Uganda - Nutrition and Early Childhood Development Project (NECDP) [formerly titled Nutrition and Child Development Project (NCDP)]

Report No. PIC3258 Project Name Uganda-Nutrition and Early Childhood ro) N Development Project (NECDP) Region Africa Sector Human Resources Project ID UGPA40551 Borrower Government of Uganda Implementing Agency Ministry of Planning and Economic Development Uganda House, PO Box 7086 Kampala, Uganda Fax: (256-41) 233-035+ Telephone: (256-41) 23-50-51 Date this PID Updated June 18, 1997 Appraisal Date May 26-June 13, 1997 Projected Board Date September 15, 1997 1. Background And Sectoral Context. Uganda's children are at risk. More than 12t of infants die before reaching their first birthday, mostly due to preventable infectious diseases. And those who survive beyond their first year of life are afflicted with malnutrition and disease and perform poorly in school. For a country endowed with fertile land and stable food supply, Uganda has an unusually high rate of malnutrition. About 25t of its preschool children are underweight for their age and 41t are stunted - or are chronically malnourished. These rates are higher than most African countries. Our sector analysis on Uganda's child development shows that malnutrition is caused by: (a) sub-optimal breastfeeding and infant weaning practices; (b) the high incidence of infectious diseases which hinder bodily absorption of food; (c) low level of education among mothers; and (d) poverty. 2. The problem of childhood malnutrition and disease in Uganda is exacerbated by AIDS which is leaving in its wake 1.2 million orphans who must be cared for by community members, primarily by women and girls because there are no other alternatives. The strong solidarity that characterizes the traditional extended family and community is being undermined and is breaking down under the strain, resulting in serious problems in education and child development. 3. In addition to general malnutrition, Ugandan children and mothers also suffer from specific micro-nutrient deficiencies that contribute to poor health. The most common form of micro-nutrient malnutrition is iron deficiency anemia, which is a cause for low birth weight, maternal death, poor school performance and lower work productivity. Iodine deficiency is also a serious problem in many parts of the country and is causing goiter, cretinism, mental retardation, reduced mental capacity in infants and children. Vitamin A deficiency, which causes xeropthalmia and blindness, is  also a problem of public health significance. 4. In response to these problems, the Government adopted a strategic sectoral plan to address child development. This is now embodied in the Uganda National Programme of Action for Children (UNPAC 1993), comprising of actions to address the survival, protection and development of children. As a national program, UNPAC was discussed widely within government, amongst donors and with NGOs and the private sector. The primary donor is UNICEF, which recently approved a new five-year country program beginning in 1995. The Ministry of Finance and Economic Planning reviewed UNPAC in December 1995 and it concluded that, despite the infusion of the new UNICEF program, the financing gap is quite large and that without new funding the program goals will not likely be achieved. The commitment of the Government towards children is also demonstrated by the proposed Child Bill which is presently under deliberation in Parliament. 5. Interventions under IDA's Uganda Nutrition and Child Development Project will support selected strategies proposed in UNPAC but will focus mainly on children in early childhood (preschool) years. Recent scientific evidence supports the view that human capital formation effectively starts at the mothers' womb and in early childhood - human brain development is almost wholly completed by age two and about 50t of the variance in intellectual development is established by age four. Early malnutrition, inadequate intellectual stimulation and care in childhood would likely result in severe and irreversible damage to the physical, intellectual and emotional capacities. 6. Project Objectives. The proposed project seeks to contribute to poverty alleviation and human capital development objectives by implementing development interventions targeted to the most vulnerable segments of the population - namely, young children and mothers. 7. The development objective of the project is to improve the health, nutritional and cognitive status of preschool children in Uganda. The project strategy involves the provision of community- based child development services and enhancement of women's ability to care for children - by providing them with knowledge on proper child caring practices and by increasing their income-earning opportunities. At the end of the five-year implementation period, the project will be evaluated on the following indicators: (a) reduced prevalence of underweight preschool children by half of the 1995 levels in the project districts; (b) reduced prevalence of stunting at entry in primary schools by one-third of the 1995 level in the project districts; (c) increased primary school enrollment by 20t in the project districts; (d) improved psycho-social and cognitive development; and (e) formation of at least 5,000 women's income and savings groups to support child development. 9. Project Description. To achieve the project objectives, a package of linked services will be provided at the community level. These services will be delivered mainly by NGOs as change agents working collaboratively with district governments. The three main - 2 -  components are: 10. Component 1--Integrated Community Child Care Package. This will support the delivery of child development services to preschool children in support of the Government's objectives: (a) to improve parental awareness on major aspects of child care, growth and development through parental education, child growth monitoring and promotion, training and sensitization; (b) to empower communities to support child development programs through capacity building and financial support grants. The target is to reduce the rate of malnutrition (underweight) of children by half by the end of the project life in the project districts, and increase readiness of this cohort of children for primary schooling and thereby support the drive for universal primary education. The package will be implemented in 20 out of 39 districts chosen by the government on the basis of level of malnutrition, infant mortality and primary school enrollment. The government intends to eventually cover all 39 districts. The package consists of two main sub-components: 11. (a) Parental Education. This sub-component will provide training to parents (and caregivers) on major aspects of child care, growth and development including child nutrition, health, and psycho-social stimulation. The notion is that a range of competencies will be strengthened in parents including those of psycho-social development. This building of parental skills and know-how will in turn improve the well-being of children and, ultimately, their receptiveness to education at the primary level. The program will mobilize groups of mothers (and parents) at the community level facilitated by animateurs from the locality, supported by the project with materials including worksheets in local languages, technical supervision and communications. Over the five year period, the project will cover 8,000 communities in 220 sub-counties in 20 districts. Emphasis will be on the enhancement of child-caring practices that promote proper growth and development of children, including: childhood nutrition (exclusive breastfeeding and appropriate weaning practices - the way feeding occurs as well as the foods given, and food preparation, child growth monitoring and promotion), psycho-social care - or the responsiveness to child needs, cognitive stimulation and social support, hygiene and home health practices. Growth monitoring and promotion will be carried out for children under three years of age. The focus will be on the prevention of malnutrition and promotion of good health. Encouraging parents to participate in weighing and monitoring of growth of children is a good mechanism for awareness creation. Nutrition counseling will be also be provided and knowledge and skills imparted to child caregivers. Protocols developed and tested in Uganda under the "integrated management of the sick child initiative" will be used as reference materials for the project. Also included in this package is maternal health and nutrition to take care of women and the unborn child. This includes pre and post natal care practices. A common theme in these component activities is that they are behaviors, and that most of the activities would be facilitated by a systematic communications strategy to change such behaviors. The parental education package - with its instruments, manuals and methodology - -3 -  is described in the Project Implementation Manual (PIM). It borrows from local experience and best practice from global experience. (b) Community Capacity Building and Empowerment for Child Care. This sub-component comprises three interrelated activities: (i) Community Capacity Building conducted through community planning and sensitization workshops; (ii) Child Day campaigns conducted at the parish level; and (iii) training in Savings and Credit Group Formation to support child development. Community planning workshops and sensitization activities will be conducted at the beginning of the project and carried out annually. These will plan annual activities to promote child development at the community, parish and sub-county level. A major activity will be a Child Day featuring programs for the whole community at the parish level. During the "Child Day" (a development bazaar concept successfully piloted for two years in the districts of Rukungiri and Iganga), weighing of children, immunization, nutrition education, demonstrations for food preparation, health care for women and children, education on sanitation and hygiene, education on psycho-social development, and agricultural extension workshops will be held at a center (usually done at a primary school). The Child Day concept features service offerings by local line ministries such as health (to assist in immunization, deworming), agriculture (in cooking demonstrations and agricultural extension workshops) and education (for promotion of schooling). (c) Ugandan women's ability to provide adequate child care is not only limited by the lack of knowledge, but also by their lack of access to and control over incomes and family resources. Poverty has been identified as one of the barriers to adequate health, nutrition and education for children. Parents need resources to succeed in their role. In particular, research has shown that women's incomes are particularly important for children. Client consultations and needs assessments carried out at preparation point to the need for an income generating activity formed around the same parents and mothers who will participate in the parental education package. The project will provide training to parents, especially women, on basic accounting and management skills that will enable them to form savings groups (how to generate and operate savings) and skills for micro-enterprise income-generating activities. 12. Component 2 - Community Support Grants and Innovation Fund. The Community Support Grants are financial grants offered on the basis of matching contributions from communities. These grants and contributions from communities will cover activities designed to promote the well-being of children. These grants would be given on the basis of proposals from communities arising out of their planning exercises, and are designed to support interventions for children: they may include community projects to assist in the production of appropriate weaning foods, community child-care centers, home-based child-care centers and similar activities which fall within the guidelines contained in the Project Implementation Manual. An Innovation Fund to support activities outside the menu of options is also included under Component 2. Community - 4 -  counterpart contributions maybe in the form of goods, works or services. The support grants component will be implemented in the same districts and communities as in Component 1: i.e., in 20 out of 39 districts chosen by the government on the basis of level of malnutrition, infant mortality and rate of primary school enrollment. The NGOs designated as implementing agents for Component 1 package will be responsible for the initiation and technical supervision of the component. The NGOs will provide training and assist community groups in accessing and utilizing these grants. Linkages will be established, particularly with the agricultural extension service and the Education Department of the district to provide the necessary technical assistance. The community will use the procedures described in the Project Implementation Manual for the use of these grants, guided by the NGOs designated by project. 13. Component 3: National Support Programme for Child Development. This component consists of central program activities and policy initiatives designed to support the district level programs in Components 1 and 2, and provide quality assurance for the frontline project activities at the community level. This component includes program monitoring and evaluation, support for central program initiatives on micro-nutrients, early childhood development (ECD) curriculum and development, communications and IEC. A monitoring and evaluation scheme has been developed (described in the Project Implementation Manual) to systematically monitor project inputs and outputs, as well as to evaluate impacts on children and parents. 14. Specific activities under Micro-nutrients Deficiency Control: (a) sensitization campaigns at national and district levels; (b) monitoring of vitamin A supplementation; (c) evaluation of effectiveness of the national micro-nutrient programs. (Note: Programs on iodine deficiency control and vitamin A are currently funded by an ongoing IDA credit, the District Health Services Project). Support to national ECD programs cover: (a) support to the National Curriculum Development Center in the finalization and production of curriculum guidelines for center-based ECD, including development of ECD workbooks, and adding health and nutrition guidelines in line with the goals of the project; (b) support for the development and pilot testing of on-the-job training methodology to upgrade skills of existing ECD workers in the semi- formal child care centers; (c) training of trainers in center-based ECD. 15. The communications and IEC strategy aim to support key target audiences on the goals of the project. At the national level, advocacy will target central and regional government officials, parliamentarians, NGOs, donors. At the community level, communications activities will be embedded in Component 1 and 2 activities, and designed to increase awareness of services and practical advice on child care practices that enhance the nutritional and education of the preschool child. Demand creation activities at the district will promote attendance in the Child Day. Radio broadcasts in Radio Uganda will feature talk shows with "Question and Answer" session with key officials, implementors, - 5 -  experts and community workers on the experience in nutrition and early childhood development. A 30-minute "Preschool on the Air" will be broadcast nationwide, possibly daily, to reach caregivers at home who could benefit from information on child care and child development. The project will also support policy-formulation activities related to child care and development. The Child Act of 1996 which protects children's rights will be disseminated through advocacy and communications workshops, and sensitization of the general population. 16. Project Financing. The total project cost is estimated at US $40.0 million, of which $30 million will be IDA funding. The Government counterpart financing is estimated at $4.0 million (US$ 2 million from the national government and US$ 2 million from the district government). The community and household counterpart contributions is estimated at US$ 2.0 million. Co-financing of some project components amounting to US $4.0 million will be provided by other donors. 17. Project Implementation. The main executing agency is the Ministry of Planning and Economic Development. NGOs and community- based organizations will be among the principal implementing agents at the community level. A National Coordinating Committee for the NECD Project (NCC) consisting of MOPED, MOE, MOH, MAARF, MGCD, MIB, MLG, MNR, other donors, NGOs, and representatives from the academic community and private sector will be created. This committee, to be chaired by the PS of Planning and Economic Development, will act as the oversight policy body responsible for approving annual project plans, reviewing project progress, and providing advice on policy issues arising from implementation of the program. A Project Coordinator will be appointed (acceptable to IDA), as coordinating officer for the project, reporting to the Permanent Secretary. The Project Coordinator will be supported by a small administrative staff (accountant and secretary ) within the Ministry. The community-based activities will be implemented through NGOs selected through national competitive bidding, using standard IDA procurement procedures. District project activities by the NGOs, as implementing agents, will be developed within the context of District Development Plans. Support to national programs will be implemented through MOE for the ECD activities and MOH for the micro-nutrient program activities. Management support for program monitoring and evaluation, IEC, and audit, will be contracted out. The project would strengthen national and community institutions to sustain programs that address children's needs. 18. Project Sustainability. There are three key elements that would likely enhance the sustainability of this project: (a) the strong political commitment by the government towards the improvement of the status of children as demonstrated by the broad- based national support for UNPAC and by the proposal of a "Child Bill" in parliament to codify children's rights in Uganda; (b) the provision to build community capacity and ownership of the project; and (c) the involvement of the main stakeholders of the project in the design particularly the district governments, NGOs, beneficiaries and central government policy makers. - 6 -  19. Lessons Learned From Previous Bank/Ida Involvement. Lessons learned from the District Health Services Pilot and Demonstration Project (DHSP--FY94), PAPSCA (FY89), and the First Health Project (1991) will be incorporated in the design of the project delivery system.). Firstly, the PAPSCA project clearly showed that details of the organizational arrangements for procurement, disbursement and monitoring should be prepared before project launching. Secondly, beneficiaries need to be consulted much more systematically to identify their needs. Thirdly, ground rules for the selection of "implementing agents" of the project should be clear and agreed upon during preparation. Fourthly, ground rules for accounting, monitoring must be clear to all "implementing agents". The project will incorporate lessons from UNICEF's Ugandan experience in the GMP and community participation. UNICEF staff will join future Bank project preparation missions to ensure coherence of project activities with on-going programs for children. 20. Rationale For Ida Involvement. This project is consistent with the Bank's Country Assistance Strategy. It addresses poverty alleviation and human resources development--two of the main goals of Uganda's long term development plan. The Nutrition and Child Development Project complements four IDA projects in Uganda--DHSP (FY94), Sexually Transmitted Infections Project (FY94), the First Health Project which will close in March 1996, and the Primary Education and Teacher Training Project (FY92). By investing in very young children, IDA is recognizing that human capital investment begins much earlier in the life cycle. IDA is supporting the government's very high priority for this sector. The government acknowledges that there is a large financing gap that needs to be addressed. 21. Environmental Aspects: The environment category is C. 22. Program Objective Categories. The project is targeted to the segment of the population most vulnerable to poverty - namely, preschool children and mothers. The program is envisioned to provide children a better headstart for life. Since specific project components address women's income and improvement of women's status, the project would result in positive gender impact. The preparation of the project and implementation strategy would use a participatory approach, PRAs, and client consultation workshops. 23. Stakeholder Participation. A multisectoral Task Force for Project Preparation coordinated by the Ministry of Planning and Economic Development was constituted to ensure that line ministries, local governments, NGOs and donors with potential roles in the project would be involved in the project design. Three national client consultation workshops were held to bring together all major stakeholders of the project and assist in project design. The first workshop was held February 26-27, 1996; a second workshop was held June 1996 to review project proposal document and a third conducted in December 9, 1996. Over the 11 months preparation period, stakeholder analyses and a needs assessment were conducted using participatory techniques. -7-  Contact Point: Public Information Center The World Bank 1818 H Street N.W. Washington, D.C. 20433 Telephone No.: (202) 458-5454 Fax No.: (202) 522-1500 Note: This is information on an evolving project. Certain components may not necessarily be included in the final project. Processed by the Public Information Center week ending July 4, 1997. - 8 -