Document of The World Bank FOR OFFICIAL USE ONLY Report No: ICR00004756 IMPLEMENTATION COMPLETION AND RESULTS REPORT (TF 014232) ON A SMALL GRANT IN THE AMOUNT OF USD 2,799,716 MILLION TO THE BRAC Uganda FOR An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) 28 February 2019 Health, Nutrition & Population Global Practice Africa Region Regional Vice President: Hafez M. H. Ghanem Country Director: Carlos Felipe Jaramillo Senior Global Practice Director: Timothy Grant Evans Practice Manager: Magnus Lindelow Task Team Leader(s): Ziauddin Hyder ICR Main Contributor: Aira Maria Htenas ABBREVIATIONS AND ACRONYMS AHP Adolescent Health Promoter AM Aide Memoire ANC Antenatal care BCC Behavior Change Communication CABI Centre for Agriculture and Bioscience International CAP Community Agriculture Promoter CHP Community Health Promoter CMU Country Management Unit DHS Demographic and Health Survey DSIP (Agriculture Sector) Development Strategy and Investment Plan ERP Enterprise Resource Planning FAO Food and Agriculture Organization FM Financial Management FY Fiscal Year GA Grant Agreement GAFSP Global Agriculture and Food Security Program GFP Grant Funding Proposal GMP Growth Monitoring and Promotion GoU Government of Uganda ICRR Implementation Completion and Results Report ICT Information, Communication and Technology IE Impact evaluation ISR Implementation Status and Results Report IR Intermediate Result IRB Iron-Rich Beans IYCF Infant and Young Child Feeding IPF Investment Project Financing JSDF Japan Social Development Fund MA Marketing Agent MD (BRAC) Monitoring Division MDD Minimum Dietary Diversity M&E Monitoring and Evaluation MTR Mid-Term Review NaCRRI National Crop Resource Research Institute NDP National Development Plan OFSP Orange Flesh Sweet Potato OPCS Operations Policy and Country Services PAD Project Appraisal Document PDO Project Development Objective PSC Project Steering Committee RCT Randomized Control Trial RETF Recipient Executed Trust Fund RF Results Framework RED (BRAC) Research and Evaluation Division RUTF Ready to Use Therapeutic Foods SHF Smallholder farmer SUN Scaling Up Nutrition TD (BRAC) Training Division TTL Task Team Leader UNAP Uganda National Action Plan UNFNP Uganda Food and Nutrition Policy UNICEF United Nations International Children’s Emergency Fund U2 Under two years of age (child) VAD Vitamin A deficiency VP Vine producer WHO World Health Organization TABLE OF CONTENTS DATA SHEET ....................................................................... ERROR! BOOKMARK NOT DEFINED. I. PROJECT CONTEXT AND DEVELOPMENT OBJECTIVES ....................................................... 4 II. OUTCOME ...................................................................................................................... 9 III. KEY FACTORS THAT AFFECTED IMPLEMENTATION AND OUTCOME ................................ 15 IV. BANK PERFORMANCE, COMPLIANCE ISSUES, AND RISK TO DEVELOPMENT OUTCOME .. 17 V. LESSONS LEARNED AND RECOMMENDATIONS .............................................................. 21 ANNEX 1. RESULTS FRAMEWORK AND KEY OUTPUTS ........................................................... 23 ANNEX 2. PROJECT COST BY COMPONENT ........................................................................... 35 ANNEX 3. RECIPIENT, CO-FINANCIER AND OTHER PARTNER/STAKEHOLDER COMMENTS ...... 36 ANNEX 4. SUPPORTING DOCUMENTS (IF ANY) ..................................................................... 37 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) DATA SHEET BASIC INFORMATION Product Information Project ID Project Name An Innovative, Integrated Approach to Enhance P143324 Smallholder Family Nutrition Country Financing Instrument Uganda Investment Project Financing Original EA Category Revised EA Category Not Required (C) Not Required (C) Organizations Borrower Implementing Agency BRAC Uganda BRAC UGANDA Project Development Objective (PDO) Original PDO To improve nutrition of an estimated 19200 vulnerable and poorest smallholder households in Mabara and Masaka districts, by promoting the cultivation and consumption of nutrient-rich crops and improving nutrition care practices of under- 2 children, adolescents girls, and pregnant women. Page 1 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) FINANCING FINANCE_T BL Original Amount (US$) Revised Amount (US$) Actual Disbursed (US$) Donor Financing TF-14232 2,799,716 2,766,623 2,766,623 Total 2,799,716 2,766,623 2,766,623 Total Project Cost 2,799,716 2,766,623 2,766,623 KEY DATES Approval Effectiveness Original Closing Actual Closing 13-Feb-2013 15-Jul-2013 11-Jun-2017 11-Jun-2018 RESTRUCTURING AND/OR ADDITIONAL FINANCING Date(s) Amount Disbursed (US$M) Key Revisions 17-Feb-2017 1.92 Change in Loan Closing Date(s) KEY RATINGS Outcome Bank Performance M&E Quality Satisfactory Moderately Satisfactory Modest RATINGS OF PROJECT PERFORMANCE IN ISRs Actual No. Date ISR Archived DO Rating IP Rating Disbursements (US$M) 01 15-Oct-2013 Satisfactory Satisfactory 0.00 02 21-Apr-2014 Satisfactory Moderately Satisfactory 0.00 03 03-Nov-2014 Satisfactory Satisfactory 0.48 04 18-Feb-2015 Satisfactory Satisfactory 0.62 05 09-Dec-2015 Satisfactory Satisfactory 1.23 Page 2 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) 06 09-Dec-2016 Satisfactory Satisfactory 1.92 07 14-Nov-2017 Satisfactory Satisfactory 2.26 08 03-Aug-2018 Satisfactory Satisfactory 2.77 ADM STAFF Role At Approval At ICR Regional Vice President: Makhtar Diop Hafez M. H. Ghanem Country Director: Philippe Dongier Carlos Felipe Jaramillo Senior Global Practice Director: Ritva S. Reinikka Timothy Grant Evans Practice Manager: Jean J. De St Antoine Magnus Lindelow Task Team Leader(s): Ziauddin Hyder Ziauddin Hyder ICR Contributing Author: Aira Maria Htenas Page 3 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) I. PROJECT CONTEXT AND DEVELOPMENT OBJECTIVES Context 1. At the time of design and appraisal of the project, Uganda had not achieved progress in reducing malnutrition commensurate to economic growth achieved. Whereas the country’s economic growth halved the national poverty rate in less than 20 years (from 56.4 percent in 1992-93 to 24.5 percent in 2009-2010), chronic undernutrition in under-five year-old Box 1: Nutritional importance of vitamin A and iron children remained at 33 percent (Uganda Demographic Health Survey, DHS, 2011). Moreover, although the prevalence of anemia among Vitamin A plays an essential role in vision and under-five children and women of reproductive age showed a immune response. Vitamin A deficiency (VAD) causes impaired resistance to decreasing trend since 2005, still 49 percent of children age 6–59 infections and frequent incidences of illness. months and 23 percent of women age 15-49 year is anemic. Also, thirty-eight percent of children aged 6-59 months, and 36 percent of Iron deficiency and iron deficiency anemia women aged 15-49 are vitamin A deficient (Uganda DHS 2011). “can slow growth, hinder physical and mental development, and reduce the ability of the Micronutrient deficiencies of vitamin A and iron among young body to maintain itself. [They are] associated children and adult women in Uganda cost lives, diminish productivity, with impaired immune response, lowered and cause significant human capital and economic losses (Box 1). resistance to infection and increased morbidity and mortality rates, adverse pregnancy outcome, and reduced school 2. The Government of Uganda (GoU) had set in place a number of performance. policies and plans calling for multisectoral action to address food security and nutrition, including through agriculture. Uganda’s Source: FAO and CABI. 2011. Combating Micronutrient Deficiencies: Food-based National Development Plan (NDP) for Fiscal Year (FY) 2011 – 2015 Approaches. Brian Thompson and Leslie aimed at reducing inequity, raising growth and living standards, and Amoroso, eds. addressing food and nutrition security through multi-sectoral action. The Agriculture Sector Development Strategy and Investment Plan (DSIP) (2010/11-2014/15) aimed to increase rural incomes and improve livelihoods and household food and nutrition security. In March 2011, the Republic of Uganda joined the Scaling Up Nutrition (SUN) Movement; thus, paving the way to strengthen multisectoral engagement to reduce chronic malnutrition, including through agriculture. At the same time, the Uganda Nutrition Action Plan (UNAP) 2011 – 2016 identified specific objectives, strategies, interventions and investments needed to implement the 2003 Uganda Food and Nutrition Policy (UFNP) to achieve specific development goals, including through the agriculture sector.1 3. The project aimed to target the poorest smallholder farmers living in the southwestern region of Uganda; a region of key concern due to a large mismatch between income poverty and health outcomes. Although the poverty rate in the region was lower than the national average (18 percent vs 24 percent), women and children were more vulnerable to undernutrition: vitamin A and chronic energy deficiencies were most prevalent among adolescent girls and women, and under-five malnutrition was higher in that region compared to the national average (stunting: 44 percent vs 39 percent; anemia: 63 percent vs 48 percent). The high level of stunting had been linked to poor Infant and Young Child Feeding (IYCF) practices, that were worse than Uganda’s national averages, and low dietary 1These included calls to: Promote production and consumption of diversified nutritious foods at household and community levels; Advocate and support integration of nutrition in agricultural programmes; Increase consumption of both raw and processed nutritious foods; Promote and support local food processing and value addition at household and community level; Promote production of fortified common staples by local manufacturers; and Promote production of biofortified varieties; and Promote consumption of nutrient enhanced foods. Page 4 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) diversity. Moreover, in southwestern Uganda, the mean duration of exclusive breastfeeding was 2.1 months instead of the recommended six months; only five percent of children 6-23 months were fed in accordance with World Health Organization (WHO) optimum feeding practices, and seven percent of children 6-23 months consumed a minimum standard of dietary diversity (four or more food groups) (Uganda DHS 2011). 4. The innovative intervention approach put forward by this Japan Social Development Fund (JSDF) supported project was not envisioned in the World Bank strategic engagement with the country at the time of the project preparation, as it was amongst the first of its kind. The project implemented for the first time in Uganda an integrated package of nutrition and agriculture interventions to improve diets for women of reproductive age, adolescent girls, infants and young children in smallholder households through increased cultivation of nutrient-rich crops, increased dietary diversity, and improved care and feeding practices. The World Bank Country Assistance Strategy for the period FY2011-2015 focused on amongst others on outcomes related to increased productivity and commercialization of agriculture (under strategic objective Promote Inclusive and Sustainable Economic Growth), and to strengthened health care delivery (under strategic objective Strengthen Human Capital Development). Nevertheless, an integrated approach combining agriculture and health that was pursued by the project to address malnutrition was not foreseen. This is not a particularly surprising observation as multisectoral approaches to nutrition were just beginning to regain traction at the World Bank, and it simply further attests to the novelty of this particular project. As a result, the project design was considered innovative in the Uganda context. Theory of Change (Results Chain) 5. The implementing agency, BRAC Uganda, made available to the ICRR team during interviews (June 2018) a theory of change (TOC) that it was following for the project (Figure 1). The ICRR team deemed, though, that the TOC presented was not suitable for the ICRR purposes, and therefore worked also with the implementing agency to develop a TOC that follows Bank Guidance.2 The revised TOC, or logic, behind the design of the project has been crafted for the purposes of this Implementation Completion and Results Report (ICRR) and is illustrated in Figure 2. The links between the activities supported under the main components of the project and the related outputs, and Project Development Objective (PDO) outcomes are presented. Figure 1: Theory of Change prepared by the Implementing Agency Secondary Tertiary Outcomes Primary Outcomes Impact Outcomes • Improved food security • Willingness to pay • Nutrition • Improved micronutrient intact for for OFSP knowledge women of reproductive age and • Height • Adoption of OFSP • Breast feeding under 2yr children • Weight • Knowledge of • Consumption of • Strengthening of local government • Household OFSP OFSP clinics on ANC and nutrition food security • Productivity • Dietary diversity • Build local markets for OFSP and • Market Participation • ANC uptake nutrient-rich crops • Decreased wasting 2Bank Guidance Preparing the Project Appraisal Document (PAD) for Investment Project Financing (IPF) (Box 1) issued on May 17, 2018 calls for a TOC whereby activities, outputs/ Intermediate Results, and Outcomes are listed in a causal pathway type of schematic. Page 5 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) Figure 2: Theory of Change PDO: To improve nutrition of an estimated 19,200 vulnerable smallholder households in Mbarara and Masaka Districts, by promoting the cultivation and consumption of nutrient-rich crops and improving nutrition and care practices of under-2 children, adolescent girls, and pregnant women. Activities Outputs/ IRs Outcomes (PDO) Agriculture, or supply side • CAPs trained activities A1 • Inputs provided Increased percentage of • Training CAPs and • Laboratory established providing them with participating farmers • OFSP vine cuttings adopting OFSP inputs for demonstration produced sites • VPs trained • Providing ICT to CAPS • Smallholder farmers • Establishing low cost trained in agriculture tissue culture laboratory practices and to produce OFSP technology cuttings for distribution to • MAs trained VPs for further • Smallholder farmers dissemination to farmers Increased percentage of (two seasons) trained on three children 6 – 23 months with financial products • Providing technology A2 minimum dietary diversity transfer (crops, inputs) and training to smallholder farmers (for • Agriculture/ nutrition fora two seasons; TA only in held third season) • Pregnant women Increased percentage of • Training MAs to develop targeted for conditional infants 0 – 5 months markets for new crops nutrient-rich food exclusive breastfed • Introducing three transfers financial products (credit, inputs voucher, price insurance) • U2 children participated A3 in monthly GMP sessions Demand-side activities to • CHPs trained promote consumption • AHPs trained • Training CHPs, AHPs, • Adolescent girls and CAPs to organize participated in education agriculture/ nutrition fora sessions to promote nutrition-rich • Health workers trained foods on ANC Activities to incentivize nutrition positive behavior/ care practices Critical assumptions • Training CHPs to A1: Improved agricultural production practices, and availability of introduce GMP sessions technologies, financial products and marketing services are used leading to for U2 children productivity and production increases • Training AHPs to A2: Increased exposure to nutrient-rich foods leading to increased demand engage adolescent girls for nutritious foods in health/ nutrition A3: Demonstrated practices of nutrition positive behavior (e.g. ANC, activities exclusive breastfeeding, etc.) are adopted leading to better care practices • Engaging pregnant women in ANC visits through nutrient-rich food transfers Page 6 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) Project Development Objectives (PDOs) 6. The PDO of this JSDF financed project is to improve nutrition of an estimated 19,200 vulnerable smallholder households in Mbarara3 and Masaka Districts, by promoting the cultivation and consumption of nutrient-rich crops and improving nutrition and care practices of under-2 children, adolescent girls, and pregnant women. 7. The PDO remained unchanged throughout the implementation period. The geographic coverage of the project was re-worded, as captured in Implementation Status and Results Reports (ISRs) to reflect the redistribution of administrative boundaries, when Mbarara District was split to create Ibanda and Sheema Districts, and Masaka District was split to create Rakai and Kalungu / Kyotera Districts. 8. Beneficiaries and Target areas. The Grant Funding Proposal states that the project would target 19,200 vulnerable smallholder households. These main beneficiaries, sixty (60) percent of who were expected to be female, were defined as “poor subsistence farmers to receive agricultural input packages and training to improve cultivation of nutrient-rich crops, and health and nutrition training to increase demand for these crops.� Moreover, these 19,200 households were part of a total of 34,020 beneficiaries that would also be positively affected by the project.4 The beneficiaries were located in 160 villages in the two districts (Mbarara and Masaka). 5 Whereas the region of intervention remained the same (southwest Uganda) throughout the life of the project, the number of villages increased from initially 160 to eventually 180 villages. The reason of the increase was not recorded in ISRs or Aide Memoires (AMs), but the implementing agency clarified during ICRR interviews that this was a result of the administrative change in district boundaries that led the implementing agency to expand operations. This wider coverage partly explains why some Intermediate Results indicators exceeded their expected end targets (please see Section II). Key Expected Outcomes and Outcome Indicators 9. The project objectives were measured against the achievement of the following key outcome indicators: (i) percentage of participating farmers adopting orange-fleshed sweet potato; (ii) percentage of infants 0 – 5 months exclusively breastfed; and (iii) percentage of children 6-23 months with minimum dietary diversity. Components 10. The project had four components. While the first two components were related to service delivery, the remaining two components financed activities in areas of monitoring and evaluation (M&E), knowledge generation, and project management. 3 The name of this District was misspelled as “Mabara� in the Grant Agreement (GA). 4 The Grant Funding Proposal lists beneficiaries as follows: 19,200 poor subsistence farmers + 8,000 children 0-24 months to be targeted for growth monitoring and promotion (GMP) + 960 adolescent girls to be targeted for peer education sessions + 80 community-based agriculture promoters + 160 community-based health promoters + 160 community-based adolescent health promoters + 40 vine producers + 80 marketing agents + 500 pregnant women to be targeted for conditional nutrient-rich food transfer + 400 health workers with initial and refresher training on strengthened antenatal care (ANC) + 900 smallholder farmers to receive financial products. Notably these amount to 30,120 beneficiaries. The implementing agency clarified during ICRR discussions that an additional 6,400 beneficiaries should be added from the agriculture/ nutrition fora activity, and that there is no double-counting. This brings total project beneficiaries to 36,520. 5 160 villages x 120 farmers = 19,200 (Grant Funding proposal). Page 7 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) 11. Component 1: Community-based agriculture and health service delivery to promote cultivation and consumption of nutrient-rich crops (Estimated cost USD 2,215,016). This component: (a) Supported community-based agriculture interventions to improve the cultivation of nutrient-rich foods among smallholder farmers, including of OFSP, iron- rich beans (IRBs), carrot, cabbage, tomato, and groundnuts through Community Agriculture Promoters (CAPs) and Vine Producers (VPs). And (b) Increased community demand and consumption of the newly introduced crops, through Community Health Promoters (CHPs) and Adolescent Health Promoters (AHPs) to mobilize the community for health/ nutrition activities and promote consumption of nutrient-rich foods. 12. Component 2: Introduction of innovative financial products to promote cultivation of nutrient-rich foods (Estimated cost USD 94,500). This component supported three financial products that were designed to address specific constraints in technology adoption. Specifically: (a) a credit scheme for products customized to improve pre- and post-harvest cash flow for agriculture inputs that poor farmers need6; (b) a voucher scheme for farmers to buy agriculture inputs (seeds and fertilizers) right after their harvest7; and (c) price insurance for the first cropping season.8 13. Component 3: Monitoring and Evaluation and Knowledge Dissemination (Estimated cost USD 258,000) provided technical assistance to BRAC’s Monitoring Division (MD), Training Division (TD), and the independent Research and Evaluation Division (RED) to ensure quality in program implementation, document processing, and knowledge captured which included two “action research evaluations,�9 and a workshop at the end of the project to share lessons learned and way forward. RED together with the World Bank’s Gender Innovation Lab undertook the independent impact evaluation of the project (please see Section IV). 14. Component 4: Project Management and Administration (Estimated cost USD 232,000). BRAC Uganda’s Agriculture Program coordinated with the Health Program for overall project implementation.10 Project staff comprised: one project coordinator, one Field Coordinator, one Nutrition Specialist, one Lab Manager, one Research Assistant, four Area Coordinators, and 16 Project Assistants. Significant changes during implementation 15. The project closing date was extended by twelve months from June 11, 2017 to June 11, 2018. The one-year extension of the closing date was approved in February 2017. The project was approved on February 13, 2013, and became effective on July 15, 2013, but implementation was delayed until December 2013 because the World Bank 6 The loan would have an eight-month duration, flat interest rate, and backloaded repayment schedule that would allow farmers to repay 25% of the loan during the first four pre-harvest monthly installments, and the remaining 75% in the final four post-harvest installments. 7 Farmers would be offered to purchase input packages for OFSP and other nutrient-rich crops after the harvest period when they would have cash on hand. These inputs would then be delivered to farmers when they were needed during the subsequent planting season. 8 The product would cover the potential downside price risk created by unpredictable demand for OFSP in the market. It would be a surplus buyback guarantee at prevailing market prices, and it would ensure that in the event of low demand, farmers would still continue to produce adequate supply. 9 The first was to assess the competency of implementers on the ground (CHPs, CAPs, VPs) and training needs (May and June 2015); and the second on the role and value of the project’s ICT application for agriculture (early 2018). 10 BRAC Uganda is a large non-governmental organization that at the time of proposal preparation was deemed uniquely and strongly positioned to implement the project: it had the largest network for micro-loans, and a strong portfolio of projects supported by development partners, such as UNICEF, UNWomen, USAID and others in areas of health, agriculture sector, adolescent development, and microfinance. Programs were also delivered in strong partnership with the government. Page 8 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) in Uganda had stopped providing advance payments to all projects in the country until resolution of an outstanding fiduciary issue with the Government of Uganda.11 16. There were no other significant changes during project implementation, and therefore no implications for the original theory of change. II. OUTCOME Assessment of Achievement of Each Objective/Outcome12 17. The intervention implemented for the first time in Uganda, an integrated package of nutrition and agriculture interventions to improve nutrition for women of childbearing age, infants and young children, and adolescent girls in smallholder households through increased cultivation of nutrient-rich crops, increased dietary diversity, and improved care and feeding practices. The project focused on introducing OFSP, which can substitute for local sweet potato, a common staple crop; on addressing market and non-market barriers to adoption of nutrient-rich staple crops; and on promoting nutrition positive behaviors, including consumption and care practices, by introducing a set of integrated interventions in agriculture and health. The project also made important inroads by building capacity of service providers, and increasing the availability of high quality planting materials through the low-cost tissue culture laboratory’s production. Overall Outcome Rating 18. The ICRR team assumed three intended objectives to assess the project’s overall outcomes. The ICRR team followed Bank Guidance to decide how to assess the project’s overall outcome. The PDO was to improve nutrition of an estimated 19,200 vulnerable smallholder households in Mbarara and Masaka Districts, by promoting the cultivation and consumption of nutrient-rich crops and improving nutrition and care practices of under-2 children, adolescent girls, and pregnant women. Per the Bank Guidance on ICR for Investment Project Financing (IPF) Operations (paragraph 45) issued on 05 July 2017, the ICRR is expected to assess the PDO statement’s first part before the word “by�, i.e. improved nutrition of an estimated 19,200 vulnerable smallholder households in Mbarara and Masaka Districts, as the section coming after “by� is outputs and/ or components’ activities. However, the first part of the PDO (to improve nutrition) is vaguely worded making it difficult to assess what the project expected to achieve. Hence per paragraph 43 of the Bank Guidance on ICR, the ICRR team assessed the PDO based on the achievement of the project’s key expected outcomes as intended objectives, which are: (i) increased production of nutrient rich-foods, specifically OFSP; (ii) increased consumption of nutrient-rich foods, specifically OFSP; and (iii) increased care practices (e.g. age appropriate feeding practices etc.). It is reasonable to assume based on the wording of the three PDO indicators, specifically “percentage of participating farmers accepting OFSP�, “percentage of children 6 – 23 months with minimum dietary diversity�, and “percentage of infants 0-5 months exclusively breastfed� that the project team was expecting to measure increase in the number of these three indicators. The ICRR team, therefore, interpreted the PDO’s statement of “promoting the cultivation and consumption of nutrient-rich crops and improving nutrition 11The bottleneck causing the initial delay was resolved in March 2014. 12Unlike ICRRs for IPFs, there is no detailed guidance available for ICRRs for small grants like this project. Teams are expected to populate an annotated, ‘simplified’ ICRR template that is generated from the OPCS (Operations Policy and Country Services) Portal for the project, and to consult Bank Guidance on ICR for IPF Operations, when needed. As per OPCS advice, this ‘simplified’ ICRR assesses Outcome only one aspect: efficacy/ achievement. Page 9 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) and care practices of under-2 children, adolescent girls, and pregnant women� to mean “increased� [percentage of farmers engaged in] cultivation and “increased� [percentage for specifically children 6 – 23 months] of consumption of nutrient-rich crops, and “increased� [percentage of infants 0-5 months being exclusively breastfed] as an expression of improved nutrition and care practices of under-2 children, adolescent girls, and pregnant women 19. The project exceeded the number of total project beneficiaries. A total of 19,208 main beneficiaries were reached with “training of smallholder farmers,� defined as (i) smallholder farmers receiving training and refresher training on good agricultural practices as well as training on adopting nutrient rich crops; and (ii) after the training, smallholder farmers received packages of improved planting materials (high quality OFSP vines and other nutrient-rich seeds). BRAC estimated at project end the male to female farmer ratio to be 15:85 i.e. exceeding the target of 60 percent women. These main beneficiaries make part of an originally foreseen 34,020 total project beneficiaries that was also surpassed. Adding all the beneficiary groups targeted, including an additional 6,400 participants/ beneficiaries of nutrition and health education trainings that were not originally taken into account, the number of total beneficiaries becomes 36,520, i.e. surpassing originally foreseen number of beneficiaries. 20. Project objectives were met. As per the Theory of Change (Figure 2), the project achieved the three outcomes: (i) increased percentage of participating farmers adopting OFSP; (ii) increased percentage of infants 0 – 5 months exclusively breastfed; and (iii) increased percentage of children 6-23 months with minimum dietary diversity. More specifically, all three (3) PDO and 11 Intermediate Results (IR) indicators met or surpassed the target As the ICRR team explains in Section IV, the project’s IRs were mainly input and output-oriented, and the link to the PDO indicators rested on unidentified and thus unmeasured outcomes. The ICRR team was advised to not include a discussion on probable expected outcomes (such as productivity measured in yields for example) when these were not explicitly foreseen. The storyline thus is based on the achievement of projects indicators as well as any other available information accessed by the ICRR team (project reports, interviews). 21. Agriculture, or supply side interventions were meant to address production and productivity constraints, and they largely met their targets. The following indicators for this objective surpassed targets: (1) PDO indicator 1 (Percentage of participating farmers adopting OFSP), (2) IRI 4 (CAPs trained), (3) IRI 7 (VPs trained), (4) IRI 8 (MAs trained), and (5) IRI 11 (farmers trained on financial products). 22. Participating farmers adopted the cultivation of OFSP, and OFSP production levels increased from baseline to endline, but a declined trend was observed between midline and endline. The decline in OFSP production post midline was attributed to the fact that the vines were no longer available for free in the second cropping season, as well as due to limited availability of cultivable land, reduced market access, and consumption of OFSP as a coping strategy (BRAC independent Endline Impact Evaluation (IE) Report). The IE evaluation controlled for the household socio-economic score, and deduced that producers who managed to improve their socio-economic status with the intervention were more likely to continue growing OFSP, because they were more capable of managing risks associated with its production. Risks, or limiting factors, were identified at midline and included the fact that unlike for conventional sweet potatoes, farmers cannot easily self-propagate OFSP, which is an option they prefer, but need to rely on specialized vine producers. It is likely that the BRAC team did not take any remedial measures to address these findings at midline, because the project had primarily a learning objective, and not a production/ productivity objective. The IE team hypothesized also that perhaps farmers at endline decided to consume OFSP rather than plant Page 10 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) them because of increased observed levels of household food insecurity.13 Nevertheless, as mentioned despite the decline observed, the PDO target value was met and exceeded. 23. OFSP vine cuttings and VPs were a central part of this objective. The project established a system to cultivate and distribute high-quality OFSP vines to small holder farmers (SHFs) through test production in a low-cost tissue culture laboratory and scaling up through community-based vine-producers (VPs). High quality vines produced through the laboratory were used to establish propagation sites that were maintained by local vine producers, who then provided the cuttings to local smallholder farmers as part of the input package14. Between 2015 – 2018 the lab produced around 110,000 cuttings (plantet) for the project. Input packages were distributed for free at the beginning of each planting season for the first two seasons (one year) from vine producers to community Agriculture Promoters (CAPs) to smallholder farmers. 24. CAPs were the intermediary to reach smallholder farmers. CAPs were trained and provided refresher trainings on a seasonal basis on production technologies for nutrient-rich crops, post-harvest management, pest management and others. They trained a total of 19,208 smallholder farmers by March 2017. Trainings were conducted at the start of the two planting seasons: March-April and August-September. Refresher trainings were provided as well. Towards the end of the project, each of the 19,208 farmers reached received garden farming tools namely: handheld hoes and handle, panga, slashers, and garden fork to aid in land clearing and production. 25. The marketing activity was not successful. Although the associated indicator project end target was met (IR8) marketing agents (MAs) were not able to link smallholder farmers to input supplies and marker information.15 A lack of a supervision framework for MAs,16 and low OFSP supply for commercial purposes impeded marketing goals. Sixty (60) percent of farmers grew OFSP for own consumption. Only 0.5 percent produced for purely sale purposes, and the remaining 39 percent of farmers who had both own consumption and sale purposes, had too small of a production for MAs to play any meaningful aggregator role. Farmers instead sold their excess production by themselves in local markets. This result, nevertheless, did not affect the achievement of the PDO indicator related to increased production of OFSP. Farmers still engaged in the crop’s production, although not for sale in markets as was originally foreseen by project. 26. Financial products introduction was not particularly successful either. BRAC’s Endline Impact Evaluation Report noted that while the project increased credit uptake and borrowing capacity during the midline phase, it witnessed an increase in default rates at the endline phase. BRAC speculates that the decline in credit uptake might be due to low profits as OFSP market sales were not high, and possibly due to credit funds use diversion by farmers. Results of price insurance indicated a limited benefit as most farmers consumed what they produced, or others in anticipation of BRAC’s purchase, did not make an effort to sell produce on their own. Voucher bearers were given a sack of disease-free planting material (vines), foliar fertilizer and pesticides at the beginning of the crop season. The Endline Impact Evaluation Report by BRAC Uganda found that vouchers had a limited impact on boosting production levels as compared to credit and insurance schemes, but also noted that decreased production could result from a variety of reasons, such as weather and climatic conditions, family circumstances, and other. These results were registered, while the associated indicator project end target was met (IR11). Even though the utilization of the financial products was not what the project had hoped for, due to reasons outlined above, this did not deflect from the achievement of PDO indicator related to increased production of OFSP. In other words, farmers were trained on financial products that they did not use, and they engaged in the crop’s production. Page 11 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) 27. Supply-side interventions were complemented with demand-side interventions meant to promote consumption of nutrient-rich crops, and they largely met their targets. The following indicators for this objective surpassed targets: (1) PDO indicator 3 (Percentage of children 6 -23 months with minimum dietary diversity), (2) IRI 1 (women, adolescent girls, U2 children reached by basic nutrition services), (3) IRI 2 (U2 children participating in GMP), (4) IRI 3 (adolescent girls in education sessions), (5) IRI 5 (CHPs trained), and (6) IR 10 (health workers trained on ANC). 28. OFSP consumption patterns and dietary diversity increased. Sixty (68) percent of children met minimum dietary diversity (MDD) requirements17. The BRAC Endline Impact Evaluation Report found that OFSP consumption patterns increased, and that improved dietary diversity levels were observed post intervention. Again, however, a declined trend was observed between midline and endline with more children consuming milk, eggs, meat and dark leafy vegetables, and less fruits and starchy staples. The shift in diet composition was not explained. The IE team inferred that an increase in dietary diversity of adults and children contributed towards increased nutritional status, specifically underweight for children. It should be noted that the Impact Evaluation baseline survey had found the baseline value for this indicator to be 53 percent. The World Bank project team deemed, however, that the baseline value was too high and subject to further investigation, and therefore did not adopt it. The high-end project result achieved (relative to the baseline value retained) was attributed to the intensive project activities over a relatively small project area. 29. A total of 6,400 pregnant/ lactating women, adolescent girls and/ or children under age five were reached by basic nutrition services delivered mainly through monthly growth monitoring and promotion (GMP) sessions. Globally, the use of GMP has been established as one of the visible child health activities to prevent and address malnutrition.18 As an incentive to participate in GMP, a 0.5 kilograms pack of soya-maize flour was provided to the primary care-taker as supplementary food for the baby. 30. Moreover, the project contributed to improved nutritional outcomes by using the project’s nutrition and health meetings, such as the GMP sessions, as an opportunity to also register and follow severe malnourished cases of children. A referral system for severely malnourished cases was established in order to receive in-patient therapeutic care in public health care facilities in order to promote linkages with the national health system. The project even procured ready-to-use-therapeutic food (RUTF) for outpatient management of acute malnutrition through supplementary feeding. The RUTF was distributed to severely acutely malnourished children as well as the moderately acutely malnourished to enable them to achieve catch up growth as well as maintain healthy weight. The distribution was supervised by health workers.19 This was not an activity originally foreseen by the project, so its 13 The IE team used the Household Food Insecurity Access Index. 14 Input packages contained planting material for OFSP and other nutrient-rich crops, such as iron-rich beans, tomatoes, carrots, pumpkins, eggplants, and groundnuts. Technical assistance on improved farming practices (making and utilizing organic fertilizer, minimizing post-harvest losses, etc.) continued throughout the three-year project duration through community fora. 15 Road side shops, where OFSP and other project-supported products would be sold, were to be established in each of the four BRAC branches. ICRR team reviews identified only one road side shop (pilot) that was set up in Kabale village (Lukaya branch) operated by a vine producer in May 2017. BRAC Uganda, MTR, June 2015. 16 BRAC Uganda, Quarterly Progress Report, April – June 2018. 17 Dietary diversity was calculated on the basis of a diversity score. A higher dietary diversity score meant that the person was consuming food from five or more groups that included dark green leafy vegetables, Vitamin A rich food, other fruits, milk and dairy products, legumes, nuts, meat, fish etc. (BRAC Endline Impact Evaluation Report). 18 Msefula D. How can growth monitoring and special care of underweight children be improved in Zambia. Trop Doct. 1993;23:107–12.; Nabarro D, Chinnock P. Growth monitoring–inappropriate promotion of an appropriate technology. Soc Sci Med. 1988;26:941–8. 19 Health workers from those facilities were provided initial and refresher training to build their capacity to address cases of severe acute malnutrition. They were also given inputs such as stethoscope, fetoscope, BP machine, MUAC tape, as well as height boards. BRAC Page 12 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) results on nutritional outcomes were not registered. It is reasonable to assume, however, that by referring severely malnourished cases and procuring RUTF the project did contribute to improved nutritional outcomes. 31. The project sought to also incentivize nutrition positive behavior and care practices, and associated interventions also largely met their targets. Nutrition-sensitive agricultural interventions and nutrition-specific interventions delivered through the health sector alone, without incorporating behavior change communication (BCC) to explicitly address nutrition determinants such as feeding and hygiene, health care visits, are not as effective at improving nutritional outcomes. Activities in PDO areas 2 and 3 reinforced each other, so a complete disentanglement of the two is not possible. Some of the IR indicators are therefore repeated. The following indicators for this objective surpassed targets: (1) PDO indicator 2 (Percentage of infants 0-5 months exclusively breastfed), (2) IRI 1 (women, adolescent girls, U2 children reached by basic nutrition services), (3) IRI 2 (U2 children participating in GMP), (4) IRI 3 (adolescent girls in education sessions), (5) IRI 5 (CHPs trained), (6) IR 9 – (pregnant women targeted for conditional nutrient rich transfers), and (7) IR 10 (health workers trained on ANC). 32. The project was successful in building critical knowledge regarding the exclusive breastfeeding practices among the beneficiary households. CHPs held training sessions with project beneficiaries on good and poor feeding practices for babies, as well as hand expressing breast milk.20 Training sessions explicitly focused on what is needed for infants below six months (the milestone until which babies are meant to be exclusively breastfed), and what food can be introduced and why21 for babies older than six months. Exclusive breastfeeding has many benefits for the newborn and the mother. The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) recommend early initiation of breastfeeding and exclusive breastfeeding for the first 6 months post-delivery. This reduces the chances of the child suffering from infections and diseases, and it contributes in ensuring effective growth for the child. The number of mothers who exclusively breastfed the children increased at a substantial rate from midline levels. The sharp increase was attributed to the increased health-based activities in the field during the endline phase. Some negative values observed at endline were attributed to rates of divorce, that usually meant that babies were left at the care of grandparents, or other relatives. Another positive finding was that mothers took less time immediately after birth to initiate babies to breastfeeding, as per recommended practice. It is worth noting that the IE baseline survey found the baseline value to be 62 percent. Nevertheless, the ISRs report a value of 57 percent with no recorded explanation. Even so, the end target was met. 33. The project used an innovative approach to increase demand for ante-natal care service where Community Health Promoters (CHPs) played a critical role. CHPs regularly informed the community on benefits of ANC for the pregnant women and their unborn child, they referred women to ANC, and disseminated knowledge on adequate maternal nutrition. Nutrient-rich food transfers (including 10 kgs of OFSP and 1 kg of porridge) were provided as an incentive to each participating pregnant woman to increase uptake of ANC services, which was conditional to completing at least four ANC visits, as per WHO recommendation for uncomplicated pregnancies. CHPs in addition to measuring the child’s growth, also visited households to monitor sanitation practices and to deliver messages and counseling on nutrition, dietary diversity, IYCF practices, in a way that would build knowledge and demand for nutrient-rich crops, but also generate maternal action to promote child growth. Project community-based staff also conducted home visits for follow up, or to check on participants who had dropped off sessions. Uganda, Quarterly Progress Report, January – March 2018 20 BRAC Uganda “Caring for Your Child� Module Training Set; Community Health Promoters Flipbook; and “Manual� on “Integrated Approach to Enhance Smallholder Family Nutrition�. 21 The project used an easy to remember classification for foods to be introduced to children over 6 months old: carbohydrates ( go foods), protein (grow foods), and vitamins (glow foods). Page 13 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) 34. The project sought to influence positive behaviors of future mothers. Peer sessions to promote adolescent health seeking behaviors included discussions on sexual and reproductive health issues, coping with adolescence, prevention of early pregnancies, as well as engage in board and outdoor games to build their physical and mental health. A total of 5,284 adolescent girls participated in these reproductive health and nutrition education sessions. 35. The project also held quarterly health and nutrition fora aimed to instill and promote behaviors amongst beneficiaries that would contribute to improved nutritional outcomes, such as improved Infant and Young Child Feeding (IYCF) practices, improved food preparation practices, sleeping under a mosquito net, seeking health services, amongst others.22 CHPs targeted female caregivers, husbands, and elders to promote consumption of nutrient-rich foods and improved feeding practices for under-2 children, adolescent girls, and pregnant women. Cooking food demonstrations were also held. 36. The project was successful in encouraging nutrition and health-enhancing practices. A positive increase was observed among the women accessing ANC in the both midline and endline phases (that could be due to the conditional food transfers). The independent evaluation team noted in general positive health seeking behavior among pregnant women and adolescent girls, and an increase in child care practices. Justification for Overall Efficacy Rating 37. As the above-provided evidence indicates, the project largely exceeded its intended outcomes. Individual activities reinforced each other across components further supporting the achievement of the project outcomes. Based on the data available, the project should be rated Highly Satisfactory. Nevertheless, given the mainly input / output oriented nature of the data (indicators) and theory of change assumptions (more under Section IV), the ICRR team has rated the overall project efficacy as Satisfactory. Other Outcomes and Impacts 38. Apart from being one of the first projects to combine agriculture and health interventions to promote nutrition in Uganda, the project interventions incorporated several innovations to promote the cultivation and consumption of nutrient rich crops among the at-risk groups. Those included the following: 39. Establishment of low-cost tissue culture laboratory. The low-cost tissue culture laboratory was set up to inoculate and multiply disease-free OFSP planting materials using materials from National Crop Resource Research Institute (NaCRRI). In ICRR interviews, NaCCRI was highly appreciative of the facility that has acted as an extension agency, and commented that after the project end it would approach the same vine producers to consider multiplying any new varieties. The lab currently supplies OFSP vines, banana plantet, and other seed types. 40. Introduction and use of an ICT application. Beneficiaries (some CAPs, MAs, vine producers, project assistants) were given and were trained on Android smart phones for real-time information about management of crop diseases, and real-time market information on prices, markets. Results of research conducted by BRAC23 revealed that smart phones were useful to project beneficiaries for receiving and using this type of information.24 22 Community Health Promoters Flipbook to help provide essential health education to communities developed by An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition. 23 Mpiira, Robert. Fortified Crops: The Relevance of ICT, CAPs and CHPs in Food Security, Nutrition and Impact Generation, BRAC International, Independent Evaluation and Research Cell. 24 Nevertheless, operational challenges were also highlighted, such as absence of electricity to recharge. As a response, CAPs in two Page 14 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) 41. Production of nutritious instant nutritious porridge, “Kipapaali�. The project added value to OFSP through the development of a composite porridge flour consisting of excess maize, soybeans, iron rich beans, and OFSP that it sourced from farmers. The flour was developed in conjunction with Makerere University Food Technology & Business Incubation Center, that led the research on it. Project beneficiaries, specifically women and youth groups, made OFSP chips by grating and then drying them. The chips were sold to a local food processor who was contracted to make Kipapaali flour. The final product was highly welcomed by project beneficiaries, who received it via vouchers designed by the project. Notably this was a one-off marketing opportunity that became possible towards the end of the project. The implementing agency had hoped that it could provide an incentive for micro- and small-enterprises to be developed by the beneficiary groups that provided and processed the raw material. At project end, however, it was not clear whether the product is viable.25 III. KEY FACTORS THAT AFFECTED IMPLEMENTATION AND OUTCOME Key factors during preparation 42. The project proposal built upon a series of in-country consultative workshops with key policy-makers from relevant government ministries and development partners to explore options to increase awareness, adoption and consumption of nutrient-rich food crops in Uganda. The promotion of Orange Flesh Sweet Potato (OFSP) presented an especially promising opportunity to combat vitamin A deficiency. Vitamin A deficiency (VAD) usually results from inadequate intake of vitamin A-rich foods.26 In the Uganda context and at project inception it was assumed that animal sources would be more expensive than plant-based sources for targeted poor small holders27. One significant opportunity was to promote vitamin A-rich (bio-fortified) sweet potato (or OFSP) given the prominence of this food as a staple. Farmers in three districts of Uganda (Iganga, Mbarara, and Lira) were interviewed on knowledge, consumption/ utilization, and production of nutrient-rich crops. Participants in the design consultative workshop reviewed previous work in Uganda by HarvestPlus and others, which explored consumer acceptability and market development for OFSP. The consultations found sufficient interest amongst the farmers in adopting this technology to warrant a moderately large pilot project. OFSP, therefore, emerged as an attractive delivery mechanism for addressing VAD.28 Consultations benefited also from the knowledge and experience of agriculture and health World Bank colleagues based in Uganda. 43. The project design drew on lessons from projects of a range of development agencies , including BRAC, working on technology adoption and nutritional improvement, and analytical work such as the rigorous evaluations conducted by HarvestPlus on nutritional values of the specific crops promoted by the project. The initiatives of extension of HarvestPlus also had been evaluated in both Uganda and Mozambique, where evaluations showed reasonably high interest amongst the farmers in adopting these technologies.29 The project also promoted GMP, which had been BRAC branches (Ibanda and Kabwohe) were each given a solar lamp and a solar charger to ease phone charging. 25 During ICRR discussions, beneficiaries said that it is too expensive to be bought after the project end, while other beneficiaries were quoted in BRAC Uganda Quarterly Progress Report (April – June 2018) saying that they would pay for it, if it was commercialized. 26 Another reason is abnormalities in intestinal absorption of retinol or carotenoids. 27 There are two types of vitamin A available for human consumption: one is preformed vitamin A found in animal products (including dairy products, and egg yolk); the other is pro-vitamin A carotenoids found in green leafy vegetables, yellow vegetables, and yellow and orange non-citrus fruits (e.g. mangoes, apricots, and papaya). Some oils and indigenous plants may also be sources of pro-vitamin A. 28 Although iron deficiency and iron deficiency anemia had also been identified as malnutrition issues, there was no comparable plant- based source for iron. High-iron beans became available only in 2016 in the country. https://www.harvestplus.org/knowledge-market/in- the-news/uganda-releases-biofortified-beans-address-iron-deficiency-anemia 29 http://www.harvestplus.org/sites/default/files/HarvestPlus_OFSP_Brief_English_2012_v2_small.pdf Page 15 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) adopted in similar settings with encouraging results to improve child nutrition and feeding practices. The three financial products to be piloted were also based on best practices from other low/ middle-income countries. 44. Focusing on adolescent girls was also pioneering. Adolescents have only recently begun to be amongst the key target in most nutrition programs, yet they remain a vulnerable group, and they constitute a window of opportunity to address future nutrition problems. In 2014, the WHO report Health for the World’s Adolescents showed that considerable gains from investments in maternal and child health programs are at risk of being lost without corresponding investments in adolescent health. Key factors during implementation 45. Factors subject to government and/ or implementing entities control. The following factors contributed to the project’s success in terms of implementation process: (i) Coordination and engagement: The inter-ministerial, cross- sectoral Project Steering Committee (PSC), comprising representatives from the Ministry of Agriculture, Ministry of Health, and Office of the Prime Minister, was viewed by members as a unique opportunity at the time to assemble and rally around the same cause, exchange information, and learn from another at local and national levels (ICRR interviews, Kampala, Uganda, June 2018). The PSC met six times throughout the life of the project. The implementing agency confirmed on various occasions the active participation and interest in project progress by the PSC members. (ii) Commitment and proactiveness: The project overall enjoyed continuous commitment on the part of the Government. Although there was some turn-over in Government between the time when the project was discussed and when it became operational, the PSC members have remained the same. Moreover, some of them are also involved in guiding the currently on-going Uganda Multisectoral Food Security and Nutrition project financed by the Global Agriculture and Food Security Program (GAFSP), the design of which was informed by this project ensuring thus continuity and consistency amongst government overseen projects. BRAC, as the implementing agency, was also proactive in expanding the project’s team when it realized that an additional position was needed (that of a Field Coordinator). 46. Factors subject to World Bank control. A mid-term review (MTR) was held in June 2015. The MTR recommended a project restructuring in order to: (i) revise the PDO, PDO indicators and IR indicators to better align them with project activities and improve monitoring of progress towards the PDO; and (ii) extent the project closing day by one year (no- cost extension). It is not clear why the MTR suggestions to revise the Results Framework (RF) were not taken on. Only the one-year no cost extension was sought through a project restructuring, and secured. 47. Factors outside control of government and/ or implementing entities. There were two main factors: (i) Project delays at outset. As mentioned earlier (paragraph 15) implementation was delayed from July –December 2013 by a major financial management bottleneck. Once a solution was found, the project’s procurement and implementation plans were promptly revised to accelerate project activities. Despite efforts exerted, however, there was a limit to how fast the project could catch up to reach expected targets and an extension became necessary. (ii) Adverse weather conditions. Drought was cited in BRAC Uganda Quarterly Progress Reports as a factor delaying agricultural activities. Although planting time was adjusted,30 in some cases the drought affected OFSP vines and other crops’ growth and production.31 30 BRAC Uganda, Quarterly Progress Report, July – September 2015. 31 BRAC Uganda, Quarterly Progress Report, January – March 2017. Page 16 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) IV. BANK PERFORMANCE, COMPLIANCE ISSUES, AND RISK TO DEVELOPMENT OUTCOME Bank performance Bank performance in Ensuring Quality at Entry Rating: Moderately Satisfactory 48. The World Bank performance at entry is rated as Moderately Satisfactory. The ICRR team deems that this is also a reflection of the fact that at the time of preparation (and implementation) of this project, institutional oversight of Recipient-Executed Trust Fund (RETF) projects was not strong, and guidance for them was not clear. The preparatory work undertaken, including consultations, background research, and use of internationally accepted theoretical frameworks on malnutrition, was laudable and set the stage for piloting this innovative project. Nevertheless, probably as a result of different rules at the time of the design of this JSDF-funded project that did not necessitate the preparation of a separate Project Appraisal Document (PAD) beyond the Grant Funding Proposal, a decreased level of scrutiny allowed for some weaknesses at design to go unnoticed. These also affected supervision. As a result: (i) the project’s Theory of Change rested on substantial critical assumptions without sufficient outcome-oriented indicators demonstrating the links between activities and ultimate objectives; (ii) the PDO was worded vaguely, which undermined the potential for measuring the intended objective of the project.; and (iii) the PDO statement included the number of beneficiaries and target areas by name, that are not common or usual practices, and are avoided because of changes that may incur during the life of the project. Quality of Supervision. Rating: Moderately Satisfactory 49. The quality of overall World Bank supervision is rated as Moderately Satisfactory. As mentioned before, the ICRR team deems that this is also a reflection of the fact that at the time of (preparation and) implementation of this project, institutional oversight of RETF projects was not strong, and guidance for them was not clear. The following factors underpin the Bank’s performance: (i) Supervision effort and arrangements: a total of six (6) Implementation Support Missions were conducted in close coordination with BRAC over the project implementation period. These included a Mid-Term Review in June 2015. Moreover, there was no turn-over of Task Team Leaders (TTLs); instead the same TTL steered the project from inception to completion ensuring continuous and consistent leadership and oversight. The TTL assumed also the leading role in the afore-mentioned GAFSP-financed project (paragraph 45) facilitating thus knowledge and experience transfer to the new team. (ii) Supervision adequacy: The Supervision Teams consisted of specialists coming both from the local World Bank office, and abroad. The majority remained the same throughout the project life. Specialized missions were also organized to examining in-depth certain areas, such as financial management (2015/ 2016). 50. Although the World Bank task team frequently visited the project and was in close contact with the implementing agency, produced regularly ISRs and AMs, and was effective in seeking a solution to the project implementation delay, it did not always follow good practice. This observation arises from examples on how the task team dealt with oversight over the quality of ISRs submitted; record keeping of project changes; and follow through with recommendations. For example, although Results Framework indicators were largely achieved or surpassed, some inconsistencies were observed in reporting (Annex 1) that were not clarified at the time. These were discussed with the World Bank task team, and they were attributed mainly to errors in ISR completing, and shortcomings of the IE design and implementation which should have been flagged and recorded during project supervision, too. Under current operational guidance, project restructuring would have been necessary to revise the PDO statement to reflect Page 17 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) the change in the administrative boundaries of the original two target areas, and to reword one of the PDO indicators to read “children 6 – 23 months are monitored for MDD�.32 Instead for this project, it was the ISRS and MTR, respectively, that simply recorded these changes. The MTR made recommendations only on the RF and the project life duration; it did not identify issues with implementation that would have merited project adjustments. 32 Previously the indicator appeared for “children 0 – 23 months.� Page 18 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) M&E Design, Implementation and Utilization 51. The limited institutional oversight of and guidance for RETF projects affected also the M&E. The assessment of the quality of the M&E is based below on three main elements: (i) quality of M&E design: as mentioned above, the project’s theory of change although grounded on proper theory, could have been cleared, with a better defined PDO, and more outcome-related indicators to monitor progress towards the PDO (i.e. tracking yields, productivity, etc.). Also, some of the IRs seem to have been assigned too low of target values, given the extent by which they were surpassed. Lastly, not all project beneficiaries were taken into account at project design. In the originally foreseen 34,020 total project beneficiaries, an additional 6,400 participants in nutrition and health education trainings should have been taken into account. They were accounted for at ICRR discussions. (ii) quality of M&E implementation: Although both regular M&E and independent impact evaluation (IE) were available for the project, the quality of regular reports was not always at par. Semi-annual progress reports were developed, but they were not made available to the ICRR team, because they are merged with all other BRAC programs. Since project implementation in the field started in the third quarter of 2014, BRAC did not have any quarterly reports before that. Not all quarterly reports were produced even for 2015. BRAC pointed the ICRR team to the MTR report that covered progress up to then. The Quarterly Progress Reports that were available reported some indicators erratically, and other indicators were presented without a clear methodology of monitoring. ICRR discussions clarified reporting of those indicators. Lastly, it is not clear why the MTR suggestions to revise the Results Framework (RF) to make it better aligned with project activities and improve monitoring of progress towards the PDO were not taken on. (iii) quality of M&E utilization: In early 2013, BRAC partnered with the World Bank Gender Innovation Lab to implement a clustered (at village level) randomized control trial (RCT) to estimate the effect of project interventions on outcomes of interest. These additional funds complemented the budgeted evaluation funds in the project, and should have set the project on a stronger M&E footing.33Nevertheless, ICRR discussions found mixed evidence on how M&E was used to inform project management and decision making. On one hand, the midline report (May 2017), for instance, noted that the number of ANC visits could be increased from four to eight (given that the average distance to a health center was slightly below 20 minutes), and eight visits can reduce perinatal death by 8 per 1,000 births, but there is no evidence whether this was discussed. On the other hand, though, the results of the operational research on competency of implementers on the ground (May – June 2015) were used to inform training needs of community-level implementers. As mentioned before, it is likely that the BRAC team did not take any remedial measures to address these findings at midline, because the project had primarily a learning objective, and not a production/ productivity objective. Justification of Overall Rating of Quality of M&E 52. Given these facts the quality of the M&E system is rated overall as Modest. Compliance issues 53. Safeguards. No safeguards were triggered under the grant. 54. Financial management (FM). Overall, FM performance by BRAC is considered Satisfactory. FM reporting was done regularly, and submission of reports was on time. An FM review conducted in 2015/ 2016, however, identified deficiencies in segregation of duties through general IT control weaknesses based on the Enterprise Resource Planning (ERP) design and configuration. Also, the review observed missed opportunities to improve FM performance due to 33These allowed also for additional operational research to better capture the impacts of the interventions. That included a market survey (to assess whether prices for agricultural outputs and substitute staple crops are impacted positively or negatively by this intervention, as this can have serious welfare implications for non-treated households and villages); and a short network survey for a subset of program-eligible households to capture information on social learning effects arising from the treatment/ on social network of respondents. Page 19 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) lack of an IT policy in relation to data classification. Weaknesses were observed in the filing system for project specific payments made both at the BRAC headquarters and branch offices. These identified did not affect the operations of the project, but actions were needed to improve internal controls. Therefore, it was recommended that the system for payment vouchers and related records be improved by introducing sequential filing system, and back-to-office reports were prepared using a standard form as confirmation that all subsistence allowances were spent on official activities (ISR No 6). The ICRR mission confirmed that actions were taken related to the above FM recommendations. 55. Audit. BRAC Uganda maintained separate accounts for the project expenditures to facilitate independent external audits, contracted in accordance to Terms of Reference acceptable to the World Bank. BRAC carries out statutory annual financial audits and a review of external audits was conducted. Institutional audits were used in 2014 (BRAC Uganda Audit Report), which was acceptable to the World Bank. It was agreed that future reports would use the institutional audits, with the additional provision that BRAC Uganda should specifically include the following specifications in the TOR of the audit: Auditors would report on (i) activities under the designated account; (ii) Expenditures under the project were for only eligible activities and in line with Bank guidelines under the project; and (iii) Compliance with other Grant Agreement covenants. The ICRR mission confirmed that actions were taken related to the above audit recommendations. 56. Procurement. Overall, procurement performance by BRAC is considered Moderately Satisfactory. Following a slow start to procurement, additional coaching on procurement processes was provided to BRAC by the World Bank in February 2014 to improve the rate of procurement (ISR No. 3). Based on the post procurement reviews report34, it was established that the procurement processes for the project were compliant to the World Bank procedures and the BRAC procurement procedures, but it also laid out the following four areas of time-bound recommendations: (1) immediately ensure that terms and conditions of contract are included in Local Purchase Order; (2) immediately follow the evaluation criteria indicated in the request for quotations (and refrain from changing the evaluation criteria during evaluation bids); (3) ensure that all procurement processing records, such as contract performance reports, are put on file for completeness; and (4) update the procurement plan regularly. The ICRR team was not able to confirm that actions were taken related to procurement recommendations. Risk to development outcome 57. There are two aspects to sustainability: one relates to the project’s direct contribution to the Government’s policy decision-making, and the other to the project beneficiaries’ continuation of practices learnt. The project managed to demonstrate the success of a model piloting integrated agriculture and health interventions for improved nutrition. This is a model that has already been taken up in the design and implementation of the GAFSP-financed Uganda Multisectoral Food Security and Nutrition project. Although now advocated as good practice, and quite common, this integrated approach was unique when the project was conceived in 2011. It is hard to demonstrate with hard evidence, but the project probably created a momentum that likely contributed to a host of similar approaches in the country, including most notably the afore-mentioned GAFSP-financed project. The JSDF-funded project informed the project structure of the latter (production and consumption promoting components), and developed training material that served as a basis for the training material of the GAFSP-financed project. 58. In terms of sustainability of results at the beneficiaries’ level, the ICRR team notes that the project had primarily a learning character as a small pilot project. As such it was aiming to register a change in beneficiaries’ practices as a result of project interventions. In terms of OFSP production, a study on sustainability of results from agricultural 34AFTPC Procurement Reviews FY2017/18, Procurement Post Review Supervision Mission Report, An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition Project, April 2018. Page 20 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) extension programs for smallholder women farmers of a 2009 – 2013 BRAC program in Uganda revealed that the practice of improved cultivation techniques persists, and that also demand for improved seeds does not decline.35 There is reasonable expectation thus that production at some level will continue within the current means of beneficiaries. Production on a large scale is not expected without corollary investments. For example, a JSDF team oversight visit to this project, noted inherent challenges that the beneficiaries raised to the team that needed to be addressed to ensure long-term sustainability including the institution of bore hole systems to help irrigate water- stressed crops during the drought season; and the provision of large-scale production tools to farmers to help increase production (a constraint identified in the Project Implementation Completion Report, June 2018). There is no record of this visit in the material reviewed for this ICRR (please see Annex 4), and therefore no registered remedial activity taken by the project. It is noted, however, that the activities flagged by beneficiaries were beyond the scope of the project, which could be a reason of the lack of addressing this challenge. Another reason could be that as mentioned this project had primarily a learning intention, and not a maximizing production intention, so it was never meant to address these constraints. The probability of the consumption and care practices being continued will depend on the beneficiaries having witnessed improvements in the nutritional status of their children. Findings in the BRAC Endline Impact Evaluation Report, and testimonials captured in BRAC Quarterly Progress Report and the Project Implementation Report, as well as interviews during the ICRR mission suggest that the stock of knowledge on all three (production, consumption, care practices) has increased. V. LESSONS LEARNED AND RECOMMENDATIONS . 59. Design-level lessons include the following. 60. Appropriate monitoring and evaluation indicators and a robust TOC are needed to properly assess achievements. Given the challenges with accurately monitoring and documenting results, it is important for future projects to ensure that outcome and PDO-level indicators on nutrition and agriculture practices are well-linked to the activities and realistic to draw improvements in practices. 61. Implementation-level lessons include the following. 62. Free inputs alone to smallholder farmers do not lead to sustainable production; structural issues need to be addressed, too. In order to sustain the production and adoption of targeted crops, it is important to invest more in infrastructure, such as irrigation, marketing and business skills, and income-generating activities. Creating entrepreneurship opportunities for small holder farmers, and supporting post-harvest handling and processing (including equipment through for example sharing schemes) are critical for sustainability of agriculture-related activities. 63. Using incentives for ANC visits is successful. An increase in uptake of ANC services by women as a result of conditional transfer of nutrient rich packages means that this seem to be one of the incentives adequate to encourage women to overcome barriers faced in accessing ANC services. 35Fishman, Ram, Stephen C. Smith, Vida Bobic, and Munshi Sulaiman. March 2017. How Sustainable are Benefits from Extension for Smallholder Farmers? Evidence from a Randomized Phase-Out of the BRAC Program in Uganda. IZA Institute of Labor Economics, Discussion Paper Series, IZA DP No. 10641. Page 21 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) 64. Consumption patterns can be influenced with availability of targeted food and nutrition education. Increased food production and concerted effort on behavior change can lead to diversification of food consumption. Projects aiming to affect consumption behavior should look into incorporating nutrition education and awareness messages as they enhance dietary consumption effects and potential for consumer demand of nutritious foods. 65. The introduction of financial products for smallholder farmers must be accompanied with more local, context- specific knowledge. Simply making financial products available for farmers is not enough to lead to desired results. Local farmer capacity to repay must be studied, and energy needs to be invested in sensitizing recipients on the proper use of products. 66. Community-based service providers can play a critical role in the success a project. These service providers can fulfill a number of critical functions (in agriculture extension and advisory services, and health services outreach), and they can also contribute to a stronger linkage between communities and the health centers. Their role should be recognized and strengthened in similar operations. Page 22 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) ANNEX 1. RESULTS FRAMEWORK AND KEY OUTPUTS A. RESULTS INDICATORS A.1 PDO Indicators Objective/Outcome: Increased production of nutrient-rich foods, specifically OFSP Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Percentage of participating Percentage 0.00 20.00 20.00 24.75 farmers adopting orange- fleshed sweet potato 25-Sep-2013 01-Jun-2017 01-Jun-2018 30-May-2017 Comments (achievements against targets): The IE baseline suggested a value of 8 % and a commensurate end project target of 28 %. The World Bank project team questioned result given that OFSP cultivation was not present in the project areas. IE values were therefore not adopted. Objective/Outcome: Increased consumption of nutrient-rich foods, specifically OFSP Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Percentage of children 6-23 Percentage 10.00 67.00 67.00 68.00 months with minimum dietary diversity (Percentage, Custom) 25-Sep-2013 01-Jun-2017 01-Jun-2018 30-May-2018 Page 23 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) Comments (achievements against targets): The IE baseline survey found the value to be 53%. The World Bank project team deemed, however, that the baseline value was too high and subject to further investigation, and therefore did not adopt it. The high end project result was attributed to the intensive project activities over a relatively small project area. Also, the name of the PDO indicator was corrected to accurately convey that children 6 – 23 months are monitored for MDD. Previously the indicator appeared for children 0 – 23 months, while 0- 5 months children are meant to be exclusively breastfed. Lastly, this indicator was also reported with two different sets of baseline and end target values in the series of ISRs (57% & 67% v. 10% & 15%), with no explanation provided. Objective/Outcome: Increased care practices (eg age appropriate feeding practices) Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Percentage of infants 0-5 Percentage 57.00 15.00 67.00 78.00 months exclusively breastfed 25-Sep-2013 01-Jun-2017 01-Jun-2018 30-May-2018 Comments (achievements against targets): The IE baseline survey found the value to be 62%. Nevertheless, the ISRs report a value of 57%. Moreover, this indicator was reported with two different sets of baseline and end target values in the series of ISRs (10% & 15% v. 57% & 67%), with no explanation provided. A.2 Intermediate Results Indicators Component: Component 1: Community-based agriculture and health service delivery to promote cultivation and consumption of nutrient-rich foods Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Children 0-24 months Number 0.00 8000.00 8000.00 14305.00 participating in monthly growth monitoring and 25-Sep-2013 01-Jun-2017 01-Jun-2018 30-May-2018 Page 24 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) promotion sessions Comments (achievements against targets): Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Adolescent girls participating in Number 0.00 960.00 960.00 5284.00 education sessions 25-Sep-2013 01-Jun-2017 01-Jun-2018 30-May-2018 Comments (achievements against targets): Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Community-based agriculture Number 0.00 80.00 120.00 120.00 promoters trained 25-Sep-2013 01-Jun-2017 01-Jun-2018 30-May-2018 Comments (achievements against targets): From ISR No. 1 to No. 5, the original target was 80, and it had been met by ISR No. 3. Starting in ISR No. 6 a revised end target value of 120 starts to be reported. Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Community based health Number 0.00 160.00 160.00 160.00 promoters trained 25-Sep-2013 01-Jun-2017 01-Jun-2018 30-May-2018 Page 25 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) Comments (achievements against targets): Achievement as reported in ISR No. 8; Irregularities in reporting were noted for ISRs No. 4 and 5 between actual current and previous values. Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Community-based adolescent Number 0.00 160.00 160.00 160.00 heatlh promoters trained 25-Sep-2013 01-Jun-2017 01-Jun-2018 30-May-2018 Comments (achievements against targets): Achievement as reported in ISR No. 8; Irregularities in reporting were noted for ISRs No. 4 and 5 between actual current and previous values. Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Vine producers trained (1 vine Number 0.00 40.00 43.00 43.00 producer per 4 villages) 25-Sep-2013 01-Jun-2017 01-Jun-2018 30-May-2018 Comments (achievements against targets): Achievement as reported in ISR No. 8; From ISR No. 1 to No. 5, the original target was 40. Starting in ISR No. 6 a revised end target value of 43 starts to be reported; Irregularities in reporting were noted for ISRs No. 4 and 5 between actual current and previous values. Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Marketing agents trained (1 Number 0.00 80.00 20.00 20.00 Page 26 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) marketing agent per 2 villages) 25-Sep-2013 01-Jun-2017 01-Jun-2018 30-May-2018 Comments (achievements against targets): Achievement as reported in ISR No. 8; From ISR No. 1 to No. 5, the original target was 80. Starting in ISR No. 6 a revised end target value of 20 starts to be reported. Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Pregnant women targeted for Number 0.00 500.00 600.00 815.00 conditional nutrient-rich food transfer 25-Sep-2013 01-Jun-2017 01-Jun-2018 30-May-2018 Comments (achievements against targets): Achievement as reported in ISR No. 8; From ISR No. 1 to No. 5, the original target was 500. Starting in ISR No. 6 a revised end target value of 600 starts to be reported. Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Health workers trained on ANC Number 0.00 40.00 40.00 40.00 25-Sep-2013 01-Jun-2017 01-Jun-2018 30-May-2018 Comments (achievements against targets): Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Pregnant/lactating women, Amount(USD) 0.00 34020.00 6400.00 6400.00 Page 27 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) adolescent girls and/or 25-Sep-2013 01-Jun-2017 01-Jun-2018 30-May-2018 children under age five- reached by basic nutrition services (number) Comments (achievements against targets): From ISR No. 1 to No. 5, the original target was 34,020. Starting in ISR No. 6 a revised end target value of 6,400 starts to be reported. Component: Component 2: Introduction of innovative financial products to promote cultivation of nutrient-rich foods Unit of Formally Revised Actual Achieved at Indicator Name Baseline Original Target Measure Target Completion Smallholder farmers trained on Number 0.00 900.00 900.00 1843.00 financial products 25-Sep-2013 01-Jun-2017 01-Jun-2018 30-May-2018 Comments (achievements against targets): Page 28 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) B. ORGANIZATION OF THE ASSESSMENT OF THE PDO Objective/Outcome 1 Increased percentage of participating farmers adopting OFSP (%) 1. PDO: Percentage of participating farmers adopting OFSP (%) Outcome Indicators 1. IR4: Community-based agriculture promoters trained 2. IR7: Vine producers trained (1 vine producer per 4 villages) Intermediate Results Indicators 3. IR8: Marketing agents trained (1 marketing agent per 2 villages) 4. IR11: Smallholder farmers trained on financial products 1. A total of 19,208 farmers received input packages (farming tools i.e. hoe, machete and slasher) and refresher training to effectively promote OFSP cultivation. 2. Low-cost tissue laboratory was established, and it produced between 2015 – 2018 around 110,000 cuttings (plantet) for the project 3. A total of 38,416 sacks of vines were distributed to small holder Key Outputs by Component farmers by Community-based Agriculture Promoters (CAPs) as (linked to the achievement of the Objective/Outcome 1) part of input packages.36 4. Input packages were distributed for free at the beginning of each planting season for the first two seasons (one year) from CAPs to smallholder farmers, after which they were available for purchase from CAPs. Input packages contained planting material for OFSP and other nutrient-rich crops, such as iron-rich beans, tomatoes, carrots, pumpkins, eggplants, and groundnuts. Technical assistance on improved farming practices (making and utilizing 36 Project beneficiaries received free vines for all three years of the project (Project Implementation Completion Report, BRAC Uganda, June 2018). Page 29 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) organic fertilizer, minimizing post-harvest losses, etc.) continued throughout the three-year project duration through community fora. 5. A total of 120 CAPs were recruited and trained (IR 4) for the project duration; 30 CAPs for each District, with each CAP responsible for one to two villages. CAPs set up 120 demonstration gardens to facilitate technology transfer to smallholder farmers. 6. Twenty (20) community Marketing Agents (MAs) (five per branch) were selected and trained to provide technical and operational assistance to smallholder farmers in market development (post- harvest handling, improved access to transportation of crops to larger markets etc.). 7. A total of 1,843 farmers were trained on financial products to promote cultivation of OFSP. 8. An ICT-enabled platform available on Android phones became available for project beneficiaries to enable them to receive real- time information about management of crop diseases, and real- time market information on prices, markets. Objective/Outcome 2 Increased percentage of children 0-23 months with minimum dietary diversity (%) 1. PDO: Percentage of children 0-23 months with minimum dietary Outcome Indicators diversity (%) 1. IR1: Pregnant/ lactating women, adolescent girls and/ or children under age five reached by basic nutrition services 2. IR 2: Children 0 – 24 months participating in monthly GMP Intermediate Results Indicators 3. IR 3: Adolescent girls participating in education sessions 4. IR5: Community-based health promoters trained 5. IR 6: Community-based adolescent health promoters trained 6. IR 10: Health workers trained on ANC Page 30 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) 1. A total of 6,400 pregnant/ lactating women, adolescent girls and/ or children under age five reached by basic nutrition services. 2. The project trained 160 Community Health Promoters (CHPs), and supported them also with refresher training on health and nutrition to address the capacity gaps identified through operational research (conducted in May and June 2015). 3. Monthly growth monitoring and promotion (GMP) services were provided to a total of 14,305 children under two years of age. 4. Moreover, the project contributed to improved nutritional outcomes by using the GMP sessions as an opportunity to also register and follow severe malnourished cases of children. A referral system for severely malnourished cases was established in order to receive in-patient therapeutic care in public health care facilities in order to promote linkages with the national health Key Outputs by Component system. The project even procured ready-to-use-therapeutic food (linked to the achievement of the Objective/Outcome 2) (RUTF) for outpatient management of acute malnutrition through supplementary feeding. The RUTF was distributed to severely acutely malnourished children as well as the moderately acutely malnourished to enable them to achieve catch up growth as well as maintain healthy weight. The distribution was supervised by health workers. Relatedly health workers from those facilities were provided initial and refresher training to build their capacity to address cases of severe acute malnutrition. They were also given inputs such as stethoscope, fetoscope, BP machine, MUAC tape, as well as height boards. 5. CHPs regularly informed the community on the well-established benefits of antenatal care (ANC) for the pregnant woman and her unborn child, they referred women to ANC, and built knowledge on adequate maternal nutrition. 6. Forty (40) health workers were trained on ANC. Page 31 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) 7. CHPs would in turn identify, mobilize and supervise Community- based Adolescent Health (AHPs), adolescent girls, in each community to hold monthly peer education sessions on nutrition and health. The project trained 160 AHPs, and supported them also with refresher training on health and nutrition to address the capacity gaps identified through operational research (conducted in May and June 2015). 8. Peer sessions to promote adolescent health seeking behaviors included discussions on sexual and reproductive health issues, coping with adolescence, prevention of early pregnancies, as well as engage in board and outdoor games to build their physical and mental health. A total of 5,284 adolescent girls participated in these reproductive health and nutrition education sessions. Objective/Outcome 3 increased percentage of infants 0–5 months exclusively breast-fed (%) Outcome Indicators 1. PDO: Percentage of infants 0–5 months exclusively breast-fed (%) 1. IR1: Pregnant/ lactating women, adolescent girls and/ or children under age five reached by basic nutrition services 2. IR2: Children 0-24 months participating in monthly growth monitoring and promotion sessions 3. IR3: Adolescent girls participating in education sessions Intermediate Results Indicators 4. IR5: Community-based health promoters trained 5. IR 6: Community-based adolescent health promoters trained 6. IR9: Pregnant women targeted for conditional nutrient-rich food transfer 7. IR10: Health workers trained on ANC Key Outputs by Component 1. A total of 6,400 pregnant/ lactating women, adolescent girls and/ (linked to the achievement of the Objective/Outcome 2) or children under age five reached by basic nutrition services. Page 32 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) 2. The project trained 160 Community Health Promoters (CHPs), and supported them also with refresher training on health and nutrition to address the capacity gaps identified through operational research (conducted in May and June 2015). 3. Monthly growth monitoring and promotion (GMP) services were provided to a total of 14,305 children under two years of age. 4. Moreover, the project contributed to improved nutritional outcomes by using the GMP sessions as an opportunity to also register and follow severe malnourished cases of children. A referral system for severely malnourished cases was established in order to receive in-patient therapeutic care in public health care facilities in order to promote linkages with the national health system. The project even procured ready-to-use-therapeutic food (RUTF) for outpatient management of acute malnutrition through supplementary feeding. The RUTF was distributed to severely acutely malnourished children as well as the moderately acutely malnourished to enable them to achieve catch up growth as well as maintain healthy weight. The distribution was supervised by health workers. Relatedly health workers from those facilities were provided initial and refresher training to build their capacity to address cases of severe acute malnutrition. They were also given inputs such as stethoscope, fetoscope, BP machine, MUAC tape, as well as height boards. 5. CHPs regularly informed the community on the well-established benefits of antenatal care (ANC) for the pregnant woman and her unborn child, they referred women to ANC, and built knowledge on adequate maternal nutrition. 6. Forty (40) health workers were trained on ANC. 7. Nutrient-rich food transfers (including 10 kgs of OFSP and 1 kg of porridge) were provided as an incentive for uptake of ANC services, and were conditional on four such visits, as per WHO Page 33 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) recommendation for uncomplicated pregnancies. ANC provides an opportunity to identify risky conditions early on, and has been shown to have a positive impact on the use of postnatal health care services. A total of 815 pregnant women targeted for conditional nutrient-rich food transfer. 8. CHPs would in turn identify, mobilize and supervise Community- based Adolescent Health (AHPs), adolescent girls, in each community to hold monthly peer education sessions on nutrition and health. The project trained 160 AHPs, and supported them also with refresher training on health and nutrition to address the capacity gaps identified through operational research (conducted in May and June 2015). 9. Peer sessions to promote adolescent health seeking behaviors included discussions on sexual and reproductive health issues, coping with adolescence, prevention of early pregnancies, as well as engage in board and outdoor games to build their physical and mental health. A total of 5,284 adolescent girls participated in these reproductive health and nutrition education sessions. 10. 6,400 beneficiaries participated in quarterly health and nutrition fora. Page 34 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) . ANNEX 2. PROJECT COST BY COMPONENT Amount at Approval Actual at Project Percentage of Approval Components (US$M) Closing (US$M) (US$M) Component 1: Community- based agriculture and health service delivery to promote 2,215,016 2,198,687 99% cultivation and consumption of nutrient-rich crops Component 2: Introduction of innovative financial products to promote 94,500 61,749 65% cultivation of nutrient-rich foods Component 3: Monitoring and Evaluation and 258,000 281,089 108% Knowledge Dissemination Component 4: Project Management and 232,200 225,096 97% Administration Total 2,799,516.00 2,766,621.00 99% Page 35 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) ANNEX 3. RECIPIENT, CO-FINANCIER AND OTHER PARTNER/STAKEHOLDER COMMENTS [ICRR is submitted for comments to recipient after Decision Review meeting] Page 36 of 38 The World Bank An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition (P143324) ANNEX 4. SUPPORTING DOCUMENTS (IF ANY) (a) World Bank Documents • Bank Guidance on ICR for IPF Operations issued on July 5, 2017. • Grant Agreement and Project Agreement (Grant No. TF-014232) dated June 6, 2013 • Grant Funding Proposal dated November 2011. • Aide-Memoires (December 2013, June 2015, November 2015, November 2016, October 2017, March 2018) • Implementation Status Reports (ISRs) No. 1 – No. 8 • Restructuring Paper dated 17 February 2017. • Post-Procurement Review Reports FY17-18. April 2018. • Uganda - Country Assistance strategy for the period FY2011-2015. (b) Project Documents • Project Operations Manual. April 2013. BRAC Uganda. • FM Supervision Report. Joint World Bank and BRAC. November 2017. • Mpiira, R. “Fortified Crops: The Relevance of ICT, CAPs and CHPs in Food Security, Nutrition and Income Generation�. BRAC Independent Evaluation and Research Cell. • “Concept Note: An Innovative, Integrated Approach to Enhance Smallholder Family Nutrition Impact Evaluation.� Prepared by World Bank Gender Innovation Lab and BRAC Uganda. • Project Implementation Completion Report. June 2018. BRAC Uganda. • Olobo Okello, P., and Prabhakar, P. Endline Impact Evaluation Report. November 2018. BRAC and Gender Innovation Lab. • “Voucher System for OFSP (Kipapaali) Porridge Flour.� January 2018. BRAC Uganda, JSDF Project. • Mpiira, R. “Financial Production Innovation for Agricultural Technology Adoption.� April – June 2016 Progress Report. • Midline Report. May 2017. BRAC Uganda. • Baseline Report. April 2015. BRAC Uganda. • Mid Term Review. June 2015. BRAC Uganda. • Quarterly Progress Reports 2014 - 2018. • Module Training Sets. BRAC Uganda. • CHPs Flipbook. BRAC Uganda. • CAPs Flipbook. BRAC Uganda. (c) Other Documents • Fishman, R., Smith, S., Bobic, V., and Sulaiman, M. “How Sustainable are Benefits from Extension for Smallholder Farmers? Evidence from a Randomized Phase-Out of the BRAC Program in Uganda.� March 2017. Discussion Paper Series No, 10641. IZA Institute of Labor Economics. • Uganda Nutrition Action Plan (UNAP) 2011 – 2016. • Thompson, B., and L. Amoroso (eds.). 2011. “Combatting Micronutrient Deficiencies: Food-based Approaches.� FAO and CABI. • Msefula D. “How can growth monitoring and special care of underweight children be improved in Zambia.� 1993. Trop Doct 23:107–12. • Nabarro D, and Chinnock P. “Growth monitoring–inappropriate promotion of an appropriate technology.� 1993. Soc Sci Med. 26:941–8. • HarvestPlus material on OFSP (links provided in the main text). Page 37 of 38