A Decade of World Bank Support to Senegal’s Nutrition Program Denise Vaillancourt ANALYSIS & PERSPECTIVE: 15 YEARS OF EXPERIENCE IN THE DEVELOPMENT OF NUTRITION POLICY IN SENEGAL A Decade of World Bank Support to Senegal’s Nutrition Program December 2016 Denise Vaillancourt Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal © 2016 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202–473–1000 Internet: www.worldbank.org Attribution—Please cite the work as follows: World Bank. 2016. Project Performance Assess- ment Report : Une décennie de soutien de la Banque mondiale au programme de nutrition du Sénégal. Washington, DC : World Bank. This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. Because The World Bank encourages dissem- ination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202–522–2625; e-mail: pubrights@worldbank.org. Cover photo: Adama Cissé/CLM Cover design: The Word Express, Inc. Acknowledgments P rofound thanks go to Mr. Abdoulaye Ka, National Coordinator, for embracing this evalu- ation, right from its design stage, as an opportunity for candid discussion, learning and improved Program effectiveness. His leadership and inspiration rallied the active support and invaluable contributions of the Cellule de Lutte contre la Malnutrition (CLM), whose members represent a range of sectors, and of staff of the National Executive Bureau (BEN) and Regional Executive Bureaus (BER) responsible for Program oversight, coordination, monitoring and eval- uation. Among these CLM members and Program staff, all named in Appendix E, special mention is given to Mr. El Hadji Momar Thiam for making available reports, studies and data—both quali- tative and quantitative—reflecting both the rigor and transparency of the Program’s management and continual improvement. This evaluation exercise was deeply enriched with the lessons and perspectives of a broad range of stakeholders in the several regions visited: administrative authorities; local authorities; local level actors in charge of implementing various facets of the Program (nurses, technicians in charge of agriculture, livestock, water and education services); civil society actors linking sector services to the communities; community, religious and traditional leaders who guided, oversaw and rallied the population around Program activities; the community nutrition workers, who de- livered the critical services; and the beneficiaries: mothers and other care givers of vulnerable children. IEG deeply appreciates the time they took to contribute to the evaluation and the value of their inputs. The quality of these exchanges was a direct result of the talents and passion of Ama- dou Hassane Sylla, Senegalese consultant, who understood their importance to the evaluation. IEG also acknowledges the support of Menno Mulder-Sibanda, World Bank Task Team Leader for Senegal Nutrition, who also welcomed the evaluation as an opportunity for improving Program effectiveness. Indeed, it was he who included this evaluation as part of this series of analytical studies, discussed and vetted with the CLM, which contributed to Senegal’s new Nutrition Policy and to strengthening the investment case for nutrition. Finally, sincere thanks are extended to Susan Caceres, IEG’s Task Team Leader, who oversaw this evaluation process and provided insightful guidance on the analysis of the service deliv- ery aspects of the Program. With the strong support of her managers, Auguste Tano Kouame, Director, Human Development and Economic Management/IEG, and Marie Gaarder, (former) Manager, Human Development and Corporate Evaluations/IEG, Susan secured funding under IEG’s Learning Engagement budget. This funding made it possible for a return visit to Senegal to share and discuss the evaluation findings and lessons with the full range of stakeholders and for their global dissemination. About the Series T he government of Senegal, through the Cellule de Lutte contre la Malnutrition (Nutrition Coordination Unit) (CLM) in the Prime Minister’s Office is embarking on the development of a new Plan Stratégique Multisectoriel de Nutrition (Multisectoral Strategic Nutrition Plan) (PSMN), which will have two broad focus areas: (1) expanding and improving nutrition ser- vices; and (2) a reform agenda for the sector. The reform agenda will include policy reorientation, governance, and financing of the PSMN. The PSMN will discuss the framework and timeline for the development of a nutrition financing strategy, which will require specific analysis of the sector spending and financial basis, linking it to the coverage and quality of nutrition services. Senegal is known for having one of the most effective and far-reaching nutrition service delivery systems in Africa. Chronic malnutrition has dropped to less than 20 percent, one of the lowest in continental Sub-Saharan Africa. Government ownership of the nutrition program has grown from US$0.3 million a year in 2002 to US$5.7 million a year in 2015, increasing from approximate- ly 0.02% to 0.12% of the national budget. Yet, these developments have not led to enhanced visibility of nutrition-sensitive interventions in relevant sectors such as agriculture, education, water and sanitation, social protection, and health. The absence of nutrition-sensitive interven- tions in the relevant sectors, combined with the recent series of external shocks, has favored continued fragmentation of approaches, discourse, and interventions that address nutrition. In addition, there is no overall framework for investment decision making around nutrition, which puts achievements made to date in jeopardy. Meanwhile, nutrition indicators are stagnating and other issues with major implications (such as low birth weight, iron deficiency anemia, maternal undernutrition, and acute malnutrition) have received little or no attention. A review of policy effectiveness can help raise the importance of these issues, including house- hold and community resilience to food and nutrition insecurity shocks, as a new priority in nutrition policy development. This series of analytical and advisory activities, collectively entitled Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal (“the se- ries”), aims to support the government of Senegal in providing policy and strategic leadership for nutrition. Further, the series will inform an investment case for nutrition (The Case for Investment in Nutrition in Senegal) that will: (1) rationalize the use of resources for cost-effective interven- tions; (2) mobilize actors and resources; (3) strengthen the visibility of nutrition interventions in different sectors; and (4) favor synergy of interventions and investments. The series was produced with guidance from a task force of development partner organizations under the leadership of the World Bank, and in close collaboration with the CLM. The task force comprised representatives from the following organizations: Government of Canada, REACH, UNICEF and the World Bank. About this Report IEG Mission: Improving World Bank Group development results through excellence in independent evaluation The Independent Evaluation Group (IEG) assesses the programs and activities of the World Bank for two purposes: first, to ensure the integrity of the World Bank’s self-evaluation pro- cess and to verify that the World Bank’s work is producing the expected results, and second, to help develop improved directions, policies, and procedures through the dissemination of lessons drawn from experience. As part of this work, IEG annually assesses 20–25 percent of the World Bank’s lending operations through fieldwork. In selecting operations for assessment, preference is given to those that are innovative, large, or complex; those that are relevant to upcoming stud- ies or country evaluations; those for which Executive Directors or World Bank management have requested assessments; and those that are likely to generate important lessons. To prepare a Project Performance Assessment Report (PPAR), IEG staff examine project files and other documents, visit the borrowing country to discuss the operation with the government, and other in-country stakeholders, interview World Bank staff and other donor agency staff both at headquarters and in local offices as appropriate, and apply other evaluative methods as needed. Each PPAR is subject to technical peer review, internal IEG panel review, and management approval. Once cleared internally, the PPAR is commented on by the responsible World Bank country management unit. The PPAR is also sent to the borrower for review. IEG incorporates both World Bank and borrower comments as appropriate, and the borrowers’ comments are at- tached to the document that is sent to the World Bank’s Board of Executive Directors. After an assessment report has been sent to the Board, it is disclosed to the public. About the IEG Rating System for Public Sector Evaluations IEG’s use of multiple evaluation methods offers both rigor and a necessary level of flexibility to adapt to lending instrument, project design, or sectoral approach. IEG evaluators all apply the same basic method to arrive at their project ratings. Following is the definition and rating scale used for each evaluation criterion (additional information is available on the IEG website: http:// ieg.worldbankgroup.org). Outcome: The extent to which the operation’s major relevant objectives were achieved, or are expected to be achieved, efficiently. The rating has three dimensions: relevance, efficacy, and efficiency. Relevance includes relevance of objectives and relevance of design. Relevance of objectives is the extent to which the project’s objectives are consistent with the country’s current development priorities and with current World Bank country and sectoral assistance strate- gies and corporate goals (expressed in poverty reduction strategy papers, Country Assistance Strategies (CAS), sector strategy papers, and operational policies). Relevance of design is the extent to which the project’s design is consistent with the stated objectives. Efficacy is the ex- tent to which the project’s objectives were achieved, or are expected to be achieved, taking into account their relative importance. Efficiency is the extent to which the project achieved, or is expected to achieve, a return higher than the opportunity cost of capital and benefits at least cost compared with alternatives. The efficiency dimension is not applied to development policy operations, which provide general budget support. Possible ratings for Outcome: Highly Satis- factory, Satisfactory, Moderately Satisfactory, Moderately Unsatisfactory, Unsatisfactory, Highly Unsatisfactory. Risk to Development Outcome: The risk, at the time of evaluation, that development outcomes (or expected outcomes) will not be maintained (or realized). Possible ratings for Risk to Develop- ment Outcome: High, Significant, Moderate, Negligible to Low, and Not Evaluable. Bank Performance: The extent to which services provided by the World Bank ensured quality at entry of the operation and supported effective implementation through appropriate supervision (including ensuring adequate transition arrangements for regular operation of supported activi- ties after loan or credit closing, toward the achievement of development outcomes). The rating has two dimensions: quality at entry and quality of supervision. Possible Ratings for Bank Per- formance: Highly Satisfactory, Satisfactory, Moderately Satisfactory, Moderately Unsatisfactory, Unsatisfactory, and Highly Unsatisfactory. Borrower Performance: The extent to which the borrower (including the government and imple- menting agency or agencies) ensured quality of preparation and implementation, and complied with covenants and agreements, toward the achievement of development outcomes. The rat- ing has two dimensions: government performance and implementing agency(ies) performance. Possible ratings for Borrower Performance: Highly Satisfactory, Satisfactory, Moderately Satis- factory, Moderately Unsatisfactory, Unsatisfactory, and Highly Unsatisfactory. vi A Decade of World Bank Support to Senegal’s Nutrition Program Report No.: 110290 Project Performance Assessment Report Senegal Nutrition Enhancement Program (IDA Credit No. 36190) Nutrition Enhancement Project in Support of the Second Phase of the Nutrition Enhancement Program (IDA Credit No. 42450) Additional Financing for the Second Phase of the Nutrition Enhancement Program (IDA Credit No. 50840) Rapid Response Child-Focused Social Cash Transfer and Nutrition Security Project (IDA Credit No. 46050) & Multidonor Trust Fund for the Global Food Price Crisis Response Program (TF 94372) December 21, 2016 Human Development and Economic Management Independent Evaluation Group A Decade of World Bank Support to Senegal’s Nutrition Program vii Currency Equivalents (Annual Averages) Currency Unit = CFA Franc (CFAF) 2002 US$1.00 CFAF 664.54 2003 US$1.00 CFAF 628.93 2004 US$1.00 CFAF 551.27 2005 US$1.00 CFAF 516.19 2006 US$1.00 CFAF 539.44 2007 US$1.00 CFAF 503.03 2008 US$1.00 CFAF 447.77 2009 US$1.00 CFAF 479.02 2010 US$1.00 CFAF 473.00 2011 US$1.00 CFAF 481.81 2012 US$1.00 CFAF 490.53 2013 US$1.00 CFAF 507.49 2014 US$1.00 CFAF 483.60 2015 US$1.00 CFAF 500.67 Fiscal Year Government: January 1–December 31 Director-General, Independent Evaluation Ms. Caroline Heider Director, Human Development and Economic Management Mr. Zeljko Bogetic (Acting) Manager, Corporate and Human Development Mr. Rasmus Heltberg (Acting) Task Manager Ms. Susan A. Caceres Acronyms Acronym English Acronyme Français APL Adaptable Program Loan PPE Prêt-Programme évolutif BEN National Executive Bureau BEN Bureau exécutif national BER Regional Executive Bureau BER Bureau exécutif régional CAS Country Assistance Strategy SAP Stratégie d’Aide-Pays CEA Community Executing Agency AEC Agence d’exécution communautaire CLM Nutrition Coordination Unit CLM Cellule de Lutte contre la Malnutrition CNP Community Nutrition Project PNC Projet de Nutrition communautaire CPS Country Partnership Strategy SPP Stratégie de Partenariat-Pays DHS Demographic and Health EDS Enquête démographique et de Survey santé HNP Health, Nutrition, and SNP Santé, Nutrition et Population Population ICR Implementation Completion and ICR Rapport sur l’état Results Report d’avancement et les résultats de projet IDA International Development IDA Association internationale de Association Développement IEG Independent Evaluation Group IEG Groupe d’évaluation indépendant IMCI Integrated Management of PCIME Prise en Charge intégrée des Childhood Illness Maladies de l’Enfance KPC Knowledge, Practice, Coverage CPC Connaissances, Pratiques, Couverture LQAS lot quantity assurance sampling LQAS Enquête par échantillonnage par lots pour l’assurance de la qualité NEP Nutrition Enhancement Program PRN Programme de Renforcement de la nutrition NGO nongovernmental organization ONG Organisation non gouvernementale PAD Project Appraisal Document DEP Document d’évaluation du projet Acronym English Acronyme Français PDO project development objective ODP Objectif de développement du projet PPAR Project Performance RERP Rapport d’évaluation Assessment Report rétrospective du projet PRSP Poverty Reduction Strategy DSRP Document de stratégie pour la Paper réduction de la pauvreté REACH Renewed Efforts Against Child REACH Efforts renouvelés contre la Hunger and undernutrition faim et la sous-alimentation SDR special drawing rights DTS Droits de tirage spéciaux SMART Standardized Monitoring and SMART Enquête normalisée de suivi Assessment of Relief and et d’évaluation des secours et Transitions de la transition UNICEF United Nations Children’s Fund UNICEF Fonds des Nations Unies pour l’Enfance USAID U.S. Agency for International USAID Agence américaine pour le Development Développement International WFP World Food Programme PAM Programme alimentaire mondial WHO World Health Organization OMS Organisation mondiale de la Santé Contents Preface xiii Executive Summary 1 Background and Context 7 Nutrition Enhancement Program 11 Nutrition Enhancement Project in Support of the Second Phase of the NEP (NEP II) 27 Rapid Response Child-Focused Social Cash Transfer and Nutrition Security Project 41 A Decade of Support in Perspective 51 Lessons 57 Appendix A: Data Sheet 59 Appendix B: National Nutrition Policies and World Bank’s Nutrition Portfolio 65 Appendix C: Costs, Financing, and Disbursements* 69 Appendix D: Statistical Data and Results 75 Appendix E: List of Persons Met 91 Endnotes 95 References 101 List of Boxes Box 2.1: Key Performance Indicators for 10-Year APL and Each of Its Phases 13 Box 2.2: NEP Phase I Components 15 Box 3.1: NEP Phase II Components: Original and Revised 29 Box 4.1: Key Performance Indicators for Rapid Response Child-Focused Social Cash Transfer and Nutrition Security Project 41 Box 4.2: Rapid Response Child-Focused Social Cash Transfer and Nutrition Security 43 Box 5.1: Service Delivery Features of the NEP 53 Box B.1: Government of Senegal Letter of Nutrition Development Policy 65 Box B.2: Republic of Senegal’s National Development Policy for Nutrition (2015–25) 66 List of Figures Figure D.1: Prevalence of Underweight in Children under Age Five Years (Weight for Age) 86 Figure D.2: Prevalence of Stunting in Children under Age Five Years (Height for Age) 86 Figure D.3: Prevalence of Wasting in Children under Age Five Years (Weight for Height) 87 List of Tables Table 3.1: Key Performance Indicators for NEP II: Original and Revised 27 Table A.1: Key Project Data 59 Table A.2: Cumulative Disbursements Estimated and Actual 59 Table A.3: Key Project Dates 59 Table A.4: Task Team Members, World Bank 60 Table A.5: Staff Time Budget and Cost for World Bank 60 Table A.6: Key Project Data 61 Table A.7: Cumulative Disbursements Estimated and Actual 61 Table A.8: Key Project Dates 61 Table A.9: Task Team Members 62 Table A.10: Staff Time Budget and Cost for World Bank 62 Table A.11: Key Project Data 63 Table A.13: Key Project Dates 63 Table A.14: Task Team members 63 Table Cumulative Disbursements Estimated and Actual A.12:  63 Table A.15: Staff Time Budget and Cost for World Bank 64 Table B.1: Timeline of Approval and Closing Dates of Nutrition Interventions in Senegal 67 Table C.1: NEP I: Planned versus Actual Costs by Project Component 69 Table C.2: NEP I: Planned versus Actual FinancingUS$ million equivalent 69 Table C.3: NEP I: Planned versus Actual Disbursements by Disbursement Category SDR, thousands 70 Table C.4: NEP II: Planned versus Actual Costs by Project Component 70 Table C.5: NEP II: Planned versus Actual Financing of Project 70 Table C.6: NEP II: Planned versus Actual Disbursements by Category SDR, thousands 71 Table C.7: Rapid Response: Planned versus Actual Costs by Project Component 71 Table C.8: Rapid Response: Planned versus Actual Financing of Project 71 Table C.9: Rapid Response: Planned versus Actual Disbursements of IDA Credit by Disbursement Category 72 Table Planned versus Actual Disbursements of Multidonor Trust Fund by Disbursement C.10:  Category 72 Table C.11: Planned versus Actual World Bank Support for 10-Year APL 72 Table Program-Wide Financing, 2004–15 CFAF, billions C.12:  73 Table Program-Wide Expenditures, 2004–15 CFAF, billions C.13:  73 Table D.1: First Nutrition Enhancement Project: Results Framework/Achievement of Objectives 75 Table D.2: First Nutrition Enhancement Project: Triggers for moving from Phase I to Phase II 78 Table D.3: Nutrition Enhancement Project Phase II: Results Framework and Achievement of Objectives 79 Table D.4: Rapid Response Child-Focused Social Cash Transfer and Nutrition Security Project: Results Framework and Achievement of Objectives 84 Table D.5: NEP II Targets 87 Table D.6: Population under Age Five, 2002–16 88 Table D.7: Program Coverage by Local Collectivity 88 Table D.8: Coverage of Key Interventions by Department and by Target Group 89 Principal Ratings NUTRITION ENHANCEMENT PROGRAM ICR ICR Review PPAR Outcome Highly Satisfactory Satisfactory Highly Satisfactory Risk to Development Negligible to Low Moderate Moderate Outcome World Bank Performance Satisfactory Highly Satisfactory Highly Satisfactory Borrower Performance Highly Satisfactory Highly Satisfactory Highly Satisfactory NUTRITION ENHANCEMENT PROJECT IN SUPPORT OF THE SECOND PHASE OF THE NUTRITION ENHANCEMENT PROGRAM ICR ICR Review PPAR Outcome Satisfactory Satisfactory Satisfactory Risk to Development Moderate Significant Significant Outcome World Bank Performance Satisfactory Satisfactory Satisfactory Borrower Performance Satisfactory Satisfactory Satisfactory RAPID RESPONSE CHILD-FOCUSED SOCIAL CASH TRANSFER AND NUTRITION SECURITY PROJECT ICR ICR Review PPAR Outcome Highly Satisfactory Satisfactory Highly Satisfactory Risk to Development Moderate Moderate Significant Outcome World Bank Performance Satisfactory Satisfactory Satisfactory Borrower Performance Satisfactory Satisfactory Satisfactory Note: The Implementation Completion and Results Report (ICR) is a self-evaluation by the responsible global practice. The ICR Review is an intermediate IEG product that seeks to independently validate the findings of the ICR. Key Staff Responsible NUTRITION ENHANCEMENT PROGRAM Project Task Manager/‌Leader Division Chief/Sector Director Country Director Appraisal Claudia Rokx Alexandre Abrantes John McIntire Completion Menno Mulder-Sibanda Eva Jarawan Madani Tall NUTRITION ENHANCEMENT PROJECT IN SUPPORT OF PHASE II OF THE NUTRITION ENHANCEMENT PROGRAM Project Task Manager/‌Leader Division Chief/Sector Director Country Director Appraisal Menno Mulder-Sibanda Eva Jarawan Madani Tall Completion Menno Mulder-Sibanda Trina Haque Vera Songwe RAPID RESPONSE CHILD-FOCUSED SOCIAL CASH TRANSFER AND NUTRITION SECURITY PROJECT Project Task Manager/‌Leader Division Chief/Sector Director Country Director Appraisal Menno Mulder-Sibanda Eva Jarawan Habib Fetini Completion Menno Mulder-Sibanda Trina Haque Vera Songwe Preface T his is the PPAR for the Nutrition Enhancement on November 13, 2006, and became effective on Jan- Program (NEP), the Nutrition Enhancement uary 29, 2007. Government counterpart financing was Project in Support of the Second Phase of planned in the amount of US$16.3 million equivalent the Nutrition Enhancement Program, and the Rapid and an additional US$11.1 million was envisaged from Response Child-Focused Social Cash Transfer and other sources.2 Additional financing for this project in Nutrition Security Project. the amount of SDR 6.5 million (US$10 million equiv- alent) was approved by the World Bank on March 29, A credit (IDA-3619) to support the first phase of the 2012, and became effective on May 23, 2012. The NEP was approved on March 14, 2002, in the amount original credit and the additional financing both closed of special drawing rights (SDR) 11.8 million (US$14.7 on June 14, 2014, and were fully disbursed. million equivalent).1 Government counterpart financ- ing in the amount of US$1.5 million equivalent was A credit of SDR 6.8 million (US$10 million equivalent) planned, along with parallel financing from the World was approved on May 6, 2009, to finance the Rapid Food Programme (WFP) of US$4 million equivalent. Response Child-Focused Social Cash Transfer and The credit became effective on June 27, 2002, and Nutrition Security Project and became effective on closed on July 15, 2006, six months after the original September 11, 2009. A Global Food Crisis Response closing date. The total cost at closing was US$19.1 Program multidonor trust fund grant (TF 94372) of million equivalent. The credit amount disbursed was US$8 million equivalent provided cofinancing to the SDR 11.4 million: 96 percent of the original credit project. No government counterpart was envisaged. amount and 100 percent of the revised credit amount The credit was closed on August 31, 2012, and was after SDR 0.4 million was canceled. 100 percent disbursed. The Trust Fund was also closed on August 31, 2012; 99 percent of its original An SDR 10.1 million (US$15 million equivalent) credit value was disbursed and US$97,218 was canceled. for the NEP in Support of the Second Phase of the Nutrition Enhancement Program (Second Nutrition En- This report is based on a review of project docu- hancement Project) was approved by the World Bank ments; the ICRs on each project; aide-mémoires and A Decade of World Bank Support to Senegal’s Nutrition Program xv supervision reports; and other relevant material, data, information and expresses its gratitude to the World and studies. A mission to Senegal was undertaken by Bank’s office in Dakar for the logistical and administra- Denise Anne Vaillancourt, international consultant, tive support provided to the mission. A list of persons and Amadou Hassane Sylla, Senegalese consultant, met is provided in appendix E. in April 2016, during which interviews were conducted with government officials and technical staff, service This report serves an accountability purpose by evalu- delivery personnel, local government authorities, civil ating the extent to which the operations achieved their society organizations, beneficiaries, relevant develop- intended outcomes. It also seeks to draw lessons to in- ment partners and other involved persons. The team form and guide future investments in the health and social visited relevant offices, facilities, and communities in protection sectors. This assessment also complements, Dahra, Sagatta Djoloff, Sagatta-Affe, Darou Mousty respectively, the ICR Reports, prepared by the World (Region of Louga); Guinguineo, Gagnick Tibou (Re- Bank’s operations teams with borrower contributions, gion of Kaolack); and Mbar and Mbam Djigane (Region and IEG’s desk review (ICR Reviews) of these reports, by of Fatick), chosen in consultation with the government providing an independent, field-based assessment some and the World Bank’s team. The beneficiary per- two years after the last of these projects’ closings. spective was enhanced by beneficiary assessments commissioned by the program. Interviews were also Following standard IEG procedures, a copy of the conducted in Washington, D.C, with additional relevant draft report was sent to the relevant government offi- staff. The IEG gratefully acknowledges all those who cials and agencies for their review and feedback. No made time for interviews and provided documents and comments were received. Executive Summary T his report assesses the performance of three In 2001, the government of Senegal issued a new projects: (1) the NEP, (2) the Nutrition Enhance- nutrition policy, supporting a 10-year goal to improve ment Project in Support of the Second Phase of nutrition through a community-based, multisectoral the NEP, and (3) the Rapid Response Child-Focused approach. The policy was translated into the 10-year Social Cash Transfer and Nutrition Security Project. NEP, financed by the government of Senegal, the World Bank, and eventually others. The government At the start of the new millennium, malnutrition in Sen- of Senegal also created the Cellule de Lutte contre egal was of great concern. Among children under five la Malnutrition (Nutrition Coordination Unit) (CLM), at- years of age almost one-third (30 percent) were stunt- tached to the prime minister’s office, responsible for ed (low height for age), 10 percent were wasted (low policy oversight and evaluation. weight for height), and 20 percent were underweight (weight for age), each of these levels categorized as high severity by the World Health Organization (WHO). Nutrition Enhancement Program Rates vary greatly, with the poor and rural, and resi- dents of the north, south and central zones, suffering This project was designed as the first of three planned disproportionately. Malnutrition contributes to child World Bank operations, packaged as a 10-year and maternal mortality and morbidity, undermines Adaptable Program Loan (APL) to support NEP imple- children’s prospects of reaching their physical and mentation. Its objectives were to assist the Borrower intellectual potential, and undercuts income-earning in building the institutional and organizational capac- potential for households and overall productivity and ity required to enable the Borrower’s CLM and its economic development. Its two principal causes are partners in the public and private sectors to develop, inadequate food intake and illness. Underlying factors implement and monitor multisectoral nutrition activities are poverty; inadequate access to quality food; inade- in both rural and urban areas. It supported two com- quate knowledge and behaviors favoring the health of ponents: (1) community-based nutrition and growth mothers and children; and inadequate services, espe- promotion (growth monitoring and promotion, health cially health, clean water, and sanitation. and nutrition education, integrated management of A Decade of World Bank Support to Senegal’s Nutrition Program 1 childhood illness, basic health services provision and political, institutional, and government ownership. promotion, micronutrients, and grants for community But financial risk is high. The government of Senegal projects); and (2) capacity building for program man- has substantially increased its financial contribution agement (technical assistance, training, and health to the NEP since project closure, but NEP costs and and education sector support). financing need to be better assessed. Moreover, the remuneration of nutrition aides is an emerging issue, The credit became effective on June 27, 2002, and with innovative financing sources and solutions under closed on July 15, 2006. Objectives were not changed, discussion and experimentation. and there were no restructurings. Total project cost was US$19.1 million equivalent or 118 percent of the Overall World Bank performance is rated highly sat- original estimate. isfactory. Quality at entry is highly satisfactory, the APL being an appropriate instrument and the de- The project’s outcome rating is highly satisfactory. Its sign and the institutional arrangements exceptionally objectives are highly relevant to current country condi- strong. Quality of supervision is highly satisfactory, tions, national strategies and priorities and the World with well-staffed missions highly focused on the proj- Bank’s current Country Partnership Strategy (CPS), ect development objective (PDO). as well as its Health, Nutrition and Population (HNP) Strategy. The design is also highly relevant, with clear Overall borrower performance is rated highly and logical results chains supporting the objectives to satisfactory. Government performance is highly sat- build capacity to develop, monitor, and oversee the isfactory, marked by its strong ownership of the NEP, NEP and to build capacity to implement NEP activities. generous counterpart, and the placement of the CLM The objective to build capacity to develop, monitor, in the office of the prime minister. Implementing agen- and oversee multisectoral nutrition activities was high- cy performance was highly satisfactory. The CLM ly achieved. The CLM fully assumed its role of setting was well staffed and recognized for its transparent the policy agenda for nutrition, overseeing its imple- management style. mentation through the NEP, and fostering cooperation across sectors. A solid monitoring and evaluation Nutrition Enhancement Project in Support of the system, with mechanisms and structures for review- Second Phase of the NEP (NEP II) ing data at every level, has fostered a strong results focus, transparency and accountability, and learning The project’s objective was to improve nutritional con- by doing. The objective to build capacity to implement ditions of vulnerable populations, in particular children multisectoral nutrition activities was highly achieved. under five years of age in poor urban and rural areas. Community-based nutrition services were established It was supported by three components: (1) communi- and delivered in the targeted areas exceeding most ty-based nutrition activities; (2) multisectoral support targets. Knowledge and behaviors of target groups for nutrition; and (3) support for implementation, mon- improved significantly in the intervention areas. Nine- itoring and evaluation of the nutrition policy. While ty-one percent of children participating in growth originally envisaged as the second in a series of three promotion sessions in the intervention areas showed projects, packaged as a 10-year APL, the World Bank adequate weight gain, a notable achievement given decided that this would be the last phase of support the 90 percent participation rate. Project efficiency is under the APL. substantial, with highly cost-effective, well-targeted in- terventions culminating in low median costs per child. The International Development Association (IDA) credit became effective on January 29, 2007. Although Risk to development outcome is rated moderate. the objective did not change, additional financing was Most risks are rated low, including technical, social, approved in 2012, adding two years and SDR 6.5 mil- 2 A Decade of World Bank Support to Senegal’s Nutrition Program lion for project implementation. And most targets were support a growing role for local government in line raised. Total project cost was US$25.3 million equiva- with decentralization policy. A shortcoming in an oth- lent or 169 percent of the original estimate. erwise very solid monitoring and evaluation design was the absence of a strong indicator to measure the The project’s outcome rating is satisfactory. The PDO. Quality of supervision is satisfactory. Wide- project’s objective is highly relevant to country con- spread feedback acknowledged the quality of the ditions, Senegal strategic priorities, the World Bank’s World Bank’s technical work and collaboration and its strategies for Senegal, and the World Bank’s sectoral strong support and advocacy. The World Bank also strategies. The relevance of design is high. Its results mobilized development partners to conduct semian- chain is well-articulated and plausible—as strong as nual joint coordination and supervision missions of the one for the first project, with both the original and the NEP and was successful in mobilizing additional additional financing designs further refined based on resources when IDA financing of the 10-year APL fell emerging evidence and lessons. Efficacy is substan- short of original commitments. tial. All outcome targets were surpassed, both the original and the revised ones. Although none of the Overall borrower performance is rated satisfactory. outcome indicators directly measured the objective Government performance is rated satisfactory. The of improved nutritional conditions, they show strong CLM successfully worked with seven prime ministers performance in intervention areas in the coverage since 2001, who are reported to have provided strong of these cost-effective services and changes in be- and unequivocal support, once briefed on the NEP. haviors, which are strongly linked in the literature to The global Scaling Up Nutrition movement cited Peru improved nutritional status. Moreover, very high rates and Senegal for strong government ownership. Coun- of children showing adequate weight gain and suc- terpart financing exceeded plans, although initial years cessful screening and rehabilitation of moderate and experienced a shortfall because of the global econom- severe acute malnutrition cases also provide reas- ic crisis. The implementing agency performance is suring evidence that nutrition status was improved. rated highly satisfactory. The CLM’s inclusive and Efficiency is substantial with evidence of strong value transparent management style continued to be very for money and strong operational and implementation effective in nurturing ownership and partnerships at all efficiency. levels of the program and stimulating a truly multisec- toral approach. Risk to development outcome is significant. As for the first project, technical, social, political, and insti- tutional risks are all assessed to be low. Likewise, Rapid Response Child-Focused Social financial and natural disaster risks are still assessed Cash Transfer and Nutrition Security to be substantial. But more weight has been given to the financial risk at the end of this World Bank project, The objective is to reduce the risk of nutrition inse- given that available national and international financ- curity of vulnerable populations, in particular children ing does not cover needs for full coverage of the NEP. under five in poor rural and urban areas by scaling Creative discussions and experimentation are under up the NEP and providing cash transfers to vulnera- way to find ways and means to provide more adequate ble mothers of children under five. Three components remuneration of nutrition aides. supported NEP implementation: (1) community-based nutrition; (2) sectoral support for nutrition results; Overall World Bank performance is rated satisfacto- (3) support to implementation, monitoring, and eval- ry. Quality at entry is satisfactory. Building on the uation of nutrition development policy. The fourth, first project’s success, the NEP was very well de- Child-Focused Social Cash Transfers, sought to use signed, its sound institutional framework refined to the NEP structure to deliver to eligible beneficiaries A Decade of World Bank Support to Senegal’s Nutrition Program 3 (mothers of young children in vulnerable families in 10 cused cash transfer has proven to be an effective districts) bimonthly cash payments over six months to low-cost means of mitigating vulnerability. Although mitigate the effects of the food price crisis, accompa- social protection is high on Senegal’s policy agenda nied by messages about maternal and child nutrition. and public budget has been allocated to this end, a major challenge is the still limited capacity to manage The IDA credit became effective on September 11, safety net and cash transfer schemes. 2009. Objectives did not change, and there was no restructuring. The credit closed on August 31, 2012, Overall World Bank performance is rated satisfacto- eight months after the original closing date. Total proj- ry. Quality at entry is satisfactory. The World Bank ect cost was US$18.2 million, close to the original proactively pulled together an emergency operation estimate of US$18.0 million. to address nutrition insecurity in Senegal, the design of which built on and expanded the successful NEP. The outcome rating is highly satisfactory. The rele- The new cash transfer mechanism design drew on vance of objective is high, with the PDO well focused extensive knowledge and experience acquired under on addressing immediate issues, as well as building NEP and was highly appropriate for the emergency, resilience for the future. Relevance of design is also pilot nature of this intervention. Quality of supervi- high, as the interventions and approaches drew on sion is highly satisfactory. Supervision continued to best practices as well as lessons learned from pro- be characterized by close collaboration between the gram experience. The cash transfer pilot was well CLM and the World Bank team, a strong results fo- and expeditiously designed as an emergency opera- cus and continuous emphasis on problem-solving and tion, with a very well-developed process and criteria learning. for targeting the most vulnerable and a beneficiary assessment and impact evaluation. The objective Overall borrower performance is rated satisfactory. to reduce nutrition insecurity through the scaling up Government performance is satisfactory. The gov- of the NEP was substantially achieved. Critical be- ernment was and remains committed to the PDO, with haviors changed in the intervention areas, and child child nutrition featured as a major priority in poverty outcomes were good, with 81 percent of children at- alleviation and economic development strategies. tending monthly weighing sessions showing adequate Commitment and involvement are broad, deep, and weight gain—exceeding the 75 percent target. The growing, encompassing a wide range of relevant sec- objective to reduce nutrition insecurity by enhancing tors and local government. The implementing agency the food-buying power of mothers with cash transfers performance is highly satisfactory. The highly satis- was highly achieved. The targeting process was effec- factory assessment of the CLM’s performance under tive, more beneficiaries than planned were reached, NEP II applies here. Its performance on the social and they all received intended benefits. A beneficiary cash transfer component was also very strong, as it assessment documented good use of the funds; and found workable mechanisms for the payment system, an impact evaluation confirmed a positive effect on the smoothed and consolidated implementation, and suc- nutrition and well-being of targeted children. Efficiency cessfully absorbed this new component into its service was substantial. The project used existing institutions delivery platform. and focused on simplicity in building new ones, and interventions were cost-effective. More than a Decade of Support in Perspective Risk to development outcome is significant. For the community nutrition components, the assessment of Sections II, III and IV document the success of these risks under NEP II applies, since this project’s time three individual projects, but the achievements of frame falls within NEP II’s time frame. The child-fo- these projects (greater knowledge, healthier behav- 4 A Decade of World Bank Support to Senegal’s Nutrition Program iors and practices, and improved nutrition outcomes) A well-earned reputation. Among many strong fea- in their intervention areas, did not culminate in sub- tures of the NEP, this evaluation highlights three in stantial declines in malnutrition nationwide. The particular that have been the result of extremely good majority of the original 10-year objectives and targets design work and ongoing refinement over the past of the APL (which were also the objectives and targets 15 years. They are (1) a service delivery scheme of the NEP), set in 2001, were not met. Underweight that is community-oriented, highly participatory, and among children was reduced, but not by 40 percent; well managed and overseen; (2) an increasingly mul- severe underweight was also reduced but not to less tisectoral approach, taking root at every level of the than 1 percent. program and culminating in improved program effec- tiveness; and (3) an approach to behavior change The main reason that the three projects performed so communication that is evidence-based, cognizant, well but the 10-year program goals were not met cen- and respectful of local tradition, culture, and practic- ters on program coverage. The APL initially aimed to es; benefiting from the involvement of opinion leaders achieve nationwide coverage of Senegal’s NEP. But and other critical family and community members; and these targets were scaled back when the World Bank complemented with the provision of other means to scaled back its financing. Financial constraints limit- effect behavior change. ed the number of intervention areas that the NEP was able to support and also the frequency and intensity Challenges and opportunities. The increasingly large of interventions. On the other hand, there are an in- and diverse number of partners supporting nutrition creasing number of national and international partners in Senegal presents both a challenge and an oppor- in Senegal, who provide substantial financial and tech- tunity for improved program performance. Senegal nical support over and above government of Senegal has already put in place many of the required building financing. This support has not culminated in ade- blocks for enhanced aid effectiveness: a well-defined quate coverage of target groups with the full package national policy; a very capable institutional and orga- of cost-effective services, nor is this support yet fully nizational framework responsible for policy oversight aligned with the highest priority areas of the country. and program implementation; well-established proto- Although some may interpret these findings as weak- cols for strong monitoring and evaluation and its use nesses in the program, this evaluation acknowledges in decision making and tracking accountabilities for CLM’s proactivity in commissioning a well-designed, performance and results; an increasingly multisectoral sophisticated survey, which uncovered and explained approach and leadership role of the local governments; for the first time detailed data on program-wide cover- a strong focus on results; and widespread ownership. age and efficiency, which paves the way for improving program effectiveness. And other critical elements still need to be put into place: (1) a medium-term strategic program, grounded In conclusion, the NEP deserves its strong reputation in national policy, with estimated costs; (2) a medi- as a well-run, evidence-based, community-focused um-term projection of resource availability; (3) a move program that has piloted and demonstrated its ef- by all partners toward the use of well-proven NEP sys- fectiveness in intervention areas and managed to tems, rather than parallel project systems; and (4) fuller increase its coverage, although not to the level initially strengthening of systems for coordination and collab- anticipated in 2001. Its success and experience pro- oration across partners, including joint missions and vide useful guidance and insights for other countries coordination meetings, chaired by the CLM. Given that attempting to establish or improve nutrition programs. there is a range from 12 to 21 partners (both nation- In addition, this evaluation reveals opportunities for al and international) in each of Senegal’s 14 regions, the CLM and its partners to further enhance program coordination efforts also need to happen at regional, performance and results. departmental, and local levels. A Decade of World Bank Support to Senegal’s Nutrition Program 5 Lessons and teamwork coalesce around shared objectives. ®® A management style that supports an evi- ®® Formidable results (establishment of a new pro- dence-based, participatory learning culture will gram, behavior change, and outcomes) can be culminate in strong ownership of the program and achieved within the time frame of a four-year project. the continual improvement of its performance and At the same time, capacity and institution building effectiveness. is a medium-term incremental process. The gradu- ®® The measurement of coverage is complex but criti- al decentralization of program oversight, evolving cal to assess program efficacy. roles and involvement of local-level and other sec- tors take time. But they are well worth the quality of this program’s mature design and capacity. ®® A truly multisectoral approach is the result of a Zeljko Bogetic shared objective and the sense of mandate and ac- Acting Director countability to contribute to that objective. At local IEG Human Development and and central levels alike, cross-sectoral coordination Economic Management 6 A Decade of World Bank Support to Senegal’s Nutrition Program 1 Background and Context T his section summarizes the background and mance did not culminate in better social indicators and context covering the period during which the living standards for the population or in reductions in three projects under review were designed and poverty. Weak investments and stagnation in agricul- implemented, 2001–15. ture and industry underlie the modest number of jobs created despite economic growth, which did not partic- ularly benefit the poorest segments of the population. General Background Climate change, low agricultural productivity, and investments not well aligned to rural, rain-fed agricul- Senegal’s total estimated population of 14.4  million ture practiced by the poor also contributed to poverty, in 2015 is inequitably distributed across its territory along with inefficient public expenditures on social of 196,722 square kilometers. Densities range from a programs. In 2001, 54 percent of households were es- high of 5,735 inhabitants per square kilometer in the timated to be living below the poverty line, showing region of Dakar to a low of 16 in the Tambacounda negligible change over the 1994 estimate of 58 per- region in the northeast. Forty-five percent of the pop- cent (core welfare indicators household surveys). ulation resides in urban areas and 55 percent in rural Poverty is much higher in the rural areas, especially in areas. Total fertility rate is five children per woman, the center, south, and northeast. with higher rates in rural areas (6.3 children) than ur- ban (4 children). Forty-two percent of the population is A decade later, the annual rate of gross domestic prod- under 15 years of age.3 uct growth per capita was 0.5 percent during 2005–11.4 During this same period the poverty rate declined but According to the government of Senegal’s first Pov- the absolute number of poor increased. Between 2001 erty Reduction Strategy Paper (PRSP), at the start of and 2005, economic growth was inclusive and pover- the new millennium Senegal had returned to a path ty declined from 55 percent to 48 percent. However, of economic growth, with an annual average of over this rate of decline slowed after 2005, reaching 47 per- 5 percent growth in gross domestic product between cent in 2011. This slowdown was consistent with the 1995 and 2001. However, improved economic perfor- macroeconomic environment and the series of shocks A Decade of World Bank Support to Senegal’s Nutrition Program 7 that affected welfare over this same period: poor rains, years; expected years of schooling increased from global food and fuel price shocks, floods, and some 5.4 to 7.9 years; and gross national income per capita deterioration in governance. Extreme poverty dropped increased from US$1,878 to US$2,188. Health sta- more slowly from 17 to 15 percent between 2001 and tus has been improving but remains unacceptable. 2011, and the poverty gap between Dakar and rural According to Demographic and Health Survey (DHS) areas widened.5 In 2011, 57 percent of the rural pop- data, infant mortality has fallen from 61 in 2005 to ulation was poor, compared with 26 percent of the 39 in 2015, under-age-five mortality has also fallen population in urban Dakar, and more than a third lived from 121 in 2005 to 59 in 2015, and maternal mor- in Kolda or Ziguinchor regions of the Casamance. tality was 392 in 2011. These rates reveal inequities Poverty levels were higher (62 percent) in house- across urban/rural divides, regions, and income quin- holds relying on agriculture as the main occupation tiles. Coverage and quality of health services remain than those relying on other occupations (33 percent). issues. Only two-thirds (68 percent) of children are ful- Factors contributing to poverty include no formal edu- ly vaccinated; both modern contraceptive prevalence cation of head of household and large household size. and use of maternal and child health services are low Natural disasters such as droughts and flooding add to and inequitable across urban/rural areas, regions, and the vulnerability of the poor. income quintiles, albeit slowly improving. Adult female illiteracy was 60 percent in 2013. Senegal enjoys considerable political stability and has strengthened its democratic structures. Senegal has As expressed in its 2002 PRSP, Senegal’s three de- had four presidents.6 Power was handed over peace- velopment priorities (and relevant sectors or targets fully from Senghor to Diouf in 1981. The 2000 election for action) were (1) creation of wealth within a healthy of Wade was contested but resulted in a democratic macroeconomic framework (agriculture, infrastruc- political transition from the traditional Socialist Party ture, livestock, fisheries, handicraft, industry, energy, of Senghor and Diouf to the Senegalese Democrat- mining, trade, tourism, information technology, private ic Party of Wade. The 2012 election of former Prime sector, and employment); (2) capacity building and Minister Sall benefited from high transparency and promotion of basic social services (education, health, universal acceptance of the results, notwithstanding drinking water, natural resources and environment, deadly protests preceding the first round of voting. sanitation, and good governance); and (3) improv- Civil society played an important role in bringing about ing living conditions of vulnerable groups (children, political change in Senegal in 2012, contributing to women, handicapped, elderly, youth, and displaced). Senegal’s second democratic transition. The media Senegal’s PRSP for 2013–17 is articulated around was also instrumental in fostering election transpar- three pillars (and areas for intervention): (1) growth ency and integrity. The 1982 separatist movement of creation, productivity, and wealth (viability of macro- the Casamance region has precipitated a sense of economic framework, employment, private sector, abandonment and distance from Dakar and conflict productive sectors, integrated development of rural has undermined economic performance (agricultural economy, industry and agri-food processing, mines, production, trade, and tourism) and displaced 30,000– and quarries); (2) human capital, social protection, and 60,000 people. Resolving this crisis is a priority of sustainable development (population and sustainable current President Sall. human development, universal education and skills development, improved healthcare and nutritional sta- Senegal was ranked 170 out of 188 countries in the tus, improved access to drinking water and sanitation, United Nation’s Development Programme’s Human housing and living conditions, social protection, risk Development Index in 2014. Between 2000 and 2014, and disaster prevention and management, and envi- life expectancy at birth increased from 58 to 67 years; ronment); and (3) governance, institutions, peace, and mean years of schooling increased from 1.9 to 2.5 security (peace and security, rule of law, human rights 8 A Decade of World Bank Support to Senegal’s Nutrition Program and justice, gender equity and equality, state reform income-earning opportunities for households, as well and public administration, and governance). as the overall productivity and economic development of the country. Its two principal causes are inadequate food intake (both quality and quantity) and illness, Nutrition which can cause or exacerbate malnutrition. Under- lying factors are inadequate access to a sufficient Issues and challenges. Malnutrition remains a sig- quantity of quality food; inadequate knowledge and nificant problem today in Senegal, notwithstanding behaviors promoting the well-being of mothers and some improvement over the past 15 years. Between children; and inadequate services, especially health, 2000 and 2015, among children under age five the clean water, and sanitation. prevalence of stunting (height for age) declined from 29.5 percent to 20.5 percent, the prevalence of wasting National priorities. In 2001, the government of (weight for height) declined from 10 percent to 7.8 per- Senegal took major steps to step up its fight against cent, and the prevalence of underweight (weight for malnutrition. In April of that year, a Letter of Nutrition age) declined from 20.3 percent to 15.5 percent (see Development Policy was issued (République du Séné- appendix D, figures D.1, D.2, and D.3). None of these gal 2001). This policy (outlined in appendix B, box B.1) trends have been smooth, with important setbacks in included a range of innovative strategies supporting a progress in certain years, especially in 2010–11, likely 10-year goal to improve the nutritional status of poor linked to the food price crisis and poor harvests due to and vulnerable groups, including a community-based droughts. Levels vary across regions. DHS data from and multisectoral approach; capacity building to mon- 2014 reveal that two zones in Senegal (south and cen- itor and manage nutrition programs; strengthened tral) register the highest levels of stunting as well as partnerships with local government, civil society, and the highest number of stunted children, with the south the private sector; and social mobilization and behav- exceeding 30 percent (the “serious” threshold for the ior change. By Decree 2001–770 of May 10, 2001, World Health Organization [WHO]). At 9.6 percent, the government of Senegal created the CLM, attached to north zone has the highest prevalence of wasting, also the Prime Minister’s office, responsible for the over- approaching WHO’s “serious” threshold of 10 percent. sight and evaluation of the new nutrition policy. The But the greatest number of wasted children are found policy was translated into the 10-year NEP, whose im- in the center (37,142). Lowest income quintiles suffer plementation was financed by government of Senegal, higher levels of malnutrition than their richer counter- the World Bank, and eventually other development parts, as do rural residents, compared with their urban partners supporting nutrition. counterparts, notwithstanding pockets of poor, vulnera- ble populations in the urban areas. Although declining, Some 14 years later, the government of Senegal anemia remains high with 60 percent of children 6–59 has issued its National Development Policy for Nu- months old and 54 percent of women 15–49 years trition (2015–25), which builds on the lessons and old anemic in 2014. About half of school-age children experience to date (République du Sénégal, Primature (6–12 years old) and women (15–49 years old) are de- 2015). Its overarching objective is to ensure a satisfac- ficient in iodine. Vitamin A deficiency is also an issue. tory nutritional status for all, particularly children under five years of age, women of reproductive age, and Malnutrition has devastating consequences on indi- adolescents (see appendix B, box B.2). It supports viduals, their households, and the country at large. six intermediate objectives: (1) adequate coverage It is one of the principal causes of child and mater- of essential nutrition services; (2) improved access to nal mortality and morbidity in Senegal. It prevents a and use of quality health services; (3) improved knowl- child from reaching his or her full potential, both phys- edge and behaviors supporting good nutrition; (4) the ical and intellectual. This, in turn, undermines the production of foods high in nutritional value; (5) suffi- A Decade of World Bank Support to Senegal’s Nutrition Program 9 cient and sustainable financing; and (6) strengthened Rapid Response Child-Focused Social Cash Transfer program capacity for management and implementa- and Nutrition Security Project was approved in 2009. tion. The new policy articulates four strategic pillars: It is these three projects (NEP Phase I, NEP Phase (1) production of food with high nutritional value; II, and Rapid Response) that are the subject of this (2) transformation, distribution and pricing of primary Project Performance Assessment Report (PPAR). An outputs into quality food that is affordable and accessi- ongoing health operation (Health and Nutrition Financ- ble; (3) a multisectoral approach to nutrition education ing) has a nutrition component, and a project to Build focused on behavior change and adequate, equitable Resilience to Food and Nutrition Insecurity Shocks is access to clean water and sanitation; and (4) integra- under preparation. Over and above the World Bank’s tion and complementarity of basic health, nutrition, long tradition of lending for nutrition in Senegal, it has and water and sanitation services. Cross-cutting also supported analytic work and technical assistance themes include a lead role for local government, ade- (see appendix B, table B.1). quate and sustainable financing, social and behavior change, multisectoral approach, participation, equity, In early 2002, at the time of approval of the World and continued capacity building. Bank’s first phase of support to NEP, various develop- ment partners provided ad hoc support to nutrition in World Bank and other support to nutrition.7 The Senegal. According to the project appraisal document World Bank first invested in nutrition in Senegal over (PAD), the United Nations Children’s Fund (UNICEF) 20 years ago with the approval in 1995 of the Com- was providing support to national nutrition strategy munity Nutrition Project (CNP). Its objectives were to implementation, salt iodization, and Integrated Man- (1) halt a further deterioration in the nutritional status agement of Childhood Illness (IMCI) activities (World of the most vulnerable groups (malnourished chil- Bank 2002b). The U.S. Agency for International Devel- dren under three and pregnant and nursing mothers); opment (USAID) was also supporting IMCI, including (2) provide potable water to under-serviced neighbor- at the community level. IMCI was also supported by hoods; and (3) enhance household food security in WHO, specifically through training of service provid- poor rural and urban areas during critical periods of ers. In addition, KfW Development Bank was financing vulnerability (World Bank 1995). Its total actual cost water and sanitation interventions. As Senegal’s NEP was US$51 million, and its outcome was rated mod- and the CLM became better established, especially erately satisfactory by the IEG. Moreover, this project from 2009 onward, more development partners joined provided a wealth of experience and lessons, which the World Bank in channeling their nutrition support influenced the design of subsequent nutrition support.8 to and through these vehicles, notably the Micronu- In 2002, the World Bank approved the first project of trient Initiative, WFP, UNICEF, Spanish Cooperation a planned series of three designed as an APL to sup- and Global Alliance for Improved Nutrition. Their finan- port Senegal’s 10-year NEP. The World Bank’s second cial contributions to the NEP over time are itemized phase of support was approved in 2006, with addition- in appendix C, table C.12). USAID and many others al financing approved in 2012. Although the World continue to finance nutrition activities through other Bank decided against financing the third phase, a sectors and programs. 10 A Decade of World Bank Support to Senegal’s Nutrition Program 2 Nutrition Enhancement Program Objectives, Design, and Relevance This project was the first of three planned World Bank operations, packaged as a 10-year APL, to support the Project Development Objectives implementation of Senegal’s Nutrition Development Policy. The overarching objective of the 10-year APL As stated in the Development Credit Agreement of (the NEP) was “to improve the growth of children un- March 29, 2002, “The objectives of the Project are der three in poor rural and urban areas and help build to assist the Borrower in building the institutional and the institutional and organizational capacity to carry organizational capacity required to enable the Bor- out and evaluate nutrition interventions” (World Bank rower’s CLM and its partners in the public and private 2002b, 3). The first project (Phase I of the NEP, and sectors to develop, implement and monitor multisec- the subject of this section) was a preparatory phase toral nutrition activities in both rural and urban areas”9 meant to consolidate and sustain results gained with (World Bank 2002a, 13). For the purposes of analy- the previous CNP, refine and extend interventions to sis, the PDO will be subdivided into two objectives. rural areas, and initiate capacity building of the new- Objective  1: Building institutional and organizational ly established CLM. Phase II was intended to further capacity to enable CLM and its partners to develop scale up interventions and refine implementation and monitor multisectoral nutrition activities in both capacity, and Phase III was to achieve nationwide cov- rural and urban areas. Objective  2: Building institu- erage of a cost-effective nutrition system, responsive tional and organizational capacity to enable CLM and to local needs and working cooperatively with commu- its partners to implement multisectoral nutrition activi- nities and local government. Outcome indicators for ties in both rural and urban areas. Assessment of the the 10-year program and for each of the three phases first objective will center on capacity built for strategic are presented in box 2.1 management of the Program, including monitoring and evaluation. Assessment of the second objec- The geographic scope of nutrition interventions to tive will focus on the results chain of service delivery be supported under the project comprised (1) con- and behavior change interventions and their relevant tinued support (albeit with design changes) of the outcomes. urban zones supported under the previous CNP,10 A Decade of World Bank Support to Senegal’s Nutrition Program 11 and (2) rural areas in the Kaolack, Fatick, and Kolda 2002 PRSP recognized the importance of nutrition regions. The targeting of geographic zones and pop- interventions to attaining Senegal’s overarching ob- ulations was thorough, participatory, and sound.11 The jective of alleviating poverty and included budgetary project’s support to nutrition program capacity building provisions for nutrition. It also advocated more active targeted national agencies and their regional branch- partnership among the government of Senegal, civil es as well as actors and stakeholders in the project society, and communities. The PRSP, issued just after intervention areas. the project’s closing, supported access to basic social services, with an explicit commitment to improving Relevance of Objective nutrition, protecting vulnerable groups, and support- ing greater transparency and participation. Senegal’s The relevance of objectives is rated high. Strategie Nationale de Developpement Economique et Social 2013–17 articulates a Priority Action Plan First, the PDO is responsive to country conditions at linked with the national budget framework, which aims the time of appraisal, project completion, and current- to improve access to basic services, with emphasis ly. Although declining over time, malnutrition remains on strengthened resilience and social protection for a serious problem among Senegal’s poor, especially in vulnerable groups. In short, the goal of reduction of the rural areas where most of the poor live and among malnutrition was both explicit and budgeted for. The the very young (six months to three years old), who PDO is directly supportive of Senegal’s Nutrition Policy are the most vulnerable. Malnutrition wreaks havoc on of April 2001, which sought to improve the nutritional a country’s socioeconomic development prospects: status of poor, vulnerable groups and reproductive-age Stunted children are more susceptible to death and women. disease and have diminished cognitive capacity, un- dermining their learning and future earning capacities. Third, the PDO was and remains relevant to the World Anemia impairs women’s health and economic produc- Bank’s strategies for Senegal over the years. Pover- tivity and, for pregnant women, can lead to maternal ty alleviation was at the center of the World Bank’s death and serious health consequences for infants 1998 Country Assistance Strategy (CAS), which in- (stillbirths, prematurity, and low birth weight). Low cluded an objective to improve the nutritional status of breastfeeding rates undermine children’s immune sys- women and children under age five. The CAS issued tems, protection from disease, and their potential for just after the project’s closing included a human de- healthy growth and intelligence. Although Senegal had velopment/shared growth pillar emphasizing access supported programs and initiatives to fight malnutrition to social services and enhanced opportunities for the prior to the launch of this project, they were neither poor and vulnerable (World Bank 2007b). It also set sufficiently coordinated nor cost-effective and offered a target to reduce malnutrition. The current World many lessons for their consolidation and improvement. Bank Group CPS for FY2013–17 is focused on one Indeed, the rationale for maintaining support to the ur- foundation—strengthening the governance framework ban zones supported under the CNP was precisely to and building resilience—and two pillars: accelerating reform the approach there in light of lessons learned, inclusive growth and creating employment and im- both to consolidate gains as well as to achieve great- proving service delivery, with an emphasis on social er cost-effectiveness. These urban populations were sector governance, access, and equity (World Bank highly vulnerable, residing in very poor squatter neigh- 2013a). Although the PDO is relevant to this CPS’s borhoods, targeted on the basis of multifaceted criteria emphasis on health-related services and outcomes, its (see paragraph 2.3). nutrition-specific content is not as strong as the previ- ous CAS. Phase II was ongoing, covering the first two Second, the PDO has remained highly relevant to years of the five-year CPS. But a Phase III nutrition Senegal’s strategic priorities over the years. Senegal’s follow-on project was no longer envisaged. Moreover, 12 A Decade of World Bank Support to Senegal’s Nutrition Program BOX 2.1: Key Performance Indicators for 10-Year APL and Each of Its Phases Outcome indicators for 10-year APL (nationwide) signs in sick children has increased by 25 percent • underweight (weight for age <−2 s.d.) among in targeted areas children under age three reduced by 40 percent • severe underweight (weight for age <−3 s.d.) Specific outcome indicators for NEP Phase II, reduced to less than 1 percent 2005–10 in the targeted areas in 7 of Senegal’s • virtual elimination of vitamin A deficiency 10 regions • at least 80 percent of rural communities made • program coverage has increased to 60 percent of aware that malnutrition is a development problem the target population in 7 of 10 regions and know of actions to address the determinants • severe underweight is reduced to less than 1 percent of malnutrition • underweight among children under age three is • the accelerated decline in under age five mortality, reduced by 25 percent due in part to the program • proportion of exclusively breastfed children up to six months increases to 45 percent in the first Specific outcome indicators for NEP Phase I, 3 (Phase I) regions and to 15 percent in the 4 2002–05 in the intervention areas regions added under Phase II • program coverage has reached 35 percent of the • use of prenatal care increased by 30 percent in all target population in the targeted rural areas and seven regions 50 percent of the target population in the targeted • local authorities work cooperatively to take over urban areas and manage basic nutrition interventions • severe underweight is reduced by half in the targeted areas Specific outcome indicators for NEP Phase III, • underweight among children under age three is 2010–12 reduced by 25 percent in the targeted areas • program coverage has extended to all regions • proportion of children exclusively breastfed until • the performance indicators of the 10-year program six months increased from 8 to 15 percent in the are achieved targeted areas • local authorities have taken over and are • use of prenatal care (at least three visits) managing basic nutrition services cost-effectively increased by 30 percent in the targeted areas • the Lettre de Politique de Dévéloppement de • proportion of caregivers (mothers and other la Nutrition (Nutrition Policy Letter) has been caregivers) who recognize at least two danger evaluated and updated as necessary Source: World Bank 2002b, 4; World Bank 2002a for NEP Phase I indicators. Note: s.d. = standard deviation. the CPS did not include nutrition-specific targets or selected Sustainable Development Goals12 and the indicators. World Bank’s twin goals, the 2016 updates to the pri- ority directions for the HNP Global Practice (2016–20) Fourth, the PDO is also very relevant to the World articulate three strategic areas to which the PDO re- Bank’s series of HNP Global Practice strategies. The sponds: fair, efficient, and sustainable financing for 1997 HNP strategy set three objectives: (1) improve HNP outcomes; equitable access to affordable, quality HNP outcomes of the poor; (2) enhance health sys- services; and harnessing the potential of other sectors tems performance; and (3) secure sustainable health to strengthen results (World Bank 2016). In 2006, a financing (World Bank 1997). The 2007 HNP strategy World Bank advocacy document laid out a strategy for sought to improve the level and distribution of HNP out- large-scale action for nutrition: strengthening global comes, particularly for the poor and vulnerable; prevent and national commitment and capacity; mainstream- poverty due to illness; improve financial sustainabil- ing and prioritizing nutrition in development strategies; ity; and improve sector governance, accountability, reorienting ineffective programs; action research and and transparency (World Bank 2007a). Aligned with learning by doing for strengthened evidence base A Decade of World Bank Support to Senegal’s Nutrition Program 13 and action (World Bank 2006c). Most recently, World forums, which include (1) at the central level, the mul- Bank President Jim Kim’s Investing in Early Years tisectoral CLM and its technical and monitoring and for Growth and Productivity initiative has identified evaluation committees; (2) at decentralized levels, the Senegal, along with 21 other countries, for scaled-up district-level consultative committees for the devel- financing focusing on child nutrition, early learning, opment of multisectoral regional nutrition plans and and early stimulation to support the development of local-level committees for the monitoring of program the child to reach full potential. interventions; and (3) at the community level, small community forums for program design and oversight.13 Project Design Third, it provides targeted support to the health sector, Designed as an APL, this project was the first of a se- in recognition of its critical role at the central or policy ries of three anticipated World Bank operations, which level, and in guiding, supervising, and directly partic- together would support implementation of Senegal’s ipating in prevention and treatment at the community new 10-year NEP. NEP Phase I supported three com- level as a part of its primary health care agenda. Last- ponents (box 2.2). ly, and perhaps most importantly, the PDO to improve program strategic management is greatly supported Relevance of Design by the development and implementation of a re- sults-based, learning-by-doing approach, underpinned The relevance of design is rated high. by routine program monitoring and evaluation and strategic studies and operations research. The regular The results chain for PDO 1 (to build the institution- review, discussion, and use of program data for deci- al and organizational capacity to develop and monitor sion making at each level of the system is designed multisectoral nutrition activities) is well conceived. It to be both transparent and participatory, serving the supports a range of activities centered on building purposes of learning and accountability. capacity for strategic management of the program, in- cluding monitoring and evaluation capacity. The results chain for PDO 2 (to build the institutional and organizational capacity to implement multisectoral nu- First, it is designed to support and further strength- trition activities) is equally well conceived. The results en the technical, managerial, and material capacities chain is clearly laid out, encompassing supply-side of all key actors in the newly established institutional (service delivery) and demand-side (awareness-rais- and organizational framework: the CLM (responsible ing, information, education, and behavior change) for the definition and implementation of national nutri- interventions targeted to the most vulnerable groups, tional policy); the BEN and its regional offices (serving which are plausibly expected to culminate in healthier as secretariat to the CLM and responsible for man- behaviors (such as breastfeeding, improved diets, and agement and oversight of the NEP); NGOs recruited proper use of health services), and ultimately lead to as community executing agencies (CEAs) to guide, fa- improved nutrition and health outcomes for vulnera- cilitate and supervise local-level activities and provide ble women and children. Interventions appropriately the interface among communities, local government, emphasize prevention and promotion but also include and the program; and community-level nutrition aides, treatment of severe cases of malnutrition, also im- selected by their peers to carry out growth monitoring portant for achieving program goals. The grants for and nutrition education and promotion. community-based nutrition projects support innovative activities, family gardens, and other relevant activities Second, it facilitates the vertical and horizontal inter- to enhance communities’ ability to improve their nu- action and collaboration of all key actors through the trition practices and outcomes. The locus of action is establishment and support of various committees and the community and the nutrition aides. Both the cred- 14 A Decade of World Bank Support to Senegal’s Nutrition Program BOX 2.2: NEP Phase I Components Component 1. Community-based nutrition and • institutional and organizational capacity, including growth promotion: This component supported a the (1) technical support and learning opportunities package of five community-based interventions, for the CLM; (2) technical support, training, to be delivered by nutrition aides selected from equipment, materials, and other support for the communities, aimed at promoting adequate growth functioning of the National Executive Bureau to prevent malnutrition: (BEN) and its regional offices; (3) support for the • growth monitoring and promotion, consisting of operations of Ministry of Health divisions in charge monthly weighing sessions and follow-up home of nutrition and health education; (4) the recruitment visits to vulnerable children (those who either did and strengthening of local nongovernmental not participate or showed inadequate weight gain); organizations (NGOs) to be contracted to promote and oversee local-level nutrition activities; • nutrition and health group education for the (5) training of service providers (nutrition aides), delivery of key messages; supervisors, and program administrative staff • IMCI, including the promotion of healthy behaviors in contract management and accounting; and design and implementation of guidelines (6) establishment of small community forums for management of severe malnutrition cases in for program design and oversight, district-level health facilities; consultative committees for the development of • basic health services provision, including regional nutrition plans; and local committees for the commodities (micronutrients, deworming tablets, monitoring of program interventions; (7) retraining of impregnated bed nets, and oral rehydration salts) urban nutrition development centers; and and promotion of prenatal care and other health • monitoring, evaluation, operational research, services; and routine program reporting, and special studies. • grants for community-based nutrition projects. Component 3. Project management and Component 2. Capacity building and monitoring reporting: This component supported the and evaluation: This component was designed to establishment and operation of the BEN and strengthen technical advisory services. Source: World Bank 2002b. Note: Planned versus actual costs by component are presented in appendix C, table C.1. ibility of the nutrition aide among her peers and her Implementation arrangements. Starting at the com- knowledge of the local community and its issues and munity level, the nutrition aides were responsible for challenges provide her with leverage to effect change. the nutrition and growth promotion activities under Supply- and demand-side interventions focus on is- component 1. NGOs and local associations were sues of highest relevance and priority, reflecting best contracted to facilitate social mobilization and the se- practices from the literature and accumulated expe- lection, training, and supervision of nutrition aides and rience, as well as the needs and priorities of specific to ensure the availability of other program support. communities, thanks to a communications program The health post was the first level at which program that is based on listening, as well as information activities were formally integrated with the health transmission.14 An evidence-based focus enables con- system. The Regional Executive Bureau (BER) was tinuous learning and improvement. The design was responsible for the mobilization of NGOs and for re- a positive shift away from Senegal’s previous efforts gional-level coordination, monitoring and evaluation, (supported under the CNP), which focused primarily with a plan for their eventual assumption of contracting on the mitigation of acute malnutrition by means of and financing responsibilities. The BEN was responsi- food supplementation, and toward the prevention of ble for day-to-day program management and served chronic malnutrition through growth monitoring and as secretariat of the CLM. The CLM was responsi- behavior change. ble for policy development, ensuring a multisectoral A Decade of World Bank Support to Senegal’s Nutrition Program 15 approach, and approving strategies, annual work and 100 percent of the adjusted amount after cancel- plans, and budgets.15 ation). Actual use of IDA funds (1) exceeded original allocations for consultants and training and operating costs and (2) fell short of original allocations for works, Implementation goods, pharmaceuticals, subprojects, and the project preparation facility. This is largely a reflection of the Key dates. Approved by the Board of Executive Di- time and resources invested during the first full year rectors on March 14, 2002, the IDA credit became of the project to establish capacity and broad-based effective on June 27, 2002. The midterm review took ownership at the local and community levels. place in February 2005. The project was not restruc- tured, but its closing date was extended by six months Factors Affecting Implementation to July 15, 2006, to allow the community-level subproj- ects to complete a full two-year cycle. Outside the government’s control. There was a severe drought in 2002, the first year of implementa- Planned versus actual costs, financing, and dis- tion, and another drought in 2004, compounded by a bursements.16 The total cost estimated at appraisal plague of locusts. This affected cereal production and was US$16.20 equivalent, net of planned WFP support food availability for the population, especially the poor- to be provided through parallel financing. The actual est and most vulnerable. cost of the project reported in the ICR, US$23.10 mil- lion, appears to be inclusive of WFP support (World Within the government’s control. With President Bank 2007c). The actual cost of the project net of Wade’s election in March 2000, both he and the First WFP’s US$4.0 million in support is US$19.1 million or Lady became strong advocates for nutrition. Newly 118 percent of the original estimate. Actual costs of created in 2001, the CLM was appropriately housed component 1 (inclusive of WFP support) were twice in the office of the prime minister, given its multi- the appraisal estimate and program management ac- sectoral mandate. Strong government support and tual costs also exceeded the original estimate. On the commitment were reflected in its overall development other hand, actual costs of institutional capacity build- policies, which focused on poverty alleviation, includ- ing and monitoring and evaluation and research were ing the improved nutritional status of the population; in less than original estimates. the appointment of highly qualified staff to serve in the CLM; and in its counterpart financing, which exceeded Although in principle they should add up, there is a dis- its initial commitment. crepancy between actual costs and actual financing. This is due to the different sources used, an actual in- Within the CLM’s control. During the project’s four- crease in the U.S. dollar value of the SDR over the life year implementation period, the CLM served under of the project and different calculations of the exchange three prime ministers.18 The CLM was proactive in rate. In U.S. dollars, actual IDA financing ($16.5  mil- ensuring the full briefing of each new prime minister, lion) exceeded the original estimate ($14.7 million) successfully securing the appreciation and support of by 112  percent. Government counterpart financing this critical program and its importance for achieving (US$1.8 million equivalent) also exceeded its obli- the country’s development goals with each new prime gation (US$1.5 million) by 120 percent (appendix C, minister. The CLM style of management was collab- table C.2). orative across sectors, participatory in including all actors and stakeholders at each level of the system, Of the originally approved World Bank financing of results-based, transparent, and focused on learning. SDR 11.8million,17 SDR 0.422 was canceled and The NGOs and CEAs contracted under the project 11.378 was used (96 percent of the original amount provided a very effective interface between the pro- 16 A Decade of World Bank Support to Senegal’s Nutrition Program gram, local authorities, and the communities for social for program planning, management, oversight, and mobilization, communication, social cohesion, opera- course correction. At the central level, the CLM, which tional support, supervision, and reporting. was responsible for policy advice, oversight of policy implementation, and multisectoral coordination, was Safeguards compliance. No safeguards were trig- established in 2001 just six months prior to project ef- gered under this project. fectiveness. The project was instrumental in building the CLM’s capacity to fulfill its mandate and in guiding Fiduciary compliance. Financial management has it in the launch of the NEP, the main vehicle for imple- been exemplary, with project financial management menting nutrition policy. The newly established BEN, reports having been rated highly by the World Bank. serving as the CLM secretariat and as the project im- External financial audits were completed on time, with plementation unit, was staffed (with about 20 staff), no qualifications, and were satisfactory to the IDA. trained, and equipped with project support and guided Procurement performance was also fully satisfactory, in its initial action planning, budgeting, and quarterly due to the high quality of staff. Some financial man- reporting to the CLM on program progress.19 Support agement and procurement tasks were carried out by was also extended to the six BERs (each staffed with the 12 NGOs operating at the local level. Their good 2 technical staff, 2 financial staff, and 2 support staff), performance was a result of initial capacity building ef- responsible for providing technical support to and forts to strengthen their fiduciary competencies. overseeing community-level activities and organiza- tions, especially the NGOs and CEAs. Achievement of Objectives At the local level, a system for contracting local NGOs and associations to operate as CEAs was developed Appendix D, table D.1, presents the baselines, targets, and implemented. CEAs were chosen on a compet- and actual achievements of all outcome and interme- itive basis for their experience, credibility, and good diate outcome indicators and all the sources of these reputation with local communities; and their staff were data. Although the PDO makes specific reference to recruited or trained to further strengthen their capac- rural and urban areas, these results are not disaggre- ities in community mobilization and in the oversight, gated by urban or rural residence. The ICR provides supervision, monitoring and evaluation, reporting on no such breakdown. Moreover, the mission was in- local-level progress, procurement, and financial man- formed by the CLM monitoring and evaluation expert agement.20,21 The CEAs were mandated to involve that it was not possible to provide this information. local government officials and district health person- nel. At the community and service delivery level, over Objective 1 and above their training in the technical aspects of service delivery (see paragraph 2.34), nutrition aides, Objective 1 of NEP I was to build institutional and or- selected by their communities, were trained by the ganizational capacity to enable CLM and its partners CEAs in the collection and recording of program per- in the public and private sectors to develop and mon- formance data and in using these data as a vehicle for itor multisectoral nutrition activities in both rural and dialogue and behavior change interventions targeted urban areas. The achievement of objective 1 is rated to mothers and other caregivers and for communicat- high. ing results to their communities. Outputs and intermediate outcomes. Project pro- At the sectoral level, the project supported the Minis- vision of technical assistance, training, material, try of Public Health and Ministry of Education in the equipment, and operating costs culminated in the es- preparation of work plans and budgets specific to their tablishment of capacity at every level of the system mandates and comparative advantages in the delivery A Decade of World Bank Support to Senegal’s Nutrition Program 17 of key nutrition inputs and interventions, and in the authorities are increasingly committed and involved. monitoring and oversight of their implementation, at The NEP has strong ownership at the community lev- every level of the system. This was a strategic first el. The community-based service delivery structure step in working toward the development of a truly mul- and decentralized implementation have catalyzed tisectoral approach. a range of actors and contributors at the local level, so critical for a multisectoral approach. Its monitoring A viable monitoring and evaluation system was estab- and evaluation system and mechanisms for discuss- lished with project support, which documents program ing and utilizing the data at every level of the system baselines and targets for the various components have promoted rigorous tracking, discussion of data, of the program results chains. The data are widely fostering a strong results focus, transparency and ac- shared with actors and stakeholders. A system of com- countability, and learning by doing. mittees has been established to discuss and improve program performance in light of regular reporting. At Objective 2 the community level, the Local Steering Committee supports nutrition aides in mobilizing community inter- Objective 2 of NEP I was to build institutional and or- est and action, managing nutrition commodities, and ganizational capacity to enable CLM and its partners general troubleshooting and problem-solving.22 At the in the public and private sectors to implement multi- district and departmental levels, the Local Monitoring sectoral nutrition activities in both rural and urban Committees meet on a quarterly basis to discuss the areas. The achievement of this objective is rated high. results and action plans presented by the CEA.23 At the regional level, the Regional Monitoring Commit- Intermediate outcomes. With project support, com- tee meets semiannually to hear and discuss regional munity-based nutrition services were established and reports on activity plans and results.24 In short, the delivered in the targeted urban and rural areas.25 One monitoring and evaluation system provides for the hundred percent (or 2,459) of nutrition aides (selected analysis of program and special studies’ data and from and by their communities) were trained in the pro- feedback to stakeholders at the community, district, motion of basic health care and in community-based regional, and national levels. IMCI, far exceeding the target of at least 25 percent. They also received on-the-job technical support and Outcome. In the space of the four-year implementation guidance from health providers and CEAs in the orga- period, thanks to the direct project support for capacity nization of monthly growth promotion sessions and in building and applied experience, CLM fully assumed social mobilization. Against a target of 820 (for 80 per- its central role of setting the policy agenda for nutrition cent coverage of targeted communities), 924 nutrition in Senegal, overseeing its implementation through the sites were established and equipped. Children under NEP, fostering cooperation across sectors and with three were regularly monitored and their caretakers the nongovernmental sector, and, increasingly, sector counseled. A total of 200,000 children under three wide monitoring and coordination of donor support to and their mothers were mobilized for monthly growth nutrition. The NEP has evolved into a nationally owned monitoring and promotion, exceeding the target of nutrition program (and not a World Bank project), which 171,000, reflecting a high participation of 90  percent is the main vehicle for national policy implementation. of targeted mothers and children. In 2006, 94 percent The BEN and its regional offices have been success- of established sites held monthly nutrition and health ful in functioning as the operational arm of the CLM, education sessions (exceeding the 80 percent target), thanks to their very capable and experienced team and these sessions were well attended by 89 percent and good management practices. CEAs were effective of targeted groups. With targets surpassed both for in ensuring that the program is well grounded in the the number of nutrition sites established and the num- needs and priorities of the communities and that local ber of children under three served by the program, 18 A Decade of World Bank Support to Senegal’s Nutrition Program program coverage appears to have exceeded plans. erage of 10 percent.29 Consumption of iodized salt But there were no data to assess the program’s aim to also increased from 46 to 59 percent (an increase of have reached 35 percent of the targeted population in 28 percent), exceeding the national average in 2005 of rural and 50 percent in urban areas.26 41 percent. Moreover, program activities in the inter- vention areas, established and supported with project Greater responsiveness and involvement of local support, culminated in improved nutrition outcomes for health services were achieved through training of children under three. Ninety-one percent of children 1,122 health post and district personnel in the pro- participating in monthly growth promotion sessions in motion of basic care and in IMCI (100 percent and the intervention areas showed adequate weight gain; 78 percent, respectively), exceeding the target of this constituted the vast majority of targeted children, 40 percent. Forty-six percent of health posts were whose participation rate in these sessions exceeded adequately equipped to manage severely malnour- 90 percent. ished children, almost achieving the 50 percent target. Reinforcing the IMCI content at the community level In short, the program’s capacity to implement multi- was the training of 23 trainers and staff of all CEAs sectoral, community-based nutrition activities in the supporting and overseeing community-level activities. intervention areas was highly achieved, exceeding tar- Micronutrient coverage in the intervention areas was gets and expectations. With project support, service significantly increased. By the project’s end (2005), vi- delivery targets were exceeded in terms of both their tamin A supplementation coverage for children ages coverage and their intensity (see paragraphs 2.34 and 6–59 months achieved a level of 85 percent, up from 2.35). In turn, this very strong performance culminated 42 percent in 2003, exceeding the national average in improvements in the knowledge and behaviors of of 75 percent that same year; and vitamin A supple- target groups, which were significantly higher than na- mentation of mothers within eight weeks postpartum tional averages, and also in the adequate weight gain achieved 51 percent (up from 27 percent in 2003), ex- of most children under three targeted by the program. ceeding the 2005 national average of 27 percent.27 The program set targets for reductions in underweight in the intervention areas, which were ambitious for Outcomes. Most targets for knowledge and behavior the project’s short time frame (see paragraph 2.54), change of priority groups were exceeded in the inter- and, moreover, not a fair or accurate measure of the vention areas, culminating in much higher levels than project’s more immediate objective to build program national averages. Knowledge, Practice, Coverage implementation capacity. Still, it is interesting to re- (KPC) surveys show that the proportion of caregiv- port progress against these. Two data sources reveal ers who recognize at least two danger signs in sick that the prevalence of underweight and severe un- children increased from 55 to 77 percent (a relative derweight among children was indeed reduced in the increase of 40 percent, exceeding the 25 percent intervention areas. Program monitoring data shows a target) (CLM 2006b). The proportion of children ex- 44 percent drop in underweight among children under clusively breastfed until six months almost doubled three in the intervention areas during the project peri- from a 30 percent baseline to 58 percent, comparing od (from 18 to 10 percent). This exceeds the project very favorably to the end-of-project average for Sen- target of a 25 percent drop. The impact evaluation also egal of 34 percent. KPC surveys also show that the shows a reduction in intervention areas, albeit a small- use of prenatal care (at least three visits) increased er one: 14 percent (from 26.8 to 23.1 percent), but still from 52 to 67 percent (a relative increase of 29 per- larger than the 10 percent reduction in control areas.30 cent, essentially achieving the 30 percent target).28 According to WHO’s Global Data, national prevalence The proportion of children under five sleeping under of underweight among children under five declined insecticide-treated bed nets more than doubled from by 29 percent from 20.3 percent in 2000 to 14.5 per- 28 to 59 percent, far exceeding the 2005 national av- cent in 2005. Field visits revealed the strong opinion A Decade of World Bank Support to Senegal’s Nutrition Program 19 of actors and stakeholders that the counterfactual for (1) provided the technical oversight and support to the intervention areas would have been worse without community-level interventions; and (2) been suffi- the project, as it prioritized and targeted areas with the ciently equipped to receive, properly rehabilitate, and highest malnutrition rates, poverty, and vulnerabilities, follow up on acutely malnourished children referred among whom results are more difficult to achieve.31 by the program. The establishment and successful The impact evaluation also shows a drop in severe implementation of the NEP would eventually provide underweight among children under three in the inter- a strong foundation for improved collaboration and vention areas from 5.7 to 4.5  percent. WHO Global coordination among development partners under the Database on Child Growth and Malnutrition shows a second phase, with the World Bank playing an import- nationwide drop from 7.0 to 3.9 percent (WHO 2014). ant catalytic role (see paragraph 3.30). Assessment of contribution or attribution. The high efficacy of the program in achieving both objec- Efficiency tives is a direct result of the project’s investments in program capacity and in the World Bank team’s tech- Efficiency is rated substantial. nical support to the program, both during its design and implementation. The World Bank took on the lead The fight against malnutrition is a highly cost-effective role among donors in encouraging and supporting the investment in a country’s development. A large body formulation of the government of Senegal’s nutrition of scientific evidence shows that improving nutrition policy and the definition of the 10-year NEP. Multiple during the critical 1,000-day window has the potential assessments of the launch and implementation of this to save lives, help children to develop fully and reach program, as well as interviews with a range of national their full potential both in school and ultimately in the and international actors, give full credit to the World workforce, and thus enable them to contribute more ef- Bank as a leader to this end. Although there were do- fectively to a country’s economic prosperity. Senegal’s nors supporting maternal and child health interventions choice to develop and invest in a nutrition program is in the three regions where the project was active, the a sound investment in its development. The program project was the main source of technical and financial is efficient in that it targets the right categories of the support for this first phase of community-based NEP population with the right interventions: weighing of implementation. The program capacity built and the children under two and counseling of their mothers, services delivered during 2001–06 (paragraphs 2.34 promotion of exclusive breastfeeding of children under and 2.35) were the result of the project’s support; and six months, improved feeding practices and IMCI for it was this newly developed capacity, which culminat- children under age five, essential health commodities ed in the program’s excellent results (see paragraphs for women and children; more effective use of mater- 2.36–2.37). WFP provided parallel financing in the nal and child health services, and promotion of healthy amount of US$4.0 million but only for a very specific pregnancies and childbirth.32 intervention: food supplementation in the urban areas supported by the project. The German KfW Develop- The delivery of community-based nutrition and growth ment Bank and UNICEF were also supporting nutrition monitoring and promotion activities under this project activities, but not specifically in the intervention areas. had a very reasonable median cost per child per year The Ministry of Public Health and its development part- of US$4.3 (US$3.7 in rural areas and US$5.0 in urban ners may have made some contribution to improved areas), substantially lower than the costs of the previ- outcomes in the intervention areas through their provi- ous CNP project, whose per child annual costs were sion of maternal and child health services. But without estimated at US$80, net of food supplementation. A the project’s discrete support to the health sector, it big reason for the higher cost of the CNP was its re- is unlikely that local-level health services would have liance on paid nutrition workers, in contrast with the 20 A Decade of World Bank Support to Senegal’s Nutrition Program NEP, which is delivered by volunteer nutrition aides. nity-based approach, the pivotal role of the nutrition And even with these substantially lower costs, the aides and the NGOs, and the evidence-based, learn- intervention areas demonstrated significant improve- ing-by-doing management style were all very strong ments in knowledge and behaviors and a decline in features of this innovative design, built on the lessons the prevalence of underweight. of the previous project. The objective to build capacity for the development and monitoring multisectoral nutri- Implementation efficiency was substantial. The CLM tion activities was highly achieved, and the objective to successfully established itself as a capable, evi- build capacity for the implementation of those activities dence-based manager and coordinator of program was also highly achieved. Most outcome and interme- implementation. The BEN and its regional offices diate outcome targets were surpassed. Although they were highly capable and effective in backstopping did decline, prevalence of underweight and severe community-based activities. Thanks to a rigorous and underweight may not have fully achieved the targets. transparent process, very capable local NGOs were Nevertheless, this impact indicator is not a fair mea- contracted to provide a viable interface between the sure of the PDO, which focused on capacity building. program and the beneficiary communities, and to Project efficiency was substantial because of good forge a stronger link and collaboration with local gov- value for money and a very efficient implementation. ernment authorities and local-level services of various key sectors (see paragraph 2.32). The start of proj- Risk to Development Outcome ect activities was delayed by about six months while several essential success factors were put into place, The risk to development outcome is moderate. including the establishment and training of local-level oversight committees, service delivery protocols, and Technical risk is low because the design has been val- a competitive process for recruiting NGOs. This slight idated as a best practice in the literature, which has delay was an investment in efficiency: when activities emerged over the past five years (almost a decade did start, the ground had been prepared for a smooth after the project was designed).33 Financial risk is sub- and accelerated implementation. A six-month project stantial. The government of Senegal has substantially extension allowed for the completion of a two-year increased its financial contribution to the NEP over the subproject cycle. years since project closure. But both the costs and the financing need to be better assessed. The issue of whether and how much to remunerate nutrition aides Ratings and with what financing source(s) is raised among ac- tors and stakeholders and needs more assessment Project Outcome and creative solutions. Further discussed in section V, it is worth noting here the strong dedication of nutrition The project’s outcome rating is highly satisfactory. aides to their mandates. Throughout field visits, the The project’s objectives are highly relevant to current remuneration of nutrition aides was consistently raised country conditions, national strategies and priorities but not always by the aides themselves. Local gov- (both higher-order development objectives and health ernment officials, NGOs, NEP staff, and communities and nutrition-specific objectives) and the World Bank’s all raised this concern, demonstrating the value they current CPS, as well as its HNP strategy. The design place on their work. Innovative financing sources and is also highly relevant, with clear and logical results solutions are under discussion and experimentation. chains supporting the first objective to build capacity to Despite very low remuneration, nutrition aides derive develop, monitor, and oversee the NEP and the second great satisfaction in serving their communities and re- objective to build capacity to implement NEP activities. ceive great respect and admiration for their work and The institutional and organizational setup, the commu- results. A Decade of World Bank Support to Senegal’s Nutrition Program 21 Social risk is low. Stakeholder awareness and support also very pragmatically reflected the lessons of pre- is extremely high across a range of groups: beneficia- vious nutrition interventions (both in Senegal and ries, communities, traditional and religious leaders, elsewhere34) culminating in a new, improved approach local government, district, regional and national pro- focused on sustainable nutrition interventions at the gram staff and oversight committees. Political risk is community level with an emphasis on prevention and low. Nutrition figures prominently among the country’s promotion. The program was appropriately targeted to development goals and indicators. The placement of the poorest, most vulnerable geographic areas, and the CLM in the office of the prime minister is a statement within these areas, to the most vulnerable segments of political commitment. The CLM has been successful of the population: children under five and mothers. in briefing new prime ministers so as to maintain its The institutional and organizational framework was prominence at the highest levels of government. Risk of very sound. The placement of the CLM in the office waning government ownership and commitment is low of the prime minister reflected high commitment on because the program’s success, and its still untapped the part of the government of Senegal to the program potential is recognized, nationally, and internationally, and provided the needed authority for coordinating a and increasingly by local governments and other sec- multisectoral approach. Implementation arrangements tors, whose support and involvement continue to grow. were extremely well thought out and highly appropri- Institutional risk is low. CLM gained acceptance as the ate, ensuring that (1) the locus of the program was national focal point for nutrition, and the BEN, its sec- the community level; (2) communities would be ad- retariat, is recognized for its very strong performance. equately supported by CEAs and local-level sector Local governments, with NGO contractual assistance, services; (3) local governments would be increas- continue to assume growing responsibility for the nu- ingly involved and committed; (4) results would be trition program, in line with Senegal’s decentralization shared and discussed at every level of the program; policy. Risk of natural disasters is substantial. Sene- and (5) decision making and management would be gal is prone to drought and locust infestation, which, transparent and results-based. These arrangements while exogenous to the program, could compromise, at have proven themselves and stood the test of time. least temporarily, gains in nutrition status. Fiduciary aspects were well designed, including an assessment and strengthening of fiduciary capacity World Bank Performance of all actors (including NGOs) to permit decentralized management. The monitoring and evaluation design Overall World Bank performance is rated highly was sound overall, with indicators measuring each satisfactory. link in the results chain. Nutrition outcome indicators established to track impact were not an appropriate Quality at entry is rated highly satisfactory. The proj- measure of the project’s capacity building objective ect design was grounded in government of Senegal but kept the program focused on medium-term results nutrition policy, which had been developed through a (see paragraph 2.54). Arrangements for its use of data participatory process involving all stakeholders in nu- for management and decision making were explic- trition and with World Bank technical assistance. The it and well developed. Potential risks were assessed policy reflects Senegal’s commitment to reduce and and appropriate mitigation measures outlined. The prevent malnutrition through a multisectoral approach World Bank’s team had solid expertise in nutrition and and is appropriately focused on a sound assessment of communication. The APL instrument was an appropri- issues and determinants of malnutrition. The 10-year ate choice for the launch and scale up of this brand NEP was developed, with World Bank technical as- new 10-year program. sistance, as the vehicle for implementing government of Senegal nutrition policy. Not only was it technical- Quality of supervision is rated highly satisfactory. The ly sound (see Relevance of Design in this section), it focus on development impact was very strong. World 22 A Decade of World Bank Support to Senegal’s Nutrition Program Bank missions and their aide-mémoire were highly fo- the project’s success, as evidenced by its manage- cused—both in their content and in their process—on ment structure placed in the prime minister’s office; the PDO: to build a capable institutional and organi- a generous counterpart provision, which exceeded its zational framework for NEP implementation at every commitment; and a well-developed policy and explicit level of the system. The missions’ close supervision objectives, which have also been captured in its over- and guidance ensured the successful implementa- arching development strategies. Under the oversight tion of the various components of the monitoring and and guidance of the director of cabinet (in the prime evaluation system. The task team was also flexible minister’s office) the CLM convened regular meetings and wise in allowing the BEN the time needed for its of representatives from all relevant sectors to support own capacity building before rolling out interventions and nurture an increasingly multisectoral approach. at the community level. Although this slightly delayed The government of Senegal supported the decen- the launch of community-level activities, the strategy tralized, community-based structure, which left much was well worth it because the rollout was smooth and flexibility and decision making to the local level, and it efficient. Fiduciary aspects of the project were well su- supported the beneficiary assessments commissioned pervised, with intensive oversight and support in the by the project. The government’s actions to recruit project’s first year. Supervision inputs and processes very highly qualified experts to staff the CLM and the were strong and well appreciated by the Borrower. BEN and BERs were pivotal to the success of project Two supervisions per year, complemented by addition- implementation and learning by doing. Transition ar- al technical missions from Dakar-based staff, provided rangements were well embedded in the APL design. ample support. The transition of responsibility to a new task team leader at the start of implementation was The performance of the CLM, as implementing agency, smooth; and both task team leaders were seasoned is rated highly satisfactory. This assessment of the nutrition experts. Both the World Bank’s dialogue CLM includes its secretariat (the BEN and its regional during these missions and subsequent report writ- offices). The CLM has been and remains highly com- ing were candid and of high quality. Feedback from mitted to achieving the PDOs, which are fully supportive the client on the World Bank’s performance was very of national policy. It both encouraged and facilitated strong and broad. Great appreciation was expressed beneficiary stakeholder consultations through regular for the quality of the team and its continued contribu- monitoring committee meetings held at every level of tions to improved performance, both on the technical the program and a monitoring and evaluation system and implementation fronts. The government of Sene- that included studies to seek the beneficiary perspec- gal’s contribution to the ICR characterized the World tive. All key staff were highly qualified, well trained, and Bank’s support as “tremendous,” and this was echoed have stayed in their positions for a long institutional throughout the PPAR mission, at all levels of the memory and accumulated experience. Some staff were program. drawn from the CNP and still remain with the program (some 10 years later) because of their high motivation Borrower Performance to make a difference. There was a change in the CLM coordinator, but he was replaced with an equally qual- Overall borrower performance is rated highly ified, well-performing leader and manager. Its fiduciary satisfactory. performance has been exemplary. The BEN has suc- cessfully managed day-to-day project management, Government performance is rated highly satisfac- effectively handled the community subcontracts, and tory. Its ownership and commitment to achieving the provided capacity strengthening for NGOs in financial PDO was strong because the PDO was fully sup- management procedures. It was instrumental in clar- portive of government of Senegal nutrition policy and ifying institutional arrangements established between objectives.35 It provided an enabling environment for CLM and sector ministries and was successful in A Decade of World Bank Support to Senegal’s Nutrition Program 23 improving the collaboration between the NEP and the The indicators were measurable and some baselines Ministry of Public Health. Systematically, during field were available and documented in the PAD, largely trips for this evaluation, the CLM was recognized for its drawn from DHS. Other baselines specific to inter- rigorous and transparent management style, grounded vention areas were established by KPC surveys and in a monitoring and evaluation system, which promotes an impact evaluation. The program coverage targets the sharing of performance data and its use for deci- (35 percent of the targeted population in the rural ar- sion making by stakeholders up and down the system. eas and 50 percent in the urban areas) might have Over time, the CLM has established itself as the fo- been more specific in defining the denominator: pop- cal point for nutrition policy development, and its good ulation in the targeted regions, districts, or within reputation has attracted more development partners these, communities directly receiving interventions. to work through this institution. It was instrumental in The numerator might also have been better specified: involving other sector ministries in planning, manag- children under age three or five, pregnant and lactat- ing, and monitoring nutrition program activities. It held ing women, or mothers of children under age three or quarterly meetings to review progress and approve five. An appropriate mix of data collection methods annual action plans and budgets, conducted regular and analysis was proposed, including national anthro- supervision missions, and approved sector and com- pometric surveys, micronutrient prevalence survey, munity-based projects. awareness and beneficiary assessments, DHS, per- formance assessments, routine project data, and an Monitoring and Evaluation impact evaluation. The quality of monitoring and evaluation is rated The monitoring and evaluation design was well em- substantial. bedded institutionally and emphasized stakeholder ownership and use for the purposes of learning, ac- Monitoring and evaluation design. The monitoring countability and decision making. The PAD specifies and evaluation design of this first phase of the APL laid output and outcome indicators, monitoring and evalua- out targets and indicators for the entire 10-year pro- tion roles and responsibilities, and participatory events gram and for each of the three individual phases. The for the discussion and use of data for each level of the 10-year indicators reflected objectives to improve the system: community, district, region, and central. Per- growth of children under age three, specifying targets formance against the triggers, under the APL design, for improved knowledge of caregivers, better nutrition for transition to Phase II was to be assessed on the outcomes, and the expected acceleration of child mor- basis of results provided by this system and indepen- tality, as an effect. The first phase indicators (relevant dent evaluation. to this project) specified targets for improved program coverage, improved knowledge of mothers and other Monitoring and evaluation implementation. Mon- caregivers, adoption of healthier behaviors (exclusive itoring and evaluation activities were implemented breastfeeding and increased use of prenatal care), largely as planned. Routine collection and reporting and better nutrition outcomes (underweight and se- of data started with the nutrition aides, who report- vere underweight prevalence among children under ed monthly trends in target populations attending three). Although ambitious for the project’s short time growth monitoring and behavior change sessions and frame and not a fair measure of the project’s capaci- in healthy weight gains of children under age three. ty building objectives, the nutrition outcome indicators These and other program data were reviewed and were reflective of the program’s ultimate intent. More- compiled by NGOs into district-level reports, then over, the design included triggers for moving from the submitted to the regional offices for further compila- first to second phase, which included measures of ca- tion and analysis, and finally to the national level for pacity built (appendix D, table D.2). program-wide compilation and analysis. This routine 24 A Decade of World Bank Support to Senegal’s Nutrition Program reporting was supplemented by special surveys and Monitoring and evaluation use. There is strong evi- studies, including beneficiary assessments, KPC sur- dence, already documented in this section, of the use of veys, and an impact evaluation. Although the results data for decision making. The initial selection of target of the impact evaluation provide some insight, dis- districts, regions, and communities was based on pov- cussions with program staff confirm doubts raised by erty and malnutrition data. The satisfaction of triggers this evaluation that “control groups” really existed in for moving from Phase I to Phase II were contingent Senegal when that evaluation was undertaken.36 Both on results and thus provided strong incentive to ensure then (2006) and now, Senegal has numerous partners that the monitoring and evaluation system operated supporting a whole variety of maternal and child health satisfactorily. Throughout implementation, positive re- and nutrition interventions. Results focus and trans- sults from regular monitoring data provided important parency in the sharing and use of information were feedback, which encouraged communities, NGOs and highly appreciated by respondents. A solid monitoring the government of Senegal to remain committed to the and evaluation plan was produced and implemented. project. Moreover, cost-effectiveness data provided a Monthly, quarterly, and annual reporting on project im- basis for comparing various approaches developed by plementation performance and financial management NGOs. The impact evaluation, as well as other program was timely and cited by World Bank for its quality. data, fed into the refinements of the Phase II design. A Decade of World Bank Support to Senegal’s Nutrition Program 25 3 Nutrition Enhancement Project in Support of the Second Phase of the NEP (NEP II) Objectives, Design, and Relevance tion in children under the age of five by 25 percent in the intervention areas by 2011. Project Development Objectives Revised PDO. On additional financing, approved on Original PDO. The financing agreement of December March 29, 2012, the PDO was reworded. As reflected 5, 2006, states, “The objective of the Project is to im- in the April 20, 2012, financing agreement, “The objec- prove nutritional conditions of vulnerable populations, tive of the Project is to improve nutritional conditions in particular children under five years of age in poor of vulnerable populations, in particular children under urban and rural areas” (World Bank 2006a, 6).37 Spe- five years of age in the Intervention Areas.” The origi- cifically, and as noted in the PAD, the program (with nal and revised objectives statements are essentially project support) aims to reduce underweight malnutri- the same: the revised objective merely clarifies that TABLE 3.1: Key Performance Indicators for NEP II: Original and Revised Original Targets and Indicators Revised Targets and Indicators • An increase in overall program coverage of children • Target increased. Target was raised to 62 percent, which was under age five in rural areas from 15 percent in 2006 to the level of progress achieved at the time of restructuring 40 percent in 2011 • Target increased. Target was raised to 65 percent in light of • An increase of 30 percent in the prevalence of exclusive the achievement 63 percent at the time of restructuring breastfeeding of children 0–6 months old • Target increased. Target was raised to 75 percent, in light of • The attainment of at least 40 percent of pregnant women the achievement of 71 percent at the time of restructuring and children under age five sleeping under insecticide- • Target increased. Target was raised to 1.1 million, which was treated bed nets the level of progress achieved at the time of restructuring • An increase in the number of people with access to • New outcome indicator. An increase in the share of a basic package of health, nutrition, and population children aged 6–23 months receiving yearly a minimum of 90 services from 265,073 to 709,124 micronutrient sprinkles sachets for three months in intervention areas from 0 to 30 percent Source: World Bank 2006b for original targets; World Bank 2012a for revised targets. A Decade of World Bank Support to Senegal’s Nutrition Program 27 the “poor urban and rural areas” will be the project sive growth and equitable social services delivery but intervention areas. Although most outcome indicators does not include a nutrition follow-up operation or nu- remained the same under this restructuring, outcome trition-specific targets or indicators. It does emphasize targets were increased, and a new outcome indicator reducing food insecurity as part of its agriculture sector and target were added to reflect additional activities program. As discussed in paragraph 2.8, the objective aimed at anemia control. Itemized in table 3.1, these is very relevant to the World Bank’s HNP strategies. changes do not warrant a split rating methodology.38 Project Design The geographic scope of interventions to be supported under the project consisted of continued support of the Although originally envisaged as the second of three intervention areas covered under the NEP I and rural phases of support under a 10-year APL, the PAD notes areas in an additional three regions.39,40 Data-based that this project would be the second and last phase.43 targeting methodology and criteria and a multi- The first project period of four years (2002–06) and the ple-tiered participatory process employed under NEP I projected five-year, implementation period of the sec- (see paragraph 2.3) were also applied for this project. ond project (2007 to early 2012) would cover almost the entire original 10-year period. The PAD states Relevance of Objective that the second phase would bring best practices “to scale” but does not specify the APL’s 10-year objective The relevance of the objective is rated high.41 of achieving nationwide coverage. Follow-on support was expected to come from the national budget and First, it is highly responsive to country conditions, other funding sources, and “possibly other more con- characterized by unacceptable rates of underweight solidated financing mechanisms from the World Bank,” among children under five and pregnant and lactating including budget support, community-driven develop- women, as well as stunting rates among children un- ment, and sector wide approaches. der five that were known at the time of project design.42 Components. Box 3.1 presents (1) the components, Second, it is highly responsive to Senegal’s strategic as originally designed, built on the accomplishments priorities, whose 2006 PRSP identified a decrease in and lessons from the first phase; and (2) changes malnutrition as critical for achieving Millennium De- made at the time of the additional financing and re- velopment Goal 1, specifically halving the number of structuring of March 2012. people who suffer from hunger between 1990 and 2015. Senegal’s National Nutrition Policy was a clear articu- Relevance of Design lation of the importance it placed on the fight against malnutrition, and the NEP was the vehicle for support- The relevance of design is rated high. ing and implementing those high-level policy goals. As such, the project builds seamlessly on the first phase In keeping with the incremental approach of the APL, of the APL. this project’s PDO (aimed at improving nutritional con- ditions) is more ambitious than NEP I, which aimed to Third, the objective is highly relevant to the World build capacity for implementing this newly established Bank’s strategies for Senegal over the years. The 2003 program. Still, it follows the same sound program log- CAS included a human development, shared growth ic as the initial project: the delivery of cost-effective pillar emphasizing access to social services and en- community-based nutrition interventions, support- hanced opportunities for the poor and vulnerable. As ing and nurturing both supply- and demand-side is already noted in paragraph 2.7, the current CPS responses; the strategically prioritized and incre- (2013–17) focuses on two pillars emphasizing inclu- mental involvement of key sectors for an increasingly 28 A Decade of World Bank Support to Senegal’s Nutrition Program BOX 3.1: NEP Phase II Components: Original and Revised Component 1. Community-based nutrition Ministry of Education—revised under additional • Promotion of community-based IMCI and financing to add ministries responsible for monitoring of growth through agriculture and childhood development; • monthly growth monitoring of children under • identification of areas of collaboration between two, counseling feedback to mothers, home the Ministry of Public Health and Ministry of visits to children requiring special attention and Education—revised under additional financing cooking demonstrations; to add ministries responsible for agriculture and childhood development, with an emphasis on • promotion of infant and young child feeding strategic planning; updating of nutrition-relevant practices, disease preventive measures, norms for the promotion of a strategy to fight particularly of malaria, by promotion of bed net anemia; health and education sector advocacy use by children and pregnant women, home- for nutrition; health and nutrition education; based care, recognition of danger signs, and and delivery of essential health and nutrition timely care-seeking for sick children; and services. • added under additional financing, community • technical assistance or coordination with sector screening, nutritional rehabilitation, and follow-up of ministries for child growth at community level; acute malnutrition of children ages 6–59 months. • support to the HIV/AIDS and nutrition strategy. • Promotion of micronutrient intake through • dissemination of information on dietary diversification, vitamin supplements, fortified Component 3. Implementation and monitoring foods such as iodized salt, and deworming and evaluation of the nutrition policy medication; • Support for implementation and monitoring and • referral of children at risk to health centers; and evaluation of the nutrition policy through • support for the intake of iron supplements by • updating of the monitoring system (and its tools) pregnant and postpartum women—revised and of community nutrition activities to include under additional financing to include distribution the role of targeted local government and sector of iron supplements and promotion of their use ministries; by children under age five and pregnant and • institutionalization of ad hoc studies, both postpartum women. quantitative and qualitative, regarding • Added under additional financing: Promotion of child growth, the hungry season, and client food security at the community level through satisfaction within the monitoring system— changed under additional financing to children’s • development of small livestock herds and nutritional status, household food security, and backyard gardens for household fruits and client satisfaction with the monitoring system; vegetables; and and • development of village grain banks for staple • strengthening of the decision-making process by food storage for lean season. enhancing analytic capacity and accountability at local, district and central levels—under Component 2. Multisectoral support for nutrition additional financing, this expanded to include • Support involves carrying out of a household survey to strengthen the information base for monitoring and • updating and strengthening of the annual evaluation; and provision of goods required for work plans of the Ministry of Public Health and the purpose. Source: World Bank 2006b for original components; World Bank 2012a and 2012b for revised components. Note: Planned versus actual costs by component are shown in appendix C. synergistic and multisectoral approach to nutrition; ports and nurtures a learning-by-doing approach at continued strengthening of the ownership, involvement every level of the system. All of these together are log- and leadership of local-level and community-based ically and plausibly and linked to expected changes actors and stakeholders, both public sector and civil in the knowledge of caregivers and in their behaviors society; and a professional, transparent, participatory, and practices, culminating in improved nutritional evidence-based approach to management that sup- status of women and children. Already deemed as A Decade of World Bank Support to Senegal’s Nutrition Program 29 highly relevant under the Phase I, the results chain with essential micronutrients. Third, and probably under this project’s design was further improved most significantly, in keeping with new responsibilities based on experience and lessons learned under the transferred to the local governments under the de- first operation. It (1) placed stronger emphasis on the centralization process, including nutrition, health, and dissemination of information on dietary diversifica- education, the local governments were responsible for tion, micronutrient supplements, fortified foods, and selecting a CEA (with BER assistance) to which it will deworming medication; (2) added support for the in- contract out community-based interventions; submit- take of iron supplements by pregnant and postpartum ting a subproject proposal to CLM for funding; signing women; and (3) included the referral of children at risk a contractual agreement with the BEN after subproject to health centers. approval; monitoring and reporting on activities; and incorporating nutrition activities and indicators in local The 2012 additional financing added further refine- development plans. BERs were to guide and support ments, making the program logic even stronger, local governments to this end. particularly for community-level screening, rehabili- tation, and follow-up of acute malnutrition of children ages 6–59 months; expansion of multisectoral support Implementation to include public agencies responsible for agriculture and childhood development (in addition to the Min- Key dates. The project was approved on November istries of Health and Education); promotion of food 13, 2006, and became effective on January 29, 2007. security at the community level through livestock Funds were reallocated twice (June 2008 and Decem- development; household production of fruits and veg- ber 2011). On March 1, 2012, the original closing date etables; and creation of village grain banks for food was extended from May 14, 2012, to June 14, 2013, storage. and targets for indicators that had been achieved (or almost achieved) were revised upward. On March 29, Implementation arrangements. Implementation ar- 2012, the World Bank approved additional financing of rangements built on the experience and lessons of SDR 6.5 million (US$10 million equivalent) to increase NEP I. Roles and responsibilities remain the same for program coverage and intensity. On May 15, 2013, the the most part: nutrition aides deliver community-based closing date was extended by one year (from June 14, interventions; NGOs and CEAs guide, oversee, and 2013, to June 14, 2014). report on community-level activities on a contractu- al basis; the Ministry of Public Health and Ministry of Planned versus actual costs, financing, and dis- Education implement key interventions that fall within bursements.44 The PAD estimated the total cost of their mandates and are included in strategic work plans the entire Phase II of the program (2007–11) to be supported under the project; and the CLM assumes US$42.4 million (equivalent), with 70 percent of the oversight responsibility, in keeping with its mandate to funds allocated to community-based nutrition (compo- coordinate government of Senegal nutrition policy im- nent 1). Within the program was the project, whose plementation through a multisectoral approach. There estimated cost at appraisal (US$15 million equivalent) were refinements to implementation arrangements un- was 100 percent World Bank–financed and allocated der this project. First, as envisioned from the start, the (as for the program) largely to community-based nu- secretariat to the CLM, the BEN and its regional offices, trition. Actual program costs were tracked by the CLM have evolved from being more of a time-bound project in CFA francs and are presented in appendix C, table management unit to a fully nationally owned structure, C.13. Actual project costs were US$25.3 million equiv- accountable to the CLM. Second, the CLM created a alent or 169 percent of the original estimate (World National Committee for Food Fortification to look into Bank 2014). This cost increase was entirely attribut- technical and operational aspects of food fortification able to the additional financing secured in 2012. Both 30 A Decade of World Bank Support to Senegal’s Nutrition Program the original IDA allocation (SDR 10.1 million) and the agreed counterpart funding for this program in the ini- additional financing (SDR  6.5  million) were fully dis- tial years of Phase II.45 This setback was, however, bursed. An amount of SDR 3.0 million was reallocated temporary, and the government of Senegal has con- to the grants subprojects categories, because other tinued to increase its allocations to the program (see partners were supporting some of the expenses in paragraph 3.15). During the project period, adminis- the other disbursement categories, especially drugs, trative regions were redrawn and increased from 10 other commodities, and technical assistance and to 14 regions. The number of local collectivities also training. Government financing of the program was increased from 384 in 2005 to 552 in 2016. Health dis- US$23.4  million (equivalent), significantly more than tricts also increased from 52 in 2005, to 69 in 2008, the US$16.3 million (equivalent) estimated at apprais- to 76 currently. This made it difficult both to plan and al. Other partners contributing to program financing measure coverage. included Micronutrient Initiative, WFP, UNICEF, Span- ish Cooperation, and Global Alliance for Improved Within the CLM’s control. Because of budget con- Nutrition, whose annual contributions are shown in straints (due to initially low counterpart funding from appendix C, table C.12. the government of Senegal and to the World Bank’s reneging on its initial financial commitment to support Factors Affecting Implementation three phases under the APL), the CLM was obliged to scale back the coverage and intensity of program in- Outside the government’s control. A series of terventions. Actual disbursements of IDA funds in the droughts and the global food price and financial crisis initial years were higher than estimates, making up for caused significant challenges to the population. Sharp temporary lack of government of Senegal counterpart increases in food prices in 2008 and 2009 had a direct funding of the program. In response, CLM increasing- and negative influence on access to food, especially ly played a catalytic role in mobilizing resources from for the poorest and most vulnerable. Given that Sen- international development partners and in promoting egal imports 80 percent of its rice consumption, many more and better partnerships within the country (multi- were unable to afford their basic food needs. Moreover, sectoral and public-private). This was facilitated by the inadequate rainfall undermined local food production. World Bank, which encouraged the coordination and There was a full-on drought in 2010, and low, errat- collaboration of development partners around the NEP. ic rainfall during the following two years culminated in poor harvests for 2011 and 2012. All of these had Safeguards compliance. No safeguards were trig- negative repercussions on the nutritional status of the gered under this project. poor and vulnerable who were the target of the project. Fiduciary compliance. As was the case for the first Within the government’s control. National elections project, financial management was of high quality, in 2007 resulted in a brief, temporary reduction in thanks to a stable and capable staff. All audit reports ownership of the program at the highest levels of gov- were unqualified and submitted on time and accept- ernment. This resulted in the CLM being moved from ed by the World Bank. There was a five-month delay the prime minister’s office to a newly created Ministry in setting up a disbursement mechanism for new ac- of National Solidarity. Thanks to the advice and input tivities added under the additional financing, but this provided by the project coordinator and the World did not have a major effect on implementation. Pro- Bank to the prime minister, the unit was subsequently curement also continued to be satisfactory, as it had reinstated at the prime minister’s office. The increas- been under the first project, and the internal control ingly precarious economic and budgetary situation system continued to perform well. One exception to of the country, linked with the global financial crisis, the strong procurement performance was a delay of caused the government of Senegal not to provide the over a year for the procurement of sprinkles sachets, A Decade of World Bank Support to Senegal’s Nutrition Program 31 due to a complex procurement process among the of children ages 6–59 months in intervention areas CLM, UNICEF, and the World Bank. Once resolved, (or about 1.5 million children) were screened on a the distribution of the entire stock was undertaken in quarterly basis for acute malnutrition, a new activity under three months. introduced under this project. This resulted in 19,799 children under age five treated for moderate or severe acute malnutrition (according to the project monitoring Achievement of Objectives system). Appendix D, table D.3, presents the baselines, targets, Ninety-five  percent of children ages 6–59 months in and actual achievements of all outcome and interme- intervention areas received high preventive doses of diate outcome indicators and all the sources of these vitamin A twice yearly (according to lot quantity as- data. surance sampling [LQAS] surveys), surpassing the original and revised targets. This translated into about Objective 1 2.2 million children. By the project’s end, 1.94 million children, or 89 percent, of the target population re- Objective 1 was to improve nutritional conditions of ceived deworming medication twice yearly, surpassing vulnerable populations, in particular children under five the original (then dropped) target of 80 percent (accord- in poor urban and rural areas or intervention areas. ing to the project monitoring system). Forty percent of children ages 6–23 months received a minimum of The achievement of the PDO is rated substantial. 90 micronutrient sprinkles sachets for three months in intervention areas, exceeding the target. A total of Outputs or intermediate outcomes. The project sup- 500,000 insecticide-treated bed nets were distributed ported the continuation of activities launched under to target populations in intervention areas to protect NEP I and the expansion of these activities into addi- against malaria (which can cause anemia), meeting tional communities, located in all regions in the country. the target. Behavior change communications, dissem- From a 2005 baseline of 924, by 2013, 2,243 commu- inated by nutrition aides and health staff, encouraged nity nutrition sites were established.46 The number of knowledge and practices that would benefit both trained nutrition aides increased from 3,271 in 2006 pregnant and lactating mothers and their children.47 to 4,922 in 2014. The project also provided essential Moreover, new community-based activities to promote program commodities, including micronutrient supple- food and dietary diversification were supported with ments, deworming medication, insecticide-treated bed the establishment of 1,321 backyard gardens and live- nets, and other small materials (scales, pans for cook- stock projects, close to four times the target of 350 ing demonstrations). (according to the project monitoring system). Community-based nutrition aides delivered a range of The health, education, and agriculture sectors com- critical services to protect and promote the nutritional plemented the community-based interventions to status of target populations in the intervention areas. contribute to the goal of improving the nutrition sta- Ninety percent of mothers of targeted children partici- tus of vulnerable groups. The Ministry of Public Health pated in monthly information and education sessions, developed a strategy for child growth promotion in chil- surpassing the original target of 60 percent and fully dren under age two and revised the anemia prevention achieving the revised target of 90 percent. A total of and control strategy, both of which were subsequently 272,796 children under two benefited from improved adopted. The local-level health system (both district infant and young child feeding practices in the inter- and post levels) carried out regular supervisions of nu- vention areas, surpassing the (unchanged) target of trition aides, participating in the key nutrition events, 222,500. By the project’s end in 2014, 91  percent guiding the technical aspects of the work and reinforc- 32 A Decade of World Bank Support to Senegal’s Nutrition Program ing critical messages. Moreover, local health services stimulated the interest and involvement of men in took on the management of severe acute cases of mal- preserving child well-being, and stimulated women to nutrition, screened at the community level and referred launch income-generation activities used to buy millet to them, while moderate cases were managed at the and establish grain storage for feeding children during community level, under the supervision of the health drought periods. system. Thanks to interventions undertaken by the Ministry of Education: (1) 99 percent of targeted chil- Program interventions appear to have precipitated dren in primary schools receive weekly micronutrient substantially healthier behaviors. The share of infants supplements during the school year in the interven- exclusively breastfed for the first six months increased tion areas, surpassing both the original (80 percent) from a national baseline of 34 percent (DHS 2005) to and revised (90 percent) targets; (2) 80 percent of tar- 65 percent among target groups in the intervention ar- geted children in primary school received deworming eas (according to LQAS surveys). This level surpassed medication twice a year in the intervention areas, fully the original target of 44 percent and fully achieved the achieving the target; and (3) school vegetable gardens revised target of 65 percent. National DHS data show a were established in 60 schools in 2013; one year later more-than-doubling of the share of mothers who initiate 850 schools had vegetable gardens. breastfeeding within an hour of birth (from 23 percent in 2005 to 48 percent in 2010–11). Unfortunately, there In collaboration with the Ministry of Agriculture, 64 lo- are no trend data for the following years. By the proj- cal governments in the eight districts most affected by ect’s end, 86 percent of pregnant women and children chronic malnutrition were targeted to address resil- under age five were sleeping under insecticide-treated ience factors at the household and community level.48 bed nets in the intervention areas (according to LQAS Backyard livestock and garden activities, backstopped surveys). There was also a substantial increase in the by local agricultural extension workers and livestock share of pregnant women making at least four pre- experts, were put in place and successfully imple- natal care visits, from a baseline of 40 percent (DHS mented with a view to reducing food insecurity of the 2005 for all of Senegal) to 61 percent, surpassing both most vulnerable families within those communities. A the initial target of 52 percent and the revised target field visit to Mbar to observe firsthand the effects of of 56 percent. Nationwide, breastfeeding peaked at a herd of goats provided to the poorest households 39 percent in 2010 and then declined to 33 percent was very revealing. In this very poor village, the villag- in 2015 (DHS 2015). Despite advocacy and informa- ers themselves decided which 10 households would tion, education, and communication, unsatisfactory benefit from three goats each. They also decided that levels nationwide persist because of the unavailability when the goats multiplied they would be given to the of mothers (whether working or sick), cultural beliefs next-poorest households in the village. The goats are and practices, and the mixing of breast milk with other well managed by the village and used only to bene- liquids. According to the DHS (2015), only 58 percent fit the mothers and children. They cannot be sold or of children ages 6–9 months received food in com- slaughtered except to support the costs of treating a plement to breast milk. Although the NEP maintains sick child, feeding a child, registering births, or vacci- a strong focus on behavior change interventions for nating children. The goats have served as household improved infant and young child feeding, its coverage and village assets that have generated income and is not yet sufficient to have made a significant impact benefited the health of children. The local-level live- countrywide. Corroborating the quantitative data, stock agent visits often to vaccinate the goats, care which reveal changes in child nutrition practices in the for the sick ones, and strengthen the breed. Benefi- intervention areas, mothers interviewed during field ciary feedback said this intervention reduced poverty, visits were emphatic and consistent in noting that their stimulated women to weigh their children, changed younger children (those born after the start of the pro- behaviors in feeding and caring for their children, gram) were much healthier and better nourished than A Decade of World Bank Support to Senegal’s Nutrition Program 33 their older children, who either were too old to have growth monitoring and promotion activities may not be benefited from the program or whose benefit was hav- affordable to implement across the country. In short, ing been rehabilitated after being screened for acute there is a tension between the goals of increased malnutrition. These mothers noted that their younger coverage on the one hand, and enhanced quality and children would never reach the undernourished state intensity of services on the other; and the desire to that their older children suffered. extend coverage as much as possible within the re- source constraints is strong. Field visits and interviews By the end of the project, coverage of children under also revealed that scaling back the intensity and range age five with community-based services in rural areas of interventions was considered critical for continuing was at 73 percent, exceeding both the original (40 per- the program, especially in anticipation of the end of the cent) and revised (62 percent) targets (according to World Bank’s financing. the project monitoring system). This translates into about 1.6  million children under age five reached by The CLM has recognized that the measurement and the project, including the regular weighing and growth tracking of program coverage needs to be both more promotion sessions for children under age two and precise and more systematic. Thus in 2014, it commis- their mothers, who are counseled on feeding and care sioned a massive survey of national and international practices, and more than a million children under age partners supporting nutrition activities in the country.50 five who are screened for acute malnutrition every The survey sought to assess the coverage of 25 spe- month. In 2014, there were an estimated 2.2 million cific nutrition interventions delivered by the program children under age five in Senegal (appendix D, table to various target groups (different age tranches of D.6). Coverage of the program by local collectivity has children; different subcategories of women: pregnant, substantially increased. In 2005, the program covered reproductive age, lactating, mothers of young children; only 25 percent of the local collectivities (97 of a total adolescents; care givers; grandmothers; households; of 384). This increased to 72 percent (400 of 552) by communities; and health providers).51 The response 2015, then declined slightly in 2016 to 70 percent (385 rate was high at 95 percent (50 of 52 partners). The of 552) (appendix D, table D.7).49 It is important to note survey results reveal low coverage, countrywide, of that local collectivities “covered” by the program are essential nutrition interventions (appendix D, table not covered 100 percent. Rather, it means that certain D.8). This explains why, notwithstanding the project’s communities, identified within the local collectivities as coverage targets being surpassed in intervention ar- highly vulnerable, have nutrition sites, which deliver eas, the nationwide coverage of certain target groups interventions. In addition, information gathered from a with certain key interventions is still modest. The CLM range of respondents and field visits has introduced intends to repeat this survey periodically as a tool for some uncertainty about the real coverage of the pro- prioritizing interventions, setting coverage targets by gram. Essentially, because of financial constraints, intervention and by target group and tracking progress there are indications that the program has cut back more systematically. on the range and intensity of its coverage, compared to the package of interventions implemented under Outcomes. In 2014, 83 percent of children under age Phase I. Villages with populations under 1,000 were two participating in monthly growth promotion inter- slated under Phase II of the NEP to receive less inten- ventions showed adequate weight gain every month. sive quarterly interventions than villages with greater This is a significant outcome, given the very high rate populations, which were to benefit from monthly inter- of participation in this program (90 percent of all tar- ventions. Although no precise numbers were offered, it get children in the intervention areas). This outcome was noted that some of the nutrition sites were closed continues postproject: in 2015, 82 percent of all chil- and that not all sites deliver the full range of inter- dren weighed (1.5 million children) showed adequate ventions. Program staff expressed the concern that weight gain. There are no data on the success rate 34 A Decade of World Bank Support to Senegal’s Nutrition Program of community-based rehabilitation of wasted chil- project, evaluated in section IV, had an implementation dren. But mothers or caregivers, nutrition aides, and period that fell fully within the period of NEP II, thus other stakeholders interviewed during field trips spon- contributing to its outcomes. The efficacy of the project taneously spoke of these services as saving the lives in the project intervention areas is certainly attribut- of children. High levels of anemia have not subsided able to the World Bank’s support—but not exclusively. with most recent DHS data available showing two- There are a number of other national and internation- thirds of children and more than half of all women as al development partners working across the country, anemic. During the project period, national prevalence including in the project intervention areas, who have of underweight in children under age five (weight for also likely contributed to these outcomes. The CLM’s age) fluctuated but culminated in a 13 percent decline first-ever survey of all partners contributing to nutrition from 14.5 percent in 2005 to 12.6 percent in 2014. (cited above) is an effort to map all the activities, inter- Likewise, there were fluctuations and an overall de- ventions, and sources of support across the country. Its cline in severe cases from 3.9 percent to 2.2 percent. purpose is not only to inventory but also to assess and However, 2015 levels have risen to slightly higher than improve nutrition program coverage and effectiveness the project baseline. Again, program coverage targets (and actuals) had to be curtailed when the World Bank cut back on the initial commitments made under the Efficiency APL and so could not be expected to have a significant impact on nationwide trends. Efficiency is rated substantial. Attribution. Various development partners and donor Economic efficiency and cost-effectiveness. The agencies provide support to parallel nutrition projects ICR undertook an economic analysis, which reveals implemented by the same implementing agency, the high value for money. The economic analysis used a CLM. These partner organizations include UNICEF, conservative scenario, showed a high benefits-costs WFP, USAID, the Micronutrient Initiative / Canadian ratio (20:1), and a resulting net present value of ap- International Development Agency, the Spanish Mil- proximately US$1 billion. Moreover, the project fully lennium Development Goal Achievement Fund and disbursed both credits and most intermediate outcome the Global Alliance for Improved Nutrition. Since 2007, and outcome targets were surpassed, even after they these partners have participated in joint supervision were increased under the restructuring. missions, organized by the World Bank; since 2010, a nutrition donor support group has been set up; and Technical efficiency was strong. Community-based since 2011, Senegal has joined the Scaling Up Nutri- service delivery of prevention and promotional activ- tion movement, which calls for governments to provide ities supported under the project are among the most institutional leadership for large-scale nutrition policies cost-effective for improving nutrition outcomes (notably and programs and for the donor community to provide stunting) and have some of the highest cost-benefit ra- coordinated support. In addition, in response to the tios for poverty reduction and economic development. 2008 food and financial crisis, the World Bank mobi- These activities built on the positive findings from the lized US$8 million from the Global Food Price Crisis Phase I impact evaluation and on robust evidence on Response Program Multidonor Trust Fund and an ad- the effectiveness of community nutrition programs, as ditional US$10 million of canceled IDA resources to documented by the World Bank and other leading insti- support an emergency operation, which aimed to chan- tutions in the world.52 Planned activities were identified nel these funds directly into the NEP for its continued to generate maximum impact based on the evidence. expansion and into a pilot effort to provide cash trans- fers to highly vulnerable mothers to mitigate the effect Operational efficiency was also strong. The project of the food price crisis on the nutrition of children. The had impressive control over the planning cycle, in A Decade of World Bank Support to Senegal’s Nutrition Program 35 which activities, expenses and disbursements were Risk to Development Outcome fully linked and integrally managed. The original credit of US$15 million was fully disbursed by the original The risk to development outcome is rated significant. closing date and the additional financing of US$10 mil- lion was disbursed in just two years. The subsidiarity As was the case for the first phase project (see para- principle applied throughout the implementation frame- graphs 2.45–2.46), technical, social, government work, resulting in a lean management structure that ownership and commitment, and institutional risks are kept management costs at less than 12 percent, and all assessed to be low for the same reasons initial- overhead at just 3 percent, of total budget expen- ly discussed. Likewise, financial and natural disaster ditures. On two separate occasions, the CLM was risks are still assessed to be substantial. However, awarded the Alpha prize for the best performing proj- more weight has been given to the significant finan- ect management unit by the Ministry of Economy and cial risk at the end of this World Bank project, given Finance. No other implementing agency has this level the following: no follow-on project is currently under of recognition. implementation; not all development partner support to nutrition is channeled through the CLM and into the program; local government budgets have very limited Ratings capacity to absorb the costs of implementation; and there is a need to assess and address fair remuner- Project Outcome ation for the work of the nutrition aides, with some promising initiatives being explored. In the meantime, The project’s outcome rating is satisfactory. The field visits, including direct exchanges with nutrition project’s objective is highly responsive to country aides and the populations they serve, point to the conditions, Senegal’s strategic priorities, the World aides strong sense of mission, the high respect and Bank’s strategies for Senegal, and the World Bank’s appreciation they receive from their villages and local sectoral strategies. The relevance of design is high. authorities, and the satisfaction they receive from their Its results chain is well-articulated, plausible, and results. This is further discussed in section V. as strong as the one for the first project, with both the original and additional financing designs further World Bank Performance refined based on emerging evidence and lessons. Efficacy is substantial. All outcome targets were sur- Overall World Bank performance is rated satisfactory. passed, both original and as revised. Although none of the outcome indicators directly measured the Quality at entry is rated satisfactory. Phase II built objective of improved nutritional conditions, these on lessons learned from Phase I, which showed that outcome indicators do show strong performance community-based communication can effect behavior in the intervention areas in the coverage of these change and a reduction in malnutrition and that engage- cost-effective and proven services and in changes in ment with local government supports local ownership key behaviors, which are strongly linked in the liter- and sustainability. The World Bank also ensured that ature to improved nutritional status. Moreover, very the technical advice and recommendations emanating high rates of children showing adequate weight gain from the 2006 strategy, outlined in Repositioning Nu- and successful screening and rehabilitation of chil- trition as Central to Development (World Bank 2006c), dren with moderate and severe acute malnutrition were reflected in project design, especially the impor- also provide reassuring evidence that nutrition sta- tance of community-level interventions. The World tus improved. Efficiency was fully substantial, with Bank coordinated with other agencies and partners evidence of strong value for money and strong oper- to share knowledge and improve implementation ar- ational and implementation efficiency. rangements. It identified relevant risk factors during 36 A Decade of World Bank Support to Senegal’s Nutrition Program preparation, especially the risk of waning government and were well staffed with qualified experts. Significant of Senegal ownership following national elections in positive feedback was provided by actors and stake- 2007. It was ultimately successful in supporting the holders at every level of the program about the quality CLM in stimulating high-level interest and ownership of the technical work of the World Bank, the collegial and financing of the NEP. But this took some time. The nature of its collaboration with the CLM, and the strong World Bank might have ensured that there would be support and advocacy that its missions brought to more specificity and measures of the objective to im- bear. The World Bank’s focus on results was strong, prove nutrition conditions. At the time of project design, with joint troubleshooting and problem-solving with a the World Bank’s Country Management Unit made a view to enhancing PDO achievement, in line with the decision not to honor the commitment of IDA funds to comparative advantages of the various actors on the the second and third phases of the APL, made at outset sides of the World Bank and the government of Sene- of the three phases. It canceled the third phase of the gal. Thanks to its sound risk mitigation plan, the World World Bank’s commitment, and though it did support Bank was able to reallocate 15 percent of the cred- the second phase, it did so with significantly less IDA it to ensure implementation of core project activities funding than originally committed. As a consequence, when government of Senegal was unable to make its the coverage targets of the program had to be scaled planned counterpart contribution on time. Still, sever- back. Although this was a setback for the NEP, the al project activities had to be scaled back. The World CLM was emphatic in conveying to the PPAR mission Bank’s team worked closely with the CLM and govern- that the financial contribution was not the only valued ment of Senegal to ensure release of government of contribution from the World Bank. Its technical advice Senegal funds. and leadership were also highly valued, and ultimately the World Bank managed to attract and coordinate sig- Late in 2008, World Bank supervision reports raised nificant additional resources for the program. the concern that the PDO may not be achieved be- cause of the fast burn rate of IDA funding and the Quality of supervision is rated satisfactory. During absence of counterpart funds. This candid report implementation, the task team was highly proactive downgraded project performance ratings. The World in mobilizing resources to compensate for the World Bank was proactive in improving collaboration and Bank’s decision to provide less financing than orig- coordination of an increasing number of development inally committed under the APL. In 2009, the World partners with a view to reducing fragmentation of donor Bank’s team prepared, on an emergency basis, the assistance. The World Bank mobilized development Rapid Response Child-Focused Social Cash Trans- partners to conduct semiannual joint coordination and fer and Nutrition Security Project, which infused more supervision missions of the NEP. Indeed, this served resources into the NEP and supported the piloting to enhance coordination in the early years of the proj- of nonconditional cash transfers to poor, vulnerable ect (2007–09). In 2010, a turnover of development mothers to mitigate worsening malnutrition brought partner staff stationed in Dakar, combined with a push about by the food price crisis. Moreover, in 2012, the (among some development partners) for humanitarian World Bank’s team succeeded in acquiring addition- responses resulted in somewhat of a setback in donor al financing for the NEP. It also mobilized support coordination in the ensuing years. through analytic work and technical assistance tasks, notably an Institutional Development Fund Grant ap- Borrower Performance proved in 2009 to strengthen operational evaluation in program implementation; and (currently under way) Overall borrower performance is rated satisfactory. analytic work to assess program performance with a view to fine-tuning strategy and action for greater im- Government performance is rated satisfactory. The pact. Supervision missions were carried out biannually government of Senegal was highly committed to A Decade of World Bank Support to Senegal’s Nutrition Program 37 project implementation. The only exception was im- development and poverty reduction prospects and of mediately after the 2007 election when commitment their roles and comparative advantages in contributing changed, albeit briefly. At that time, the CLM was to NEP objectives. This was evident both in meetings moved out of the prime minister’s office and into the with the various sector representatives and during newly created Ministry of National Solidarity. Based on field visits, where local-level sector agents are already information provided to the prime minister by the proj- contributing to the program and local government of- ect coordinator and the World Bank (the task team and ficials are increasingly recognizing, nurturing, and the Country Management Unit), the prime minister ap- supporting these critical inputs (see also the section V preciated the strategic importance of keeping the CLM discussion on the multisectoral approach). in his office and the decision was quickly overturned. Different levels of government collaborated closely Implementing agency performance is rated highly sat- with the World Bank, which had a positive impact on isfactory. The CLM (including the BEN and its regional the decentralization of project implementation to the offices) continued the highly satisfactory performance local governments. The government of Senegal’s sup- it exhibited under the first project. The CLM had a port was also evident in the strong and stable staffing clearly defined mandate, which it fulfilled very well. Its of the CLM. staff had well-specified roles for which they were ful- ly qualified. Over and above their high qualifications The CLM has successfully worked with at least sev- were their high level of commitment to the program en prime ministers since its inception in 2001. All of and their long institutional memories.53 The project them are reported to have all provided strong and became effective earlier than planned due to efficient unequivocal support to the nutrition policy and pro- preparation by the CLM and the World Bank. The CLM grams. Counterpart funding was temporarily withheld worked across sectors and built effective partnerships during the 2007–08 budget crisis, but this was not with Ministries of Education and Agriculture, as well exclusive to the NEP. Rather, the budget crisis affect- as other sectors (in addition to the Ministry of Public ed counterpart funding of the entire portfolio of World Health). The CLM creatively overcame the monitoring Bank–financed projects. Once the budget crisis was and evaluation challenges related to striking health solved, the NEP, because of its outstanding perfor- districts holding back data. The conduct of LQAS mance, was first to receive the counterpart funding, surveys, a Standardized Monitoring and Assessment including 100 percent of all arrears. And government of Relief and Transitions survey in 2012 (producing of Senegal financing of the program exceeded initial departmental-level data) and household surveys all plans (see paragraph 3.15). The global Scaling Up served to fill this void and provide vital information on Nutrition movement singled out Peru and Senegal as project performance, over and above program data two model countries with strong government owner- reported from the intervention areas. Fiduciary perfor- ship. The Minister of Economy and Finance is highly mance continued to be exemplary (as under the first appreciative and supportive of Senegal’s NEP. During project). Indeed, CLM’s financial management was the World Bank’s Spring Meetings, the minister gave often used as example for other projects to follow. a speech on the importance of investing in nutrition The one exception to superlative performance was and on the success of Senegal’s NEP. A Ministry of the procurement of sprinkles sachets (see paragraph Economy and Finance official in charge of human 3.20). But the delay in procuring these sachets was development oversight, who met with the PPAR mis- mitigated with their very rapid and efficient distribution sion, stated that it was the best performing program in nationwide. government. During project implementation, there has been a growing recognition and commitment, across CLM, supported by the prime minister, proactively an expanding range of sectoral actors, of the impor- searched for additional resources to scale up inter- tance of the nutrition program to Senegal’s economic ventions. It did so by building partnerships with local 38 A Decade of World Bank Support to Senegal’s Nutrition Program development partners and by participating at several Development Goal documents); adoption of enabling international events on maternal newborn and child health sector policies and strategies; various mea- health at which they showcased their work. Additional sures of service coverage and use (by target group, financing was used to widen the intervention area, but type of intervention, and geographic area); and result- it was not sufficient to include all districts. The Minis- ing behavior changes (exclusive breastfeeding, bed ter of Economy and Finance awarded CLM the Alpha net use, prenatal visits). It did include indicators to prize for best performing program management unit track achievement of the PDO—improvements in the on two separate occasions. The World Bank’s inter- nutritional status of target groups (such as adequate nal reporting system continually pointed out CLM’s weight gain of children under age two). But comple- mastery of planning, implementation oversight, and mentary indicators might have included measures of monitoring, which also earned the praise of other severe and moderate underweight among children development partners and the government of Sene- under five; severe and moderate stunting among chil- gal. The CLM was successful in smoothly integrating dren under five; and women’s health and nutritional new activities into its core program, including: bed net status.54 distribution, therapeutic care of acute malnutrition, social cash transfers, salt iodization, and household The monitoring and evaluation system, already well food security, each of which became a success story. established under the first project, was functioning This is the mark of a well-established, well-perform- well, as managed by the CLM and coordinated with ing program. The CLM itself pointed out another key CEAs, which collected and reported community-level management skill, corroborated by other evidence: its program information. It was further refined to inte- ability to adapt proactively to a rapidly changing en- grate with CEA and health and education sector plans. vironment (changes in financing, CLM’s institutional Monitoring and evaluation activity was to rely on a home, country leadership, high-level government of multiplicity of complementary data sources: bottom-up Senegal ownership, exogenous factors, such as the program data, baseline and end line KPC surveys for economic crisis and drought among others). The CLM each subproject, and other studies of project impact. has also been recognized for the evidence base and transparency of its management and its strong focus Implementation of monitoring and evaluation. on results and learning. This was raised consistently The monitoring and evaluation design, grounded in throughout the PPAR mission, ranging from the high- the well-established system under the first phase, est levels of government to the local-level actors and was implemented largely as planned. But there were stakeholders. The mission was overwhelmed with very challenges. First, the tracking of coverage was com- positive feedback about the performance of the CLM. plex, given that the number of administrative regions, local collectivities, and health districts changed over Monitoring and Evaluation the life of the project. The monitoring of coverage by target group (children under age two, children under The quality of monitoring and evaluation is rated age five, mothers and caregivers, among others) in substantial. intervention areas overcame this constraint some- what. But the establishment of trends in geographic Monitoring and evaluation design included indi- coverage is tricky.55 Second, between 2010 and 2014, cators (with baselines and targets) for key elements health districts had been holding back the reporting of of the results chain: institutional development and critical data, motivated by a partial strike. To compen- stakeholder ownership and involvement (local gov- sate for this lack of data, CLM commissioned LQAS ernments incorporating nutrition objectives into their surveys to provide additional quality monitoring infor- annual development plans); integration of nutrition mation on indicators. These surveys also provided a into government of Senegal’s PRSP and Millennium cheaper, but good quality alternative to the KPCs.56 In A Decade of World Bank Support to Senegal’s Nutrition Program 39 2012, a good quality national SMART (Standardized Monitoring and evaluation use. Results from various Monitoring and Assessment of Relief and Transitions) surveys informed decision making. Regular feedback survey was undertaken, the first to have data repre- to regional and local stakeholders encouraged ad- sentative at the level of the department. This survey justments in project implementation when necessary. focused on the underlying determinants of undernu- Thanks to the already strong results-based manage- trition and provided the basis for the design of the ment focus of the program, information generated by additional financing. the monitoring and evaluation system was discussed and used at all levels of the program (community, lo- Drawing on the above studies, the 2012 restructuring cal, regional, and central levels) to monitor progress and additional financing documented the very strong and to make adjustments where progress was stall- performance of the project against the original outcome ing. Project support missions to operational levels targets and raised those targets as a consequence. It were organized around the findings of monitoring also added a new outcome indicator to measure cov- and evaluation systems, thus giving them a distinct- erage of micronutrient sachets for children ages 6–23 ly issues-oriented, problem-solving focus. As a result, months for anemia control. The adding and dropping stakeholders at all levels were fully informed of imple- of indicators and changes in targets are itemized in mentation progress and actively oriented to ways and appendix D, table D.3. means of further enhancing program performance. 40 A Decade of World Bank Support to Senegal’s Nutrition Program 4 Rapid Response Child-Focused Social Cash Transfer and Nutrition Security Project Objectives, Design, and Relevance improved nutrition-related knowledge and behaviors) and (2) to reduce the risk of nutrition insecurity of vul- Project Development Objectives nerable populations by providing cash transfers to vulnerable mothers of children under age five, improv- As stated in the financing agreement between Sen- ing their ability to procure essential foods and other egal and the IDA of June 12, 2009, “The objective of investments in their children’s well-being. the Project is to reduce the risk of nutrition insecurity of vulnerable populations, in particular children under Geographic coverage and targeting. The project in- five in poor rural and urban areas in the Recipient’s fuses additional World Bank financing to support the territory, by scaling up the Recipient’s Nutrition En- nationwide expansion of the NEP and the intensification hancement Program and providing cash transfers to vulnerable mothers of children under five” (World BOX 4.1:  Key Performance Indicators for Rapid Bank 2009a, 5).57 The project paper also states that Response Child-Focused Social Cash the overarching objective of government of Senegal’s Transfer and Nutrition Security Project NEP is to contribute to the attainment of the first Mil- lennium Development Goal of eradicating extreme • An increase from 22 to 45 percent in the target poverty and hunger through implementation of the population (children under age five) reached by the NEP Nutrition Development Policy, aimed at improving the • A 30 percent increase in share of mothers nutrition status of vulnerable groups, notably children providing exclusive breastfeeding for the first six and pregnant and lactating women (World Bank 2009c, months 5). For the purposes of this evaluation, two objectives • Number of beneficiaries of the cash transfer program: 50,000 and results chains will be assessed: (1) to reduce the • Percentage of selected beneficiaries who receive risk of nutrition insecurity of vulnerable populations all intended cash transfers: 80 percent by scaling up the NEP (community nutrition monitor- ing, promotion activities and other services leading to Source: World Bank 2009c. A Decade of World Bank Support to Senegal’s Nutrition Program 41 of program activities (scope and targeting described CAS, which was in effect at the design of the project in paragraph 3.3). The new child-focused social cash and whose second pillar aimed at “improving human transfer component applied three targeting mechanisms development through better delivery of social ser- to reach intended beneficiaries: category targeting (lim- vices, notably to the most vulnerable groups” (World iting eligibility to mothers of children under age five); Bank 2007b); and (2) the current 2013 CPS, which geographical targeting (based on the most up-to-date includes technical assistance for continued strength- data on poverty, malnutrition, and household food secu- ening of nutrition policy and program implementation, rity), culminating in the selection of 10 “critical districts”; as well as support for establishing an efficient safety and community-based household targeting (assessing net system, which was to be tested through pilot cash the presence of children under age five, inadequate transfer programs (World Bank 2013a). food consumption, and limited possessions), with the involvement of community-level organizations.58,59 Fourth, the project is highly relevant to the World Bank’s poverty alleviation mission and strongly sup- Relevance of Objectives portive and reflective of its thematic strategies for health and nutrition and for social protection. The relevance of objectives is rated high. Project Design First, the objectives are highly relevant to country con- ditions. Already high rates of malnutrition in Senegal The project was designed around four components, increased further following a series of shocks to the the first three aimed at scaling up and intensifying the economy, leading to a sharp rise in food prices and package of NEP activities and the fourth being the new deteriorating living conditions. This especially affected child-focused social cash transfer. the poorest and most vulnerable, whose food insecu- rity and nutritional risks were worsening under these Relevance of Design conditions. Two years of inadequate rainfall (2006–07 and 2007–08) resulted in a 25 percent reduction in ce- The relevance of design is rated high. real production, while prices for imported cereals were rapidly rising due to the global food crisis. The project design in support of the first objective (to reduce nutrition insecurity through the scaling Second, the objectives were highly relevant to Senegal’s up of the NEP) is strong. As laid out in paragraphs strategic priorities. Both Senegal’s poverty reduction 3.11–3.12, the underlying logic of the NEP is strong. and social protection strategies highlight the goal of bet- It comprises cost-effective, well-targeted, communi- ter nutritional outcomes. Moreover, Senegal’s nutrition ty-based interventions, commodities and services, policy supports the goals of improved health and nutri- which are directly supportive of improvements in tion and reduced nutritional insecurity, which it seeks to knowledge and behaviors, which, in turn, are ex- achieve through the scaling up of its main implemen- pected to culminate in improved nutritional status. tation mechanism—the NEP. In addition, the project is The design promotes key activities, ownership, and highly relevant to government of Senegal’s search for accountability for nutrition results of key sectors, in- new ways and means to accelerate its essential poverty cluding health (provision of maternal and child health alleviation programs and to provide more effective and and nutrition services and supervision of community efficient safety nets to those most in need, especially activities), education (provision of micronutrients and during a time of food price crisis. deworming activities in schools), and food fortifica- tion (with iodine, iron, and vitamin A), among other Third, the objectives are also highly relevant to the sectors. The involvement of communities, local gov- World Bank’s strategies for Senegal, both (1) the 2007 ernment, and a range of other sectors, combined with 42 A Decade of World Bank Support to Senegal’s Nutrition Program BOX 4.2: Rapid Response Child-Focused Social Cash Transfer and Nutrition Security Component 1. Community-based nutrition: This and education sector efforts in agreed annual work component supported community-based nutrition plans to improve growth and nutrition. Activities activities to be carried out monthly in targeted included periodic distribution of micronutrient communities with a population over 1,000 and supplements and deworming medicines in schools; quarterly in targeted communities with a population supervision of nutrition services; and scaling up of under 1,000. The following are key activities: food fortification. • Growth monitoring and promotion of child health Component 3. Support to implementation and nutrition: (1) community-based growth and monitoring and evaluation of nutrition promotion and integrated management of development policy: This component aimed to childhood illness sessions for children under age strengthen the implementation and monitoring two and for all children under age five through performance of the CLM, local governments, improved infant and young child feeding practices, and line ministries, with a particular focus on recognition of danger signs during illness and integrating the adapted the cash transfer program. home-based care; (2) mobilization of extended Technical assistance, training, and workshops caregivers to take part in social and behavior supported continued promotion of ownership and change communication, including grandmothers, accountability of stakeholders, especially local in-laws, men and other relatives, important government. for the survival of infants and young children; (3) screening of acute malnutrition and support Component 4. Child-focused social cash for the management of identified cases at the transfers: The cash transfer component was to use community level; and (4) training and supervision the NEP community organization structure to identify of nutrition aides. eligible beneficiaries (mothers of young children • Micronutrient provision and promotion: (1) provision in vulnerable families), who would receive small of iron and vitamin A supplements, deworming bimonthly payments of CFAF 14,000 for six months, medication, and insecticide-treated bed nets for a total of CFAF 42,000. The cash transfer along with behavior change communication and would be accompanied by a strong communication counseling to address micronutrient needs of campaign emphasizing messages about maternal mothers and pregnant women, as well as children; and child nutrition and close monitoring of (2) community-level communication activities to process and effect. Beneficiaries were identified create demand for fortified foods (especially iodized through geographical (most vulnerable districts), salt), vitamin A, iron supplements, and dietary category (mothers of children under age five), and diversification. community-based (most vulnerable households) targets, with oversight and verification provided by Component 2. Sectoral support for nutrition local selection and regional monitoring committees results: This component aimed to support health as well as the CEAs. Sources: World Bank 2009a, 2009c. Note: Planned versus actual costs by component are shown in appendix C, table C.7. a monitoring and evaluation system that is used at fers were unconditional, based on the evidence of each level of the system, enhances awareness and international studies, which show that additional cash monitoring of nutrition efforts by communities and all provided to female household members is spent on levels of government. family welfare, especially the well-being of the children. Its pilot design sought to test and refine a feasible and The project design in support of the second objec- replicable instrument that could effectively mitigate ad- tive (to reduce nutrition insecurity by enhancing the verse effects of shocks on populations most in need, food-buying power of mothers with cash transfers) is and it relies on the NEP, a delivery system that has also strong. It targeted the most vulnerable families been proven. with children under the age five in 10 high-poverty dis- tricts with high levels of malnutrition as a means of Implementation arrangements. Implementation ar- increasing household consumption. The cash trans- rangements for the first three components were the A Decade of World Bank Support to Senegal’s Nutrition Program 43 same as for the World Bank’s second phase support Implementation to NEP (see paragraph 3.13). In summary, the CLM, through its secretariat (the BEN and its regional offic- Key dates. The IDA credit was approved on May 6, 2009, es), is responsible for coordinating and supervising became effective on September 11, 2009, and closed on the various implementing actors: line ministries, local August 31, 2012. The original closing date (December governments, CEAs, decentralized public services, 31, 2011) was extended because of implementation de- communities, and nutrition aides. Sector ministries lays in the cash transfer program due to the absence formulate policies, norms, and protocols, undertake of payment outlets in remote areas and the consequent quality assurance, and implement discrete activi- need to develop ad hoc distribution arrangements. ties agreed in work programs. On behalf of the local governments, responsible for program design and Planned versus actual costs, financing, and disburse- implementation at the local level, CEAs (select- ments.60 The actual cost of the project was calculated ed and contracted by local government) assume at US$18.2 million at the time of project completion, or primary responsibility for subgrant proposals, im- 101 percent of the original estimate of US$18.0 million plementation, oversight, and financial management. (World Bank 2013b). Because there was no government To this end, a grant agreement is cosigned by CEAs counterpart planned or provided for in this particular proj- and local government under which CEAs report to ect, the total estimated cost of the project (US$18.0 million) local authorities and the health district. Communities was equal to the total estimated financing, which com- choose nutrition aides, determine sites for program prised an IDA credit of US$10 million equivalent and a activities, and establish committees to oversee those multidonor trust fund of US$8 million equivalent. Actual activities. CEAs, in collaboration with health service financing data, retrieved from the World Bank’s informa- providers and local authorities, provide technical tion system in October 2016, reveals total financing of support to communities. US$18.5 million, of which US$10.6 equivalent was pro- vided by the IDA credit and US$7.9 million was provided The cash transfer component was to rely on the NEP by the multidonor trust fund. The difference between the structures and processes for its implementation, in- actual cost of the project and its actual financing in U.S. cluding the overall coordination and oversight of the dollar equivalents is likely a function of different calcula- CLM. In non-NEP areas, the same cash transfer tions of the exchange rate.61 mechanisms were to be used, accompanied by nutri- tion communication activities, but without the monthly Both the IDA credit and the multidonor trust fund were NEP activities. The first set of beneficiary communi- fully disbursed, according to World Bank system data. ties were to be deliberately selected from areas where There was a reallocation of the IDA credit proceeds in community-level interventions had been implemented December 2011, which increased allocations for sub- for at least six months. Over time, other communities grants for community nutrition activities and reduced where NEP was not operating would also be selected. the allocations in the two other categories (commod- Cash transfers to families in these communities would ities, consulting fees, training, audits, and operating be accompanied by nutrition communication activities. costs). This reallocation was in response to contribu- The two implementation models were to be assessed tions by development partners, which covered some of and compared. The distribution of funds was contract- the costs under these two categories and thus liberat- ed out to a financial institution with local outlets as ed funds for subproject financing (World Bank 2011). close to the beneficiaries as possible. In the interest of transparency, whistleblowers were to be set up at dif- Factors Affecting Implementation ferent stages of the process, particularly targeting and payment, and the eligibility criteria and list of selected Within the government’s control. PRSPs for 2002 beneficiaries were to be publicly disclosed. and 2007 highlighted the development of a national 44 A Decade of World Bank Support to Senegal’s Nutrition Program social protection strategy as an integral step for the the contracting and training of CEAs, who animated country’s development and poverty alleviation goals. and oversaw implementation on behalf of local gov- This provided an enabling environment for the piloting ernments. Intensity of interventions was tailored to of the cash transfer scheme. Also enabling the success the size of communities, with those with over 1,000 of this project, and within control of the CLM, were: inhabitants having monthly activities and those with a well-established, intersectoral, community-based populations under 1,000 having quarterly activities. platform for the delivery of services; the strong com- Activities supported under subprojects included: com- mitment and participation of a range of actors at every munity-based growth promotion, health, and nutrition level of the system; a transparent, trustworthy man- education; provision of essential micronutrients and agement style; and an evidence-based approach. other commodities and related behavior change inter- ventions; outreach to caregivers in addition to mothers Safeguards compliance. No safeguards were trig- (grandmothers and in-laws among others); screening gered under this project. of acute malnutrition and education on community management of moderate cases, with severe cases Fiduciary compliance. Fiduciary compliance was rat- referred to the health post; and training and supervi- ed satisfactory throughout the project period. Annual sion of nutrition aides by the Ministry of Public Health. audit reports were submitted on time with unqualified audit opinions and were acceptable to IDA. The pro- Intermediate outcomes and outcomes. The program curement plan was in place at the beginning of the was successfully scaled up in terms of both its overall project. Implementation was satisfactory, and the in- coverage of the main target group and of the expansion ternal control system performed well. of the menu of interventions delivered. From a base- line of 22 percent, program coverage of children under age five increased to 65 percent, exceeding the target Achievement of Objectives of 45 percent. This translated into 1.34 million children, of whom 453,997 were urban and 886,878 were rural Appendix D, table D.4 presents the baselines, targets, (according to the project monitoring system). More- and actual achievements of all outcome and interme- over, as the program gained a strong reputation and diate outcome indicators and all the sources of these increasingly involved local government in implementa- data. tion, monitoring, and evaluation, local-level ownership and leadership continued to grow. Thirty percent of Objective 1 local governments incorporated nutrition objectives and interventions in their local development plans at Objective 1 was to reduce the risk of nutrition inse- the end of the project, surpassing the target of 25 per- curity of vulnerable populations, in particular children cent, and this level has been maintained each year under age five, in poor rural and urban areas, by scal- thereafter (2013–2015), according to the CLM project ing up the NEP. monitoring system). The achievement of objective 1 is rated substantial. With project support key, proven nutrition and child well-being services were delivered to vulnerable pop- Outputs. Project support was largely channeled ulations and their use was high. Growth promotion through the negotiation and award of subgrants for and monitoring activities covered close to 90 percent community nutrition interventions, focused on mo- of children ages 0–24 months. A very high 95 percent bilizing and supporting new health districts with high of mothers of children under age five participated in malnutrition rates and on increasing coverage in dis- monthly information and education sessions, or a to- tricts already mobilized. Project support also included tal of 1.73 million mothers (according to the project A Decade of World Bank Support to Senegal’s Nutrition Program 45 monitoring system). This exceeded the project target of oil were fortified. The quantity of iron-enriched flour of 80 percent (1.5 million mothers) and encompassed produced by local industry was 164,710 tons in 2015, both the newer, harder-to-reach areas as well as more surpassing the project target for 2011. established NEP communities. The share of children ages 6–59 months receiving vitamin A supplementa- Critical behaviors changed in the intervention areas, tion was 94 percent in 2012, surpassing the target of particularly the share of mothers practicing exclusive maintaining a level of 80 percent. This high level was breastfeeding of children up to age six months, which continued postproject: 96 percent in 2013, 95 percent exceeded the project target. But these have not yet in 2014, and 95 percent in 2015. Although there were translated into substantial changes at the national level. no end-of-project data for the share of children ages Baseline and end line LQAS surveys show an increase 12–59 months receiving deworming medication twice in the share of mothers exclusively breastfeeding their annually, program data show high coverage postproj- children under age six months from 34 percent to ect: 89 percent in 2014 and 86 percent in 2015. Under 62 percent over the project period, surpassing the tar- this project, a new intervention—the quarterly screen- get of 44 percent. However, available data show very ing of children under age five for acute malnutrition little change at the national level: 34.1 percent in 2005, and their rehabilitation at the community level—was 39.0 percent in 2010–11, 37.5 in 2012–13, and 33 per- introduced. By the project’s end, 90 percent of children cent in 2014. The share of pregnant women making at were screened on a quarterly basis, surpassing the least four prenatal care visits rose from a baseline of target of 80 percent. 39 percent (national level DHS data from 2005; USAID 2006) to 51 percent (end-of-project LQAS), achieving Multisectoral interventions improved the supply of, and the 30 percent target increase. Intervention-level ar- access to, micronutrient supplements, other essential eas show slightly higher levels than national DHS data medication, and fortified foods. Ministry of Education for 2014 (48 percent) and 2015 (47 percent). Field vis- interventions culminated in 95 percent of children its benefited from discussions with mothers or clients in primary schools receiving weekly micronutrients of the community-based program. They noted that supplements and 95 percent receiving deworming the program informed them and incited them to adopt medication twice annually. These levels surpassed improved infant and child feeding practices. And they the target of 80 percent and translate into about asserted that their younger children would never reach 300,000 school children reached. Through support to the level of malnutrition of their older children, some the private sector, small producers adequately iodized having been screened for acute malnutrition and reha- 73,300 tons of salt, falling below both the 87,000 base- bilitated by the program. line and the 139,000 target. This was due to seasonal shocks and a six-fold increase in the price of the for- Child outcomes were good. Eighty-one percent of chil- tifier. Since the project has closed, there has been a dren under age two were showing adequate weight trend of improvement, although still short of the tar- gain, exceeding the target of 75 percent. This already get, with 89,209 tons adequately iodized in 2014 and high level continued to improve: 82 percent in 2012; 112,022 in 2015 (CLM 2012c, 2013, 2014). With proj- 83 percent in 2013; 83 percent in 2014; and 84 per- ect support, an increasing quantity of oil was fortified cent in 2015. In 2012, the CLM conducted a national with vitamin A by the oil industry: at the end of the proj- anthropometric survey using the SMART methodolo- ect, 107,178 liters were fortified, surpassing the target gy, which showed that stunting levels had been further of 80,000 liters.62 Under this public-private partner- reduced, measuring at 16 percent in 2012. This is the ship, the government of Senegal bought oil from local lowest rate of stunting seen in Sub-Saharan Africa. Al- producers, which was subsequently fortified by the oil though national trends are positive overall, progress industry. This reduced the amount of unfortified oil that nationwide is slower than progress in the intervention would be sold to the population. In 2014, 124,465 liters areas (see appendix D, figures D.1, D.2, and D.3). 46 A Decade of World Bank Support to Senegal’s Nutrition Program Objective 2 The beneficiary assessment documented good use of the funds (CLM 2006a). Over three-quarters Objective 2 was to reduce the risk of nutrition inse- (77 percent) of mothers spent some of the cash on curity of vulnerable populations, in particular children their child(ren) under age five, and 22  percent spent under age five in poor rural and urban areas, by pro- the cash exclusively on the child. Six percent spent viding cash transfers to vulnerable mothers of children part of the funds on an income-generation activity. In in that age group. order of frequency, the type of expenses covered by the transfer included food (99 percent); clothes for the The achievement of objective 2 is rated high. child (77 percent); health care and medicines (70 per- cent); shoes for the child (66 percent); and donation of Outputs. The cash transfer pilot was successfully set a part of the transfer to another person (27 percent). up and implemented. Local payment service providers This validates the project’s assumption (based on evi- with strong local presence were contracted to deliv- dence) that unconditional cash transfers culminated in er the payments to beneficiaries in the target districts. appropriate use of the funds. In difficult to reach areas, mobile units were created to extend their reach. The project also invested in the The impact evaluation revealed that the cash transfers design and delivery of an elaborate communication had a positive effect on the nutrition and well-being of strategy, linked with the cash transfers, comprising children in targeted households (Institut Fondamental large community meetings with discussions, drama, d’Afrique Noir n.d.). The share of households in which and songs; group education; orientation and decision children received at least four meals or snacks per meetings with local authorities; and counseling and day increased from 26 to 54  percent of beneficiary other forms of interpersonal communication. households, compared to a smaller increase in control groups (from 21 to 37 percent). General food insecu- Intermediate outcomes and outcomes. The tar- rity remained largely unchanged (31 percent before geting process was effective, more beneficiaries and after intervention) for beneficiary households, than planned were reached, and virtually all received compared to worsening food insecurity (from 35 to intended benefits. Only 2.5  percent of selected ben- 42 percent) in control areas. Health benefits in benefi- eficiaries did not meet eligibility criteria (inclusion ciary households were also noted, compared to control error), far below the project target of 20 percent. areas: cases of diarrhea cases decreased, while the This is a significant indicator of the appropriate de- likelihood of the child having a vaccination card and sign, verification, and implementation of the targeting receiving regular vaccinations were slightly higher. mechanism.63 By the second year of implementation, The impact evaluation points to a significant increase all transfers were made by local payment service (from 36 percent to 60 percent) in women participating providers. Both the social cash transfer to mothers in nutrition information and education sessions after of vulnerable children and the community targeting they receive cash transfers, with no such increase in system have been adopted by the government. The control areas. The beneficiary assessment revealed number of beneficiaries (mothers of children under good use of the funds. five) receiving the cash transfers was 54,512 (CLM project monitoring system, 2012 data), exceeding the target of 50,000. The transfers are estimated to have Efficiency benefited at least 300,000 people, including those living in the households of the direct beneficiaries. Efficiency is rated substantial. Virtually all beneficiaries (96  percent) received all intended cash transfers. This is substantially higher Economic efficiency and cost-effectiveness. than the 80 percent target. For the community nutrition component, efficiency A Decade of World Bank Support to Senegal’s Nutrition Program 47 discussions for NEP II from section III apply, which The project took advantage of existing institutions and highlight the low annual cost per child of approxi- focused on simplicity in building new ones, and inter- mately US$5. This section thus focuses on the new ventions were cost-effective. cash transfer component. Although neither the Emer- gency Project Paper (World Bank 2009c) nor the ICR Risk to Development Outcome (World Bank 2013b) included an economic or financial analysis, the project design did contain features that The risk to development outcome is significant. enhanced its efficiency. For the community nutrition component, the assess- Operational and implementation efficiency. Only ment of risk to development outcome for NEP II (see 2.5  percent of selected beneficiaries did not meet paragraph 3.40) applies, because this component’s eligibility criteria (inclusion errors), versus the 20 per- time frame falls within that project’s time frame. The cent target. Technical efficiency was high. The project pilot cash transfer has proven to be an effective low- included some of the most cost-effective nutrition cost means of adding to the government of Senegal’s interventions (household and community-focused instruments for mitigating future economic risks in the behavior change communication, screening, simple face of economic crisis. It remains to be seen whether treatment protocols). Project management for the it actually will become a permanent safety net instru- NEP elements drew on existing national structures ment and how affordable it really is. Support of NEP and well-established partnerships at the local level. continues with government of Senegal and donor fund- The management structure for the cash transfer was ing. The CLM continues to play its critical role in the kept purposefully light, amounting to only 3 percent of coordination of nutrition policy and increasingly serves total project costs. as the entry point for nutrition policy dialogue with de- velopment partners, thanks to its strong technical and organizational capacity. The World Bank continues its Ratings policy dialogue on health, nutrition, and social safety nets with the government of Senegal in general (and Project Outcome the CLM in particular) through its portfolio of technical assistance, analytic work, and projects (planned and The outcome rating is highly satisfactory. The rele- ongoing). vance of objective is high, with the PDO well focused on addressing immediate issues, as well as building Social protection programs are high on the policy resilience for the future. Relevance of design is also agenda, and budgetary allocations have been made to high, as the interventions and approaches drew on continue safety net operations. In addition, the World best practices, as well as lessons learned from pro- Bank continues to provide IDA financing to social pro- gram experience. The first objective was substantially tection policy implementation. The CLM’s analysis of achieved, with NEP reaching some 65 percent of the the importance of targeting mechanisms and distilla- target population. The second objective was highly tion of other lessons is being used to adjust and guide achieved, with the cash transfers reaching 96 per- safety net programs. A major challenge is the coordi- cent of beneficiaries with all intended payments and nation of a large number of public institutions, many very low inclusion errors. Moreover, the funds were with limited or no capacity to manage safety net or indeed used for investments in child nutrition and pro- cash transfer schemes. The government of Senegal’s tection with positive effects on children’s health and plans for a third phase of NEP will position the CLM well-being. The efficacy of this second objective is at the center of a new partnership for nutrition devel- heavily weighted because this was the main thrust of opment and further strengthen its role in coordination this emergency operation. Efficiency was substantial. and policy oversight. 48 A Decade of World Bank Support to Senegal’s Nutrition Program World Bank Performance investment in an operation that was prepared as an emergency intervention and was still seeking to pilot Overall World Bank performance is rated satisfactory. test a major intervention. Success in extending the reach of the program to the most remote populations Quality at entry is rated satisfactory. The World Bank serves to demonstrate its viability and reach of the deserves credit for pulling together an emergency program. The World Bank’s internal reporting system operation to address nutrition insecurity in Senegal, and aide-mémoires document broad consultation with especially given the underfinancing of the APL. The stakeholders and were focused on learning and results. project focused on child welfare, and in particular, re- sponded to nutritional risks that children were facing Borrower Performance as a result of domestic climate shocks and the global food crisis. It included a fast track response, benefiting Overall borrower performance is rated Satisfactory. from Operational Policy 8.0. A preproject survey in- formed the selection of districts to target for scaling up, Government performance is rated satisfactory. The gov- and community-level screening of children was under- ernment was and remains committed to the PDO. Child taken before project effectiveness. Design built on and nutrition has been a major priority for over a decade, and expanded the successful NEP, which was already per- this is reflected in government of Senegal’s poverty and forming to international standards in achieving healthy social strategies. It has developed and maintained the child measurements. Design of the cash transfer mech- NEP—an innovative community-focused mechanism—to anism was able to draw on extensive local field-level pursue this objective. The NEP involves a broad segment knowledge from the NEP experience to identify risks of public and private stakeholders at the national and and incorporate mitigating measures into the design of subnational level and is supported by donors. During proj- the cash transfer. A strong project monitoring system ect preparation and implementation, the government of already existed for the NEP, which allowed a mix of Senegal provided continuous support through the prime monitoring data and independent evaluation studies to minister’s office. As documented in paragraphs 3.46 and measure results. The project was to be implemented 3.47, the highest levels of government, a wide range of by the CLM, which was already implementing the NEP. relevant sectors, and local governments are all very com- With the introduction of the cash transfer, emphasis mitted to NEP’s success and increasingly involved in its was placed on adequate reporting, flow of funds, and implementation. Striking health workers retained data as auditing processes for this component. There was a a means of protest during 2010–13. slight delay at the level of the World Bank’s loan de- partment in setting up and activating the trust fund that Implementing agency performance is rated highly was to be disbursed prior to the IDA funds. This minor satisfactory. This project’s time frame falls within the shortcoming delayed the start of implementation. longer time frame of NEP II, so the highly satisfacto- ry performance of the CLM, described in paragraphs Quality of supervision is rated highly satisfactory. 3.48–3.49, also applies here. The CLM also performed The supervision process was characterized by close very well on the new social cash transfer component. collaboration between the CLM and the World Bank It was instrumental in finding workable mechanisms for team. The World Bank provided technical assistance the cash transfer payment system. Selection of the lo- and encouraged the CLM to develop its own solutions cal payment service provider to manage the distribution to implementation challenges. During implementation, of the cash transfers was well implemented and moni- the local payment service provider for the cash trans- tored very closely during implementation. When it took fer did not have sufficient coverage in all target areas. longer than the agreed 15 days for the local payment This did delay implementation and required a project service provider to check the transfer balance and sub- extension of some eight months, but the delay was an mit the report of a completed region, the CLM formed a A Decade of World Bank Support to Senegal’s Nutrition Program 49 team to assist in the verification process to submit the prenatal care, and immunizations. Baseline and bian- transfer balance and report in a timely manner. nual LQAS surveys were also envisaged. Monitoring and Evaluation Implementation of monitoring and evaluation. Thanks to the well-established monitoring and evaluation system The quality of monitoring and evaluation is rated for NEP, data was collected on a monthly basis permitting substantial. the close monitoring of community-level activities, ser- vice quality, outcome indicators and costs. The system Monitoring and evaluation design was grounded in the also integrates the tracking of progress of health and ed- already well-established monitoring and evaluation ucation sectors against their agreed plans. Data quality system for the NEP. In keeping with the sound design is good and reports have been completed on time. This of NEP (ongoing at the same time as this operation) good implementation performance is due in significant and the NEP program objectives, outcome indicators part to the roles of the CEAs in closely monitoring activi- appropriately sought to track increased coverage of the ties; the strong demand of stakeholders at all levels of the program (percent of children under age five reached system, who were accustomed to and highly interested in by the nutrition program) and behavior change (an tracking performance in their respective catchment areas; increase in exclusive breastfeeding). As well, project and the technical support and managerial capacity of the intermediate outcome indicators were also consistent CLM (including the BEN and its regional offices), whose with those already tracked by the NEP (and under the management was strongly grounded in the evidence and World Bank’s second-phase operation): service deliv- emphasized continued learning. The CLM creatively over- ery indicators; weight gain of children under age two; came the monitoring and evaluation challenges related to crucial behavior changes; food fortification measures; striking health districts holding back data (see paragraph and local government involvement. Baselines and tar- 3.48). New tools were integrated into the monitoring and gets were specified. One shortcoming was the lack of evaluation system to monitor the cash transfers and specificity of the coverage indicator.64 proved to be effective in tracking performance. A number of evaluation studies were implemented to exploit the ex- New indicators added for the cash transfer component perience and lessons of the cash transfer pilot: an impact were also appropriate, monitoring both process and evaluation (comparing baseline and end line data) in ran- programmatic outcomes: the number of beneficiaries; domly selected intervention areas and control areas; a any errors of inclusion; the extent to which they re- process evaluation, which assessed the effectiveness of ceived benefits; the degree to which payments were cash delivery to the beneficiaries, service utilization and made by local-level entities; and the development and the validity of the targeting process; and an assessment adoption by the government of Senegal of a social of the beneficiaries’ appreciation of the intervention. No cash transfer scheme as a part of its social protec- rigorous impact evaluation was undertaken for the NEP tion strategy. The already established monitoring and because one had been done in 2004–06 during Phase I evaluation system and processes will ensure the trans- of the NEP. parency, availability, and discussion of performance data at every level of the system to support and nurture Monitoring and evaluation use. The data generated learning by doing. Two types of evaluation of the cash from the NEP’s monitoring system and related surveys transfer pilot were envisaged: a process evaluation fo- monitored project outcomes and is still being used to cused on the delivery system, beneficiary satisfaction, evaluate the need for shifts in NEP design. Regular service use, validity of targeting, and effectiveness of feedback is provided to regional stakeholders. Data communication; and an impact evaluation, focused on on the cash transfer are used to evaluate processes, positive externalities of the project, such as household impact, and beneficiary satisfaction for adjusting pro- food and iodized salt consumption, birth registration, gram features as necessary. 50 A Decade of World Bank Support to Senegal’s Nutrition Program 5 A Decade of Support in Perspective 10-Year Program Results: An Overview NEP. But these targets were scaled back considerably when the World Bank scaled back its financing. The Sections II, III, and IV documented the success of projects performed well in their intervention areas, three individual projects, with two culminating in highly culminating in greater knowledge, healthier behaviors satisfactory outcomes and one culminating in a fully and practices, and improved nutrition outcomes. But, satisfactory outcome. But the individual assessments even though these intervention areas extended to all of each project do not reveal the full experience and of Senegal’s 14 regions and 45 departments, they did lessons of the last 15 years. A broader look at these not achieve sufficient coverage of at-risk communities investments together reveals a number of key findings (within regions and departments) to effect major im- and messages. provements in nutrition outcomes at the national level that were initially anticipated. First, the majority of the 10-year objectives and tar- gets of the APL (which were also the objectives and Third, the World Bank’s strategic and technical con- targets of Senegal’s NEP) were not met. Underweight tributions to the NEP have been highly acclaimed, among children was reduced—but not by 40 percent; but the retraction of its commitment under the APL to severe underweight was also reduced but not to less provide substantial financial and technical support to than 1 percent; vitamin A deficiency was not eliminat- three phases of the program was a factor in the failure ed; and, because declines in malnutrition have been to achieve a level of coverage that would have a signifi- modest (see appendix D, figures D.1, D.2, and D.3), cant effect on nationwide trends. Indeed, fieldwork and their impact on declining trends in under age five mor- interviews have revealed that financial constraints not tality is not likely to be significant. only limited the number of intervention areas that the NEP was able to support, they also had an effect on Second, the main reason that the three projects per- the frequency and intensity of interventions. Already in formed so well but the 10-year program goals were the Phase II design, it was decided that villages with not met centers on program coverage. The APL initial- a population under 1,000 would receive services less ly aimed to achieve nationwide coverage of Senegal’s frequently (quarterly) than those with a population A Decade of World Bank Support to Senegal’s Nutrition Program 51 over 1,000 (monthly). Field visits also revealed, an- Some may interpret these findings as weaknesses in ecdotally, that some nutrition centers were closed and the program. But this evaluation acknowledges CLM’s others were scaling back their activities, especially in proactivity in commissioning this survey with a view to anticipation of the end of the World Bank’s financing. gathering information that puts it in a position to improve There were even echoes of concern that highly effec- program effectiveness and efficiency. Indeed, this has tive growth monitoring and promotion may no longer been a hallmark of the CLM’s excellent and transparent be affordable. management style: to be on a continual quest for opportu- nities to learn and improve through the gathering, sharing, Fourth, although the World Bank has been the major analysis, and use of evidence. And it is timely, given that source of external financing for the NEP, an increas- Senegal is preparing a new 10-year nutrition program. ing number of development partners provide financial and technical support to nutrition activities in Senegal In conclusion, the NEP deserves its strong reputation over and above the financial support provided by the as a well-run, evidence-based community-focused government of Senegal. A recent survey of over 50 na- program that has piloted and demonstrated its ef- tional and international partners supporting nutrition in fectiveness in intervention areas and managed to Senegal (commissioned by the CLM and undertaken increase its coverage, although not to the level initially by Renewed Efforts Against Child Hunger and malnu- anticipated. Its success and experience are useful to trition (REACH) has revealed two important findings highlight for the benefit of other countries attempting (note 55): to establish or improve programs to enhance the nutri- tional status of their respective populations. In addition, The support of all of these partners together does not this evaluation reveals opportunities for the CLM and culminate in the adequate coverage nationwide of its partners to enhance further program performance critical categories of at-risk populations (women and and results. Both the strengths and the challenges of children) with an essential package of cost-effective, the NEP are briefly reviewed below. community-based services appropriate to the type(s) of malnutrition they are suffering. As detailed in appen- dix D, table D.7, the NEP, with support from all of its A Well-Earned Reputation partners together, covers all of Senegal’s 14 regions and 45 departments. There is a strong presence of Among many strong features of the program, this eval- multiple partners in each region, ranging from a low uation highlights three in particular, which have been of 12 partners in Ziguinchor to a high of 21 partners the result of both extremely good design work and in Tambacounda. But coverage of target groups with their ongoing refinement over the past 15 years. They key interventions is still somewhat modest (appendix are service delivery, an increasingly multisectoral ap- D, table D.8). proach, and behavior change communication. This support reveals some degree of alignment of in- Service delivery. The program has set up a top-notch terventions and intensity of support with needs across institutional and organizational structure that is high- regions: the high levels (more than 30 percent) of ly focused on community services responsive to the stunting in Tambacounda and Kolda, for example, needs of target groups and embraces the roles, re- appear to be matched with strong support. But there sponsibilities, and comparative advantages of a range is room for improvement, with other regions in the of actors and stakeholders. Box 5.1 lists the multiple south, also suffering from equally high stunting rates strengths of nutrition service delivery, as designed (Ziguinchor, Sedhiou, and Kedougou), receiving light- and nurtured under the program, which were directly er support than other regions with lower stunting rates observed by the evaluation mission to be very good that receive more support. practice and pivotal to the program’s success. 52 A Decade of World Bank Support to Senegal’s Nutrition Program BOX 5.1: Service Delivery Features of the NEP • Services are linked to a clear objective around stakeholders is achieved through contracts with which all service providers are united and for NGOs possessing both technical expertise and which the clients have strong ownership and the trust of the communities. Contracting evolved appreciation from the first project, under which NGOs were • Sound understanding and strong involvement of contracted directly by the NEP, to three signatories key local actors supports and facilitates the use (NGOs, NEP, and local collectivities responsible of services and application of knowledge by the for nutrition financing and implementation under targeted clients the decentralization policy) • Roles, responsibilities, and complementarities • Community-level structures, whose members are of all actors and stakeholders are clear and chosen by the community for troubleshooting, understood and their synergies exploited problem-solving, prioritization, and targeting of services, provide an enabling environment, • Room is provided for supporting and nurturing evidence-based management, and learning to innovation in the prioritization and delivery of allow communities to lead where they have the services comparative advantage • Service delivery standards are established, clear, • Communities choose community-based nutrition adhered to, and validated by technical support and aides who are trusted, respected, and accountable data to deliver services • The service pyramid is turned upside down, • A creative, innovative focus on evolving toward putting clients at the top. Service providers are services sustainability allows exploration of ways accountable to the clients (and to the authorities and means of remunerating nutrition aides that represent them) and the CLM and policy makers are in a supportive role • The “horizontal integrity” of the institutions and actors ensures coordination of actors at each • Good governance pervades every level of the level of the program through joint oversight of program and every dimension of the strategic financing and performance, thereby nurturing and management cycle (starting and ending supporting an increasingly multisectoral approach with monitoring and evaluation for learning, accountability, and improvement) • The “vertical integrity” of the institutions and actors ensures the collaboration of resources up and • Program management is transparent and down the system to ensure the delivery of quality credible, underpinned by strong and recurrent services communications; validation, discussion, and use of data for decision making at the point of data • Strong program leadership delegates collection; regular, bottom-up meetings for candid responsibilities to the level or actors closest to assessments of program performance and continual the target populations and then supports them, improvements; involvement of local and traditional addressing only those problems that cannot be authorities and opinion leaders; and strong resolved locally appropriation of objectives by local authorities • Systems and structures support a participatory • A strong interface between local-level technical process of learning and fine-tuning, which has services and community level actors and been institutionalized at every level of the program Source: Compilation of evaluation mission’s direct observations, field visits, and other assessments. A multisectoral approach has truly taken hold. The the delivery of services; reinforcing health and nutrition Phase I project judiciously and strategically limited its messages of the nutrition aides; and taking on cases of initial support to two sectors: health and education. The severe acute malnutrition referred to health facilities by project successfully strengthened these sectors’ capac- the nutrition aides and other community members. The ities and involved them in critical activities for which they education sector delivers micronutrients and deworm- had the comparative advantage. The health sector now ing services to school children, delivers health and contributes in a number of ways to the nutrition agenda, nutrition messages for students and their families, pro- including preparing and enforcing service standards; motes girls’ education, and is serving as an innovative training, supervising, and supporting nutrition aides in vehicle for promoting the NEP messages and agenda A Decade of World Bank Support to Senegal’s Nutrition Program 53 in communities. As local governments became more widespread consensus that the ongoing development involved in the financing, coordination, and implemen- of a new strategic plan is an important vehicle and op- tation of the nutrition program, and as the goal of the portunity to continue this evolution. Rather than merely NEP became more strongly understood and owned at preparing sectoral plans for insertion into a multisec- the local level, an increasing number of sectors be- toral nutrition plan, each sector now sees its nutrition came active and involved. Field visits demonstrated contribution as an integral part of its own sector plans. how this is taking hold. Local authorities were eloquent in appreciating NEP progress to date but quick to add Behavior change interventions. Behavior change that other sectors must become increasingly involved, communication was designed at the outset based on especially clean water and sanitation. An agriculture studies documenting local-level knowledge, beliefs, extension agent who was interviewed expressed his and practices, which undermined the health and nu- strong sense of responsibility when he mentioned that trition of mothers and children. During implementation, he provides mothers with the best (drought-resistant) and thanks to the results-focused learning by doing, seeds for their family gardens and stated that if he sees refinements were made as experience was gained. a malnourished child in his area, it is a signal that he is Communication efforts are not only about sending not doing his job well. Livestock agents have become messages to target populations but also about listening key in keeping village and family herds of goats safe, to them. Knowledge and behaviors should be under- well, and fully vaccinated by frequent visits, caring for stood and addressed as well as the roots and rationale sick goats and seeking to upgrade the breeds. Indeed, behind them. A behavior is not likely to change if it is beneficiaries interviewed expressed their appreciation deeply embedded in religion, tradition, and culture. of multisectoral support under the project (family gar- The involvement of religious, traditional, and cultural dens, family livestock projects, and cash transfers), leaders turned out to be an effective approach both which were pivotal in allowing them to fully apply the to mobilize populations to attend education sessions knowledge and behaviors promoted by the program. and to encourage changes in behavior. The involve- ment and support of other people with strong influence A meeting with the focal points of all sector ministries on mothers’ behavior were also important, especially and public agencies, who are members of the CLM rep- mothers-in-law and husbands. Moreover, changes in resenting all relevant sectors, revealed a strong and still behavior are contingent on more than just knowledge increasing commitment to a multisectoral approach. In- and the support of community and family. Some are deed, many respondents (inside and outside the CLM) possible only with the provision of means. Beneficia- noted that the building of this multisectoral approach ries were unanimous across all field visits in noting that has been nothing short of a revolution. Sectors’ con- proper nourishment of children and their basic health tributions are increasingly less about what money they care were greatly facilitated by family gardens, fami- receive and more about what they understand to be a ly livestock projects, grain storage projects, and cash national objective, which they have the mandate and ac- transfers. Behavior change was also greatly stimulated countability to effect. Moreover, this meeting highlighted by data and group discussions. Trends documented in plans and opportunities for joint work, for example, be- individual growth charts (both good and bad), and then tween Agriculture and Industry and between Industry discussed in a group, incited mothers to adopt practic- and Commerce, among others. Although at the time es to improve their children’s growth trajectories. of the CLM’s creation, focal points attended meetings somewhat reluctantly, this meeting exhibited a true re- form in the way this forum works. There is a unanimous Challenges and Opportunities demand for meetings to continue their evolution toward being more technical, operational, creative, and entre- Both the success of the NEP (including its effective preneurial in nature, rather than institutional. There is management by the CLM) and the high priority of ad- 54 A Decade of World Bank Support to Senegal’s Nutrition Program dressing malnutrition in Senegal (and elsewhere) have First, a medium-term strategic program grounded attracted a large number of national and internation- in national policy needs to be defined. Indeed, the al partners that are supporting nutrition interventions, definition of a new medium-term program was being some channeled through, and others bypassing, the launched around the time of the PPAR mission. It is not NEP and CLM. According to a recent survey, over enough to define the program, however. The full cost- 50 partners are supporting nutrition in Senegal, with ing of the program is critical for attracting financing. a strong presence of multiple partners in each of the The program needs to be realistic in terms of its rel- 14 regions. Although they all support nutrition pol- evance to needs and issues, its ambition, time frame, icy objectives, they are not fully coordinated around implementability, and affordability, and it needs to be the national strategic plan, and this undermines the sufficiently prioritized and phased. Growth monitoring effectiveness of this support. The design of numer- (or any other critical activity) should not be eliminated ous projects by partners, not necessarily in sync because of fear it may not be affordable. with national needs and priorities, risks undermining local ownership and commitment. This can result in Second, the preparation of a medium-term projection resource allocation and priority setting driven by part- of resource availability and expenditure plans would ners and their projects, instead of government. It also provide an inventory of available resources, sources makes it difficult to track fully and routinely total expen- of financing, and earmarks. Reconciling the program ditures on nutrition. The bypassing by some projects costs and available financing would provide a basis and financiers of well-established, strong institutional for mobilizing additional resources, negotiating real- and organizational structures for nutrition is inefficient locations for greater equity, efficiency, coverage, and and can create high transaction costs and duplication complementarity among the partners and financiers. of efforts. Third, the government of Senegal and development Empirical evidence from reviews of the sector-wide partners have the opportunity to rally to use, to the ex- approach in the health sector around the world have tent feasible, well-proven country systems rather than much to offer in guiding the government of Senegal parallel project systems. This could apply to fiduciary in general and the CLM in particular to achieve great- systems. But this evaluation emphasizes the further er aid effectiveness for nutrition (Vaillancourt 2009, strengthening and full use of the very capable program 2012). Senegal has already put in place many of the monitoring and evaluation system, which has oversight required building blocks for enhanced aid effective- responsibility for all nutrition activities. Fourth, fuller ness: a well-defined national policy; a very capable strengthening and exploitation of systems and process- institutional and organizational framework responsi- es already in place for development partner coordination ble for policy oversight and program implementation; might be pursued. The practices of joint missions and well-established protocols for strong monitoring and coordination meetings, chaired by the CLM, could be evaluation and its use in decision making and track- strengthened and become more regular. Fifth, all of ing accountability for performance and results; an these recommendations apply equally to the local level, increasingly multisectoral approach and leadership as well as to the central level. Given that, there is a role of the local governments; a strong focus on re- range from 12 to 21 partners in each of Senegal’s 14 re- sults; and widespread ownership at all levels of the gions; coordination of the wide range of partners—both program. Other critical elements still need to be put national and international—needs to take place at the into place. regional, departmental, and local levels. A Decade of World Bank Support to Senegal’s Nutrition Program 55 6 Lessons T hese three projects demonstrate that formidable of the program has been strong and continues to grow results can be achieved within the time frame of with new evidence about sector-wide coverage and a four-year project. Phase I was highly success- support of other partners. There is scope for the further ful in establishing a new innovative program, showing enhancement of evidence and learning by prioritizing and a strong capacity for its successful management and supporting research. Senegal has untapped technical ca- implementation, and tangible results in the intervention pacity in nutrition that could be exploited. areas. The three projects together also demonstrate that capacity and institution building is a medium-term, incre- Senegal’s nutrition policy and program have attracted mental process. The gradual decentralization of program many partners, both national and international, but inade- oversight, the evolving roles and involvement of local quate coordination of this financial and technical support governments, CEAs, and other sectors could not have has undermined its overall effectiveness. Considerable happened all at once. The time invested is well worth the scope exists for enhancing the aid effectiveness of nu- quality of this program’s mature design and capacity. trition interventions by preparing and brokering a fully costed, prioritized multiyear program with a fully developed Cross-sectoral coordination and teamwork coalesce inventory of available financing and technical support. around shared objectives. A truly multisectoral approach cannot be achieved solely through an organigram or The measurement of coverage is complex but critical to sectoral work plans with resource allocations. Rather, a assess program efficacy. It was difficult to reconcile the shared objective and sense of mandate and accountabili- robust outcomes in the intervention areas with modest ty to contribute to that objective light the way. This applies trends at the national level, in the absence of detailed to local and central levels alike. data on program coverage. It is not enough to measure geographical coverage. Even program coverage by tar- A management style that supports an evidence-based, get group (for example, children under age five) does not participatory learning culture will culminate in strong own- provide sufficient detail. The REACH survey is a landmark ership of the program and the continual improvement of in the program’s capacity to define and assess coverage its performance and effectiveness. The evidence base by specific intervention and by specific age group. A Decade of World Bank Support to Senegal’s Nutrition Program 57 APPENDIX A Data Sheet Nutrition Enhancement Project (Credit 3619-SE) TABLE A.1: Key Project Data TABLE A.3: Key Project Dates Actual or Project stage Original date Actual date Appraisal current Actual as Concept review 01/16/01 01/16/01 estimate estimate percent of Appraisal 01/22/02 01/22/02 (US$, (US$, appraisal Board approval 03/14/02 03/14/02 million) million) estimate Signing 03/29/02 03/29/02 Total project costs 14.70 16.48 112 Loan amount 14.70 16.48 112 Effectiveness 06/27/02 06/27/02 Cancelation 0.00 0.00 0 Closing date 01/15/06 07/15/06 Source: Project portal. TABLE A.2:  Cumulative Disbursements Estimated and Actual FY03 FY04 FY05 FY06 FY07 Appraisal estimate 2.26 7.19 10.75 13.76 14.70 (US$, millions) Actual (US$, millions) 1.45 5.15 10.42 14.96 16.47 Actual as percent of appraisal 64 72 97 109 112 (percent) Date of final disbursement: November 14, 2006 Source: CAS—Project disbursement data. Note: FY = fiscal year. A Decade of World Bank Support to Senegal’s Nutrition Program 59 TABLE A.4: Task Team Members, World Bank Name Title Unit Harold H. Alderman Adviser AFTHD Siaka Bakayoko Sr Financial Management Specialist MNAFM Demba Balde Social Development Specialist AFTS4 Laurent Mehdi Brito Procurement Specialist AFTPC Flavia Bustreo Sr Public Health Specialist HDNHE Willyanne DeCormier Plosky E T Consultant AFTHD Aissatou Diack Sr Public Health Specialist AFTH2 Bourama Diaite Sr Procurement Specialist AFTPC Astou Diaw-Ba Team Assistant AFCF1 Eleonora Genovese Consultant HDNHE Meri Paula K. Helleranta Consultant AFTH3 Alessandra Marini Economist LCSHS Menno Mulder-Sibanda Sr Nutrition Specialist AFTH2 Claudia Rokx Lead Health Specialist EASHD Fily Sissoko Sr Financial Management Specialist LCSFM Julia Van Domelen Consultant MNSHD TABLE A.5: Staff Time Budget and Cost for World Bank Finance (including travel and Staff weeks consultant costs) Stage or year of project cycle (number) (US$, thousands) Lending FY01 16 118.63 FY02 36 169.70 FY03 8 28.03 FY04 0 0.00 FY05 0 0.00 FY06 0 0.00 FY07 0 0.00 Total 60 316.36 Supervision and Implementation Completion and Results Report FY01 0 0.00 FY02 0 0.00 FY03 14 51.06 FY04 27 103.90 FY05 23 97.77 FY06 21 137.64 FY07 0.86 Total 85 391.23 Note: FY = fiscal year. 60 A Decade of World Bank Support to Senegal’s Nutrition Program Nutrition Enhancement Project II (Credit 4245-SE and Credit 5084-SE) TABLE A.6: Key Project Data Actual or Appraisal current estimate (US$, Actual as percent of estimate (US$, million) million) appraisal estimate Total project costs 15.0 25.3 169 Loan amount 15.0 24.7 165 Cofinancing 0.0 0.0 0.0 Source: Project portal. TABLE A.7: Cumulative Disbursements Estimated and Actual FY07 FY08 FY09 FY10 FY11 FY12 FY13 FY14 FY15 Appraisal estimate (US$, 3.3 7.0 10.8 12.8 13.7 14.7 15.0 15.0 15.0 millions) Actual (US$, millions) 3.4 7.3 11.2 13.2 13.8 15.2 17.2 23.8 25.4 Actual as percent of 101 103 105 103 100 104 115 158 169 appraisal Date of final disbursement: October 14, 2014 Source: CAS—Project disbursement data. Note: FY = fiscal year. TABLE A.8: Key Project Dates Project stage Original Actual Concept review 12/06/2005 12/06/2005 Appraisal 06/06/2006 06/13/2006 Board approval 11/13/2006 11/13/2006 Signing 12/05/2006 12/05/2006 Effectiveness 12/18/2006 01/29/2007 Closing date 05/14/2012 06/14/2014 A Decade of World Bank Support to Senegal’s Nutrition Program 61 TABLE A.9: Task Team Members Names Title Unit Lucy Katherine Bassett Social Protection Specialist GSPDR Wolfgang M. T. Chadab Senior Finance Officer CTRLA Alain W. D’Hoore Senior Economist GMFDR Astou Diaw-Ba Executive Assistant AFCF1 Saidou Diop Senior Financial Management Specialist GGODR Maimouna Mbow Fam Senior Financial Management Specialist GGODR Ronnie W. Hammad Senior Operations Officer GPSOS Mamadou Mansour Mbaye Consultant GGODR Nathalie S. Munzberg Senior Counsel LEGEN Mademba Ndiaye Senior Communications Officer AFRSC Mamadou Ndione Senior Country Economist GMFDR Fatou Fall Samba Financial Management Officer GGODR Afroditi Smagadi E.T. Consultant GHNDR Ludovic Subran Senior Social Protection Economist GSPDR Moukim Temourov Senior Human Development Economist GEDDR Marietou Toure Diack Senior Human Resource Assistant HRDTA Cheick Traore Senior Procurement Specialist GGODR Menno Mulder-Sibanda Senior Nutrition Specialist GHNDR Aissatou Diack Senior Health Specialist GHNDR Boury Ndiaye Program Assistant AFCF1 Demba Balde Senior Social Development Specialist GSURR Maya Abi Karam Senior Counsel LEGAM Nicole Hamon Language Program Assistant GHNDR Sariette Jippe Program Assistant GHNDR TABLE A.10: Staff Time Budget and Cost for World Bank Finance (including travel and Staff weeks consultant costs) Stage or year of project cycle (number) (US$, thousands) Lending FY 07 6.43 25,347.45 Total 6.43 25,347.45 Supervision FY 07 2.82 9, 743.15 FY08 8.15 49, 319.55 FY09 5.09 34, 115.74 FY10 6.68 59, 037.38 FY11 4.91 44, 049.24 FY12 3.40 33, 948.86 FY13 4.45 44, 080.63 FY14 7.11 80, 664.04 FY 15 1.05 9, 061.30 Total 43.66 364,019.89 Note: FY = fiscal year. 62 A Decade of World Bank Support to Senegal’s Nutrition Program Rapid Response Child-Focused Social Cash Transfer and Nutrition Security Project (Credit 4605-SN) TABLE A.11: Key Project Data TABLE A.12:  Cumulative Disbursements Estimated and Actual Actual or Appraisal current Actual as FY10 FY11 FY12 FY13 estimate estimate percent of Appraisal estimate 1.58 5.94 9.75 10 (US$, millions) (US$, (US$, appraisal million) million) estimate Actual (US$, 2.67 4.65 7.84 10.62 millions) Total project costs 18.00 18.62 103 Actual as percent 169 78 80 106 Loan amount 10.00 10.62 106 of appraisal Cofinancing 8.00 8.00 100 Date of final disbursement: December 31, 2012 Cancelation 0.00 0.00 0 Source: CAS—Project disbursement data. Source: Project portal. Note: FY = fiscal year. TABLE A.13: Key Project Dates Project stage Original Actual Concept review 02/10/2009 02/10/2009 Appraisal 02/20/2009 02/20/2009 Board approval 05/06/2009 05/06/2009 Signing 06/12/2009 06/12/2009 Effectiveness 09/11/2009 09/11/2009 Closing date 12/31/2011 08/31/2012 TABLE A.14: Task Team members Names Title Unit Lending or supervision Lucy Katherine Bassett Social Protection Specialist LCSHS Wolfgang M. T. Chadab Senior Finance Officer CTRLA Alain W. D’Hoore Lead Economist AFTP1 Astou Diaw-Ba Program Assistant AFCF1 Saidou Diop Sr. Financial Management Specialist AFTME Maimouna Mbow Fam Sr. Financial Management Specialist AFTME Ronnie W. Hammad Senior Operations Officer ECSSD Mamadou Mansour Mbaye Consultant AFTPE Nathalie S. Munzberg Senior Counsel LEGEN Mademba Ndiaye Senior Communications Officer AFRSC Mamadou Ndione Senior Economist AFTP4 Fatou Fall Samba Financial Management Analyst AFTME Afroditi Smagadi E.T. Consultant LEGAF Ludovic Subran Social Protection Economist LCSHS Moukim Temourov Resident Representative MNCDZ Marietou Toure Diack Program Assistant HRSER Cheick Traore Senior Procurement Specialist AFTPE A Decade of World Bank Support to Senegal’s Nutrition Program 63 TABLE A.15: Staff Time Budget and Cost for World Bank Cost (including travel and Staff weeks consultant costs) Stage or year of project cycle (number) (US$, thousands) Lending FY09 0.0 26.1 FY10 0.0 0.00 Total 0.0 26.1 Supervision or Implementation and Completion Review Report FY09 0.0 0.0 FY10 9.9 61.4 FY11 4.8 45.4 FY12 3.0 40.4 FY13 2.6 40.6 Total 20.3 187.8 Note: FY = fiscal year. 64 A Decade of World Bank Support to Senegal’s Nutrition Program APPENDIX B National Nutrition Policies and World Bank’s Nutrition Portfolio BOX B.1: Government of Senegal Letter of Nutrition Development Policy Principles Objectives • Equality: with particular attention to more The broad purpose of this policy is to improve vulnerable groups living in poor areas the nutritional status of poor vulnerable groups, • Decentralization and deconcentration: supporting reproductive women, and old people. It will local authorities’ involvement in nutrition through specifically consist of reducing underweight among identifying, implementing, and monitoring children over the next 10 years. To this end, the strategies applicable to the social, economic, and state will support efforts to (1) ensure availability cultural environment and accessibility of food for all Senegalese people, (2) address and prevent poor feeding practices. All • Partnership: ensuring harmonization of development sectors will be involved. interventions and synergies among stakeholders involved in nutrition, coordinated at local, regional, and central levels Strategic steps • Know-how: ensuring effective, adequate • Strengthening the Community Approach: interventions for improved performance and including growth monitoring promotion, exclusive outcomes breastfeeding, and food supplementation from • Community appropriation: fostering participation at 6–24 months, micronutrient supplementation, all levels to support sustainability and nutrition during and after illness, deworming, disease prevention and wellness visits • Transparency in management: emphasizing clarity in management and decision making at all levels • Food Security Enhancement: through and a monitoring system to ensure efficiency improvement of agricultural production, agribusiness research, and food supply and • Sustainability: including commitment of storage, which will play a paramount role in beneficiaries and stakeholders and effective, long- programs for food product enrichment to control of term financing mechanisms micronutrient deficiencies • Ethics: ensuring morale and human dignity in • Improvement of water and sanitation conditions actions to be undertaken of households: focusing on the combination of nutrition programs with efforts to improve (continued on next page) A Decade of World Bank Support to Senegal’s Nutrition Program 65 BOX B.1: Government of Senegal Letter of Nutrition Development Policy (continued) access to drinking water and sanitation for poor • Improve systems of data collection, analysis, households reporting, and promote studies and research: • Restructuring and institutional capacity building to to allow for the development of targeted monitor and manage nutrition programs: including interventions, and including the definition of nutrition policy development and a multisectoral nutrition-related indicators approach, requiring the establishment of • Enhancement of human resource capacity operational and strategic forums of coordination, at national and community levels: to ensure planning, implementation and program monitoring sustainability of activities at the community level and evaluation and to ensure expertise at the national level • Strengthening Partnership with local government, • Information, Education and Communication for NGOs, associations, executing agencies and behavior change and social mobilization: with a the private sector: to promote interactions focus on local-level leaders and organizations and among the different actors, develop contracting the testing of innovative communication methods arrangements, improve communication and • Promotion of income generation: especially for coordination women Source: République du Sénégal 2001. BOX B.2: Republic of Senegal’s National Development Policy for Nutrition (2015–25) Vision • Transformation, distribution, and pricing of • A country in which each individual enjoys an primary outputs from agriculture, livestock, optimal nutritional status for having adopted the and fisheries into high-quality food that is proper behaviors and practices. affordable and accessible; this involves a range of multisectoral actors, both governmental and private sector Overarching objective • A multisectoral approach to nutrition education • Ensure a satisfactory nutritional status for all focused on behavior change and adequate, citizens, particularly children under age five, equitable access to clean water and sanitation women of reproductive age, and adolescents. • Effective integration and complementarity of basic health, nutrition, and water and sanitation Intermediate objectives services, covering a range of elements, including • Ensure adequate coverage of essential nutrition community-based services, social protection, services for children under age five, women of adequate access to and utilization of basic reproductive age, and adolescents services, with local collectivities playing a catalytic role in the mobilization and coordination of actors • Improve access to and use of quality health and resources services • Improve nutritional knowledge of the population leading to the adoption of behaviors supporting Cross-cutting support for four pillars good nutrition • Local governance and administration • Promote research and the production of foods • Adequate and sustainable financing with high in nutritional value contributions by the State, local collectivities, • Secure sufficient and sustainable financing for private sector and other partners nutrition interventions • Advocacy and communication for social change • Strengthen the coordination, monitoring, and and behavior change evaluation of nutrition interventions in the context • Strengthening of multisectoral approach; of a multisectoral approach participation and equity in coverage and outcomes • Coordination, research, monitoring and evaluation, Four strategic pillars and capacity strengthening of all actors • Production of food with the highest nutritional value Source: République du Sénégal, Primature 2015. 66 A Decade of World Bank Support to Senegal’s Nutrition Program TABLE B.1: Timeline of Approval and Closing Dates of Nutrition Interventions in Senegal Year Interventions, by type 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 Projects Community Nutrition A C Project APL Phase I: Nutrition A C Enhancement Program APL Phase II: Nutrition Enhancement Program II Initial IDA Credit A C Additional Financing A C Rapid Response Child- A C Focused Social Cash Transfer and Nutrition Security Health and Nutrition A C Financing Building Resilience A C to Food and Nutrition Insecurity Shocks Analytic Work and Technical Assistance Strengthening Operational A C Evaluation in Program Implementation (Institutional Development Fund Grant) Health Results-Based A C Financing Impact Evaluation (linked to Health and Nutrition Financing project) Health and Nutrition A C Financing (same objectives as Country Nutrition Status Report) Note: For projects, A refers to approval by the World Bank’s Board of Executive Directors and C refers to the closing date. For analytic work and technical assistance, A refers to activity sign-off and C refers to the completion of the task. A Decade of World Bank Support to Senegal’s Nutrition Program 67 • TO WHAT DOES ASTERISK REFER? APPENDIX C Costs, Financing, and Disbursements* TABLE C.1: NEP I: Planned versus Actual Costs by Project Component Planneda (including Actual/ contingencies) Actualb planned Component (US$, millions) (US$, millions) (percent) Community-Based Nutrition and Growth Promotion 7.70 16.7 217 Program Institutional and Organizational Capacity Building 4.50 1.20 27 Monitoring and Evaluation and Research 1.50 0.70 47 Program Management 2.50 4.50 180 Total Project Costs 16.20 23.10 143 Source: World Bank 2002b for planned; World Bank 2007c for actual. a Total project cost estimated at appraisal equaled the sum of IDA financing (estimated at $14.7 million) and government of Senegal financing (estimated at $1.5 million). It was presented net of anticipated WFP parallel financing estimated at $4.0 million. b It is assumed that total actual costs presented in the ICR are inclusive of WFP parallel financing, because this estimate is very close to the end-of-project financing provided by the IDA, government of Senegal and WFP (table C.2). TABLE C.2: NEP I: P  lanned versus Actual Financing US$ million equivalent Financing source Planned Actual IDA Credit 14.70 16.47 MDRI (IDA 3619A) 4.28 4.97 IDA Credit (IDA 36190) 10.42 11.50 Government of Senegal 1.50 1.80 Subtotal Project Financing for Phase I APL 16.20 18.27 WFP (parallel financing) 4.00 4.00 Total Phase I Support including WFP Parallel Financing 20.20 22.27 Source: World Bank 2002b; World Bank project system for IDA credit; World Bank 2007 for government and WFP financing. Note: The Multilateral Debt Relief Initiative calls for 100 percent cancellation of IDA, African Development Fund, and International Monetary Fund debt for countries that reach the heavily indebted poor countries completion point. A Decade of World Bank Support to Senegal’s Nutrition Program 69 TABLE C.3: NEP I: P  lanned versus Actual Disbursements by Disbursement Category SDR, thousands Disbursement category Original allocation Fall 2006 restructuring Actual Works 150 28 23 Goods 700 575 575 Pharmaceuticals 600 425 415 Consultants/Training 7,450 8,914 8,941 Subprojects 400 195 294 Operating Costs 600 978 994 Refund of Project Preparation Advance 700 263 263 Unallocated 1,200 0 0 Designated account A n.a n.a –115 Designated account B n.a n.a –12 Total disbursements 11,800 a 11,378 11,378 Amount of credit canceled n.a. 422 422 a Includes an IDA credit of SDR 8.363 million and an MDRI of SDR 3.437 million. The MDRI calls for 100 percent cancellation of IDA, African Development Fund, and International Monetary Fund debt for countries that reach the heavily indebted poor countries completion point. TABLE C.4: NEP II: Planned versus Actual Costs by Project Component Entire Phase II (2007–11) (all financing, including Project NEP II project World Bank) (World Bank financing only) Additional Planned Actual Planned Financing Actual Actual/ (US$, (US$, (US$, (US$, (US$, planned Component millions) millions) millions) millions) millions) (percent) Community-based nutrition 29.5 — 10.4 7.6 18.3 176 Multisectoral support 3.9 — 1.4 1.3 2.7 193 Support to national policy and 2.2 — 3.2 1.1 4.3 134 monitoring and evaluation Program management 5.4 — 0 0 0 n.a Unallocated 1.4 — 0 0 0 n.a Total 42.4 — 15.0 10.0 25.3 169 Source: World Bank 2006b for all planned financing; World Bank 2014 for the remainder. TABLE C.5: NEP II: Planned versus Actual Financing of Project Additional Original plan financing Actual Actual/ (US$, millions (US$, millions (US$, millions original Financing source equivalent) equivalent) equivalent) (percent) IDA credit 15.0 10.0 25.3 167% Government of Senegal 16.3 n.a 23.4 144% Others (Projet Santé II/African 11.1 n.a — — Development Bank, WFP, UNICEF, Micronutrient Initiative) Total 42.4 10.0 — — Source: World Bank 2006c for original; World Bank 2011 for additional financing; World Bank 2014 and World Bank disbursement data for actual. 70 A Decade of World Bank Support to Senegal’s Nutrition Program TABLE C.6:  NEP II: Planned versus Actual Disbursements by Category SDR, thousands Most recent allocation Original and Original Additional Additional Additional Actual Category allocation Financing Original Financing Financing disbursements Drugs and 2,690 1,850 1,720 1,830 3,550 3,550 pharmaceutical equipment Grants subprojects 3,500 4,650 6,400 4,700 11,100 11,100 Consultants services, 1,950 0 1,550 0 1,550 1,550 training and audits Operating costs 470 0 300 0 300 300 Refund of Project 410 0 120 0 120 120 Preparation Advance Unallocated 1,080 0 0 0 0 0 Total 10,100 6,500 10,100 6,500 16,600 16,600 Source: World Bank 2006a for original allocation, World Bank 2012a for additional financing, and World Bank’s project information system for actual disbursements. Rapid Response Child-Focused Social Cash Transfer and Nutrition Security Project TABLE C.7:  Rapid Response: Planned versus Actual Costs by Project Component Planned Actual Actual/planned Component (US$, millions) (US$, millions) (percent) Community-based nutrition 9.7 10.8 111 Sectoral support 1.3 0.7 54 Implementation and monitoring and 0.7 0.9 129 evaluation Child-focused cash transfers 6.3 5.8 92 Total 18.0 18.2 101 Source: World Bank 2009c for planned; World Bank 2013b for actual. TABLE C.8:  Rapid Response: Planned versus Actual Financing of Project Planned Actual Actual/planned Component (US$, millions) (US$, millions) (percent) IDA credit 10.0 10.62 106 Global Food Crisis Response 8.0 7.90 99 Program, Multidonor Trust Fund Government of Senegal 0.0 0.0 n.a Total 18.0 18.52 103 Source: World Bank 2009a, 2009b; World Bank’s project information system and operations portal for actual financing. A Decade of World Bank Support to Senegal’s Nutrition Program 71 TABLE C.9:  Rapid Response: Planned versus Actual Disbursements of IDA Credit by Disbursement Category Actual/ Disbursement Original allocation 12/2011 reallocation Actual disbursements original category (SDR, thousands) (SDR, thousands) (SDR, thousands) (percent) Subgrants for 3,520 5,320 5,250 99 subprojects under part 1 Drugs, 2,800 1,200 1,200 100 pharmaceutical equipment, consultants, audits, and training Project operating 480 280 0.260 93 costs Total 6,800 6,800 6,800a 100 Source: World Bank 2009a, 2009b; World Bank 2011 for reallocation; World Bank’s project information system and operations portal for actual disbursements. aTotal may not add due to rounding. The World Bank system shows that SDR 6.8 million were fully disbursed. TABLE C.10: Planned versus Actual Disbursements of Multidonor Trust Fund by Disbursement Category December 2011 Original allocation reallocation Actual disbursements Disbursement category (US$, thousands) (US$, thousands) (US$, thousands) Grants for subprojects for Regions A 3,100 2,940 99 under part 1of the Project Cash transfers for part 4of the project 4,900 4,640 100 Totala 8,000 7,580 100 Source: World Bank 2009b, 2011, and World Bank project information system. a The Multidonor Trust Fund grant agreement shows the original amount as US$8 million equivalent, whereas the World Bank system shows the original amount as US$7.9 million (World Bank 2009). Actual disbursements shown in the World Bank system add up to $7.58 million. But the World Bank system also shows that the trust fund was fully disbursed. These numbers are reflected here with the assumption that the discrepancies are due to exchange rate fluctuations in the various currencies of the Technical and Financial Partner’s contributions. TABLE C.11: Planned versus Actual World Bank Support for 10-Year APL Initially committed World Bank–Financed for APL Actual commitment Actual/initial Operations (SDR, millions) (SDR, millions) (percent) Phase I 11.8 11.8 100 Phase II 19.2 16.6 86 Initial credita n.a 10.1 n.a Additional financing n.a 6.5 n.a Phase III 8.0 0.0 0 Rapid Response b 0 6.8 (unanticipated) Total 39.0 35.2 90 Total net of non-NEP support 39.0 30.8 79 Source: World Bank 2002b for initial APL commitments; World Bank 2002a, 2006a, 2009a, 2009b, and 2012a for actual commitments. a SDR 3.4 million (US$5 million) was from the Malaria Booster Program. b SDR 1.0 million (US$1.4 million) was for the Social Cash Transfers pilot. 72 A Decade of World Bank Support to Senegal’s Nutrition Program TABLE C.12:  Program-Wide Financing, 2004–15 CFAF, billions Financiers 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 World Bank 2.664 2.693 0.654 2.575 2.535 2.776 1.416 5.252 1.589 3.852 0.961 0.961 Government of 0.176 0.176 1.076 1.810 1.307 3.143 1.427 0.274 2.738 1.613 3.023 2.190 Senegal Micronutrient 0.131 0.194 0.211 0.187 0.145 0.088 Initiative WFP 0.005 0.478 0.016 0.088 0.098 0.163 0.147 UNICEF 0.049 0.056 0.529 0.533 0.132 0.123 0.558 Spanish 0.180 0.328 Cooperation Global Alliance 0.514 0.203 0.131 for Improved Nutrition Total 2.840 2.869 1.730 4.386 3.842 6.105 4.086 6.282 5.135 6.019 4.888 3.987 Source: CLM/Program Financial Data. TABLE C.13:  Program-Wide Expenditures, 2004–15 CFAF, billions Expenditures 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Nutrition/IMCI 2.002 1.961 1.039 2.470 3.250 2.991 2.586 2.768 3.162 3.896 4.701 3.071 Multisectoral 0.179 0.095 0.177 0.294 0.515 0.227 0.157 0.247 0.159 interventions Policy support and 0.397 0.166 0.147 0.109 0.149 0.181 0.501 0.361 0.642 0.599 0.317 0.173 oversight Program 0.542 0.487 0.434 0.655 0.595 0.640 0.788 0.690 0.790 0.784 0.822 0.797 management Cash transfers 0 0 0 0 0 0.144 0.933 1.326 0.522 0 0 0.054 Total 2.940 2.614 1.620 3.414 4.091 4.132 5.101 5.661 5.343 5.437 6.087 4.255 Source: CLM/Program Financial Data. A Decade of World Bank Support to Senegal’s Nutrition Program 73 APPENDIX D Statistical Data and Results Project-Level Results TABLE D.1: First Nutrition Enhancement Project: Results Framework/Achievement of Objectives Objectives or indicatorsa Outcomes Project Development Objective (PDO) PDO 1: To assist the Borrower in building the institutional and organizational capacity required to enable the Borrower’s CLM and its partners in the public and private sectors to develop and monitor multisectoral nutrition activities in both rural and urban areas. PDO 2: To assist the Borrower in building the institutional and organizational capacity required to enable the Borrower’s CLM and its partners in the public and private sectors to implement multisectoral nutrition activities in both rural and urban areas. End-of-Phase I Outcome Indicators: PDO 1: the prevalence of severe 2006 impact evaluation shows a drop from 5.7 percent to 4.5 percent (a 21 percent underweight is reduced by half in the relative decrease) in target areas, not meeting the target and less than the 28 percent targeted areas relative decrease (from 5.3 percent to 3.8 percent) in control areas. 2005 shows Baseline: severe underweight nationwide at 3.0 percent. Target: 50 percent reduction Target not achieved at end of first phase project. Target achieved nationwide by the end of the program, with severe underweight among children under five falling by 54 percent from 7.0 percent in 2000 to 3.2 percent in 2015. (Source: WHO and DHS data; see Graph in Chapter ... ). PDO 2: the prevalence of underweight Decreased from 18 percent to 10 percent or a drop of 44 percent, according to among children under three is reduced program monitoring data. by 25 percent in targeted areas Impact evaluation shows a 14 percent reduction in intervention areas (from 26.8 Baseline: percent to 23.1 percent) and a 10 percent reduction in control areas (from 24 percent Target: 25 percent reduction to 21.7 percent). National average in 2005 was 17.3 percent (Source: DHS). Achievement of target not clear at end of first phase project. Target essentially achieved nationwide by the end of the program, with underweight prevalence among children under five falling by 24 percent from 20.3 percent in 2000 to 15.5 percent. (Source: WHO and DHS data; see Graph in Chapter ...). (continued on next page) A Decade of World Bank Support to Senegal’s Nutrition Program 75 TABLE D.1: First Nutrition Enhancement Project: Results Framework/Achievement of Objectives (continued) Objectives or indicatorsa Outcomes Proportion of children gaining weight, compared to the month before, increased from 84 percent to 91 percent. Very strong performance, albeit no specific target. PDO 3: the proportion of children Increased from 30 percent to 58 percent, virtually doubling, comparing favorably exclusively breastfed until six months to 2005 national level of 34 percent. Absolute increase of 28 percentage points, has increased in the targeted areas compared to target of 7 percentage points (Source: KPC surveys). Baseline: 8 percent Impact evaluation showed increase from 17 percent to 49 percent in intervention Target: 15 percent areas. Target surpassed at end of first phase project. However, nationwide prevalence has not substantially changed (34 percent in 2005; and 33 percent in 2014). (Source: DHS data) PDO 4: The use of prenatal care (at Increased from 52 percent to 67 percent, a relative increase of 29 percent (Source: least three visits) has increased by KPC surveys). 30 percent Impact evaluation shows an increase from 65 percent to 78 percent in intervention Baseline: areas and from 64 percent to 70 percent in control areas. In retrospect, and as Target: increase of at least 30 percent discussed and agreed with CLM experts, there are no true control areas in Senegal because of multiple interventions and efforts to stimulate improved maternal and child health through enhanced service delivery and utilization. Nationwide, since project completion the percentage of women having at least 3 prenatal visits rose from 40 percent to 50 percent in 2010 and then regressed slightly to 48 percent in 2014 and 47 percent in 2015. Target essentially achieved. PDO 5: the proportion of caregivers Increased from 55 percent to 77 percent (a relative increase of 40 percent) (Source: who recognize at least two danger KPC surveys). signs in sick children has increased by Target surpassed. 25 percent in targeted areas Baseline: Target: increase of at least 25 percent Component Outputs Community-Based Nutrition and Growth Promotion Program Component 1.1 Growth Monitoring and Promotion Children under three regularly 200,000 and their mothers mobilized for monthly growth monitoring and promotion, as monitored and their caretakers of last six months of project. counseled Target exceeded. Baseline: Participation in growth monitoring was high at over 90 percent. Target: 171,000 Vitamin A supplementation coverage in last six months for children 6–59 months was 85 percent, exceeding the national average of 75 percent. Vitamin A supplementation of mothers within eight weeks postpartum: 51 percent (up from 27 percent in 2003), exceeding the national average (27 percent). Component 1.2: Nutrition and Health Group Education Monthly nutrition and health education 94 percent of established sites in 2006. This high rate has been maintained, as sessions are held in 80 percent of recorded in program monitoring reports: 96 percent in 2008; 97 percent in 2011; established sites 91 percent in 2013 and 88 percent in 2015. Baseline: The percent of target group/mothers who attended these sessions was also high: Target: 80 percent of established sites 89 percent in 2006; 93 percent in 2009; 97 percent in 2011; 91 percent in 2013; 89 percent in 2015. (Source: CLM Progress Reports) Component 1.3 IMCI Percent of health staff in targeted 1,122 health post and district personnel trained (100 percent and 78 percent, areas trained in IMCI respectively); 163 staff from NGOs and CEAs and 23 trainers also received Baseline: Community IMCI training. (Source: CLM Progress Reports) Target: at least 40 percent Target surpassed. (continued on next page) 76 A Decade of World Bank Support to Senegal’s Nutrition Program TABLE D.1: First Nutrition Enhancement Project: Results Framework/Achievement of Objectives (continued) Objectives or indicatorsa Outcomes Percent of sites where training sessions for nutrition aides were held Baseline: Target: at least 25 percent of sites Component 1.4 Basic Health Services Percent of health staff in targeted 1,122 health post and district personnel trained (100 percent and 78 percent, areas trained in promotion of basic respectively). health services Target surpassed. Baseline: Target: at least 40 percent Percent of sites where training 2,459 nutrition aides were trained in the promotion of basic health care (100 percent). sessions for nutrition aides were held Target surpassed. Baseline: Target: at least 25 percent of sites Proportion of children sleeping under insecticide-treated bed nets more than doubled from 28 percent to 59 percent, far surpassing the 2005 national average (10 percent). Component 1.5 Fighting the Roots of Malnutrition Percent of sites having successfully Not reported applied for small grants Baseline: Target: at least 40 percent Consumption of iodized salt increased from 46 percent to 59 percent (an increase of 28 percent), surpassing 2005 national average (41 percent). Capacity Building and Monitoring and Evaluation Component 2.1 Institutional and Organizational Capacity Building Comprehensive Growth Monitoring Target achieved. and Promotion strategy and materials developed Baseline: Target: Growth Monitoring and Promotion Strategy Developed Number of nutrition sites that are 924 nutrition sites were established and equipped and delivered growth monitoring functional and promotion services to the communities. New sites were gradually added reaching Baseline: 5,105 in 2013, but fell slightly to 4922 in 2014. Target: 820 (80 percent community Target surpassed. coverage) Percent of health posts adequately 48 percent equipped to manage severely Target almost achieved. malnourished children Baseline: Target: at least 50 percent Component 2.2 Monitoring and Evaluation and Research Percent of sites where learning events Monitoring and evaluation learning events held in 100 percent of communities. are held Target surpassed. Baseline: Target: 50 percent Studies conducted and Phase II work plan benefited from the program performance data, as well as from the recommendations integrated into impact evaluation. Phase II work plan Target achieved. (continued on next page) A Decade of World Bank Support to Senegal’s Nutrition Program 77 TABLE D.1: First Nutrition Enhancement Project: Results Framework/Achievement of Objectives (continued) Objectives or indicatorsa Outcomes Program Management (central and regional) Staff in place and trained 100 percent of BEN (secretariat to the CLM) staff were recruited and received training; they played an important role in clarifying the institutional arrangement between the CLM and the sector ministries. Thirty-six staff of NGO Executing Agencies (100 percent of staff responsible for administrative and financial management) were trained in procurement and financial management. Target achieved. NGO staff were trained in financial management and procurement; and 34 subproject coordinators (100 percent) were trained in monitoring and evaluation. Management cost less than Target achieved. 15 percent of total budget At least 80 percent of activities in Ninety-two percent of activities in annual action plan were completed within cost annual plan completed within cost estimates. estimates. Target surpassed. a World Bank 2002, as outlined in Appendix 1: Project Design Summary. TABLE D.2: First Nutrition Enhancement Project: Triggers for moving from Phase I to Phase II Trigger Degree of achievement at the project’s end Both urban and rural nutrition interventions The monitoring system shows a considerable drop in the prevalence of show positive impact on child growth in targeted malnutrition in both urban and rural areas and an increase in the proportion regions. of children demonstrating weight gain from one month to the other. The CLM effectively coordinates the application (1) The CLM approved four proposals from three sector ministries (health, of the Lettre de Politique de Dévéloppement de la education, and literacy) and one agency (early childhood development) Nutrition measured by: and signed technical agreements with each. (1) at least three sectors having proposed work (2) The audit firm Coopers and Lybrand audited the BEN in 2002, 2003, programs that have been approved; and 2004 and 2005. Results of each audit have been judged satisfactory to (2) the performance of the BEN is evaluated by IDA. an independent bureau and satisfactory to IDA. An independent evaluation of Phase I is Two KPC surveys (November 2003 and November 2005) were conducted completed and its recommendations incorporated in all intervention areas and preliminary results were used in preparing the into the design of Phase II. Phase II project. An independent impact evaluation was under way at the time of project closing, with a first round of data collection completed in April 2004 and the second in April 2006. These results were also used to guide the implementation of Phase II. Reasonable sustainability is reached with the The median cost per child per year for both zones is US$4.3 (US$5.0 in implementation of the nutrition interventions urban areas and US$3.7 in rural areas). Eighty percent of community- (direct implementation cost per child less than based projects have a cost per child per year below the norms fixed in the US$8 in urban areas and less than US$4 per trigger. child in rural areas). Source: World Bank 2007c. 78 A Decade of World Bank Support to Senegal’s Nutrition Program TABLE D.3: Nutrition Enhancement Project Phase II: Results Framework and Achievement of Objectives Revised Outcomes objectives/2013 against original targets for additional targets, Outcomes against financing and as of 2014 revised targets, Original objectives, indicators, or restructuring (60 percent as of 2014 targetsa (approved in 2012) weight) (40 percent weight) Project Development Objective (PDO) Original Objective: To improve nutritional conditions of vulnerable populations, in particular children under five years of age in poor urban and rural areas. Revised Objective (under 2012 additional financing/ restructuring): To improve nutritional conditions of vulnerable populations, in particular children under five years of age in the Intervention Areas. Outcome Indicators PDO 1: Increased overall program coverage Target increased: 62 73 percent 73 percent of children under the age of five in rural areas percent Target surpassed. Target surpassed. Baseline: 14 percent (preliminary DHS 2005 (ICR notes revised target of (CLM Project Coverage of 387/552 local results) 70 percent) Monitoring System) collectivities (72 percent) Target for 2011: 40 percent Achieved at year-end 2011: and 74 percent coverage of 50 percent children under age five in 2015. (CLM Project Monitoring System) PDO 2: Increase in percentage of infants Target increased: 65 65 percent Target 65 percent Target achieved. exclusively breastfed for first six months by percent Achieved at year- surpassed. (LQAS Surveys) 30 percent in intervention areas end 2011: 63% (LQAS Surveys) Baseline: 34 percent (preliminary DHS 2005 results) Target for 2011: 44 percent PDO 3: At least 40 percent of pregnant Target increased: 75 86 percent 86 percent women and children under five years of age percent Target surpassed. Target surpassed. sleeping under insecticide-treated bed nets in Achieved at year-end 2011: (LQAS Surveys) intervention areas (LQAS Surveys) 71 percent Baseline: 12 percent (preliminary DHS 2005 results) Target for 2011: 40 percent PDO 4: CORE INDICATOR: Not in PAD, Target increased: 1.64 million children 1.64 million children but shown as original indicator in additional 1.1 million (CLM data) Target surpassed. financing/Restructuring Paper: People with Achieved at year-end 2011: Target surpassed. access to a basic package of health, nutrition (CLM Project Monitoring 1.1 million (CLM Project System) and population services (Core Indicator refers to the number of children reached by Monitoring System) the community nutrition activities) Baseline: 265,073 Target: 709,124 Added: PDO#5: Children n.a. 40 percent aged 6–23 months Target surpassed. Only receiving yearly a minimum 20 percent was achieved by of 90 micronutrient sprinkles the project’s closing, but the sachets for three months in 40 percent was achieved intervention areas soon after. Reflecting new activities on (CLM Project Monitoring distribution and promotion System) of supplemental iron. Target: 30 percent Achieved at year-end 2011: 0 (continued on next page) A Decade of World Bank Support to Senegal’s Nutrition Program 79 (continued) TABLE D.3: Nutrition Enhancement Project Phase II: Results Framework and Achievement of Objectives Revised Outcomes objectives/2013 against original targets for additional targets, Outcomes against financing and as of 2014 revised targets, Original objectives, indicators, or restructuring (60 percent as of 2014 targetsa (approved in 2012) weight) (40 percent weight) Intermediate Outcome Indicators (IOI) Intermediate Outcome 1: Adequate child growth in targeted children IOI 1: At least 75 percent of targeted children Target increased: 80 83 percent 83 percent (CLM data) aged 0–24 months show adequate monthly percent Target surpassed. Target surpassed. weight gain (additional financing added: “in Achieved at year-end 2011: intervention areas”) (CLM Project In 2015, 1.5 million children 80 percent Monitoring System) under 2 years (82 percent Baseline: 50 percent (preliminary DHS 2005 of all weighed) showed results) adequate weight gain. Target for 2011: 75 percent (CLM Project Monitoring System) IOI 2: Increase in percentage of pregnant Target increased: 56 61 percent 61 percent women making at least four prenatal care percent Target surpassed. Target surpassed. visits by 30 percent in intervention areas (ICR notes revised target of (LQAS Surveys) (LQAS Surveys) Baseline: 40 percent (preliminary DHS 2005 60 percent) results) Also exceeds nationwide Achieved at year-end 2011: level of 48 percent (2014 Target for 2011: 52 percent (ICR notes target 52 percent DHS) and 47 percent (2015 of 50 percent) DHS) IOI 3: At least 80 percent of mothers of Target increased: 90 90 percent 90 percent targeted children participate in monthly percent Target surpassed. Target achieved. information and education sessions Achieved at year-end 2011: (CLM Project 89 percent in 2015 Baseline: 60 percent (preliminary DHS 2005 95 percent Monitoring System) results) (CLM Project Monitoring System) Target for 2011: 80 percent Number of children under 24 months Target maintained. 272,796 272,796 benefitting from improved infant and young Target surpassed. Target surpassed. child feeding practices in the target area (CLM Project This number fell to 207,365 Baseline: 200,000 Monitoring System) in 2015. (CLM Project Target: 222,500 Monitoring System) Children 6–59 months screened on a 73 percent (2009); quarterly basis for severe malnutrition 86 percent (2010); 90 percent (2012); 91 percent (2014); 84 percent (2015); 1.5 million children quarterly Targeted children under 5 treated for 19,799 19,799 moderate or severe acute malnutrition. No (CLM Project (CLM Project Monitoring target set because aim was to treat the Monitoring System) System) maximum number of cases, while reducing malnutrition prevalence Intermediate Outcome 2: Improved micronutrient status in targeted children aged 6–59 months IOI 4: At least 80 percent of children Target increased: 90 95 percent 95 percent aged 6–59 months in intervention areas percent Target surpassed. Target surpassed. receive high preventive doses of Vitamin A (Baseline shown as 70 supplements twice yearly (LQAS Surveys) (LQAS Surveys) percent in Project Paper) Baseline: 79 percent (preliminary DHS 2005 Achieved at year-end 2011: results) 120 Target for 2011: 80 percent (continued on next page) 80 A Decade of World Bank Support to Senegal’s Nutrition Program (continued) TABLE D.3: Nutrition Enhancement Project Phase II: Results Framework and Achievement of Objectives Revised Outcomes objectives/2013 against original targets for additional targets, Outcomes against financing and as of 2014 revised targets, Original objectives, indicators, or restructuring (60 percent as of 2014 targetsa (approved in 2012) weight) (40 percent weight) IOI 5: CORE INDICATOR: Not in PAD, but Target: 1.58 million 2.3 million In 2014, 2.2 million children shown as original indicator in Additional Achieved at year-end 2011: Target surpassed. 6–59 months received Financing/Restructuring Paper: Number of 2.15 million Vitamin A supplements or children receiving a dose of vitamin A (Health Information 91 percent of the target System, as reported group. (Core indicator—information derived from in ICR) IOI 4) Target achieved. Baseline: 1.58 million In 2015, the number of children was reduced to 1.5 million. (CLM Project Monitoring System, as reported to PPAR mission) At least 80 percent of children aged 12–59 Dropped: This indicator 1.94 million children 1.94 million children or months receive deworming medication twice is tied to vitamin A or 89 percent of the 89 percent of the target yearly supplements because the target population; 86 population; 86 percent Baseline: 79 percent (preliminary DHS 2005 interventions are coupled. percent coverage in coverage in 2015. results) 2015. Target surpassed. Target for 2011: 80 percent Target surpassed. (CLM Project Monitoring (CLM Project System) Monitoring System) At least 90 percent of target number of Target increased: 100 100 percent 100 percent insecticide-treated bed nets distributed percent (according to Target exceeded. Target achieved. Baseline: 0 page 14 of the Project Paper indicates both that This activity carried (CLM Project Monitoring Target for 2011: 90 percent the target did and did not out in 2011 only. System) change) while p. 11 notes (CLM Project the target did not change). Monitoring System) Achieved at year-end 2011: 100 percent CORE INDICATOR: Not in PAD, but shown Target: 500,000 nets 500,000 nets 500,000 nets as original indicator in Additional Financing/ Achieved at year-end 2011: Target achieved. Target achieved. Restructuring Paper: Long-lasting insecticide- 500,000 nets treated malaria nets purchased and/or (CLM Project (CLM Project Monitoring distributed (number) Monitoring System) System) Baseline: 0 Added: Backyard gardens n.a. 1,321 backyard gardens in intervention areas Target exceeded. (number) reflecting new activities on promotion (CLM Project Monitoring of food and dietary System) diversification Target: 350. Achieved at year-end 2011: 0 (continued on next page) A Decade of World Bank Support to Senegal’s Nutrition Program 81 (continued) TABLE D.3: Nutrition Enhancement Project Phase II: Results Framework and Achievement of Objectives Revised Outcomes objectives/2013 against original targets for additional targets, Outcomes against financing and as of 2014 revised targets, Original objectives, indicators, or restructuring (60 percent as of 2014 targetsa (approved in 2012) weight) (40 percent weight) Intermediate Outcome 3: Sectoral ownership and accountability for nutrition results, particularly in health and education Adoption of child growth promotion in Target maintained. Target achieved. Target achieved. children under two years of age and revision Achieved at year-end 2011 (CLM Project (CLM Project Monitoring of anemia prevention and control strategy Monitoring System) System) by Ministry of Public Health by 2009. Target: Updated in 2009 At least 75 percent of planned supervision Dropped: This indicator n.a. n.a. activities by implicated health districts is not even an output conducted indicator, but more an input Baseline: 0 indicator. Target for 2011: 75 percent At least 80 percent of targeted children Target increased: 90 99 percent 99 percent in primary education receive weekly percent Target surpassed. Target surpassed. micronutrient supplements during the school Achieved at year-end 2011: year in the intervention areas (CLM Project (CLM Project Monitoring 95 percent Monitoring System) System) Baseline: 0 Target for 2011: 80 percent 80 percent of 80 percent of targeted targeted children in children in primary primary education education received weekly received weekly iron iron supplements in 2015 supplements in 2015 (CLM Project Monitoring (CLM Project System) Monitoring System) At least 80 percent of targeted children Dropped: This indicator is 80 percent in 2015 80 percent in 2015 in primary education receive deworming closely tied to IOI on vitamin Target achieved. Target achieved. medication twice in one-year period in the A because the interventions intervention areas are coupled (CLM Project (CLM Project Monitoring Monitoring System) System) Baseline: 0 Target for 2011: 80 percent Intermediate Outcome 4: Government at all levels is aware of importance of nutrition in development and effectively monitors implementation progress of National Nutrition Policy Nutrition indicators are integrated in Target maintained. Target achieved. Target achieved. monitoring tools and documents of Achieved at year-end 2011 (CLM Project (CLM Project Monitoring poverty reduction strategy and Millennium Monitoring System) System) Development Goals Baseline: (not quantified) Target for 2011: (not quantified) At least 25 percent of targeted local Target increased: 35 34 percent 34 percent (135 local governments have incorporated nutrition percent Target surpassed. governments) objectives and interventions in Local Achieved at year-end 2011: Target achieved. Development Plans (CLM Project 31 percent Monitoring System) (CLM Project Monitoring Baseline: 0 System) Target for 2011: 25 percent (continued on next page) 82 A Decade of World Bank Support to Senegal’s Nutrition Program (continued) TABLE D.3: Nutrition Enhancement Project Phase II: Results Framework and Achievement of Objectives Revised Outcomes objectives/2013 against original targets for additional targets, Outcomes against financing and as of 2014 revised targets, Original objectives, indicators, or restructuring (60 percent as of 2014 targetsa (approved in 2012) weight) (40 percent weight) Added Core Indicator: 2.1 million in 2012; 2.2 Direct project beneficiaries million in 2013; 2.2 million in (number), of which female 2014; 1.9 million in 2015. (percent) Target almost achieved, Although data on total but declining slightly number will be available, postproject. data on the proportion (CLM Project Monitoring female will not. System, as reported to Target: 2.3 million PPAR mission; ICR reported beneficiaries 2.3 million in 2014, also Achieved at year-end 2011: citing CLM) 2.0 million beneficiaries Note: Percent of total disbursements under original project: 10.0/16.6 = 60 percent weight; under restructured project/additional financing: 6.6/16.6 = 40 percent weight. a World Bank 2006, as outlined in Appendix 3: Results Framework. A Decade of World Bank Support to Senegal’s Nutrition Program 83 TABLE D.4:  Rapid Response Child-Focused Social Cash Transfer and Nutrition Security Project: Results Framework and Achievement of Objectives Objectives or indicatorsa Outcomesb PDO Project Development Objective: To reduce the risk of nutrition insecurity of vulnerable populations, in particular children under five in poor rural and urban areas, by scaling up the NEP and providing cash transfers to vulnerable mothers of children under five. Project Outcome Indicators: PDO 1: percent of the target population (children under five) reached by the 65 percent community nutrition program Target surpassed. Baseline: 22 percent (CLM Project Monitoring System) Target for 2011: 45 percent PDO 2: percent of targeted mothers providing exclusive breastfeeding for the 62 percent first six months Target surpassed. Baseline: 34 percent (PAD notes that this baseline refers to national level (Source: LQAS, commissioned by CLM) data from 2005. Area-specific data were to become available within four months of effectiveness.) Target for 2011: at least 30 percent PDO 3: the number of beneficiaries (individuals) of the cash transfer program 49,315 in 2011; 54,512 in 2012 Baseline: 0 Target surpassed. Target for 2011: 50,000 (Source: CLM Project Monitoring System) PDO 4: percent of selected beneficiaries who receive all intended cash 96 percent transfers Target surpassed. Baseline: 0 (Source: CLM Project Monitoring System) Target for 2011: 80 percent Intermediate Outcome Indicators IOI 1: percent of children 6–59 months screened for acute malnutrition 90 percent Baseline: 0 Target surpassed. Target for 2011: 80 percent (Source: CLM Project Monitoring System) IOI 2: percent of children 0–24 months showing adequate weight gain 82 percent (2012); 83 percent (2013); 83 Baseline: 60 percent percent (2014); 84 percent (2015) Target for 2011: 75 percent Target surpassed. (Source: CLM Project Monitoring System) IOI 3: percent of pregnant women making at least four prenatal care visits 51 percent (Source: LQAS, commissioned by Baseline: 39% (PAD notes that this baseline refers to national level data CLM); from 2005. Area-specific data were to become available within four months of 48 percent (2014); 47 percent (2015) (Source: effectiveness.) Continuous DHS) Target for 2011: at least 30% (or 51%) Target surpassed. IOI 4: percent of mothers of target children who participate in monthly 95 percent information and education sessions Target surpassed. Baseline: 80 percent (Source: CLM Project Monitoring System) Target for 2011: 80 percent IOI 5: percent of targeted children 6–59 months receiving vitamin A 94 percent (2012); 96 percent (2013); 95 supplementation percent (2014); 95 percent (2015) Baseline: 80 percent Target surpassed. Target for 2011: 80 percent (Source: LQAS commissioned by CLM) percent of targeted children 12–59 months receiving deworming medication 89 percent (2014); 86 percent (2015) twice in a one-year period (no baseline or target) (continued on next page) 84 A Decade of World Bank Support to Senegal’s Nutrition Program TABLE D.4:  Rapid Response Child-Focused Social Cash Transfer and Nutrition Security Project: Results Framework and Achievement of Objectives (continued) Objectives or indicatorsa Outcomesb IOI 6: percent of targeted children in primary education receiving weekly 95 percent micronutrient supplements Target surpassed. Baseline: 80 percent (Source: CLM Project Monitoring System) Target for 2011: 80 percent IOI 7: percent of targeted children in primary education receiving deworming 95 percent (2012); 80 percent (2015) medication twice in a one-year period Target surpassed at end of project, then fully Baseline: 80 percent met post-project. Target for 2011: 80 percent (Source: CLM Project Monitoring System) IOI 8: Quantity of salt adequately iodized by small producers 73,299 tons (2012); 89,209 tons (2014); Baseline: 87,000 tons 112,022 tons (2015) Target for 2011: 139,000 tons Target not achieved, reflecting seasonal shocks and six-fold increase in price of fortificant. (Source: CLM Project Monitoring System) IOI 9: Quantity of oil adequately fortified with vitamin A by oil industry 107,178 liters (2012); 124,465 liters (2014) Baseline: 0 Target surpassed. Target for 2011: 80,000 liters (Source: CLM Project Monitoring System) Quantity of iron-enriched flour produced by local industry 164,710 tons (2015) Target for 2011: 150,000 tons Post-project (2015) target surpassed. (Source: CLM Project Monitoring System) IOI 10: Percent of local governments incorporating nutrition objectives and 30 percent (2012) and each year thereafter interventions in Local Development Plans (2013–15) Baseline: 0 Target surpassed. Target for 2011: 25 percent (Source: CLM Project Monitoring System) IOI 11: % selected beneficiaries not meeting eligibility criteria (inclusion error) 2.5 percent Baseline: 0 Target surpassed. Target for 2011: less than 20 percent (Source: CLM Project Monitoring System) IOI 12: Percent of transfers made by local payment service providers 76 percent (2010); 100 percent (2011); 100 Baseline: 0 percent (2012) Target for 2011: 80 percent Target surpassed. (Source: CLM Project Monitoring System) IOI 13: Development and adoption by the government of an efficient child- Both the social cash transfer to mothers focused social cash transfer scheme as part of the National Social Protection of vulnerable children and the community Strategy targeting system have been adopted by the Baseline: Not completed government. Target for 2011: Done Target achieved. a World Bank 2009, as outlined in Appendix 1: Project Design Summary. b Mid-2012 data reported in ICR (World Bank 2013), revalidated by the CLM, and CLM’s updates for recent years. A Decade of World Bank Support to Senegal’s Nutrition Program 85 National Trends FIGURE D.1: Prevalence of Underweight in Children under Age Five Years (Weight for Age) 25 21.9 20.3 19.2 20 7.8 16.8 15.5 7 14.5 5.8 14.4 15 4.5 12.6 Percent 3.2 3.9 2.8 2.2 10 14.1 13.3 13.4 5 11.6 12.3 12.3 10.6 10.4 0 1992 2000 2005 2010–11 2012 2012–13 2014 2015 Year Severe (-3SD) Moderate (-2SD) WHO Medium Severity Threshold WHO HighSeverity Threshold Totals Source: WHO, Global Nutrition Data for 1992–2012/13, which recalculates DHS data based on new comparator groups and definitions (WHO 2014, DHS 1992–93, DHS 1999, DHS 2005, DHS 2010–11, DHS 2012–13, DHS 2014, DHS 2015). FIGURE D.2: Prevalence of Stunting in Children under Age Five Years (Height for Age) 40 33.7 29.5 28.7 30 15.6 20.5 12.3 20.1 19.2 Percent 12 18.7 20 15.5 5.2 7.4 5.9 5.2 3.6 10 18.1 17.2 16.7 13.3 13.5 15.3 12.7 11.9 0 1992–93 2000 2005 2010–11 2012 2012–13 2014 2015 Year Severe (-3SD) Moderate (-2SD) WHO Medium Severity Threshold WHO HighSeverity Threshold Totals Source: WHO, Global Nutrition Data for 1992–2012/13, which recalculates DHS data based on new comparator groups and definitions; (WHO 2014, DHS 1992–93, DHS 1999, DHS 2005, DHS 2010–11, DHS 2012–13, DHS 2014, DHS 2015). 86 A Decade of World Bank Support to Senegal’s Nutrition Program FIGURE D.3: Prevalence of Wasting in Children under Age Five Years (Weight for Height) 30 25 20 Percent 15 9.4 10.0 9.8 8.7 8.7 8.9 10 7.8 3 3 2.2 1.2 1.9 5.9 2.3 1.4 5 0.7 6.4 7 6.4 7.6 7.5 7 6.4 5.2 0 1992 2000 2005 2010–11 2012 2012–13 2014 2015 Year Severe (-3SD) Moderate (-2SD) WHO Medium Severity Threshold WHO HighSeverity Threshold Totals Source: WHO, Global Nutrition Data for 1992–2012/13, which recalculates DHS data based on new comparator groups and definitions; (WHO 2014, DHS 1992–93, DHS 1999, DHS 2005, DHS 2010–11, DHS 2012–13, DHS 2014, DHS 2015). Program Coverage TABLE D.5: NEP II Targets Underweight Children to be reached Children ages prevalence Coverage target (Rural and Urban) 0–5 years (ages 0–5 years) Rural Urban Region (number) (%) (%) (%) Percent Number Kolda 155,413 32 70 39 61 96,121 Matam 69,572 29 70 50 62 42,923 Saint Loius 96,644 28 70 45 57 55,395 Tambacounda 105,442 25 70 42 60 63,584 Louga 105,771 21 55 44 51 53,703 Diourbel 155,101 20 55 32 50 77,670 Fatik 100,649 16 45 23 41 41,523 Thies 236,749 13 45 26 37 86,850 Kaolack 184,318 11 45 17 38 69,827 Dakar 350,699 6 15 30 29 102,820 National 1,629,326 17 53 32 43 706,789 A Decade of World Bank Support to Senegal’s Nutrition Program 87 TABLE D.6: Population under Age Five, 2002–16 Population Urban under age five Rural under age five Total under age population five Year (millions) REACH (14.7%) REACH Percent Number Percent Number 2002 10.4 1.53 40.64 621,792 59.36 908,208 2003 10.7 1.57 40.78 640,246 59.22 929,754 2004 11.0 1.62 40.94 663,228 59.06 956,772 2005 11.3 1.66 41.12 682,592 58.88 977,408 2006 11.6 1.71 41.31 706,401 58.69 1,003,599 2007 11.9 1.75 41.52 726,600 58.48 1,023,400 2008 12.2 1.79 41.74 747,146 58.26 1,042,854 2009 12.6 1.85 41.98 776,630 58.02 1,073,370 2010 13.0 1.91 42.23 806,593 57.77 1,103,407 2011 13.4 1.97 42.50 837,250 57.50 1,132,750 2012 13.8 2.03 42.78 868,434 57.22 1,161,566 2013 14.2 13.9 a 2.09 2.09 a 43.08 900,372 56.92 1,189,628 2014 14.7 2.16 43.39 937,224 56.61 1,222,776 2015 15.1 2.22 43.72 970,584 56.28 1,249,416 Source: World Bank World Development Indicators (database), World Bank, Washington, DC, http://data.worldbank.org/data-catalog/world-development- indicators; Dankoko 2011; Index Mundu (database), http://www.indexmundi.com/facts/senegal/urban-population. Note: REACH is a country-led approach to scaling up proven and effective interventions to address child undernutrition through the partnership and coordinated actions of United Nations agencies, civil society, donors, and the private sector, under the leadership of national governments. REACH cofacilitates the United Nations network for Scaling-Up Nutrition, together with the United Nations Standing Committee on Nutrition. a According to REACH in 2013, the totals for each target group were: women of reproductive age (15–49 years): 3,427,417; children under six months: 225,708; children ages 6–24 months: 670,854; children ages 6–59 months: 1,864,180; and children under five years: 2,089,888. TABLE D.7: Program Coverage by Local Collectivity Local 2005a 2013 2014 2015 2016 Region Dep’ts collectivities Number Number Number % Number % Dakar 4 52 8 29 29 56 29 0 Diourbel 3 40 4 36 36 90 40 40 Fatick 3 40 21 28 28 70 28 29 Kaffrine 4 33 12 26 26 79 26 26 Kaolack 3 41 17 25 25 61 25 26 Kedougou 3 19 1 14 14 74 19 19 Kolda 3 40 10 27 27 68 27 27 Louga 3 55 1 39 39 71 39 39 Matam 3 26 0 26 26 100 26 26 Saint-Louis 3 38 3 33 33 87 38 38 Sedhiou 3 43 19 26 26 61 26 27 Tambacounda 4 46 1 46 46 100 46 46 Thies 3 49 0 30 30 61 30 29 Ziguinchor 3 30 0 1 1 3 13 13 Senegal 45 552 97 386 386 400 385 Number of local collectivities 384 552 552 552 552 Geographic coverage of NEP (percent) 25 70 70 72 70 a In 2005 Senegal was made up of communes and rural communities, and the regions of Kaffrine, Kedougou, and Sedhiou did not yet exist. This table has taken into account the communes and rural communities of Kaolack, Tambacounda, and Kolda and allocated them to the yet to be created regions of Kaffrine, Kedougou, and Sedhiou for the purpose of trend analysis. 88 A Decade of World Bank Support to Senegal’s Nutrition Program TABLE D.8: Coverage of Key Interventions by Department and by Target Group Coverage Departments less more covered than 25%– 50%– than Interventions (number) Target or age group 25% 50% 75% 75% Nutrition Vitamin A supplementation 45/45 Children ages 6–59 months Iron and folic acid supplementation 42/45 Pregnant women Household fortification 45/45 Children ages 6–23 months Screening for acute malnutrition 45/45 Children ages 6–59 months Rehabilitation of severe acute 45/45 Children ages 6–59 months malnutrition Rehabilitation of moderate acute 45/45 Children ages 6–59 months malnutrition Deworming 45/45 Children ages 12–59 months 45/45 School children ages 5–14 years Growth monitoring and promotion 45/45 Children ages 0–23 months Small-scale or community fortification 19/45 Children ages 6–59 months Promotion of Infant and Young Child Feeding Practices Exclusive breastfeeding for children 45/45 Lactating mothers of children under 6 months under 6 months 45/45 Pregnant women Proper feeding of children ages 6–23 45/45 Lactating mothers of children months ages 6–23 months 45/45 Lactating mothers of children under 6 months Food Security Development of family agriculture, 45/45 Households livestock, fishing Biofortification of food consumed in 8/45 Households household Social assistance for vulnerable groups 33/45 Households Communication for Behavior Change Nutrition education 45/45 Mothers or other child care providers for children under five Promotion of behavior change for good 45/45 Mothers or other child care nutrition providers for children under five Gender Functional literacy program 12/45 Women 15–49 years Health and Environmental Services (promotional activities) Promotion of hand washing with soap 45/45 Mothers or other child care providers for children under five Promotion of latrine use 43/45 Households 43/45 Mothers or other child care providers for children under five (continued on next page) A Decade of World Bank Support to Senegal’s Nutrition Program 89 TABLE D.8: Coverage of Key Interventions by Department and by Target Group (continued) Coverage Departments less more covered than 25%– 50%– than Interventions (number) Target or age group 25% 50% 75% 75% Treatment of drinking water in 29/45 Mothers or other child care households providers for children under five 29/45 Households Proper care of diarrhea 45/45 Mothers or other child care providers for children under five Proper care of upper respiratory 45/45 Mothers or other child care infections providers for children under five Reproductive health and birth spacing 19/45 Women 15–49 years 19/45 Pregnant women Healthy pregnancy monitoring (antenatal 45/45 Pregnant and lactating care, assisted deliveries, postnatal visits) women Disease prevention (vaccination, IMCI) 45/45 Children ages 0–59 months 45/45 Pregnant and lactating women 90 A Decade of World Bank Support to Senegal’s Nutrition Program APPENDIX E List of Persons Met Government of Senegal, National Level ®® Mr. Mouhamadou Lamine Sow, Ministry of Industry and Mines Ministry of Economy and Finance ®® Ms. Ramatoulaye Aidara, Ministry of Commerce ®® Ms. Ndeye Maye Diouf, Officer in Charge of Health ®® Ms. Khady Mbaye, Ministry of Commerce and Social Development ®® Mr. Ismaila Ba, Familyt Directorate, Ministry of the Family CLM/National Level Staff ®® Ms. Seynabou Tuore Laye, Ministry of Agriculture ®® Mr. Abdoulaye Ka, National Coordinator and Rural Equipment ®® Mr. El Hadji Momar Thiam, monitoring and evalua- ®® Ms. Khady Diallo, Ministry of National Education tion Specialist ®® Dr. Maty Diagne Camara, Ministry of Health ®® Mr. Makick Faye, Financial Management and Ac- counting Specialist Former Focal Points ®® Ms. Aminata Ndoye, Director of Operations ®® Dr. Mame Mbayame Dione, Deputy of National As- ®® Mr. Ibrahima Gaye, Manager of the Food Fortifica- sembly, former Focal Point for Ministry of Health tion Program ®® Professor Galaye Sall, Pediatrics Department, ®® Ms. Adama Cisse, Communication Adviser Hospital Aristide Le Dantec, former Focal Point for ®® Mr. Ousseynou Diakhate, Communication Officer Ministry of Health ®® Ms. Ndeye Rokheya Seck, Thies Regional Office Local Level Actors and Stakeholders CLM Focal Points Representing Various Sectors Contributing to Nutrition Efforts Field Visit to Louga Region-Dahra Actors ®® Ms. Sophie Gyeye Sow, Focal Point, National ®® Mr. Moussa Yatte, Sous-Prefet, Sagatta Djoloff, Agency for Young Children, National Agency of Dahra Early Childhood Development and Reception ®® Mr. Mamadou War, Chief of Project, ADEV, Dahra Center ®® Mr. El Hadji Faye, Supervisor, ADEV, Dhara A Decade of World Bank Support to Senegal’s Nutrition Program 91 ®® Mr. Serigne Ndiaye Beye, Community Agent, ®® Ms. Ndeye Sokhna Thiam, President C.G., Local ADEV, Sagatta Djoloff Collectivity, Darou Mousty ®® Mr. Aliou Ndao, Community Agent, ADEV, Deali ®® Ms. Cina Hosny, Nutrtrition Aide, District, Darou ®® Mr. Semou Diop, Community Agent, ADEV. Mousty Sagatta-Affe ®® Ms. Astou Toure, President, Association of Aides, ®® Ms. Coumba Diaw, Mayor, Local Collectivity, Darou Mousty Sagatta Djioloff ®® Ms. Ndeye Diagne, Treasurer, Local Pilot Commit- ®® Ms. Bator Ndiaye, President, Local Pilot Commit- tee, Darou Mousty tee, Sagatta Djioloff ®® Ms. Rokheya, Community Health Educator, Local ®® Mme Oumou Diop, Vice President, Local Pilot Collectivity, Mbadiane Committee, Sagatta Djioloff ®® Mr. Modou Dema Seck, President, Local Pilot ®® Ms. Fatou Ndiaye Diaw, Assistant Treasurer, Local Committee, Local Collectivity, Darou Mousty Pilot Committee, Sagatta Djioloff ®® Mr. Mansour Ndoye, Community Health Educator, ®® Mr. El Hadji Bassirou Ndao, Village Chief, Local Local Collectivity, Ndoyene Collectivity, Sagatta Djioloff ®® Ms. Aissatou Sow, ECS, Health District, Darou ®® Ms. Fatou Ndiaye Faye, Nurse Chief of Municipal Mousty Health Post, Dahra ®® Mr. Amadou Ndiagne Diagne, Plan-Senegal, Darou Marnane Darou Mousty Actors ®® Mr. Ibra SEck Ba, Deputy Mayor, Local Collectivity, ®® Mr. Gallo Cisse, Chief of Project, Plan-Senegal, Darou Marname Darou Mousty ®® Mr. Mor Seck, Municipal Secretary, Local Collec- ®® Mr. Pape Ly, Deputy Sous-Prefet, Darou Mousty tivity, Darou Marnane Arrondissement ®® Ms. Fatou Fall Dieye, Chief of Service, CADL, Beneficiaries/Mothers of Dahra-Ndiayene/ Darou Mousty Dahra Djoloff ®® Mr. Wagane Faye, Representative of Village Chief, ®® Ms. Mboyo Ka, Nutrition Aide Darou Mousty ®® Ms. Hawa Sow ®® Mr. Madiop Biteye, Mayor, Local Collectivity, ®® Ms. Oumou Sow Darou Mousty ®® Ms. Farimal Sow ®® Mr. Mamadou Sambou, Overseer of agriculture ®® Ms. Toylaye Dia component, ANCAR, Darou Mousty ®® Ms. Binta Diallo ®® Mr. Mamadou Gaye, Village Chief, Local Collectiv- ®® Ms. Gueda Ba ity, Darou Mousty ®® Ms. Ndeye Coumba Guisse ®® Mr. Mansour Diop, Health Educator, Local Collec- ®® Ms. Mareme Guisse tivity, Ndoyene ®® Ms. Fama Diaw ®® Mr. Moustapha Badji, Nurse Chief of Health Cen- ®® Ms. Diarra Ndiaye ter, Darou Mousty ®® Ms. Astou Toure, President ARC ®® Ms. Astou Toure, President, Association of Nutri- tion Aides, Darou Mousty Beneficiaries/Mothers of Darou Marnane ®® Mr. Alioune Mbaye, Director, Centre of Social Re- Local Collectivity integration/Directorate of Social Action, Ministry of ®® Ms. Ndeye Diop Health and Social Development, (visiting) Darou ®® Ms. Fatou Ba Mousty ®® Ms. Anta Sock ®® Ms. Adja Seynabou Diop, Nutrition Aide, Local ®® Ms. Ndeye Sow Collectivity, Darou Mousty ®® Ms. Kokhna Gaye 92 A Decade of World Bank Support to Senegal’s Nutrition Program ®® Ms. Bomba Sylla ®® Ms. Cecile Man Dione, Professor, Secondary ®® Ms. Awa Ngom School, Mbar ®® Mr. Barra Dieng, Student/President Nutri-Ecole Field Visit to Kaolack Region Actors Project ®® Mr. Cheikh Seye, Accountant, ARAF, Gossas ®® Mr. Ndiaye Seye, Student/Secretary, Nutri-Ecole ®® Mr. Momar Mbodji, Chief of Project ARAF, Gossas Project ®® Mr. Ibrahima Diallo, Chief of Project, ARAF, ®® Ms. Amy Diouf, Student/Organizer, Nutri-Ecole Guinguineo Project ®® Mr. Mamadou Sarr, President, ARAF, Gossas ®® Mr. Modou Diouf, Student/Treasurer, Nutri-Ecole ®® Mr. Waly Faye, Secretary General ARAF, Gossas Project ®® Ms. Fatou Ndiaye, President, Local Pilot Commit- ®® Ms. Racky Ane Ndiaye, Student/External Relations tee, Gagnick Tibou Officer, Nutri-Ecole Project ®® Ms. Oumy Ndiaye, Vice President, Local Pilot ®® Ms. Aida Kane, Student/Vice-President, Nu- Committee, Gagnick Tigou tri-Ecole Project ®® Ms. Awa Faye, Secretary, Local Pilot Committee, ®® Mr. Alassane Sy, Student/External Relations Offi- Gagnick Tibou cer, Nutri-Ecole Project ®® Ms. Ndioba Sow, Treasurer, Local Pilot Commit- ®® Mr. Khadim Diouck, Student/Organizer, Nu- tee, Gagnick Tibou tri-Ecole Project ®® Ms. Awa Mbaye, Nutrition Aide, Local Collectivity, ®® Mr. Aziz Seye, Student/External Relations Officer, Gagnick Tibou Nutri-Ecole Project ®® Ms. Diaw Samb, Nutrition Aide, Local Collectivity, ®® Ms. Khady Gueye, Student/Deputy Treasurer, Nu- Gagnick Tibou tri-Ecole Project ®® Ms. Soda Mareme Kane, Nutrition Aide, Local Col- lectivity, Gagnick Tibou Mbar Actors ®® Mr. Mbaye Ndiaye, Nurse Chief of Health Post, ®® Mr. Mbaye Samb, Mayor, Local Collectivity, Mbar Gagnick Khodjil ®® Mr. Pape Makhtar Lo, Community Agent, Local ®® Mr. Falou Ndour, Chief of Departmental Livestock Collectivity, Mbar Service, Gossas ®® Mr. Seydou Seye, Municipal Secretary, Local Col- lectivity, Mbar Beneficiaries/Mothers of Gagnick Tibou/ ®® Ms. Mougnane Ka, Municipal Adviser, Local Col- Guinguineo Local Collectivity lectivity, Mbar ®® Ms. Fatou Dkouf ®® Ms. Asou Niane, Nutrition Aide/President, Village ®® Ms. Ramatoulaye Diop Management Committee, Mbam Djigane ®® Ms. Mboye Badiane ®® Mr. Adama Sow, Shepherd/village flock, Village ®® Ms. Ndeye Fatou Top Management Committee, Mbam Djigane ®® Mr. Aly Ndiaye, Chief of Village ®® Mr. Aly Dieng, Village Chief/Treasurer, Village ®® Ms. Amy Ndiaye, Traditional Midwife Management Committee, Mbam Djigane ®® Mr. Mbaye Sakho, President, Association of Poly- ®® Mr. Mamadou Niang, Secretary General, Village valent Community Aides Management Committee, Mbam Djigane Field Visit to Fatick Region Actors Nutri-Ecole World Bank Project ®® Mr. Babacar Diop, Principal, Secondary School, Mbar ®® Ms. Eva Jarawan (retired), Former Sector Manag- ®® Mr. Lamine Barro, Professor, Secondary School, Mabar er, Human Development, Africa A Decade of World Bank Support to Senegal’s Nutrition Program 93 ®® Ms. Claudia Rokx, Former Task Team Leader, ®® Ms. Yaikah M. Jeng Joof, Program Director, Senegal Nutrition Childfund ®® Mr. Menno Mulder-Sibanda, Task Team Leader, ®® Dr. Balla Moussa Dhiedhiou, Director for the Sa- Senegal Nutrition hel, Micronutrient Initiative ®® Ms. Leslie Elder, Senior Nutrition Specialist ®® Ms. Megan Kyles, Nutrition Leader, USAID ®® Mr. Christophe Lemiere, Task Team Leader, Sene- ®® Ms. Maria E. Garcia Noguera, Officer for Humani- gal Health tarian Programs, AECID/Spanish Cooperation ®® Ms. Aminata Bop Ndiaye, Administrative Assistant ®® Ms. Marieme Diaw, Nutrition Program Officer, ®® Mr. El Hadji Mamadou Cisse, Financial Manage- World Food Programme ment and Accounting Officer ®® Ms. Aida Gadiaga Facilitator, REACH ®® Ms. Sophie Cowppli-Bony, International Facilitator, Other International Development Partners REACH and International Experts ®® Ms. Elodie Becquey, Research Officer, Internation- al Food Policy Research Institute (IFPRI) ®® Ms. Aissatou Dioum, Nutrition Specialist, UNICEF ®® Mr. Ibrahima Mbodji, Communication Expert, UNICEF 94 A Decade of World Bank Support to Senegal’s Nutrition Program Endnotes 1. This amount was for the first of three phases of an the approach was very costly, and there were low Adaptable Program Loan. Total envisaged Inter- levels of capacity strengthening. Lessons reveal national Development Association support for the that the project could have benefited from more three phases was SDR 39 million (US$48.7 million substantial use of local women’s groups, nongov- equivalent). ernmental organizations (NGOs), and other local 2. Projet Santé II/African Development Bank, WFP, structures and capacity (World Bank 2001). UNICEF, and Micronutrient Initiative. 9. The PAD of February 20, 2002, states this same 3. Data in the General Background section are from PDO but also adds another one: “To consolidate the Government of Senegal Poverty Reduction and sustain the results gained with the earlier Strategy Paper, 2002, https://www.imf.org/Exter- (Community Nutrition) project, which contribut- nal/NP/prsp/2002/sen/01/100502.pdf. ed to reversing the negative trend in nutritional 4. National Strategy for Economic and Social Devel- status among children under three in the urban opment (2013–17), November 8, 2012. areas” (World Bank 2002b, 3). In line with har- 5. Extreme poverty is defined as the portion of the monized guidelines, this project will be evaluated population whose total consumption is less than against the PDO, as stated in the Development the cost of a food basket providing minimum calo- Credit Agreement. Trends in nutritional status rie requirements. among children under age three years will also 6. Senghor (1960–80); Diouf (1981–2000); Wade be assessed. (2000–12); and Sall (2012–present). 10. Specifically neighborhoods in the cities of Dakar, 7. Appendix B provides an overview of World Bank Pikine, Diourbel, Kaolack, and Ziguinchor. support to nutrition efforts in Senegal from 1995 11. For the urban zones the PAD on the CNP devotes to the present. an entire appendix to the targeting methodology. 8. Completed in 2000, this project succeeded in halt- Four types of targeting were used: geographic tar- ing a further deterioration of the nutritional status gets (neighborhoods with high poverty and poor or of young children in the highly vulnerable urban no basic services); demographic targets (specific neighborhoods targeted by the project. However, target groups, for example, pregnant and nursing A Decade of World Bank Support to Senegal’s Nutrition Program 95 women and children ages 6–36 months); nutrition- chasing power for food, women’s status, workload al status of children and at-risk children; and food and education.” security. A range of sources (including household 15. Technical divisions within Ministry of Public Health survey data and malnutrition data) and techniques and other line ministries are represented in the (local-level participation) was also envisaged. For technical committee, which assists the CLM with the rural areas the regions of Kaolack, Fatick, policy development and expert advice. A moni- and Kolda were selected because they were de- toring and evaluation committee evaluates the termined (based on available poverty data and performance of the BEN. studies) to be the three poorest regions in Sene- 16. Detailed data are provided in appendix C, tables gal. Within these regions, 34 health districts were C.1, C.2, and C.3. selected with the assistance of Regional Health 17. Of which 8.4 million is an IDA credit and 3.4 million Officers on the basis of social indicators and, with- a multilateral debt relief initiative. The latter calls in these districts, communities were selected with for 100 percent cancelation of IDA, African Devel- Health District and NGO input on the basis of mal- opment Fund, and International Monetary Fund nutrition data. debt for countries that reach the heavily indebted 12. The relevant Sustainable Development Goals as poor countries completion point. listed are: (1) no poverty; (2) zero hunger; (3) good 18. Mame Madior Boye (2001–02); Idrissa Seck health; (5) gender equality; (10) reduced inequali- (2002–04); Macky Sall (2004–07). ties; (11) sustainable cities and communities; (13) 19. The chair of the BEN was the director of the NEP. climate action; and (16) peace and justice. 20. Project leader, community supervisor, fiduciary 13. Vertical interaction is the collaboration and ex- staff, and others. change across the multiple levels of the NEP: 21. Thirty-six CEA staff (100 percent of staff responsi- central, regional, district, and local levels. Hor- ble for administrative and financial management) izontal interaction and collaboration implies a were trained in procurement and financial man- multisectoral approach, which seeks to involve agement. All 34 subproject coordinators were all relevant sectors and public or private actors at trained in monitoring and evaluation. each level of the system. 22. Members include community representatives se- 14. See IFPRI 2016, World Bank 2006c, and The Lan- lected by the community. These committees are cet Maternal and Child Nutrition Series (2008). typically led by village chiefs or spiritual leaders. Components capture (1) the “short routes” to 23. Chaired by the local authority (sous-préfet at the improved nutrition advocated in Repositioning district level and préfet at the departmental level), Nutrition as Central to Development (World Bank members include the district health officer other 2006c) (community-based health and nutrition relevant sector representatives and representa- services, facility-based services, micronutrient tives from beneficiary communities. supplements, nutrition education and behavior 24. Chaired by the governor, members include dis- change interventions including: maternal nutrition, trict and regional medical officers, representatives knowledge and care-seeking during pregnan- from local collectivities, and CEAs. cy and lactation; infant and young child feeding, 25. Urban zones covered under the CNP and selected hygiene education, and promoting healthy diets); local collectivities in rural areas of three priority re- and (2) are cognizant of and serve to stimulate a gions: —Fatick, Kaolack, and Kolda. multisectoral approach to the “long routes to im- 26. Although this was stated in the PAD as a target, proved nutrition (health, water and sanitation, it was not among the key performance indicators. supportive food and agricultural policies, fruit and Moreover, the CLM has noted difficulty in disag- vegetable production, poverty alleviation, pur- gregating data by urban or rural residence. 96 A Decade of World Bank Support to Senegal’s Nutrition Program 27. The low coverage in 2003 was the result of a sudden plementation) to the community-based approach. policy change for campaign-style delivery of services, But these faded as the program demonstrated its which was rectified in 2004 (World Bank 2007c). effectiveness. 28. Preliminary results from an impact evaluation sug- 36. Indeed, the CLM and the task team leader have gested use of prenatal care increased from 65 to indicated that (1) the project did not operate in 78 percent in intervention areas, and from 64 to 70 isolation—there was a lot of institutional com- percent in control areas. But these results were ap- munication around the new approach, which propriately discounted because there were really trickled to other actors, service providers, and no control areas in Senegal, given the wide range beneficiaries; and (2) the random selection of partners and interventions promoting maternal could not be controlled at 100 percent due to and child health care, covering (in different ways) local political economy issues. Moreover, the most of the country (see also paragraph 2.56). time allowed for impact (two years) was too 29. Malaria and malnutrition combine in a vicious circle: short given the age range of children for growth malnourished children have weak immune sys- monitoring and promotion (0–36 months old). tems, so their bodies are less able to fight diseases Not much influence could be expected among such as malaria, and children sick with malaria are the older children, and the enrollment or obser- more likely to become dangerously malnourished. vation only of newborns may have revealed the 30. The reduction in control areas was from 24 per- true effect of the project. The impact evaluation cent to 21.7 percent. Again, both the CLM and confirmed that the impact was most significant its BEN (secretariat to the CLM) and the PPAR among those under age one. understand the methodological challenges of de- 37. The PAD (World Bank 2006b, 5) states essentially fining true control groups for this study in Senegal the same objective but also mentions expansion of (paragraph 2.56). access to program services: “The second phase 31. The national improvements in underweight are objective is to expand access to and enhance nu- likely linked to the strong, inclusive economic tritional conditions of vulnerable populations, in growth and especially to the poverty reduction particular those affecting growth of children under achieved between 2001 and 2005 (paragraph five in poor urban and rural areas.” It also mentions 1.3). But the project’s intervention areas remained that although “the first phase was meant to ex- extremely poor even during this period of strong plore, learn, and identify best practices on a limited economic performance, highly dependent on scale,” the second phase is “dedicated to scaling rain-fed agriculture and vulnerable to unfavorable up interventions and refining strategies and imple- environmental and climatic conditions. mentation capacity for the provision of appropriate, 32. Under Phase I, children ages 0–36 months were cost-effective nutrition services in collaboration targeted for growth promotion; under Phase II, the with communities and local government.” target age was amended to ages 0–24 months. 38. Strictly speaking, the logic of the split rating as 33. The literature includes Scaling Up Nutrition: A outlined in the harmonized guidelines do apply. Framework for Action (2010), Lancet (2008), The However, in this case, targets were revised up- First 1,000 Days (IFPRI (2016). ward, and both original and revised targets were 34. International lessons were drawn from the World met or exceeded. Therefore, for the sake of ele- Bank’s nutrition investments in Madagascar, Ban- gance and simplicity, this evaluation does not go gladesh, and India, and other community-based through the mechanisms of a split. multisectoral nutrition experiences. 39. The urban areas included five quartiers in Da- 35. Initially, there were some elements of the gov- kar, one in Diourbel, four in Kaolack, and four ernment of Senegal that had misgivings about in Ziguinchor. The additional rural areas were in the transition from the CNP approach (food sup- three regions: Kaolack, Fatick, and Kolda. A Decade of World Bank Support to Senegal’s Nutrition Program 97 40. This project thus continued support in the urban areas 51. The interventions were: Vitamin A supplementa- provided under the Phase I and scaled up its coverage tion; iron and folic acid supplementation; household of rural areas, selected on the basis of their levels of fortification; screening for acute malnutrition and poverty and malnutrition, to include 7 regions. At the severe acute malnutrition and rehabilitation of time of project design and through the early years of these cases; deworming; growth monitoring and implementation, there were 10 regions in Senegal. promotion; small-scale community fortification; 41. This rating is not split across original and revised exclusive breastfeeding; infant and young child objectives because the PDO did not change under feeding practices; development of family agricul- the restructuring. ture; food biofortifiers; social protection; nutrition 42. According to the 2000 Multiple Indicator Cluster education; behavior change interventions; func- Survey, 23 percent of children under age 5 and 15 tional literacy; promotion of handwashing with percent of women aged ages 15–49 years were soap; promotion of latrine use; treatment of drink- underweight and 19 percent of children under age ing water; diarrhea treatment; treatment of upper 5 were stunted (MICS 2000). respiratory infections; reproductive health; safe 43. As detailed in section V, the World Bank cut back pregnancy, antenatal care; and IMCI. substantially on its initial financial commitment un- 52. See World Bank (2006c; Scaling Up Nutrition: der the APL. What Does It Cost? (Horton 2010); and Lancet 44. Detailed data are provided in appendix C, tables (2008). Moreover, the world’s top economists C.4, C.5, and C.6. placed these activities among the top 10 of any 45. Indeed, the government of Senegal did not pro- global development solution in two rounds of the vide the agreed counterpart funding for any of the Copenhagen Consensus in 2008 and 2012, based World Bank’s projects in the country for a period of on the latest cost-effectiveness evidence. time, due to its financial constraints. 53. The change of CLM Coordinator was smoothly im- 46. The number of nutrition sites has decreased plemented because the Coordinator was replaced somewhat in the ensuing years, due to financing with an equally capable leader, who had been with constraints (section V). the program from the outset. Most staff had been 47. Areas covered: healthy pregnancies (husband’s with the program for many years, many for a de- support, antenatal care, iron supplementation, dan- cade or more and some had been recruited from ger signs), infant care (danger signs in newborn, the CNP. They spontaneously noted to the PPAR postnatal care, early initiation of breastfeeding, team that they had no intention of ever leaving and exclusive breastfeeding until six months), the program because they believed so strongly infant and young child supplemental feeding and in their mission and that they aspired to achieve diet, and feeding the sick child. even greater impact based on unfolding evidence 48. The target districts (regions) were Gossas (Fatick), and lessons. Kongheul (Kaffrine), Koumpentoum (Tamba- 54. The PAD mentions a program objective of reduc- counda), Medina Yoro Foula (Kolda), Bambey ing undernutrition by 25 percent in the intervention (Diourbel), Ranerou (Matam), Linguere (Louga), areas by 2011, but this is not included as a key and Podor (Saint-Louis). outcome indicator for the project. 49. The decline in coverage was due to the elimination 55. Moreover, in recognition of this challenge, the from the program of local collectivities in the Dakar CLM has since (after project closing) commis- region as a result of financial constraints. sioned REACH (Renewed Efforts Against Child 50. Some 50 partners responded to the surveys, Hunger and undernutrition) to undertake a survey including government ministries, research institu- of all partners to assess coverage of key interven- tions, local and international NGOs, and bilateral tions across the country. REACH is a country-led and multilateral partners. approach to scaling up proven and effective inter- 98 A Decade of World Bank Support to Senegal’s Nutrition Program ventions addressing child undernutrition through 61. The IDA credit amount is designated in SDR, and the partnership and coordinated actions of United the multidonor trust fund is designated in a num- Nations agencies, civil society, donors, and the ber of different currencies provided by its various private sector, under the leadership of nation- contributors. al governments. REACH cofacilitates the United 62. The end-of-project, full-year production estimate is Nations network for Scaling-Up Nutrition together made up of production data from the fourth quarter with the United Nations Standing Committee on of 2011 and the first three quarters of 2012. Nutrition. 63. A combination of geographic, category, and com- 56. KPC surveys require large household sample siz- munity-based targeting was used. The CLM has es and are therefore expensive. LQAS surveys undertaken a detailed analysis of the targeting require very small sample sizes and provide ac- mechanism applied under the project and its positive curate information on categorical hypotheses. results, which were instrumental to the government Because LQAS surveys are implemented at the of Senegal’s adoption of the cash transfer scheme. local level, aggregating data from multiple LQAS 64. The outcome indicator tracks the share of the tar- surveys allows the calculation of KPC estimates get population (children under age five) reached on specific indicators. by the community nutrition program (baseline: 57. The financing agreement’s PDO statement is con- 22 percent; target: 65 percent). However, differ- sistent with the statement in World Bank (2009c). ent interventions targeted different age groups, 58. The 10 critical districts are Bakel, Darou Mousty, and (because of underfinancing) villages with Dianke Makha, Kidira, Louga, Goudiry, Goudoump, populations under 1,000 would receive fewer in- Guinguineo, Kebemer, and Matam. terventions, delivered less frequently, than villages 59. The community-level organizations are the Local with populations greater than 1,000. Moreover, the Selection Committee of the Social Affairs Commis- program sought to expand interventions to hard- sion of local government; the CEA involved in NEP er-to-reach populations as well as to intensify implementation; and the Arrondissement-Level activities where the program was already oper- Monitoring Committee. ating. More precision in measuring these various 60. Detailed data are provided in appendix C, tables types of program expansion and coverage would C.7, C.8, C.9, and C.10. have brought more clarification and certainty. 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A Decade of World Bank Support to Senegal’s Nutrition Program 105 1818 H Street, NW Washington, DC 20433 Financial support for this study was provided by IEG; the high-level dissemination event was supported by the World Bank and the Japanese Trust Fund for Nutrition. The task force providing oversight of the series was composed of members of the following organizations: