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Nutrition Toolkit Tool #1: Incorporating Nutrition into Project Design

Tool contents. The first tool of the Nutrition Toolkit delineates nutrition-related tasks and issues for World Bank Task Managers charged with developing a nutrition component or freestanding nutrition project. Set in the context of the standard project cycle, the tool emphasizes nutrition-specific activities at each stage. Technical guidance includes indicators and data sources for a range of determinants of malnutrition, intervention options for addressing nutrition deficiencies, lessons of experience for program design and implementation, indices and cut-offs for anthropometric, clinical, and biochemical measures of nutrition status, guidelines for assessing data quality, and contact information for a range of institutions responsible for nutrition data collection.

Nutrition status determines individual well-being and impacts significantly on economic development. Most decisions to borrow and budget for nutrition are made by people other than nutritionists, and economic sector work offers an important opportunity for advocacy. Furthermore, unanticipated effects of non-nutrition policies can harm the nutrition condition of different population groups. It is assumed that by the start of project cycle, consideration of the nutrition status of a country or community should be well advanced through earlier activities such as the development of country assistance strategies, public expenditure reviews, and country economic memoranda.

Project identification: Verify that malnutrition is a problem. During the identification phase of project development, the main tasks are related to determining the presence and type(s) of malnutrition in a community, region or country, and the primary determinants of the deficiency conditions. Data collection and analysis are required to answer these basic questions. In addition to measurements of physical nutrition status (anthropometric, clinical, and biochemical), it is important to collect information about food access and consumption (e.g., cost of the minimum food basket relative to household income), morbidity and mortality statistics, information about nutrition caring practices such as rates of exclusive breastfeeding and weaning practices (timing and type of foods), availability and quality of health and agricultural extension services and water supply and sanitation conditions.

The task manager should also evaluate existing nutrition programs and national nutrition strategies and assess the institutional capacity available to the project for design, implementation, and supervision of a project or nutrition component. Begin to discuss possible targeting strategies at this stage. Options include targeting based on poverty status or health risk, geographic region, season, occupation, nutrition status, reproductive status, gender or age, and self-targeting of food using commodities consumed predominantly by the poor.

Project preparation: Select the best interventions and strategies to address the nutrition problem(s). Most Bank-supported nutrition projects and components build on existing programs and use existing institutions to deliver services. Ideally, the communities targeted for receipt of project services are consulted on the priority interventions and strategies that best fit with the current programs, institutional capacities, and community needs. Analysis of data collected during project identification results in a list of specific indicators of (or potential contributors to) compromised nutrition status that should help clarify priority concerns for action. Such indicators include a high incidence of low birth weight babies, child malnutrition and growth failure, micronutrient malnutrition, household food insecurity, and poor health/nutrition among school-age children. It falls to Bank and client country staff to identify which among multiple intervention options make the most sense for the nutrition problem(s) to be addressed.

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Indicator of compromised nutrition status

 
Intervention options
Low birth weightPrenatal nutrition services:
- counseling on improved dietary intake, reducing calorie
expenditure
- weight gain monitoring
- iron-folate supplementation
- deworming
Targeted supplementary feeding to pregnant/lactating women, and/or adolescent girls
Child malnutrition and growth failureCommunication for behavior change (e.g., breastfeeding promotion, weaning practices)
Growth promotion: counseling targeted through growth monitoring
Targeted supplementary feeding
Infectious disease control
Care of the sick child
Micronutrient malnutritionFortification of foods with micronutrients (salt iodization, cereal fortification with iron)
Micronutrient supplementation (iron-folate tablets; vitamin A capsules)
Dietary diversification
Household food insecurityFood consumption policy reforms (subsidies, trade, agric. sector investments)
Nutritional safety nets (food stamps, targeted food programs)
Income generation/micro-credit cum nutrition education
School-age child malnutritionDeworming
Micronutrient supplementation
School feeding programs (breakfasts/snacks)
Nutrition education/communication for nutrition behavior change

Project design flows from decisions about the best mix of strategies and past experience. Service delivery and program implementation issues -- not which nutrients are missing from the diet -- remain the most serious stumbling blocks to positive project impact.

1. Use existing institutions if possible.
2. Combine both short-term (micronutrient supplementation, income transfers and targeted feeding programs) and long-term (income-generation programs, food fortification, and education for behavior change) intervention strategies.
3. Target services and inputs to benefit the greatest number of at-risk individuals or households (within reasonable administrative cost boundaries).
4. Institute the lowest affordable worker:client and supervisor:worker ratios.
5. Prioritize work routines and assure reasonable work load of workers.
6. Ensure frequent job-relevant in-service training and supportive (not punitive) supervision.
7. Recruit nutrition workers from the community.
8. Design the management information system (MIS) to give quick, program-relevant feedback to project staff and the community. Use the MIS to target supervision.
9. Collaborate with donors to capitalize on other agencies' strengths.
10. Adjust the speed and scale of project expansion to local capacity; allow for redesign based on early implementation results.
11. Begin to design the monitoring and evaluation (M/E) system from the start and initiate economic analysis of intervention options during project preparation.
12. It may be desirable to design several pilot delivery and/or intervention strategies for the early implementation stage of the project. Once evaluation of the pilots is completed, the more cost-effective method(s) can be implemented on a larger scale. Greater efficiency is achieved by funding the identification of follow-on projects within current ones.

Project pre-appraisal/appraisal: Maximize the impact of the project on malnutrition. Evaluate project design to enhance project performance at this stage of the project and modify the design if necessary. The technical content of the project or component is assessed (including such things as food and micronutrient supplementation and deworming protocols, food fortification and growth monitoring equipment specifications, staff training programs, and the project communications strategy), as well as the adequacy of the M/E system, and the efficacy and effectiveness of project targeting.

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Project implementation and supervision: Assure effective implementation. The project launch workshop is one way that the Bank can support a smooth start-up and assist with implementation of the project. By including a broad spectrum of participants (from cabinet ministers to NGO representatives and poor farmers), a common purpose and widespread commitment to the project are developed. The implementation manual should detail work routines, supervision and training protocols and curricula, procurement arrangements, project costs, and intervention guidelines for every level of the project; it is critical to effective project execution.

Employing the same team of senior technical nutrition consultants for supervision over the life of the project leads to improved design, institutional development, a strong partnership, and constructive dialogue between project staff, government officials, and Bank staff. Use supervision to develop local institutional capacity. Strengthen personal relationships that develop on supervision missions between Bank and client country staff, experiment with locally-based technical assistance (such as technical staff in a UNICEF office) for project supervision, and target supervision funds to those projects or components with the greatest complexity or most innovative programs.

Project completion/evaluation: Synthesizing lessons learned to inform future projects. Effective project completion reports (PCRs) include impact analysis and frank discussion of lessons (positive and negative) learned. Solicit input to the evaluation of the project from the borrower as well as Bank staff. Disseminate project results and design advice through Bank networks and Friends of Nutrition and Food Policy.

To obtain the Toolkit or individual tools, please contact the Nutrition Advisory Service by sending an e-mail to nutrition@worldbank.org





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