point: Menno Mulder-Sibanda Senior Nutrition Specialist Tel: (202) 458 7724 Email: mmuldersibanda@worldbank.org 12. For more information contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-4500 Fax: (202) 522-1500 Email: pic@worldbank.org Web: http://www.worldbank.org/infoshop 4 By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties claims on the disputed areas 11
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