Document ofThe World Bank

FOR OFFICIAL USE ONLY

ReportNo: 25183

IMPLEMENTATION COMPLETION REPORT(IDA-27350)

ONA

CREDIT

IN THE AMOUNT OF SDR 40.1 MILLION (US$ 59.8 MILLION EQUIVALENT)

TO THE

PEOPLE'S REPUBLIC OF BANGLADESH

FOR AN

INTEGRATED NUTRITION PROJECT

December 16, 2002

This document has a restricted distribution and may be used by recipients only in the perfonnance of theirofficial duties. Its contents may not otherwise be disclosed without World Bank authorization.

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CURRENCY EQUIVALENTS

(Exchange Rate Effective as of 11/14/2002)

Currency Unit = Bangladesh Taka (Tk.)Tk. 1.00 = USS 0.01669

US$ 1.00 = Tk. 59.93

FISCAL YEARJuly 1, 2002 June 30, 2003

ABBREVIATIONS AND ACRONYMS

BINP - Bangladesh Integrated Nutrition ProjectCAS - Country Assistance StrategyCBN - Community-Based Nutrition ComponentCNC - Community Nutrition CenterCNO - Community Nutrition OrganizerCNP - Community Nutrition PromoterDO - Development Objective

GOB - Government of BangladeshIEC - Information, Education and CommunicationINC - Inter-Sectoral Nutrition ComponentINFS - Institute of Nutrition and Food Science

DhakaICDDR,B - International Center for Diarrhoeal Disease

Research, BangladeshKPI - Key Performance IndicatorMTE - Midterrn EvaluationMTR - Midterm ReviewMIS - Management Information SystemMOHFW - Ministry of Health and Family WelfareNGO - Non-Governmental OrganizationNNC - National Nutrition ComponentNNP - National Nutrition Project

PCR - Project Completion Report

PSR - Project Status ReportQEA - Quality at Entry AssessmentSAR - Staff Appraisal Report

SENA - Strengthening Existing Nutrition ActivitiesTINP - Tamil Nadu Integrated Nutrition ProjectUNICEF - The United Nations' Children's Fund

Vice President: Mieko NishimizuCountry Manager/Director: Fredrick Thomas Temple

Sector Manager/Director: Anabela Abreu/Charles GriffinTask Team Leader/Task Manager: Michele Gragnolati

BANGLADESHINTEGRATED NUTRITION PROJECT

Implementation Completion Report

CONTENTS

Page No.1. Project Data 12. Principal Performance Ratings 13. Assessment of Development Objective and Design, and of Quality at Entry 24. Achievement of Objective and Outputs 55. Major Factors Affecting Implementation and Outcome 96. Sustainability 107. Bank and Borrower Performance 118. Lessons Learned 149 Partner Comments 1610. Additional Information 18Annex 1. Key Performance Indicators/Log Frame Matnx 19Annex 2. Project Costs and Financing 20Annex 3. Economic Costs and Benefits 22

Annex 4. Bank Inputs 23Annex 5. Ratings for Achievement of Objectives/Outputs of Components 25

Annex 6. Ratings of Bank and Borrower Performance 26Annex 7. List of Supporting Documents 27

'Project ID.' P009496 Project Name: Integrated Nutrition ProjectTeam Leader. Michele Gragnolati TL Unit: SASHD

ICR Type. Core ICR Report Date: December 16, 2002

1. Project Data

Name: Integrated Nutrition Project LIC/TF Number: IDA-27350Country/Department' BANGLADESH Region* South Asia Regional

OfficeSector/subsector: Health (90%), Central government administration

(7%); General agriculture, fishing and forestry sector(2%), Other social services (1%)

KEY DATESOriginal Revised/Actual

PCD: 04/27/1990 Effective: 07/12/1995 07/12/1995Appraisal. 01/10/1994 MTR 06/30/1998 03/31/1999Approval: 05/30/1995 Closing: 12/31/2001 06/30/2002

Borrower/lImplementing Agency GOVERNMENT OF BANGLADESH/MINISTRY OF HEALTH AND FAMILYWELFARE

Other Partners: None

STAFF Current At AppraisalVice President: Mieko Nishimizu Joseph D. WoodCountry Manager: Frederick Thomas Temple Paul IsenmanSector Manager: Anabela Abreu Barbara HerzTeam Leader at ICR. Michele Gragnolati S. K. SudhakarICR Primary Author: Meera Chatterjee

2. Principal Performance Ratings

(HS=Highly Satisfactory, S=Satisfactory, U=Unsatisfactory, HL=Highly Likely, L=Likely, UN=Unlikely, HUN=HighlyUnlikely, HU=Highly Unsatisfactory, H=High, SU=Substantial, M=Modest, N=Negligible)

Outcome: S

Sustainability: L

Institutional Development Impact' M

Bank Performance: S

Borrower Performance S

QAG (if available) ICRQuality at Entry: S

Project at Risk at Any Time: No

3. Assessment of Development Objective and Design, and of Quality at Entry

3.1 Original Objective:

The Project aimed to initiate a national nutrition program with the long-term goal of improvingnutritional status, particularly of children under five, women and adolescent girls, to the extent thatmalnutrition would cease to be a public health problem in Bangladesh. The Project's DevelopmentObjectives (DOs) were: (a) to improve the capacity of national nutrition institutions in the areas ofadvocacy, analysis of malnutrition, policy advice, operational research and support of programs; (b) toimprove the capacity of communities, households and individuals in the project areas to understandnutritional problems in practical terms and take appropriate action to address them at their own levels; and(c) to improve the nutritional status of the population in the project areas, with particular emphasis onpregnant/lactating women and children under two years of age.

These development objectives were quite appropriate as malnutrition was a serious problem inBangladesh. At the time of project preparation over two-thirds of children under five years of age weremoderately or severely malnourished, and one-third to one-half of newbom were 'low birth weight',pointing to malnourishment among pregnant women. The country had the potential to implement acommunity-based approach to nutrition improvement as it had demonstrated the success of such anapproach in other similarly complex areas such as family planning, girls' education, and women's incomegeneration. However, it needed stronger nutrition institutions to pursue the long-term goal. The objectiveswere also consistent with sectoral knowledge and Bank sector policy as they advocated attention to thecritical target groups, focused on community-level action, and highlighted the importance of policy andresearch support to successful nutrition intervention.

The DOs remain highly relevant to the Borrower's current development priorities and Bankpolicies, strategies and goals, including at least four of the eight Millenium Development Goals. Attentionto malnutrition, which continues to be a very serious problem, is central to Bangladesh's - and to theBank's - poverty reduction aims. The Country Assistance Strategies (CAS) since 1994 have focused onhuman development and poverty reduction, of which nutrition is an important part. The 2002 InterimPoverty Reduction Strategy Paper explicitly identifies the reduction of child and matemal malnutrition asone of the major challenges that need to be addressed to achieve sustainable development and povertyreduction in Bangladesh.

The Project was developed in the wake of a Child Nutritional Status Survey (1989-90 and 1992)and a Demographic and Health Survey (1993-94) by the Government of Bangladesh. An advocacy effort(the development of nutrition 'Profiles') was supported by the Bank to enhance the environment fornutrition intervention. In addition, a pilot effort, on which the design of this project was based, had beenimplemented in one thana (administrative unit of about 150,000 people, also known as an upazila) forabout two years.

The objectives of the Project were clearly understood by project managers, staff and associatedentities. The Project has been quite successful in achieving its third objective, as a result of widespreaddevelopment of human resources, good technical inputs and high-effort field management. However, itsfirst and second objectives, which are crucial to sustaining project outcomes and expanding efforts fornutrition, were more complex and demanding, and proved difficult to achieve.

3.2 Revised Objective:

The Project's objectives were relevant and remained unchanged throughout the project period.

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3.3 Original Components:

The Project had three components:

ComPonent 1: National Nutrition Activities (US$20.6 million),with four sub-components:

i Program Development and Institution Building (US$3.1 million),ii Information, Education and Communication Development (US$4.8 million),

iii Strengthening Existing Nutrition Activities (US$6.8 million), and

iv Project Management, Monitoring and Evaluation (US$5.9 million);

Component 2: Community-based Nutrition (US$39.1 million); and

Component 3: Inter-sectoral Nutrition Program Development (US$7.6 million).

The first component, National Nutrition Activities, aimed to increase general awareness ofmalnutrition, and of its solutions at policy and decision-making levels. It intended to support the

formulation of a national nutrition program and to develop capacity for its implementation. It included

activities to coordinate and strengthen on-going nutrition programs, to manage this project, and to monitor

the effects of all nutrition interventions.

The Program Development and Institution Building sub-component was to undertake advocacy atthe highest levels to maintain political commitment and coordinate the development of national expertise.

The roles of existing nutrition institutions and NGOs was to be reviewed and streamlined to ensure

complementarity, and to identify areas that needed strengthening. The sub-component was also to fund

policy and operational research, and training and fellowships for key personnel to update country

knowledge in nutrition.

The Information, Education and Communication Development (IEC) sub-component was centralto the community-based nutrition activities (described below). It included advocacy and mass media

campaigns, the development of messages and materials based on formative research (studies of the cultural

and behavioral aspects of nutrition), and assessment of EEC needs. These activities were to be contracted

out to private firms with the necessary expertise, and managed by a unit within the Project Office in the

Ministry of Health and Family Welfare (MOHFW), the key implementing agency.

A third sub-component was concemed with Strengthening Existing Nutrition Activities, i.e.,programs addressing different aspects of nutrition, particularly the control of micronutrient deficiencies.These included the Camnpaign for the Protection and Promotion of Breastfeeding, the Baby-Friendly

Hospital Initiative, vitamin A distribution, control of anemia through iron-folate distribution to pregnant

women, and control of iodine deficiency disorders through quality testing of iodized salt, legal prevention of

marketing of non-iodized salt, and improved consumption practices.

The Project Management, Monitoring and Evaluation sub-component included acommunity-based nutrition monitoring system, a project Management Information System (MIS), and

evaluation activities (encompassing baseline, midterm and endline surveys). A nutritional surveillance

system was to be established in a sample of thanas. Annual reviews and a special review of project

implementation after two years in the first six thanas covered by the Project were to be conducted.

The Community-Based Nutrition Component included mobilization of women's groups in theproject villages, establishment of Community Nutrition Centers, selection and training of Community

Nutrition Promoters and their supervisors, Community Nutrition Organizers, growth monitoring and

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promotion, basic health and nutrition counseling of mothers, preparation of supplementary food andtargeted feeding of children, and pregnant/lactating women, micro-nutrient supplementation, and somebasic health inputs.

The Inter-sectoral Nutrition Program Development Component was to set up an Inter-sectoralFund to finance sub-projects from other sectors focusing on improving the nutritional impact of activities inthose sectors. The sub-projects were to be new, pilot initiatives rather than on-going programs. AnInter-sectoral Nutrition Cell was to be established to oversee this component, including inter-departmentalcoordination, review of proposals, and monitoring.

3.4 Revised Components:

There was no change in the design of the Project.

3.5 Quality at Entry:

Quality at Entry Assessments were not carried out in the Bank at the time of project initiation(FY95). At the current time, the Project can be considered to have been satisfactory quality at entry. Asdiscussed in section 3.1, the Project's strategic relevance -- development rationale, consistency with CASand sector strategies, basis in sectoral knowledge and experience, and Borrower ownership -- was high.The Project incorporated attention to poverty and social issues, including gender, very well, but currentenviromnental and other safeguard policies (such as the policy for indigenous people) would have placedadditional preparation requirements on it. For example, an environmental management framework wouldhave been required for the inter-sectoral activities, and greater attention would have been needed to ensurethat indigenous people would benefit from project activities. In the event, the Project did not include tribalareas of Bangladesh and negative environmental impacts did not occur as few inter-sectoral activities wereundertaken.

The Bank had a comparative advantage in assisting this project because of its involvement in thesimilar Tamil Nadu Integrated Nutrition Project (TINP) in India, and other relevant nutrition projects inIndonesia, Guinea-Bissau and Colombia. The TINP had started in 1980 and, at the final evaluation of itsfirst phase in 1989, was considered to be a successful project. Preparation of this project began thereafterand involved several Bank staff who had been part of the Bank's TINP team. In addition, representativesof the Govemment of Bangladesh (GOB) visited several nutrition projects in Tamil Nadu, Indonesia, SriLanka and the Phillippines during project preparation. These visits were useful to gather inputs for projectdesign and to build ownership and partnership. The Bank also had good access to intemational nutritionexpertise and the ability to foster partnership among agencies such as UNICEF and other national andinternational non-govemmental organizations (NGOs) to assist in the development and implementation ofthe Project.

While the project design incorporated a number of lessons from the four Bank-financed nutritionprojects mentioned above, particularly lessons related to community nutrition activities, it appears to haveoverlooked other important information. For example, the earlier projects identified strong projectmanagement as a critical factor for success, and at least two of the four projects pointed to the difficultiesof achieving inter-sectoral coordination. These two omissions were critical as weak management andcomplication of the design with the inter-sectoral nutrition component ultimately conspired to limit theProject's achievements. Early Project Status Reports (PSR) suggest that management was inadequate atentry and slow to start-up. This had been flagged as a project risk, to be mitigated by technical supportfrom outside and phasing of the Community-Based Nutrition Component (CBN), but these mitigationmeasures were insufficient. While coordination for inter-sectoral action was also identified as a risk, theCell proposed to manage the Inter-sectoral Nutrition Component (INC) and hence mitigate this risk was

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unable to do so effectively. Overall, preparation of the policy and institutional aspects was weak,particularly the assessment of capacity for implementation and of risks, and the implementationarrangements.

4. Achievement of Objective and Outputs

4.1 Outcome/achievement of objective

The Project was Satisfactory in terms of achieving its main development objective, i.e., improvingthe nutritional status of pregnant/lactating women and children in the project areas. According to projectmonitoring data, the 'targets' for improvement of children's nutritional status have been well exceeded.Severe malnutrition was apparently reduced from a base level of 13% to 0.9% in June 2002, and moderatemalnutrition from 32% to 16.4%, declines of 92 and 49%, respectively, in excess of the targeted decreasesof 40% and 25%. Low birth weight was reduced from 40% to 18%, below the targeted 20%. In the firstphase upazilas, the proportion of adequately nourished pregnant women increased from 43% to 61%during the project period. It should be noted, however, that these are program data. Although the Project'smonitoring system is believed to be good, discussions and observations in the field did not support thereported, sigrificant decline in moderate malnutrition. The Midterm Evaluation which was carried out in1998, 40-42 months after the Baseline Survey showed a significant improvement in severe malnutritionamong children, and a difference between project and control thanas, but these differences were notobseved in moderate malnutrition. The Endline Evaluation is expected to give more reliable figures.

These improvements in nutritional status were in part the result of some progress toward thesecond objective, improving the capacities of communities, households and individuals to understand andaddress malnutrition. Only one indicator among those reported in the PSRs is a good proxy for householdknowledge and nutrition-related practices: the extent to which lactating women in the project areas practiceexclusive breastfeeding of their infants for five months. The data show that this increased from 10% to41% up to October 2001, still short of the 70% expected by project closing.

A recent study conducted independently of the Project, after the devastating flood of 1998, throwsuseful light on the achievements of the Project. Although many households were able to smoothconsumption expenditure, not all were able to maintain adequate calorie consumption during and after theflood. As a result, the nutritional status of children in households that were more severely exposed to theflood deteriorated. The study investigated which households were better protected from longer termnutritional problems, and whether the health of flood-exposed children recovered to the level of theirunexposed neighbors. It found that children exposed to the flood did not recover from the shock to theirhealth. However, children in project areas were able to recover better from the deleterious effects of theflood on their health than children living in areas where there was no nutrition program. Further, withinproject areas, the 'catch up' growth of girls following the crisis was found to be better than that of boys,the presumed result of the Project's focus on girls. These findings suggest that the Project invested well inchildren's health, and that the investment in nutrition has a positive impact cushioning children's growthagainst shocks.

Overall, the Project's design was appropriate to achieve its objectives. It was, however, less wellsuited to available implementation capacity, which caused two components to lag behind the third.Existing capacity was inadequate to the tasks entailed in the national nutrition component, particularly theinstitution-building sub-component, and the inter-sectoral component. While some difficulties also arose inthe management of the govemment-NGO partnership required to implement the Community-basedNutrition Component, this was relatively more successful.

These variations in achievement suggest that although project design and objectives were well

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aligned the Project may have been too ambitious for a 'first' nutrition project. By taking a wide view ofnutrition and attempting to build synergies across sectors and levels, the Project diverted attention from itscore activities. Simplification of Component 1 and exclusion of Component 3 could have improved theoverall performance of the Project. Bank supervision, too, could have re-channeled the effort expended onComponent 3 to providing stronger technical oversight of the community nutrition activities and toenhancing the position of nutrition in the structure and functions of the MOHFW, making for an improvedand more sustainable program.

4.2 Outputs by components:

National Nutrition Components The key outputs of this component were: a review of nationalnutrition institutions, a formative research study for the development of IEC activities, establishment ofsupport cells and teams, contracts with specific agencies to strengthen existing nutrition activities orprovide technical assistance (e.g., the Bangladesh Breastfeeding Foundation and Helen KellerInternational), operational research studies, project evaluation surveys (baseline and midterm) and otherproject management items (such as the Project Implementation Volume, bidding documents, auditstatements and progress reports).

Two output indicators were used by the Project to assay this component and recorded in the PSRs:Completion of the Review of Major National Nutrition Institutions, and Development of an OperationalResearch Strategy. The review of national institutions was completed after significant delay, and follow-upaction by way of capacity development of these institutions was slow and remains incomplete. Several keyinstitutions that were identified before Appraisal (e.g., the Bangladesh National Nutrition Council, theInstitute of Food Sciences and Technology, the Institute of Public Health Nutrition) do not appear to havereceived much attention under the Project.

Eighteen operational research studies were completed and produced useful results and insights.Although the studies were relevant to the problems experienced in the on-going nutrition programs, astrategy to utilize the results does not appear to have been developed. However, some findings influencedthe design of the expanded National Nutrition Project (NNP) in FY00. (Additional information on the NNPis given below in Section 6.2.)

The two specific indicators above relate to outputs under the Program Development andInstitution Building sub-component. No output indicators related to the IEC, Strengthening ExistingNutrition Activities (SENA), or Project Management, Monitoring and Evaluation sub-components werereported in the PSR. The chie,f outputs of the IEC sub-component were various communications materialsand activities. On account of a mis-procurement declared on an IEC contract - for which the Bank hadgiven no objection and the Borrower did not award the selected agency - to produce materials centrally,field activities depended largely on materials produced by the implementing NGOs and on mass mediaefforts such as radio and TV broadcasts, documentary films and news media campaigns. These wereregarded as quite successful (though not evaluated) and a range of people associated with the Project feltthat there had been no real need for the external assistance contract. Efforts under the SENAsub-component included promotion of breastfeeding and micro-nutrient supplementation. While the'outputs' of these activities were not measured, some of their outcomes have been discussed above. Theendline survey (which has been delayed due to contracting problems) will collect information on ironsupplementation of pregnant and lactating women, and vitamin A supplementation of post-partum women,which are among 'existing nutrition activities'.

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Community-based Nutrition Component. The main outputs of this component, produced largelyby field-based NGOs, were: village, union and thana nutrition committees; Community Nutrition Centers(CNC) with trained Community Nutrition Promoters (CNP) and Organizers (CNO), women's groups,growth monitoring sessions, meetings with adolescent girls and newly-wed women, and supplementation ofwomen and children with therapeutic nutrition or micro-nutrients. Achievements under the component werereported on the basis of key performance indicators (KPI) related to program outreach and community(especially women's) participation, in addition to the outcomes related to improved nutrition practices andnutritional status that were discussed above. The targeted levels for the four KPIs - 80% of VillageNutrition Committees active, 80% of Community Nutrition Centers functioning, 100% of Women'sGroups preparing supplementary food, and 80% coverage of 0-24 month-old children with GrowthMonitoring and Promotion - were almost fully (90-100 %) achieved (see Annex 1).

Some additional information on project outputs and outcomes is available in the MidtermEvaluation (MTE) report. The MTE data showed that while a number of improvements in health andnutrition took place in both project and non-project areas, there were also many positive changes that couldbe attributed to the Project. For example, sanitation practices were considerably better in the project areasthan control areas. Similarly, ante-natal visits to and by mothers were higher in the project areas, as wasprotection of mothers against tetanus. The most remarkable change was in mothers' eating habits duringpregnancy: over twice as many (55.7%) had increased their food intake in project thanas compared withcontrol thanas (21.9%). Positive outcomes of this were seen in higher pregnancy weight gains of women,and in a lower percentage of underweight newborn in the project areas. Vitamin A supplementation in thepost-partum period was also considerably higher in the project areas (56.1%) compared with control areas(10.2%). Some other factors, such as child immunization, exclusive breastfeeding, and timely weaning ofinfants, were not very different in the two areas.

Inter-sectoral Nutrition Component. The key outputs of this component were home gardens andpoultry units. A third proposed activity, an Assessment of the Effects of Agricultural Policies andPrograms on Food Consumption and Nutrition, did not develop due to lack of interest on the part of theparent Ministry of Agriculture, and was terninated around December 1999. Additional activities were tobe identified and financed as the project evolved, but this did not occur - Bank supervision Aide Memoiressuggest that management of this component was wrongly located in the GOB and, hence, ineffective.While the Staff Appraisal Report identified several indicators of achievement for this component, they werenot included in the PSRs, and apparently were not monitored during supervision.

Information on the garden and poultry activities is only available from a recent study of thesesub-components (Karim et al., 2002). Although the activities were to cover at least ten beneficiaries eachin every CNC, this coverage was not at all achieved. Data were not collected on actual coverage. Thestudy points out that a significant proportion of beneficiary households (64% and 56% for the garden andpoultry activities, respectively) were not from the desired target group, and that the complementarity neededwith community-based nutrition activities was absent. The inputs and services needed for the success ofthese activities were inadequate, resulting in high drop-out rates from the activities or in increments inconsumption that were insufficient to improve the nutritional status of children in the participatinghouseholds.

4.3 Net Present Value/Economic rate of return

Not applicable.

4.4 Financial rate of return:

Not applicable.

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4.5 Institutional development impact.

Institutional development under the Project was, on the whole, modest. The Project aimed todevelop two types of institutions: national institutions to support nutrition improvement efforts andgrassroots institutions, including CNCs, women's groups, Village Nutrition Comnittees, managementcommittees at thana and union levels, and the NGOs responsible for implementation. The development ofnational nutrition institutions fell short of expectations. A few key institutions, such as the InternationalCenter for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) and the Institute of Nutrition and FoodScience (INFS), benefited from participating in the Project. However, several other importantorganizations that had been identified were not assisted. Further, key institution-building objectives, suchas obtaining an important position for nutrition within the Ministry of Health and Family Welfare, andgetting other departments, such as the Ministry of Agriculture, to focus on nutrition and food security werenot achieved.

On the other hand, the Project was quite successful in developing local-level institutions, andparticularly the associated human resources, for nutrition improvement. A pioneering feature of the Projectwas the participation of NGOs, as key partners and implementors. The Project built their capacities tocarry out nutrition and health related work in village communities, including technical and managerialknowledge and skills, and abilities in important areas such as communications for behavioral change. Thecapabilities of people ranging from NGO headquarters' staff to thana and union-level workers andcommittees members, to CNOs and CNPs at village level were enhanced. This in turn extended theoutreach of the country's health and family welfare system, particularly for ante-natal care. Theseachievements will enable the NGOs who play an important role in the delivery of social services inBangladesh, to mainstream nutrition in their development activities. The creation of village-levelinstitutions, and their involvement in a systematic effort including knowledge sharing and development andthe use of simple technologies, was also successful. The survival of all these institutions will be importantto ensure continued attention to nutrition among poor communities in the project areas.

5. Major Factors Affecting Implementation and Outcome

5.1 Factors outside the control of government or implementing agency:

The impact of factors outside the control of Govermment on the Project was negligible. During theproject period, Bangladesh experienced a major flood in 1998 and some political crises. While the floodcould have had a negative impact on the Project, by all accounts project implementation continued in mostareas, with no serious interruptions. Similarly, no specific untoward effects can be ascribed to the changesin govemment that occurred during this period.

5.2 Factors generally subject to government control.

Factors under the control of the Govemment at large had a partial impact on the Project. Somethat may have contributed to the Project's achievements are: (a) Bangladesh's success in family planningand in increasing the age at marriage, particularly in the project areas, which would have encouragedparents to take better care of their 'wanted' children and improved the knowledge and health of mothers; (b)increased agricultural production in the country during the project period, which resulted in lower pricesand, possibly, improvements in the availability of food among poor families; and (c) declines in poverty.Data on foodgrain production show that total output in Bangladesh grew steadily during 1995-1999,achieving an increase of over 30% during this period. Country-wide data also show that poverty levels fellduring the 1990s by 15-20%, which would have contributed to the reduction of malnutrition.

The Project's success is widely credited to the Borrower's commitment to reducing malnutrition,

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on the one hand, and effective implementation of the community nutrition component by the field NGOs, onthe other. While government commitment was avowedly strong, its delayed action in terms of establishingthe Project Office and contracting NGOs to implement the Project resulted in lesser achievement. Lowinvolvement in the Project of departments outside the MOHFW caused in weak implementation of theinter-sectoral nutrition component, and particularly the failure of the agricultural policy assessment work.An issue that arose with the Audit Directorate on taxation of NGO contracts undermined projectimplementation. The provision of counterpart funds was never a major problem.

5.3 Factors generally subject to implementing agency control*

Factors specifically under the control of the key implementing agency (the Project Office in theMOHFW) determined project achievement substantially. Among these, the following appear to havereduced the pace or quality of implementation: inadequate staff capacity in quantity and quality, technicalas well as managerial, which resulted in a weak ability to follow Bank procurement guidelines; untimelystaff transfers; and the unwillingness or inability to identify or engage technical assistance, both nationaland intemational. The ability to initiate project activities as well as to supervise on-going ones waslimited. Both continuity of staff in the Project Office and quality of leadership at various times wereinsufficient for the tasks at hand. These factors undermined progress in the national nutrition component,particularly the IEC and institution-building sub-components. There were cumulative delays in theimnplementation schedule, many due to tardiness in issuing contracts or making agreements. EEC activitieswere never implemented fully because of inadequate financing of the mass media activities, andmismanagement of the contract for the production of materials. The absence of a procurement plan (whichwas not mandated by the Development Credit Agreement) may have contributed to these delays. Otheraspects of the NNC were perhaps inadequately detailed during preparation. For example, had the review ofinstitutions been done during preparation rather than left to the Project, the institution-buildingsub-component could have been expedited. The financial management and audit systems were establishedslowly, as were the project MIS and follow-up of supervision recommendations. Many issues identifiedduring Bank supervision missions and the Midterm Review remained unresolved to the end of the Project.

The field NGOs were also key implementing agencies in this project. Important factors thatenhanced implementation were: broad community mobilization around the CNCs and particularly theparticipation of women; good training of CNOs and CNPs; and a well-organized supervisory system.While field workers and managers reported that coordination with the government health system wasdifficult, project data suggest that this did not overly constrain the provision of nutrition-related healthservices, including ante-natal care and recording of birth weights.

5.4 Costs andfinancing:

The total Project cost was US$67.3 million, and the IDA credit US$ 59.8 million (equivalent toSDR 40.10 million) for six years. The Borrower's contribution was US$ 7.5 million or 11.1 % of the total.The allocations of total project costs to components were as follows: 32 % to national nutrition activities(US$20.6 million), 56% to community-based nutrition activities (US$39.1 million), and 12% to theinter-sectoral nutrition program (US$ 7.6 million).

This level of project financing was quite adequate to meet the objectives of the Project. Substantialdisbursement lags were reported during the first three years of the Project (76-86%), in large part becauseof delays in issuing contracts. At Midterm Review (MTR) a disbursement lag of about 60% was reported.The Project was extended for six months. After the MTR, the disbursement lag declined steadily to 14% atthe last supervision (June 2002). Counterpart funds were rated Unsatisfactory in only one (of 15) PSRs, inMayI999.

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The final actual cost of the Project was: US$ 65.74 million, of which the IDA contribution wasUS$ 58.63 million and the Borrower contribution US$ 7.11 million (all figures amounting to 97.7% of theAppraisal estimates). The amounts spent on the three components, and the percentage spent on eachcomponent relative to the Appraisal estimates were: National Nutrition Component: US$18.44 million,99.7%; Community Nutrition Component: US$32.31 million, 99%; Inter-sectoral Nutrition Component:US$6.54 million, 93%.

The Borrower's Project Completion Report (PCR) shows that the use of consultant funds was verylow, funds for training abroad were hardly utilized, and expenditure on IEC and educational materials fellshort of planned amounts. On the whole expenditure on the policy and institution building sub-componentswas low. On the other hand, expenditure on office costs was seven times the planned amount although only8% of expected amounts were spent on project management staff and one-third on vehicles. Due to a rulingby the Audit Directorate the Project spent 80 times the expected amount on taxes, as Income and VATtaxes were levied on NGO contracts and paid from project funds.

6. Sustainability

6.1 Rationale for sustainability rating:

Project sustainability is Likely, but with some qualifications. The chief basis for this is the extentto which the Project has brought about change in the knowledge and practices related to matemal and childnutrition in the project areas. This change is likely to persist at least in those households that haveparticipated in the program, and there is a fair chance that it will spread to other members of the targetgroup over time. Second, strong community participation, including the participation of women andadolescent girls, local women CNPs and CNOs, and community management of activities such thepreparation of supplementary food, augurs well for continued attention to malnutrition at the communitylevel. Third, the NGOs responsible for implementing the Project could continue community nutritionactivities using the considerable knowledge and skills they have built. During project periods whenpayments to NGOs were delayed, they continued their services and, similarly, delays in worker paymentsdid not cause major disruptions of their activities. However, access to financial resources is clearlyimportant for continuation of the NGO programs (see below). Fourth, the Project is technically sustainableas it has shown that relatively modest technical inputs coupled with strong community education andmobilization can achieve tangible results.

Project sustainability, however, is limited by some of its key weaknesses. First, despitegovernment commitment, the institutional and managerial framework for the Project has remained weak.The location of the Project Office outside the MOHFW reduced prospects of project assimilating nutritionactivities in the Ministry's programs. As the discussion above on Institutional Development suggests, thequality of institution-building in the Project was mixed, so that institutional sustainability overall is low.Second, failure to implement the inter-sectoral component well has diminished likelihood of itssustainability both at the household level (in terms of increased income and/or food availability) andprogramatically. Third, constraints on worker time and inadequacy of 'mass' IEC resulted in theopportunity to reinforce inter-personal messages being missed. Hence, sustaining behavioral change willmost likely require continued interactions between workers and mothers, rather being powered by anenvironment of nutrition knowledge conducive to positive practices. Fourth, the Project did not includesignificant cost recovery measures in any component, and an effort to develop incentives for workers tocarry on the program was not completed. The NGOs would need access to funds to continue providing the(free to beneficiaries) nutrition and health services. While the costs of workers, training and suppliesappear reasonable, about a third of project costs were for nutrition supplements. All these costs arecurrently being met by the NNP. Fifth, better integration of nutrition concems in the health system could

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have increased attention to nutrition during health service delivery and enhanced sustainability. Finally,delays in the final phases of the Project and in implementation of the follow-on National Nutrition Project,and a consequent reduction of activity in project areas, may have eroded some of the base of this project.

6.2 Transition arrangement to regular operations:

One of the objectives of the Project was to develop a National Nutrition Program (NNP), whichwould commence with this project. Preparation, appraisal and start-up of the NNP took place between1997 and 2000 when the results of this Project were emerging. The design of the new project took some ofthese lessons and achievements into account. The NNP put community nutrition at the center, andstreamlined the activities contained in the national nutrition component. Only selected 'existing nutritionservices' were included and the sub-component to develop national nutrition institutions was dropped. Theinter-sectoral component was merged with the community nutrition component and is to be managed 'in apackage' by the field NGOs.

Thus, in effect, the Project was remodeled and scaled up. Following closure of the Project in June2002, the 59 upazilas covered were absorbed into the NNP, which is to expand to 139 upazilas over itsfour-year life (FY01-04). IDA committed a further US$ 92 million (SDR 68.5 million) to a total cost ofUS$ 124.46 million for the NNP in this period. However, current delays in the NNP's implementationsuggest that the preparation of the NNP may have been premature, and that lessons from the Project hadnot been adequately absorbed. These include the need for strong leadership and technical and managerialcapacity for nutrition in the Project Office, and effective integration between the community-basedimplementing NGOs and the govemment health and family welfare delivery system. Bank supervision willneed to address these issues early to ensure that the gains of this Project are not eroded.

7. Bank and Borrower Performance

Bank7.1 Lending:

Satisfactory

This Project was well prepared, with strong involvement of the Bank. The Staff Appraisal Report(No. 13193-BD, dated April 26, 1995) is a 'state-of-the art' document with an excellent analysis of thenutritional situation in Bangladesh at the time, a clear expose of the main issues in nutrition, and goodarguments for IDA involvement in the sector. The conceptual basis for the Project was sound, standingscrutiny even seven years later. This is vindication of the fact that project preparation took five years from

concept to Appraisal. It should be noted that while the knowledge base for project design was adequate,definitive Bank Sector Work on nutrition in Bangladesh was done during the Project, and published in 2001

when this Project was drawing to a close and the NNP had already been under implementation for over ayear (World Bank, 2001). The Project's objectives, strategies and activities were well-conceived, thoughgreater attention could have been devoted to ensuring integration between the 'direct' community nutrition

activities and the allied ones, notably health services and food production/income generation activities, inview of their inclusion in the Project.

Many excellent Bank staff and consultants participated in project preparation. A couple areas ofexpertise, however, were inadequately represented: micro-enterprise development, that was crucial to the

inter-sectoral nutrition component, and institutional analysis, which would have benefited the national

nutrition component. Despite the availability of other donors in the sector and country, there were no

formal co-financing or cooperative plans. As a multilateral agency working in Bangladesh on similar

issues, UNICEF provided support at the request of the Borrower and the Bank often tiding over delays --for example, in Start-up of NGO activities and in the baseline survey. Other key aspects of Appraisal have

- 1 1 -

already been discussed in various sections above, including the issues of government commitment,implementing agency capacity, complexity of project design, lessons from earlier projects, safeguardpolicies, 'incentives' for project sustainability, and financing. Project risks were probably underestimated,while performance indicators and the implementation schedule were quite specific.

The Project was innovative in its approach, including, for example, supplementary food producedby women's groups at the village level (a successful pilot component of the precursor, Bank-financed,Tamil Nadu Integrated Nutrition Project), and operational research. It is also noteworthy that the Projectproposed a manageable geographic coverage (which, in fact, was exceeded during implementation), andhad a strong gender dimension. An important feature of the design was the allowance for activities to beadded to address issues that arose during implementation. One such issue was arsenic contamination ofwells, and a strategy to address it was included in the community nutrition component. Issues related to theproject management structure have been discussed above and below. Project costs and financing werereasonably accurate, taking into account the increase in coverage from 40 to 59 upazilas and the extensionof six months that was accorded to the Project.

7.2 Supervision:

Satisfactory

Bank supervision of this project was regular despite country disturbances at critical junctures (suchas the time the first mission was expected), and one or two brief gaps during the seven years fromAppraisal to closure. The task teams usually had a mix of managerial (including financial andprocurement) and technical expertise, but an inter-sectoral and social specialist only from the fifthsupervision. While task management changed hands three times in the first three years of the Project, formost of the project period the task manager was located in the field office (Dhaka). There was somecontinuity in the task team over the life of the Project. The Aide Memoires are rich reports ofimplementation and, while this richness is not captured in the Project Status Reports (PSRs), the earlyForm 590s record reasonable ratings and have useful 'issues and actions' sections. Unfortunately, thearchived sequence of PSRs, including the later ones, are less candid and useful. Performance ratings aresometimes optimistic, and attention to development impact was not broad enough, given the ambitiousscope of the project. There was a tendency to focus on the well-achieving community nutrition componentto the exclusion of the other two in the ratings. Not unusually, the weakest aspect of the PSRs is the KeyPerformance Indicator Annex. The KPIs for "outcomes and outputs" were not adequately distinguished oridentified. The data were not filled in until after the Midterm Evaluation, and the latest data available arefor October 2001.

Initial missions focused attention on project start-up activities (e.g., establishment of projectmanagementlimplementation entities, staffing, development of plans, strategies and proposals, contracts,etc.) and reported implementation delays, providing the Borrower appropriate guidance. Subsequentmissions paid greater attention to technical content, training, monitoring, and field activities. The role ofthe field office was strong, but some aspects of the Project such as growth monitoring and the adolescentgirls' programs would have benefitted from stronger technical supervision. The Bank teams addressedproblems pro-actively and their follow-up of recommendations and agreed actions was good. No majorissues arose with regard to covenants, and there was no need for the use of remedies other than suggestingdiscontinuation (e.g., of the agricultural policy review). In general, flexibility was shown with regard to theaddition or cessation of project activities, without major detriment to the project (with the exception,perhaps, of the EEC sub-component). Management inputs were adequate and so was procurement andfinancial management support. The Bank team appears to have had a cordial relationship with theBorrower and other implementation agencies throughout, if not always an effective one. While low levelsof disbursement were pointed out repeatedly, the Project was slow to respond, as noted above. The

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Midterm Review (carried out 3 years and 8 months into the six-year Project) was clearly a turning point. Itincluded a detailed plan of action for implementation of its recommendations, and it is after this thatdisbursements increased.

7.3 Overall Bankperformance:

Satisfactory

A chief concern relates to the diming of the follow-on National Nutrition Project. While thephasing was appropriate because Project funds appear to have been almost fully spent following asix-month extension, preparation of the NNP had the effect of reducing both the Bank's and the Borrower'sattention to this project when it had begun to do well (after the Midterm Review) and had the GOB'ssupport. While the differential success of the three components was taken into account in designing theNNP, the lack of adequate project management capacity in the GOB to handle this project, andcommensurate requirement for greater capacity to handle the NNP were not adequately addressed.

Borrower7.4 Preparation:

Satisfactory

The Borrower either prepared or facilitated the preparation of important inputs for the design of theProject including a detailed analysis of the nutrition situation of Bangladesh, review of food security andrelated programs in the country, a proposal for linkages between the Project and the existing health andfamily welfare program, and a study of existing nutrition activities. A Project Concept Paper and 'ProjectProforma' (similar to the SAR) were ready at Appraisal, while the Project Implementation Volume wascompleted after the first Bank supervision mission. Bank documents make repeated reference to the highlevel of Borrower commitment to the Project. Assistance was also provided by UNICEF and other donorsin Bangladesh, and technical preparation of the project drew on several national agencies and experts (inaddition to staff and international consultants brought in by the Bank).

7.5 Government implementation performance:

Satisfactory

Despite its slow start, the Project was effectively implemented. Initial ratings of projectimplementation progress as Unsatisfactory were due to delays in staffing of the Project management unit,procurement and contracting of the field implementation agency, and monitoring, with consequent partialcompliance with some legal covenants. Because this project was implemented pre-LACI, a FinancialManagement Assessment was not completed but there was due attention to Financial Management issuesduring implementation. The national nutrition component, inter-sectoral nutrition component, anddevelopment of the MIS lagged considerably behind the community-based nutrition activities for the firsttwo to three years. After initial effort, the IEC sub-component was impeded by the Borrower's failure toaward the contract to the selected agency (resulting in a declaration of misprocurement). Unfortunately theMIS was never used to provide feedback to the field. Project Office staff also did not visit the field enoughon account of insufficient allowances and vehicles, among other constraints. Local level meetings helped toovercome some of these problems. Despite these vicissitudes, the Project was able to meet its keydevelopment objectives, and was extended beyond the originally planned project area.

There is no evidence of undue interference in operational decisions, but decisions on projectstaffing were sometimes untimely and inappropriate. Integration of the Project with the Health andPopulation Sector Program resulted in diminished attention to it in the MOHFW at monthly meetings and

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in monitoring reports While the Project decided in mid-course to replace its two implementation models("government-run and NGO-assisted" and "NGO-run and government-assisted" - see section 8 for furtherdetails) with a single hybrid, this important change was not carried out effectively. At the time of the ICRmission (September 2002) 20 of the original 40 upazilas were still govermnent-run, and only the 19 'new'upazilas were NGO-run in keeping with the decision. In the government-run upazilas, the NGOs facedproblems with payment of staff, timely hiring, and obtaining supplies. The follow-on project will need topay detailed attention to ensuring a workable model in form and function.

7.6 Implementing Agency-

Satisfactory

In the Project NGOs were contracted for the community-based nutrition component, and theinter-sectoral nutrition component, and institutes, such as the ICDDR, B, for key tasks such as, in this case,operational research. This partnership model of implementation was unique in South Asia at the time theProject was initiated, and most of the organizations concerned performed at very high levels. The Projectwas, by and large, able to avoid or overcome some of the usual problems in such a model, such as seriouslynegative attitudes among NGO and government staff towards each other. However, problems ofcoordination were rife and could have been reduced through better supervision.

While the community nutrition program is vibrant and effective, there is evidence that it could havebenefitted from better technical supervision by the field implementing agencies, the Project Office and theBank. The CNPs are doing commendable work in community mobilization, growth monitoring andpromotion, and provision of supplementary feeding at the CNCs. However, they require additional trainingand supervision to address growth faltering through proper use of growth charts, for the promotion ofdietary micro-nutrient intake, and for the adolescent girl and newly-wed couple programs. The decision tohave CNOs provide additional ante-natal services needs to be carefully reviewed. Similarly, additionalsupervision could have benefitted the inter-sectoral nutrition component as a substantial investment wasmade in both the poultry-keeping and home-gardening sub-projects.

7.7 Overall Borrower performance:

Satisfactory

An important insight was obtained by the Bank ICR mission during discussions in the field. Staffwho were managing and delivering high quality services were asked what they thought were the goodaspects of the Project, and what its weaker aspects. Among the things they found gratifying were thechanges brought about by the program in household and community dynamics, and the visible impacts onchildren's and mothers' nutrition. However, foremost among the difficulties they identified was an inabilityto express their problems at higher level fora (such as upazila meetings) to have them resolved. TheProject (and the NNP) could have benefitted a great deal if it had maintained an environment in which allparticipants and staff were free to voice their concems and have these addressed squarely.

8. Lessons Learned

There are several important lessons of value to future nutrition projects in Bangladesh, South Asiaand elsewhere. Other lessons would be useful for community-based projects in similar sectors and areaswhere poor communities resemble those of Bangladesh. And finally, some lessons pertain to projects atlarge.

Lessonsfor Nutrition Projects

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* It is possible to reduce severe malnutrition in a relatively short period of time (e.g., one year)

with the combination of services provided by the Project, i.e., systematic identification of those at risk,followed by intensive counseling and food supplementation. Broad awareness of nutrition in communities

is a facilitating factor. Relapse into severe malnutrition is probably associated with other social andpsychological factors, or underlying health problems, that are more difficult to address in 'simple'community-based programs. The Project had less success in reducing moderate malnutrition, which is

more difficult to do as it requires a more complex message to get across to workers and mothers (attentionto "growth faltering"). This calls for better trained and more alert workers and more intensive education of

mothers.

* It is also possible to reduce under-nourishment of women during pregnancy through education

and food supplementation over at least 5 months of pregnancy. The earlier education begins (e.g., during

adolescence) and the more widespread it is in the community and household, the more likely this success.(Associated factors, such as reduced fertility, also have a role.) Low birth weight can be reduced through

these processes.

* The package of program inputs had a straightforward organizing principle - growth monitoring

and promotion of very young children - around which most of the other efforts were built, including care of

pregnant women, preparation of food, and micronutrient supplementation. An important corollary is that it

is more difficult to introduce, sustain and achieve impact from activities that have a wider set of goals and

inputs, such as inter-sectoral interventions and adolescent girls' and newly-wed women's education.

* Preparation of the food supplements in the villages by local women was an important approach

to spreading the message of nutrition and sustaining it.

Lessons for Community-based Programs

* Community involvement helps to bring about behavioral change - and consequent development.

Perhaps the most commendable aspect of the Project was its success in bringing about behavioral change in

poor, traditional settings. A number of factors were implicated in this achievement (and the resultantimprovements in the nutrition and health of mothers and children). The most important of these were:

widespread community mobilization and, particularly, the involvement of women in communicationactivities as well as in 'hands-on' efforts, such as growth monitoring of children, preparation of

supplementary food at the village level, in management committees, and as community nutrition workers.The result of these two approaches was a cost effective system that spread the basic technical inputs for

better nutrition while exerting positive pressure on communities and families to care for children and

mothers.

* "Community involvement" in turn means that a high degree of organization and professionalism

are required of the field implementing agencies. The technical inputs could be introduced by NGOs

through community workers with a modicum of education, provided they were well-trained, organized and

supervised. They achieved a high level of behavioral change through inter-personal communication

involving two-way information flows, counseling, demonstration, and locally-produced LEC materials.

Good organization and supervision are particularly important to ensure quality when implementation is

decentralized.

Lessons for General Programs

* A good partnership requires a learning environment. The partnership between the Government

and NGOs facilitated the Project's community-based approach while providing a management frameworkand resources for a widespread program. An important ingredient of this partnership was the 'learning'

- 15-

nature of the Project. This allowed for implementation to be strengthened from one phase to the next, andfor decision-making to be based on reviews of implementation. For example, the Project acknowledged theproblems faced when govermnent family planning officers were responsible for payments of field nutritionstaff in the 'government-run and NGO-assisted' model and rectified these by giving NGOs theresponsibility for payments. Another example is the testing of efforts focussed on newly married couplesand iron folate supplementation of adolescent girls. This gradual, informed and tested phasing could be ofimmeasurable value to projects, particularly in the social sectors.

* Another example of the learning environment, and a strong feature of the Project was the inclusionof operational research. The studies financed by the Project were based on identified issues, and on datacollected within the Project itself. Their reports facilitated the application of knowledge in a timely mannerwithin the Project, and its spread to other efforts.

* Short-term solutions need to be carefully weighed against long-term needs, and theintroduction ofparallel strategies against systemic changes. An important example from the Project thatillustrates both these sets of choices is the decision to provide additional antenatal services through CNPs.The Project's goals would most likely have been served better by attention to improving the performance ofhealth and family welfare clinics given responsibility for antenatal care.

* Integration requires complementary and coordinated approaches. Project design called forcommunity nutrition services by NGOs to be complemented by inter-sectoral efforts to increase householdfood security, managed by other ministries and NGOs. This coordination proved difficult. Not only wasthe ministry/NGO different but a different 'message' was communicated through the activity and adifferent range of inputs was involved which confounded implementation and reduced its effectiveness.

* Careful timing of the scaling-up of a successful project to a more ambitious program isthe key to ensuring institutionalization of activities and their sustainability. Successful initiativesneed to be consolidated before they are expanded and limited govemrnent and Bank capacities callfor attention and resources be distributed wisely across activities.

* A good Procurement Management System is crucial to efficient project implementation. Inorder to ensure an effective Procurement Management System, procurement capacity of the implementingagency should be addressed adequately at the time of project preparation. Adequate emphasis should begiven to ensure a core procurement team consisting of trained and experienced procurement staff.Arrangements should also be ensured to retain the procurement staff with the project throughout the projectperiod. Requirement of Procurement Plan and its yearly update with the Bank's prior review should bemandated through the credit agreement. In addition, when working in future projects it is important to takeinto account disbursement problems that may delay payment and cause the loss of important partners.

9. Partner Comments

(a) Borrower/implementing agency:

In its Project Completion Report (PCR) and comments to the Bank, the Borrower has stressed theProject's achievement of nutritional improvements, including reduction in moderate malnutrition andmicro-nutrient related problems, birth-weight improvements and pregnancy weight gain. It has also pointedout coverage and service delivery achievements, and reductions in infant and maternal mortality. The PCRcites improved knowledge of nutrition and changed behavior among the people of Bangladesh as a majorimpact of the Project, brought about through mass media efforts, and avers that these changes are the basisfor the Project's sustainability. It suggests that the Project has contributed to poverty alleviation throughits impact on nutrition and through the generation of employment for about 150,000 CNOs, CNPs and

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women organized into groups. This engagement, and some improvements in access to micro-credit underthe poultry scheme, are seen to have empowered women, with a spillover effect to other areas such asincreased women's participation in local government. The GOB has also commented that the cooperationbetween Government and non-government organizations was effective. The PCR also mentionsenvironmental improvements achieved through home gardening, improved sanitary practices and healtheducation. Among problems, the GOB listed the delay in awarding of the IEC contract as having hamperedcommunication activities in the field, disruptions in some CNCs during the 1998 flood, and the levying of

income and VAT taxes on the NGO contracts by the Audit directorate that resulted in delayed paymentsduring calendar 2002. They also mentioned that they found Bank guidelines onerous and the procurementsection of the Bank office under-staffed. On the whole, the PCR states, " This is a very successfulinnovative project..." and suggests that it be continued "in the present or modified form for at least tenyears," giving legitimacy to the NNP.

Some additional comments were recieved from the MOHFW on the draft ICR. They correctlyadvocate caution in the interpretation of project monitoring data on nutritional status and behaviouralchange. They also express concem that the 'GOB-run and NGO-assisted model', which research hadshown to be lower cost and potentially more sustainable, had been dropped in favor of NGO-run model.However, this was because the latter was found to run more smoothly and effectively. The MOHFWcomments highlight that the Project was able to train and motivate women with little schooling as CNOsand CNPs to provide social services, and that the GOB helped to develop the capacity of NGOs in trainingand social mobilization. Finally, they point out that messages 'on the ground' were consistent andcoordinated, and that the messages and lessons of the Project could be spread through school children tocombat malnutrition sustainably.

(Z) Cofinanciers:

There were no co-financiers.

(c) Other partners (NGOs/private sector):

Comments were received from a number of partner NGOs in writing and/or at meetings held withthem at various stages of project completion. Generally, the NGOs felt that the partnership model wasgood, and community participation excellent. The Project was well accepted in the target communities andhad significant achievements such as the reduction in severe malnutrition and changes in eating habits.They felt that the spread of 'the nutrition message' was more important in reducing malnutrition thanmanagement of malnutrition per se. They felt that supplementary feeding had wrongly over-emphasized in

the Project. Increased nutrition awareness was accompanied by communities "knowing what to do" and by

confidence among health providers. An important NGO has commented that improvement in mother's

nutrition was due not only to intensive nutrition education but also to provision of ante-natal care by

CNOs. The NGOs felt that referral to the health system worked well for ante-natal care, but that

micro-nutrient supplements were often not available and health workers did not perform well on growthmonitoring or care of the malnourished. They believe that the innovative adolescent girls' and newly-wedcouple schemes contributed to women's empowerment and social change, in addition to nutritionalimprovements. The NGOs mentioned that the Bank's main contribution to the Project (in addition tofinancing) was increasing nutrition knowledge in the country, and encouraging documentation of knowledgeand experience. They considered it an advantage to have a country-based task manager (acknowledgedlywith a "tough coordination job") but felt that not enough pressure had been put on the Project during thefirst two years.

On the less positive side, lack of technical personnel in and, hence, inadequate supervision by the

Project Office, irregular fund flows, delays in procurement and logistical support, inadequate recognition

and support from high officials and decision-makers in the GOB, insufficient attention from lower-level

- 17 -

officials in the field, lack of dissemination of information about the Project -- and particularly of itssuccessful features, and poor coordination between inter-sectoral and community nutrition activities werementioned most frequently. The NGOs felt that the project should have invested more in the training ofcommittee members and in securing the participation of elected representatives at the upazila, union andvillage levels. Other suggestions for improvement include raising the salaries of CNOs and CNPs to allowthem to work full time, strengthening the managerial and decision-making abilities of CNPs, preparation ofan 'exit strategy' with NGOs handing the program over to local govemments, increasing the involvement ofmen in the program. For the future, the NGOs felt strongly that a Project Office should have a "90percent" non-govemmental character, and that training and communications activities must receive greaterattention.

10. Additional Information

None.

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Annex 1. Key Performance Indicators/Log Frame Matrix

Outcome / Impact Indicators:

- ^p . Indicator/Matrix., .. Projected in last PSR .,.,' ',test EstLate;m.,.

Severe and moderate malnutrition reduced by Severe -8% Severe -1%, moderate - 15%40% and 25% respectively of the baseline Moderate -24%levels. Baseline levels were 13% and 32%,respectivelyLow birth weight reduced by half of the 20% 18%

baseline level. Baseline level was 40%.Parents knowledge and pracbtces regarding 70% 41%child care improved: exdusive breasffeedingup to 5 month, basline level was 10%

Output Indicators:

Indicator/lMatrix Projected In last PSR - ActuaULate'it!EsUmate

National Nutrition Component Capacity developed in identified institufions Capacity not yet developed(a) complebon of review of major nabonallevel institutions(b) Development of an operational research All 18 operabons research completed and Studies completed; some results utilized

strategy some of the results utilised

Community Nutbition Component 100% 95%(c) 80% of the village nutntion committeesactve and taking decisions(d) 80% of the Community Nutrition Centres 100% 90%

are functioning effectively(e) Women's group prepare and supply 100% 100%

supplementary food(f) 80% of 0-24 month children covered by 95% 94%Growth Monitoring and PromotonInter-Sectoral Nutntion Component No indicators specified not applicable

End of project

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Annex 2. Project Costs and Financing

Project Cost by Component (in US$ million equivalent)Apprailsal Actual/Latest Percentage ofEstimate Estimate Appraisal

Project Cost By Component US$ million US$ millionNational Level Nutrition Activities 19.00 18.44 99.7

Conmnunity Based Nutrition Component 32.60 32.31 99Inter-Sectoral Nutrition Program Development 7.00 6.54 93

Total Baseline Cost 58.60 57.29Physical Contingencies 3.60 3.41 94.7Price Contingencies 5.10 5.04 98.82

Total Project Costs 67.30 65.74Total Financing Required 67.30 65.74

Project Costs by Procurement Arrangements (Appraisal Estimate) (US$ million equivalent)Procurement Method

Expenditure Category ICB NCB otb 2 N.B.F: Total Cost

1. Works 0.00 0.00 0.00 0.00 0.00(0.00) (0.00) (0.00) (0.00) (0.00)

2. Goods 2.16 5.03 2.75 0.00 9.94(2.16) (4.03) (2.75) (0.00) (8.94)

3. Services 0.00 0.00 42.16 0.00 42.16(0.00) (0.00) (39.36) (0.00) (39.36)

4. Miscellaneous 0.00 0.00 14.60 0.60 15.20(0.00) (0.00) (11.52) (0.00) (11.52)

5. Miscellaneous 0.00 0.00 0.00 0.00 0.00(0.00) (0.00) (0.00) (0.00) (0.00)

6. Miscellaneous 0.00 0.00 0.00 0.00 0.00(0.00) (0.00) (0.00) (0.00) (0.00)

Total 2.16 5.03 59.51 0.60 67.30(2.16) (4.03) (53.63) (0.00) (59.82)

Project Costs by Procurement Arrangements (Actual/Latest Estimate) (US$ million equivalent)Procurement MethodExpenditure Category ICB NCB Other2 N.B.F. Total Cost

1. Works 0.00 0.00 0.00 0.00 0.00(0.00) (0.00) (0.00) (0.00) (0.00)

2. Goods 0.20 1.75 1.55 0.00 3.50(0.20) (1.65) (1.45) (0.00) (3.30)

3. Services 0.00 0.00 51.96 0.00 51.96(0.00) (0.00) (46.22) (0.00) (46.22)

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4. Miscellaneous 0.00 0.55 9.73 0.00 10.28

(0.00) (0.46) (8.65) (0.00) (9. 11)5. Miscellaneous 0.00 0.00 0.00 0.00 0.00

(0.00) (0.00) (0.00) (0.00) (0.00)

6. Miscellaneous 0.00 0.00 0.00 0.00 0.00(0.00) (0.00) (0.00) (0.00) (0.00)

Total 0.20 2.30 63.24 0.00 65.74

(0.20) (2.11) (56.32) (0.00) (58.63)

u Figures in parenthesis are the amounts to be financed by the Bank Loan All costs include contingencies.

2'Includes civil works and goods to be procured through national shopping, consulting services, services of contracted staffof the project management office, training, technical assistance services, and incremental operating costs related to (X)managing the project, and (ii) re-lending project funds to local government units.

F'roject Financing by C mponent (in US$ million equivalent)

Component Appraisal Estimate Actual/Latest Estimate Percentage of Appraisal

Bank Govt. CoF. Bank Govt. CoF. Bank Govt. CoF.

National Level Nutrition 16.90 2.20 16.20 2.74 95.9 124 5.ctivities

Community Based 29.60 3.00 29.40 2.91 99.3 97.0Irutrition ComponentI nter-Sectoral Nutrition 6.25 0.75 6.00 0.54 96.0 72 0E rogram Developmentl'otal Baseline Cost 52.75 5.95 51.60 5.69 97 8 95.6

Physical Contingencies 3.20 0.40 3.11 0.30 97.2 75.0F rice Contigencies 3.95 1 15 3.92 1.12 99 2 97.4

'otal Project Costs 59.90 7.50 58.63 7.11 97.9 94.8

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Annex 3. Economic Costs and Benefits

Not calculated

- 22 -

Annex 4. Bank Inputs

) Missions:Stage of Project Cycle No. of Persons and Specialty Performance Rating

(e.g. 2 Economists, 1 FMS, etc.) Implementation Development

Month/Year Count Specialty Progress Objective

Identification/PreparationMarch 1993 S Population and Health,

Management, Economist,Procurement, Operations Analyst

Appraisal/NegotiationJanuary 1994 5 Population and Health,

Public Health, Management(2), Team Leader

March 1994 4 Population and Health, Legal,Procurement, Operations Analyst

Supervision06/30/1995 PSR initial Summary S

03/07/1996 5 Procurement; Matemal & Child U SHealth; Public Health; PHN(Mission Leader); Management

09/29/1996 4 PHN/Technical; Management S S

(M/Leader); Nutrition/Technical;Procurement

05/13/1997 3 Procurement; Mission Leader; S S

Nutrition/Technical

12/17/1997 4 Procurement; Disbursement; S SAudit and Finance; MissionLeader

07/30/1998 6 Management; Team Leader; S SProcurement Specialist;Disbursement Specialist;Financial management specialist,Inter Sectoral and WID

11/22/1999 3 Task Leader; Operations Officer; S SOperations Analyst

07/20/2000 5 Nutrition; Operations Officer; S S

Operations Analyst;Procurement; FinancialManagement

05/17/2001 8 Task Leader; Operations; S STraining; Procurement;Disbursement; FinancialManagement; Management,M&E

05/23/2002 8 Mission Leader; Technical; S STraining; FinancialManagement, Disbursement;

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Procurement; Social, PublicHealth

ICR09/28/2002 4 Social Development (2);

Economist (Task TeamLeader) (1); OperationsOfficer (1)

(b) Staff:

Stage of Project Cycle Actual/Latest EstimateNo. Staff weeks US$ ('000)

Identification/Preparation 122.3 398.6Appraisal/Negotiation 11.4 30.7Supervision 292.3 409.1ICR 10 60Total 436 898.4

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Annex 5. Ratings for Achievement of Objectives/Outputs of Components

(H=High, SU=Substantial, M=Modest, N=Negligible, NA=Not Applicable)Rating

O Macro policies O H OSUOM O N * NAO Sector Policies O H OSUOM S N O NAD Physical OH OSU-M ON ONAFII Financial O H OSUOM O N O NAEl Institutional Development O H O SU *M O N 0 NAO Environmental O H OSUOM S N O NA

SocialO Poverty Reduction O H OSU*M O N O NAL Gender O H *SUOM O N O NAO Other (Please specif) OH *SUOM ON O NACommunity driven development

Involvement of NGOsFIi Private sector development 0 H O SU O M 0 N S NALI Public sector management 0 H O SU O M 0 N 0 NALI Other (Please specify) O H O SU O M S N 0 NAIntersectoral Coordination

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Annex 6. Ratings of Bank and Borrower Performance

(HS=Highly Satisfactory, S=Satisfactory, U=Unsatisfactory, HU=Highly Unsatisfactory)

6.1 Bankperformance Rating

O Lending OHS*S OU OHU

rO Supervision OHS OS O U O HUOII Overall OHS OS O U O HU

6.2 Borrowerperformance Rating

O Preparation OHS OS O U O HUEl Government implementation performance O HS O S 0 U 0 HUO Implementation agency performance OHS OS 0 U O HU

L Overall OHS OS 0 U O HU

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Annex 7. List of Supporting Documents

S.No. Title Prepared by Date1. Baseline Survey Final Report Mitra and Associates2. Health and Nutrition Baseline Survey of 44 Rural Institute of Nutrition and January 1998

Thanas in Bangladesh -- Final Report Food Science, Dhaka;Department of Statistics,Dhaka University; andNational Institute ofPreventive and SocialMedicine

3. Mid-Term Evaluation, 1998 Institute of Nutrition and March 1999____ Food Science, Dhaka4. Review of Information, Education and World Bank Consultant -- December 1998

Communication Component for Mid-Term Marcia Griffiths, The ManoffReview Group, Inc.

5. Management Review Report for Mid-Term World Bank Consultant -- November 1998Review James A. Greene

6. List of 18 Completed Operations Research BINP officeProjects

7. Results from the Bangladesh Integration Nutrition Centre for Health and November 1999 -Project's Operation Research Project (ORP) Population Research, August 2000

ols. I -V ICDDRB8. Proposal for Endline Evaluation Institute of Nutrition and May 2002

Food Science, Dhaka9. Pre-appraisal mission report The World Bank March 199310. Pre-appraisal mission report The World Bank January 199411. Project Proforma Ministry of Health and April 1995

Family Welfare, Governmentof Bangladesh

12. Staff Appraisal Report The World Bank April 199513. Memorandum and Recommendation of the The World Bank April 1995

President to the Executive Directors14. Development Credit Agreement The World Bank June 199515. Project Implementation Volume Ministry of Health and May 1996

Family Welfare, Government-of Bangladesh

16. Proposal for Amendment of Development Credit Ministry of Finance, April 2001Agreement Government of Bangladesh

17. Aide-Memoires of Supervision Missions for the The World BankIntegrated Nutrition ProjectFirst Supervision Mission April 29, 1996Second Sept. 29, 1996Third May 13, 1997

ourth Dec. 31, 1997ifth August 17, 1998

Sixth/Mid-Term Review May 26, 1999

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Seventh Nov. 22, 1999Eighth July 20, 2000Ninth May 29, 2001Tenth May 23, 2002

18. Project Status Reports for the Bangladesh The World BankIntegrated Nutrition Project: Sequence No. I June 30, 1995

2 March 28, 19963 June 13, 19964 October 17, 19965 May 20, 19976 January 26, 19987 August 27, 19988 May 23, 19999 January 3, 2000

10 June 18, 200011 Sept. 17, 200012 March 15, 200113 June 25, 200114 Dec. 11, 200115 June 12,2002

19. Lessons Learned in the Bangladesh Integrated AFM Iqbal Kabir and F. June 2002Nutrition Project (Draft) James Levison,

20. Bangladesh: Breaking the Malnutrition Barrier The World Bank December 2001_ Key to Development

21. Technical Assistance on Assessing the Effects of Policy Planning Branch, August 1996Agricultural Policies and Programs on Food Ministry of Agriculture,_ Consumption and Nutrition Government of Bangladesh

22. Household Food Security Through Nutrition Ministry of Agriculture, 1996_ Gardening (A Sub-project of BINP) Government of Bangladesh

23. Report of the Analysis of Nutritive Values of Food Institute of Nutrition and April 1997Items Supplied from Six BINP Thanas Food Science,

24. Annual Report July 2001-June 2002 BINP and BRAC June 200225. Treading Water: Long-Tern Impact of the 1998 IFPRI and The World Bank October 14, 2002

Flood on Nutrition in Bangladesh _

26. Identification Mission Aide-memoire for the The World Bank August 1998N_ ational Nutrition Project

27. Project Appraisal Document of National Nutrition The World Bank April 2000Project

28. Aide-Memoires of National Nutrition Project The World BankFirst Supervision Mission May 2001Second April 2002Third October 2002

29. Contracting for Health Services: Lessons from Ben Loevinsohn, The World June 3, 2002___ Two Large Projects in Bangladesh (Draft) Bank

30. Poverty in Bangladesh: Building on Progress PREM Sector Unit, South June 2002Asia, The World Bank

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Type: fCR

R eo4N o.: 25183